Assessment and Treatment of Acne in the Retail Clinic Setting

Angela Patterson, DNP, FNP-BC, NEA-BC
Tuesday August 30, 2016

Acne is a common, chronic skin disorder involving inflammation and/or blockage of the sebaceous follicles. The major pathogenic factors involved include follicular hyperproliferation and keratinization with abnormal desquamation, increased sebum production due to androgenic stimulation, and microbial colonization of pilosebaceous units by Propionibacterium acnes, which results in inflammation. Clinical features include a range of lesions, such as open and closed comedones, inflammatory papules, pustules, nodules, and cysts. Presentations of acne can range from a mild comedonal form to severe inflammatory cystic acne of the face, chest, and back.1-3

Acne Facts

An estimated 50 million individuals in the United States are affected by acne, and the cost of treating acne is more than $3 billion per year.4 The disorder has an 85% prevalence rate among those 12 to 24 years old, with peak prevalence occurring during adolescence. Recent studies also cite the increasing prevalence of adult acne, particularly in women.5,6 The physical effects of acne include the potential for disfigurement, scarring, and permanent discoloration. Psychological effects can be significant and include the potential for psychological scarring due to emotional trauma, poor self-esteem, depression, and anxiety.7–9

Acne Risk Factors

Evidence supports the presence of several risk factors in the development of acne. Common risk factors include the following:

  • Use of certain medications, such as corticosteroids, bromides, lithium, certain anti-epileptics, and iodide-containing drugs

  • Family history of acne (80% heritability in first-degree relatives)

  • Hormonal changes, such as those experienced during the menstrual cycle or pregnancy

  • Certain conditions such as polycystic ovary syndrome, Cushing’s syndrome, and congenital adrenal hyperplasia

  • Stress

  • Smoking

  • Occlusion of the skin surface with greasy products, clothing, or sweat


Some evidence exists for high glycemic foods and possibly dairy intake as risk factors for acne.10 Opinion to no evidence exists for chocolate intake as a risk factor.3,4,11

Acne Assessment

Subjective assessment of the patient with acne should include the following:

  • Patient medical history, medication history, and family history

  • Hobbies

  • Duration, distribution, and severity of lesions

  • Presence of risk factors

  • Skin care routine and products used

  • Therapies tried and response to treatment

  • Psychological and social impact of disorder10

Objective assessment should include clinical assessment of acne severity. Categorization of acne severity, based on clinical presentation, is presented in Table 110.

TABLE 1: ASSESSMENT OF ACNE SEVERITY10

Mild

  • Predominantly noninflammatory comedonal lesions, occasional small papules:

  • Closed micro-comedones 1-3mm, flesh-colored, possible white plug

  • Open comedones with black-colored central plugs

  • - Typically limited to facial involvement

Moderate

  • Mainly inflammatory lesions involving reddened or hyperpigmented papules and pustules

  • Pustules with pointed yellow-green colored tops that become fluctuant and rupture spontaneously

  • Involves face and trunk

Severe

  • Severe papular and pustular inflammatory lesions

  • Nodular-cystic lesions, appear bright to dark red, sinus tracking

  • Hyperpigmentation present

  • Scarring: atrophic pits to large depressed scars, keloids 


Acne Treatment Goals

Principles of acne treatment include the control of noninflammatory and inflammatory processes, prevention or minimizing of scarring and permanent pigmentation changes, and elimination or reduction of modifiable acne-causing factors. Long-term treatment is often necessary. It is essential that interventions to support therapeutic adherence be included in each patient’s treatment plan, such as engaging the patient in shared decision making. Lastly, treatment of patients with acne should support optimal psychosocial health and well-being.1,10



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