3. DEFINITION
• Acne vulgaris is a common dermatological disorder of the pilosebaceous unit
that has a complex pathophysiology.
• it can be triggered by a number of factors such as,
abnormalities in sebum production
follicular desquamation
bacterial proliferation and inflammation
Prevalence
• 85% in adolescents
• 3.8% in 25 - 34 year old’s
• 4.3% in 35 - 44 year old’s
4. ACNE VULGARIS (an overview)
• Affects the Pilosebaceous unit
• Self-limited disorder that is seen primarily in adolescents
Variety of lesions:
Comedones - (closed and open)Whiteheads and blackheads
Papules- Small or larger red or skin-colored acne bumps
Pustules- Bumps filled with white or yellow pus
Nodulocystic- Very large pus-filled, often painful acne lesions
5. EPIDEMEOLOGY
• Mild degrees of acne frequently seen at birth, resulting from
follicular stimulation by adrenal androgens in neonatal period
• In the very young patients the predominant lesions are Comedones
• Particularly in women, acne may persist through out the third
decade or even later
• Nodulocystic acne has been more common in white males than in
black males.
6. ETIOLOGY AND PATHOGENESIS
Pathogenesis of acne
Four basic steps have been identified
I. Follicular epidermal hyperproliferation (microcomedones)
II. Excess sebum production
III. Inflammation
IV. The presence and activity of Propionobacterium acnes
9. EXCESS SEBUM PRODUCTION
• Excess sebum production from sebaceous glands
• Components of sebum :
1) Triglycerides – free fatty acids converted by p.acnes
2) Promote bacterial clumping and colonization of p.acnes, incites
inflammation.
10. INFLAMMATION
• Micromedo continues to expand with densely packed keratin
sebum, and bacteria.
• This distension causes follicular wall rupture.
• Extrusion of keratin, sebum and bacteria into the dermis results in a
brisk of inflammatory response.
11. CLINICAL FINDINGS
• Neonatal acne appears at approximately 2 weeks of age and
infantile acne develops at 3 to 6 months of age.
• Hyperandrogenism should be considered in the female patient
whose acne is severe, sudden onset, or associated with hirsutism or
irregular menstrual periods.
12. • Drug-induced acne may be caused by:
Anabolic steroids
Corticosteroids
Corticotropin
Phenytoin
Lithium
Isoniazid
• Vitamin B complexes - Prolonged use might cause an irritation of
the follicular epithelium and subsequently produces an
inflammatory reaction
13. Chemotherapy medication
Cancer drugs
Doxorubicin (Andriamycin)
Erlotinib (Tarceva)
Paclitaxel (Taxol)
Cetuximab (Erbitux)
EGFR-blocking agents playing a central role in the normal differentiation
and development of hair follicle.
15. NON INFLAMMATORY TYPES
lesions are Comedones
It may be either open (blackheads) or closed (whiteheads).
16. INFLAMMATORY TYPES
• Papules- Small or larger red or skin-coloured acne bumps
• Pustules- Bumps filled with white or yellow pus
• Nodulocystic- Very large pus-filled, often painful acne lesions
17. ACNE VARIANTS
• Neonatal acne - Lesions appear within 2 weeks and resolve in 3
months
• Infantile acne - 3 to 6 months of age marked by the presence of
comedones
18. • Acne Conglobata - Common in teenage males
• Acne Fulminans - Known as (acute febrile ulcerative acne) Treated with
systemic glucocorticoids and isotretinoin
19. SAPHO syndrome
• Synovitis Acne Pustulosis Hyperrostosis Osteitis (SAPHO)
• Inflammatory bone disorder
PAPA syndrome
• PyogenicArthritis, Pyodermagangrenosum and Acne
• Rare genetic disorder
20. Acne Excoriee des Jeunes Filles( Excoriated acne)
• Mild acne accompanied by extensive excoriations.
Acne Mechanica
• Acneiform eruption, observed after repetitive physical trauma to
the skin (rubbing, occurring from clothing (belts and straps) or
sports equipments (football helmets and shoulder pads)
21. Acne with Solid Facial Edema
• Known as Morbihan disease
Can be treated with,
• Isotretinoin (0.2 to 0.5 mg/kg/day)
• Oral glucocorticoids (1 to 2 mg/day)
• Clofazimine for 4 to 5 months
Acne with Associated Endocrinologic Abnormalities
Due to Irregular menstrual cycle
Causes deepened voice
hirsutism
22. LABORATORY TESTS
• Laboratory workup is not indicated for patients with acne unless
hyperandrogenism is suspected.
• Elevated serum levels of androgens (severe cystic acne) and in acne
associated with a variety of endocrine conditions:
1) Congenital adrenal hyperplasia
2) Ovarian or adrenal tumors
3) Polycystic ovarian disease
23. TREATMENT OF ACNE VULGARIS
Non-inflammatory (Comedones) acne
Retinoids
1) Comedolytic and anti-inflammatory properties
2) Inactivated by concomitant use of benzoyl peroxide
3) Photolabile
24. Salicylic acid
• Promotes desquamation
Azelaic acid
• Antimicrobial and comedolytic properties
• Competitive inhibitor of tyrosinase, decreasing pigmentation
• Safe in pregnancy
25. Benzoyl Peroxide
• antimicrobial
• Anti - comedonal
• safe in pregnancy
Glycolic acid
reduce wrinkles, acne scarring and hyperpigmentation
• Promotes desquamation
• commonly used as a chemical peel
33. ADVERSE EFFECTS OF MEDICATIONS USED TO
TREAT ACNE
MEDICATIONS ADVERSE EFFECTS
TOPICAL RETINOIDS
EX: Tretinoin
Local irritation
photosensitivity
Adapalene Local irritation (slightly less than tretinoin)
photosensitivity
Isotretinoin Local irritation
Photosensitivity
Contraindicated in pregnancy and
nursing
Benzoyl peroxide Local irritation
Can bleach hair and clothing
34. TOPICAL ANTIBIOTICS
MEDICATIONS ADVERSE EFFECTS
Metronidazole
Tetracycline Can cause yellow staining of skin and
clothing
Clindamycin Theoretically can cause pseudomembranous
colitis
Erythromycin
Azelaic acid
35. ORAL ANTIBIOTICS
MEDICATIONS ADVERSE EFFECTS
Tetracycline Contraindicated in pregnancy and in children
under age 12 due to tooth discoloration
Doxycycline Photo toxicity
Oesophageal ulceration
Minocycline Vertigo
pseudotumour
Erythromycin Gastrointestinal compliants
Oral isotretinoin Teratogenecity (absolute contraindicated in
pregnancy and nursing )
Mucocutaneous effects
hypertriglyceridemia
Depression
Bone marrow supression
36. ACNEIFORM ERUPTIONS
Steroid Folliculitis
• Occur in adolescents and adults ,2 weeks after the start of
steroids.
• Lesions have the same stage of development
Drug-Induced eruptions
Glucocorticoids
Phenytoin
Lithium
Isoniazid
High-dose vitamin B complex
38. Epidermal Growth Factor Receptor Inhibitor-Associated Eruption
• Used to treat
i. small cell lung cancer
ii. colorectal cancer
iii. breast cancer
• Highly expressed in the basal cell layer of the epidermis
• follicular keratinocytes
• sebaceous epithelium, resulting in eruptions.
Occupational acne and Chloracne
Due to tar derivatives
Insoluble cutting oils
Chlorinated hydrocarbons- (chloracne)
39. Gram- Negative Folliculitis
• Treated with long-term oral antibiotics
• Improves with oral Isotretinoin for 4 to 5 months
Radiation acne
• Ionizing radiation and UV radiation
• Lesions usually distributed at temporal and periorbital areas
• Treated with oral or topical retinoids and extraction
Tropical acne
• Mainly on trunk and buttocks
40. ROSACEAE
Rosacea
• Mild, moderate, and severe
• Causes burning and stinging of the facial skin
• Sebaceous or glandular features characterized by thickened skin and large
follicular orifices
• Ocular rosacea may develop before cutaneous symptoms up to 20%
• Severe cases - rosacea keratitis may lead to vision loss
41. PERIORAL DERMATITIS
• Discrete and grouped erythematous papules, vesicles, and
pustules
• Unilateral and appear in the perioral, perinasal, and periorbital
regions
• Distinct of 5-mm clear zone at the vermilion edge
• In addition also appears on the ears, scalp, trunk and extremities
42. OTHER DIFFERENTIAL DIAGNOSIS
Diagnosis is available most likely for,
Closed comedonal acne
• Milia
• Sebaceous hyperplasia
Open comedonal acne
• Dilated pore of Winer
• Favre- Racouchot syndrome
Inflammatory acne
• Rosacea
• Perioral Dermatitis
Neonatal acne
• Miliariarubra
43. ALWAYS RULE OUT:
Closed comedonal acne eruptions could be due to,
* Acne due to systemic agents (ex: corticosteroids)
* Contact acne (ex: occupational acne)
* Chloracne
Open comedonal acne eruptions could be due to,
* Acne due to systemic agents
* Contact acne
* Chloracne
44. • Inflammatory acne eruptions due to,
* Acne due to systemic agents
* Staphylococcal folliculitis
* Gram negative folliculitis
*Eosinophillic folliculitis
*Furuncle/carbuncle
• Neonatal acne eruptions due to,
*Candidal infections
*Benign neonatal cephalic pustulosis
45. COMPLICATIONS
• Acne lesions have the potential to resolve with sequelae.
• Acne lesions leave a transient macular erythema after resolution
causing,
1) post-inflammatory hyperpigmentation
2) Scarring
• Acne vulgaris also take a psychological toll
1) 30% to 50% adolescents have psychiatric disturbances due to acne
46. Sequelae:
4 general types of acne scars:-
• Ice pick- narrow, deep scars widest at the surface of the skin and taper
to a point in the dermis.
• Rolling- shallow, wide scars that have undulating appearance.
• Box scar – wide, sharply, demarcated scars.
• Hypertrophic- scars on the trunk
47. REFERENCES
• Fitzpatrick’s Dermatology in General Medicine Seventh
Edition(Volume 1, Chapter 78; pp 690-703)
• Sheretz EF. Acneiform eruption due to "megadose" vitamins B6 and
B12. Cutis. 1991 Aug,48(2): 119-20
• Adams DH, Nutt T. A case report and discussion of cetuximab-
induced folliculitis. Am J ClinDermatol 2006.
