1: Acne vulgaris/rosacea

Published on 22/06/2015 by admin

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Last modified 22/04/2025

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Case 1 Acne vulgaris/rosacea

Description of acne vulgaris/rosacea

Definition

Acne is an integumentary disorder that affects the pilosebaceous units (acne vulgaris) and/or the underlying blood vessels (rosacea) of the skin. Some of the variants of the disease include acne vulgaris, acne conglobata, acne fulminans, acne excorié, mature onset, pyoderma faciale, rosacea, neonatal and infantile acne.

Males and females of all ages can be affected by acne;¹ however, the type of acne can vary between sexes. The vulgaris, conglobata and fulminant variants of acne, for example, are most prevalent among adolescent males, while acne excorié, rosacea, mature onset and pyoderma faciale are more likely to manifest in women.¹

Aetiology and pathophysiology

Many factors can be implicated in the pathogenesis of acne, including genetic, hormonal, infectious, dietary and environmental elements. In terms of hormonal influence, it is believed that elevated androgen levels increase sebum production and abnormal follicular keratinisation and desquamation, which leads to the blockage of pilosebaceous units and the formation of comedones.¹ The peak elevation in androgen, sebum and growth hormone levels during the adolescent period provides some explanation for the increased prevalence of this condition during adolescence.² Findings from a case study of 34 men and women with acne adds further support to the relationship between androgen levels and acne lesion count.²

The bacterium Propionibacterium acnes is another contributing factor in acne development. This is because the bacterium promotes inflammation by releasing chemotactic factors and proteases while hydrolysing sebum into proinflammatory free fatty acids.^1,³ In rosacea, an underlying vascular defect may be responsible,³ although the actual aetiology of this disorder remains unclear. What is apparent is that rosacea can be triggered by a range of exogenous and endogenous stimuli, including cold or hot weather, wind, sun exposure, exercise, hot baths, emotional stress, alcohol, spicy foods, cosmetics and hot drinks.⁴

Other environmental factors that may be implicated in the pathogenesis of acne include medications (e.g. steroids, anticonvulsants), occlusive objects (e.g. shirt collars, helmets), topical agents (e.g. cosmetics, lotions, creams) and perspiration.^4,⁵

The chronic consumption of foods with a high glycaemic index or glycaemic load also contributes to acne development by promoting hyperinsulinaemia and insulin resistance. This can be followed by elevated free levels of insulin growth factor and androgens, and a subsequent rise in keratinocyte proliferation, sebum production and acne formation.⁶

Clinical manifestations

Acne can range in severity from mild to severe. In mild cases, acneiform lesions might be limited to open (blackheads) and closed (whiteheads) comedones, and papules. In more severe cases, inflamed papules, pustules, nodules and cysts may develop, which can lead to scarring.^1,³ The presence of these lesions, as well as scarring, can impact negatively on the psychological wellbeing of the client and their family. Systemic manifestations of the disease can also present in certain variants, such as acne fulminans, with symptoms that include pyrexia, malaise, arthralgia and weight loss.³ In most cases, acneiform lesions are confined to the face, upper back and chest where pilosebaceous units are most abundant. In rosacea, lesions are generally localised to the face and are often accompanied by facial erythema, oedema and telangiectasia.⁵

Clinical case

16-year-old male with acne vulgaris to the face and upper back

Rapport

Adopt the practitioner strategies and behaviours highlighted in Table 2.1 (chapter 2) to improve client trust, communication and rapport, as well as the accuracy and comprehensiveness of the clinical assessment.

Assessment

Once measures have been put into place to build client–practitioner rapport, the clinician can begin the clinical assessment.

Health history

History of presenting condition

A 16-year-old adolescent presents with concerns about long-standing acne to the face, as well as to the forehead, nose and cheeks, and to the upper back. The lesions began to emerge at the age of 13 and have since gradually increased in number and severity. When applied twice daily, five per cent benzoyl peroxide reduces the intensity of the inflammation, but chocolate and stress seem to aggravate the condition. A recent course of broad-spectrum antibiotics, prescribed by the client’s general practitioner, produced a modest improvement in lesion severity, although this medicine had to be discontinued due to antibiotic-associated diarrhoea. The client is embarrassed by the condition and feels the acne is dampening his self-image and self-esteem.

Medical history

Diet and fluid intake
Breakfast	Large glass of full-cream milk.
Morning tea	Apple, muesli bar.
Lunch	Two sandwiches, made with white bread and spread with peanut butter or Vegemite®.
Afternoon tea	Sweet biscuits, toasted white bread spread with Vegemite®.
Dinner	Spaghetti bolognaise, fettuccine carbonara, lasagne, supreme pizza.
Fluid intake	1 cup of cordial daily, 1 cup of juice daily, 2 cups of water daily, 1 cup of milk daily.
Food frequency
Fruit	1–2 serves daily
Vegetables	1–2 serves daily
Dairy	2 serves daily
Cereals	7 serves daily
Red meat	6 serves a week
Chicken	1 serve a week
Fish	0 serves a week
Takeaway/fast food	2–3 times a week

Quality and duration of sleep

Continuous sleep; average duration is 6–7 hours.

Frequency and duration of exercise

Is not engaged in any sporting activities, is transported to and from school by car, engages in active play or exercise less than 1 hour a day, and sedentary activities (out of school) more than 5 hours a day.

Socioeconomic background

The client is Australian-born with an Australian-born mother and Italian-born father, who are married. He lives with his parents. His father works full time; his mother is a stay-at-home parent. He is studying Year 11 at a private school (which the client considers to be moderately stressful), is Roman Catholic and has three younger siblings, aged 9, 12 and 14. The client states he lives in a happy and supportive household.

Physical examination

Inspection

Multiple acneiform lesions are present on the forehead (18 lesions – papules and pustules), nose (6 lesions – open comedones), left cheek (3 lesions – papules), right cheek (4 lesions – closed comedones and papules) and upper back (17 lesions – closed comedones and papules). There is no bleeding, scarring, oedema, nodules, excoriation or ulceration. Finger and toenails are strong and intact, with no notable markings.

Olfaction

There is no abnormal odour to the lesions or patient.

Palpation

Skin to the face and upper back is oily. Papules and pustules are warm. The surrounding skin demonstrates good turgor, moisture and mobility.

Percussion

Not applicable.

Auscultation

Subcutaneous crepitus is not detectable.

Additional signs

Client is afebrile (36.4°C per oral) and overweight (body mass index (BMI) is 27 kg/m²).

Clinical assessment tools

Using the Bikowski acne severity index (BASI), facial acne was graded as follows: forehead (moderate grade III acne), nose (mild grade II acne) and left and right cheeks (mild grade II acne).

Diagnostics

CAM practitioners may request, perform and/or interpret findings from a range of diagnostic tests in order to add valuable data to the pool of clinical information. While several investigations are pertinent to this case (as described below), the decision to use these tests should be considered alongside factors such as cost, convenience, comfort, turnaround time, access, practitioner competence and scope of practice, and history of previous investigations.

Pathology tests

The use of culture and sensitivity tests to detect the presence of P. acnes is not a reliable diagnostic for acne as this bacterium is a normal resident of human skin. Testing serum androgen levels is also unreliable as most patients with acne demonstrate normal androgen levels.¹

Low plasma concentrations of vitamin A are reported in people with acne.⁷ Assessing hair or serum vitamin A levels may help to determine whether vitamin A deficiency is implicated in this condition.

Radiology tests

Not applicable.

Functional tests

Not applicable.

Invasive tests

Not applicable.

Miscellaneous tests

Not applicable.

Diagnosis

Clusters of data extracted from the health history, clinical examination and pertinent diagnostic test results point towards the following differential CAM diagnosis.

Acne (actual), related to genetic predisposition (client has a family history of acne), hormonal imbalance (androgen and growth hormone levels are typically elevated during adolescence), high glycaemic load diet (client’s diet largely consists of highly refined carbohydrates; acne is exacerbated by chocolate consumption), P. acnes colonisation (the severity of acneiform lesions improved following antibiotic treatment) and emotional stress (acne is aggravated by stress).

Planning

The goals and expected outcomes that best serve the client’s needs and that are most relevant to the presenting case (as determined by the clinical assessment and CAM diagnoses) are as follows.

Goal

1. Client will be free from acneiform lesions (client’s primary concern is the longstanding acne).

Expected outcomes

Based on the degree of improvement reported in clinical studies that have used CAM interventions for the management of acne,⁸^–¹¹ the following are anticipated.

1. Client will demonstrate a forty-five per cent decrease in the baseline number of acneiform lesions on the forehead, nose, cheeks and/or upper back in 9 weeks or by dd/mm/yyyy (measured by the severity component of the BASI).

2. Client will exhibit a forty-five per cent reduction in the baseline severity of acneiform lesions in 9 weeks, or by dd/mm/yyyy (measured by the grade component of the BASI).

3. Client will report a twenty-five per cent improvement in baseline self-esteem in 9 weeks or by dd/mm/yyyy (measured by a 0–10 visual analogue scale).

Application

The range of interventions reported in the CAM literature that can be used in the treatment of acne are appraised below.

Diet

Low glycaemic-load diet (Level II, Strength A, Direction +)

The consumption of foods with a high glycaemic index or glycaemic load may, as discussed earlier, contribute to the pathogenesis of acne. Hence, the substitution of high glycaemic-load foods such as sweetened, refined and highly processed products with foods that have a low glycaemic-load, such as wholegrains and fruits with edible skins or are high in protein, including eggs and lean meat, may be of benefit to those suffering from acne. Indeed, two controlled clinical trials have shown young males who follow a 12-week low glycaemic-load diet demonstrate a significant reduction in insulin resistance, fasting insulin, free androgen levels, BMI, total acneiform lesion counts and inflammatory lesion counts when compared to those consuming a high glycaemic-load diet.^9,¹⁰

Lifestyle

Relaxation therapy (Level II, Strength B, Direction +)

Psychological stress is positively correlated with the severity of acne.^12,¹³ It is therefore reasonable to assume that successful attempts at reducing stress could lead to clinical improvements in acne. This assumption was tested in a small randomised controlled trial (RCT) of thirty dermatology patients with acne vulgaris, and found 6 weeks of biofeedback-assisted relaxation and cognitive imagery was significantly more effective than attention-comparison and medical control at reducing acne severity.¹⁴ Further research is now needed to determine whether similar effects can be observed using other stress reduction techniques, including meditation, yoga and tai chi.

Nutritional supplementation

Ascorbic acid (Level II, Strength C, Direction +)

Vitamin C has the potential to attenuate the pathogenesis of acne by reducing cutaneous lipid peroxidation, P. acnes replication ¹⁵ and serum C-reactive protein (CRP) levels (a marker of acute inflammation).¹⁶ Findings from an open comparative study add some support to this theory, with topically applied five per cent sodium ascorbyl phosphate (SAP) (a vitamin C derivative) twice daily for 12 weeks shown to be more effective than five per cent benzoyl peroxide in reducing the number of inflammatory and non-inflammatory acneiform lesions in 49 subjects.¹⁵ A small double-blind RCT (n = 30) also found five per cent SAP lotion (applied twice daily for 8 weeks) to reduce inflammatory lesion count in adults with acne vulgaris, although the difference between the SAP and 0.2 per cent retinol groups was not statistically significant.¹⁷ Given that studies have used different active controls, no firm conclusions can yet be made about the efficacy of topical SAP in acne.

Nicotinamide (Level II, Strength B, Direction +)

Vitamin B₃ reduces inflammatory mediator release ¹⁸ and, as such, may play a role in the treatment of inflammatory skin disorders. Several controlled clinical trials have confirmed this, with topically administered nicotinamide gel (four per cent) found to be as effective as antibiotic gel in reducing the number and severity of inflamed acneiform lesions.^11,¹⁹ Whether this affect can be demonstrated with orally administered vitamin B₃ is not yet clear.

Vitamin A (Level II, Strength B, Direction +)

Collagen synthesis, phagocytosis, antibody production and epithelial cell differentiation are key functions of vitamin A.²⁰ Given these actions and the significantly lower plasma concentration of vitamin A reported in people with acne,⁷ it is not surprising that many studies (albeit methodologically limited studies) have found synthetic vitamin A derivatives to be effective at reducing the severity of acne vulgaris when administered as oral or topical preparations.²¹^–²⁶ Whether these effects translate to betacarotene and/or natural vitamin A is not yet certain.

Zinc (Level II, Strength C, Direction o)

Zinc modulates inflammatory and immune activity ²⁷ and demonstrates antimicrobial activity against Propionibacterium strains.²⁸ While low serum and epidermal zinc concentrations have been reported in people with acne vulgaris,^29,³⁰ the evidence is not conclusive. Likewise, evidence from trials investigating the clinical efficacy of zinc in acne has not been consistent.³¹^–³⁵

Lactobacillus spp., omega 3 fatty acids, selenium and vitamin E

These supplements exhibit myriad effects that are desirable in the management of acne, including anti-inflammatory and immunomodulatory activity; however, there is insufficient clinical evidence to justify the administration of these agents in individuals with acne.

Herbal medicine

Commiphora molmol (Level II, Strength C, Direction o)

Myrrh has long been used as an anti-inflammatory, vulnerary and antimicrobial herb. These effects appear to be of some benefit to patients with nodulocystic acne, with a small RCT of 20 patients finding oral Gugulipid extract (equivalent to 25 mg guggulsterone), administered twice daily for 3 months, to be as effective as oral tetracycline at reducing the number of inflamed acneiform lesions.³⁶ No firm conclusions can be made about the efficacy of myrrh until further evidence from larger studies becomes available.

Vitex agnus-castus (Level III-1, Strength D, Direction +)

Chaste tree may exert a mild antiandrogenic effect by reducing serum prolactin levels ³⁷ and thus may attenuate the sequence of events leading to the manifestation of acne. This action may explain why an earlier controlled trial of 161 subjects found chaste tree treatment to be significantly superior to placebo at improving the signs of acne at 12 weeks.³⁸ In view of the paucity of corroborating data and the insufficient details of the study, these results should be interpreted with caution.

Other herbs

Arctium lappa (burdock), Galium aparine (cleavers), Trifolium pratense (red clover), Rumex crispus (yellow dock) and Scrophularia nodosa (figwort) have long been used as treatments for skin complaints because of their depurative action. Experimental data suggest that Glycyrrhiza glabra (licorice) and Echinacea spp. (echinacea) may also be indicated for the treatment of acne because of their anti-inflammatory, immunomodulatory and antimicrobial activity against P. acnes.^39,⁴⁰ Despite the availability of traditional and/or experimental evidence in this area, there is insufficient clinical evidence to support or refute the effectiveness of these herbs in acne.

Other

Acupuncture (Level II, Strength D, Direction +)

Many case reports have been published on the effectiveness of acupuncture in acne;⁴¹^–⁴³ however, given the methodological limitations of these reports, no firm conclusions can be drawn. A more recent RCT of 52 patients with acne conglobata adds much-needed rigour to this body of evidence. Four weeks of treatment, daily encircling acupuncture, together with twice weekly venesection and cupping, was found to be as effective as orally administered isotretinoin (10 mg three times a day) at reducing the signs of acne, and superior to isotretinoin at lowering serum interleukin-6 levels.⁴⁴ The risk of placebo bias in this trial and the unknown confounding effect of venesection and cupping makes the translation of these findings into clinical practice difficult.

Melaleuca alternifolia (aromatherapy) (Level II, Strength B, Direction +)

Indigenous Australians traditionally used tea tree for its anti-inflammatory, antimicrobial and antiseptic properties. These effects, as well as the sensitivity of P. acnes to tea tree oil,⁴⁵ indicate that tea tree may be effective as a treatment for acne. Findings from a systematic review of one RCT (n = 124) support this proposition,⁴⁶ with the topical application of five per cent tea tree oil gel found to be as effective as five per cent benzoyl peroxide at reducing the number and severity of acneiform lesions, albeit with a relatively slower onset of action.⁴⁷ Similar outcomes were observed in a more recent RCT (n = 60) that compared five per cent tea tree oil gel to placebo in 60 adolescents and young adults.⁸