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11/13/24, 8\:17 PM Guide | Explaining a diagnosis of acne vulgaris

Explaining a diagnosis of acne vulgaris

Table of contents

Introduction

Being able to share information in a clear and concise way is an essential skill in all
simple explanations, such as why a blood test may be needed, to more complex situations, such as explaining a new diagnosis.
Often, sharing information with a patient occurs naturally during a consultation. However, providing clinical information may
also be the primary focus of an appointment, and in these situations, it is crucial to have a structured format in order to
communicate more e

Structure

Explaining a diagnosis requires structure and adequate background knowledge of the disease. Whether the information
being shared is about a procedure, a new drug or a disease, the BUCES structure (shown below) can be used.
Explanation structure

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
BUCES can be used to remember how to structure a consultation in which providing information is the primary focus. Before
explaining the various aspects of a disease, it is fundamental to have a common starting point with your patient. This helps to
establish rapport and creates an open environment in which the patient can raise concerns, ask questions and gain a better
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understanding of their problem. After introducing yourself, it is important to take a brief history (this is the
structure)\:
What has brought the patient in to see you today?
What are their symptoms?
Are there any risk factors that can be identi
For example, a patient with acne vulgaris will likely mention areas such as the face, chest and upper back being a
will report symptoms such as pustules and redness. They will also potentially mention exacerbating factors such as cosmetic
use or medications such as steroids.
Tip\: Practice taking concise histories to get the timing right. In OSCE stations, timing is crucial and you do not want to spend all
your time taking a history when you are meant to be explaining a diagnosis! A rough guide would be to keep the introduction
and brief history between 1-2 minutes maximum.

What does the patient understand?

Following a brief history, it is important to gauge the patient’s knowledge of their condition. Acne vulgaris is very common
amongst teenagers (80-90% are a
they may have a very good understanding of the condition and the ways it might be managed. On the other hand, this may be
their
Due to these reasons, it is important to start with open questioning. Good examples include\:
“ W h a t d o y o u t h i n k i s c a u s i n g y o u r s y m p t o m s ?”
“ W h a t d o y o u k n o w a b o u t a c n e ?”
“ W h a t h a s b e e n e x p l a i n e d t o y o u a b o u t a c n e s o f a r ?”
Open questioning should help you to determine what the patient currently understands, allowing you to tailor your
explanation at an appropriate level.
At this stage, primarily focus on listening to the patient. It may also be helpful to give positive feedback as the patient talks
(i.e. should a patient demonstrate some understanding, reinforce this knowledge with encouraging words and non-verbal
communication such as nodding).
Checking the patient’s understanding should not be solely con
throughout by repeatedly ‘chunking and checking’
.
Tip\: Try using phrases such as\:
“ J u s t t o c h e c k t h a t I a m e x p l a i n i n g a c n e c l e a r l y , c a n y o u r e p e a t b a c k t o m e w h a t y o u u n d e r s t a n d
s o f a r ?”
. This is far better than only saying “ W h a t d o y o u u n d e r s t a n d s o f a r ?” as the onus is placed upon the quality of your
explanation rather than there being an issue with the patient’s ability to understand.

What are the patient’s concerns?

The patient’s concerns should never be overlooked. While acne itself is not necessarily harmful it can have a signi
psychological impact, particularly if the patient is of school age. Asking the patient if they have any concerns before beginning
your explanation allows you to speci
explanation. The “ICE” (ideas, concerns and expectations) format, can provide a useful structure for exploring this area further.

ICE

Ideas\:
What does the patient think is causing their symptoms?
What is their understanding of the diagnosis?
Concerns\:
What are the patient’s concerns regarding their symptoms and diagnosis?
Expectations\:
What is the patient hoping to get out of the consultation today?
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Explanation

After determining the patient’s current level of understanding and concerns, you should be able to explain their condition
clearly. For more information on acne, see the Geeky Medics guide to acne vulgaris.
You should begin by signposting what you are going to explain to give the patient an idea of what to expect.
“ I’ m g o i n g t o b e g i n b y t a l k i n g a b o u t t h e n o r m a l f u n c t i o n o f t h e s k i n a n d t h e n m o v e o n t o d i s c u s s w h a t a c n e i s , w h a t c a u s e s i t
a n d h o w w e c a n m a n a g e i t t o g e t h e r .
”
Tip\: Use the mnemonic “Normally We Can Probably Manage” to help you remember the structure of explaining a disease.

Normal anatomy/physiology

“ T h e n o r m a l f u n c t i o n o f t h e s k i n i s t o a c t a s a b a r r i e r . W e c a n i m a g i n e t h e s k i n t o b e l a y e r s o f b r i c k s s t a c k e d o n t o p o f e a c h
o t h e r . I n n o r m a l s k i n , t h e r e a r e g l a n d s t h a t p r o d u c e a n o i l y s u b s t a n c e c a l l e d s e b u m w h i c h h e l p s m a i n t a i n a n d p r o t e c t t h e s k i n .
I n a c n e , t h e r e i s t o o m u c h s e b u m p r o d u c e d w h i c h l e a d s t o s p o t s .
”

What the disease is

Acne is a disease of the pilosebaceous unit (hair follicle and associated sebaceous gland). Increased sebum production from
these glands leads to the development of comedones, papules and pustules on the skin. It is very common in teenagers and
a
It most commonly a
present. The most common form of acne is acne vulgaris (the form typically a
types such as infantile acne and adult acne.
Mild acne tends to present with comedones, which are blocked hair follicles. Closed comedones are also known as
"
whiteheads" and open ones are known as "blackheads"
.
More severe acne can present with papules and pustules on the skin or even the formation of cysts in severe cases. Once the
lesions have healed there can be leftover scarring or changes in the pigmentation of the skin.

Cause of the disease

" A c n e i s a p r o b l e m w i t h t h e h a i r f o l l i c l e s a n d t h e i r a s s o c i a t e d gl a n d s i n t h e s k i n . T h e s e gl a n d s p r o d u c e a n o i l y , w a x y s u b s t a n c e
c a l l e d s e b u m . I n s o m e p e o p l e , t h e s e gl a n d s p r o d u c e m o r e s e b u m t h a n n o r m a l , w h i c h l e a d s t o s p o t s o n t h e s k i n - t h i s i s
k n o w n a s a c n e . I t i s v e r y c o m m o n i n t e e n a ge r s , w i t h a r o u n d 8 0 % h a v i n g a c n e a t s o m e p o i n t .
T h e r e a r e a f e w d i
h a p p e n s w h e n p e o p l e g o t h r o u g h p u b e r t y . T h i s c a n a l s o e x p l a i n w h y p a t i e n t s w h o m e n s t r u a t e h a v e s y m p t o m s t h a t v a r y
t h r o u g h o u t t h e m e n s t r u a l c y c l e .
S o m e o t h e r t h i n g s t h a t c a n c a u s e o r w o r s e n a c n e i n c l u d e c e r t a i n b a c t e r i a o n t h e s k i n , b e i n g b l o c k e d b y t h i n g s l i k e m a k e-u p .
"
m e d i c a t i o n s l i k e s t e r o i d s o r t h e g l a n d s

Problems/complications

Outlining potential complications of acne is necessary so that the patients can identify problems early and seek medical advice.
Being aware of common problems will also encourage patients to adhere to their treatment.
The most common complication of acne is post-in
scars and can persist long after the initial lesion has healed. Some treatments are available for acne scarring, such as
laser therapy.
It is also important to be aware of the potential mental health implications of acne. It can often lead to feelings of self-
consciousness and low self-esteem in patients and can contribute to depression and anxiety.
" S o m e t i m e s o n c e t h e s p o t s h a v e h e a l e d y o u c a n b e l e f t w i t h s c a r r i n g o n t h e s k i n o r c h a n ge s t o t h e n o r m a l c o l o u r o f t h e s k i n .
T h i s i s w h y i t' s i m p o r t a n t t o t r y a n d t r e a t a c n e w e l l . B u t i f y o u d o d e v e l o p t h e s e p r o b l e m s t h e r e a r e p o t e n t i a l t r e a t m e n t s
a v a i l a b l e .
A c n e c a n a l s o o f t e n m a k e p e o p l e f e e l s e l f -c o n s c i o u s o r w o r r i e d a b o u t t h e i r a p p e a r a n c e . r e a l l y i m p o r t a n t t h a t y o u t a l k t o s o m e o n e a b o u t i t .
"
I f t h i s i s h a p p e n i n g t o y o u t h e n i t' s
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Management

Reinforce to the patient that they need to work with you as a team to achieve a good result.
Patients should be advised to avoid any exacerbating factors/triggers that they have identi
scratching at the lesions.
Topical therapies
Most patients with mild to moderate acne can be managed with topical therapy.
Some of these are available over-the-counter without a prescription, such as salicylic acid and benzoyl peroxide. Salicylic acid
is present in several cleansers and skincare products, and benzoyl peroxide is available as a gel or face wash.
If these are ine
important to warn patients that these can be quite drying, so it may be best to try using them on alternate days if their skin
becomes irritated. Even though it is topical it is still considered teratogenic, so should not be prescribed to patients who are
trying to conceive, are pregnant or breastfeeding.
Systemic therapies
severe acne.
If topical therapies fail to improve symptoms then there are several systemic treatments that can be prescribed for moderate to
Patients assigned female at birth can be prescribed anti-androgenic options. The oral contraceptive pill
(OCP). While this can be very e
Another option is spironolactone, although this is less commonly prescribed and is contraindicated in pregnancy.
Sometimes oral antibiotics (usually tetracyclines or erythromycin) can be used. They are prescribed at low doses and have an
anti-in
Isotretinoin
If the above options fail or the acne is severe then patients can be referred to dermatology to consider isotretinoin.
This is a very e
induce remission in some patients.
It should only be prescribed in specialist settings, however, as it can have signi
sensitivity to the sun and potential mental health issues. Patients also need to have their cholesterol and LFTs monitored while
taking isotretinoin and again, it is considered teratogenic.
Example of how you might explain the management of acne
" A c n e c a n b e r e a l l y u n p l e a s a n t t o l i v e w i t h s o i t' s i m p o r t a n t w e t r y a n d g e t i t u n d e r c o n t r o l .
W e c a n s t a r t o u t b y t r y i n g s o m e t o p i c a l c r e a m s , y o u c a n g e t s o m e o f t h e m o v e r-t h e-c o u n t e r . O n e i s c a l l e d s a l i c y l i c a c i d a n d i t' s
a v a i l a b l e i n a l o t o f s k i n c l e a n s e r s - t h i s h e l p s t o u n b l o c k t h e g l a n d s i n y o u r s k i n . A n o t h e r i s c a l l e d b e n z o y l p e r o x i d e , w h i c h y o u
c a n b u y i n p h a r m a c i e s . T h i s h e l p s w i t h a n y b a c t e r i a o n y o u r s k i n t h a t m i g h t b e c a u s i n g y o u r a c n e . Y o u c a n u s e t h e s e e v e r y d a y
t o c l e a n s e a n d w a s h y o u r s k i n .
A s y o u h a v e s o m e s i g n s o f m o d e r a t e a c n e I' l l a l s o p r e s c r i b e y o u s o m e t h i n g c a l l e d a t o p i c a l r e t i n o i d t o u s e a s w e l l . T h i s h e l p s
r e d u c e t h e a m o u n t o f s e b u m y o u r s k i n m a k e s a n d b e c a u s e o f t h i s i t c a n b e q u i t e d r y i n g. S o t r y u s i n g i t e v e r y o t h e r d a y a t
a n d s e e h o w y o u g e t o n w i t h i t .
I f t h e s e d o n' t w o r k o r y o u r a c n e g e t s w o r s e t h e n c o m e b a c k a n d t h e r e a r e s o m e t a b l e t s t h a t w e c a n t r y t h a t o f t e n h e l p a n d i f
w e' r e r e a l l y s t r u g g l i n g t h e n w e c a n r e f e r y o u t o t h e s k i n s p e c i a l i s t s f o r s o m e m o r e o p t i o n s .
"

Closing the consultation

Summarise the key points back to the patient.
" I n s u m m a r y a c n e i s a p r o b l e m w i t h t h e gl a n d s i n t h e s k i n p r o d u c i n g t o o m u c h s e b u m s o t h e y ge t b l o c k e d a n d c a u s e s p o t s t o
d e v e l o p . Y o u m i g h t n o t i c e c e r t a i n t h i n g s l i k e m a k e-u p m a k e t h i n gs w o r s e a n d i f s o y o u s h o u l d t r y t o a v o i d t h i s a n d t r y t o a v o i d
p i c k i n g a t t h e s p o t s a s t h i s c a n l e a d t o s c a r s . W e' l l s t a r t o
c a n b o o k a n o t h e r a p p o i n t m e n t a n d w e c a n t r y s o m e t a b l e t s t h a t m i g h t h e l p a b i t m o r e .
"
Ask the patient if they have any questions or concerns that have not been addressed.
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“ I s t h e r e a n y t h i n g I’ v e e x p l a i n e d t h a t y o u’ d l i k e m e t o g o o v e r a ga i n ?”
“ D o y o u h a v e a n y o t h e r q u e s t i o n s b e f o r e w e
Arrange appropriate follow-up to discuss their acne further. Acknowledge that you have discussed a large amount of
information and it is unlikely that they will remember everything.
O
gather more information (examples include patient.info and the BAD)
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

1. British Association of Dermatologists. H a n d b o o k f o r M e d i c a l S t u d e n t s a n d J u n i o r D o c t o r s . 2020. Available from\: [LINK]
2. DermNet NZ. A c n e . 2014. Available from\: [LINK]
3. Patient.info. A c n e V u l g a r i s . 2021. Available from\: [LINK]
4. Patient.info. A c n e . 2021. Available from\: [LINK]
5. British Association of Dermatologists. A c n e P I L . 2020. [LINK]
Source\: geekymedics.com
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