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clinical
David Cook
George Krassas
Tom Huang
The audit
Background
Acne vulgaris can have a substantial impact on a patient’s quality of life; there can be
the audit was prospective, fixed time and significant psychosocial consequences and it can leave permanent physical scarring. conducted online fol owing the rAcGP’s five Early and effective acne treatment is important.
step audit procedure. General practitioner Objective
participation in the audit was voluntary, with To describe the outcome of an accredited clinical audit by The Royal Australian College advertising, direct mail and personal invitation of General Practitioners investigating general practitioner management of acne vulgaris and to provide an outline of current ‘best practice’ acne management. General practitioners were provided with Discussion
quantitative questionnaires and were required The audit was conducted over two cycles with GPs receiving educational material to evaluate their management of acne in 25 between cycles. Eighty-five GPs contributed data on 638 patients. General practitioner adolescent patients who had visible acne over management of acne was assessed against a set of preset standards and some acne two audit cycles (15 patients in cycle 1 [c1] and treatment was found to be inconsistent with best practice, particularly for patients 10 patients in cycle 2 [c2]). the type and scope with moderate and moderate to severe acne, where many patients were either being of data col ected is summarised in Figure 1.
undertreated or treatment with antibiotic therapy was suboptimal. It is likely that An education committee (comprising eight this treatment gap is overestimated due to practical limitations of the audit process; GPs) assisted with the development of the audit, however, the audit revealed a need to address the main sources of apparent divergence determining the five standards of care and setting from best practice to improve the quality use of acne therapies. the acceptable levels for GP assessment (Table 1).
Keywords: education, medical, continuing; education, medical; clinical audit; quality
Fol owing completion of c1, GPs were sent of health care; skin diseases, acne vulgaris; skin diseases an individual performance report and a brief education report discussing the initial audit findings and giving advice on best practice management. After having appropriate time to reflect on their results (at least 3 months), GPs conducted c2. on completion of c2, GPs received a second individual performance report.
to assess the quality use of medicines, impact on quality of life.1,2 Even though treatment algorithm that represents best practice (Table 2) as identified from a systematic search of the literature.7,8 if the physical scarring.4,5 Early and effective that recommended by the algorithm, it was considered consistent or ‘appropriate’ (Table 3) and if not, treatment was considered to be inconsistent. this assessment is likely to We conducted a clinical audit, accredited overestimate the number of patients whose by the royal Australian col ege of General therapy is inconsistent with best practice Practitioners (rAcGP), to investigate general practitioner management of acne vulgaris.
investigated. therefore, appropriate reasons for AustrAliAn FAmily PhysiciAn Vol. 39, no. 7, July 2010 1
clinical Acne – best practice management
which therapy differed from the algorithm, such the audit revealed that GPs are discussing preset acceptable standards (Table 1). however, as issues of tolerability and patient choice are acne, assessing severity and evaluating its their pharmacological management of acne psychosocial impact at a frequency above the was found to be inconsistent with best practice in approximately half of al patients. the most common divergences were: Have you discussed acne?
• concurrent use of topical and oral antibiotics • use of antibiotics without benzoyl peroxide Yes (this consult)
Yes (previous)
• undertreatment, or nontreatment, of acne. Have you classified severity?
What is the severity?
divergence from best practice and discuss the Potential for scarring?
implications for the quality use of medicines.
Can you estimate severity?
What is the severity?
Treatment of acne
Considered psychosocial impact?
Potential for scarring?
identification of acne severity is determined by How is acne currently
specific clinical features. the severity of acne How is acne currently treated?
treated?
plays a major role when it comes to determining the most appropriate acne treatment. optimal use Review date set? When for?
of medication involves understanding the specific clinical features and lesion types that identify the Has the patient been referred
different degrees of acne severity (Table 4).8 to a dermatologist?
Considerations before treatment
Was the patient receiving treatment
while waiting for dermatologist's
Acne is one sign of androgenisation in women. if present with hirsutism, obesity or menstrual What was the treatment?
irregularity, endocrine evaluation is warranted. occupational exposures to halogens; industrial Figure 1. A schematic flow diagram summarising the data that was col ected in the audit oils; and hot, humid working environments can contribute to acne.9 Where possible, exposure to aggravating factors should be avoided or Table 1. Aggregated performance results of GPs in both cycles compared to the
minimised. Patient education is key and common acceptable standards
myths should be addressed (Table 5).
Acceptable standards
Psychosocial assessment
(n=1067)
Acne can have a significant emotional and GP has at some point had a discussion about acne 86.9 social impact. it can cause, or be a contributing with 80% of adolescent patients with visible signs factor to, social isolation, distorted body image, poor self confidence, depression and suicidal As part of routine care, GP has assessed severity ideation. these negative consequences don’t of acne in 80% of adolescent patients with visible necessarily correlate with acne severity;9 As part of routine care, GP has discussed the assessed in al patients. start with open ended psychosocial impact of acne in 50% of adolescent questions such as, ‘how do you feel about your GP has offered appropriate acne treatment, after Mild acne
considering the severity, the likelihood of scarring, and the psychosocial impact of acne in 70% of the course of treatment is determined by acne adolescent patients with visible signs of acne severity, but even mild forms of acne should be GP should routinely review acne treatment (within 69.1 treated. Appropriate treatment for mild forms 12 weeks) in 85% of patients for whom treatment involves a topical monotherapy such as salicylic acid, retinoids or BPo. topical antibiotic may be 2 AustrAliAn FAmily PhysiciAn Vol. 39, no. 7, July 2010
Acne – best practice management clinical
Table 2. Acne treatment algorithm7,8
Moderate
Moderate to severe
Comedonal
Papular/pustular
First line
Alternatives
Oral AB + topical retinoid + BPOorBPO/topical AB* Alternatives
for female
patients
Maintenance
BPO = benzoyl peroxide; AB = antibiotic [AUTHOR PROVIDE MEANING OF ASTERIX] antiandrogen in females, and advice from a Table 3. ‘Appropriate’ treatment by acne severity
dermatologist should be sought (Table 3).
Patients receiving appropriate
treatment
Severe acne
severe acne can initial y be treated in the same manner as moderate to severe acne. however, if response to therapy is inadequate, or there is a risk of scarring, or the acne is psychosocial y debilitating, referral to a dermatologist is recommended. in this case, the systemic added after 6 weeks in mild inflammatory acne the whole area of the affected skin, not just the retinoid, isotretinoin, is the treatment of choice.9 if no improvement is seen, but should be used infected lesions.9 Female patients also have the in conjunction with BPo to prevent antibiotic option of oral contraceptive therapy.12 however, being used, avoid the use of a second retinoid, hormonal therapy should be used in addition to concomitant tetracyclines and photosensitising a topical therapy to achieve optimal results. agents, such as nonsteroidal anti-inflammatory Moderate acne
drugs (nsAiDs), due to the increased risk of Moderate to severe acne
moderate acne should also be treated with adverse events. Females must have adequate topical agents. topical retinoids are the main moderate to severe acne should be treated with contraception, with the concurrent use of treatment for comedonal or mild papulopustular topical retinoid (eg. 0.05% or 0.1% tretinoin)9 plus acne. however, as the inflammatory component topical BPo and a topical antibiotic. Alternatively, increases so does the role of antibiotic therapy, an oral antibiotic can be prescribed. if there is including fixed dose combinations containing BPo.
The role of antibiotics in the
no response to the antibiotic by 6 weeks, or if the acne improves and then relapses, consider management of acne
combination with 5% BPo) should be used for changing the antibiotic.9 if no improvement Propionibacterium acnes are believed to play a a 6 week period, with the therapy applied to is seen, consider supplementing therapy with major role in the pathogenesis of acne vulgaris. AustrAliAn FAmily PhysiciAn Vol. 39, no. 7, July 2010 3
clinical Acne – best practice management
resistance to erythromycin is most common, Table 4. Clinical characteristics of the various degrees of acne severity8
fol owed by clindamycin, with little increase in Mild acne
Primarily composed of noninflammatory lesions Concurrent use of BPO and
or comedones. These may be open and/or closed antibiotics
and present as clogged pores (blackheads or whiteheads) the addition of BPo to topical antibiotic therapy Some papules (red pimples) may also be present has been shown in several studies to prevent the development of bacterial resistance.10,11 Moderate acne
the concurrent use of BPo is now considered Contains both noninflammatory comedones as the primary strategy to prevent resistance to well as inflammatory lesions including papules topical antibiotics. the concurrent use of BPo and a few pustules (pimples with a white top) was previously recommended if oral antibiotic therapy extended beyond 2 months; however, the use of BPo from the beginning of treatment is now advised.15 While topical retinoids are Moderate to severe acne
commonly used in the treatment of acne, there Characterised by numerous comedones, pustules is no evidence to suggest that they exhibit and papules and a few cysts (large pus filled inflammatory lesions >5 mm in diameter) or a preventive effect on the development of nodules (cysts that have ruptured) may be Conclusion
the clinical audit revealed there is scope for
Severe acne
improvement in GP management of acne. it also highlighted the need for the development noninflammatory symptoms as described above but with the presence of numerous of less complicated treatment regimens in order to simplify management of acne. General Nodules and cysts are often painful and found practitioners need to consider not only the physical signs of acne but also the psychosocial impact, independent of acne severity. treatment needs to be tailored to the individual and must suppressing P. acnes with the use of oral or 6–8 weeks and if no improvement is observed, consider issues of therapeutic adherence. topical antibiotics plays an integral role in the a change in oral antibiotic should be made. management plan of patients with moderate, When acne is under reasonable control, oral monitor disease progress and effectiveness and moderate to severe, acne (and acne of lesser antibiotic therapy should cease with the topical of prescribed therapy. Early and effective severity that is refractory to other treatments) treatment regimen of retinoids (with or without treatment of acne is key to preventing scarring where both noninflammatory and inflammatory the addition of topical antibiotics plus BPo) and minimising psychosocial implications.6 pathways are involved. topical antibiotics are being continued for another 3–6 months for if the patient’s condition is not responding to highly effective13 with topical clindamycin and maintenance.15 concomitant use of oral and treatment, referral to a dermatologist should topical antibiotics offers no benefit as they be sought before the condition progresses to a oral antibiotic therapy should be restricted possess no synergistic action and combined use more severe disease and becomes increasingly to patients with moderate to severe, and severe acne. Doxycycline is the agent of Future audits might investigate how the Risk of antibiotic resistance
first choice, while minocycline use is limited management of acne changes over time to better by poorer tolerability – tetracyclines are A major drawback with the use of antibiotics assess the appropriateness of current therapy contraindicated in children and in pregnancy. is the possible development of antibiotic and whether dermatologist referral is timely. Due to photosensitivity reactions, patients resistance. A restricted range of topical antibiotic taking tetracyclines should be counsel ed on formulations are available, therefore responsible sun exposure. oral erythromycin is reserved use and limited courses of topical antibiotics are QuAliFiciAtions & APPointmEnt] Department for patients who can’t take tetracyclines.14 the advised.13 A 10 year surveil ance study found the of Dermatology, concord hospital, sydney, new efficacy of therapy should be reviewed after prevalence of antibiotic resistance has increased. 4 AustrAliAn FAmily PhysiciAn Vol. 39, no. 7, July 2010
Acne – best practice management clinical
therapy. Br J Dermatol 1992;126:586–90.
Table 5. Patient education and myth busting1,9
11. Leyden JJ, Wortzman M, Baldwin EK. Antibiotic- resistant propionibacterium acnes suppressed General advice on acne
Myth busting
by a benzoyl peroxide cleanser 6%. Cutis • Sexual activity does not influence acne 12. Bershad sV. the modern age of acne therapy: a – although acne is related to androgen review of current treatment options. mt sinai J 13. Elston Dm. topical antibiotics in dermatology: – it can increase the risk of scarring emerging patterns of resistance. Dermatol clin 14. Australian medicines handbook. Adelaide: Australian medicines handbook, 2010.
– low irritant, pH-balanced, soap free 15. Del Rosso JQ, Kim G. Optimizing use of oral antibiotics in acne vulgaris. Dermatol clin 16. coates P, Vyakrnam s, Eady EA, et al. Prevalence of antibiotic-resistant propionibacteria on the skin of acne patients: 10-year surveil ance data • Chocolate and fatty foods do not cause and snapshot distribution study. Br J Dermatol – diet has not been directly linked to – there is some suggestion that dairy products and a high glycaemic index diet may worsen acne in some individuals – leaving hair long, greasy or wearing psychosocial effects of acne on adolescents. PlEAsE ProViDE APPointmEnt] scius solutions 3. chen cl, Kuppermann m, caughey AB, et al. A community-based study of acne-related health preferences in adolescents. Arch Dermatol QuAliFiciAtions & APPointmEnt] stiefel, A GsK company, sydney, new south Wales.
4. Pearl A, Arrol B, lel o J, et al. the impact of acne: a study of adolescents’ attitudes, percep- tion and knowledge. n Z med J 1998;111:269–71.
conflict of interest: this clinical audit was 5. Kilkenny m, merlin K, Plunkett A, et al. the prev- sponsored by stiefel, A GsK Pharmaceutical alence of common skin conditions in Australian company. David cook declared no conflict of school students: 3. acne vulgaris. Br J Dermatol interest. George Krassas of scius solutions, 6. Kligman Am. An overview of acne. J invest the education provider, was funded by stiefel 7. Zaenglein Al, thiboutot Dm. Expert commit- to design, develop and implement the clinical tee recommendations for acne management. audit as wel as to aid the preparation of this 8. Warner GT, Plosker GL. Clindamycin/benzoyl per- manuscript. tom hsun-Wei huang is an employee oxide gel: a review of its use in the management of stiefel, A GsK Pharmaceutical company. of acne. Am J clin Dermatol 2002;3:349–60.
9. Dermatology Expert Group. therapeutic guide- References
10. harkaway Ks, mcGinley KJ, Foglia An, et al. 1. Goodman G. Acne – natural history, facts and Antibiotic resistance patterns in coagulase–nega- myths. Aust Fam Physician 2006;35:613–6.
tive staphylococci after treatment with topical 2. Krowchuk DP, stancin t, Keskinen r, et al. the erythromycin, benzoyl peroxide, and combination AustrAliAn FAmily PhysiciAn Vol. 39, no. 7, July 2010 5

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