Acne

{Acne evaluation}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

PRESENTING COMPLAINTS OR ISSUES
Presenting symptoms:
[+] Pimples/pustules
[+] Comedomes

Areas affected: 
[-] face 
[-] shoulders 
[-] back 
[-] chest

Age at onset:

Management to date: [+] effective, [?] unsure, [-] ineffective
[+] 
[?] 
[-]

Diagnostic investigation results:
[+] 
[-]

PAST MEDICAL HISTORY
Relevant past medical, surgical and mental health history:
[+] 
[?] 
[-]

Use of medication that can cause or worsen acne:
[-] topical corticosteroids
[-] androgenic steroids
[-] anticonvulsants
[-] barbiturates
[-] lithium
[-] bromides
[-] iodides

SOCIAL HISTORY
Occupational exposures associated with acne:
[-] mineral oils (mechanical workers, etc)
[-] cooking oils (e.g. frying)
[-] chloracne [-] exposure to halogenated aromatic hydrocarbons (including polychlorinated biphenyls [PCBs], dioxins, organochlorine pesticides)

[Examination findings]

Skin:
[-] seborrhoea [-] red, scaly and oily skin
[-] comedones [-] blackheads and whiteheads
[-] pustules
[-] cysts
[-] scarring
  Areas affected:
  [-] face
  [-] neck
  [-] shoulders
  [-] upper back
  [-] chest

ASSESSMENT
Clinical summary:
[+] 
[?] 
[-]

Problems and issues:
_

Diagnosis/es:
[-] acne vulgaris (common acne)
  [-] papular
  [-] comedonal
  [-] cystic
[-] acne medicamentosa (drugs/cosmetics that cause or worsen acne):
  [-] topical corticosteroids
  [-] androgenic steroids
  [-] anticonvulsants
  [-] barbiturates
  [-] lithium
  [-] bromides
  [-] iodides
[-] occupational exposures associated with acne:
  [-] mineral oils (mechanical workers, etc)
  [-] cooking oils (e.g. frying)
  [-] chloracne [-] exposure to halogenated aromatic hydrocarbons (including polychlorinated biphenyls [PCBs], dioxins, organochlorine pesticides)
[-] acne mechanica (caused by friction/rubbing)
[-] rosacea
[-] folliculitis barbae (ingrown hairs)

Differential diagnosis:
[-] Rosacea

MANAGEMENT PLAN
Diagnostic investigations requested:
-

Treatment:
MILD ACNE
Antibacterial (once to twice daily): either
[-] Topical benzoyl peroxide
[-] Topical erythromycin (Eryacne gel)
[-] Topical clindamycin (ClindaTech solution, Topicil solution and Duac Once Daily gel)

MODERATE ACNE
1. Anti-inflammatory:
[-] Oral antibiotics: either
  First-line:
    [-] Doxycycline 50-100 mg daily^
      * Warned about photosensitivity
    [-] Minocycline (50-100 mg daily^
  Second-line (due to GI side effects):
    [-] Erythromycin ethyl succinate 400–800 mg twice daily
      * convert to topical antibiotics or cease antibiotics where possible
      * Long-term oral antibiotics may be required in some cases

2. Normalise keratinisation (topical retinoids [-] once daily at bedtime): *either*
[-] Topical adapalene (0.1-0.3%)
[-] Topical tretinoin (0.01-0.1%)
[-] Topical tretinoin (0.025%) and clindamycin (1%) [-] Acnatac
[-] Topical tazarotene (0.05-0.1%)

3. Sebaceous gland inhibition (hormonal agents): {females only}
[-] OCP containing ethinylestrodiol (oestrogen) and an antiandrogenic progesterone
  [-] Cyproterone acetate: Diane-35, Estelle 35 and Ginet-84
  [-] Drospirenone: Yasmin, Yaz
  [-] Dienogest: Valette

SEVERE ACNE
{Will generally involve specialist referral}
1. Anti-inflammatory:
[-] Oral antibiotics: either:
  First-line:
    [-] Doxycycline 50-100 mg daily^
      * Warned about photosensitivity
    [-] Minocycline (50-100 mg daily^
  Second-line (due to GI side effects):
    [-] Erythromycin ethyl succinate 400–800 mg twice daily
      * convert to topical antibiotics or cease antibiotics where possible
      * long term oral antibiotics may be required in some cases
    [-] Corticosteroids^^ (intralesional or oral)
    [-] NSAIDs

2. Antibacterial:
[-] Oral isotretinoin^^ (indirect effect)

3. Normalise keratinisation:
[-] Oral isotretinoin^^

4. Sebaceous gland inhibition:
[-] Oral isotretinoin^^
[-] Intralesional corticosteroids^^

5. Scarring treatments (referred for):
[-] Dermabrasion
[-] Chemical peels
[-] Laser resurfacing
[-] Collagen injections

^ Not suitable for children younger than 10 years old because they may stain teeth yellow.
^^ Treatment should be managed by a dermatologist.

Information and advice given:
1. Gentle face washing (no more than twice a day) using warm (not hot) water and a gentle non-soap skin cleanser. Avoid scrubbing; this will make acne worse.
2. Avoid picking or squeezing the pimples or blocked pores.
3. Avoid oil-based moisturisers and make-up (use only non-oily products; these are sometimes labelled as "non-comedogenic").
5. Use a mild acne treatment such as benzoyl peroxide. Used either as a wash or as a lotion applied at night and washed off the next morning [-] beware, this product can cause bleaching of pillow cases.

Referrals:
[-] Dermatologist
[-] Plastic surgeon
[-] Endocrinologist

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

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Acne

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