Acne vulgaris

ACNE VULGARIS

1. ACNE VULGARIS Prepared By :- Dr Monther Fadel Nagi Dermatology Resident

2. ACNE VULGARIS

3. Definition • Acne vulgaris is a chronic disorder of the pilosebaceous apparatus caused by abnormal desquamation of follicular epithelium leading to obstruction of the pilosebaceous canal, inflammation, and subsequent formation of comedones , papules, pustules , nodules, and scarring. Based on their appearance, the acne lesions can be divided into inflammatory (presence of papules, pustules, and nodules) and noninflammatory (open and closed comedones ). For inflammatory acne, lesions can be classified as papulopustular , nodular, or both.

4. Definition The American Academy of Dermatology classification scheme for acne denotes the following three levels: 1. Mild acne: characterized by the presence of comedones ( noninflammatory lesions ), few papules and pustules (generally <10), but no nodules. 2. Moderate acne: presence of several to many papules and pustules (10–40) along with comedones (10–40). The presence of more than 40 papules and pustules along with larger , deeper, nodular, inflamed lesions (up to 5) denotes moderately severe acne. 3. Severe acne: presence of numerous or extensive papules and pustules as well as many nodular lesions.

5. Etiology • Acne is a follicular disease, with the principal abnormality being comedo formation. • Overactivity of the sebaceous glands and blockage in the ducts result in acne vulgaris . The obstruction leads to the formation of comedones , which can become inflamed because of overgrowth of Propionibacterium acnes. The condition can be exacerbated by environmental factors (hot, humid, tropical climate), medications (e.g., iodine in cough mixtures, hair greases), and industrial exposure to halogenated hydrocarbons. Mechanical or frictional forces can aggravate existing acne (e.g., excessive washing by some patients to help rid them of their blackheads or oiliness).

6. Clinical Manifestation(s) • Various stages of development and severity may be present concomitantly. • Common distribution of acne is on the face, back, and upper chest . Physical Examination • Open comedones (blackheads), closed comedones (whiteheads ). • Inflammatory papules, pustules , and ectatic pores. • Inflammatory and noninflammatory acneiform cysts. • Greasiness (oily skin) • Presence of scars from prior acne lesions.

7. Diagnostic Tests • Laboratory evaluation is generally not helpful. • Patients who are candidates for therapy with isotretinoin (Accutane) should have baseline liver enzymes, cholesterol, and triglycerides checked because this medication may result in elevation of lipids and liver enzymes. • Negative urine or serum pregnancy test must be obtained in female patients one month prior to, upon initiation of, and monthly when taking isotretinoin . • In female patients, if hyperandrogenism is suspected, levels of dehydroepiandrosterone sulfate (DHEAS), testosterone (total and free), and androstenedione should be measured. Generally, for women with regular menstrual cycles, serum androgen measurements are not necessary.

8. DIFFERENTIAL DIAGNOSIS • Gram-negative folliculitis • Staphylococcal pyoderma • Acne rosacea • Drug eruption • Sebaceous hyperplasia • Angiofibromas , basal cell carcinomas, osteoma cutis • Occupational exposures to oils or grease • Steroid acne • Flat warts

9. TREATMENT First Line • Treatment generally varies with the type of lesions ( comedones , papules, pustules, cystic lesions) and the severity of acne. • Comedones ( noninflammatory acne) can be treated with retinoids or retinoid analogs. Topical retinoids are comedolytic and normalize follicular keratinization. Commonly available agents are adapalene (0.1% gel or cream, applied once or twice daily), tazarotene (0.1% cream or gel applied daily), and tretinoin (0.1%, 0.5%, or 0.025% cream or gel applied once nightly). Tretinoin is inactivated by UV light and oxidized by benzoyl peroxide; therefore, it should only be applied at night and not used concomitantly with benzoyl peroxide. Tretinoin is pregnancy category C; tazarotene is pregnancy category X.

10. First Line cont ….. • Salicylic acid preparations (e.g., 2% wash) have keratolytic and antiinflammatory properties and are also useful in the treatment of comedones . Large open comedones (blackheads ) may be expressed. • Benzoyl peroxide gel (2.5% or 5%) may be added if the comedones become inflamed or form pustules. The most common adverse effects are dryness, erythema, and peeling. • Topical antibiotics (erythromycin, clindamycin lotions or pads) can also be used in patients with significant inflammation. They reduce P. acnes in the pilosebaceous follicle and have some antiinflammatory effects.

11. First Line cont ….. Combination products containing 5 % benzoyl peroxide with topical antibiotics (3% erythromycin or 1% clindamycin) are highly effective in patients who have a mixture of comedonal and inflammatory acne lesions. Fixed-dose combinations of clindamycin phosphate 1.2% and tretinoin 0.025% are also available and are more effective than either product used alone; however, they are much more expensive than the individual generic components. • Pustular acne can be treated with tretinoin and benzoyl peroxide gel applied on alternate evenings ; drying agents (sulfa containing products) are also effective when used in combination with benzoyl peroxide. • Azelaic acid, a bacteriostatic dicarboxylic acid, is used to normalize keratinization and reduce inflammation. It may be preferred in pregnancy (pregnancy category B).

12. Second Line • Oral antibiotics (doxycycline 50–100 mg QD-BID or minocycline 50–100 mg QDBID) are effective in patients with moderate to severe pustular acne. Erythromycin may also be used but has high rates of bacterial resistance. It is pregnancy category B . • Patients with nodular cystic acne should be treated with systemic agents, including antibiotics (erythromycin, tetracycline, doxycycline, minocycline), isotretinoin , and/or oral contraceptives. Periodic intralesional triamcinolone injections are also effective for individual painful lesions. The possibility of endocrinopathy should be considered in patients responding poorly to therapy.

13. Second Line cont ….. • Oral contraceptives reduce androgen levels and therefore sebum production. They represent a useful adjunctive therapy for some types of acne in women and adolescent girls but are not considered first-line therapy and should not be used as monotherapy for acne vulgaris. Commonly used agents are norgestimate / ethinyl estradiol and drospirenone / ethinyl estradiol. • Spironolactone 100 to 200 mg/day can be administered to women only and has been shown to be particularly effective for adult-onset or “beard distribution” acne . • Blue light can be used for treatment of moderate inflammatory acne vulgaris. Light in the violet/blue range can cause bacterial death by a photoreaction in which porphyrins react with oxygen to generate reactive oxygen species, which damage the cell membranes of P. acnes. Treatment usually consists of 15-minutes of exposure twice weekly for 4 weeks

14. Third Line • Isotretinoin is indicated for acne resistant to antibiotic therapy, severe acne, and scarring acne. Dosage is 0.5 to 1 mg/kg/day, and duration of therapy is generally 20 weeks for a cumulative dose 120 to 150 mg/kg. Before using this medication, patients should undergo baseline laboratory evaluation as described previously. Isotretinoin is absolutely contraindicated during pregnancy because of its teratogenicity. Patients , providers, pharmacies, and distributors of the drug must register in the iPLEDGE program prior to initiation of therapy.