Presentation by: Francine Carson SUNY IT Utica-Rome NUR 652.

Acne VulgarisPresentation by: Francine Carson

SUNY IT Utica-RomeNUR 652

Definition of the Problem

Pathophysiology Etiology Inflammatory disorder of

pilosebaceous unit Hormonal influence

Androgens(Lavers, 2014,

p.330)

pilolsebacesous

Four key processes are involved in the pathogenesisof acne:

1. Androgen-driven excessive sebum production

2. Abnormal keratinization (hyperkeratinization)

3. Colonization with Propionibacterium acnes (P. acnes )

4. Release of inflammatory mediators

(Lavers, 2014, p.330)Normal pilosebaceous unit [Illustration]. 2005. Retrieved September 14, 2014 from http://images.niams.nih.gov/detail.cfm?id=89

Incidence“Most common dermatological condition

worldwide”(Lavers, 2014, p.330)

Effects persons of all ages80-100% will be effected in their lifetimeBegins around puberty; peaks in adolescence;

tends to resolve third decade of lifeMay be present in the newborn (Watkins, 2013)

Screening/Risk FactorsDrugsFamily HistoryStressHormonal changes

Pregnancy, menstrual cycle Conditions with excess androgen production

Polycystic ovary syndrome, congenital adrenal hyperplasia, Cushing’s Syndrome

SmokingOcclusion of skin surface

Cosmetic products

(Lavers, 2014 p.332; Lavers & Courtenay, 2011, p.58)

Clinical FindingsDiagnosis based on clinical findings, H&P : Other findings

Inflammatory & Noninflammatory lesions (Titus & Hodge, 2012) Noninflammatory

Open or Closed Comedones Inflammatory Lesions

Papules, pustules, nodules, and cysts May feel hot, painful, and tender

to pressure

Visible to naked eye (Lavers & Courtenay , 2011, p.58)

Distributed to face, neck, chest, upper back, and shoulder (Lavers, 2013)

Seborrhoea ScarringPost-inflammatory

pigmentationGrading severity helps

determine treatment

Images Retrieved September 14th , 2014 from http://emedicine.medscape.com/article/1069804-clinical

Assessing Severity of Acne Mild

Seborrhoea Predominantly comedonal lesions Micro-comedones (first stage of comedone

formation) Open (blackheads) and closed (whiteheads)

comedones Few papular inflammatory raised lesions Typically limited to the face

Moderate Seborrhoea Open and closed comedones Moderate acne presents with greater

numbers of inflammatory papules and pustules, involving face and trunk

Severe Seborrhoea Open and closed comedones Papular and pustular inflammatory lesions Nodular-cystic lesions Scarring

(Lavers, 2014, p.334)

(Image from British Journal of School Nursing, 2011, p. 382)

Differential DiagnosisRosaceaSeborrheic dermatitisDrug-induced acne Bacterial folliculitis Perioral/Periorbital dermatitisKeratosis pilaris

(Lavers, 2014; Lavers & Courtenay, 2011; Titus & Hodge, 2012)

Social/Environmental ConsiderationsPsychological impact (Lavers, 2014, p.333)

StressAnxiety DepressionSuicidal ideationsLow self-esteemPoor body image

Social withdrawal & higher rates of unemployment - especially in teenagers (Joseph & Sterling, 2010, p. 122)

Laboratory Testing/DiagnosticsAcne vulgaris is diagnosed by clinical

appearanceCulture for sensitivities (Watkins, 2010, p.115)

Test for underlying condition Hyperandrogenism

LH, FSH, Free testosterone (Domino, 2013, p.16)

Management/Treatment GuidelinesPharmacologic (Lavers, 2014,

p.334-335)

Topical Retinoids – for all grades of

acne (except when oral retinoid used) First line treatment Adapalene – best tolerated

Antibiotics – mild-to-moderate inflammatory lesions Combination with benzoyl

peroxide or topical retinoid Limit treatment to 12 weeks First line: Clindamycin or

Erythromycin Benzoyl peroxide –

Comedolytic, anti-inflammatory Azelaic acid Salicylic acid

Oral – moderate-to-severe or mild-to moderate acne Antibiotics - moderate-to-severe

inflammatory acne Tetracycline (avoid use in pregnant

women), Doxycycline Limit course :12 weeks Combine treatment with topical

retinoid or benzoyl peroxide Hormonal therapy – moderate-to-

severe acne Combined oral contraceptives,

Spironolactone Results: 3-6 months

Retinoids - severe acne First line treatment Accutane (Isotretinoin)

16-24 week course Teratogenic

Management/Treatment continuedNon-pharmacological

Surgery; I&D for abscesses (Domino, 2013, p.17)

Laser and light therapy (Titus & Hodge, 2012, p.739)

BiofeedbackAcupunctureMicrodermabrasion

ComplicationsScarringPsychological manifestationsAntibiotic resistance

(Joseph & Sterling, 2010; Lavers, 2014, p.336)

Follow-up4-6 weeks

Reevaluate response to treatmentAdverse effects

(Dunphy, Winland-Brown, Porter, & Thomas, 2011, p. 209)

Counseling/EducationAvoid picking at scabs or acne (Lavers & Courtenay, 2011,

p.64)

If acne doesn’t improve, return for reevaluation

Wash face twice daily with a gentle cleanser Wash oily hair regularlyUse medication as directed and give it time

to work 6 weeks (Titus & Hodge, 2012, p. 740)

Consultation/ReferralDermatologyFamily and peer group support Psychological counseling

10 Questions 1. A client returns after 2 weeks of treatment for acne and states it isn’t

working. What should the practitioner tell the client?a) Return in 4 weeks, b) Let’s change your treatment, c) Refer to dermatology 2. T/F : Popping acne is ok because it gets the pus out. 3. Which lab study should the provider obtain prior to starting a female

client on Isotretinoin?a) CBC, b) ESR, c) pregnancy test 4. Why are acne vulgaris lesions mostly located the face, back, neck, and

chesta) Lower concentration of ebaceous glands, b) Higher concentration of

sebaceous glands, c) Skin pigmentation 5. A client says they have been scrubbing their face to get rid of the oils

and their acne isn’t getting any better. What should you say to the client? a) Scrubbing can irritate the skin and make the acne worseb) It takes about 1 week of scrubbing to see improvementc) Let’s take a look at your acne medication

10 Questions (continued)6. Who should the provider refer a client who is feeling

embarrassed and depressed about their acne?a) Psychologist, b) Plastic surgeon, c) School nurse7. Why should the provider limit the duration of antibiotic

treatment for clients?a) Cdiff, b) Photosensitivity, c) Antibiotic resistance 8. Which medications can one use for treatment of acne?

(Multiple correct)a) Retinoids, b) Antibiotics , c) Oral contraceptives9. Acne vulgaris is diagnosed based on:a) Culture results, b) clinical appearance, c) TSH studies10. T/F: Clients taking corticosteroids or women with

polycystic ovarian syndrome are at risk for acne vulgaris?

ReferencesBritish Journal of School Nursing, Oct 2011, Vol. 6 Issue 8, p379-384, 5p, 2

Color Photographs, 1 Black and White Photograph, 1 Diagram, 1 Chart

Color Photograph; found on p382

Domino, F. (2014). Griffith’s 5-minute clinical consult (22nd ed.).

Philadelphia: Lippincott Williams & Wilkins

Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2011). Primary care: The

art and science of advanced practice nursing (3rd ed.). Philadelphia: F.A. Davis.

Joseph, D., & Sterling, A. (2010). The psychological effects of acne in teenagers. British Journal Of School Nursing, 5(3), 122-126.

Lavers, I. (2013). Therapeutic strategies for acne vulgaris. Nursing Times, 109(48), 16-18.

ReferencesLavers, I. (2014). Diagnosis and management of acne

vulgaris. Nurse Prescribing, 12(7), 330-336.

Lavers, I., & Courtenay, M. (2011). A practical approach to

the treatment of acne vulgaris. Nursing Standard, 25(19), 55-55-6, 58,

60 passim.

Titus, S., & Hodge, J. (2012). Diagnosis and treatment of acne. American Family Physician, 86(8), 734-740.

Watkins, J. (2013). Looking at the potential impact and management of acne. British Journal Of School Nursing, 8(3), 115-117.