Acne

Digital Lecture Series

Dr Sanjay Khare
Professor and Head, Department of Dermatology,
Venereology & Leprology,
Mahatma Gandhi
Memorial Medical College, Indore
Contents

• Introduction • Treatment guidelines

• Acne Vulgaris • Topical treatment
• Epidemiology • Oral antibiotics
• Pathogenesis • Hormonal therapy
• Grading • Isotretinoin
• Variants • Physical modalities
• Psychosocial aspects • Newer options
• Polycystic ovarian syndrome • MCQs
• Adult acne • Photoquiz
• Differential diagnosis
Introduction

• Common skin condition

• Readily diagnosable

• May affect mental and social well being

• Affects more than 90% people at some point in their life

Acne Vulgaris

Definition :
• Acne is a chronic, self limiting, inflammatory disease of pilo-
sebaceous unit, presenting with pleomorphic lesions like comedones,
papules, nodules, and in severe case with cyst
• Scarring is common
Epidemiology

• Age of onset, puberty or a few months earlier

• Peak incidence
− Women : 14 to 17 yrs
− Men : 16 to 19 years
• More common and more severe in men
• More common in urban boys
• Genetic factors influence the susceptibility
Pathogenesis of Acne

• Altered keratinization within sebaceous follicle

• Androgen activity

• Quantity and quality of sebum secretion

• Colonization by follicular microbial flora

• Immunological factors

• Environmental factors
Altered keratinization within
Sebaceous Follicle

• Micro-comedones are initial lesions of acne

• Increased production of follicular-ductal keratinocyte

• Increased adhesion of follicular-ductal keratinocytes

• Retention of hyperproliferating ductal keratinocytes

Androgen Activity

• Spurt of hormones during puberty correlates with onset of acne

• Increase in androgen-estrogen ratio
• Androgen increases sebum secretion and sebaceous gland hyperplasia
• Increased sebum :
− Excessive production by gonads / adrenal
− Decreased sex hormone binding globulin
− Increased responsiveness of sebaceous glands
Quantity and Quality of Sebum Secretion

• Sebum is acnegenic

• Change in quality of sebum – irritation of ducal keratinocytes

Colonization by Follicular Microbial Flora

• Resident bacterial flora: Propionibacterium acnes, Propionibacterium

granulosum, Pityrosporum ovale, and Staphylococcus epidermidis

• increased count of P. acnes

• Resident flora secretes enzymes and pro-inflammatory chemokines

• Lipases – sebum to free fatty acids – follicular irritation –

keratinocyte hyperproliferation

• Chemokines – inflammation
Immunological Factors

• Inflammation precedes microcomedone

• Interleukin – 1 initiates keratinocyte hyper- proliferation
• P. acnes activates classical and alternate complement pathways
• Toll like receptor 2 (TLR-2)
Environmental factors

• Hot & humid climate– aggravates

• Emotional stress – aggravates
• High-glycemic load diet – hyperinsulinemia – free IGF 1 – increased
sebum, altered keratinization, excess gonadal androgens
• Milk & dairy products – contains IGF 1 as well as increases endogenous
production of IGF 1
• Natural light – beneficial
Acne Vulgaris

• Pathogenesis
Grades of Acne
(Pillsbury, Shelley and Kligman)
- Earliest Published Grading System
• Grade I : Comedones, occasional papules

• Grade II : Comedones, many papules, few pustules

• Grade III : Predominant pustules, nodules, abscesses

• Grade IV : Mainly cysts, abscesses, scars

Grades of Acne

• Other grading systems have been also defined similar to Pillsbury by

James & Tisserand and Tutakne & Chari
• In 1997, Doshi, Zaheer and Stiller devised a global acne grading
system; this system utilizes six areas - forehead, each cheek, nose,
chin and chest and back, and assigns a factor to each area on the
basis of size
The Global Acne Grading System

Location Factor

Forehead 2

Right cheek 2

Left cheek 2

Nose 1

Chin 1

Chest and upper back 3

The Global Acne Grading System

• Note : Each type of lesion is given a value depending on severity :

no lesions = 0, comedones = 1, papules = 2, pustules =
3 and
nodules = 4
• The score for each area (Local score) is calculated using the formula :
Local score = Factor × Grade (0-4)
• The global score is the sum of local scores, and acne severity was
graded using the global score
• A score of 1-18 is considered mild; 19-30, moderate; 31-38, severe;
and >39, very severe
Acne Vulgaris

Grade 1 - Open and close comedones

Acne Vulgaris

Grade 2 - comedones, papules with few pustules

Acne Vulgaris

Grade 3 - papules, few nodules & deep pustules

Acne Vulgaris

Grade 4 - large nodulocystic lesion on the cheeks

Scarring

• Consequence of abnormal resolution or wound healing following the

inflammation

• Atrophic scars • Hypertrophic scars

– Ice pick scars • Keloid
– Rolling scars
– Boxcar scars
Hyperpigmentation

• In patients particularly with type III/IV skin, hyperpigmented macules

may persist following the resolution of inflammatory acne lesions
Variants of Acne

• Drug induced acne/ acneiform • Occupational acne/chloracne

eruption • Pyoderma faciale
• Acne excoriee • Late onset acne/endocrine acne
• Acne conglobata • Cosmetic/pomade acne
• Acne fulminans • Tropical acne
• Acne mechanica • Gram negative folliculitis
• Maskne
Acne Excoriee

Excoriated papular lesions on forehead with hyperpigmentation.

Acne Conglobata
Chloracne

• Multiple comedones, occupational dermatosis due to aromatic

hydrocarbon
• Should be investigated for systemic complication (ophthalmic,
neurological, hepatic, lipoprotein abnormality)
Maskcne

• Long-time mask wearing could increase the flare of acne

• Higher temperature and humidity on the surface of facial skin caused
by expired air and the perspiration.
• Recently described entity during covid-19 pandemic
• Itching and excessive seborrhea
• Comedones, papules on cheek and nose
Drug Induced Acne

• Papules and pustules , comedones usually absent

• Drugs implicated:
− Halogens
− Androgens
− Steroids
− Isoniazide, Rifampcin
− Lithium
− Phenytoin
− PUVA
Acneiform Eruption

Post steroidal Acneiform eruption

Psychosocial Aspects

• Stress induces acne

• Increased anger and anxiety

• Social embarrassment

• Lack of self confidence

• Depression

• Dysmorphophobia
Polycystic Ovary Syndrome and Acne

• Persistent, severe, acne of late onset in females

• Other associated features may be
− Hirsutism
− Acanthosis nigricans
− Patterned hair loss
• Key etiological feature of PCOS are increased androgen secretion and
insulin resistance
• Hormonal therapy along with lifestyle modifications (e.g. weight
reduction) are helpful treatment options
Adult Acne

• Acne above 25 years of age

− Persistence of adolescent acne, or
− First appearing in the age above 25 years
• May last in sixth decade
• Familial cases are very common
• Hormonal or drug induced causes are more commonly associated
• Hormonal causes-PCOS, Congenital adrenal hyperplasia, Cushing
Syndrome
Differential Diagnosis

• Rosacea

• Pityrosporum folliculitis

• Pseudo folliculitis

• Milia

• Plane warts

• Tuberous sclerosis

• Acne scarring may be mistaken for acne keloidalis, varioliform,

atrophy and porphyria cutanea tarda.
Rosacea

Absent comedones, erythematous papulopustules

on central part of face & cheeks
Pityrosporum Folliculitis

Itchy papulopustular lesion on seborrheic areas

Guidelines of Treatment

• Acne assessment (of severity)

• Patient education

• Discussion of goals of treatment and patient expectations

• Choice of therapy
Topical Agents

• Topical antibiotics - erythromycin, clindamycin, tetracycline,

clarithromycin

• Benzoyl peroxide – 2.5 to 10%, gel/cream/lotion; comedolytic; no

effect on sebum production

• Azelaic acid – effective; safe during pregnancy

• Topical retinoids - retinoic acid, adapalene, tazarotene, trifarotene

(4th gen. retinoid)

• Clascoterone (Anti-androgene)

• Topical dapsone, Sulfur, Resorcinol etc

Oral Therapy

• Antibiotics :

− Erythromycin

− Azithromycin (pulse dosing)

− Tetracycline

− Doxycycline

− Minocycline

− Lymecycline

− Trimethoprim

− Dapsone
Side Effects of Oral Antibiotics

• Doxycycline - onycholysis, oesophagitis with ulceration, fixed drug

eruptions, photosensitivity

• Minocycline - benign intracranial hypertension, pappiloedema, blue-

black pigmentation and rarely hypersensitivity reactions

• Macrolide group - gastritis, diarrhoea

• Co-trimoxazole - severe drug reactions

• Dapsone - hemolytic anemia, dapsone syndrome

Hormonal Therapy

• Antiandrogens – cyproterone acetate(50-100 mg/day)

• Oral contraceptives - 35 mcgs ethinyl estradiol plus 2 mgs

cyproterone acetate

• Levonorgestrel+ethinyl estradiol (100+20 mcgs)

• Other regimens - prednisolone plus oestrogen, spironolactone and

antiandrogens

• Drosperinone – novel progestin derived from spironolactone

• Oral contraceptives containing androgenic progesterones such as

norethisterone must be avoided.
Side Effects of Hormonal Therapy

• Weight gain

• Menstrual irregularity

• Occasional fluid retention

• Melasma

• Hypertension

• Thrombophlebitis

• Pulmonary embolism
Isotretinoin

• 13-cis-retinoic acid (Vitamin A derivative)

• Mechanism of action:
− Decreases the size of sebaceous glands
− 80% reduction in sebum
− Alters the composition of sebum
− Reduces comedogenesis
− Lowers P. acnes concentration and has anti-inflammatory activity
Isotretinoin

• Indicated for :
− Nodulocystic/ severe Acne
− Pyoderma faciale
− Acne recalcitrant to routine treatment
− Excessive seborrhoea
− Depression / Dysmorphophobia
− Acne conglobata / other unusual variants
− Scarring
Isotretinoin

• Dose : 0.1 – 2 mg/ kg per day is given after meals. Ideal would be 1
mg/kg/day
• Cumulative dose : 120-150 mgs/kg
• Side effects
− Teratogenicity (iPLEDGE)
− Mucocutaneous side effects, dryness
− Elevation of serum lipids
− Neurological : pseudotumor cerebri, optic
− Neuritis, depression, mood swing
− Arthritis, myalgia
− Acne flares
Physical Modalities

• Comedone expression

• Superficial electrocautery

• Aspiration of cystic lesions

• Intralesional steriods

• Cryotherapy

• Alpha-hydroxy acids or salicylic acid peels,TCA CROSS

• Dermaroller/Dermapen with or without PRP

• Subcision
Physical Modalities

• Photodynamic therapy using blue red light

• Low fluence pulsed dye laser light

• MNRF

• Dermabrasion / CO2 laserbrasion (ice-pick scars)

• Erbium-YAG laser for atrophic /hypertrophic scars

• Punch grafting / punch floats (for depressed scars)

• New anti-inflammatory agents such as 5-lipooxygenase inhibitors

Selection of Treatment Modality

• Mild involvement (comedones only)

− Benzoyl peroxide
− Azelaic acid
− Salicylic acid in cleanser or face wash

• Mild to moderate involvement (comedones and some

papules/pustules)
− Benzoyl peroxide
− And topical retinoids
− Topical antibacterial – inflammatory lesions
Continue…
Selection of Treatment Modality

• Moderate or severe (many inflammatory papules, pustules and/or

scarring)
− Oral antibiotics
− If oral does not respond – isotretinoin or hormonal therapy
• Cystic acne (more than two nodules, cysts, abscesses, bridging scar)
− Aspiration of cyst and intralesional steroid injection
− Systemic antibiotics
− Dapsone or hormonal or isotretinoin
− Adjuvant therapy : comedone expression, peel, acne surgery for
scar
Selection of Treatment Modality

• Post acne erythema

− Azelaic acid
− Tacrolimus / pimecrolimus
− Trenexamic acid cream
− Brimonidine gel
− Chemical peeling
− Intensepulse light
− Pulse-dye laser
− Fractional microneedling radiofrequency
Selection of Treatment Modality

• Post inflamatory hyperpigmentation

− Sunprotection − Pulse-dye laser
− Azelaic acid − Fractional microneedling
− Kojic acid radiofrequency
− Vitamin C
− Trenexamic acid
− Glutathione
− Chemical peeling
− Intense pulse light
Selection of Treatment Modality

• Post acne scarring

• Atrophic scar
− Chemical peeling , TCA − CO2 Laser

CROSS − Punch grafting/punch

− Microneedling (With or flotation/elevation

without PRP) − Dermal graft or fat grafting

− Subcision • Hypertrophic scar

− Dermabrasion − Silicone gel

− Radiofrequency cautery − Intralesional steroid

− MNRF − Cryotherapy

− − Pulse dye laser

Poor Response to Therapy

• Poor compliance

• Inadequate instructions

• Side effects

• Resistance of P. acnes

• Inadequate dosage

• Folliculitis due to staphylococci, gram negative enterobacteria or

malassezia
Before After 10 weeks

Topical Clindamycin gel and benzoyl Peroxide 2.5% gel

Before After 8 weeks

Oral Isotretinoin and topical clindamycin gel

Before After 12 weeks

Oral Minocycline and Benzoyl peroxide 2.5 % gel and topical

clindamycin gel (young married female – no isotretinoin was used)
MCQs

Q.1) Acne is caused by

A. Propionibacterium acne
B. Malassezia furfur
C. M. tonsurans
D. Cornyebacterium

Q.2) Stage 1 of acne is :

E. Severe pustules and nodules
F. Few pustules with scars
G. Few comedones mainly
H. Pustules with comedones
MCQs

Q.3) Acne is basically disease of :

A. Pilosebaceous gland
B. Epidermis
C. Eccrine gland
D. Estrogens and progesteron imbalance
Q.4) Side effects of Minocycline include all except :
E. Benign cranial hypertension
F. Pigmentation
G. Hemolytic anaemia
H. Photosensitivity
MCQs

Q.5) The following is not the feature of steroidal acne

A. Absence of comedone
B. Absence of nodulocystic lesion
C. Polymorphous eruption
D. Occasional puritus
Photo-quiz

Grade the acne and outline

Give differential diagnosis
management options
Thank You