Acne vulgaris

By Dr. LOK BUNTHAY,

Diploma in Dermatology and Dermatosurgery,
THAILAND
ACNE AT A GLANCE
Common disorder of the pilosebaceous unit.
Four key elements of pathogenesis:
(1) follicular epidermal hyperproliferation,
(2) excess sebum production, (3) inflammation, and
(4) the presence and activity of Propionibacterium
acnes.
Comedones, papules, pustules, nodules on face, chest,
and back.
Treatment often includes combinations of oral and
topical agents such as antimicrobials, retinoids, and
hormonal agents. Laser and light sources are
additional treatment options.
Introduction
Common disorder of the pilosebaceous unit, primarily in
adolescents.
Pleomorphic array of the lesions: comedones, papules,
pustules, and nodules.
The course of acne may be limited in the majority of
patients, the sequelae can be lifelong, with scar formation
and psychological impairment, especially
in young people.
Epidemiology
Acne has no predilection for ethnicity
Mild degrees are frequently seen at birth, (stimulation
by adrenal androgens), and may continue into the
neonatal period
Often an early manifestation of puberty
In girls, may precede menarche by more than 1 year.
Highest number : the middle-to-late teenage
Nodulocystic acne: white males > black males
Seems to be familial, genetic and more severe in
patients with the XYY genotype.
Etiology and Pathogenesis
There are 4 basic steps:
(1) Follicular epidermal hyperproliferation,
(2) Excess sebum production,
(3) Inflammation, and
(4) The presence and activity of P. acnes.
CLINICAL MANIFESTATION
Duration of lesions: from weeks to months.
Season: often worse in fall and winter.
Symptoms: pain in lesions (nodulocystic type).
Skin Lesions Comedones —open (blackheads) or
closed (whiteheads); comedonal acne . Papules
and papulopustules —i.e., a papule topped by a
pustule; papulopustular acne . Nodules or cysts —
1–4 cm in diameter
Soft nodules: result from repeated follicular
ruptures and re-encapsulations with inflammation,
abscess formation, and foreign-body reaction.
Cysts are actually pseudocysts as they are not lined by
epithelium but represent fluctuating abscesses
Sinuses : draining epithelial-lined tracts, usually with
nodular acne.
Scars : atrophic depressed (often pitted) or hypertrophic
(at times, keloidal).
Seborrhea of the face and scalp often present and
sometimes severe.
Sites of Predilection Face, neck, trunk, upper arms,
buttocks.
Laboratory Tests
In general, laboratory workup is not indicated for
patients with acne unless hyperandrogenism is
suspected
DHEAS: precursor for testosterone and DHT
↑androgens : severe cystic acne and in acne associated
with a variety of endocrine conditions, including
congenital adrenal hyperplasia (CAH; 11β- and 21β-
hydroxylase deficiencies), ovarian or adrenal tumors,
and polycystic ovarian disease.
Most of cases: serum androgens are normal
Differential Diagnosis
Diagnosis is usually easy, but acne may be
confused with:
- folliculitis,
- rosacea,
- perioral dermatitis
Complications
Transient macular erythema after resolution
Darker skin: post-inflammatory hyperpigmentation
Permanent scarring: pitted, hypertrophic scars,Keloids
Psychological, and emotional impairment
Prognosis and Clinical Course
The age of onset of acne varies considerably
Acne most often clears spontaneously by the early
twenties but can persist to the fourth decade or older.
Flares occur in the winter and with the onset of menses.
The sequela is scarring, which should be avoided by
proper treatment
Treatment
An understanding of the 4 major steps in the
pathophysiology of acne in turn governs its therapeutic
principles
LOCAL THERAPY:
- Cleansing
Topical Agents
- SULFUR/SODIUM SULFACETAMIDE/RESORCINOL AND SALICYLIC ACID
AZELAIC ACID(20% cream or 15% gel)
- Antimicrobial and comedolytic properties
- Competitive inhibitor of tyrosinase
- Well tolerated, though transient burning can occur,
and is safe in pregnancy
BENZOYL PEROXIDE 2.5%, 5%,10%
- Most common topical medications prescribed by
dermatologists and OTC
- Powerful antimicrobial
- Dryness and irritation.
- ACD: uncommonly reported.
- Usually, combination therapy.
TOPICAL ANTIBIOTICS
- Erythromycin and clindamycin are the most
commonly used topical antibiotics
- Combination of benzoyl peroxide/erythromycin or
clindamycin
RETINOIDS(topical)
- Tretinoin: potent comedolytic and anti-inflammatory
properties, it is widely used, contact irritant, photolabile
- Adapalene: a synthetic retinoid, greater tolerability.
photostable and can be used in conjunction with BP without
degradation
- Tazarotene: also a synthetic retinoid, potent comedolytic
agent. applied for 5 minutes then washed off with a gentle
cleanser. Category X. and female patients of childbearing age
should be adequately counseled.
SYTEMIC THERAPY
TETRACYCLINES.
- broad-spectrum antibiotics are widely used in the
treatment of inflammatory acne.
- suppression of the number of P. acnes, but part of its
action may be due to its anti-inflammatory activity.
- dosages of 500 mg/day to 1000 mg/day. Higher doses
of up to 3500 mg/day have been used in severe cases
Doxycycline and minocycline, are also commonly
used.
advantage: able to be taken with food without impaired
absorption.
Dosages: 50 to 100 mg twice daily.
The major disadvantage of the use of doxycycline is that
it can produce photosensitivity reactions, including
photo-onycholysis.
Minocycline: 100-200 mg/day. Patients on minocycline
should be monitored carefully as the drug can cause
blue-black pigmentation
MACROLIDES.
Erythromycin:
- who have difficulty in taking tetracycline on an empty
stomach,
- but due to the prevalence of erythromycin-resistant strains of
P. acnes its use is generally limited to pregnant women or
children.
More recently, the use of azithromycin in the treatment of acne
has been reported.
dosage: 250 mg to 500 mg x 3 time/week
gastrointestinal upset and diarrhea as the most common side
effects.
CLINDAMYCIN AND DAPSONE (Less commonly
used)
Clindamycin : because of the fairly high risk of
pseudomembranous colitis, it is now rarely used for acne
Dapsone(DDS):
- inflammatory acne and select cases of resistant acne.
- doses of 50 to 100 mg daily for 3 months.
- Glucose-6-phosphate dehydrogenase levels should be
examined before initiation of therapy and regular
monitoring for hemolysis and liver function
abnormalities
- low cost and should be considered in severe cases
where isotretinoin is not an option
HORMONAL THERAPY OF ACNE
- is to counteract the effects of androgens on the
sebaceous gland.
- anti-androgens, to decrease the endogenous
production of androgens by the ovary or adrenal
gland, including oral contraceptives,
glucocorticoids, or gonadotropin-releasing
hormone (GnRH) agonists.
Oral Contraceptives.
- Ortho Tri-Cyclen and Estrostep: approved for the
treatment of acne.
- Side effects: nausea, vomiting, abnormal menses,
weight gain, and breast tenderness.
- Rare but more serious: thrombophlebitis, pulmonary
embolism, and hypertension
Glucocorticoids:
antiinflammatory activity, high-dose systemic
glucocorticoids may be of benefit in the treatment of
inflammatory acne.
because of the potential side effects, these drugs are
ordinarily used for limited periods of time, and
recurrences post-treatment are common
Gonadotropin-Releasing Hormone Agonists.
act on the pituitary gland to disrupt its cyclic release of
gonadotropins.
The net effect is suppression of ovarian steroidogenesis in
women. These agents are used in the treatment of ovarian
hyperandrogenism
Their use, however, is limited by their side-effect profile,
which includes menopausal symptoms and bone loss.
Antiandrogens.
- Spironolactone: androgen receptor blocker and
inhibitor of 5α-reductase. Dose: 50-100 mg twice a day
- Cyproterone acetate is a progestational, blocks the
androgen receptor. It is combined with ethinyl
estradiol in an oral contraceptive.
- Flutamide, an androgen receptor blocker, doses of 250
mg twice a day in combination with oral contraceptives for
treatment of acne or hirsutism in females
Liver function tests should be monitored as cases of fatal
hepatitis have been reported. Pregnancy should be avoided
Isotretinoin
- severe treatment-resistant acne, severe, recalcitrant,
nodular acne.
- Isotretinoin is also effective in the treatment of gram-
negative folliculitis, pyoderma faciale, and acne
fulminans.
DIET
- not clear and the role of chocolate, sweets, milk, and
fatty foods in acne requires further study.
- Because patients cling to their beliefs, it is best to
restrict those dietary agents that they feel produce
flares.
ACNE SURGERY
- for the removal of comedones and superficial
pustules
- was a mainstay of therapy in the past
- Its use is primarily restricted to those patients
who do not respond to comedolytic agents
- greater ease and less trauma if the patient is treated
first with topical vitamin A acid or a similar topical
agent for 3 to 4 weeks
 INTRALESIONAL GLUCOCORTICOIDS
- The injection of 0.05 to 0.25 mL per lesion of a TA
suspension (2.5 to 10 mg/mL) is recommended as the anti-
inflammatory agent.
- This is a very useful form with nodular acne, but it
often has to be repeated every 2 to 3 weeks
- Hypopigmentation, particularly in darker skinned
patients, and atrophy are risks.
Laser and Light Therapy
IPL alone or IPL+5-Aminolevulinic acid(5-ALA):
- 420-430nm,15J-20J/cm2 , weekly X 4 sessions
- Pulse duration 12ms
Pulse Dye Laser
- Fluence 3J/cm2 X 12 weeks
ACNE VARIANTS
Neonatal Acne
- Up to 20% of healthy newborns
- appear around 2 weeks of age and resolve
spontaneously within 3 months
- sebum excretion rates in newborns are transiently
elevated in the perinatal period
- Malassezia sympodialis, a normal commensal on
human skin, may also play a role
Infantile Acne
- At 3 to 6 months of age and is usually marked by
the presence of comedones. Papules, pustules, and
nodules can also present on the face and scarring may
occur even with relatively mild disease
- transient elevation of DHEA produced by the
immature adrenal gland
- during the first 6 to 12 months of life boys may
also have an increased level of luteinizing hormone
that stimulates testosterone production. Around 1 year
of age, these hormone levels begin to stabilize until
they surge again during adrenarche.
- Treatment: same acne vulgaris in adults
Acne Conglobata
- Severe cystic acne with more involvement of the
trunk than the face. Coalescing nodules, cysts,
abscesses, and ulceration; occurs also on buttocks.
- Spontaneous remission is long delayed.
- Rarely, acne conglobata seen in XYY genotype
(tall males, slightly mentally retarded, with
aggressive behavior) or in the polycystic ovary
syndrome
Acne Fulminans Teenage boys (ages 13 to 17).
- Acute onset , severe cystic acne with concomitant
suppuration and always ulceration ; also present
are malaise, fatigue, fever, generalized arthralgias,
leukocytosis, and elevated erythrocyte
sedimentation(ESR)rate.
SAPHO Syndrome Synovitis, acne, acne fulminans,
palmoplantar pustulosis, hidradenitis suppurativa,
hyperostosis, and osteitis. Rare.

PAPA Syndrome Sterile pyogenic arthritis,

pyoderma gangrenosum acne. An inherited
autoinflammatory disorder; very rare.
Tropical Acne
- Flare of acne, usually with severe folliculitis,
inflammatory nodules, and draining cysts on trunk
and buttocks in tropical climates; secondary
infection with Staphylococcus aureus .