ACNE ACNE VULGARISVULGARIS

Acne vulgaris (AV)Acne vulgaris (AV) is a self is a self

limiting disease, seen limiting disease, seen

primarily in adolescents primarily in adolescents

involving the sebaceous involving the sebaceous

follicles.follicles.

Definition

May be present at birth or May be present at birth or

first 6 months of life.first 6 months of life.

In girls, the occurrence of In girls, the occurrence of

acne may precede acne may precede

menarche (14 – 16 years).menarche (14 – 16 years).

Epidemiology

Boys tend to have a peak Boys tend to have a peak incidence between ages 16 & incidence between ages 16 & 19 years.19 years.

Nodulocystic acne to be more Nodulocystic acne to be more common in while males than common in while males than in black males.in black males.

Acne is more severe in Acne is more severe in patient with xyy genotypepatient with xyy genotype

Etiology & Pathogenesis

Basic cause of acne in Basic cause of acne in

unknown.unknown.

Acne is a multifactorial Acne is a multifactorial

disease.disease.

Four principal pathologic in Four principal pathologic in acne are :acne are :1.1. Abnormal follicular Abnormal follicular

keratinization.keratinization.2.2. Increased sebum production.Increased sebum production.3.3. Proliferation of Proliferation of

Propionibacterium acnes in Propionibacterium acnes in the sebum.the sebum.

4.4. Inflammation.Inflammation.

Androgen are known to Androgen are known to

regulate the development of regulate the development of

the sebaceous gland & sebum the sebaceous gland & sebum

production.production.

Patient with acne may have Patient with acne may have

increased levels of circulating increased levels of circulating

androgens.androgens.

Stress is known to increase Stress is known to increase

the output of adrenal steroids, the output of adrenal steroids,

which may affect the which may affect the

sebaceous glands.sebaceous glands.

Clinical Manifestations

Primary site Primary site face, upper face, upper

back, chest, shoulder.back, chest, shoulder.

Lesion may be non Lesion may be non

inflammatory or inflammatory.inflammatory or inflammatory.

Non-inflammatory lesion Non-inflammatory lesion

comedones :comedones :

• Open (blackheads).Open (blackheads).

• Closed (whiteheads).Closed (whiteheads).

Open comedoOpen comedo a flat or a flat or

slightly raised lesion with a slightly raised lesion with a

central dark colored central dark colored

follicular impaction of keratin follicular impaction of keratin

& lipid.& lipid.

Closed comedoClosed comedo pale, pale,

slightly elevated, small slightly elevated, small

papules & do not have a papules & do not have a

clinically visible orifice.clinically visible orifice.

Inflammatory lesions vary Inflammatory lesions vary from small papules with an from small papules with an inflammatory areola to inflammatory areola to pustules to large, fluctuant pustules to large, fluctuant nodules.nodules.Large nodules Large nodules nodulocystic (severe cases nodulocystic (severe cases of inflammatory acne).of inflammatory acne).

Patient may have scars of Patient may have scars of

varying size varying size a sharply a sharply

punched out pit.punched out pit.

Diagnosis

Finding of mixture of Finding of mixture of lesions of acne :lesions of acne :

Comedones.Comedones.Pustules.Pustules.Papules.Papules.Nodules on the face.Nodules on the face.Back.Back.Chest.Chest.

Differential Diagnosis

Folliculitis.Folliculitis.

Rosasea.Rosasea.

Perioral dermatitis.Perioral dermatitis.

Treatment

1.1. Topical therapy :Topical therapy : Tretinoin :Tretinoin :

• Cream : 0,025%, 0,05%, Cream : 0,025%, 0,05%,

0,1%.0,1%.

• Gel : 0,01%, 0,025%.Gel : 0,01%, 0,025%.

• Liquid : 0,05%.Liquid : 0,05%.

Benzoyl peroxideBenzoyl peroxide : lotion, : lotion,

creams, gels, washes creams, gels, washes

(2,5%, 5%, 10% (2,5%, 5%, 10%

concentrations).concentrations).

Topical antibiotics :Topical antibiotics :• Clindamycin : gel, lotion, Clindamycin : gel, lotion,

solution (1%).solution (1%).• Erythromycin in 1 – 2% Erythromycin in 1 – 2%

solution, ointment.solution, ointment.• Azelaic acid : cream 20%.Azelaic acid : cream 20%.• Cleaning agents.Cleaning agents.• Astringents.Astringents.

2.2. Physical therapy :Physical therapy : Cryoslush therapy.Cryoslush therapy. Ultraviolet light.Ultraviolet light. Radiation therapy.Radiation therapy. Acne surgery.Acne surgery. Intralesional Intralesional

corticosteroid : 0,05 – 0,25 corticosteroid : 0,05 – 0,25 ml per lesion ml per lesion (triamcinolone acetate).(triamcinolone acetate).

3.3. Systemic therapy :Systemic therapy : Antibiotic :Antibiotic :• Tetracycline : 500 – 1000 Tetracycline : 500 – 1000

mg/d for 4 – 5 weeks.mg/d for 4 – 5 weeks.Dose can be reduced to a Dose can be reduced to a maintenance level of 250 maintenance level of 250 – 500 mg/d for several – 500 mg/d for several months.months.

• Minocycline : 50 – 100 mg Minocycline : 50 – 100 mg

once ro twice daily.once ro twice daily.

• Doxycycline : 50 mg twice Doxycycline : 50 mg twice

daily, severe cases daily, severe cases 100 mg 100 mg

twice daily.twice daily.

• Sulfonamide.Sulfonamide.

Hormonal therapy :Hormonal therapy :• Estrogens : ethynil Estrogens : ethynil

estradiol 0,035 – 0,050 mg.estradiol 0,035 – 0,050 mg.• Oral contraceptives.Oral contraceptives.• Glucocorticoids.Glucocorticoids.• Gonadotropin-releasing Gonadotropin-releasing

hormon agonists.hormon agonists.• Antiandrogen.Antiandrogen.

Retinoids : Retinoids :

Recommended dose Recommended dose 0.5 0.5

– 2 mg/kg for 15 – 20 – 2 mg/kg for 15 – 20

weeks.weeks.

Favorable with spontaneous Favorable with spontaneous

resolution.resolution.

Physical sequela : Physical sequela : scar scar

special cure (peeling and special cure (peeling and

dermabration).dermabration).

Prognosis