Acne vulgaris
Nino Lortkipanidze

Acne Vulgaris
Acne vulgaris is the formation
of comedones, papules,
pustules, nodules and/or cysts
as a result of obstruction and
inflammation of pilosebaceus
units (hair follicles and their
accompanying sebaceus gland)

Etiology
The most common trigger is puberty
Other triggers include hormonal changes
that occur with pregnancy or throughout the
menstrual cycle; occlusive cosmetics,
cleansing agents, humidity and sweating
Acne may improve in summer months
because of sunlight anti-inflammatory effects

Pathogenesis
Key factors are follicular keratinization, androgens
and Propionibacterium acnes

Symptoms and Signs
Comedones appear as whiteheads (closed
comedones) or blackheads (open comedones).
Whiteheads are flesh-colored or whitish
paplable lesions 1 to 3 mm in diameter.
Blackheads are similar in appearance but with a
dark center
Papules and pustules are red lesions 2 to 5 mm
in diameter
Nodules are larger, deeper and more solid than
papules
Cysts are suppurative nodules

Symptoms and Signs

Acne conglobata
Acne conglobata is the most
severe form of acne vulgaris,
affecting men more than
women
Patients have abscesses,
fistulated comedones,
keloidal and atrophic scars
The back and the chest are
severely involved. The arms,
abdomen, buttocks and even
the scalp may be affected

Acne Fulminans
• Rare form of extremely severe cystic acne
• Teenage boys, chest and back
• Rapid degeneration of nodules leaving ulceration
• Fever, leukocytosis, arthralgias are common
• Tx; oral steroids, isotretinoin

Diagnosis
Assessment for contributing factors (eg,
hormonal, mechanical or drug-related)
Determination of severity (mild, moderate,
severe)
Assessment of psychosocial impact

Differential diagnosis
• Rosacea
• Corticosteroid-induced acne
• Perioral dermatitis
• Acneform drug eruption
Rosacea
Corticosteroid-induced acne Perioral dermatitis Acneform drug eruption

Treatment
Comedones: Topical tretinoin
Mild inflammatory acne: Topical antibiotics,
benzoyl peroxide or both
Moderate acne: Oral antibiotics
Severe acne: Oral isotretinoin
Cystic acne: Intralesional triamcinolone

Perioral dermatitis
A facial rash that tends to occur around the mouth
Most often it is red and slightly scaly or bumpy
Any itching or burning is mild
It may spread up around the nose, and occasionally
the eyes while avoiding the skin adjacent to the lips
It is more rare in men and children

Couse
• One of the most common factors is prolonged
use of topical steroid creams and inhaled
prescription steroid sprays used in the nose and
the mouth
• Overuse of heavy face creams and moisturizers
are another common cause
• Other causes include skin irritations, fluorinated
toothpastes, and rosacea.

Diagnosis
Diagnosis is by appearance
Perioral dermatitis is distinguished from acne by
the absence of comedones and from rosacea by
the latter’s lack of lesions around the mouth and
eyes
Seborrhoeic dermatitis and contact dermatitis
must be excluded
Biopsy, which is generally not clinically necessary,
shows spongiosis and a lymphohistiocytic
infiltrate affecting vellus hair follicles

Treatment
• first step in treating perioral dermatitis is to
discontinue all topical steroid creams and
fluorinated dental products
• Once the steroid cream is discontinued, the
rash appears and feels worse for days to
weeks before it starts to improve
• Heavy face creams should also be stopped

Treatment
The most reliably effective treatment is oral
antibiotics. These are taken in decreasing doses for
three to twelve weeks
Topical antibacterial creams and lotions may also be
used for faster relief. These can be continued for
several months in order to prevent recurrences
Isotretinoin has been successfully used to treat
granulomatous perioral dermatitis
Even after successful treatment, perioral dermatitis
sometimes comes back later. Usually, the same type
treatment will again be effective. Many cases that
come back eventually turn into rosacea

Rosacea
• Chronic inflammatory eruption
of the flush areas of the face
• Erythema, papules, pustules,
teleangectasia, hypertrophy of
the sebaceous glands
• Usually mid-face
• Often women ages 30-50

Ocular Rosacea
• Blepharitis, conjunctivitis
• Keratitis, iritis, episcleritis
• C/o gritty, stinging sensation
• occurs in about 58% of
rosacea patients

Chronically inflamed eyelid margins
may be confused with seborrheic
dermatitis
•

Etiology
Vasomotor liability
Hot liquids, ETOH, steroids (oral and topical)
ie: perioral dermatitis
Demodex folliculorum not causative

Differential Diagnosis
 Acne Vulgaris
 Lupus erythematosus
 Bromoderma, ioderma
 Papular syphilid

Inflammatory
rosacea
• Papules and pustules
are characteristic
Granulomatous
Rosacea
• Midface, perioral, lateral mandible
areas
• Noncaseating granulomas

Rhinophyma
• Men over 40
• Pilosebaceous
gland hyperplasia
with fibrosis,
inflammation,
and
telangiectasia
• Treatment is
surgery

Rosacea Treatment
• Long-term oral tetracycline is suppressive,
required for ocular rosacea
• Topical metronidazole
• Sunscreens, avoidance of flushing triggers
• Flash lamped pumped dye laser for
telangectasias