ACNE

Dr. Gazi Asma Sultana

Associate Professor & Head of the Dept.
Department of Dermatology & Venereology
Tairunnessa Memorial Medical College and Hospital
 ACNE

• Definition – Acne vulgaris is a chronic inflammatory disease of the

pilosebacious follicle, characterized by comedone, papular, pustuler, cyst, nodules
and often scars.

• Epidemiology –

• Incidence – Very common, affecting approximately 85% of young people.

• Age – Greatest frequency between the age of 15 – 18 in both sexes.

Involution of the disease before age 25.

• Sex – Almost equal ratio, but more severe in males then the females.

• Race – Lower incidence in Asians and Africans.

 ACNE (Etiology)
• Hereditary factor – Several members of the same family may be affected with
severe scarring
• Androgenic stimulation of sebaceous gland.
• Proliferation of the resident anaerobic organism Propionibacterium acnes.
• Drugs – Lithium, Hydantoin, INH, Glucocorticoids, OCP, Iodides, Bromides and
androgen (e.g. Testosterone), Danazole.
• Others –
• Emotional stress – Can definitely cause exacerbation.
• Occlusion & pressure – on the skin, such as by leaning face on hand.
• Diet – No evidence that dietary habit influence acne. But still controversy is
there.
 ACNE (Pathogenesis)
• Acne vulgaris is exclusively a follicular disease. Comedo is produced by the
impaction and distension of the follicles with tightly packed horny cells.
• Disruption of the follicular epithelium permits discharge of the follicular contents
into the dermis. This in turn causes the formation of inflammatory papules,
pustules and nodulocystic lesions.
• As the retained cells block the opening of follicle, lower portion of the follicle
become dilated by entrapped sebum. Bacterial lipase of P. acne acts on sebum to
produce free fatty acids.
• Free fatty acids are chemotactic to the components of inflammation.
• When follicle rupture, these free fatty acids and other irritants are released to the
dermis, where inflammation occur.
 ACNE (Clinical Features)
• Symptoms –
 Local pain & tenderness.
 Systemic symptoms are most often absent.
 Depression & anxiety may present.
• Signs –
 Sites of predilection – Face, neck, upper trunk, upper arm.
 On face – Frequently on the cheeks and a lesser degree on the nose, chin & fore
head.
 Ears are frequently involved with large comedones in the concha & cyst in the lobule.
 On the neck, especially in the nuchal area.
 ACNE (Clinical Features)
• Lesions –
 In mild acne vulgaris – comedones predominate, with occasional pustules.
 In moderately severe acne – Cystic lesions occur.
 In severe acne – Papules & pustules predominate.
 If the lesions are deep seated, they heal with scar formation.
• Histopathology –
 Acne is characterized by perifollicular inflammation around comedones.
 In pustular cases, folliculocentric abscess surrounded by dense inflammatory exudates
of lymphocytes and polymorphs are found.
 Indolent lesions frequently shows plasma cells, foreign body giant cell & proliferation
of fibroblast, in addition to these findings.
 In large lesions, sebaceous glands are partly or completely destroyed, sometimes
large cysts are formed. Even epithelial sinus tracts may form.
 ACNE (Other varients)
• Acne conglobate –
 Severe cystic acne with more
involvement of the trunk than face.
 Most frequently in young men around
the age of 16.
 ACNE (Other variants)
• Acne Fulminans –
 Teenage boys (ages 13 to
17 yrs.)
 Rare form of extremely
severe cystic acne.
 ACNE (Other variants)
• Tropical Acne –
 Is usually severe acne occurring in tropical areas where the weather is hot & humid.
• Acne venenata –
 Contact with acnegenic chemicals can produce comedones and results in acne
venenata.
 Acnegenic chemicals are chlorinated hydrocarbon, coal tar and pitches.
• Acne cosmetica –
 A persistent low grade acne manifested as closed comedone and papulopustules
occurring on cheeks and chin of adult woman, presumably from acnegenic cosmatics.
• Acne mechanica –
 Many types of mechanical forces including serious pressures, tensions, frictions,
stretching, rubbing, pinching & pulling can aggravate existing acne.
 ACNE (Other variants)
• Acne aestivalis –
 Also known as mallorcea acne
 Almost exclusively in women between age of 25 – 40 yrs.
 It starts in the spring, progress during summer and resolve completely in the fall.
• Excoriated acne –
 Also known as picker’s acne.
 This type of acne is seen in girls.
• Pre menstrual acne –
 Many women with acne may show premenstrual exacerbation of
papulopustular lesion.
 ACNE (Cont.)
• Diagnosis – Comedones are required for diagnosis of any type of acne.
• D/D –
 Rosacea
 Perioral dermatitis
 Acniform drug eruption.
 Milia
 Early stage of adenoma sebaccum
 S. areus folliculitis.
 ACNE (Investigation)

• No investigation is required.

• If there is a suspicion of endocrine disorders, testosterone, FSH, LH & DHEAS

should be determine to exclude hyperandrogenism.

• If systemic treatment is planned, transaminases (ALT, AST), triglyceride and

cholesterol levels should be done.

 ACNE (Treatment)
• General –
 Assurance
 Explanation of the process
 Avoidance of the precipitating factors.
• Factors –

 Acnegenic chemical.
 Mechanical forces
 Squeezing or excoriation of the comedones.
 ACNE (Treatment)
• Tropical – These are preventive. So 4-6 weeks is required to judge efficacy.
Entire acne affected area is treated, not just the lesions and long term usages is
the rule. Formulations are –
 Benzoyl peroxide
 Topical retinoids
 Topical antibiotics
 Clindamycine
 Erythromycin
 Sulfur Resorcin & salicylic acid.
 Azalelic acid.
 TOPICAL RETINOIDS
• Tretinoin (Retin A), Adapalene (Differin), Tazarotene (Tazorac)

• Excellent choice for comedomal acne

• Improves follicular desquamation and dyschromia

• Anti-inflammatory action (Differin best)

• Use at night over entire face, exposure to the sun increases irritation

• Results in six to eight weeks. May increase concentration over time

• Degraded by prolonged exposure to the sun and when used with benzoyl
peroxide (Differin most photostable)
 TOPICAL RETINOIDS
• Adverse affects
 Irritant potential (Tazorac most irritating, Differin least)
 Sun sensitivity
 Pustular eruption after 3-4 weeks
 Potential hyper/hypopigmentation in black and Asian patients
 Contraindicated in pregnancy
 ACNE (Treatment)
• Vitamin A
• Isotretinois
• Hormonal Therapy –
• OCP
• Spironolactone
• Dexamethasone
• Prednisolosne
• Surgical treatment.
 ACNE (Treatment)
• Systemic –
• Antibacterials
• Tetracycline
• Minocycline
• Doxycyline
• Erythromycine
• Clindamycine
• Sulphonamide
• Dapsone
• Intra-lesional Steroids
 ACNE (Complications)
• Pitted scar
• Wide mouth depression
• Keloid
• Hypo pigmented follicular papules or papular acne scars
• Prominent residual hyperpigmentation
• Pyogenic granuloma
• Osteoma cutis
• Solid facial edema.
Thank you
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