What is Acne Vulgaris ?
Acne vulgaris is a disorder of the sebaceous units. It is a chronic inflammatory dermatosis that results in open and closed comedones, papules, pustules and nodules. It affects the exocrine part of the body which is the skin.
Predominant age from early to late puberty, it may persist in 20% to 40% of the affected individuals to the fourth decade. It’s also predominant in males more than females in adolescence. And in females more than males in adults.
- androgens stimulate sebum production and proliferation of keratinocytes in hair follicle.
- Keratin obstructs hair follicle causing sebum accumulation and follicular distention.
- Propionibacterium acnes is an anaerobic bacterium that colonizes and proliferates in the plugged follicle. It promotes proinflammatory mediators causing inflammation of follicle and dermis.
- Increased endogenous androgenic effect.
- Oily comedogenic cosmetics.
- Rubbing or occluding the skin surface with mobile phones and hands against the skin.
- Numerous drugs including androgenic steroids, some birth control pills
- Endocrine disorders like polycystic ovarian syndrome, Cushing syndrome, congenital adrenal hyperplasia, acromegaly and androgen secreting tumors.
- Psychological distress
- High glycemic load and high diary diets may exacerbate acne.
Ask about duration, medications, cleansing products, stress, smoking, exposures, diet and family history. Females may worsen 1 week prior to menses.
- Closed comedones (whiteheads)
- Open comedones (blackheads)
- Nodules or papules
- Most common areas affected are face, chest, back and upper arms.
- Tests are only indicated if additional signs of androgen increase, if so, test for free and total testosterone, LH and FSH.
- Grading system are done according to:
Mild: few papules/ pustules with no nodules
Moderate: some papules/ pustules with few nodules
Severe: numerous papules/ pustules with many nodules
- Mild inflammatory acne: benzoyl peroxide or topical retinoid.
- Moderate inflammatory acne: add systemic antibiotic to grade two regimen.
- Severe inflammatory acne: as in grade three or isotretinion.
- Avoid topical antibiotics as monotherapy.
- Can use isotretinoin for treatment of resistant moderate acne.
- Use mild soap daily to control oiliness and avoid abrasives.
- Avoid drying agents with keratinolytic agents.
- Use gentle cleanser and non-comedogenic moisturizer to help decrease irritation.
- Use oil-free and non-comedogenic sunscreens.
- Topical retinoids are first line agents for maintenance, avoid long term antibiotics for maintenance.
- Keratinolytic agents (alpha-hydroxy acids, salicylic acid, topical retinoids, azelaic acid); side effects include dryness, erythema, and scaling; start with lower strength, increase as tolerated and tretinoin with varying strengths and formulations: Apply at bedtime; wash skin; let skin dry 30 minutes before application.
- Oral antibiotics: use for shortest possible period, generally needs 8 to 12 weeks of therapy, indicated when acne is more severe, unresponsive to topical agents, or at greater risk for scarring
- Tetracycline: 500 to 1,000 mg/day divided BID; high dose initially, side effects: photosensitivity, esophagitis
- Minocycline: 100 to 200 mg/day, divided daily—BID; side effects include photosensitivity, urticaria, gray-blue skin, vertigo, hepatitis, lupus.
- Doxycycline: 20 to 200 mg/day, divided daily—BID; side effects include photosensitivity.
- Erythromycin: 500 to 1,000 mg/day; divided BID–QID; decreasing effectiveness as a result of increasing P. acnes resistance
- Azithromycin 500 mg 3 days/week × 1 month, then 250 mg every other day × 2 months
- Oral retinoids
Isotretinoin: 0.5 to 1.0 mg/kg/day divided BID to maximum 2 mg/kg/day divided BID for very severe disease; 60–90% cure rate; usually given for 12 to 20 weeks. Side effects: teratogenic, pancreatitis, excessive drying of skin, hypertriglyceridemia, hepatitis, blood dyscrasias, hyperostosis, premature epiphyseal closure, suicidal ideation and psychosis.
- Drospirenone/ethinyl estradiol or drospirenone/ethinyl estradiol/levomefolate.
- Spironolactone at 25 to 200 mg/day; antiandrogen; reduces sebum production.
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AL Chien, J Qi, B Rainer, et al. Treatment of acne in pregnancy. J Am Board Fam Med. 2016;29(2):254–262.
S Admani, VR Barrio. Evaluation and treatment of acne from infancy to preadolescence. Dermatol Ther. 2013;26(6):462–466.
AL Dawson, RP Dellavalle. Acne vulgaris. BMJ. 2013;346:f2634.
AL Zaenglein, AL Pathy, BJ Schlosser, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945.e33–973.e33.