ACNE

By
DrAfshan Mughal
Resident Dermatology
CHK/DUHS
OUTLINE

 Acne Vulgaris
 Variants
 Severe forms
 Complications
 Investigation
 Treatment
 Acne vulgaris
DEFINITION

“Chronic inflammatory disease of the pilosebaceous units”

 Acne vulgaris

• Onset  adolescence

Peak age:
• 14 & 17 years in females
• 16 & 19 years in males

• Resolves  mid twenties

• Family history positive

 Acne vulgaris
PATHOGENESIS
1. Seborrhoea

2. Comedo formation

3. Colonization of the duct with P.acnes

4. Inflammation
 Acne vulgaris

PREDISPOSING FACTORS
Genetics

Enviromental

• Diet (milk)/ High BMI • Stress/lnsomnia

• Premenstrual flare • Cosmetics/ Steroids

• Occupation • Seasonal factor/ Sweating/UVR

• Smoking /Alcohol • Pregnancy/ low birth weight

 ACNE

Factors associated with severe acne & Relapse

• Positive family Hx.

• Early onset

• Prolonged duration

• Seborrhea

• Truncal acne
 Acne vulgaris

CLINICAL FEATURES
 Polymorphic, inflammatory disease of skin.

Sites
 Face 99%> Back 60% > Chest15 %

Type of lesions:
 Non-inflammatory
 Inflammatory
 Acne vulgaris
Non-inflammatory lesions

 Earliest lesions to develop

 Comprise of comedones:

 Closed (Whiteheads)

 Open (Blackheads)
 Acne vulgaris
Non-inflammatory lesions
Subtypes:

 Sandpaper comedones

 Macro comedones

 Sub-marine comedones

 Secondary comedones
 Acne vulgaris
NON-INFLAMMATORY
CLOSED COMEDONES (WHITEHEADS)

 Skin colored papule

 1mm in diameter

 No visible follicular opening.

 Often inconspicuous
 Acne vulgaris
NON-INFLAMMATORY
OPEN COMEDONES (blackheads)

 Dome shaped papules.

 Dilated follicular outlets filled with keratin.

 Black colour due to melanin

 Mid-facial distribution

 Evident earlyPoor prognosis

 NON-INFLAMMATORY LESIONS Acne vulgaris
SANDPAPER COMEDONES
 Multiple ,very small whiteheads

 Distributed on forehead

 Roughened, gritty feel

 Responds poorly to topical

treatments.
NON-INFLAMMATORY LESIONS Acne vulgaris

MACROCOMDONES

 Large whiteheads

 >1mm in diameter

 Respond poorly to topical

treatments
 NON-INFLAMMATORY LESIONS Acne vulgaris

SUBMARINE COMEDONES

 Large comedones

 > 5mm in diameter

 Reside more deeply in skin

 Source of recurrent inflammatory

nodular lesions.
 Acne vulgaris
NON-INFLAMMATORY LESIONS
SECONDARY COMEDONES
After exposure to:

 Dioxins (chloracne)
 Pomades (pomade acne)
 Topical steroids
 Other drugs (drug induced acne)
 Acne vulgaris

INFLAMMATORY LESIONS

SUPERFICIAL DEEP

 Pustule
 Papule
 Nodule
 Pustule  Cyst
 Sinus formation.
 Scarring

 Very tender
 Chronic
 Resistant to treatment.
 Acne vulgaris
INFLAMMATORY LESIONS
Inflammatory macules

 Regressing lesions

 General inflammatory appearance

 Persist for many weeks

 Acne vulgaris
INFLAMMATORY LESIONS
Scarring

 Hypertrophic scars

 Atrophic scars

 Ice-prick scars

 Boxcar scars

 Rolling scars
 Acne vulgaris

Hypertrophic scars
 Acne vulgaris
Keloid scar
 Acne vulgaris
Atrophic scars
 Acne vulgaris
Ice-pick scars
 Acne vulgaris
Boxcar scars
 Acne vulgaris

Rolling scars
VARIANTS OF ACNE
VARIANTS OF ACNE

 Acne excoriee  Mechanical

 Drug induced  Occupational

 Endocrine  Tropical acne

 Cosmetic  Virally induced

 Infantile  Granulomatous
 VARIANTS OF ACNE

ACNE EXCORIEE

 Adolescent girls

 Self-inflicted skin condition.

 Obsessively pick real/ imagined acne lesions on face

 Personality / psychological problem

 Significant scarring
 VARIANTS OF ACNE

ACNE EXCORIEE
 VARIANTS OF ACNE

DRUG INDUCED ACNE

 Acute onset

 Monomorphic inflammatory lesions on face & upper trunk

 Absence of comedones
 VARIANTS OF ACNE

DRUG INDUCED ACNE

 Corticosteroids  Antineoplastic

 Anabolic steroids/ synthetic  Calcium antagonist

androgens
 Halogens
 Isoniazid/ pyrazinamide

 Phenitoin  Vitamin B12

 ACTH  Growth hormone

 Antidepressant/  Ciclosporin & tacrolimus

antipsychotic
 VARIANTS OF ACNE

DRUG INDUCED ACNE

 VARIANTS OF ACNE

ENDOCRINE ACNE

 Polycystic ovarian syndrome

 Late onset congenital adrenal hyperplasia

 Cushing disease
 VARIANTS OF ACNE
COSMETIC ACNE

 Comedogenic Cosmetic contain:

o Lanolin/ Oleic acids

o Petroletum /Lauryl alcohol

o Vegetable oils/ Butylstearate

 Closed comedones on the face

 VARIANTS OF ACNE
POMADE ACNE
 Greasy preparation

 Used to defrizz curly hair

 Afro-Caribbeans

 Papules, pustules around fore-head

 SEVERE ACNE FORMS

1. ACNE CONGLOBATA
2. ACNE FULMINANS
 SEVERE ACNE FORMS

ACNE CONGLOBATA
• Rare & severe destructive form

• Pathogenesis Unclear

• 20-25 yrs old males

• Insidious onset

• Chronic & unremitting course

• Acute deterioration of existing inflammatory acne

 SEVERE ACNE FORMS
ACNE CONGLOBATA

 Background of previous acne

 Trunk, U.limbs & buttocks

 Polyporous grouped comedones, papules & pustules

 Abscesses & cysts sinus tracts  scarring

 Gram+ve bacteria secondary infection

 SEVERE ACNE FORMS

ACNE CONGLOBATA

 Poor response to antibiotic therapy

 Malignancy in chronic scars.

 SEVERE ACNE FORMS

ACNE CONGLOBATA
 SEVERE ACNE FORMS

ACNE FULMINANS
 Adolescent white males

 Triggers:

o Testosteorone
o Oral isotretinoin
o Infection

 Mild to moderate acne for 2 yrs

 Sudden onset
 SEVERE ACNE FORMS

ACNE FULMINANS
 Numerous, infl. tender & ulcerative nodules with
haemorrhagic crusts

 Rapid degeneration  ulcerations filled with necrotic debris

 Trunk > face

 Comedones are rare

 SEVERE ACNE FORMS

ACNE FULMINANS
 Fever, Polyarthropathy,Weight loss, Anorexia

 Painful splenomegaly, EN, bone pain

 Lab. findings:
o Leucocytosis
o High ESR
o Anaemia
o Proteinuria
o Haematuria
 SEVERE ACNE FORMS

ACNE FULMINANS
 ACNE

COMPLICATIONS

 Impact on QoL
 Anxiety, depression & suicide
 Acne scarring
 Solid facial oedema
 Osteoma cutis
 Pyogenic granulomas

 Majority of people suffer acne for many years

 ACNE

INVESTIGATIONS
 Not required

 Endocrine evaluation if:

 Signs of hyperandrogenism

 Severe/ sudden / resistant acne

 Rapid relapse post isotretinoin

 ACNE
INVESTIGATIONS
 LH, FSH, Estrogen, Testosterone

 Cortisol, ACTH,CRH

 GH,TSH, Prolactin

 FLP, FBS, Insulin, IGF-1

 DHEAS, 17‐HOP

 Ultrasound pelvis/Testicular ultrasound

 Semen analysis
 ACNE
TREATMENT
Aims:

 Alleviate symptoms

 Clear existing lesions

 Limit disease activity

 Avoid negative impact on quality of life

 ACNE
TREATMENT

 General measures

 Topical therapy

 Systemic therapy

 Physical therapy
 ACNE
GENERAL MEASURES

 Antibacterial soaps containing triclosan

 Medicated cleansers- BPO/ salicylic acid

 Avoid overcleansing/ harsh alkaline soaps

 ACNE
TOPICAL TREATMENT

 Monotherapy(except antibiotics) or in combination

 All areas of affected skin

 Side effect Primary irritant dermatitis

 ACNE
TOPICAL TREATMENT
 Most widely used drugs are:

1. Benzyl Per Oxide (BPO)

2. Retinoids

3. Antibiotics

4. Azelaic acid
 ACNE
TOPICAL RETINOIDS

 Tretinoin 0.01% to 0.05% gel/ cream

 Isotretenoin 0.05% gel

 Adapalene 0.1% cream/ gel

 Tazarotene(available in US)

 Adapalene & tazarotene > efficacious than tretinoin

TOPICAL TREATMENT ACNE
BENZOYL PER OXIDE

 Available in 2.5%, 5% & 10% formulation

 Powerful antimicrobial & anti‐inflammatory activity

 Some comedolytic activity

 Uses: inflammatory & non infl. acne

TOPICAL TREATMENT ACNE
BENZOYL PER OXIDE

Side effects :

 Irritation

 Bleaching of hair & clothes

 Allergic contact dermatitis

 ACNE
TOPICAL ANTIBIOTICS

 Clindamycin, erythromycin & tetracycline cream/ lotion base

 Not advised as monotherapy

 Uses: inflammatory acne

 Safest therapy in pregnancy  topical BPO &/or

topical erythromycin
 ACNE

TOPICAL TREATMENT
AZELAIC ACID

 Available in 20% cream

 MECHANISM OF ACTION
 Antimicrobial
 Anti inflammatory
 Comedolytic activity
 ACNE
SYSTEMIC TREATMENT

1. ANTIBIOTICS

2. HORMONES

3. ISOTRETINOIN

4. CORTICOSTEROIDS
 ACNE
SYSTEMIC ANTIBIOTICS

1. CYCLINES (Antibiotic of choice)

Minocycline is not recommended as first line

2.Erythromycin
Pregnant female/ Children

3.Trimethoprin:
Always combine with topical agents.
 ACNE
SYSTEMIC ANTIBIOTICS
SIDE EFFECTS
 Oxytetracycline & Doxycycline

Common: GI effects,
Rare: Onycholysis, photosensitivity,
BIH

 Tetracylines

 Contraindicated in children
 MSK problems & discoloration of teeth
SYSTEMIC ANTIBIOTICS ACNE
SIDE EFFECTS
 Minocycline BIH, blue-black pigmentation
Drug hypersensitivity syndrome
Aut. hepatitis/ LE‐like syndrome

 Macrolide : GI upset

 Trimethoprim
Maculopapular rash,Agranulocytosis
Hepatic/renal toxicity
ACNE
 ACNE
SYSTEMIC ANTIBIOTICS

Resistance to antibiotics suspect when:

 Failure to respond to antibiotic therapy

 Deterioration in acne

 Poor compliance

 Multiple courses
SYSTEMIC TREATMENT ACNE
HORMONAL TREATMENTS
Indication :

1. Antibiotic regimen failed.

2. Concomitant menstrual control, contraception

& acne therapy required.

3. Oral isotretinoin is inappropriate or not available.

SYSTEMIC TREATMENT ACNE
HORMONAL TREATMENTS

1. Inhibitors of ovarian androgen production (OCPs)

2. Inhibitors of adrenal androgen production

low dose corticosteroids

3. Androgen receptor blockers

CPA, Spironolactone, flutamide

 Should be combined with topical therapies

SYSTEMIC TREATMENT ACNE
HORMONAL TREATMENTS
Mechanism of action

 Suppress androgen production & Alter its

binding to SHBG

 Impair peripheral androgen conversion

 Inhibit androgen action at site of target tissue

 Resulting in Dec. Sebum production & hair growth

 ACNE
ORAL ISOTRETINOIN
 Most potent therapy for acne

 SyntheticVitamin A analogue

Mechanism of action:

 Lowers sebum production

 Reduces comdeognesis
 Lowers P.acnes concentration
 Anti- inflammatory activity
 ACNE
ORAL ISOTRETINOIN
 Recommendations from the European Directive

 Severe acne not responding to appropriate therapy

 Shouldn’t be used as first line therapy
 Shouldn’t be used in patient< 12 yrs

 Dose  0.5mg/kg/day

 Ideally start on day 3 of the menstrual cycle.

ACNE
 ACNE

ORAL ISOTRETINOIN
Monitoring

 FLP & LFTs

baseline after 1 month  3monthly

 Pregnancy test
2wks prior monthly 5 weeks after therapy

 Two methods of effective contraception throughout 30

days after therapy
 ACNE
ORAL ISOTRETINOIN SIDE EFFECTS
 Teratogenicity  Bone pain

 Myalgias/Arthralgia
 Dermatitis/Cheilitis

 Anemia/ low platelets

 Nasal dryness/soreness
 Elevated liver enzymes
 Blepharo-conjunctivitis
 Hyper-lipidaemia

 Xerosis /Pruritus  Depression /suicide

 Acne flare/Skin fragility  Hair loss

 ACNE
SYSTEMIC TREATMENT
CORTICOSTEROIDS
 Combine with isotretinoin

 0.5–1 mg/kg/day prednisolone4–6 weeks

 To control the inflammatory component

o At initial onset
o During acute exacerbations

 USES: Acne conglobata /acne fulminans

 ACNE
PHYSICAL MODALITIES
 Gentle cautery

 Laser therapy

 Photodynamic therapy

 Chemical peeling

 Blue-red light
 ACNE
TREATMENT OF SCARS
 Dermabrasion

 Laser resurfacing

 Collagen injection

 I/L Steroids

 Gelatin matrix implant

 Excision of scar