Spotty skin will affect most teenagers at some point, and usually improves into their twenties. Spots occur on the face, neck, chest or back and can have a significant effect on quality of life irrespective of severity. Acne is caused by increased sebum secretion, blockage of pilosebaceous ducts, colonisation with Propionibacterium acnes and release of inflammatory mediators. In teenagers increased androgen is the main trigger.

Ask women about their use of the combined oral contraceptive pill. Some worsen acne, others may be used to treat it. Enquire about OTC medications and consider steroid use (topical, systemic and anabolic all exacerbate). Look for open comedomes (blackheads – dilated pores with keratin plug), closed comedomes (whiteheads), inflammatory papules, pustules, nodules, cystic areas and scarring.

Mild acne can be treated topically with benzoyl peroxide, with or without topical antibiotics, or retinoids. It takes 6–8 weeks before benefit is seen. Moderate acne involves papules and pustules and often requires oral antibiotics (first line treatment tetracycline) which should be continued for 2–3 months usually with topical treatments. Severe acne is nodular cystic. Anti-androgens (e.g. Dianette®) can be considered in females who haven’t responded to treatment.

Indications for referral to secondary care include patients with severe nodular cystic acne, scarring or acne not responding to 6 months of oral treatment. Appropriate patients will be considered for oral retinoid (isotretinoin) treatment, which is teratogenic and needs regular blood monitoring.

Acne Rosacea

b. Acne rosacea.

This is a chronic condition affecting the forehead, cheeks and nose, characterised by redness, papules, pustules and telangiectasia. Patients may complain of blushing easily, and will often identify triggers for flares of their symptoms such as stress, alcohol, spicy foods, extremes of temperature, and it usually gets worse in direct sunlight. Ask about eye symptoms as it can cause rosacea keratitis. It mostly affects fair-skinned and middle-aged people, more commonly in women but more severe in men. Treatments aim for control, not cure, and include topical metronidazole, oral tetra­cyclines and camouflage creams to hide redness. Avoid triggers (e.g. alcohol) and irritants (e.g. soaps).

Seborrhoeic Dermatitis

c. Seborrhoeic dermatitis.

This commonly presents in general practice as a sudden rash over the face and chest, which produces red areas of skin with greasy looking white or yellow scales. It is also the most common cause of dandruff and commonly affects the nasolabial folds, forehead, scalp, also beard area in men, and chest. It may affect the eyelashes (blepharitis) and ears (otitis externa). It commonly occurs in babies and throughout adult life. The aim of treatment is to control, not cure. The cause is not fully understood, but it responds to anti-fungal preparations (which kill commensal yeast cells) supplemented by short courses of steroid creams. Remember, it is also one of the most common skin manifestations of HIV.

Pityriasis Versicolor

d. Pityriasis versicolor.

This produces a patchy rash over the shoulders and trunk. ‘Pityriasis’ is a fine scale, and ‘versicolor’ means colour changing. It is a common rash, mostly affecting young people, and is caused by the overgrowth of commensal yeast cells. It often appears pale on darker skins and darker on pale skins. It can be mildly itchy but often goes unnoticed. Anti-fungal shampoos (e.g. selenium) as a body wash often work well, oral anti-fungals are reserved for rashes that don’t respond or are very widespread. Warn patients that pale patches of skin may take several months to return to their normal colour even though treatment has been successful.

Pityriasis Rosea

e. Pityriasis rosea.

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