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Referral and warning signs
When to refer
Refer to Dermatologist/Specialist if: Severe nodulocystic acne. Scarring present. Failure to respond to adequate trial of standard therapy (e.g., topical + oral antibiotic). Consideration for oral Isotretinoin. Suspected underlying hormonal cause (PCOS, etc.). Significant psychological distress.
Red flags
- Sudden onset of severe, fulminant acne with systemic symptoms (Acne Fulminans - rare emergency).
- Acne unresponsive to multiple standard therapies.
- Signs of hyperandrogenism.
Signs and symptoms
- Lesions typically on face, neck, chest, upper back, shoulders.
- Non-inflammatory lesions:
- - Open comedones (blackheads).
- - Closed comedones (whiteheads).
- Inflammatory lesions:
- - Papules (small red bumps).
- - Pustules (papules containing pus).
- - Nodules (larger, deeper, painful, solid lesions).
- - Cysts (deep, painful, pus-filled lesions).
- Post-inflammatory hyperpigmentation.
- Scarring (pitted, hypertrophic).
Risk factors
- Age (adolescence - hormonal changes).
- Genetic predisposition / Family history.
- Hormonal influences (androgens, PCOS).
- Certain medications (corticosteroids, lithium, androgens, phenytoin).
- Occlusive cosmetics or hair products.
- High glycaemic load diet (potential factor).
- Stress (can exacerbate).
Diagnosis
Clinical assessment
Diagnosis based on presence of characteristic lesions (comedones are key) in typical distribution.
Differential diagnosis
- Rosacea (erythema, telangiectasias, papules/pustules, NO comedones, usually older adults).
- Folliculitis (inflammation centered on hair follicles, often itchy).
- Perioral dermatitis (papules/pustules around mouth, spares vermillion border).
- Milia (small white keratin cysts).
- Drug-induced acneiform eruption (monomorphic papules/pustules, often abrupt onset, lacks comedones).
Investigations
- Usually clinical diagnosis only.
- Hormonal evaluation if signs of hyperandrogenism (hirsutism, irregular menses).
Management
Non-pharmacological management
- Gentle skin cleansing BID with mild soap/cleanser. (LOC: HC2)
- Avoid harsh scrubbing or picking/squeezing lesions.
- Use non-comedogenic (oil-free) cosmetics and sunscreens.
- Healthy diet (role of specific foods controversial, general advice is balanced diet).
- Stress management.
- Reassurance and managing expectations (treatment takes time).
Pharmacological treatment
- Treatment based on severity (Mild: comedones +/- few papules/pustules; Moderate: more numerous papules/pustules +/- few nodules; Severe: numerous nodules/cysts, scarring).
- Topical Therapy:
- - Retinoids (e.g., Tretinoin, Adapalene, Tazarotene): First-line for comedonal and inflammatory acne. Normalize follicular keratinization. Start low strength, apply pea-sized amount at night. Cause dryness/irritation initially. Avoid in pregnancy. (LOC: HC4/Specialist)
- - Benzoyl Peroxide (BPO): Antibacterial and comedolytic. Available 2.5%, 5%, 10%. Can bleach fabric. Apply OD/BID. (LOC: HC4/UCG Option)
- - Topical Antibiotics (e.g., Clindamycin, Erythromycin): Reduce P. acnes and inflammation. Often used in combination with BPO to reduce resistance. Apply OD/BID.
- - Combination Topicals: (e.g., Adapalene/BPO, Clindamycin/BPO).
- - Azelaic Acid.
- - Salicylic Acid (weaker comedolytic).
- Systemic Therapy (Moderate-Severe Acne or Failed Topical):
- - Oral Antibiotics: Tetracyclines (Doxycycline 100mg OD/BID, Lymecycline) OR Macrolides (Erythromycin 500mg BID - UCG option, Azithromycin). Used for anti-inflammatory effect. Typically 3-6 months course. Combine with topical retinoid/BPO. (LOC: HC2/3 - Doxy/Erythro per UCG)
- - Combined Oral Contraceptives (COCs): Certain COCs with anti-androgenic effect effective for females. (LOC: HC4/Specialist)
- - Oral Isotretinoin: Highly effective for severe, nodulocystic, scarring acne. Teratogenic - requires strict pregnancy prevention (iPLEDGE program in some countries). Specialist prescription and monitoring only. (LOC: Specialist/RR)
- - Anti-androgens (Spironolactone) - off-label use in females (Specialist).
Monitoring
Assess response after 2-3 months of therapy. Monitor for side effects. Adjust regimen as needed. Continue maintenance therapy (often topical retinoid) after control achieved.
Complications
- Scarring (atrophic, hypertrophic, keloid).
- Post-inflammatory hyperpigmentation (PIH) - especially in darker skin types.
- Psychosocial impact (low self-esteem, anxiety, depression).
Prevention
- Gentle skin care.
- Avoid comedogenic products.
- Early treatment to prevent scarring.
Patient education
- Explanation of acne pathogenesis (blocked pores, bacteria, inflammation, hormones).
- Treatment takes time (weeks to months) - need for patience and adherence.
- Correct use of topical medications (pea-sized amount, potential irritation).
- Importance of avoiding picking/squeezing.
- Use of non-comedogenic products.
- Managing expectations and addressing psychosocial impact.
- Sun protection (some treatments increase sensitivity).
Uganda-specific notes
Common, affects QoL. Over-the-counter BPO may be available. Doxycycline/Erythromycin often used systemically. Access to topical retinoids and oral isotretinoin very limited outside specialized/private settings. Address myths about diet.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 22, Section 22.5.1