Acne

Dr.Halilma Arebi
26.o6.08
Acne is self limiting subacute inflamatory condition of pilosebaceus follicle , affect
mainly adolescents , the most commen presentation is pleomorphic ; presenting
with comedons , papules and pustules ± nodules & as sequlae : scars &
hyperpigmentation ( acne vulgaris ) .

Etiology :
- genetic factors : multifactorial ; familial incidence!
heridity determines size & activity of sebaceus gland.
Nodulocystic acne more common in white men than in black males .
-seborrhic activity : acne is directly related to increased sebum secretion
No acne in age between 2 to 6 yrs of age ( sebum secretion extremly law)
Treatments that reduce sebum secretion ( such as retinoids & estrogens ) improve
acne .
- Bacteria : Propionibacterium acnes ; anaerobic, gram positive , diphtheroid
bacteria
multiply only in follicular canal.
at age of 11 to 15 yrs , practically no P. acnes in persons with out acne , but in
acne pts : about 114,800 bacteria ∕ cm² , in individuals > 20 yrs →equal № of
bacteria with or without acne .
- Hormonal factor : normal circulating levels of androgens from gonads & adrenals
are absolute requirment or sebaceus glands remain small.
 . Acne ↑ in 2nd half of menstrual cycle .
. Premenstrual exacerbation .
. Improvement during pregnancy and lactation .
. Levels of DHEAS , testosterone or dihydrotestosteronemay be higher in
acne pts compared to normal controls ( but still within normal levels ).
. Stress : ↑ adrenal steroids → acne flares .
- Psychogenic factor : ( stress → ↑ adrenal androgens ) .
- Climatic factor : cold countries → severe in winter .
hot countries → severe in summer .
- Diet : no relation to any Food .
- Drugs & chemicals :
Iodides , Promides : ( Halogen acne ) ; present in sedatives ,expectorants ,
vitamins & other drugs .
Lithium , antiepileptics , anti-TB , corticosteroids, B12 .
- Occlusion & pressure on the skin : ( Acne mechanica ) ; only in areas with
preexsisting acne .
Pathogensis of acne : •

1- Androgens ( quantitatively & qualitatively normal ) stimulate sebaceous •

glands to produce large amounts of sebum (in genetically predisposed )

2- Corynebacterium acne contains lipase enzyme that acts on lipids of •

sebum→ free fatty acids , whitch acts as chemotactic factor for neutrophils
. •
3- both ↑ sebum & FFA cause sterile inflammation of pilosebacous gland→ •
Hyperproliferation of upper portion of sebaceous duct +hyperkeratinization •
of the lining of the follicle resulting in plugging .

4- the enlarged follicular lumen containing inspassated keratin & lipid •

debris..→ white heads = white comedons .

5- if the follicle has open portal of entery to the skin →the plugg protrudes & •
the Tyrosine contained in the Keratin will be oxidized to Melanin in the
follicular orifice → black heads = black comedons .

6-the distended follicular wall may break dawn , the contents [ sebum , lipids •
, FFA , &keratin ] enter the dermis → forgn body response → papules ,
pustules & nodules .

7- rupture of these lesions + intense inflammation → post inflammatory •

hyperpigmentation & scaring
C.P:
Race: ↑ in caucasians , ↓ in Mongoloid & black people.
Sex : ♀ = ♂ , but more severe in ♂ > ♀.
Age : ♀ : 14 - 17 yrs , ♂: 16 – 19 yrs .
distribution : in early ages more on the face ( fore head , nose ,cheek & chin )
(comedones , Papules , pustules ± Nodules ) .
Later ages : more on the trunk ∕ Start as big erythematous Painful nodules
… even > 2 cm → pustules → scaring → keloid .

D/D:
- Folliculitis .
- Rosacea .
- Acniform rash . (anti -TB , anti – epileptics …etc ) .
Acne vulgaris
D∕D
Investigations :
- no special investigations are required .

- in case of : female pt with severe acne , sudden onset ± htirsutism or

irregular menstrual period → hyperandrogenism should be considered
so, ask for : DHEAS , Testosteron ( total & free ) & LH ,FSH .

(should be done in Luteal phase → with in 2 wks prior to onset of Menses).

if the pt is taking pils → should be stopped for 1 Mo before investigation.

DHEAS = 4000 - 8000 → congenital adrenal hyperplasia .

> 8000 → adrenal tumors .

Total testosteron = 150 – 200 ng/dL → ? Polycystic ovary .

LH : FSH ratio > 2 → ? Polycystic ovary.

Testosteron > 200 ng / dL → ? Ovarian tumors .

Treatment :
- acne treatment needs pt‘s complete cooperation , Explanation & removal
of precepitating factors .

- cleansing !

- local treatments:

1 – Local Retinoids ( other comedolytic agents : Salicylic acid ).

2 – benzylperoxide ( lotion or gel ) → antibacterial .

S.E : dryness , irritation , allergic contact dermatitis .

3 – Local antibiotics: - erythromycin

- Clindamycin
(less resistance when combined with Penzylperoxide )

4 – Azelaic acid ( natural dicarboxylic acid –in cereal grains )

( 20 % , cream ) = skinoren® cream
active against inflammatory & non inflammatory lesions & lighten
Postinflammatory hyperpigmentations .
- systemic treatments: - Antibiotics
- hormones
- Retinoids

1– systemic Antibiotics :

Tetracyclins →
mode of action : - ↓ FFA in sebum .
( also by erythromycin + clindamycin + minocyclin )
- ↓ number of P.acnes.
- anti- inflammatory activity .
dose : 500 – 1000 mg / day , divided doses on empty stomach , ½ hr before
meal to Promote absorption … then ↓ dose & frequency.
may be continued for many months .

- Tetracyclins have the affinity of rapidly mineralizing tissues & deposited in

developing teeths → irriversible yellow – brown staining .
- they Inhibit Skeletal growth in the fetus .
SO : contraindicated in Pregnancy & young children .

Side effects :
- GIT upset → Nausea .
- Vaginitis or Perianal itching ( candida ).
- Photosensitivity.
- Pseudotumor cerebrei ( ↑ ICP ) – specially in combination with retenoids .
- staining of growing teeth ( green on flouresence ) .
- long term therapy : transient hyperbilirubinemia
- development of gram –neg . Folliculitis during RX .
multiple Pustnles with inflammatory areola → Enterobacter, Klebsiella.
indolent Nodules → Proteus.
RX : Ampicillin .

doxycycline →
50 -100 mg / twice daily ( Photosensitivity ).
Minocyclin→
90% execerted in sebaceus glands .
100 – 200 mg / day – reduced after 2 wks (50 -100 /day).
Side effects :
- blue black pigmentation – specially in acne scars , hard Palate,
alveolar ridge , ant- shins .
- Autoimmune hepatitis .
- SLE-like syndrome ( Rare ).
. Clindamycin →
150 mg ∕ day.
S.E : pseudomembranous colilis .

Erythromycin →
2nd choice
pregnant ♀ & yonng children .

2 - Systemic Retinoids :

isotretinoin ( Roaccutan® )
dose : 0.5 – 1 mg / Kg ≈ ( 16 -20 wks ) .

it‘s action : - inhibition of sebaceus gland activity → ↓ sebum prodution.

- effect on pattern of keratinization .
- no effect on p.acnes .

S.E :
- dryness of the lips .
- dryness of the mouth , nose & eyes ( + night blindness ) .
- dryness of the skin ± eczematous rash ( Retinoid Dermatitis ).
So , Pt needs 6 extra glasses of H20 daily + emollient .
- Hepatotoxicity .
- hyperlipidemia & hypercholesterolemia .
[ when TG ↑ > 800 mg ∕ dl → risk of acute pancreatitis + coronary artery ds ]
to control it → - ↓ body wt .
- ↓ dietery fat .
- restrict alkohol .
- ↓ dose of the drug .

- Arthralgia , tendinitis & calcifications ( ligaments & tendons ) .

- Loss of hair .
- Pseudotumor cerebrei ( should not be given with tetracyclins ) . -

-Teratogenicity : -
it is not mutagenic .
it has effect on Organogenesis [ ≈ 3rd wk of pregnancy ] .
pt should take contraception during therapy & 1 Mo. After stopping the treatment.
3 – Hormonal treatment : •

Sebum secretion : - increased by agents with androgenic activity like •

→anabolic steroids .
- decreased by agents that counteract androgen action •
→ estrogens & antiandrogens .

a - Oral contraceptives ( containing estrogens + progestin ) . •

b – Glucocorticoides : •
indicated in small doses in ♀ pt with ↑ DHEAS . •
prednisone 2.5 -5 mg at bed time . •

- Physical treatment : * superficial X-ray . •

* UV light . •
*Cryotherapy ( more for superficial scars ). •
- Acne surgery : •
•
mechanical comedone removal ( 2-3 wks after local retinoids ) . •
→ by comedo extractor or by expression . •

•
- intralesional steroides: •
for deep nodular lesions & cysts •
- chemical peeling: •
with glycolic acid , for active lesions , scars & hyperpigmentations . •

Prognosis : •
the usual course of acne is several years followed by remission . •

favorable prognosis •
•
sequalae : scarring & hyperpigmentation •

treatment of scarring : - Dermabrasion . •

- Laser resurfacing . •
- chemical peels . •
•
Other types of Acne :
- Neonatal acne ∕ infantile. acne
- Acne excoree` , young ♀ ( picking the face , small lesions → scarring )
- Steroid acne ( follicullitis ) .
- Drug induced ( acne medicamentosa ) → no comedones .
- Acne Venenata :
contact with acnegenic chemicals : cosmetics , grooming agents , toiletries ,
chlorinated hydrocarbons , cutting oils , petroleum oils , cool tar , pitches .
- Pomade acne :
↑ in black ♂
pomade applied to scalp → comedones close to hair line .
- Acne mechanica :
rubbing , friction , tension , pinching …etc
mainly in areas with preexisting lesions ….e.g : after occluding the skin with
adhesive tapes .
- Acne Aestivalis ( Mallorca acne ) :
monomorphus small red papules , after exposure to sun , ♀ , 20-30 yrs .
shoulders , arms , neck & chest ∕ no response to antibiotics .
RX : local retinoids.
 - steroid acne :
( follicullitis ) , as early as 2 wks after administration of systemic steroids , or after
local application → Pustules & red papules at same stage , mainly on the trunk
, shoulders & arms > face .
- Acne conglobata :
usually severe form of acne ∕ highly inflammatory numerous comedones , large
abscesses with interconnecting sinuses , cysts with clear viscid fluid , grouped
inflammatory nodules → suppuration is characteristic .
healing with scarring & sinus-tract formation ….frequently with keloid formation .
different from acne vulgaris in :
later onset , chr.unremitting course , ♂ > ♀ , more involvement of the trunk than the
face.
Complications : - emotional disturbances .
- scarring & keloid .
- slow growing –well differentiated squ.c.ca .
- spondyloarthropathy .
Investigations : the pt may have
- ↑ WBCs , ↑ PMNs .
- normocytic , monochromic anemia .
- ↑ ESR .
 - swabs for c ∕ s some times show coaggulase +ve staph > - hemolytic strept
( ?! True pyoderma )
RX :
- systemic Retinoids .
- ± systemic antibiotics .
- systemic steroids .
- ± local measures : drainage , excision , local steroids …etc .
- Acne fulminance :
= Acute Febrile Ulcerative Acne .
teenager boys ( 13 -17 yrs ) , sudden explosive onset , usually the face is not
involved
the lesions are mainly : ulcerative , crusted lesions .
fever , leukocytosis ( 10,000 -30,000 ∕ mm³ ) , polyarthralgia , myelgia ,
x-ray : osteolytic lesions at sites of bone tenderness .
RX :
- systemic steroids .
- systemic antibiotics .
- ± intralesional steroids.
- then ; add systemic retinoids .
Acne conglobata
Acne fulminance