Acne vulgaris
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This document provides an overview of acne vulgaris, including its definition, pathogenesis, variants, treatment, and complications. Acne is caused by abnormalities in sebum production, desquamation, and bacterial proliferation in pilosebaceous units. It commonly presents as comedones, papules, pustules or nodulocystic lesions in adolescents. Treatment involves topical retinoids, benzoyl peroxide or antibiotics for mild-moderate acne, and oral isotretinoin or antibiotics for severe nodulocystic acne. Complications can include post-inflammatory hyperpigmentation or scarring.
Acne vulgaris
- 2. INDEX • DEFINITION • ACNE VULGARIS (an overview) • EPIDEMEOLOGY • ETIOLOGY AND PATHOGENESIS • ACNE VARIANTS • LABORATORY TESTS • TREATMENT
- 3. DEFINITION • Acne vulgaris is a common dermatological disorder of the pilosebaceous unit that has a complex pathophysiology. • it can be triggered by a number of factors such as, abnormalities in sebum production follicular desquamation bacterial proliferation and inflammation Prevalence • 85% in adolescents • 3.8% in 25 - 34 year old’s • 4.3% in 35 - 44 year old’s
- 4. ACNE VULGARIS (an overview) • Affects the Pilosebaceous unit • Self-limited disorder that is seen primarily in adolescents Variety of lesions: Comedones - (closed and open)Whiteheads and blackheads Papules- Small or larger red or skin-colored acne bumps Pustules- Bumps filled with white or yellow pus Nodulocystic- Very large pus-filled, often painful acne lesions
- 5. EPIDEMIOLOGY • Mild degrees of acne frequently seen at birth, resulting from follicular stimulation by adrenal androgens in neonatal period • In the very young patients the predominant lesions are Comedones • Particularly in women, acne may persist through out the third decade or even later • Nodulocystic acne has been more common in white males than in black males.
- 6. ETIOLOGY AND PATHOGENESIS Pathogenesis of acne Four basic steps have been identified I. Follicular epidermal hyperproliferation (microcomedones) II. Excess sebum production III. Inflammation IV. The presence and activity of Propionobacterium acnes
- 8. FACTORS AFFECTING KERATINOCYTE HYPERPROLIFERATION • Androgen stimulation • Decreased linoleic acid • Increased interleukin (IL) 1a activity
- 9. EXCESS SEBUM PRODUCTION • Excess sebum production from sebaceous glands • Components of sebum : 1) Triglycerides – free fatty acids converted by p.acnes 2) Promote bacterial clumping and colonization of p.acnes, incites inflammation.
- 10. INFLAMMATION • Micromedo continues to expand with densely packed keratin sebum, and bacteria. • This distension causes follicular wall rupture. • Extrusion of keratin, sebum and bacteria into the dermis results in a brisk of inflammatory response.
- 11. CLINICAL FINDINGS • Neonatal acne appears at approximately 2 weeks of age and infantile acne develops at 3 to 6 months of age. • Hyperandrogenism should be considered in the female patient whose acne is severe, sudden onset, or associated with hirsutism or irregular menstrual periods.
- 12. • Drug-induced acne may be caused by: Anabolic steroids Corticosteroids Corticotropin Phenytoin Lithium Isoniazid • Vitamin B complexes - Prolonged use might cause an irritation of the follicular epithelium and subsequently produces an inflammatory reaction
- 13. Chemotherapy medication Cancer drugs Doxorubicin (Andriamycin) Erlotinib (Tarceva) Paclitaxel (Taxol) Cetuximab (Erbitux) EGFR-blocking agents playing a central role in the normal differentiation and development of hair follicle.
- 14. SITES OF PREDILECTION • Primary sites of acne are : Face Back Chest shoulders
- 15. NON INFLAMMATORY TYPES lesions are Comedones It may be either open (blackheads) or closed (whiteheads).
- 16. INFLAMMATORY TYPES • Papules- Small or larger red or skin-coloured acne bumps • Pustules- Bumps filled with white or yellow pus • Nodulocystic- Very large pus-filled, often painful acne lesions
- 17. ACNE VARIANTS • Neonatal acne - Lesions appear within 2 weeks and resolve in 3 months • Infantile acne - 3 to 6 months of age marked by the presence of comedones
- 18. • Acne Conglobata - Common in teenage males • Acne Fulminans - Known as (acute febrile ulcerative acne) Treated with systemic glucocorticoids and isotretinoin
- 19. SAPHO syndrome • Synovitis Acne Pustulosis Hyperrostosis Osteitis (SAPHO) • Inflammatory bone disorder PAPA syndrome • PyogenicArthritis, Pyodermagangrenosum and Acne • Rare genetic disorder
- 20. Acne Excoriee des Jeunes Filles( Excoriated acne) • Mild acne accompanied by extensive excoriations. Acne Mechanica • Acneiform eruption, observed after repetitive physical trauma to the skin (rubbing, occurring from clothing (belts and straps) or sports equipments (football helmets and shoulder pads)
- 21. Acne with Solid Facial Edema • Known as Morbihan disease Can be treated with, • Isotretinoin (0.2 to 0.5 mg/kg/day) • Oral glucocorticoids (1 to 2 mg/day) • Clofazimine for 4 to 5 months Acne with Associated Endocrinologic Abnormalities Due to Irregular menstrual cycle Causes deepened voice hirsutism
- 22. TREATMENT OF ACNE VULGARIS Non-inflammatory (Comedones) acne Retinoids 1) Comedolytic and anti-inflammatory properties 2) Inactivated by concomitant use of benzoyl peroxide 3) Photolabile
- 23. RETIN A CREAM • Tretinion - 0.05% • Hyodrophilic base • Butylated hydroxytoluene • Isopropyl myristate • Polyoxyl stearate • Purified water • Sorbic acid • Stearic acid • Stearyl alcohol • Xanthan gum
- 24. Cleargel AP Gel • Clindamycin phosphate -1.0% • Adapalene - 0.1% • Emmolient gel base • Methyl paraben – 0.1% • Phenoxyethanol – 0.25%
- 25. Azelaic acid • Antimicrobial and comedolytic properties • Competitive inhibitor of tyrosinase, decreasing pigmentation • Safe in pregnancy Azelaic acid - 10% w/w Tretion BP – 0.05%w/w Phenoxyethanol IP – 0.5%w/w Aloevera gel 3 glyceryl ascorbate
- 26. Benzoyl Peroxide • antimicrobial • Anti - comedonal • safe in pregnancy Glycolic acid cream reduce wrinkles, acne scarring and hyperpigmentation • Promotes desquamation • commonly used as a chemical peel
- 27. INFLAMMATORY ACNE (PAPULAR) Topical Retinoids • Reduces keratinization Benzoyl Peroxide • antimicrobial • Anti - comedonal • safe in pregnancy
- 28. Sodium Sulfacetamide Promotes desquamation Topical antibiotic • Anti-microbial spectrum
- 29. TREATMENT OF ACNE VULGARIS ,INFLAMMATORY (PUSTULAR) Pustular Doxycycline • Antibiotic spectrum Minocycline • Bacteriostatic antibiotic Erythromycin • Antimicrobial spectrum Lymecycline • Antibiotic spectrum
- 30. TREATMENT OF INFLAMMATORY ACNE VULGARIS Nodulocystic Isotretinoin Oral corticosteroids
- 31. HORMONALLY INDUCED ACNE Oral contraceptives Antiandrogens(Spironolactone)
- 32. TREATMENT OF HORMONALLY INDUCED ACNE VULGARIS _ (CONT) * Corticosteroids * flutamide
- 33. INTRALESIONAL GLUCOCORTICOIDS • Decrease the size of deep nodular lesions • Injection of triamcinolone acetonide suspension
- 34. ADVERSE EFFECTS OF MEDICATIONS USED TO TREAT ACNE MEDICATIONS ADVERSE EFFECTS TOPICAL RETINOIDS EX: Tretinoin Local irritation photosensitivity Adapalene Local irritation (slightly less than tretinoin) photosensitivity Isotretinoin Local irritation Photosensitivity Contraindicated in pregnancy and nursing Benzoyl peroxide Local irritation Can bleach hair and clothing
- 35. TOPICAL ANTIBIOTICS MEDICATIONS ADVERSE EFFECTS Metronidazole Tetracycline Can cause yellow staining of skin and clothing Clindamycin Theoretically can cause pseudomembranous colitis Erythromycin Azelaic acid
- 36. ORAL ANTIBIOTICS MEDICATIONS ADVERSE EFFECTS Tetracycline Contraindicated in pregnancy and in children under age 12 due to tooth discoloration Doxycycline Photo toxicity Oesophageal ulceration Minocycline Vertigo pseudotumour Erythromycin Gastrointestinal compliants Oral isotretinoin Teratogenecity (absolute contraindicated in pregnancy and nursing ) Mucocutaneous effects hypertriglyceridemia Depression Bone marrow supression
- 37. ACNEIFORM ERUPTIONS Steroid Folliculitis • Occur in adolescents and adults ,2 weeks after the start of steroids. • Lesions have the same stage of development Drug-Induced eruptions Glucocorticoids Phenytoin Lithium Isoniazid High-dose vitamin B complex
- 38. • Halogenated compounds • Chemotherapy Induced eruptions, Doxorubicin (Andriamycin) Erlotinib (Tarceva) Paclitaxel (Taxol) Cetuximab (Erbitux
- 39. Epidermal Growth Factor Receptor Inhibitor- Associated Eruption • Used to treat i. small cell lung cancer ii. colorectal cancer iii. breast cancer • Highly expressed in the basal cell layer of the epidermis • follicular keratinocytes • sebaceous epithelium, resulting in eruptions. Occupational acne and Chloracne Due to tar derivatives Insoluble cutting oils Chlorinated hydrocarbons- (chloracne)
- 40. Gram- Negative Folliculitis • Treated with long-term oral antibiotics • Improves with oral Isotretinoin for 4 to 5 months Radiation acne • Ionizing radiation and UV radiation • Lesions usually distributed at temporal and periorbital areas • Treated with oral or topical retinoids and extraction Tropical acne • Mainly on trunk and buttocks
- 41. ROSACEAE Rosacea • Mild, moderate, and severe • Causes burning and stinging of the facial skin • Sebaceous or glandular features characterized by thickened skin and large follicular orifices • Ocular rosacea may develop before cutaneous symptoms up to 20% • Severe cases - rosacea keratitis may lead to vision loss
- 42. PERIORAL DERMATITIS • Discrete and grouped erythematous papules, vesicles, and pustules • Unilateral and appear in the perioral, perinasal, and periorbital regions • Distinct of 5-mm clear zone at the vermilion edge • In addition also appears on the ears, scalp, trunk and extremities
- 43. OTHER DIFFERENTIAL DIAGNOSIS Diagnosis is available most likely for, Closed comedonal acne • Milia • Sebaceous hyperplasia Open comedonal acne • Dilated pore of Winer • Favre- Racouchot syndrome Inflammatory acne • Rosacea • Perioral Dermatitis Neonatal acne • Miliariarubra
- 44. ALWAYS RULE OUT: Closed comedonal acne eruptions could be due to, * Acne due to systemic agents (ex: corticosteroids) * Contact acne (ex: occupational acne) * Chloracne Open comedonal acne eruptions could be due to, * Acne due to systemic agents * Contact acne * Chloracne
- 45. • Inflammatory acne eruptions due to, * Acne due to systemic agents * Staphylococcal folliculitis * Gram negative folliculitis *Eosinophillic folliculitis *Furuncle/carbuncle • Neonatal acne eruptions due to, *Candidal infections *Benign neonatal cephalic pustulosis
- 46. COMPLICATIONS • Acne lesions have the potential to resolve with sequelae. • Acne lesions leave a transient macular erythema after resolution causing, 1) post-inflammatory hyperpigmentation 2) Scarring • Acne vulgaris also take a psychological toll 1) 30% to 50% adolescents have psychiatric disturbances due to acne
- 47. Sequelae: 4 general types of acne scars:- • Ice pick- narrow, deep scars widest at the surface of the skin and taper to a point in the dermis. • Rolling- shallow, wide scars that have undulating appearance. • Box scar – wide, sharply, demarcated scars. • Hypertrophic- scars on the trunk
- 48. REFERENCES • Fitzpatrick’s Dermatology in General Medicine Seventh Edition(Volume 1, Chapter 78; pp 690-703) • Sheretz EF. Acneiform eruption due to "megadose" vitamins B6 and B12. Cutis. 1991 Aug,48(2): 119-20 • Adams DH, Nutt T. A case report and discussion of cetuximab-induced folliculitis. Am J ClinDermatol 2006.
- 49. Thank You