What is Acne Vulgaris ?
Overview
Acne vulgaris is a disorder of the sebaceous units. It is a chronic inflammatory dermatosis that results in open and closed comedones, papules, pustules and nodules. It affects the exocrine part of the body which is the skin.
Epidemiology:
Predominant age from early to late puberty, it may persist in 20% to 40% of the affected individuals to the fourth decade. It’s also predominant in males more than females in adolescence. And in females more than males in adults.
Etiology:
- androgens stimulate sebum production and proliferation of keratinocytes in hair follicle.
- Keratin obstructs hair follicle causing sebum accumulation and follicular distention.
- Propionibacterium acnes is an anaerobic bacterium that colonizes and proliferates in the plugged follicle. It promotes proinflammatory mediators causing inflammation of follicle and dermis.
Risk factors
- Increased endogenous androgenic effect.
- Oily comedogenic cosmetics.
- Rubbing or occluding the skin surface with mobile phones and hands against the skin.
- Numerous drugs including androgenic steroids, some birth control pills
- Endocrine disorders like polycystic ovarian syndrome, Cushing syndrome, congenital adrenal hyperplasia, acromegaly and androgen secreting tumors.
- Psychological distress
- High glycemic load and high diary diets may exacerbate acne.
Diagnosis
History:
Ask about duration, medications, cleansing products, stress, smoking, exposures, diet and family history. Females may worsen 1 week prior to menses.
Physical examination:
- Closed comedones (whiteheads)
- Open comedones (blackheads)
- Nodules or papules
- Pustules
- Most common areas affected are face, chest, back and upper arms.
- Tests are only indicated if additional signs of androgen increase, if so, test for free and total testosterone, LH and FSH.
- Grading system are done according to:
Mild: few papules/ pustules with no nodules
Moderate: some papules/ pustules with few nodules
Severe: numerous papules/ pustules with many nodules
Treatment
- Mild inflammatory acne: benzoyl peroxide or topical retinoid.
- Moderate inflammatory acne: add systemic antibiotic to grade two regimen.
- Severe inflammatory acne: as in grade three or isotretinion.
- Avoid topical antibiotics as monotherapy.
- Can use isotretinoin for treatment of resistant moderate acne.
- Use mild soap daily to control oiliness and avoid abrasives.
- Avoid drying agents with keratinolytic agents.
- Use gentle cleanser and non-comedogenic moisturizer to help decrease irritation.
- Use oil-free and non-comedogenic sunscreens.
- Topical retinoids are first line agents for maintenance, avoid long term antibiotics for maintenance.
- Keratinolytic agents (alpha-hydroxy acids, salicylic acid, topical retinoids, azelaic acid); side effects include dryness, erythema, and scaling; start with lower strength, increase as tolerated and tretinoin with varying strengths and formulations: Apply at bedtime; wash skin; let skin dry 30 minutes before application.
- Oral antibiotics: use for shortest possible period, generally needs 8 to 12 weeks of therapy, indicated when acne is more severe, unresponsive to topical agents, or at greater risk for scarring
- Tetracycline: 500 to 1,000 mg/day divided BID; high dose initially, side effects: photosensitivity, esophagitis
- Minocycline: 100 to 200 mg/day, divided daily—BID; side effects include photosensitivity, urticaria, gray-blue skin, vertigo, hepatitis, lupus.
- Doxycycline: 20 to 200 mg/day, divided daily—BID; side effects include photosensitivity.
- Erythromycin: 500 to 1,000 mg/day; divided BID–QID; decreasing effectiveness as a result of increasing P. acnes resistance
- Azithromycin 500 mg 3 days/week × 1 month, then 250 mg every other day × 2 months
- Oral retinoids
Isotretinoin: 0.5 to 1.0 mg/kg/day divided BID to maximum 2 mg/kg/day divided BID for very severe disease; 60–90% cure rate; usually given for 12 to 20 weeks. Side effects: teratogenic, pancreatitis, excessive drying of skin, hypertriglyceridemia, hepatitis, blood dyscrasias, hyperostosis, premature epiphyseal closure, suicidal ideation and psychosis. - Drospirenone/ethinyl estradiol or drospirenone/ethinyl estradiol/levomefolate.
- Spironolactone at 25 to 200 mg/day; antiandrogen; reduces sebum production.
For further reading:
https://www.webmd.com/skin-problems-and-treatments/acne/acne#1
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References
AL Chien, J Qi, B Rainer, et al. Treatment of acne in pregnancy. J Am Board Fam Med. 2016;29(2):254–262.
S Admani, VR Barrio. Evaluation and treatment of acne from infancy to preadolescence. Dermatol Ther. 2013;26(6):462–466.
AL Dawson, RP Dellavalle. Acne vulgaris. BMJ. 2013;346:f2634.
AL Zaenglein, AL Pathy, BJ Schlosser, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945.e33–973.e33.
