Acne vulgaris

Published on 05/05/2015 by admin

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Last modified 22/04/2025

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184 Acne vulgaris

Instruction

Look at this patient.

Diagnosis

This patient has blackheads on the face with greasy skin (lesions), which is acne vulgaris caused by Propionibacterium acnes (aetiology); it may be cosmetically unacceptable to the patient (functional status).

Advanced-level questions

What do you know about the pathogenesis of acne?

Follicular keratinization, seborrhoea and colonization of the pilosebaceous unit with P. acnes are central to the development of these lesions. Genetic and hormonal factors also play a role, possibly by optimizing the follicular environment suitable for the growth of P. acnes or by influencing the inflammatory response and thus the nature of these lesions.

How is the severity of acne graded?

Lesions can be inflammatory or non-inflammatory and are graded by severity (Fig. 184.2):

• Mild disease: open and closed comedones and some papules and pustules

• Moderate: more frequent papules and pustules with mild scarring

• Severe disease: all of the above plus nodular abscesses; leads to more extensive scarring, which may be keloidal in some instances.

Fig. 184.2 Acne classification. (A) Mild, open and closed comedones and some papules/pustules. (B) Moderate, many papules/pustules plus some nodules. (C) Severe, with multiple papules/pustules and nodules, leading to scarring.

(With permission from Habif 2009.)

What factors may exacerbate acne?

• Cosmetics, oils

• Clothing (turtlenecks, bra straps, sports helmets)

• Excessive sweating.

How would you manage acne?

The aims of treatment are to prevent scarring, limit the disease duration and reduce the impact of the psychological stress, which may affect over half of sufferers:

• Wash affected parts with soap not more than twice a day

• Avoid steaming: saunas, Turkish baths

• Dietary restriction has no role in therapy (N Engl J Med 1997;336:1156).

• Reduce P. acnes proliferation:

• Topical therapy: sulfur, benzyl peroxide, retinoic acid, azaleic acid, erythromycin, tetracycline

• Systemic therapy: tetracycline, erythromycin, doxycycline, minocycline, co-trimoxazole, clindamycin, isotretinoin.

• Reduce sebum overproduction with systemic agents: oestrogens, anti-androgens, spironolactone, isotretinoin

• Reduce inflammation:

• Systemic agents: corticosteroids, isotretinoin

• Topical agents: metronidazole, intralesional steroids.

• Reduce abnormal desquamation of follicular epithelium:

• Systemic agents: isotretinoin, antibiotics by indirect effect

• Topical agents: tretinoin (most effective), salicyclic acid, adapalene, tazarotene, isotretinoin, antibiotics.

• Physical or surgical methods: comedo extraction, dermabrasion, chemical peeling, laser resurfacing, pulsed-dye laser treatment and punch grafts.

Randomized, controlled trials are needed to define the relative efficacies of various therapies outlined above.

Have you heard of acne fulminans?

It is a rare but severe variant seen exclusively in adolescent boys. It is caused by an immune complex reaction to P. acnes. The lesions eventually become necrotic and form haemorrhagic crusts, causing disfigurement and scarring. There may be associated systemic features such as fever, malaise, arthralgia, arthritis and vasculitis. Osteolytic bone lesions can arise. Inpatient treatment with systemic steroids is necessary.

What do you know about acne conglobata?

It is seen in tall Caucasian males with cystic skin lesions and multiple abscess formation. It rarely regresses.

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