Acne Vulgaris

Mohammed Beyan/MD/

Dermatovenereologist

ALERT

Acne Vulgaris

Studies indicate that white patients are more likely to experience moderate to severe acne than black patients

Patients tend themselves as nervous tend to suffer more from acne

The peak of severity in females is 16-17 yrs and in males 17-19 yr

Acne clears by age of 23 – 25 in 90% of patients

Some 5% of women and 1% of men still need treatment in their thirties or even forties

Introduction

Etiology

Many factors combine to cause chronic inflammation of

blocked pilosebaceous follicles

The Pilosebaceous unit consists of cell lined hair follicle containing rudimentary ―بدائي‖ vellus hair (the

fine, non pigmented hairs that cover most of the body) and also consists of sebaceous gland.

The sebaceous gland’s secretions pass up ward

through the duct that carries the hair to the surface

Pilosebaceous density is greatest on the face, upper neck and chest

At puberty, an abnormal cohesion takes placebetween the epithelial cells that cover the unit,this is called keratinization – sebum outflow

is retarded.

Also androgens provoke the sebaceous glandsto become multilobular which results in anincreased sebum output.

Bacteria infect the part and leads toinflammation.

As sebum accumulates behind the keratoticplug, dilation distorts the normal folliculararchitecture, forming a microcomedo (asmall white head), …………………………..it

grows and become closed comedo known aswhite head

The pathophysiology

of acne

Increased and abnormal keratinization at theexit of the pilosebaceous follicle obstructs theflow of sebum, bacteria play a pathogenicrole.Propionibacterium acnes is a normalcommensal, it colonizes the pilosebaceousducts, breaks down the triglycerides, releasingfree fatty acids, produces substanceschemotactic for inflammatory cells andinduces the ductal epithelium to secrete proinflammatory cytokines.

Follicular rupture, which occurs to an inflamed pilosebaceous unit, results in formation of a papule, pustule or cyst (nodule)

In summary there are four main factors responsible for the

pathogenesis of acne: Increased sebum production,ductal hypercornification, bacterial proliferation

and inflammation

Whitehead: A condition of the skin characterized by a small, firm, whitish, closed elevation of the skin. Also known as a closed comedo; is a non inflammatory lesion.

Blackhead: A condition of the skin characterized by a black coloration at the skin surface. Also known as an open comedo; is a non inflammatory lesion.

Progression of acne

Comedo (plural comedones)—A comedo is a sebaceous

follicle plugged with sebum, dead cells from inside the

sebaceous follicle, tiny hairs, and sometimes bacteria

Comedonal acne

Comedonal acne is the earliest clinical expression of acne, is usually non inflammatory

Typically affects the central forehead, chin, nose and paranasal areas.

This form of acne develops in the preteenage or early teenage years as a result of increased sebum production and abnormal desquamation of epithelial cells.

Colonization by P. acnes has not yet occurred, so there usually are no inflammatory lesions. At this stage, therapy should be focused on prevention, minimizing formation of new comedones and the proliferation of P. acnes.

Cont……

Papular acne

papule is caused by localized cellular reaction to the process of acne

Most patients with acne present with comedones and papules on the face and trunk.

Their formation begins with noninflammatory comedonal acne progressing to a small number of inflammatory lesions on the face, which then evolve into a more generalized eruption first on the face and then trunk.

Papule; Circumscribed raised lesion <1cm in diameter

This photo shows papules and comedones on the face of an acne patient

Pustular acne

dome-shaped, fragile lesion containing pus that typically consists of a mixture of white blood cells, dead skin cells, and bacteria

A pustule that forms over a sebaceous follicle usually has a hair in the center

Acne pustules that heal without progressing to cystic form usually leave no scars

Pustules; Circumscribed raised lesions containing cloudy fluid. >0.5cm in diameter, Not

necessarily infected

papules and comedones on the face of an acne patient

Nodule acne

Nodular acne is a severe form of acne that may not respond to therapies other than isotretinoin

Cyst

Larger than a pustule, may be severely inflamed, extends into deeper layers of the skin, may be very painful, and can result in scarring

Cysts and nodules often occur together in a severe form of acne called nodulocystic

Nodule; Circumscribed raised lesion >1cm in diameter

Unpleasant cystic acne in teenager

Clinical features

More common

• Lesions are limited to the face, shoulders, upper chest and back

• Seborrhea (greasy skin) is often present

• Open comedones (black heads) due to plugging by keratin and sebum of the pilosebaceous orifice

• Closed comedones (white heads) due to accretions of sebum and keratin deeper in the pilosebaceous ducts are always evident

• Scarring may follow

Less common

•Conglobate acne is severe with many abscesses and cysts

•Acne fulminans is a type of conglobate acne accompanies by fever joint pains and a high erythrocyte sedimentation rate

•Exogenous acne may be caused by tars, chlorinated hydrocarbons, oils and oily cosmetics; comedones dominate the clinical picture

•Drug induced acne may result from treatment with corticosteroids, androgenic steroids, lithium, oral contraceptives and anti convulsant therapy.

Severity rating for acne

Type 1: comedones only, fewer than 10 lesions on theface, no lesions on the trunk and no scarring

Type 2: papules, 10 to 25 lesions on the face and trunk,mild scarring

Type 3: pustules, more than 25 lesions, moderatescarring

Type 4: nodules or cysts, extensive scarring

Premenstrual exacerbations of acne are very common, with about 70 percent of women frequently experiencing flare-ups of acne two to seven days before the onset of menses and gradual improvement at the beginning of the next menstrual cycle

Certain cosmetic ingredients, such as lanolins, petroleum bases, cocoa butter and pomades, can precipitate acne development

Exacerbating factors

Medications That Cause Acne•Hormones

•Testosterone, a male hormone, can induce acne in females and in pre-adolescent children.

•Gonadotrophin that may be prescribed in certain pituitary disorders can indirectly induce acne by

stimulating testosterone production.

•Anabolic steroids are masculinizing hormones that can provoke or aggravate acne.

•Corticosteroids, taken orally or applied topically to the skin, may cause a degeneration of the

epithelial lining of sebaceous gland

•Anti-epileptic Drugs

•Individuals with severe epilepsy often have many endocrine (hormonal) problems, including

abnormal testosterone secretion.

•Anti-tuberculosis Drugs

•Isoniazid, the most widely used drug for treating tuberculosis, has been associated with

precipitation or aggravation of acne in small numbers of patients.

•Lithium

•Acne precipitation or aggravation is one of the dermatologic side effects of lithium, a medication

prescribed in the treatment of bipolar disorder.

•Cyclosporin

•Dermatologic reactions, including precipitation or aggravation of acne, are frequently seen in post-

transplant patients who must take cyclosporin to prevent organ rejection. Since cyclosporin cannot

be discontinued in a post-transplant patient, the side effect of acne should be treated by a

dermatologist.

•Halogenated Drugs

•Medications containing iodine or bromine can cause acne-like eruptions. These medications are

much less common today than in earlier years, but some are still in use. In the United States today, it

is probably more likely to see acne-like outbreaks resulting from heavy consumption of iodine-

containing health foods such as kelp. An acneiform eruption caused by eating large amounts of kelp

is seen in this photo:

Therapy

Goals of therapy

Relieving discomfort

Preventing pitting or scarring

Limiting psychosocial distress

Good skin hygiene is a basic tenet in acne prevention

Twice-daily cleansing with warm water and a mild soap can effectively remove excess sebum and improve skin appearance.

Aggressive skin washings will not alter the course of acne and may actually aggravate acne by promoting the development of inflammatory lesions.

Abrasive or antibacterial cleansers are not recommended, and squeezing or picking of acne lesions should be discouraged without the use of disinfectants

Drugs, cosmetics or other known precipitants also should be avoided.

Non-drug therapy

Drug therapy

Retinoids work to normalize follicular keratinization;

Isotretinoin and hormone manipulations decrease sebum production;

Antibiotics and benzoyl peroxide target P. acnes.

Antibiotics and retinoids also are used to prevent inflammation associated with bacterial colonization,

Topical therapy generally is preferred over systemic agents for mild to moderate acne.

Comedonal acne

Topical antibacterial agents, such as benzoyl peroxide, Comedolytic agents, such as salicylic acid and tretinoin(Retin-A), that unplug follicles with their exfoliative effects.

Is one of the most effective agents against acne vulgaris, causing mild desquamation and comedolysis by increasing epithelial cell turnoverand unblocking pores.

Its main effect is due to its antibacterial property of releasing free radicals and oxidizing bacterial protein. While benzoyl peroxide minimally reduces sebum production, it significantly lowers FFA concentrations

Benzoyl peroxide

A mild comedolytic agent agents with mild antibacterial activity

Combination of these agents are considered synergistic

It may actually enhance absorption of other topical agents when used concurrently.

A recent review shows that salicylic acid pads are safe, effective and superior to benzoyl peroxide in preventing and clearing both types of acne lesions.

Salicylic acid, and Sulfur

Have been used successfully to treat acne for many years.

Tretinoin (Retin-A(R)), also called all-trans-retinoic acid, is the naturally occurring form of vitamin A acid and is considered the most effective topical comedolytic agent.

Retinoids indirectly reduce P. acnes colonization by decreasing sebum production, a requisite for bacterial survival.

Vitamin A analogues

They also decrease horny cell cohesiveness by stimulating epidermal cell turnover and normalizing keratinization.

These actions unplug follicles, which ultimately prevents microcomedone formation

Considered highly effective agents because their pharmacologic activities target each of the four known pathogenic factors.

Adverse effects with retinoid therapy occur in nearly all patients, with dryness, rednessand peeling at the site of application topping the list.

Cont…… Vitamin A analogues

Exposure to sunlight can significantly intensify irritation to the skin. If sun exposure is unavoidable, patients should use a sunscreen with an SPF of at least 15.

Topical tretinoin may further darken skin in patients with dark complexion.

Patients should be made aware that improvement may take six to 12 weeks, and that flare-ups of acne can occur during the first few weeks of therapy.

Cont…… Vitamin A analogues

Topical antibiotics are effective in treating mild to moderate inflammatory acne, and they offer the advantage of direct topical application and less systemic absorption.

The side effects are minimal, the most common being mild burning or irritation.

They also can be used as an adjunct therapy in nodulocystic acne.

Papular acneCont……

Available in a 1% solution, lotion or gel (Cleocin-T);

Various studies show it to be as effective as topical erythromycin or oral tetracycline.

A 12-week course of 1% clindamycin solution

twice daily showed significant reduction in the number of inflammatory and noninflammatory acne lesions.

Rare cases of pseudomembranous colitis have been reported with topical use of clindamycin.

Clindamycin

Considered to be the safest acne agent to use during pregnancy.

It is available in a 2% solution (Eryderm),

Topical erythromycin

њGels usually have a high alcohol content that allows for

better absorption, but they also can be more drying.

Therefore, a cream or ointment may be better tolerated in

patients with sensitive skin.

њGels are useful for patients with oily skin.

њFor optimal results, the entire susceptible area, not just

the lesions, should be treated.

Vehicle consideration is important in topical formulations

Patients with moderate to severe inflammatory acne may require oral antibiotics in addition to topical therapy

Systemic antibiotics can achieve a more rapid clinical improvement, usually two to six weeks, with maximal clinical improvement in three to four months

The disadvantages of oral antibiotics, though, lie in their side effects: gastrointestinal distress and vaginal candidiasis.

Pustular acne

Twice-daily dosing of systemic antibiotics normally improves compliance, is usually as effective as more frequent dosing and may be used for chronic therapy

Long-term use of antibiotics has been found to be safe and effective in treating acne

Cont…… Pustular acne

Generally considered the first choice of oral agents in pustular acne due to its documented effectiveness and low cost

With a usual starting dose of 250 mg four times daily or 500 mg twice daily, 250 mg twice daily for four months also was found to be safe and effective in treating papulopustular acne, with 95 percent of patients showing clinical improvement

Tetracycline

The antibiotic of choice in acne if cost were not a consideration.

It is highly effective in acne treatment due to its lipid solubility and ability to penetrate the sebaceous follicle

Minocycline is used in patients with tetracycline-resistant acne and achieves good absorption even when administered with food.

Minocyline

Doxycycline Is less expensive than minocycline and its high lipid

profile also makes it a good agent in acne treatment

The usual dose is 100 mg once daily, and side effects include

photosensitivity and gastrointestinal distress

The usual dose of erythromycin is similar to that for tetracycline.

P. acnes resistance to erythromycin is more common than with

tetracyclines according to various studies and gastrointestinal side

effects limit its use.

Erythromycin, though, has the advantages of not inducing

photosensitivity and not interacting with antacids and dairy

products.

Trimethoprim-sulfamethoxazole is reserved for

severe cases of acne refractory to other antibiotics

Therapy initiated at one double-strength tablet of

trimethoprim - sulfamethoxazole daily

Potential side effects include rash, photosensitivity,

dizziness and Steven-Johnson's syndrome ―SJS, is an extreme

allergic reaction, usually to a drug, but also to certain bacterial and viral

infections‖, a severe eruption reaction.

Despite the relative success of antibiotic therapy, many patients do

not achieve full suppression of inflammatory lesions with continued

antibiotic usage, explanations for which include differences in

dosage regimens, drug absorption and patient compliance

Resistance to P. acnes should be considered in patients whose

response decreases with therapy that previously was successful

It did not become a problem until the mid 1970s, despite nearly two

decades of antibiotic usage

British studies reveal that resistance to erythromycin is most

prevalent, with the majority of the strains also being resistant to

clindamycin. Cross-resistance between tetracycline and doxycycline

also has been reported

Failure of antibiotic therapy

Treatment options for these patients include isotretinoin,

steroid injections and hormone therapy

Systemic antibiotics can also be used in treating cystic

acne, but long-term use may be limited by resistance and

adverse effects, including photosensitivity, gastrointestinal

disorders and vaginitis

Nodulocystic acne

Is a synthetic 13-cis-isomer of tretinoin, usually more effective than tretinoin and available as 10-, 20- or 40-mg oral capsules

It is the only systemic agent that decreases sebum production and reverses the abnormal epithelial desquamation process

It also can decrease the population of P. acnes in the sebaceous follicle, making it the treatment of choice for patients with severe nodulocystic acne

Isotretinoin

The initial dose of isotretinoin is 0.5 to 1.0 mg/kg or 40 mg to 80 mg per day, with a usual course of therapy of four to five months

Transient exacerbation of acne may occur during the first few weeks of therapy, but most patients respond well over time

Usually no further therapy is needed. Satisfactory response rate has been as high as 90 percent with a low relapse rate of 31 percent at nine years

Cont……

Adverse effects of systemic isotretinoin include cheilitis (lip inflammation), dry skin, pruritus, photosensitivity and mild to moderate musculoskeletal symptoms

Dryness of the eye also can occur, so patients wearing contacts should be warned not to wear them

Pseudo-tumor cerebri (benign intracranial hypertension) can occur if isotretinoin is taken concurrently with tetracycline

Cont……

Isotretinoin is contraindicated throughout pregnancy due to teratogenic effects

Contraception should be used throughout therapy and continued for at least one month after the last dose

Due to these serious adverse effects and overuse potential, strict guidelines exist for isotretinoin therapy

Cont……

Don't Pick!Not only does squeezing pimples cause further infection and inflammation, but it can also spread the bacteria (and the acne) from one pore to the next.

Acne 2007 SC

Acne 2007 SC

Acne 2007 SC

Acne 2007 SC

Acne 2007 SC