Acne

Acne- definition, etiology, classification, lab diagnosis and management.

1. ACNE VULGARIS

2. What is it? Disorder of pilosebaceous complex which predominantly affects the peripubertal population and manifest as comedones , papules, nodules, pustules and cysts and heals with scars.

3. ETIOLOGY Increased sebum secretion. Follicular duct hypercornification . Increased colonization with Propionibacterium . Inflammation.

4. PATHOGENESIS Occlusion of pilosebaceous orifice. Increased sebum secretion. Microbial colonization. Release of inflammatory mediators.

5. OCCLUSION OF PILOSEBACEOUS ORIFICE Occluded by keratinous plug induced by chemicals and reduced level of linoleic acid in sebum Retention of sebum encouraging growth of microbes. Distended follicle rupture, releasing proinflammatory chemicals into dermis Stimulate inflammation.

6. INCREASED SEBUM SECRETION Occurs due to end organ sensitivity to androgens. Increased activity of 5 α reductase in sebaceous gland. Converts testosterone to 5 α testosterone Binds to receptors in sebaceous gland Increase sebaceous secetion .

7. Microbal colonization Organisms involved- Propionibacterium , Malassezia furfur,Staph epidermidis Bacteria thrive Inflammation results Chemotactic factors attract neutrophils Depending on conditions Non-inflammatory open/closed comedones Inflammatory papule/ pustule/nodule

8. EPIDEMIOLOGY PREVELANCE -affects all adolescents. AGE- Onset-12-14 years. GENDER- Both sexes equally but nodulocystic acne common in males.

9. FACTORS GENETIC PREDISPOSITION Found to be familial Identical twins shows greater concordance of severity of acne. DIET High glycemic diet. COSMETICS Seen in women using oil based cosmetics for long time. Follows facial massage. MENSTRUAL CYCLE Premenstrual edema of pilosebaceous duct. PSYCHOLOGICAL FACTORS

10. MORPHOLOGY Polymorphic eruption consisting of papules, pustules, nodules, cysts, and pathognomic open and closed comedones on a background of oilness .

11. COMEDONES H yperkeratotic plug made of sebum and keratin in follicular canal. Pathognomic lesions of acne vulgaris. 2 types: Open comedones . Closed comedones .

12. OPEN COMEDONES Also known as Black head. Due to plugging of pilosebaceous orifice by keratin and sebum on the skin surface.

13. CLOSED COMEDONES Due to keratin and sebum accretions plugging the pilosebaceous ducts below the skin surface. SUBMARINE COMEDONES-deep seated and seen by stretching the skin.

14. Grades of Acne ( Pillsburry’s classification) Grade I: C omedones (open or closed), occasionally pustules or papules; no scarring. Grade II: papules, comedones , few pustules; mild scarring. Grade III: predominant pustules, nodules, abscesses; moderate scarring. Grade IV: mainly cysts, abscesses, scars; severe scarring.

15. SCARS Acne scars can be: Depressed scars Ice pick scars- deep pits. Box car scars-superficial/deep Rolling scars Hypertrophic and keloidal scars.

16. VARIANTS

17. ACNE CONGLOBATA Severe form of acne characterised by intercommunicating abscess, cysts, and sinuses loaded with serosanguinous fluid or pus. Multiporous comedones . Lesions take months to heal and on healing leave behind deep pitted or hypertrophic scars.

18. OCCUPATIONAL ACNE Caused by exposure to industrial chemicals (tar, chlorinated hydrocarbons) and cutting oils. Predominantly comedones

19. COSMETIC ACNE Seen in women using cosmetics(oil based ones) Comedones Frequently on the chin

20. DRUG INDUCED ACNE Steroids, androgens, oral contraceptives, antitubercular drugs, iodides, bromides and anticonvulsants. Lesions are monomorphic, consisting of papules and pustules Site- trunk especially back.

21. INFANTILE ACNE Due to presence of maternal hormones in child. Common in males.

22. LATE ONSET ACNE Onset after 25 years of age. Predominantly women. Deep seated persistent lesions on lower half of face.

23. ACNE EXCORIEE Seen in young girls, who obsessively pick their mild acne. Results in discrete excoriations on face, while comedones , and papules are few and far between.

24. ACNE FULMINANS Acute onset. Crusted ulcerated lesions. Associated with fever, myalgia and arthralgia.

25. ACNE AFTER FACIAL MASSAGE 3-6 weeks later as acneiform eruption. Indolent deep seated nodules with vey few comedones . Predominantly on cheeks along the mandible.

26. DIFFERENTIAL DIAGNOSIS Rosacea Folliculitis Acne scarring may be mistaken for acne keloidalis , varioliform , atrophy and porphyria cutanea tarda

27. TREATMENT General measures Topical therapy Systemic therapy Physical therapy

28. GENERAL MEASURES Local hygiene Regular cleansing with soap and water and avoiding use of oil based cosmetics. Diet Avoid use of high glycemic diet. Stress

29. TOPICAL THERAPY Retinoids Most frequently used agent in acne. Effective against comedones and inflammatory acne. Reduces formation of microcomedo . Side effects include irritation and photosensitivity.

30. Benzoyl peroxide Powerful antimicrobial which decrease population of Propionibacterium acnes. Used in both inflammatory acne and non inflammatory acne. Side effects include irritation and bleaching of hair.

31. Topical antibiotics Clindamycin(1-2%) and erythromycin(2-4%) Used in inflammatory acne since it suppress P.acnes . Side effect : antibiotic resistance. So should be combined with retinoids or benzoyl peroxide.

32. Systemic treatment Antibiotics Mostly Doxycycline and minocycline; Erythromycin and azithromycin. Inhibit growth of P.acnes and has direct anti inflammatory effect.

33. ADVERSE EFFECTS Doxycycline - onycholysis , oesophagitis with ulceration, fixed drug eruptions, photosensitivity etc. Minocycline - benign intracranial hypertension, pappiloedema , blue-black pigmentation and rarely hypersensitivity reactions Macrolide group - gastritis, diarrhoea .

34. HORMONES Act by decreasing sebum secretion rate. Used only in females with late onset acne and menstrual irregularities.

35. Adverse effects of hormonal therapy Weight gain Menstrual irregularity Occasional fluid retention Melasma Hypertension Thrombophlebitis Pulmonary embolism

36. ISORETINOIN 13-cis- retinoic acid (Vitamin A derivative ) Mechanism of action: Inhibiting sebum secretion. Alters the composition of sebum Lowers P.acnes concentration and has anti- inflammatory activity

37. Indicated for : Nodulocystic / severe Acne Pyoderma faciale Excessive seborrhoea Depression / Dysmorphophobia Acne conglobata / other unusual variants Scarring

38. Dose: 0.5 – 1 mg/ kg per day is given after meals. Cumulative dose: 120-150 mgs/kg Side effects Teratogenicity Mucocutaneous side effects, dryness Elevation of serum lipids Neurological : pseudotumor cerebri Optic Neuritis , depression, mood swing Arthritis, myalgia Acne flares

39. PHYSICAL MODALITIES Intralesional corticosteroids Cryotherapy Laser therapy Photodynamic treatment Dermabrasion Fillers

40. Thank You…..