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Nursing Field Notes / Skin & Wound · Med-Surg Course

Acne 🧴

The pilosebaceous unit · Three factors · Isotretinoin safety

NG-393 Skin & Wound ADHD-friendly visual edition

Acne is a chronic inflammatory condition of the pilosebaceous unit — the hair follicle and its oil gland. Three things have to line up: too much sebum, a follicle that plugs itself, and bacteria multiplying in the plugged space. Most of what people blame — chocolate, greasy food, poor hygiene — is not on the list.

The unitPilosebaceous — hair follicle plus oil gland
Does NOT cause itChocolate, greasy food, poor hygiene
Does aggravate itCorticosteroids, stress, high-carb diet, oil-based cosmetics
The dangerous drugIsotretinoin — a teratogen, two forms of contraception

🧨 What starts it

Lecture slide on acne describing a chronic inflammatory skin condition of the pilosebaceous unit with three factors: increased sebum production, abnormal keratinisation of follicles causing them to block or plug, and Propionibacterium acnes bacteria dividing in the follicles, with a cross-section showing healthy skin, whitehead, blackhead, papule and pustule.
From your lecture. Follow the cross-section left to right — healthy follicle, then plugged and closed (whitehead), plugged and open (blackhead), then inflamed (papule) and infected (pustule).
The three factors, in order
  • Increased sebum production — androgen-driven, which is why it starts at puberty and flares premenstrually.
  • Abnormal keratinisation — the follicle lining sheds cells that stick together and plug the opening.
  • Cutibacterium acnes (still written Propionibacterium acnes on many slides) multiplies in the trapped sebum and triggers inflammation.
Lecture slide titled What Can Make Our Acne Worse, with a true and false table. True: medications such as corticosteroids, high carbohydrate diet, stress, and oil based cosmetics. False: water based cosmetics, hygiene, chocolate, and greasy food. Beside the table is a photograph of a young man with moderate inflammatory acne across the forehead, cheek and jawline showing scattered red papules and pustules.
From your lecture — and this is a test question. Learn the FALSE column as hard as the true one. Chocolate, greasy food and hygiene are the three the exam wants you to reject, and the photograph on the right is what moderate papulopustular acne actually looks like.
What actually makes it worse

Their true list: medications such as corticosteroids, a high-carbohydrate diet, stress, and oil-based cosmetics.

What does not

Water-based cosmetics, hygiene, chocolate and greasy food were all scored FALSE. Scrubbing harder makes it worse, not better.

🔎 What you will see

Naming the lesions
  • Comedones — the plugged follicle. Open = blackhead (dark from oxidized keratin, not dirt). Closed = whitehead.
  • Papule — small, raised, red, solid.
  • Pustule — the same with visible pus.
  • Nodules and cysts — deep, painful, and the ones that scar.

Distribution follows the oil glands: face, neck, chest, upper back and shoulders.

Grading it

Mild = comedones only. Moderate = papules and pustules. Severe = nodulocystic, and that one gets systemic treatment early because scarring is permanent.

The part that is not skin

Visible acne in adolescence carries real psychosocial weight — withdrawal, low self-esteem, depression. Ask about it; do not treat it as cosmetic.

🩺 What you do

Teaching that actually works
  • Wash gently twice a day with a mild cleanser. Do not scrub, and do not wash more often — both worsen it.
  • Do not pick or squeeze. That is how a lesion becomes a scar.
  • Water-based, non-comedogenic cosmetics; remove make-up before bed.
  • Improvement takes 6 to 8 weeks. Stopping early because “it is not working” is the commonest failure.
  • Benzoyl peroxide bleaches towels and clothing — warn her.
The drugs, stepwise
  • Benzoyl peroxide — antibacterial, first line, expect dryness.
  • Topical retinoids (tretinoin, adapalene) — unplug the follicle. Apply at night, use sunscreen daily, and expect it to look worse before better.
  • Topical or oral antibiotics — doxycycline, minocycline. Photosensitivity; no dairy or antacids around the dose.
  • Combined oral contraceptives for hormonal acne in women.
Isotretinoin — the one to be careful with
  • Severe teratogen. Two forms of contraception from a month before until a month after, monthly pregnancy tests, and enrollment in the iPLEDGE program.
  • Monitor lipids and liver function; expect severe dryness of lips, skin and eyes.
  • Never combine with a tetracycline — together they raise intracranial pressure.
  • Report mood change, and any visual change or severe headache, immediately.
  • No blood donation during treatment or for a month after.

⚡ Quick recall

The unitPilosebaceous — hair follicle plus oil gland
Does NOT cause itChocolate, greasy food, poor hygiene
Does aggravate itCorticosteroids, stress, high-carb diet, oil-based cosmetics
The dangerous drugIsotretinoin — a teratogen, two forms of contraception
Does chocolate cause acne?
No. Their false list was chocolate, greasy food, hygiene and water-based cosmetics.
Open comedone or closed — which is the blackhead?
Open. The dark color is oxidized keratin, not dirt.
How long before it works?
6 to 8 weeks. Tell her that at the start or she will stop.
The two absolute rules with isotretinoin?
Two forms of contraception with monthly pregnancy testing, and never alongside a tetracycline.