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Incidence, Prevalence, and Pathophysiology of Acne : Roceedings
Incidence, Prevalence, and Pathophysiology of Acne : Roceedings
ABSTRACT
Acne is the most common dermatologic condition encountered in clinical practice, affecting
nearly all adolescents and young adults to some
degree. The pathophysiology of acne is complex.
Increased sebum production by sebaceous glands
and abnormal desquamation of hair follicles
occur in response to increasing androgen levels
with the onset of puberty. Obstruction of follicles
causes follicular distention, which is often accompanied by the proliferation of the bacteria
Propionibacterium acnes and the activation of an
inflammatory response. Although the diagnosis of
acne is usually straightforward, some conditions
are occasionally confused with acne, including
periorificial dermatitis, keratosis pilaris, angiofibromas, bacterial folliculitis, and demodex folliculitis. In addition to physical discomfort, acne is
associated with considerable psychological distress, limitation of activities, and increased risk of
depression and suicide. The relationship between
acne and diet is controversial. Some studies have
demonstrated that diets that are high in minimally
processed plant or animal foods or low in highly
processed carbohydrates are associated with
lower rates of acne, although other studies have
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become colonized by Propionibacterium acnes, a grampositive anaerobe that is part of the normal skin flora.2
The proliferation of P acnes stimulates the infiltration of
immune cells (eg, CD4 T lymphocytes and neutrophils),
which disrupt the follicular wall and cause the dispersal
of lipids, cellular components, and bacteria into the surrounding dermis. Cytokines, peptides, and other inflammatory mediators released during this process stimulate
a localized inflammatory response, resulting in papule
formation. A more intense inflammatory response results
in the formation of pustules, which are often accompanied by overlying comedonal acne. Larger inflammatory
lesions may result in the formation of cysts. Nodules are
deeper lesions that often involve more than 1 follicle and
are associated with a high likelihood of scarring.1
Typical clinical presentations of acne are depicted in
Figures 2 and 3. Comedonal acne is shown in Figure 2,
including open and closed comedones on the patients
chin. Inflammatory acne is illustrated in Figure 3. As
described in more detail later in this monograph, postinflammatory dyspigmentation or hyperpigmentation
often occur following acne healing, especially in patients
of color. Finally, scarring is a common complication of
acne that may be prevented by early treatment.5
The diagnosis of acne is usually straightforward,
although some conditions may occasionally be confused with acne. Periorificial dermatitis is a common
acneiform disorder in children and young adults that is
generally thought to represent a pediatric form of acne
rosacea. Previously referred to as perioral dermatitis,
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a follow-up period of more than 2 years. It has been suggested that increasing glycemic load modulates acne risk
by altering serum insulin concentration and the production of insulin-like growth factor-1 (IGF-1), a mitogen
that may stimulate follicle growth.
Test subjects from New Guinea have been shown
to exhibit low serum insulin concentrations and high
insulin sensitivity, in contrast to hyperinsulinemia and
insulin resistance that are more commonly encountered in association with westernized high-carbohydrate diets.19 Diet-related hyperinsulinemia may also
contribute to acne by stimulating androgen production.20 Smith et al recently conducted a randomized
study to evaluate the effect of a lowglycemic-load diet
on acne in male subjects between 15 and 25 years of
age.20 A total of 43 subjects were randomly assigned to
1 of 2 dietary treatment groups for 12 weeks. Subjects
in 1 group consumed a lowglycemic-index diet consisting of 25% energy from protein, 30% from fats,
and 45% from carbohydrates with low glycemic index
values. Subjects in the control group consumed a diet
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high in carbohydrate-dense foods similar to their baseline diets. After 12 weeks, subjects in the
lowglycemic-index diet group exhibited a greater
reduction from baseline than the control subjects for
both inflammatory lesion counts and total lesion
counts (Figure 4). The dietary intervention was also
associated with reduced circulating insulin and
improved insulin resistance,20 in addition to reduction
in the free androgen index and an increase in IGF-
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REFERENCES
1. Krowchuk DP. Managing adolescent acne: a guide for pediatricians. Pediatr Rev. 2005;26:250-261.
2. Zaenglein AL, Thiboutot DM. Expert committee recommendations
for acne management. Pediatrics. 2006;118:1188-1199.
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