Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Acne
ACNE
An inflammatory eruption involving the pilosebaceous follicles characterized by comedones (open and closed), pustules, or cysts. It is a chronic disorder, has a varied presentation, and is often resistant to treatment.
I. Etiology
A. Pilosebaceous follicle activity is stimulated by increased androgen levels during puberty. Desquamation of the follicular wall occurs, creating a number of cells that, combined with sebum, result in a plug, obstructing the lumen of the follicle. Corynebacterium acne enzymes hydrolyze these trapped sebaceous lipids, causing distention and rupture of the sebaceous ducts.
B. An inflammatory reaction occurs in the dermis with the release of the keratin, bacteria, and sebum.
II. Incidence
A. Affects approximately 80% of adolescents in varying degrees.
B. Generally disappears by the early 20s in males, somewhat later in females
C. Severe disease affects males 10 times more frequently than females.
III. Subjective data
A. Vary according to the degree of severity; complaints include:
1. “Bumps,” blackheads, whiteheads, pimples, cysts, scarring
2. Pain on application of pressure
3. Premenstrual flare
B. Location: Face, chest, back, buttocks
C. Pertinent subjective data to obtain
1. Does patient see acne as a problem and want treatment for it?
2. Does acne flare with stress or emotional upheaval?
3. Does acne flare premenstrually?
4. Do seasonal changes affect acne (e.g., improve in summer or worsen with high humidity)?
5. Does acne worsen in response to certain foods? What are these types of food?
6. What treatment has been used in the past?
7. What was the response to previous treatment?
8. Has female patient been on birth control pills?
9. Are there any associated endocrine factors?
a. Does patient have regular menstrual periods?
b. Does patient complain of hirsutism?
10. Does patient use cosmetics or creams on skin? Determine type— oil-based or water-based.
11. Is patient exposed to heavy grease and oil?
D. Note: Often the patient will not complain of any symptoms because of embarrassment. It is the responsibility of the nurse practitioner to raise the issue.
IV. Objective data
A. Inspect the entire body. Lesions may be found on the face, earlobes, scalp, chest, back, buttocks; they generally recur in the same areas.
B. Lesions
1. Mild acne
a. Closed comedones (whiteheads)
b. Open comedones (blackheads)
c. Occasional pustules
2. Moderate acne
a. Comedones—open and closed
b. Papules
c. Pustules
3. Severe, inflammatory acne
a. Comedones—open and closed
b. Erythematous papules
c. Pustules
d. Cysts
C. Scarring may be present in any stage.
D. Hair is often very oily.
V. Assessment
A. Diagnosis is easily made by the appearance of the different lesions present on the skin.
B. Assess degree of involvement—both physical and emotional—to determine the best therapeutic plan.
VI. Plan
A. Mild acne
1. Topical bacteriostatic: Benzoyl peroxide products are potent antimicrobial agents as well as exfoliant, sebostatic, and comedolytic agent.
a. Use one of the following:
(1) Desquam-X (clear aqueous gel)
(2) Benzagel (clear alcohol gel)
(3) PanOxyl (clear alcohol gel)
(4) Benzac W (2.5% aqueous base gel)
b. Begin with 5% used once daily. (With fair or sensitive skin, use every other day and increase frequency accordingly.)
c. Follow-up telephone call in 2 weeks. If no sensitivity, gradually increase application to twice daily.
or add
2. Topical antibiotic
a. T-Stat pads, bid
b. Cleocin T lotion, gel, or solution, bid or
3. Retinoid
a. Retin-A: Use 0.025% cream or 0.01% gel. or
b. Differin 0.1% gel or cream
(1) Initially, use on a small area every other day, and increase use to once daily if no irritation develops.
c. Combined retinoid-bacteriostatic therapy
(1) Apply retinoid cream or gel at bedtime
(2) Apply benzoyl peroxide preparation in AM
(3) With Retin-A, do not apply simultaneously; will inactivate both chemicals.
(4) Differin gel or cream has a lower incidence of irritation than Retin-A gel and is compatible with concurrent application of benzoyl peroxide.
4. Recheck in the office in 1 month. Continue regimen if condition responds to treatment. If there is no response to treatment and no sensitivity to the medication:
a. Increase strength of benzoyl peroxide preparations to 10% used once daily. Increase frequency to twice daily after 2 weeks if no sensitivity.
b. Increase strength of Retin-A to 0.05% cream or 0.025% gel used once daily. Increase frequency to twice daily after 2 weeks if no sensitivity. Use cream base for dry skin, gel base for oily skin.
c. During early treatment, an increase in inflammatory lesions is common. Improvement may take as long as 2 months.
5. Further follow-up should be individualized according to the patient’s needs and the degree of response to therapy.
B. Moderate acne
1. Benzoyl peroxide gel (types and dosages as above) or
2. Retin-A Cream 0.05% or
3. Differin gel 0.1% or
4. BenzaClin Topical gel, twice a day
5. Hot soaks to pustules 5 to 6 times a day
6. Tetracycline 250 mg qid or 500 mg bid, over age 12 or alternately
Erythromycin 1 gm/d
7. Recheck in 5 weeks
a. With no improvement and no local irritation:
(1) Increase tetracycline to 1.5 g/d for 2 weeks, then 2 g/d for 2 weeks.
(2) Increase strength of keratolytic gel to 10% or increase Retin-A to 0.1% cream or change to 0.025% gel.
b. With marked improvement, decrease tetracycline to 250 mg bid.
8. Recheck again in 4 weeks.
a. With no improvement:
(1) Continue tetracycline at 2 g/d.
(2) Use keratolytic gel at bedtime and Retin-A in the morning.
b. With improvement:
(1) Decrease tetracycline to 250 mg qid or discontinue if already decreased to bid.
(2) Continue with topical medication.
9. Continue individualized follow-up:
a. Every 4 to 8 weeks while on tetracycline
b. Every 3 to 6 months while on topical medication
10. Note: If patient is an adolescent female on the birth control pill or seeking oral contraception order, Ortho Tri-Cyclen #28.
a. It has minimal intrinsic androgenicity.
b. Studies have shown clinically significant improvement in total acne lesions and inflammatory lesions.
C. Severe or inflammatory acne
1. Topical medication as above
2. Hot soaks to inflamed lesions 5 to 6 times a day
3. Tetracycline 250 mg qid
4. Recheck in 4 weeks. With no improvement, increase tetracycline as above.
5. Refer to dermatologist if no improvement on this regimen.
D. Note:
1. Limit refills on tetracycline to ensure follow-up visits.
2. Tetracycline is generally drug of choice. It is inexpensive, has few side effects, and is well-tolerated for long-term administration. The usual precautions for young children or possibility of pregnancy should be followed.
3. Antibiotic therapy may take 6 to 8 weeks for any noticeable improvement to occur.
4. Sulfur can be comedogenic.
5. Keratolytic gels penetrate better than creams or solutions.
6. When discussing acne, do not hesitate to touch the area so child does not feel he or she is “dirty.” Tell child that blackheads are not dirt but oxidized melanin.
7. Psychological scarring may occur.
8. Appropriate therapy should be instituted if patient perceives acne as a problem.
9. “Prom Pills”—Emergency clearing of inflammatory acne for a prom, wedding, or other major event: Prednisone, 20 mg every morning for 7 days
10. Do not use BenzaClin gel in conjunction with erythromycin.
VII. Education
A. Acne is chronic. It cannot be cured, but it can be controlled. Acne flare ups occur in cycles, both hormonal and seasonal.
B. Explain etiology (for psychological support).
C. When local treatment is instituted, acne may appear worse before it improves. Expect 6–8 weeks before treatment is effective.
D. For mild and moderate acne, the aim is to dry and desquamate the skin. Expect some dryness, peeling, and faint erythema of the skin.
E. Topical medication
1. If marked erythema and pruritus develop in response to topical medication, discontinue use temporarily and then resume with less frequent application.
2. Apply 20 to 30 minutes after gentle washing.
3. Apply lightly to affected area. Do not rub in vigorously.
4. Expect a feeling of warmth and slight stinging with application.
F. Hygiene
1. Avoid abrasive agents (e.g., over-the-counter scrubs).
2. Shampoo frequently; no special shampoo is necessary.
3. Change pillowcase daily.
4. Do not pick or squeeze lesions; this will retard healing and cause scarring.
5. Use face cloth and hot water for soaks. Try to soak for 10 to 20 minutes 5 to 6 times a day.
6. Wash face gently three times daily with mild soap; excess scrubbing can exacerbate acne.
7. Facials may exacerbate acne.
8. Use only water-based cosmetics.
a. Oil-free is not necessarily water-based.
b. Use loose powder and blush.
9. Acne medications can be applied under cosmetics and sunscreens.
10. Avoid oily sunscreens. Sundown and PreSun are generally acceptable.
G. Avoid foods that seem to make acne worse.
H. Overexposure to sunlight can exacerbate acne, alone or in combination with topical medications. Topical medications can be used under sunscreens. It may, however, be necessary to discontinue these medications in the summer.
I. Mild sun exposure often dramatically improves acne.
J. High humidity and heavy sweating exacerbate acne, as does exposure to heavy oils and grease.
K. Tetracycline
1. While on medication, restrict exposure to sunlight.
2. Do not take if there is any question of pregnancy.
3. Take 1 hour before or 2 hours after a meal.
4. If unable to take four times a day because of schedule, take 500 mg every 12 hours. Nurse practitioner should acknowledge that it may be a problem for an adolescent to have an empty stomach
4 times a day.
5. Patient must take the full dose for at least 1 month for effective treatment.
6. Moniliasis may occur in females.
L. Discuss preparations available over the counter. Explain to adolescent (and parent, if applicable) that it is more cost-effective to follow the treatment regimen than to try all the latest acne products for the dramatic cures that advertisements promise.
M. Birth control pill may need to be changed to one that does not contain norgestrel, norethindrone, or norethindrone acetate.
N. T-Stat should be applied with the disposable applicator pads. Drying and peeling can be controlled by reducing the frequency of application.
O. BenzaClin gel may bleach hair or fabric.
P. Inflammatory acne can result in scarring and/or pigment changes. Treatment will prevent or minimize these changes.
VIII. Follow-up
A. Acne is chronic. Treatment should be continued until the process subsides spontaneously but may be interrupted or discontinued during summer months when temporary remission may occur because of sun exposure.
B. Return visits need to be individualized according to the severity of the acne and the emotional needs of the adolescent. Once control has been achieved, however, the frequency of follow-up can be decreased. The patient may need to remain on a 250to 500-mg daily maintenance dose of tetracycline for several months, in which case 6to 12-week return visits should continue. If patient is on topical medications alone, after acne is controlled, the frequency of application can be adjusted by the patient, and telephone follow-up may be sufficient.
IX. Complications
A. Psychological problems
B. Secondary bacterial infection
C. Scarring
X. Consultation/referral
A. Moderate acne: Consult for treatment if no improvement noted after treatment with tetracycline for 2 months before continuing treatment plan.
B. Severe or inflammatory acne: Consult for treatment. Refer if no improvement noted after treatment with tetracycline for 1 month. It may require more aggressive therapy, such as treatment with Accutane.
C. Severe or resistant acne in a woman if accompanied by hirsutism, irregular menses, or other signs of virilism