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ACNE

Dr Behram
Khan
Associate Professor Dermatology
J.P.M.C

Acne vulgaris: overview


Introduction:
Acne is a disorder of pilosebaceous apparatus characterized
by comedons, papules, pustules, cysts and scars with
significant psychological morbidity and, rarely, mortality due
to suicide.
Prevalence:
85% adolescents experience it
Prevalence of comedones (lesions) in adolescents
approaches 100%
affects 8% of 25 - 34y yr olds, and 3% of 35-44yr olds.
Peak ages: Male

17- 19 yrs
Female 16-17 yrs

PATHOGENESIS

Pilosebaceous
follicle

Pathogenesis:
Acne vulgaris is a disease of
pilosebaceous follicles.
Factors:
Retention hyperkeratosis.
Increased sebum production.
Propionibacterium acnes

within the follicle.


Inflammation

Initial pathogenesis (reason unknown):


follicular hyperkeratinization
proliferation +
decreased desquamation of keratinocytes
hyperkeratotic plug
(microcomedone)

Pathogenesis
Sebaceous glands enlarge
Sebum production increases
Growth medium for P. Acnes
plugs provide anaerobic
Lipid-rich environment

Pathogenesis
Bacteria thrive
Inflammation results
Chemotactic factors attract neutrophils
Depending on conditions
Non-inflammatory
open/closed comedones

Inflammatory papule/
pustule/nodule

External factors:
Oils, greases, or dyes in hair products
Cosmetics
water-based products are less comedogenic
Repetitive trauma may worsen inflammation
Soaps decrease sebum but do not alter production
Humidity
perspiration

Sites
Commonly effect face, neck, chest, upper

back and upper arm


Differential Diagnosis:
Acne Rosacea:
Late onset
No comedoms
Female predominance
Absence of telengiectasias

Whitehead and blackheads

Closed comedones (whiteheads)

closed comedo

(a whitehead):
Accumulation of
sebum
converts a
microcomedo into
this.

Open comedo (blackhead)


open comedo

(a blackhead):
when follicular orifice
is opened + distended.

Open comedo (blackhead)

Cysts
Cysts:

when follicles rupture


into surrounding
tissues, resulting in
papule/pustule/nodule.

Cysts

Pustular

Comedonal acne
Topical agents:
Isoretinoin (most effective)
Salicylic acid (promotes desquamation)
Azelaic acid (antimicrobial, reduces
hyperpigminetation)
Gycolic acid
Sulfur in OTC rx (keratolytic)

Comedonal acne
Mechanical removal of comedones
useful adjunct to topical rx

Mild to moderate inflammatory acne


Benzoyl peroxide: (antimicrobial, anticomedonal,

pregnancy risk C)
Topical antibiotic (Clindamycin, Erythromycin)
Combination of both (more effective)

Moderate to severe acne:


If topical Rx not effective oral isotretinoin

oral antibiotics
hormonal rx
Oral isotretinoin
Reduces sebaceous gland size/sebum production
regulates cell proliferation and differentiation
Effect last 1 yr after cessation
Only med altering course of A. Vulgaris

Moderate to severe acne:


oral isotretinoin
Adverse effects

Teratogenic
Increase TG
Bone marrow suppression
Hepatotoxicity

Monitoring parameters: CBC w/ diff, ESR, glucose,

Chol, TG, LFT, CPK


Obtain baseline, then regular intervals.
LFT 1-2 x week until response to rx
Lipids 1-2 x week until response to rx.

Moderate to severe acne:


Oral antibiotics

-Tetracycline - erythromycin
- minocycline - TMP-SMX
- doxycycline - clindamycin

Given daily over 4-6 mo, with taper.

Moderate to severe acne:

HORMONE Rx
Unresponsive acne
Send for Gyn eval if hirsutism/menstrual

irregularities.
Consider adult onset congenital adrenal
hyperplasia, ovarian/adrenal tumour, Cushings dz
/syndrome, PCOS (hirsutism, acne, irregular menses,
acanthosis nigrans, insulin resistance)

Anti-androgens (spironolactone, flutamide, ketoconazole,


cimetidine)

estrogen
Min 3-6 mo of rx

Other Therapies
Blue light therapy
Laser therapy

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