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Final version_L'Oreal acne webinar report

This report and the webinar have been commissioned and funded by L’Oréal (UK) Limited and developed in partnership with Guidelines and Guidelines in Practice. Please see bottom of page for full disclaimer.

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Foreword—Dr Angelika Razzaque

On Friday 8 April 2022, Dr Padma Mohandas (Consultant Dermatologist) and I participated in a live webinar discussing the importance of optimising the management of acne and its impact on mental health. This report summarises the key content and outcomes from the webinar, highlighting the current guidance and useful resources to help support healthcare professionals with the management of their patients.

Acne is extremely common and as such has been rated the eighth most common disease worldwide by the Global Burden of Disease Project.1 In 2021 NICE published updated guidance for acne management in primary and secondary care emphasising timely management of the skin condition and also addressing possible associated mental health conditions.2 We are ideally placed in primary care to manage both and are very familiar with suitable screening tools, guidance to self-help tools, and referral pathways. The Primary Care Dermatology Society (PCDS) has developed a two-sided acne treatment guideline for ease of reference and hosts a comprehensive website for further disease specific information.3,4 Clinicians should of course always check local guidelines, which at times may differ from national guidelines.

Access to mental health services and psychodermatology services, in particular, varies greatly.5 Empathy through primary care clinicians can go a long way and optimising treatment of acne may prevent further manifestation of mental health conditions and ease the personal and economic burden this disease can pose. It is therefore paramount that clinicians are familiar with the various treatment options available for the different severities of acne and are confident in stepping up and maintaining treatments. A timely referral after no response to treatment in primary care or in scarring acne should be generated. Particular emphasis should be on skin of colour where it is difficult to distinguish whether hyperpigmentation is an expression of active disease or a sign of scarring.4 Patients with considerable mental health impact should also be referred early.2–4  

As clinicians we want to give the best care possible to our patients and I am certain this report will help you achieve this for your patients with acne.

Introduction

The 1-hour webinar featured a presentation from Dr Padma Mohandas, followed by questions answered by Dr Mohandas and Dr Angelika Razzaque (Box 1).

Box 1: Speaker biographies

Dr Padma Mohandas is a Consultant Dermatologist with a special interest in Psychodermatology at Barts Health NHS Trust, London and Co-secretary of Psychodermatology UK. She helps run a dedicated complex needs clinic at the Royal London Hospital, which was awarded ‘BMJ Dermatology Team of the Year’ in 2017. Dr Mohandas aims to provide a holistic approach to patient care, which takes into consideration the interdependence of the mind, body, and skin.

Dr Angelika Razzaque is a GP in London, Educational Subcommittee Lead of the Primary Care Dermatology Society (PCDS), and Associate Specialist in Dermatology at King’s College Hospital, London. She has developed a community dermatology service, of which she is the clinical lead. She lectures nationally and publishes articles on skin related matters for the quarterly PCDS bulletin, Pulse, and Guidelines in Practice

Session: Best practice: Management of mental health in patients with acne 

Acne vulgaris 

Acne vulgaris is an inflammatory disease that affects the pilosebaceous follicles. Pathogenic factors include increased sebum production that is induced by androgens, follicular hyperkeratinisation, inflammation, and bacterial colonisation of hair follicles on the face, neck, chest, and back by Cutibacterium (formerly Propionibacterium) acnes.6,7  

Acne is rare in people under the age of 10 years, and peaks at 15–19 years.8 Approximately 3% of men and 5% of women will still have some acne at 40–49 years of age.9 Acne is moderate to severe in about 15–20% of young people.9 Permanent scarring after acne can be a problem: 95% of patients will have some degree of facial scarring and 80% of males usually have some degree of scarring on the back.8

Acne negatively affects people’s quality of life and self-esteem, and can lead to anxiety, depression, and suicidal ideation.9 Acne of any severity can impact a patient’s mental health.2,9

Management of acne vulgaris

Treatment should be given to reduce the severity of skin lesions and prevent scarring, as well as to prevent acne from recurring. It should be tailored to the severity of the acne and agreed with the patient following a discussion of the advantages and disadvantages of each treatment option.2 The NICE guideline ‘Acne vulgaris: management’ (NG198) makes recommendations for first-line treatment of acne (Box 2).2

Box 2: First-line treatment options for acne2[A]

Any acne severity

  • A fixed combination of topical adapalene with topical benzoyl peroxide
  • A fixed combination of topical tretinoin with topical clindamycin

Mild-to-moderate acne

  • A fixed combination of topical benzoyl peroxide with topical clindamycin

Moderate-to-severe acne[B]

  • A fixed combination of topical adapalene with topical benzoyl peroxide and either oral lymecycline or oral doxycycline
  • Topical azelaic acid with either oral lymecycline or oral doxycycline.

[A] Topical benzoyl peroxide monotherapy may be considered as an alternative treatment if the other options are contraindicated or the patient wishes to avoid using a topical retinoid or an antibiotic.
[B] For patients who cannot tolerate or who have contraindications to lymecycline or doxycycline, consider trimethoprim or an oral macrolide.

Advise patients to apply the medication for about an hour every night, see how they feel and then increase it on a daily basis to a stage where they can tolerate it for the whole night. Ask patients to persevere with their treatment and complete the course as it can take 6–8 weeks for positive effects to become noticeable.2 NICE recommends that patients should be reviewed after 12 weeks and the guideline includes further recommendations for patients depending on their response including maintenance options if their acne has cleared, or further treatment if their acne has improved but not cleared or if it has not responded.2

Poor response to treatment?

If a patient does not respond well to treatment, then clinicians should check for:10

  • adherence—frequency of application and patient’s understanding of treatment
  • side effects may require a change in treatment
  • drug-related reasons—change concentration or dosage form of drug if necessary; offer combined contraception to replace progesterone-only contraception
  • non-drug related reasons—endocrine profile, for example polycystic ovary syndrome (PCOS), skin care, or stress levels.

Myth busters

  • Diet: The role of diet in acne is unclear:
    • there is some evidence that eating low glycaemic index foods may have a positive effect on the condition of the skin9  
    • there is only weak evidence that dairy products are associated with acne,9 but if a patient believes their acne is affected by animal milk it may be worth suggesting they try plant-based milk instead
  • Sunlight: There is no evidence that sunlight improves acne,9 however it can damage the skin;11 sunscreens are an essential add-on to acne management as some medications make the skin sensitive to UV light11
  • Hygiene: It is important to keep the skin clean, but there is no evidence that acne is caused by a lack of hygiene9
  • Smoking: The role of smoking in patients with acne is unclear,9 but smoking affects the skin and clinicians are always advised to recommend smoking cessation 
  • Obesity: Acne is often found alongside obesity in patients with PCOS9  
  • Stress/picking: Stress may increase acne severity and patients with more perfectionist or compulsive personality traits are more likely to pick acne lesions.9  

Secondary care referral

Patients should be referred to secondary care if:2

  • they have acne fulminans (urgent referral to be assessed within 24 hours)
  • there is diagnostic uncertainty about their acne 
  • they have acne conglobata
  • they have nodulo-cystic acne. 

Consider referral of patients to secondary care if they have:2

  • not responded to multiple treatments in primary care
  • acne with scarring or persistent pigmentary changes
  • significant psychological distress regardless of acne severity.

Skin care

Advice for patients to aid skin care is:11–13

  • DO wash your face every morning, evening, and after exercise 
  • DO choose skin care products that are labelled ‘oil-free’ and ‘non-comedogenic’
  • DO use a gentle face wash rather than scrubs or exfoliation
  • DO apply moisturiser daily
  • DO wear sunscreen outdoors
  • DON’T scrub face
  • DON’T use oil-based or alcohol-based cleansers
  • DON’T sleep in your make-up 
  • DON’T touch your face throughout the day.

Some useful advice to give people with darker skin tones to help their acne is:14

  • treat acne and dark spots at the same time
  • prevent dark spots and scars by treating acne early
  • skin picking or scratching of acne lesions can increase the risk of scarring
  • switch hair care products from an oily preparation to one that contains water or glycerine 
  • if using hair oil, then only use it in the middle of the scalp and at the ends of the hair.

Mental health in patients with acne

In a survey, people living with acne (n=2166) described the impact of acne on their life:15

  • 29.0% received what they regard as unfair treatment at work 
  • 30.1% received what they regard as unfair treatment by staff while in full-time education 
  • 18.2% have been physically abused by another member of the public
  • 40.5% have been verbally abused by another member of the public
  • 57.1% have been verbally abused by a friend, family member, or someone they know
  • 15.2% have been unfairly dismissed at work
  • 30.3% have been wrongfully dismissed by a member of the medical profession
  • 44.2% have been bullied on a regular basis.

There is a relationship between sex and suicidality in people with acne—more males than females expressed that they have suicidal ideation as a result of their acne.15 The extent of disease does not correlate with psychosocial comorbidities.2 Effective treatment can significantly improve patients’ quality of life.8  

Patients should be screened for:

  • anxiety
  • depression
  • social avoidance disorder (agoraphobia) 
  • body dysmorphic disorder 
  • suicidal ideation.

The Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire (PHQ-9) are useful tools to identify depression and anxiety, as well as assess response to treatment.

Summary

Acne vulgaris is a common condition affecting the face, chest, and back.2 Clinical presentations are on a spectrum, physically and psychologically. The psychosocial impact of acne may not reflect the clinical presentation. It is good practice to screen for mental health issues in all patients with acne.

Q&A session

Q1. What is your personal perspective on the challenge of managing patients with acne?

Dr Razzaque outlined several challenges for GPs:

  • a lack of dermatology training in medical schools and in GP rotations 
  • insufficient time in a standard consultation to cover the complexity posed by acne and mental health 
  • patient expectation—it is important to set realistic expectations and advise patients that acne is a complex condition that is multifactorial and needs to be addressed as such, often with combination treatments that take time to work 
  • specialised psychodermatology services are rare across the country 
  • unless they include specialist counsellors, Improving Access to Psychological Therapies (IAPT) services will often provide a generic approach and may not take into account the physical condition of acne and body dysmorphia.

Q2. When should patients with acne be referred to secondary care?

Healthcare professionals should not hesitate to refer anyone with very severe acne. Treatment failure for moderate-to-severe acne after one treatment cycle of about 3 months warrants a referral to secondary care. In mild-to-moderate acne, treatment failure after two treatment cycles of 3 months each with a different combination of treatment approaches should warrant a referral. It can be difficult to tell if hyperpigmentation is active acne, post-inflammatory, or early scarring in patients with skin of colour so it is advisable to treat earlier and more aggressively and refer much earlier. If a patient with mild acne is consumed by their skin, that should alert you that they need specialist intervention, either through IAPT or secondary care specialist services.

Q3. What is your experience in using dermocosmetics as adjunctive therapies in patients with mild-to-moderate acne?

NICE advises twice-daily gentle washes using synthetic detergents that are non-alkaline (either skin pH neutral or slightly acidic) and a non-comedogenic moisturiser.2 For example, you could use CeraVe Hydrating Cleanser or La Roche Posay Effaclar. This is also useful after treatment as a maintenance treatment. There is a lot of choice, so suggest that patients look at the ingredients and ignore the packaging.

Q4. Do you have any advice about make-up?

It is best to avoid oil-based and comedogenic products and remove make-up at the end of the day.2 Some tinted moisturisers include sun protection factor (SPF), and it is particularly important to advise patients who are using retinoids to make sure to use SPF as part of their acne treatment. Less is more, layering various different formulations onto your skin is probably not ideal when managing acne.

Q5. Does the treatment of acne differ between males and females?

The topical treatment options and the antibiotic options are the same. Only hormonal treatment varies because hormonal options are not available for males. Perhaps we see a few more males with truncal acne, so it is always worth asking whether the acne is just on the patient’s face or if other areas are involved.

Q6. Are there any tips to help patients minimise acne stigma?

Normalise the fact that the patient does have acne and be honest and say most people have spots at some point in their lives. Focus on the positives—we can treat their acne and improve their skin. If the stigma that they feel is causing social avoidance it becomes a mental health problem and we can steer the conversation into how we can support the patient while their skin is being treated with pharmaceutical therapy. If they are quite debilitated by their skin, then psychological help/talking therapies have been proven to help people deal with their perception of their skin.

Q7. Do you think that behaviour is changing because there is more accessible information for teens from social media?

There is a lot of misinformation from influencers who are paid to promote certain products, which are not necessarily evidence-based. This is a challenge for primary and secondary care and it is important for clinicians to be realistic about what the evidence is and offset the marketing. Clinicians can only recommend a certain array of products that are pharmaceutically tried and tested. When we give advice we should keep it simple, so there is less room for error.

Q8. Are there any assessment tools other than PHQ-9/HADS that you would recommend for patients with acne?

Dermatology Life Quality Index is a good tool for any skin condition. But often it helps to just use simple questions, such as ‘is this actually bothering you?’ The level of acne does not necessarily correlate with the effect on the patient’s mental health.3 If the clinician picks up on a mental health issue, they must arrange more specialist input such as a psychodermatology service or a more generic service such as IAPT service alongside treatment of acne.

Case study

A 21-year-old female with skin type 6 (dark brown/black skin) presents complaining of spots that she has had for a while. She has tried over-the-counter scrubs and exfoliation, and is worried about her spots, as well as pigmentation and scarring. She is entering the job market and is worried that people will not employ her because of the way she looks. She feels embarrassed and her self-esteem is quite low. She is using progesterone-only contraception.

History

When assessing a patient with acne, the clinician should examine physical and psychological aspects, including:

  • duration of acne
  • extent—which parts of the body are affected: face, shoulders, chest, back, scalp 
  • treatments tried so far—which treatments, how long for, why they were stopped and any side effects
  • exacerbating factors: such as (in women) premenstrual flares, contraception (progesterone-heavy contraception worsens acne and anti-androgenic contraception is a preferential choice),6 cosmetics especially in African-Caribbean and Asian populations who regularly use oils for their hair, hair care products (wax/gels also relevant), skin picking 
  • smoking
  • medication: for example, corticosteroid use
  • family history: PCOS—ask patient if her periods were regular before starting contraception 
  • psychosocial impact: consider mood, depression, and suicidal ideation
  • systemic features (very rare) to look for are fever, joint pains, and swelling.

Examination

When examining the patient we look at the face, chest, and back but also other seborrhoeic regions such as the scalp, which can sometimes harbour follicular inflammation. Patients can also have eruptions on the buttocks and sides of the thighs—it is important to ask, as they will not always volunteer this information.

Assess the acne lesions—are they non-inflammatory or inflammatory?

  • Non-inflammatory:   
    • open/closed comedones
  • Inflammatory:
    • papules
    • pustules
    • nodules/cysts
    • post-inflammatory pigmentation—important in patients with skin of colour as it can persist even when acne is treated.

Healthcare professionals should offer information and advice on acne-rated scarring.2 Consider other clues or syndromes such as, hidradenitis suppurativa, high BMI, and PCOS. We should also check the patient’s hospital anxiety and depression scale (HADS) if their mood might be impaired.

Management

Set out various treatment options and work out between clinician and patient which works the best for them, in this case: 

  • over the counter salicylic acid wash 
  • no physical exfoliation or scrubs as a general rule
  • topical retinoid/benzoyl peroxide once daily
  • change contraception to combined oral contraception or something that is anti-androgenic
  • offer support and reassurance regarding skin—it will improve, there is help available, and we can support them
  • treat depression—non-pharmacological or pharmacological management
  • consider oral tetracycline (doxycycline/lymecycline) antibiotics for 3 months to reduce papules.

BMI=body mass index; PCOS=polycystic ovary syndrome

Acknowledgement

Sonia Davies, independent medical writer, helped draft this document.

Conflicts of interest

The speakers have received an honorarium to develop this webinar and report. They have also received consultancy fees from other pharmaceutical companies, which may include L’Oréal (UK), for activities other than the development of this webinar and report. 

References

  1. Tan J et al. Br J Dermatol 2015; 172 (Suppl 1): 3–12.
  2. NICE. Acne vulgaris: management. NICE Guideline 198. NICE, 2021. Available at: www.nice.org.uk/ng198
  3. Primary Care Dermatology Society. Acne – Primary care treatment pathway. PCDS, 2019. Available at: www.pcds.org.uk/files/general/Acne-Treatment-2019-final-web.pdf
  4. Primary Care Dermatology Society. Acne: acne vulgaris. www.pcds.org.uk/clinical-guidance/acne-vulgaris (accessed 4 March 2022).
  5. All-Party Parliamentary Group on Skin. Mental health and skin disease. APPGS, 2020. Available at: www.appgs.co.uk/wp-content/uploads/2020/09/Mental_Health_and_Skin_Disease2020.pdf
  6. Williams H et al. Lancet 2012; 379 (9813): 361–372.
  7. Zaenglein A et al. J Am Acad Dermatol 2016; 74 (5): 945–973.
  8. Layton A et al. Br J Dermatol 2021; 184 (2): 219–225. 
  9. Bhate K et al. Br J Dermatol 2013; 168 (3): 474–485.
  10. Gollnick H et al. J Eur Acad Dermatol Venerol 2016; 30 (9): 1480–1490.
  11. American Academy of Dermatology Association. Acne: tips for managing. www.aad.org/public/diseases/acne/skin-care/tips (accessed 3 May 2022)
  12. American Academy of Dermatology Association. Moisturiser: why you may need it if you have acne. www.aad.org/public/diseases/acne/skin-care/moisturizer (accessed 3 May 2022)
  13. American Academy of Dermatology Association. 10 skin care habits that can worsen acne. www.aad.org/public/diseases/acne/skin-care/habits-stop (accessed 3 May 2022)
  14. American Academy of Dermatology Association. 10 tips for clearing acne in darker skin tones. www.aad.org/public/diseases/acne/diy/skin-color (accessed 3 May 2022)
  15. Ra A et al. Br J Dermatol 2022; 186 (1): 191–193.

This report and the webinar have been commissioned and funded by L’Oréal (UK) Limited and developed in partnership with Guidelines and Guidelines in Practice. L’Oréal (UK) suggested the topic and presenters, who were paid an honorarium. L’Oréal (UK) carried out full medical approval on all materials to ensure compliance with regulations. The views and opinions of the presenters are not necessarily those of Guidelines, Guidelines in Practice, their publisher, advisers, or advertisers. No part of this publication may be reproduced in any form without the permission of the publisher.

June 2022