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1. Acne and rosacea
Dr Daniel Hewitt
Dermatologist
Skin and Cancer Foundation Westmead

2. Objectives
Understand that acne and rosacea are
extremely common and have a significant
burden on patients
To understand the most common clinical
findings
To be able to list the management options

3. Acne
Acne is extremely common, affecting
approximately 85% of people at some stage.
It most commonly presents in teenagers but can
occur at any age.
It has a profound psychological and social impact.
Acne may have a big impact even when there
are few lesions in the skin.

4. Pathogenesis
There is no single cause.
Acne tends to run in families as there is a genetic basis.
The main aetiological factors are
1 Blocking of the follicle or “pilosebaceous unit”– this occurs most
commonly on the face and trunk
2 Increased production of sebum by the sebaceous glands which are
connected to the follicle
3 Inflammation in the follicle – this seems to occur after rupture of the
follicle or sebaceous duct
4 Bacteria such as Propionobacterium acnes – these probably have a
role in stimulating inflammation
5 Hormonal stimulation of sebaceous glands, although the majority of
patients with acne have normal hormone levels.

5. Myths abound regarding acne
It is not strongly related to any lifestyle factors. Dietary
modification is not generally helpful in its management.
It is not caused by dirt or poor hygeine.
Like many dermatoses, it can flare during stressful times,
but stress is not a common cause.

6. Clinical features
Acne is a clinical diagnosis and usually obvious
The hallmarks are
papules – small red, raised lesions
pustules – yellow papules, often on an
erythematous base
comedones – a plug in the follicle seen as black
dots (blackheads) or small white lumps
(whiteheads)
There are usually combinations of these

7. Classic acne with the
combination of papules,
pustules and comedones

8. Acne

9. More severe acne has deeper nodules and cysts. These
lesions frequently produce scarring.
There may also be excoriations, erythematous or
pigmented macules and shallow or deep scars.

10. Severe nodulo-cystic, scarring acne

11. Acne conglobata

12. Acne excorie

13. Treatment
Treatment can be divided into two main categories - topical
treatments and systemic treatments.
All treatments require at least 6-8 weeks to work. Generally
patients are asked to stay on treatment regimes for at
least 3 months.
Various light and laser treatments have been used, but
they are not commonly helpful for active acne.

14. Topical treatments
Retinoids
These are vitamin A derivatives. They normalize
keratinization to decrease follicular occlusion in addition
to decreasing sebaceous gland secretion.
Examples are tretinoin 0.025%, 0.05% or 0.1%
adapalene 0.1%
isotretinoin 0.05%
Antibiotics and antiseptics
These aim to kill bacteria in the follicles and decrease
inflammation.
Examples include
erythromycin 2% gel
benzoyl peroxide 5% lotion
clindamycin 1% lotion or gel

15. Keratolytics
These can be prescribed in larger quantities and may be
useful for truncal acne.
An example is 3% salicylic acid in 70% ethanol
Combination products are also available
eg benzoyl peroxide 5% + clindamycin 1%
benzoyl peroxide 5% + adapalene 0.1%
All of these products have the potential to produce dryness
or irritation

16. Systemic treatments
Antibiotics
These can be used with or without topical products. They
control inflammatory or pustular acne most effectively.
Tetracyclines are most commonly used. These kill bacteria
in hair follicles but probably also have an anti-
inflammatory effect on the skin
eg doxycycline 50mg bd
minocycline 50mg bd
Other antibiotics are also used
eg erythromycin ethyl succinate 400mg bd
this is safe in pregnancy
cotrimoxazole one tablet od or bd

17. Isotretinoin
This is a very useful medication for severe, cystic acne.
It can only be prescribed on the PBS by dermatologists.
Female patients must have absolutely no risk of becoming pregnant
while on oral isotretinoin as it causes birth defects.
Most people on it get dryness of their mucosal surfaces and skin.
Possible other side effects include – muscle aches and pains,
stiffness, photosensitivity, headaches, hair thinning, nail brittleness,
tiredness, liver enzyme elevation, elevated cholesterol and
decreased visual acuity.
Patients are given detailed information prior to commencing and blood
counts, liver function, lipids and a pregnancy test must be checked
prior to commencing.
The usual dose is 40-60mg per day
A cumulative total dose of 100 to 150mg /kg is aimed for.

18. Rosacea
Rosacea is a chronic inflammatory condition
of the face, usually seen in older adults.
It is difficult to understand as it has many
different characteristics.

19. Clinical features
Rosacea has different forms. It does not necessarily
progress from one form to the next
1 Telangiectatic – often there is a history of flushing and
blushing or heat in the face. This can then develop into
fixed erythema and telangiectasia in this form of
rosacea.
2 Inflammatory – papules and pustules, centred on the
follicles characterise this type. Comedones are not seen,
unlike in acne
3 Proliferative – Sebaceous hyperplasia, chronic oedema
and connective tissue proliferation lead to this form seen
most commonly in men. The nose is most frequently
affected – “rhinophyma.”
The eyes are sometimes involved, most commonly as a
blepharitis.

20. Papulo-pusutlar rosacea

21. Papulo-pustular rosacea

22. Erythemo-telangiectatic rosacea

23. Erythemo-telangiectatic rosacea

24. Sebo-rosacea

25. Rhinophyma

26. Triggers
The fundamental causes are not well understood but there
are a number of triggers
Alcohol – although this is not an important cause
Hot food and drinks
Spicy food
Heat
Sun exposure
Irritating products eg soaps and cleansers
Stress

27. Strong topical steroids are often problematic on the face.
They can produce a rosacea-like eruption known as
perioral dermatitis. This comprises monomorphic
papules and small pustules and can occur around the
mouth, nose or eyes.
It flares on cessation of topical steroids. It settles slightly
with their use but patients can become dependent on
them and they must be avoided.
Tetracyclines (eg minocycline 50mg po bd) are used for 2-3
months to control this condition. They must be warned
that there will be an initial flare.

28. Perioral dermatitis

29. Perioral dermatitis

30. Management
There are four main areas
1 General measures
2 Topical therapy
3 Systemic therapy
4 Surgery and physical modalities

31. General measures
Patients should avoid normal soaps and drying products to
their face. Daily use of a gentle soap free wash (eg QV
soap free wash) and low irritant sunscreens are
appropriate.
Known triggers are to be avoided – eg sunlight, heat, hot
and spicy food and drinks.
Sympathetic explanation of the chronicity of the condition
and the need to adapt to it is essential.
All treatments require perseverence – often no response is
seen until 6 to 8 weeks and often maintainence therapy
is required.

32. Topical therapy
The two most commonly used products are
metronidazole 0.75% gel or cream
azaleic acid 15% gel
Other options include
Erythromycin 2% gel
Extemperaneous preparations eg 1% sulfur + 2% salicylic
acid in aqueous cream
Topical treatments are used twice a day initially but can be
reduced to once a day once a response has been
achieved. They can be used for long term maintainence,
if required.
Topical steroids are to be avoided as the condition often
flares on their withdrawal.

33. Systemic therapy
This is used in more severe cases, or when inadequate
control is achieved topically.
Antibiotics are used, as in acne
eg doxycycline 50 to 100mg daily
minocycline 50 to 100mg daily
erythromycin ethyl succinate 400mg bd
Isotretinoin is sometimes used in very difficult cases.

34. Surgery and physical modalitites
Vascular laser or intense pulsed light therapy is effective for
the erythema and telangiectasia of rosacea.
Improvement is usually only partial and several
treatment sessions may be required.
Shave excison and laser ablation procedures may be
appropriate for the more proliferative forms of rosacea
(eg rhinophyma) once it is more resistant to medical
treatment.

35. Conclusion
Acne and rosacea are very common skin conditions that
impair patients’ quality of life.
Treatments are numeorus but can de divided into topical
and systemic treatments. They need to be used for at
least several weeks to obtain an optimal response.