Professional Documents
Culture Documents
Abstract
Acne vulgaris is one of the commonest skin disorders, which dermatologists have to treat, mainly
affect adolescents, though it may present at any age. Acne is chronic inflammatory disease of
pilosebaceous units. Clinically it can present as seborrhea, comedones, erythematous papules,
pustules and nodules. In recent years, due to better understanding of the etiopathogenesis of acne,
new therapeutic modalities are designed. The purpose of this article is to review the
etiopathogenesis and treatment options available with us in the present scenario.
Key words
Acne vulgaris, Pilosebaceous units, Seborrhea, Comedones.
International Archives of Integrated Medicine, Vol. 2, Issue 5, May, 2015. Page 226
Copy right © 2015, IAIM, All Rights Reserved.
Acne: Etiopathogenesis and its management ISSN: 2394-0026 (P)
ISSN: 2394-0034 (O)
A high glycemic diet induces hyper-insulinemia General measures
which results in androgen synthesis, similar to Eliminate stress by reassurance.
poly cystic ovarian disease (PCOD) [22]. Diet Counseling of the patient regarding
induced hyper-insulinemia also increases level of nature of illness, treatment modalities
IGF-1 (Insulin Like growth factor) and reduce IGF and its outcome.
binding proteins. The increased free IGF-1 level Advice to avoid scratching of lesions.
results in unregulated growth of follicular Assess the endocrinal status and
epithelium, increased sebum production and premenstrual flares.
synthesis of androgens from gonads [22]. Advise to avoid the use of acnegenic
drugs, oils, pomades and heavy
Sequence of events cosmetics.
The microcomedones are the first subclinical Balanced diet should be advised. Avoid
lesion. It is caused by blockage of the sebaceous high glycemic diet.
canal due to altered keratinization leading to Regular washing of face with soap and
retention of sebum and initiation of an water.
inflammatory process. An increase in the
microbial flora increases inflammation (papules Specific measures
and pustule formation). Further retention of The general principles of treatment are based
sebum leads to rupture of sebaceous gland and upon four strategies that may be combined
spreads the sebum in the dermis resulting in according to the clinical aspect of acne patient.
nodule formation. Confluence of affected glands Decreasing the sebaceous gland
results in accumulation of pus, fluid and cyst secretion.
formation. A scar results when such cysts heal Correcting the ductal hypercornification.
after rupture or absorption of fluid [4]. Decreasing P. acne population and
associated flora.
The severity of acne can be graded on clinical Producing an anti-inflammatory effect.
grounds as under [4]. Keep in mind “one treatment does not fit all”
Grade 1 (mild): Comedones, occasional [23].
papules.
Grade 2 (moderate): Comedones, many Topical therapy
papules, few pustules. Numerous topical preparations are in use for
Grade 3 (severe): Predominantly their anti-comedogenic, anti-seborrheic and
pustules, nodules and abscesses. antibacterial properties.
Grade 4 (cystic): Mainly cysts or abscess,
widespread scarring. Topical Retinoids
The grading is arbitrary and is used as one of the Various topical retinoid preparations available
parameters for treatment and follow up. are
Tretinoin: 0.025%, 0.05%, 0.1% gel
Management of acne vulgaris patients [4] /cream.
General measures. Isotretinoin: 0.05% gel.
Specific measure. Adaplene: 0.03%, 0.1% gel.
Tazarotene: 0.1%and 0.05% gel.
International Archives of Integrated Medicine, Vol. 2, Issue 5, May, 2015. Page 227
Copy right © 2015, IAIM, All Rights Reserved.
Acne: Etiopathogenesis and its management ISSN: 2394-0026 (P)
ISSN: 2394-0034 (O)
Mechanisms of action include restoration of the Lactic acid is found useful in
disturbed keratinization, increase in cell reducing acne lesions [30].
turnover and regulation of prostaglandin Tea-tree oil 5% [31]
synthesis. Topical retinoids reduce the number Picolinic acid gel 10% [32]
and formation of precursor lesions; reduce Dapsone gel 5% [33]
mature comedones and inflammatory lesions. Topical 5-fluorouracil [34]
The main adverse effect with these agents is
primary irritant dermatitis which can present as Systemic therapy
erythema, scaling, and burning sensation and Tetracyclines [35]
can vary depending on the skin type, sensitivity Tetracyclines - 500mg - 1gm
and formulation [24]. per day.
Benzoyl Peroxide: It is as effective as Doxycycline - 50-200mg per
topical retinoids and used in gel, cream day.
or lotion in a strength varying from 2.5 Minocycline - 50-200mg per
to 10%. It is a broad-spectrum day.
antimicrobial agent effective via its Lymecycline - 150-300mg
oxidizing activity. It has anti- per day.
inflammatory, keratolytic and
Sulpha drugs [36]
comedolytic activities. It is indicated in
Cotrimoxazoles (80 mg
mild to moderate acne. Its main side
trimethoprim + 400 mg
effects are excessive dryness, irritation,
sulphamethoxazole).
allergic contact dermatitis and bleaching
Dapsone – 50 – 200 mg per
of clothes, hair and bed linen [25].
day.
Topical antibiotics: These are used in
Macrolides [36]
inflammatory acne. Topical
Erythromycin – 250-500 mg
erythromycin and clindamycin are the
qid
most popular [26], used in 1-4%
formulation either alone or in Azithromycin – 500 mg once
a day for three days in a
combination with benzoyl peroxide or
week
adaplene. Side effects are minor Hormonal therapy [37]
including erythema, peeling, itching,
Estrogen – ethynyl estradiol
dryness, burning and development of
30 micro gm with
resistance.
progesterone.
Other topical agents are mentioned as
below. Antiandrogens: Cyproterone
Azelaic acid available 10- acetate – 50-200 mg,
Spironolactone – 50-100 mg
20% cream and effective in
per day
inflammatory and
comedonal acne [27, 28]. Corticosteroids:
Salicylic acid used as Prednisolone – 2.5-5 mg per
comedolytic agent, but is day [38].
less potent then topical Oral zinc therapy – 200 mg per day [39].
retinoid [29]. Oral retinoids - isotretinoin 0.1-2 mg
per kg per day [40].
International Archives of Integrated Medicine, Vol. 2, Issue 5, May, 2015. Page 228
Copy right © 2015, IAIM, All Rights Reserved.
Acne: Etiopathogenesis and its management ISSN: 2394-0026 (P)
ISSN: 2394-0034 (O)
Phototherapy – the efficacy of UV Acne surgery - draining of
radiation in acne is because of presence cysts and punch grafts for
of porphyrins in p-acne [41]. scars, skin resurfacing with
Chemical peeling with 10-50% glycolic acid or laser, cryosurgery, derma-
10-30 % salicylic acid leads to significant abrasion and fillers.
resolution of comedones, papules and pustules.
Repeated glycolic acid peeling is necessary for References
acne scars and cystic lesions [42].
1. Leyden J J. Therapy for Acne vulgaris.
The New Eng J Med., 1997; 1156-62.
Conclusion 2. Leyden JJ. Current issues in
Various topical and systemic drugs are available antimicrobial therapy for the treatment
to treat acne. A summary of the approach to of acne. J Eur Dermatol Venereol.,
treatment of acne as per the severity is as 2001; 15: 51-5.
follows [43]. 3. Koo J. The psycho-social impact of
A. Mild involvement (only comedones ) acne: Patient’s perceptions. J Am Acad
benzoyl peroxide gel Dermatol., 1995; 32: s26-30.
salicylic acid as cleanser 4. Tutakne M A, Vaishampayan S S. Acne,
azelaic acid Rosacea and perioral dermatitis. In:
B. Mild to moderate involvement (comedone , Valia R G, Valia A R editors, IADVL text
few papules and or pustules) book of dermatology. Vol 1; 3rd edition;
benzoyl peroxide gel or Bhalani publishing house: 2008; p. 839-
topical retinoids and 50.
topical antibiotics. 5. Thiboutot D, Gollnick H, Bettoli V, et al.
C. Moderate to severe involvement (many Global alliance to improve outcomes in
inflammatory papules , pustules , 1-2 acne. New insights into the
nodules and or scarring) management of acne: An update from
Oral antibiotics the Global Alliance to Improve
Sebostatic agent - hormonal Outcomes in Acne group. J Am Acad
therapy, Isotretinoin. Dermatol., 2009; 60: S1-50.
D. Cystic acne (more than 2 nodules, cysts 6. Zaenglein A l, Thiboutot D M. Acne
abscess, scar) vulgaris. In: Jorizzo J L, Rapini R P,
Aspiration of the cysts and Olognia J L, editors. Dermatology. 2nd
intra-lesional steroid and edition. Edinburgh: Elsevier Mosby;
Systemic antibiotics and 2009.
Dapsone or sebostatic agent 7. Cappel M, Mauger D, Thiboutot D.
Adjunctive therapy - Correlation between serum levels of
comedone expression, insulin-like growth factor-1, dihydro-
chemical peels, micro- epiandrosterone sulfate and dihydro-
derma-abrasion. testosterone and acne lesion counts in
adult women. Arch Dermatol., 2005;
Laser and light therapy -
141: 333-8.
blue light, UV light, pulsed
8. Pochi P E, Strauss J S. Sebum
dye laser.
production, causal sebum levels,
International Archives of Integrated Medicine, Vol. 2, Issue 5, May, 2015. Page 229
Copy right © 2015, IAIM, All Rights Reserved.
Acne: Etiopathogenesis and its management ISSN: 2394-0026 (P)
ISSN: 2394-0034 (O)
titrable acidity of sebum and urinary human sebaceous glands. J Invest
fractional 17 keto steroid excretion in Dermatol., 1962; 39: 139-55.
males with acne. J Invest Dermatol., 19. Borgia F, Cannavo S, Guarneri F,
1964; 43: 383-8. Cannavo S P, Vaccare M. Correlation
9. Kenaar P. Lipolysis of skin surface lipids between endocrinal parameters and
of acne vulgaris patients and healthy acne severity in adult women. Acta
controls. Dermatologica, 1971; 143: Derm Venereol., 2004; 84: 201-04.
121-9. 20. Chiu A, Chon S Y, Kimball A B . The
10. Morello A M, Downing D T, Strauss JS. response of skin diseases to stress:
Octadecadienoic acids in the skin Changes in the severity of acne vulgaris
surface lipids of acne patients and as affected by examination stress. Arch
normal subjects. J Invest Dermatol., Dermatol., 2003; 139: 897-900.
1976; 66: 319-23. 21. Simpson N B, Cunliffe W J. Disorders of
11. Downing D T, Stewart M E, Wertz P W, sebaceous glands. In: Burns T,
et al. Essential fatty acids and acne. J Breathnach S, Cox N, editors. Rook’s
Am Acad Dermatol., 1986; 14: 221-5. Textbook of dermatology. 7th edition.
12. Guy R, Kealy T. Modeling the Oxford: Blackwell Publishing; 2004, p.
infundibulum in acne. Dermatology, 43.1-75.
1998; 196: 32-7. 22. Cordain L, Linedeburg S, Hurtado M, et
13. Cunliffe W J, Holland D B, Clark S M, et al. Acne vulgaris: A disease of western
al. Comedogenesis: Some new civilization. Arch Dermatol., 2002; 138:
aetiological, clinical and therapeutic 1584-90.
strategies. Br J Dermatol., 2000; 142: 23. Longshore S J, Hollandsworth K. Acne
1084-91. vulgaris: One treatment does not fit all.
14. Habif T P. Acne, rosacea, and related Cleve Clin J Med., 2003; 70: 670,672-
disorders, In: Habif T P, Editior. Clinical 4,677-8.
dermatology: A color guide to diagnosis 24. Jain S. Topicaltretion or adapalene in
and therapy, 4th edition. Edinburgh: acne vulgaris: An overview. J Dermatol
Mosby; 2004, p.168-70. Treat., 2004; 15: 200-7.
15. Whiteside J A, Voss J G. Incidence and 25. Mills O H, Jr Kligman A M, Pochi P,
lipolytic activity of Propionibacterium Comite H. Comparing 2.5%, 5% and
acnes and P. granulosum in acne and 10% benzolperoxide: On inflammatory
normal skin. J Invest Dermatol., 1973; acne vulgaris. Int J Dermatol., 1986; 25:
60: 94-7. 664-7.
16. Jeremy A H, Holland D B, Roberts S G, 26. Eady E A, Cove J H, Joanes D N, Cunliffe
et al. Inflammatory events are W J. Topical antibiotics for the
vinvolved in acne lesion initiation. J treatment of acne vulgaris: A critical
Invest Dermatol., 2003; 121: 20-7. evaluation of the literature on their
17. Pochi P E, Strauss J S. Sebaceous gland clinical benefit and comparative
suppression with ethinyloestradiol and efficacy. J Dermatol Treat., 1990; 1:
diethylstilbestrol. Arch Dermatol., 215-26.
1973; 108: 210-14. 27. Cunliffe W J, Holland K T. Clinical and
18. Strauss J S, Kligman A M, Pochi P E. The laboratory studies on treatment with
effect of androgens and estrogens on 20% azelaic acid cream for acne. Acta
International Archives of Integrated Medicine, Vol. 2, Issue 5, May, 2015. Page 230
Copy right © 2015, IAIM, All Rights Reserved.
Acne: Etiopathogenesis and its management ISSN: 2394-0026 (P)
ISSN: 2394-0034 (O)
Derm VenerolSuppl (stockh), 1989; edition, London: Martin Dermitz ltd;
143: 31-4. 2001.
28. Iraji F, Sadeghinia A, Shahmoradi Z, 36. Mernadier J, Alirezai M. Systemic
Siadat A H, Jooya A. Efficacy of topical antibiotics for acne. Dermatology, 1998;
azelaic acid gel in the treatment of 196: 135-9.
mild- moderate acne vulgaris. Indian J 37. Redmond G F, Elson W H, Lippman J S,
Dermatol Venereol Leprol., 2007; 73: Hafrisen M F, Jones T M, Jorizzo J L.
94-6. Norgestimate and ethinylestradiol in the
29. Shalita A R. Treatment of mild and treatment of acne vulgaris. A
moderate acne vulgaris with salicylic randomized placebo controlled trial.
acid in an alcohol –detergent vehicle. Obstet Gynaecol., 1997; 89: 615-22.
Cutis, 1981; 28: 556-8, 561. 38. Saiohan E M, Burton J L. Sebaceous
30. Garg T, Raman M, Pasricha JS, Verma gland suppression in female acne
KK. Long term topical application of patients by combined glucocortcoid and
lactic acid/lactate lotion as a preventive oestrogen treatment. Br J Dermatol.,
treatment for acne vulgaris. Indian J 1981; 103: 139-42.
Dermatol Venereol Leprol, 2002; 68: 39. Dreno B, Amblerd P, Agache P, et al. Low
137-9. doses of zinc gluconate for inflammatory
31. Enshaieh S, Jooya A, Sidat A H, Iraji F. acne. Acta Derm Venereol., 1989; 69:
The efficacy of 5% topical tea tree oil 541-3.
gel in mild to moderate acne vulgaris: A 40. Gollnick H, Cunliffe W, Birson D, et al.
randomized, double-blind placebo Management of acne; A report from
controlled study. Indian J Dermatol global alliance to improve outcome in
Venereol Leprol, 2007; 73: 22-5. acne. J Am Acad Dermatol., 2003; 49: S1-
32. Hefferman M P, Nelsoa M M, Anadkat 37.
M J. A pilot study of the safety and 41. Papageorgiou P, Katsambas A, Chu P.
efficacy of picolinic acid gel in the Photo therapy with blue (415 nm) and
treatment of acne vulgaris. Br J red (660 nm) light in the treatment of
Dermatol., 2007; 136: 548-52. acne vulgaris.Br J Dermatol, 2000; 142:
33. Draelos Z D, Carter E, Maloney J M, et 973-8.
al. Two randomized studies 42. Wang C M, Haung C L, Hu C T, Chan M I.
demonstrate the efficacy and safety of The effect of glycolic acid on the
dapsone gel, 5%for the treatment of treatment of acne in Asian skin.
acne vulgaris. J Am Acad Dermatol., Dermatological Surgery, 1997; 23: 23-8.
2007; 56: 439. 43. Batra RS. Acne. In: Arndt K A, Hsu J T S,
34. Milstein H G. 5-Fluorouracil as an aid in editors. Manual of dermatologic
the management of acne and melasma. therapeutics. 7th edition, Philadelphia:
Jam Acad Dermatol., 1981; 4: 97-8. Lippincott Williams and Wilkims; 2007,
35. Cunliffe W J, Gellnick H P. Acne: p. 7- 17.
Diagnosis and management. First
International Archives of Integrated Medicine, Vol. 2, Issue 5, May, 2015. Page 231
Copy right © 2015, IAIM, All Rights Reserved.