8/16/2019 Practice Essentials Acne

http://slidepdf.com/reader/full/practice-essentials-acne 1/6

Practice EssentialsAcne vulgaris is a common chronic skin disease involving blockage and/or inflammation

of pilosebaceous units (hair follicles and their accompanying sebaceous gland). Acne can

 present as noninflammatory lesions, inflammatory lesions, or a mixture of both, affecting

mostly the face but also the back and chest.[1 !ee the image belo".

 Acne, grade #$ multiple open comedones.

Acne vulgaris has a multifactorial pathogenesis, of "hich the key factor is genetics.

[% 

Acne develops as a result of an interplay of the follo"ing four factors& (1) follicular

epidermal hyperproliferation "ith subse'uent plugging of the follicle, (%) excess sebum

 production, () the presence and activity of the commensal bacteriaropionibacterium

acnes, and (*) inflammation.[

Signs and symptoms

Acne vulgaris is characteri+ed by noninflammatory, open or closed comedones and by

inflammatory papules, pustules, and nodules. Acne vulgaris typically affects the areas of

skin "ith the densest population of sebaceous follicles (eg, face, upper chest, back). ocal

symptoms of acne vulgaris may include pain, tenderness, or erythema.

!ystemic symptoms are most often absent in acne vulgaris. !evere acne "ith associatedsystemic signs and symptoms, such as fever, is referred to as acne fulminans. !evere

acne, characteri+ed by multiple comedones, "ithout the presence of systemic symptoms,

is kno"n as acne conglobata. -his severe form of acne fre'uently heals "ith disfiguringscars. Additionally, acne vulgaris may have a psychological impact on any patient,

regardless of the severity or the grade of the disease.[*

!ee linical resentation for more detail.

8/16/2019 Practice Essentials Acne

http://slidepdf.com/reader/full/practice-essentials-acne 2/6

Diagnosis

xamination in patients "ith acne vulgaris includes the follo"ing features&

•

omedonal acne& resence of open and closed comedones but usually no inflammatory papules or

nodules

•

•

0ild acne& resence of comedones and a fe" papulopustules

•

•

0oderate acne& resence of comedones, inflammatory papules, and pustules$ a greater number of

lesions are present than in milder inflammatory acne

•

•

 odulocystic acne& resence of comedones, inflammatory lesions, and large nodules greater than 2

mm in diameter$ scarring is often evident

•

aboratory tests

Acne vulgaris is a clinical diagnosis. 3o"ever, laboratory testing may be indicated in thefollo"ing situations&

•

4emale patients "ith dysmenorrhea or hirsutism& onsider a hormonal evaluation "ith levels of total

and/or free testosterone, dehydroepiandrosterone sulfate, luteini+ing hormone, and follicle5

stimulating hormone

•

•

ases refractory to treatment or "hen improvement is not maintained& ulture skin lesions to rule

out gram5negative folliculitis•

!ee 6orkup for more detail.

Management

-reatment of acne vulgaris should be directed to"ard the kno"n pathogenic factors,

including follicular hyperproliferation, excess sebum, acnes, and inflammation. -hemost appropriate treatment is based on the grade and severity of the acne.

harmacotherapy

-he follo"ing medications are used in the treatment of ropionibacterium acne vulgaris&

•

7etinoid5like agents (eg, topical tretinoin, adapalene, ta+arotene, isotretinoin)

•

•

Antibiotics (eg, tetracycline, minocycline, doxycycline, trimethoprim/sulfamethoxa+ole,

clindamycin, topical clindamycin, topical erythromycin, daptomycin)

•

•

8/16/2019 Practice Essentials Acne

http://slidepdf.com/reader/full/practice-essentials-acne 3/6

!elective aldosterone antagonists (eg, spironolactone)

•

•

strogen/progestin combination oral contraceptive pills (eg, ethinyl estradiol, drospirenone, and

levomefolate$ ethinyl estradiol and norethindrone$ ethinyl estradiol and norgestimate$ ethinyl

estradiol and drospirenone)

•

•

Acne products (eg, erythromycin and ben+oyl peroxide, clindamycin and tretinoin, clindamycin and

 ben+oyl peroxide, a+elaic acid, ben+oyl peroxide)

•

6hen a topical or systemic antibiotic is used, it should be used in con8unction "ith

 ben+oyl peroxide or topical retinoid to reduce the emergence of resistance.

 onpharmacotherapy

9iet therapy, such as a lo"5glycemic diet and avoidance of “ 8unk foods,” has been

suggested as a nonpharmacologic measure to manage acne vulgaris.

rocedures

rocedural treatments for acne vulgaris include the follo"ing&

•

0anual extraction of comedones

•

•

#ntralesional steroid in8ections

•

•

!uperficial peels that use glycolic or salicylic acid

•

!ee -reatment, :uidelines, and 0edication for more detail.

BackgroundAcne vulgaris is characteri+ed by noninflammatory, open or closed comedones and byinflammatory papules, pustules, and nodules. Acne vulgaris typically affects the areas of

skin "ith the densest population of sebaceous follicles$ these areas include the face, the

upper part of the chest, and the back.

Acne vulgaris is the most common skin disease in the ;nited !tates$ it affects an

estimated <=> of Americans at some time during their lives.[2 -"enty percent have

severe acne, "hich can result in permanent physical and mental scarring.

0edscape 7eference articles on acne include Acne onglobata,Acne 4ulminans,Acne

?eloidalis uchae, and Acneiform ruptions. Also see the 0edscape Acne 7esource

enter .

Pathophysiology

8/16/2019 Practice Essentials Acne

http://slidepdf.com/reader/full/practice-essentials-acne 4/6

-he pathogenesis of acne vulgaris is multifactorial. -he key factor is genetics.[%Acne

develops as a result of an interplay of the follo"ing four factors[ &

•

7elease of inflammatory mediators into the skin

•

•

4ollicular hyperkeratini+ation "ith subse'uent plugging of the follicle

•

•

ropionibacterium acnes follicular coloni+ation

•

•

xcess sebum production

•

7esearch has sho"n that inflammatory responses actually occur before

hyperkeratini+ation. ytokines produced by 9*@ - cells and macrophages activate localendothelial cells to up5regulate inflammatory mediators such as vascular cell adhesion

molecule51 (A051), intercellular adhesion molecule51 (#A051), and human

leukocyte antigen (3A)–97 in the vessels around the pilosebaceous follicle.[B

4ollicular hyperkeratini+ation involves increased keratinocyte proliferation and decreaseddes'uamation, leading to sebum5 and keratin5filled microcomedones.[C

acnes is an anaerobic organism present in acne lesions. -he presence of

acnes promotes inflammation through a variety of mechanisms. acnes stimulates

inflammation by producing proinflammatory mediators that diffuse through the follicle

"all. !tudies have sho"n that acnes activates the toll5like receptor % on monocytes andneutrophils.[<

 Activation of the toll5like receptor % then leads to the production of

multiple proinflammatory cytokines, including interleukins 1% and < and tumor necrosisfactor. 3ypersensitivity to acnes may also explain "hy some individuals developinflammatory acne vulgaris "hile others do not.[D

xcess sebum is another key factor in the development of acne vulgaris. !ebum

 production and excretion are regulated by a number of different hormones and mediators.

#n particular, androgen hormones promote sebum production and release.[1= -he degree

of comedonal acne in prepubertal girls correlates "ith circulating levels of the adrenal

androgen dehydroepiandrosterone sulfate (93A5!).[11

 umerous other mediators and receptors, including gro"th hormone and insulinlike

gro"th factor, as "ell as peroxisome proliferator5activated receptors also regulate the

sebaceous gland and may contribute to the development of acne.[1%, 1

4urthermore, thesebaceous gland acts a neuroendocrine5inflammatory organ that is activated via

corticotrophin5releasing hormones in response to stress and normal functions.[1*

EpidemiologyUnited States

8/16/2019 Practice Essentials Acne

http://slidepdf.com/reader/full/practice-essentials-acne 5/6

Acne vulgaris affects <=> of Americans at some time during their lives.[2 -"enty percent

have severe acne, "hich can result in permanent physical and mental scarring.

Inte national

ersons of some races are affected more than others. ystic acne is prevalent in the

0editerranean region from !pain to #ran.[12

Race

Acne is common in orth American "hites. African Americans have a higher prevalenceof pomade acne, likely stemming from the use of hair pomades. thnicities "ith darker

skin are also more prone to postinflammatory hyperpigmentation.[1B

Se

9uring adolescence, acne vulgaris is more common in males than in females. #n

adulthood, acne vulgaris is more common in "omen than in men.[1C

!ge

Acne or acneform lesions, such as in neonatal cephalic pustulosis, may be present in thefirst fe" "eeks and months of life, "hen a ne"born is still under the influence of

maternal hormones and "hen the androgen5producing portion of the adrenal gland is

disproportionately large.[1< -his neonatal acne tends to resolve spontaneously. 3o"ever,

some neonates may re'uire therapy (eg, topical retinoids).[1<

Adolescent acne usually begins "ith the onset of puberty, "hen the gonads begin to produce and release more androgen hormone.

Acne is not limited to adolescence. -"elve percent of "omen and 2> of men at aged %2

years have acne. Ey age *2 years, 2> of both men and "omen still have acne.[1D

PrognosisAcne may cause long5lasting and detrimental psychosocial and physical effects. #t is

associated "ith depression and anxiety, regardless of disease severity, although the

 psychological effects usually improve "ith treatment. 4urthermore, acne may cause permanent scarring that is difficult to correct.[%=

#n male patients, acne generally clears by early adulthood. 4ive percent of men still have

acne at age %2 years. 4emale patients fre'uently have adult acne. -"elve percent of

"omen still have acne at age %2 years. 4ive percent of "omen still have acne at age *2years.[1D

-he overall prognosis for persons "ith acne is good.

Patient Educationatients should be instructed on their morning and evening treatment programs. 7etinoiddermatitis may develop at approximately day 1= of therapy. atients must be informed of

this in advance so they "ill not consider this exfoliation an allergy. Ey skipping a day or

% and restarting the program slo"ly, the skin can adapt to this irritation.

8/16/2019 Practice Essentials Acne

http://slidepdf.com/reader/full/practice-essentials-acne 6/6

rescriptions should be accompanied by a discussion of the potential adverse effects.

4or patient education resources, see the !kin onditions and Eeauty enter  as "ell as the

 patient education article Acne. Also see the 0edscape Acne 7esource enter .