management of acne qr · 2018-12-04 · • acne is a medical disease which requires treatment. •...
TRANSCRIPT
Dermatological Society of MalaysiaMinistry of Health Malaysia Academy of Medicine Malaysia
1
MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERS
KEY MESSAGES
• Acneisamedicaldiseasewhichrequirestreatment.
• Ifleftuntreated,acnemayhaveaprofoundpsychologicalandemotionalimpact.
• Pathogenesis of acne is multifactorial which includes increased sebum production,Propionibacterium acnesproliferation,alteredfollicularkeratinisation&inflammation.
• Alowglycaemicloaddietandhighfibredietshouldbeencouragedforacnepatients.
• Aimsofacnemanagementaretoinduceclearanceoflesions,maintainremissionandpreventrelapse,physicalandpsychologicalcomplications.
• ComprehensiveAcneSeverityScale(CASS)maybeusedforgradingofacneseverityinclinicalpractice.
• Topicaltherapyisthemainstayoftreatmentformildandmoderateacne.
• Oralantibioticsmaybeusedastreatmentformoderatetosevereacne,butshouldnotbeusedformorethansixmonths.
• Maintenance treatment should be commenced after an initial successful inductiontherapytosustainremission.
• Oralisotretinoinshouldonlybeprescribedbydermatologist.
This Quick Reference provides key messages and a summary of the main
recommendations in the Clinical Practice Guidelines (CPG) Management
of Acne (January 2011).
Details of the evidence supporting these recommendations can be found
in the above CPG, available on the following websites:
Ministry of Health Malaysia : h t t p : / / w w w . m o h . g o v . m y
Academy of Medicine Malaysia : h t tp : / /www.acadmed.org.my
2
MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERS
COMPREHENSIVE ACNE SEVERITY SCALE (CASS)
A new grading system named Comprehensive Acne Severity Scale – CASS (modification
of an Investigator Global Assessment [IGA] of Acne Severity) was validated and simple
to use in clinical practice (refer to the following table).
GRADE* DESCRIPTION
CLEAR 0Nolesionstobarelynoticeableones.Veryfewscatteredcomedonesandpapules.
ALMOST CLEAR 1Hardly visible from 2.5 metre away. A few scatteredcomedones,fewsmallpapulesandveryfewpustules.
MILD 2Easilyrecognisable;lessthanhalfoftheaffectedareaisinvolved.Manycomedones,papulesandpustules.
MODERATE 3Morethanhalfoftheaffectedareaisinvolved.Numerouscomedones,papulesandpustules.
SEVERE 4Entire area is involved. Covered with comedones,numerouspustulesandpapules,afewnodulesandcyst.
VERY SEVERE 5Highlyinflammatoryacnecoveringtheaffectedarea,withnodulesandcystpresent.
*Appliedtoeachoftheface,chestandbackindependently.
Inspectionisdoneatadistanceof2.5metersawayforacneonface,chestandback.
Chest area defined as: Anterior torso superiorly defined by suprasternal notch extending laterally to shoulders
and inferiorly by a horizontal line defined by the xiphoid process.
The back area defined as:(Is demarcated by the) superior aspects of the shoulders extending to the neck and
inferiorly by the costal margins
3
MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERS
FOOD LIST ACCORDING TO GLYCAEMIC INDEX (GI) CLASSIFICATIONThe GI is a numerical system used to classify carbohydrate food based on the impact they produce on the postprandial blood glucose level. The higher the GI values of the food, the greater the blood glucose response. In general, most refined carbohydrate with devoid of fibre is high in GI while intact carbohydrate (whole grains products), legumes, milk (and milk products), fruits and vegetables are low GI foods.
Foods/DrinksLow GI Medium GI High GI
Example GI Example GI Example GI
Rice Rice,parboiled 48 Brownrice,boiledBasmati,white,boiled
6858
Whiterice,boiledGlutinousrice,white
7398
Bread WholegrainbreadChapatti
5152
Pitabread 57 WholemealbreadWhitebreadSardinesandwich
747573
Breakfast cereals
Oatbran,raw 50 Instantporridge,oats
66 CornflakesCocoa-flavouredpuffedrice
8177
Pasta and noodles
Spaghetti,wholemeal,boiled
37 Ricenoodles,dried,boiled
61 FriedmeehoonFriedmacaroni
9974
Fruits Apple,rawOrange,rawBanana,raw
384351
Pineapple,raw 59 Watermelon,raw 76
Dairy products and alternatives
Milk,fullfatMilk,skimIcecream,lowfatYogurtLow-fatyogurt,fruit,sugar.Soymilk
2732503633
32
Icecream 61
Sugars Fructose 19 SucroseHoney
6861
GlucoseTehtarik
9978
Categories of GI (based on glucose as the reference)
Low : <55Medium : 55 - 70High : >70
4
MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERS
DIAG
NOSI
S &
SEVE
RITY
ASS
ESSM
ENT
OF A
CNE
(BAS
ED O
N CA
SS)*
SEVE
REM
ODER
ATE
MIL
D
Pred
omin
antly
com
edon
esPr
edom
inan
tly p
apul
es/p
ustu
les
Pred
omin
antly
com
edon
esPr
edom
inan
tly p
apul
es/p
ustu
les
Topi
cal b
enzo
yl pe
roxid
e OR
Top
ical r
etin
oid*
* OR
Topi
cal a
zela
ic ac
id O
R To
pica
l sal
icylic
acid
Co
mbin
ation
of 2
topic
al ag
ents
Topic
al ag
ent(s
) + O
ral a
ntibi
otic
Com
bina
tion
of
2 to
pica
l ag
ents
Com
bina
tion
of
2 to
pica
l age
nts
OR
Firs
t lin
e to
pica
l age
nt +
topi
cal a
ntib
iotic
Topi
cal a
gent
(s) +
Or
al a
ntib
iotic
Com
binati
on of
2 to
pical
agen
ts +
Oral
ant
ibio
tic O
RHo
rmon
al th
erap
y (fe
mal
es o
nly)
± to
pica
l age
nt
Refe
r der
mat
olog
ist fo
r phy
sical
ther
apy
Refe
r der
mat
olog
ist fo
r ora
l iso
tretin
oin
± P
hysic
al th
erap
y
Mai
nten
ance
ther
apy
with
topi
cal r
etin
oid
or to
pica
l ben
zoyl
pero
xide
* Sev
erity
ass
essm
ent i
s ba
sed
on C
ASS
(mild
1 -
2, m
oder
ate
3, s
ever
e 4
- 5).
Qual
ity o
f life
sho
uld
be ta
ken
into
con
sider
atio
n.
** T
opica
l ret
inoi
ds a
re to
be
avoid
ed in
pre
gnan
cy.
†If t
here
is n
o im
prov
emen
t in
3 m
onth
s, c
onsid
er th
e ne
xt li
ne o
f tre
atm
ent.
‡
Oral
ant
ibio
tic is
reco
mm
ende
d to
be
used
for 4
- 6
mon
ths.
Nodu
les
and
cyst
s
FIRS
T LI
NE
TR
EATM
ENT
THIR
D LI
NE
TREA
TMEN
T
SECO
ND L
INE
TR
EATM
ENT
MAN
AGEM
ENT
OF A
CNE
5
MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERSSU
GGES
TED
MED
ICAT
ION
DOSA
GES
AND
SIDE
EFF
ECTS
Drug
Reco
mm
ende
d Do
sage
Com
mon
Adv
erse
Effe
cts
Cont
rain
dica
tions
Spec
ial P
reca
utio
ns
Topi
cal b
enzo
yl
pero
xide
Appl
yon
ceto
twic
eda
ilyCo
ntac
tder
mat
itis,
dry
ness
,sk
ind
isco
lour
atio
n,s
kin
rash
,pe
elin
g,tr
ansi
entl
ocal
oed
ema
Hype
rsen
sitiv
ityto
be
nzoy
lper
oxid
eAv
oid
cont
actw
ithe
yes,
eye
lids,
lips
and
muc
ous
mem
bran
es.
May
ble
ach
fabr
ics
orh
air.
Topi
cal t
retin
oin
Appl
yon
cein
the
even
ing
befo
rere
tirin
gIn
itial
exa
cerb
atio
nof
sy
mpt
oms,
ski
nirr
itatio
n,
stin
ging
,oed
ema,
blis
terin
g,
crus
ting
ofs
kin,
ery
them
a,
scal
ing,
pho
tose
nsiti
vity,
tem
pora
ryh
ypo/
hype
rpig
men
tatio
n
Hype
rsen
sitiv
ityto
tre
tinoi
n,
preg
nanc
y,la
ctat
ion,
ec
zem
a,s
unbu
rn
cond
ition
s
Avoi
dco
ncom
itant
use
oft
opic
alk
erat
olyt
ica
gent
s.
Avoi
dex
posu
reto
sun
light
oru
ltrav
iole
t(UV
)lig
ht.
Avoi
dco
ntac
twith
eye
s,m
outh
,ang
les
ofn
ose,
muc
ous
mem
bran
esa
ndo
pen
wou
nds.
Avoi
dfa
cial
scr
ub.
Avoi
dus
eof
topi
calp
repa
ratio
nsw
ithh
igh
conc
entra
tion
ofa
lcoh
ol,m
enth
ol,s
pice
sor
lim
e.
Topi
cal a
dapa
lene
Appl
yon
ced
aily
to
affe
cted
are
asa
fter
was
hing
inth
eev
enin
gbe
fore
retir
ing
Mild
ski
nirr
itatio
n,s
calin
g,
eryt
hem
a,d
ryne
ss,s
tingi
ng,
burn
ing,
pru
ritus
Hype
rsen
sitiv
ityto
ad
apal
ene
Avoi
dco
ntac
twith
eye
s,li
ps,a
ngle
sof
nos
ean
dm
ucou
sm
embr
anes
.
Avoi
dcu
ts,a
bras
ions
,ecz
emat
ous
skin
ors
unbu
rned
ski
n.
Min
imis
eex
posu
reto
sun
light
.
Topi
cal c
linda
myc
inAp
ply
twic
eda
ilyIrr
itatio
n,d
ryne
ss,s
tingi
ng,
eryt
hem
a,c
onta
ctd
erm
atiti
sHy
pers
ensi
tivity
to
clin
dam
ycin
or
linco
myc
in,
ulce
rativ
eco
litis
,an
tibio
tic-r
elat
edc
oliti
s
Alco
holb
ase
solu
tion
may
cau
seb
urni
nga
ndir
ritat
ion
of
the
eyes
esp
ecia
llyin
ato
pic
indi
vidua
ls.
Topi
cal e
ryth
rom
ycin
Appl
ytw
ice
daily
Dryn
ess,
ery
them
a,b
urni
ng,
prur
itus
Hype
rsen
sitiv
ityto
er
ythr
omyc
inAv
oid
cont
actw
ithe
yes
and
othe
rmuc
ous
mem
bran
es.
Topi
cal s
alic
ylic
aci
dAp
ply
once
toth
rice
daily
Irrita
tion,
sen
sitiv
ity,e
xces
sive
dr
ynes
sHy
pers
ensi
tivity
to
salic
ylic
acid
Avoi
dpr
olon
ged
use
inh
igh
conc
entra
tions
and
ove
rlar
ge
area
sof
the
body
.
Avoi
dbr
oken
ski
n,m
outh
,eye
san
dm
ucou
sm
embr
anes
.
6
MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERS
Drug
Reco
mm
ende
d Do
sage
Com
mon
Adv
erse
Effe
cts
Cont
rain
dica
tions
Spec
ial P
reca
utio
ns
Topi
cal s
ulfu
r and
its
com
bina
tions
Appl
yon
ceto
twic
eda
ily.I
nitia
tew
itho
nce
daily
,the
nin
crea
se
grad
ually
.
Skin
irrit
atio
n,d
erm
atiti
sHy
pers
ensit
ivity
tos
ulfu
r,
child
ren
less
than
2
year
sol
d
Avoi
dco
ntac
twith
eye
s,m
outh
and
oth
erm
ucou
sm
embr
anes
.
May
sta
inth
esk
inb
lack
and
em
itfo
uls
mel
lwhe
nap
plie
dco
ncom
itant
lyw
ithm
ercu
rialc
ompo
unds
.
Topi
cal a
zela
ic a
cid
Appl
ytw
ice
daily
Skin
irrit
atio
n,m
ostly
bur
ning
or
itchi
ng,o
ccas
iona
llye
ryth
ema
and
scal
ing
Hype
rsen
sitiv
ityto
pr
opyle
neg
lycol
Avoi
dbr
oken
ski
n,m
outh
,eye
san
dm
ucou
sm
embr
anes
.
Oral
tetr
acyc
line
500
mg
-1
gda
ilyin
2
divid
edd
oses
Ga
stro
inte
stin
ald
istu
rban
ces,
di
scol
oura
tion
ofte
eth
and
nails
,pho
tose
nsiti
vity,
visua
ldi
stur
banc
es
Hype
rsen
sitiv
ityto
te
tracy
clin
es,
child
ren≤8
yea
rso
ld,
preg
nanc
y,la
ctat
ion
Shou
ldb
ead
min
iste
red
with
ple
nty
ofw
ater
,whi
les
ittin
gor
sta
ndin
g,1
hou
rbef
ore
or2
hou
rsa
fterm
eals
toa
void
oe
soph
agea
lulc
erat
ion.
Abs
orpt
ion
isim
paire
dby
food
,m
ilk,d
airy
pro
duct
s,ir
ons
alts
and
ant
acid
s.
Oral
dox
ycyc
line
50-
100
mg
once
to
twic
eda
ilyGa
stro
inte
stin
ald
istu
rban
ces,
ph
otos
ensi
tivity
,hyp
erse
nsiti
vity,
perm
anen
tsta
inin
gof
teet
h,
rash
Hype
rsen
sitiv
ityto
te
tracy
clin
es,
child
ren≤8
yea
rso
ld,
preg
nanc
y,la
ctat
ion
Shou
ldb
ead
min
ister
edw
ithp
lent
yof
wat
er,w
hile
sitt
ing
ors
tand
ing,
1h
ourb
efor
eor
2h
ours
afte
rmea
lsto
avo
id
oeso
phag
ealu
lcera
tion.
Oral
ery
thro
myc
in
Eryt
hrom
ycin
Eth
ylSu
ccin
ate
(EES
):
400
-800
mg
twice
dai
ly
Eryt
hrom
ycin
Ste
arat
e:
25
0-5
00m
gtw
iced
aily
Gast
roin
test
inal
dis
turb
ance
s,
rash
,urti
caria
,hea
dach
e,
dizz
ines
s
Hype
rsen
sitiv
ityto
er
ythr
omyc
inHe
patic
and
rena
lim
pairm
ent,
pr
olon
ged
QTin
terv
al,
conc
omita
ntth
erap
yw
ithc
olch
icin
e(to
xicity
)and
lo
vast
atin
(rha
bdom
yolys
is)
Disc
laim
er:
•Th
eou
tline
ofd
rug
dosa
gea
nda
dmin
istra
tion
isin
tend
eda
sa
gene
ralg
uide
toth
erap
y.
•Th
ead
vers
eef
fect
slis
ted
are
note
xhau
stive
.
•Ca
utio
nis
adv
ised
whe
npr
escr
ibin
gfo
rpat
ient
sw
itho
ther
med
ical
pro
blem
sor
on
mul
tiple
dru
gs.
7
MANAGEMENT OF ACNE QUICK REFERENCE FOR HEALTHCARE PROVIDERS
REFERRAL
Theurgencyforreferralisdividedintothefollowingcategories:
Urgent : Within24hours
SeenEarly : Withinoneweektofourweeks
Non-urgent : Basedonavailableappointmentdate
i. Urgent referral (to a psychiatrist)
Majordepressionoranysuicidalbehaviour
ii. Seen Early
a. Severeacneornodulocysticacnethatmayneedisotretinoin
b. Severesocialorpsychologicalproblemsincludingamorbidfearofdeformity(dysmorphophobia)anddepression
iii. Non-urgent
a.Fordiagnosis
r Suspectedrosacea
r Suspecteddrug-inducedacne
r Acnebeginningorpersistingoutsidethenormalagerangefortheconditionorlateonsetacne
r Suspectedoccupationalcauses
r Suspectedunderlyingendocrinologicalcause(suchasPolycysticOvarianSyndrome)requiringfurtherassessment
r Rarevariantsofacnesuchasacneexcoriae,chloracneandacnefulminans
r SuspectedDemodexfolliculitis
r Pityrosporumfolliculitis
r Gramnegativefolliculitis
b. Specialistservices
r Resistanceorintolerancetocurrenttreatment
r Moderateorsevereacne
r Possiblescarringorfailuretoachieveadequateresponse
r Failedoralantibiotictherapy
r Pregnancywithmoderateandsevereacne
r Acnerequiringsurgery(suchasincisionanddrainageofcysts)
r Forspecialisedphysicaltreatment