Acne Vulgaris: Not Just Skin Deep

Hello. I’m Norman Swan. Welcome to this program on acne, which
is going out as a satellite broadcast over the Rural Health Education
Foundation’s satellite network. While acne affects almost all adolescent
boys and most adolescent girls, it isn’t necessarily
a transient part of growing up. The condition may persist for years,
affecting all ages. Those who are severely affected
frequently encounter significant physical and emotional scarring, and it’s that emotional scarring which
is often missed or underestimated. And that has enormous implications
for how you look after people with acne. Tonight, the latest evidence-based care and a few surprising new developments
as well. As always, there are resources available on the Rural Health Education
Foundation’s website – Now let me introduce our panel to you. John Sullivan is a consultant
dermatologist and Director of Research at the Skin & Cancer Foundation
Australia. That’s based in Darlinghurst,
New South Wales. Welcome, John. Thank you, Norman. John Bell is a Principal Advisor
of the Self Care Program at the Pharmaceutical
Society of Australia, one of Australia’s
most respected pharmacists. – Welcome, John.
– Thank you, Norman. Dr Parker Magin
is a general practitioner and Senior Lecturer in General Practice,
University of Newcastle. – Welcome, Parker.
– Hello. And Neil Mann
is a Professor of Human Nutrition at RMIT University in Melbourne. – Welcome.
– Thanks, Norman. Last but not least is Suzie Hoitink a registered nurse and the founder
of the Clear Complexions Clinic, which is based in Canberra in the ACT. – Welcome, Suzie.
– Thank you. Welcome to you all. Suzie, what’s your story? You just didn’t happen across
a good business idea, did you? No, I didn’t. As you said,
I am a registered nurse and my interest in skin really started
from when I was a teenager because I had acne. And I had that typical teenage acne,
just like 85% of the population, and found it very difficult
to get some straight answers. So I went, like most people, to my GP
and I did do the course of antibiotics – I did a couple of courses – and sort of managed it
throughout my teenage years, but I found it very difficult
to get some advice on skin care. How bad did it get? It didn’t… It certainly didn’t… I didn’t feel like it needed
anything like Roaccutane, so, because of that,
I never went to a dermatologist. So it was about trying
to manage it myself through what was available,
over-the-counter products, and from advice from a GP. What did it do to you psychologically
and emotionally? I just hid under a veil of make-up,
as we all do. You know, it’s lucky
that I suppose we women can, but I think it becomes a bit of a cycle
where we make it worse, so very, very psychologically troubling
when I was a teenager. And then when I came into my 20s, the hormones…
it became more of a hormonal acne, so it definitely changed,
became more around my jawline, much more difficult to cope with,
because, in your 20s, it should be well and truly
over and done with. And it really persisted
right through having children as well. And then in my 30s,
I just was sick and tired of it, and I think my search for answers
led me to realise there’s a lot of other treatments
out there and a lot of very, very good skin care. So have you applied an industrial sander
to your face? From where I sit,
it looks pretty smooth to me. It’s a lot better now.
I still have to be careful. I still break out every now and then – if you’ve got acne-prone skin, you’ve
pretty much always got acne-prone skin – but I certainly… So, apart from the industrial sander,
what did you happen across? Really good, effective skin care
that was right for me, because when you’ve got hormonal acne… And we’ll, I’m sure,
get into this a lot more in detail, but with hormonal acne,
the over-the-counter products aren’t particularly appropriate for you, and certainly doing treatments
such as… ..I’ve done some peels on my skin using
some light-based therapies as well. So tell me about
these light-based therapies. It’s very different to the typical
approach of applying creams and… So, is this UV, or what is it? No, it’s not UV – it’s LED technology, and it basically works on admitting
a specific wavelength of light to achieve a result in the skin. So, when we… We use one
called the ‘Omnilux Medical’, and we use a blue-light therapy. And the blue-light causes
the P acnes bacteria to admit a… ..essentially to self-destruct
by admitting a single… – Don’t like blue. Pink’s their colour.
– No. Absolutely. So the blue light kills the… ..depresses the amount of bacteria
on the surface of the skin, and then we follow that
with a red light, which decreases the inflammation in the skin
and also promotes wound healing, so putting those together. It’s done in a course
and it needs to be… It’s about client-selection too,
so you wanna make sure you’ve got the client right for that,
but it’s very good for hormonal acne. And how long before you
sort of pulled through the… ..what it did to your self-confidence
and your psyche? Um…
As soon as it starts getting better, you start feeling better about yourself. It’s something that, um… the moment
you start seeing improvement, your whole outlook changes. It’s an incredibly depressing disease. And skin care – what sort of
skincare tips have you got? It’s about… It depends on the acne. So what is right for somebody
in their teens, is certainly not gonna be right for
somebody in the 30-plus age group – it totally depends on the individual. And that’s where we come in
with a little bit of guidance as to what… wading through all that
cosmetic confusion out there. Right. So I don’t need to change
my make-up just yet? – Not just yet.
– OK, OK. Parker, what do you… do you feel
uncomfortable with this light therapy? Is it all mumbo jumbo
or is there something to it? Ah, there’s… Excuse me. There’s certainly science behind it
and, um… ..light-based therapies
have been shown to work, especially blue light and blue-red
light – those wavelengths work in just the way Suzie says,
by inhibiting the P acnes in skin. But it’s pretty expensive, John,
so it’s not… (Laughter) Depending on the type of acne, benzoyl peroxide’s gonna be the cheapest
and best option for many people, especially teenagers,
but, as Suzie was also saying, in the adult where you want
that quick or good control, they’ve already spent a lot of money,
it does work well. For me, it won’t be my first line, but it’s been useful
in a number of patients. I think, Norman, too, that whilst there
is some evidence about light therapy, I think we should be cautious that our patients –
our customers, our clients – don’t think that light therapy’s
UV therapy, because there’s lots of those people
with acne that sit out in the sun,
thinking that sunlight and salt and all those things down by the beach, are gonna be the answer,
and they’re not. It’s probably one of the biggest myths
apart from chocolate. Probably. (Chuckles) It’s certainly a myth,
and in the work we’ve done, there’s certainly been
a widespread perception that… NORMAN: What other myths
and misconceptions are there? Uh… Well, certainly,
about chocolate, um, being a cause… As we’ll hear from your man in a moment, might not be entirely true about
chocolate – may be something to it. No, sorry, they’ve got that right. But there are misperceptions about
cleanliness being a cure for acne and dirt causing acne. And those misconceptions
are actually quite important, because they feed into
over-vigorous cleansing of the skin, which can be damaging. And tonnes of Phisohex being used
on a three-times-a-day basis. So, is this just one disease, John? I think with acne, there are probably
different types of people that… As mentioned by Suzie,
the teenager is different to the adult, and there is probably increasingly
a metabolic component too to a certain bunch of people with acne,
and for the more-severe acne it’s actually become more
an inflammatory disease or an allergy to…
– So it’s a different disease when it goes severe? There’s something…
It’s all centred round the hair follicle but it’s how the body’s reacting to what’s happening there,
that inflammatory component, and what drives that
will be a mixture of things. It makes it a different disease
to the mild… So the response may be different.
Take us through the basic pathology. OK. So with acne,
it starts during the adolescent years, you need those androgens around
sort of puberty to come through. And the first thing is
the pilosebaceous follicles make more sebum
and with that increase in sebum, there’s a change in the keratinisation
or formation of a keratin plug where the hair comes out. There’s other factors
that can make that worse such as soap, irritation, we’ll find out
later about insulin resistance, and even sort of
if you’ve got bad acne nearby, that’ll actually promote
comadogenesis nearby. So when the hair follicle blocks, there’s a build up of bacteria
or P acnes which digest and breaks down the sebum and a lot of the sebum is made up with
very proinflammatory things and also from the bacteria –
the propionibacterium acnes – it produces a lot of
proinflammatory agent as well. Normally that’s contained
in the hair follicle, comes out to the skin without trouble, but if that follicle gets distended,
it becomes leaky, those things leak out into the dermis
and you get those inflammatory lesions. So you just might be a reactor? You might be just a reactor, and if
you’re a mild reactor, it’s mild acne and if you’re a severe reactor,
you can get that scarring, cystic acne. And do we know if things
like smoking makes it worse? Do we know about alcohol… ..alcohol flushing can make…
What’s the story here? Um… I’d have to say with cigarettes, it can cause a different type
of trouble. It reduces important… Adults, they can get those
solar comedones that makes the solar damage worse, but when it comes to acne,
you can’t blame cigarettes. NORMAN: Damnit!
(Laughter) What’s… Give me a bit of background
to your research, Neil, because this’ll be a surprise
for many people watching. Well, first of all, I’m not
a dermatologist or a clinician – I work in the area
of nutrition biochemistry, and for years we’ve, as a group –
international colleagues and I – have been looking at
aspects of human diet that have changed –
i.e. the food composition we eat today – and the impact that has on
our physiology and biochemistry. And we’re particularly interested
in insulin resistance and things driven by high-carbohydrate
diets that impact on diabetes, but we come across
a connection to acne as well, and we started investigating that, so… NORMAN: How did you come across that? Mainly through our colleagues in the
anthropology fields that we work with reporting to us that the groups
they study round the world don’t show any acne while they’re eating their normal, hunter-gatherer type,
primitive diet, but as soon as start a Western diet,
they break out in acne, and it was usually associated,
they said, with consumption
of processed carbohydrates, starchy, sugary foods. So we started piecing
the bits together… Or it could be just a coincidence – the diet might not be
anything to do with it… Quite possibly, because
all the medical books tell you it isn’t. But that’s another story. We started piecing together the
biochemistry of what could be going on, and we believe we came up with
a very well-based hypothesis of what it might be,
and we tested that in a clinical trial, and actually showed… ..not only did we improve
the acne condition, as measured by dermatologists, but improved all those
biochemical parameters we suspected. Let’s just look at what you found. You actually studied insulin resistance,
you looked at… You’ve got some graphs to show us. NEIL: Yeah, if we can bring up that. Now, this is not our work – this is a work we studied
prior to designing our study, and we found a lot of studies
had been done that gave clues to what was going on. This one shows
what happens when you do an oral glucose-tolerance test
with young people and you compare an age-gender match
group with acne and without acne. So, not all people react the same – it does depend to a certain extent,
on your genes… NORMAN: What happens when
you do a glucose challenge… NEIL: Well, as this graph here shows, the two groups had virtually the same
glucose response over the two hours and people thought,
‘Well, it’s no different.’ And then if you measure the
insulin response simultaneously, which is shown here,
the group with acne always have a much higher
insulin response, so it’s showing that
they’re less insulin sensitive than the non-acne sufferers. So this started giving us clues
that perhaps acne, like diabetes, is about insulin resistance, and… NORMAN:
And that changes through adolescence? NEIL: Oh, absolutely.
Particularly during puberty, there’s a drop in
people’s insulin sensitivity – as you can see in this slide here –
in both males and females. So as your insulin sensitivity drops
during those puberty years, we call that ‘insulin resistance’. Temporarily, you go through
a period of insulin resistance as a teenager. Possibly because of growth hormones –
we’re not sure of the connection. NORMAN: And why should… So, again,
that could still be coincidence. So what’s the biological link then,
with acne, do you believe? NEIL: The next thing we discovered is there was work being done
on a growth factor called ‘IGF-1′, which is insulin-like growth factor 1, and we found, much to our surprise,
that this also peaks during puberty. And so we’re putting all this together
with other studies – we’ve observed studies on PCOS women –
Polycystic Ovarian Syndrome women – who have severe acne, and some of the American studies
were showing that the best thing that they responded to was metformin, which was increasing
their insulin sensitivity… NORMAN: Basically,
the drugs for type 2 diabetes. NEIL: That’s right.
And their acne was going away. Similarly, they were treated
with things like acarbose, which is an alpha-glucosidase inhibitor, which actually stops starches
being digested in your intestine, so your blood-sugar levels don’t go up
so quickly after a carbohydrate meal, and that actually
helped their acne as well. So how does the IGF affect…
What might be the… Well, before we did the study, we spent several years putting
all these pathways together and we came up with this hypothesis – and this our guiding hypothesis
that we actually tested – that if you’re insulin resistant – and these adolescent boys and girls
mostly are – they’re going to develop
hyperinsulinaemia after a carbohydrate meal. NORMAN: This is independent of obesity, ’cause there’s plenty of thin kids
who get acne. In fact, that’s the stereotype –
the thin, spotty kid. NEIL: We measure insulin resistance
in many young boys and girls, and often it’s the thin ones with
higher levels of insulin resistance, whereas, in older people,
it’s the overweight people. But, if you look at this diagram,
this is our hypothesis that once you eat a
high-carbohydrate load meal, you develop these high insulin levels
that stay around most of the day because they keep grazing on these
high-carbohydrate foods all day. NORMAN: As well as high-carbohydrate,
it’s high-glycaemic index. NEIL: Yes. Anything with readily
digestible starch, sugary materials and so on –
even a potato, it has quite a high GI, for instance. And what happens then, the high
insulin levels drive up IGF-1, so the IGF-1 levels start to go up. Part of that’s due to just an inherent
effect on IGF-1 production, but insulin also drops
the liver’s production of IGFBP1, the binding protein
that usually incapacitates IGF-1. So you have more free IGF-1. And IGF-1 is one of those factors that –
John alluded to before – can actually block
the pores in the skin. It causes the hyperkeratinisation
in the sebaceous gland which actually blocks the follicle. And, on the other side,
you’ve got… High insulin levels
actually reduce another binding protein which is a sex hormone binding globulin,
which binds up androgen hormones. So you’ve got more of those free,
so your FAI – your free-androgen index – goes up, and these free androgens then stimulate
sebum production in the skin. So you’ve got this dual effect – you’ve got the blocking of the gland
and this over-production of sebum, all being generated
by high insulin levels and IGF-1. And the acid test of this
is a randomised trial to see if you intervene and actually
change the diet, you get an effect, and you’ve done that in a small trial. We did that with about 50 or 60 boys
in a controlled study… NORMAN: How bad was their acne?
– Very bad. These were people referred to us
by our dermatology colleagues, that had come off Roaccutane
and other things for other reasons, and we recruited them into our study. It was a three-month trial,
so we had ’em for three months. We had some of the boys
on a natural food-type diet – low-glycaemic load,
so it was lots of vegetables, fruit, low-fat dairy foods, fish… NORMAN: Just what adolescent boys love. Yeah. We cut out all the things
like the pastries and the doughnuts and the sugary drinks. And the other group
ate their normal diet. And we saw quite a big difference
in the biochemistry of what was going on with IGF-1
and the binding hormones in that group
that was quite protective then, of acne, and their acne scores
dropped substantially. Hard though, to maintain in adolescence? Yes, it’s very hard to get
adolescent boys – free-living boys, living at home –
even with parents involved, to actually stick to that sort of diet,
so we did provide… NORMAN: No adolescent’s free.
– True. We provided a lot of their foods
to make sure they ate the right things, we corresponded with their parents, and I had two lovely PhD girls
who controlled the boys very well and got them to eat the right things. Yes, well, they can’t be
around forever either. So… So here we have a situation
with different diseases, different… ..maybe different routes
to the same problem and then reactions and the influence
of lifestyle as well. So this is the background. And, presumably, John Bell, you see people coming into your pharmacy
with the same myths and misconceptions, buying the wrong stuff over the counter. We do, Norman. Often they’ve… ..they’re predisposed towards
purchasing something, not only from the pharmacy but
from other outlets, by advertising, and there’s a lot of that, but… You’ve even got high-glycaemic foods
by the counter as well. Well, some of us do,
not all pharmacies – we’ve gone in for the lower GI products
these days. But, having said that,
as Parker was saying, there’s inherently, I think,
a concern that it’s poor hygiene that maybe causes acne
or at least is one of the causes, and therefore there’s sometimes
an obsession with abrasive scrubs to clean the face. There’s certainly a concern about food,
but maybe the wrong food. I’m not too sure whether Neil
answered the question about chocolate. I guess we can get low-GI chocolate,
can’t we? Yeah, that’s right. Chocolate’s not
really a high-GI food – it’s moderate. There’s worse things than chocolates – I’d take them off white bread
and potatoes before chocolate. We’ve got a question from a general
practitioner in Central Queensland, asking about ethnic differences here. Is this the story
that Neil’s been giving us, or are there true ethnic differences? Because… there’s a sense
that people from South Asia tend to be afflicted with acne worse
than other ethnic groups. I think, in answer to that question, I think Westernisation has changed
sort of people’s type of acne from the country of origin versus
Western countries like Australia, and often you’ll have patients
where there’s no family history of severe cystic acne or scarring acne, they come to Australia
from China, from Vietnam, and suddenly they’ve got scarring acne. And something has changed, and whether
it’s just diet, stress or other bits, we’ll discuss that. But I thought one other
sort of interesting bit is even, say, with Aboriginals whose diet is probably no longer low-GI
in many ways, that’s one group where,
when our college has done studies looking at the prevalence of acne
and severe scarring acne, it’s actually not seen in anywhere near the same proportion as in other groups
so there are some… Complex interactions. Can you predict
who’s going to progress to severe acne? So… I think there’s a few
warning signs where it’s more likely, so if someone’s got a family history
of severe cystic or scarring acne, if one of the parents has got scars
from their acne, you’ve got to be very careful
in managing those children. They might have
quite rapidly progressive acne, that will result quickly in scars. So, in some ways, those deep, tender
nodules that have come up quite quickly, especially with that family history,
or if they had mild acne as a teenager, but when they hit 19s, 20s or early
20s, suddenly their acne comes back… NORMAN: Blows up.
– That can be the more aggressive type. Let’s go to our first case study,
who’s Ramesha. And let’s see a picture of Ramesha
or a child like Ramesha. Parker, she’s your patient. So, she’s a 14-year-old girl, so she’s quite young to have acne
of that severity. We’re also told she has
nodular/cystic acne. She’s certainly got inflammatory acne,
and we’re told it’s nodular/cystic. It’s often… If you get up close,
it’s often better to appreciate that. In those circumstances, it’d be very
reasonable to start her on treatment, but you’re especially alerted
by her father’s history. A parent or another first-degree
relative who’s had scarring acne alerts you that she’s in danger
of scarring. So it’d also be reasonable
to organise her to see a dermatologist for assessment. What would you do for her…
apart from the referral? It’d be quite reasonable to go through
the whole situation – her situation – find out her circumstances and look at those things we talked
about – her perception of acne. But, with her, she really needs
treatment, as well as sorting that out, so it’d be quite reasonable
to start her on an oral antibiotic and topical treatment,
but to organise… get on the phone and organise
a dermatologist appointment. If she’d come into the pharmacy, looking
like that, what would you have done? We’d refer her to her GP
immediately, Norman. Yes. NORMAN: No messing around. No. no, that’s not the kind of patient
that we would feel comfortable recommending
a non-prescription product for. So she comes to you, John.
What do you do? Um… I think the good part is hopefully
we get to see her early, and the important part in this lady
is preventing her acne having an impact on her
at that young age and that crucial phase of development,
but also, later, to prevent the scars. The scars of acne can really affect
people’s self-confidence, their interpersonal relationships and even reduce their risks
of getting certain jobs, going for certain careers… Suzie, she’ll already be feeling bad
about herself at 14? – It can be devastating. Absolutely.
NORMAN: And it’s quite bad. – So what would you do?
– I think with this lady, I would be sort of quite aggressive
in the treatment. There’s warning signs,
as mentioned by Parker, that she’s at great risk of scarring, so if the antibiotics
have worked really well, and often that lead, lag phase of
a few months to see the dermatologist… So is there evidence
that antibiotics help? Yes. No, there is good evidence
they work, and often they can work well, especially with that sort of
inflammatory acne. – Um…
– Do they need to be oral? And for the face, actually, topical
products are at least as effective as the oral antibiotics. So some of the newer
combination products, which combine benzoyl peroxide
and an antibiotic, are at least as effective as an oral,
so often I’ll reach for those first, before going for a systemic agent,
in that there are a lot more controversies
regarding oral antibiotics. So, antibiotics – benzoyl peroxide or
salicylic acid, what’s the story here? Um… I think if someone’s on
an oral antibiotic or antibiotic, it’s actually good to combine it with either benzoyl peroxide
or salicylic acid because that actually helps
reduce the risk of resistance. Both salicylic acid and benzoyl peroxide
have antimicrobial activities. They open the hair follicle and make it
unfriendly to the bacteria as well. Actually, anyone I’m putting on
an oral antibiotic, I’ll still try and push
one of those options as well. And so,
if people have very sensitive skin, I’d probably go
more towards salicylic acid whereas people with more
the teenage skin, the benzoyl peroxide’s
a good way to go. John, would you start this young lady
off on a combination topical, or would you begin with
a retinoid or benzoyl peroxide? Would you go straight
to the combination? And I think with this lady,
if she’s quite young and her acne’s rapidly getting worse,
I’d actually be sort of… ..if the oral antibiotic’s not working, I’d actually be probably
looking towards Roaccutane if she came back a bit later
and she really wasn’t getting better… So you’d give her an oral antibiotic
from the start? And I think it’s always good
to give it a go ’cause sometimes it might settle down
and clear with that oral antibiotic and it might be good for a while. So, I’m not getting it clear here. So, she might have come to you
from Parker on an oral antibiotic, but you might change to a topical
antibiotic/benzoyl peroxide combination? I must admit, in this lady,
I’d actually have a low-threshold to put her on Roaccutane ,
to turn it off, clear up the acne
and prevent those scars. So you jump in early here? I would sort of, um… And what are the current criteria
for the prescribing of Roaccutane? Roaccutane’s prescribed – or isotretinoin – when other agents
are failing or not doing well, and traditionally
it had meant an oral antibiotic, but my interpretation now
is that you can have one of those combination topical products,
which work just as well. So it’s good to try
one or two things first. And it’s still a dermatologist-only
prescription? But I suppose in country or rural areas,
there will be other sort of doctors or paediatricians accredited to
prescribe Roaccutane or isotretinoin. So what’s the schtick here? What’s the informed consent,
what do you have to do? This child will need the pill,
won’t she, if she’s menstruating? I think at the age of 14, it needs to be
definitely very well discussed and, um, the oral contraceptive
would be a preferred agent. Um… there are a number of issues
with oral contraceptive, but sort of going through studies, say,
in Western Sydney, the risk of a 13 or 14-year-old
being sexually active may be up to sort of 28 or 32%,
so that issue needs to be addressed and preferably you want them
stabilised on the pill for two cycles before considering
Roaccutane . Could the pill help her acne? And the pill can work well for acne. Unfortunately, it takes
three to six months to kick in, but the pill can work
for quite severe acne…. All pills or just some? So, the cheaper, sort of older agents
with high-dose levonorgestrel tend to sort of worsen acne
unless someone’s got an irregular cycle and just regulating that cycle
can be useful. Then the most effective pill
traditionally, have been the cyproterone
acetate-containing pills, which, unfortunately,
take a while to work, and they go most with
weight-gain, mood-change and probably have
the higher risk of clots, so nowadays the newer but
more expensive contraceptives containing drospirenone or dienogest,
such as Valette, Yaz or Yasmin, are probably the most effective ones
for reaching to with the lower doses. John Bell, this could be
an expensive process for people, the treatment of acne,
’cause it’s not all covered. It’s not all covered, Norman, no. And, um… I mean, the products
that John’s been talking about, the topicals are not PBS-subsidised. The Roaccutane is, provided
there’s an authority, of course. Um… but we’re looking at
maybe between $30 and $50 for a course of treatment, which would could last
for a couple of months nonetheless. Maybe not too different –
not so much more anyway – than a PBS prescription, but for a concession card holder, there
is a significant difference in cost, so that needs to be discussed obviously. What I’m hearing here –
the message here with Ramesha is you won’t mess around –
you’re gonna get in early. – I think…
– The parents say they’ve read awful things about Roaccutane –
children commit suicide, your skin peels, you get headaches. What’s the story with side effects
and complications of Roaccutane? And I think it still remains our
most effective medication for acne, and it doesn’t work for everyone, but
it sort of works in all types of acne, and it works best for the more severe
or cystic and scarring acne that… For the mild acne, it’ll clear it up
without the remission, but in this sort of patient,
she’s one of the type of patients most likely, with one or two courses,
to be cured of her acne. What’s a course? How long’s a course? In the past it used to be
a high dose over four months, but these days we generally
go a bit slower, a bit more gently and do it over seven or eight months
on average, for a dermatologist, and, that way,
it’s not quite as harsh on the body – skin doesn’t dry out,
not at risk of hair falling out, or they get used to putting on
moisturiser and things like that. So these days we are bit more cautious
and starting at a lower dose – you’re a bit more likely
not to get a bad flare. Um… But I think the big controversies
with Roaccutane, telling someone
it can cause birth defects can really worry the whole family,
‘This is pretty toxic.’ Um… But it is just really
a high dose of vitamin A, it’s out of your body in sort of
five days from stopping it, but if someone does get pregnant
on Roaccutane it is a disaster, and that usually means an abortion,
which comes with many concerns, like later depression
and maybe trouble with fertility even. But I think the big thing, I suppose,
with Roaccutane controversies, which have been useful
to highlight acne issues, is just the controversy
regarding mood and depression – that acne itself
can really get people down – it is associated with depression
and even a higher suicide rate. And I think if people do any search
on the internet with Roaccutane, it will highlight there’s been
people who on Roaccutane, have got depressed
or even committed suicide, and reassuring them
when you look at the cases, there have always been
multiple factors involved, and a lot of areas where
intervention could’ve been done. But I think the important part
in anyone with bad acne is warning
both that patient and the parents what are the signs of depression. So, do you ever send off
a child like this for cognitive behavioural therapy,
to see a psychologist to help them through psychologically? And I think when you sort of talk about
these patients with psychiatrists, in that if their acne’s
a big reason for their depression, most people are gonna say
‘Treat their acne and that’ll make a big difference.’ But I think it’s those patients where
they do feel down for no reason or do go flat… NORMAN: So you want to assess
their psychological state. Parker, you wanted to say something? It’s worthwhile restating that
you might go online, the internet, and find a whole lot of evidence
for the effect of isotretinoin on suicide and depression, but in fact, if you do a Medline search,
there’s no evidence. It’s all anecdotal stories. What evidence we have is that
there’s nothing linking isotretinoin to depression or to suicide. It’s biologically plausible, and it may be that
it’s a rare idiosyncratic reaction, but that’s only anecdotal. What we do know is that studies
have shown that treating patients with Roaccutane
actually makes their depression better. So there may be rare
idiosyncratic cases, but it’s not something
that should not stop us, or should have parents
concerned about their kids. NORMAN: Suzie?
– Absolutely. With Roaccutane, too, I think it’s something that
there’s a lot of information out there, as you said, that certainly makes people
very wary and very cautious of it. But with the right patient,
if they need Roaccutane, that’s the only thing
that’s going to help their acne. So that real, severe, nodular cystic
acne with the risk of scarring, there really is no other option. Some people believe that light therapy
can modify the flare. I think, actually… with Roaccutane,
one of the risks is you can get a bad flare
before you then improve. That sort of patient,
I’ll start concurrent antibiotics, but I’ve actually found
the light treatment really good to help prevent that. So, we’ve got a few questions coming in. A nurse from Rockhampton asks, ‘What validity is there
for some of these home remedies? Toothpaste on pimples, hot flannel
to draw out the pus.’ Yum, yum. ‘Sulphur to dry it out, extraction of
blackheads at the local beauty salon.’ NORMAN: Suzie, anything to any of these?
– Well, you got to be very careful. Anyone who says…
we often get clients in, and we say, ‘Do you pick at them?’
And they say, ‘No, we definitely don’t.’ But in truth, almost everybody does. So, it’s all about client education,
or patient education, making sure you get to
the heart of the matter with it. So ‘popping the plook’, as we used
to say in Glasgow, is not a good idea? Not a good idea at all, but they’re
definitely, definitely going to do it. So it’s a way of making sure that
you give them the information on… There’s all sorts of little devices, little easy-squeezes
and things like that out there. – Generally, we…
NORMAN: Steer clear. We try and tell our clients… The hot flannel seems to be a nice idea. I suppose it softens it up a little bit. I don’t know that there’s a lot
of evidence that that would help at all, and as far as toothpaste goes,
that’s a new one on me. – Depends which sort.
– Yeah, it does. Rural Victorian general practitioner – ‘How’s acne best looked after
in pregnancy?’ John Sullivan? With pregnancy, often actually
one or two babies are very good for the long-term improvement in acne. And that might be one reason why
hormonal acne and female acne has become more of an issue. During pregnancy, often
the first trimester, acne gets worse. Second trimester it starts to improve, and hopefully clears
during the third trimester. So it’s just that first period
that it’s usually an issue. My favourite sort of one… sticking to,
you know, what is very safe, and I’ll start with the topical agents –
things such as benzoyl peroxide, clindamycin,
or combination of the two such as Duac. And, say, if it’s more widespread,
erythromycin’s the only sort of systemic oral treatment I’d use. – But I’d have to say…
NORMAN: Salicylic acid’s OK? Salicylic acid, at least
not in a large amount. So if you’re doing a widespread area,
I’d say no. But just for the face,
the 2% products would be OK. This’ll be one area where I do think
light treatment’s another good option if those things are failing. Light treatment can be very good
short term, to get good control. – We don’t do it when they’re pregnant.
SULLIVAN: The laser or the light? No, the LED. All light-based therapies
we don’t do when they’re pregnant. – So, yeah, it’s very difficult.
SULLIVAN: Playing safe? Yeah, playing safe, and generally, they don’t want to use anything at all
anyway, even though we can… A low-glycaemic index,
that’d be alright if you’re pregnant? Probably, but I tend to err
on the safe side, not try to interfere
in pregnancy situations at all. I think women and their diet
is up to them. They’re under enough stress. Norman, I was going to say,
although erythromycin is obviously the best choice
in terms of an oral antibiotic – I mean, we wouldn’t use a tetracycline – the estolate, erythromycin estolate,
is not suitable for a pregnant woman. It’s likely to cause
cholestatic jaundice. So we use the erythromycin base. Good. That was a good question,
so thank you for that question. A nurse in central New South Wales
asks – a patient of hers has PCOS,
Polycystic Ovarian Syndrome, and complains of excess oily skin
before her periods. Does the build-up of this oily skin
inflame acne? Should she blot the oily skin? Well, there are a few questions there. Unfortunately, people with oily
or seborrheic skin, they’re more likely to have
that persistent and ongoing acne, and they’re one of the ones
that won’t do well with Roaccutane, and they’re the ones where you’re going
to have to do that long-term strategy. I think, definitely, look at the
low-GI diet as much as you can there. With someone who’s, say,
overweight and polycystic ovaries, that’s where metformin’s a good option,
and that… NORMAN: That might help the…
– The oiliness. After three or six months,
that can kick in. Unfortunately, in that situation, often the oral contraceptive pill
doesn’t work that well for it. Something like the benzoyl peroxide is
not bad, ’cause it dries out the skin, and will get rid
of some of that oiliness. Usually in an adult,
the skin can be quite sensitive, but that sort of patient will usually
tolerate benzoyl peroxide well. And just make sure she’s using
white towels, not the coloured ones, for the benzoyl peroxide. Linda in Wagga asks,
‘How do we convert the findings from Neil Mann’s research
on diet and acne to effective health promotion
or patient education?’ Parker? PARKER: I think that’s
a really good question because Neil’s study was done in
people with really quite severe acne, and that’s not the kind of people
that we see most of the time. And normally we’re very careful about extrapolating those results
to our patients. But in this case,
I think it’s a no-contest. What we’re advocating is basically
something that may well help them, even though it hasn’t been shown
in this particular group. It’s likely to help them, and it will do a whole lot
of other good things for them. So, look, there’s no doubt that
you really should be encouraging it. The question is – how can you convey
to your patient the benefits? So, some patients will be so motivated
because of their acne that they’re going to adopt, really,
what’s a fairly strict diet, which is what you’re going to need
if you’re doing what Neil did. Some kids probably
aren’t that keen on it. So, again, it’s a matter
for negotiation. But I think it’s a no-contest. You really should be
trying to stress that. Yeah. And, Neil, we don’t know
about exercise, ’cause exercise can change
your insulin resistance. It could, but our study
didn’t involve exercise. Being a clinical, controlled study,
we have to keep everything constant, except the one thing
we’re trying to experiment with. So we don’t know the answer to that. But just to reiterate what Parker said,
it’s a type of dietary approach. It’s not going to do any harm. We got all sorts of other improvements
in these young people as well, including lower triglyceride,
lower cholesterol. They met their RDIs
for all their micronutrients much better than they did
on their previous diet. So, it’s a win-win all round,
even if their acne isn’t cured. There’s a lot of other health benefits. Another question from Michael in Cairns asks, ‘Does humidity have any effect
on acne?’ The further north you go in Queensland,
does it get better? Michael should know the answer to that.
He comes from Cairns. I suppose there’s definitely
sort of a tropical acne. So when you get to the extremes,
just the oedema and that can sort of help contribute
to blocking of the hair follicles there. Other bits can be sort of sweating. Friction and that can cause acne in
other places like on the back and that. But, I think, the big thing besides
the difference in humidity, just really change what sort of topicals
you choose, and also sunscreens
and other sort of skincare products. And that sort of patient, they’ve already got sort of
quite sweaty, moist sort of skin. You’re definitely won’t be using
heavy products. You’re going to be having
various light sunscreens, gels. And often it might be the heavy,
occlusive sunscreens, or irritant sunscreens that can bring
out acne in that situation. That’s what you spend a lot of time
advising people on, Suzie. Yeah, definitely.
Generally, sunscreen is something most people with acne tend to avoid, ’cause they’ve just got
this misconception that it will clog their pores,
yet it’s very important, obviously with… you know, with our sun here that we obviously
need to protect our skin. But even more so if you’re suffering
from acne, because as your skin’s
healing from the lesion, it’s very prone to damage
from UV-A and UV-B – from collagen and elastin destruction. So you definitely need to protect that. But using something like
a physical blocker, like a zinc, which is very calming
and anti-inflammatory, is good. But, again, in a humid environment
can be a little bit clogging. So, if you can get something, as I said,
in a gel is fantastic. Now one of the better sort of sprays
or lotions or gels actually are by J&J. Helioplex has the best
UV-B, UV-A protection. It’s very photostable. Great with people
on Roaccutane, tetracyclines. But it won’t clog the pores
and it’s not irritant, so that actually is the best… Ask your friendly pharmacist
for those gel preparations. Absolutely, Norman. Let’s go to your second case study,
who’s Dianne. 17 years old, rural New South Wales, presents to Parker, her general practitioner. She has open and closed comedones, with early evidence of inflammation. Her naturopath recommended a liver-cleansing diet to reduce toxins throughout the body. She stuck at that for seven days, but she thinks she’d better come along for some advice. When you ask her, Parker, she tells you she washes her face three times a day, and she’s pretty well made up when she comes to see you. That’s not an unusual situation.
Two things there. One is a situation
Suzie described earlier of trying to hide behind the make-up, and it can actually be making
things worse. The second thing, again,
is that… the face cleansing. A particular concern there is not
just how often she’s cleaning, but… NORMAN: What with.
– What with. And how vigorously she’s abrading her… This is an inflammatory condition. If you go abrading,
it’s going to make it worse. So, I think, the first…
and also a liver-cleansing diet is not something that’s been shown
to work with acne, and there are things
that have been shown to work. So I think we need to gently
go through her perceptions, and talk to her about how her approach
to this is going to be, and that’s going to involve… Although, Neil, it’s not very
high-glycaemic index. In fact, almost nothing. Yeah. Look, as a physiologist
and biochemist, I’m very sceptical
about liver-cleansing diets. There’s no real proven result
at a biochemical level. But it could inadvertently
be doing some good, because that type of diet does tend
to be very low-glycaemic index, low-glycaemic load. So you might be getting some
improvement, but for the wrong reason. And too restrictive. But anyway,
sorry, Parker got interrupted. I think that’s important,
because some kids do come in on quite restrictive diets,
that through misconceptions they’ve abolished milk products. So their calcium intake is suboptimal. So I think it’s important to go to her
and talk about… You use Neil’s study as an example
that actually… NORMAN: There is a way of eating
which helps. A way of eating that’s good for your
acne as well as the rest of your body. But the other thing with her is to go
through that and negotiate that. And depends on her priorities
and how fast she wants to work on this. Given some of the hints we’ve got there, she may be keen to get cracking
straightaway and be giving her medication. I think the first thing
is to stop the things that are actually making things worse. So, let’s just, John, have a look
at some pictures of grades of acne, and just see where Dianne
may sit on this. SULLIVAN: With Dianne, she’ll fall
somewhere between these two, the Grade I and Grade II acne. With the Grade I there,
you’ve got the comedonal, or relatively non-inflammatory,
where you’ve just got the blackheads, and/or some whiteheads. And it’s the whiteheads, largely, that
progress to the inflammatory ones there. But as you can see, there’s a mixture
of whiteheads and blackheads causing the inflammatory lesions
on the right. And the big thing for patients, I mean,
they all notice the blackheads, but the inflammatory lesions
can fluctuate quite a bit, and they’re the ones
that are most noticeable. So that’s the sort of thing you want
to try and control and prevent. And, fortunately,
for this sort of acne, the topical and good skin care
can make quite a big difference. NORMAN: Before we get on
to Dianne’s management, let’s go to the more severe grades
of acne to remind ourselves what they look like. SULLIVAN: As acne, sort of,
gets worse with severity, No.1, it can involve a bigger area. So extending from the face,
onto the shoulders, maybe onto the chest, back and
for the more severe, down to the thighs, and that can just be the lesion count. So, a few comedones,
through to a lot more. But the severity of the acne of the acne is mostly to do with the severity
of inflammation. So, as acne gets more severe, you go from, sort of, small,
slightly inflammatory red papules to ones with sort of pustules,
right through to cysts and nodules, and then you can get these
quite complex, sort of, scarring, and inflammatory changes,
as in the Grade IV there. So, Parker, she might be pretty
psychologically knocked about with her acne, but it doesn’t have the urgency,
necessarily, of Ramesha’s condition medically. Medically, it doesn’t have
anywhere near the urgency, and providing psychologically she’s OK, I think you can start talking about
using topical medications. With inflammatory things like that,
there’s a choice. You’ll probably find she’s already used
benzoyl peroxide over the counter. So you can find out if that helped.
Is that something she’ll continue with? Are you going to add in
a topical retinoid, etc? How do you decide about salicylic acid?
‘Cause that can be quite effective. Yeah, salicylic acid is an option, and
that can be used as first line as well. NORMAN: What strength?
– I think it’s 2%? SULLIVAN: Just 2% allowed, yeah. So the key here, John,
is that it stays on… you’ve got to prescribe something
that stays on. I think when you look at the studies
looking at the cleansers, if they’re going to do something, it’s
fairly minimal and not a big difference. The most effective products
are the leave-on products. So what are the formulations,
John Bell, that we look for there, for stay-on salicylic acid,
stay-on benzoyl peroxide? Well, as John mentioned there, there are washes containing
salicylic acid and benzoyl peroxide which are probably not going to do
any much more, and maybe even counterproductive
in terms of the other option, which would be a gentle,
non-soapic cleanser, something like QV Wash or Cetaphil. In terms of the stay-on products, benzoyl peroxide begins at 2.5%
and goes up to 10%. But there’s no evidence
that the 10% product is any more effective than the 5%,
but it’s certainly more irritating. You can get creams? You can get gels?
What’s the technology here? Sure. The gel for really oily skin
would be much more suitable. If the skin tends to be very dry,
then the cream would be satisfactory. But benzoyl peroxide
is generally in a gel. Some of the prescription products,
like adapaline, is available in a gel and a cream. NORMAN: That’s the retinoid? That’s right. That’s one
of the retinoids, yeah. But… Is there any evidence that
that’s any better than tretinoin? Um… no. I think that they’re probably
much of a muchness, and I think it’s just a matter
of what a GP or a specialist would have a personal preference for. I’m actually confused. Give me a protocol here.
I want a protocol. And something that’s systematic,
because I think the risk here, as a general practitioner,
is you do what the patient does – a little bit of this
and a little bit of that, and you’re not systematic
about how you approach this. What’s the systematic way? Do I start with benzoyl peroxide?
Do I start with salicylic acid? How long do I go for?
Do I escalate the dose? What’s the advice here?
Give me concrete protocols. Dr Sullivan? I think, for this lady, her acne
is mild, as suggested there, my choice between salicylic acid
or benzoyl peroxide would be if she’s got sensitive
or easily irritated skin, I’d go for the salicylic acid. But if it’s more oily skin
and she’s had no trouble with eczema, either one would be OK and I probably
would reach for the benzoyl peroxide. NORMAN: In what formulation? So, as mentioned, I wouldn’t go
for the 10% or even 5%. I’d usually sort of be around
the 4% or 5% with the benzoyl peroxide. NORMAN: And how many times a day? Usually you have to start once a day. Once you get up to twice a day,
there’s more risk of irritation, patients getting frustrated
and giving up on the treatment. So it’s always better to start slow. I always think, if once-a-day benzoyl
peroxide isn’t working well enough, I’d be looking to maybe seeing a GP
about what would be the next option. You could use it alternate nights,
couldn’t you, John? Just for the first week or so. And especially sensitive skin,
start second nightly, and as you said, be careful
with your white towels. And how long are you going to wait
before you escalate ’cause… ..before you escalate,
it’s not being helped? It’s going to take longer
to actually have maximum effect. But if you’re not seeing some effect
in four to six weeks, it’s reasonable to go up
the next step. NORMAN: What’s the next step?
The protocol. Well, I mean,
there is a step-type approach in the dermatology therapy guidelines,
which is topicals. This current set, they’ve changed
and had retinoids as the first line, and then second line topicals – topical
antibiotics and benzoyl peroxide. So they’d start a combination,
benzoyl peroxide-retinoid, earlier on? No. No, they’d start with a retinoid,
and then if you’re not getting control, add the morning topical antibiotic
or topical benzoyl peroxide to the evening retinoid. I think that’s probably not practical in that everyone’s already used
benzoyl peroxide before they get to you. So I think there’s flexibility to talk
through those options with the patient. And how do you approach this? ‘Cause this’d be the sort of
typical person you’d see, Suzie. Yes… (Clears throat) Excuse me.
It certainly would be. First thing we would do is make sure
they’ve seen their GP. Because with a client like this,
we often want them to talk to their GP about possibly talking to them about
the oral contraceptive pill as well. That is an option, though I understand
that it does take quite a bit of time
before they see the effect of that. That’s often the first point. We like to break it down to
‘What are you doing every day?’ So, what are they washing
their skin with? Are they using sunscreens?
Are they using moisturisers? The thing about starting
on the retinoids, I think, is compliance with the client, because with the patient,
it makes the skin quite red and irritated
when you first start using them. And in this age group,
they’re often going to stop. Anything they perceive as making it
worse, they’ll stop straightaway. So, just making sure you can give them
an appropriate moisturiser to counteract the fact
that they are very dry… NORMAN: What’s an appropriate
moisturiser? Something that’s very light. Sometimes a lotion
rather than a cream is better. That’s something we often give
advice on – on those sort of things. And also, again, this lady’s…
this young girl, sorry, has come in with her mum, and she’s wearing
some quite thick make-up. That’s something that we… NORMAN: So, heavy foundation.
What do you recommend for make-up? Look, I mean, it’s the lesser
of all the evils, I think. We usually recommend
a pure mineral make-up. NORMAN: That’s the powder stuff. It is powder,
but it doesn’t contain talc, and talc is a very refined powder
that sits in the hair follicle. Usually contains zinc
and titanium dioxide, sits on the surface of the skin
a little bit better. Most clients see almost… within a
couple of weeks, a change in their skin, less comedones because of that,
less inflammation because of that. So ideally no make-up.
If you’ve got to wear it… It’s unrealistic.
It’s just so unrealistic. Because you’ve got to make sure this
young girl feels good about herself. So it’s giving her the options
of using a better make-up, rather than no make-up, ’cause for her,
no make-up’s not an option at all. I think I wouldn’t reach
straight for retinoid in that situation. The big trouble with retinoids,
as you said, they take a while to work. You’re looking 12 or 26 weeks, and
they’re going to be frustrated and slow. So it’s actually one of the best times
to use antibiotics short term, ’cause that will settle the acne
more quickly. It actually improves your tolerance
to retinoids, so you’re less likely to get irritation. By the time the retinoids are kicking
in at 12 weeks, their acne is good. You stop the antibiotic
and they’re tolerating the retinoid for their long-term control. In that situation, I think, antibiotics
are good in that short-term… So you’re using them concurrently. When you’re starting a retinoid,
often if they’ve got moderate or inflammatory acne,
I’ll start the antibiotic, an oral one, oral topical,
in that first three months. Let’s go on to our next
case study involving Jennifer. 30 years old. Recently ceased the oral contraceptive. Wants to get pregnant. She’s developed severe acne to the jaw area, mainly papulopustular. Some cysts. It’s red, it’s inflamed, painful to touch, and she’s still not having any success at conceiving. Parker. Well, that’s a description
of post-adolescent hormonal acne, and coming on after ceasing the pill
and then having… She had irregular periods, didn’t she? You’d be quite suspicious
that that may be polycystic ovaries. NORMAN: What would you do for her? In terms of her acne… NORMAN: She won’t be wanting
to go back on the pill. Beg your pardon? No. No. You’re limited in that
she’s trying to get pregnant, and we’ll leave aside for one moment the management
of her polycystic ovarian syndrome. But her wanting to get pregnant,
she can’t go back on the pill. If she is quite likely to conceive,
despite her sub-fertility there, you’re not going to be wanting to use,
or you’re not able to use, a great many of the treatments we’d use. So, again, I’d be using benzoyl peroxide, salicylic acid
as the topicals. And if she had to have… if she
did require systemic treatment, erythromycin is the antibiotic
of choice. NORMAN: It’s an awkward one. I think, the other bit adding here, this
patient’s going to have sensitive skin, that the female adult…
especially on the lower face. You’ve got to have
a very gentle cleanser. And my favourite product, actually,
would be combining a topical antibiotic
and the benzoyl peroxide to improve tolerance and safety
and control. It’s the clindamycin combo
you were talking about earlier. Clindamycin and benzoyl peroxide,
either in a fixed combination, Duac or the two prescribed separately. NORMAN: How do you…
how often do you apply that? The good part is
with a fixed combination, it works better than twice a day
of the individual products. So it’s just once a day.
Generally I’ll do it an hour before bed, so they don’t rub it on their clothes,
on the bedding, so they’ll have less trouble
with bleaching. Once a day is usually quite practical, and spot treatment if required
with the same product. – John Bell?
– Yes, I agree. That’s the most appropriate treatment. We talked earlier about the antibiotic,
oral antibiotic, if necessary. But certainly in the first instance,
the Duac-type formulation, I think, is the way to go. Suzie, what would you do in general
sort of…? Well, in general, it’s about
nothing too harsh on the skin. So, your over-the-counter products
that might work for a teenage skin are going to irritate her skin no end. But most importantly, it’s about… She’s got an awful lot
going on in her life, so for us initially, it would be just…
in our consultation… NORMAN: Let her vent.
– Absolutely. Yeah, unburden. You know, we see a lot of clients like
this that have come into the clinic. Very, very low self-esteem,
difficulty in maintaining eye contact, a lot of frustration at why
this is still happening to them, a lot of confusion about
what they should be using, why they can’t use what they used
to be able to use on their skin. Their skin’s definitely different. But most of all, they feel relief
at finally being able to unburden it. So it’s a very… For this particular lady,
it would be an exceptionally… Oh, it would be devastating. And you’ve got some pictures
of treatment of a woman like this. A very, very similar client to this.
Her name’s Lindsay. She’s a lovely client of ours
and when she came in… NORMAN: So this is a typical picture… SUZIE: Look, to a lot of people,
that’s not particularly severe acne. To this lady,
it was absolutely life-affecting. So it was… her self-esteem
was very low. And through a course of treatment
with her, she’s virtually come full circle. For her, it was about
getting her ready for her wedding. So we had a goal in mind. There, she’s still got a few
vascular scars, but, you know, hardly any lesions left. So, for her, a really lovely outcome.
She was ready for her wedding. NORMAN: That’s using light therapy?
SUZIE: Using a combination. Good skin care, advice…
got her on to some good make-up that was appropriate for her,
and light-based therapies, yeah. NORMAN: How expensive are they? The light-based therapies
can be more expensive. We usually use them
as sort of a last resort. We’ve tried everything. This lady had been through… similar
to myself and had tried everything – the antibiotics, over-the-counter
products, and nothing had worked. Expensive. Usually a course of treatment
is about 800 or something like that. We usually do a course
of eight treatments over four weeks, so we see the client twice a week. And then, after that,
we usually see them once a month. It takes about four or five months
to really get good control. Our aim is realistically to get
to the point where our clients have… they get one or two pimples
every now and then, one or two lesions, but other than that
they’ve got great control. This age group,
they’re more likely to take on the dietary advice
that Neil suggested as well. They’re so compliant. They’re ready. Whatever you tell them to do, they’ll
do. They’re just ready for the answer. They don’t want any more. Let’s go
to our final case study, who’s Gregory. 22 years old, distant Aboriginal heritage. He lives in a remote community in southern Queensland, and works part time as a builder’s labourer. He suffers from severe acne – nodular and cystic characteristics. He’s had it for about six years. It’s affecting his back, neck, face, chest, and they’ve left, it’s left, atrophic and hypertrophic scars. It really has knocked him about psychologically, and he has become really withdrawn, and has never seen a dermatologist. Parker? The dermatological part of this patient, he requires things
that I can’t provide for him. So he needs an urgent referral
to a dermatologist, and I’ll help deal
with his psychological issues. – But he needs isotretinoin.
– So what are going to do for Gregory? I think we discussed earlier
that this sort of patient, Roaccutane is the treatment of choice,
especially if done early. So, he lives well out of the way,
country town. The dermatologist has, you know,
an eight-month waiting list. What’s the GP going to do? I think with this patient,
it is good to start the antibiotics. I always like combining
Roaccutane with… ..or isotretinoin with erythromycin
to help prevent that bad flare. So if you’re going to start
an antibiotic, something like erythromycin is
a good one to start on this gentleman, and fast-track him in to see
a dermatologist. And for this sort of patient,
it’s females who have most issues in prescribing isotretinoin
with the pregnancy prevention and risks. This gentleman, hopefully, is going to
feel much happier as his acne goes away. And how much will you be able to do
for his scarring at 22? Unfortunately, once you’ve got
the bad scarring, particularly on the chest and trunk, our treatments aren’t very effective,
and time will only improve them a bit. The most important part would be to try
and get this sort of patient early on. But for his face, with his scarring,
we could do quite a bit to help. And what can country GPs do,
if it really is difficult to get access to dermatologists,
even for an urgent case like this? Hopefully, in sort of areas
where there is no dermatologist, there will be sort of some paediatrician
or someone in the area who’s quite familiar and comfortable
with prescribing isotretinoin. So, hopefully, in most areas,
where there is a need, there’ll be someone
you can work well with… Of course, in Queensland and some other
areas, you can get teledermatology. And there’s definitely a few areas
where it’s supported, and if you’re having trouble, it’s often
good just to call our college to ask, you know, who in area could help out,
is there an outreach service. Hopefully,
we’ll have more and more with time. So, talk me through scarring in acne. OK, so the big thing with scarring,
prevention’s the best treatment, and seeing people early, or referring
ones who are at risk of scarring. We mentioned before
people with a family history, with a severe nodular cystic acne, or acne that’s been quite inflamed
for more than two years are another group. And once you get scars like these… Um… so the first picture there
is of the ice pick scars. NORMAN: That’s not the scar,
that’s the nose we’re seeing. (Norman continues indistinctly)
..guessing games. SULLIVAN: The ice pick scars,
you can probably see them better on the right side, next to the box cars. The ice pick ones are the ones that are
like little sharp indents in the skin. Typically you see them
on the temples or cheeks, and, you know, for people
where their acne hasn’t been too bad, these scars are often
due to manipulation, or picking or squeezing of pimples. The first thing to do when you start
seeing these is tell the patient not to squeeze or manipulate
their pimples. And once you’ve got a patient
who’s doing that, you’ve got to be quite aggressive
in controlling their acne. This is also the sort of patient
where I’ll avoid any irritant topicals, or anything that gets their attention
to the skin. I would be looking at antibiotics,
initially, to get control, and/or hormonal treatments
and that there. NORMAN: What about other forms
of scarring? SULLIVAN: So with the other forms,
the box car ones are sort of like a punched out box. These, like the ice pick scars, are some
of the harder ones to treat with laser. Often they need to be cut or excised before doing laser,
to blend in the scars. But with these sort of more soft,
depressed or rolling scars, where you’ve lost the tissue,
collagen or elastin, it becomes a bit more lax. With time, these can age greater
than surrounding skin. So, often people who’ve bad acne,
when they hit 40 or 50, suddenly their face will start to sag,
and they suddenly feel old. So you’ll get another group of people worried about their scarring when they’re in their mid-40s. But treating those early and combining that with good sun protection… NORMAN: Just go back to those pictures there. The hypertrophic one. Just explain the hypertrophic one. Could you go back to that short there? SULLIVAN: With the hypertrophic scars,
where you get increased collagen in the area where
there’d been some cystic acne before, for those, they can be quite irritable,
quite tender, and they do very well with an injection
of triamcinolone or corticosteroids. You just got to make sure,
if you are injecting these, be familiar. Either get your dermatologist
or other person to help out, but on the face, never use something
more than 10mg/ml for a very bad scar, and for a finer scar,
you’re looking at say… NORMAN: So let’s double back and
go through the management of scarring. We’ve already talked about prevention, which is what most of today’s program
has been about. But scarring. What are the modalities? You’ve talked about intradermal
injection of triamcinolone, which is for the hypertrophic. The hypertrophic or keloidal one,
the injections… NORMAN: How often? Corticosteroids about every four
to six weeks until they flatten down, and the aim is to keep going
until they’re completely flat to help stop them coming back. That’s all people want on the trunk
and the shoulders. They’re the uncomfortable
or unsightly ones. You raise the layer beneath each lesion? You inject it into the solid bit,
make it go just a bit white, but make sure you don’t inject it
into the surrounding dermis or area. But for the face, if you’ve got those
soft, depressed or rolling scars, they’re the ones which do really well
with laser, and they’re the people that you could recommend to go and see
someone who does those treatments. NORMAN: What kind of laser? These days, the fractionated lasers
are sort of the main standard for treating most types of acne scars. It improves all the different types
of acne scars, except maybe the ice pick one
and box car one as much. NORMAN: Is that covered? Unfortunately, all fractionated laser
is not subsidised by Medicare for acne scarring. The only laser covered
are more the old-fashioned resurfacing, or carbon dioxide,
or resurfacing erbium laser, and they do work well
for the very bad or severe acne. But they have a lot more downtime,
it really takes a few weeks to heal. You’ve got redness. That’s really quite an aggressive peel,
Suzie. Oh, essentially it is, yeah.
It’s resurfacing. But that’s where fractionated lasers
are a better option. There’s less downtime for the client. You certainly do need to do
a few of the treatments, but it means their recovery
is a lot better. You’re at far less risk of
postinflammatory hyperpigmentation, which means we can treat clients
with darker skin types as well, which previously have had
some pigmentary changes with ablative resurfacing. So it’s certainly opened up a whole new
scope of options for darker skin tones. NORMAN: What about chemical peels? SUZIE: Chemical peels aren’t really used
for scarring very effectively anymore. Again, too much risk of
postinflammatory hyperpigmentation, poor wound healing, things like that. So it’s definitely something
where fractionated lasers seems to be the gold standard. – But how much does that cost?
– It can be quite expensive. So, a treatment of fractionated lasers
for a full face usually is about 1,200, 1,250, something like that. NORMAN: Is that one…
– One treatment, yeah. NORMAN: Just one sitting
in front of the machine? And how many would you need to
actually… Depends how bad it is. Depends on the extent of the scarring. Usually about three to five treatments,
depending on the scarring. Hm. So this isn’t for the Gregorys of
this world, who are builder’s labourers? Something you could save up for. So this is something, really,
to consider. Do you get a lot of patients wanting it
and not being able to afford it? Personally, I haven’t had
a lot of patients wanting that, but again,
it depends what you’re seeing. SUZIE: I think John
touched on a point there. The clients for scarring
are usually in their 40s, 30s-40s. It’s something they’ve wanted
to do for a long time. It’s definitely affected
their self-esteem. So they’ve got other issues as well. NORMAN: And they may have
more disposable cash or set some aside. A little bit as well, but it’s also… The resurfacing part of it is very good
for rejuvenation in the skin. So I suppose it has that added bonus
in there as well. Interesting.
Look, it’s been fascinating. What are your take-home messages
for those watching? I think my take-home message
would definitely be, as a nurse, to not underestimate the psychological
impact that acne has on people. It can be quite devastating. It definitely affects
every facet of your life. So, to get in there early
with treatment, to be an open ear for them, for sure. NORMAN: Neil? I think my advice to the public,
to the consumer out there, would be to eat a healthy diet, and beware of sugary,
starchy, processed foods, and eat more natural foods. And for the clinicians,
probably two pieces of advice. It’s probably worthwhile doing
an oral glucose tolerance test, and having their insulin measured
by a laboratory to look at
their insulin sensitivity level. And if it is
an insulin resistance problem, involve a dietician in your treatment. NORMAN: Parker? My message is simply like Suzie’s –
to take it seriously. Patients with acne have significant
psychological morbidity quite often, and they sometimes feel
that they don’t get an adequate hearing. NORMAN: John Bell? I’ll sneak in two messages if I might,
Norman. One is… we’ve touched on it briefly,
and that is… well, not so briefly – that is to take a good history,
a good medical history. We haven’t mentioned the fact
that there are some drugs that can predispose towards acne. NORMAN: Such as? Um… the steroids, corticosteroids,
anabolic steroids, androgenic steroids. The antiepileptics, the old ones.
Barbiturates, phenazone. Isoniazid. I think even vitamin B12
can do that sometimes. So, there’s a range of them,
and we need to be aware of those. But… my main message,
take-home message, is that whatever the treatment we choose, we need to make sure we have
effective advice and counselling. There’s no quick fix,
and we need to ensure compliance. I’m going to wave a little leaflet
around most pharmacies would have. I think it’s pretty good. It just reinforces the advice
and counselling that I think is so necessary. NORMAN: John Sullivan. I think acne really is
a medical disorder, with some acute or short-term,
medium-term and long-term aspects that are important in its management. In the short term, you really want
to get good control for the patient. So you’re going to prevent scarring and
help them feel better about themselves. In the medium term,
address the other issues. If they’ve got questions
of polycystic ovaries, things such as diet,
other sort of lifestyle issues. And long term, if you can prevent
the scarring, or manage the scarring, or the psychological consequences
of acne, you’ll make a big difference
to these people. Thank you very much to you all and hope
you got a lot from this program on acne. Thanks to the Department of Health and
Aging for making the program possible. Thanks to you for taking the time to
attend and contribute and ask questions. If you’re interested in
obtaining more information about the issues raised in the program, there are number of resources available on the Rural Health Education
Foundation’s website – Don’t forget to complete and send in
your evaluation forms to register for CBD points. I’m Norman Swan
and I’ll see you next time. Captions by
Captioning & Subtitling International Funded by the Australian Government
Department of Families, Housing, Community Services
and Indigenous Affairs�

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