Acne Vulgaris

An inflammatory disorder of the sebaceous glands, acne vulgaris is the most common skin problem in adolescents, although lesions can appear as early as age 8. Although acne is more common and more severe in boys than girls, it usually occurs in girls at an earlier age and tends to last longer, sometimes into adulthood. The prognosis is good with treatment.

Causes

• Exact cause unknown
• Possible primary causes: follicular occlusion, androgen-stimulated sebum production, and Propionibacterium acnes

Flare-ups

• Certain drugs, including corticosteroids, glucocorticoids, halogens, phenobarbital, phenytoin (Dilantin), isoniazid (Laniazid), and lithium
• Cosmetics
• Emotional stress
• Exposure to industrial compounds
• Trauma or rubbing from tight clothing
• Unfavorable climate

Signs and symptoms

• Closed comedo, or whitehead (if it doesn't protrude from the follicle and is covered by the epidermis)
• Open comedo, or blackhead (if it does protrude and isn't covered by the epidermis)
• Inflammation and characteristic acne pustules, papules or, in severe forms, cysts or abscesses
• Scarring, if chronic recurring lesions

Diagnostic tests

• Results of culture and sensitivity testing of pustules show causative organism of secondary bacterial infection.

Treatment

• A topical antibacterial (such as benzoyl peroxide, clindamycin [Cleocin], or erythromycin) is prescribed, alone or with tretonin (Avita), a keratolytic, or salicylic acid.
• A systematic antibiotic, usually tetracycline (Sumycin), decrease bacterial growth until the patient is in remission; then a lower dose is used for long-term maintenance. Tetracyline is contraindicated during pregnancy and childhood because it discolors developing teeth. Erythromycin is an alternative for these patients.
• Because of its severe adverse effects, a 16 to 20-week course of oral isotretinoin (Accutane) is limited to those with severe papulopastular or cystic acne who don't respond to conventional therapy.

Avoiding risks of isotretinoin therapy

Because isotretinoin is known to cause birth deftects, the manufacturer, with approval of the Food and Drug Administration, recommends th following precautions:

• Pregnancy testing before dispensing
• Effective contraception during treatment
• Dispensing only a 30-day supply
• Repeat pregnancy testing throughout the treatment period
• Informed consent of the patient or parents regarding the drug's adverse effects

• Oral hormonal contraceptives (such as Ortho Tri-Cyclen) or spironolactone (Aldactone) may be prescribed for female patients because these drugs have anti-androgenic effects.
• Intralesional cortecosteroid injections may be oredered.
• Exposur to ultraviolet light may be ordered (but never when a photosensitizing agent, such a tretinoin, is being used).
• Cyrotherapy may be ordered.
• Additional treatments include comedo extraction, which involves drainage and extraction of larger cysts.

Nursing Considerations

• Check the patient's drug history because certain drugs may cause an acne flare-up.
• Try to identify predisposing factors that may be eliminated or modified.
• Explain to the patient and his family that the prescribed treatment is more likely to improve acne than a strict diet and fanatic scrubbing with a soap and water. Provide written instructions regaring treatment.
• Intsruct the patient using tretinoin to apply it at least 30 minutes after washing the face and at least 1 hour before bedtime. Warn against using it around the eyes or lips. After treatments, the skin should look pink and dry. If it appears red or starts to peel, the preparation may have to be weakened or applied less often. Advise the patient to avoid exposure to sunlight or ro use a sunscreen.
• If the prescribed regimen includes tretinoin and benzoyl peroxide, avoid skin irritation by using one preparation in the morning and the other at night.

Drug Challenge

Instruct the patient to take tetracycline on an empty stomach and not to take it with antacid or milk.

• If the patient is taking isotretinoin, tell him to avoid vitamin. A supplements, tell him to avoid vitamin A supplements, which can worsen any adverse reactions.
• Warn the female patient taking isotretinoin about the severe risk of terato genesis associated with the use of this drug.
• Monitor the patient's liver function and lipid levels when isotretinoin is used.
• Offer emotional support.

BY: Lippincott Williams & Wilkins