Acne

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Chapter 9 Acne

INTRODUCTION

Description: Acne is an inflammatory disorder of the sebaceous glands that results in comedones, papules, inflammatory pustules, and scarring. The significance of acne for a woman often exceeds that dictated by medical considerations. It is often a reason to either choose or discontinue the use of oral contraceptives. Acne, or the fear of it, is a major factor in poor compliance with oral contraceptives.

Prevalence: Most adolescents, 15% seek care.

Predominant Age: Early teens to 20s, may persist into 40s.

Genetics: No genetic pattern. Women generally have milder forms of acne than men, although the social consequences are often greater.

ETIOLOGY AND PATHOGENESIS

Causes: Increased turnover of keratin in sebaceous glands under the influence of androgens. This results in a keratin plug (comedone) that obstructs sebum drainage from the gland. Infection by Propionibacterium acnes results in inflammation and pustule formation.

Risk Factors: Increased androgen of adolescence, oily cosmetics or moisturizers, virilizing conditions, medications (oral contraceptives, iodides, bromides, lithium, phenytoins, corticosteroids), and poor local hygiene.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Closed comedones (whiteheads)

• Open comedones (blackheads, black because of oxidation of sebum)

• Nodules and papules

• Pustules and cysts, with or without erythema and edema, may result in scarring

• Most lesions concentrated over the forehead, cheeks, nose, upper back, and chest

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: General hygiene, nail clipping (to reduce secondary trauma and infections), twice-a-day cleansing with a mild soap, oil-free sunscreens.

Specific Measures: Comedone extraction (with extractor), topical medical therapy. Light-based treatment modalities have also begun to show efficacy.

Diet: No specific dietary changes indicated. (None have been shown to be effective.)

Activity: No restriction.

Patient Education: General hygiene measures, need for long-term treatment. American College of Obstetricians and Gynecologists Patient Education Pamphlet AP014 (Growing Up [Especially for Teens]), AP112 (Birth Control [Especially for Teens]), AP021 (Birth Control Pills).

Drug(s) of Choice

Benzoyl peroxide 5% applied to skin every night

Tretinoin (retinoic acid) 0.025% cream applied to skin every night (applying 1/2 hour after washing reduces side effects)

Topical antibiotics—erythromycin, clindamycin (2%) in water base

Systemic antibiotics—tetracycline 250 mg PO four times daily for 7 to 10 days then tapering to lowest effective dose, erythromycin 250 mg PO four times daily for 7 to 10 days then tapering to lowest effective dose.

Oral contraceptives

Contraindications: Known or suspected allergy, hepatic dysfunction for oral agents, pregnancy (tetracycline and isotretinoin).

Precautions: Tetracycline may cause photosensitivity.

Interactions: Tetracycline should not be given with antacids, dairy products, or iron. Erythromycin should not be given with terfenadine (Seldane) and astemizole because it may cause cardiac abnormalities including arrhythmias and death. Broad-spectrum antibiotics may (theoretically) interfere with oral contraceptive efficacy.

Alternative Drugs

Tretinoin (retinoic acid) 0.025% gel applied on chest or back every night.

Isotretinoin (Accutane) 0.5 to 1 mg/kg/day in two doses for 12 to 16 weeks with a second course possible after an 8-week interval (associated with significant side effects including dry skin, dryness of the mucous membranes, and cheilitis).

FOLLOW-UP

Patient Monitoring: Periodic follow-up (monthly) until control is obtained. For patients receiving isotretinoin, liver function, lipid concentrations, and the possibility of pregnancy should be monitored.

Prevention/Avoidance: None.

Possible Complications: Scarring, hypopigmentation or hyperpigmentation, keloidal scarring on the sternum or shoulders.

Expected Outcome: Gradual improvement over time and with therapy.

MISCELLANEOUS

Pregnancy Considerations: Pregnancy may cause a flare-up or remission of acne. Isotretinoin and erythromycin should not be used during pregnancy.

ICD-9-CM Codes: 706.1.

Rafiei R, Yaghoobi R. Azithromycin versus tetracycline in the treatment of acne vulgaris. J Dermatol Treat. 2006;17:217.

Santos MA, Belo VG, Santos G. Effectiveness of photodynamic therapy with topical 5-aminolevulinic acid and intense pulsed light versus intense pulsed light alone in the treatment of acne vulgaris: comparative study. Dermatol Surg. 2005;31:910.

Arowojolu AO, Gallo MF, Lopez LM, et al. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev. 24, 2007. CD004425.

Mariwalla K, Rohrer TE. Use of lasers and light-based therapies for treatment of acne vulgaris. Lasers Surg Med. 2005;37:333.

Purdy S, de Berker D. Acne. BMJ. 2006;333:949.

Strauss JS, Krowchuk DP, Leyden JJ, et alAmerican Academy of Dermatology/American Academy of Dermatology Association. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. 2007;56:651.

Williams C, Layton AM. Persistent acne in women: implications for the patient and for therapy. Am J Clin Dermatol. 2006;7:281.

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