Acne is a chronic inflammatory disease of the
pilo sebaceous follicles.
Acne is rare in children and old age.
The sites involved are the seborrheic areas rich
in sebaceous glands mainly face, upper chest , back and the shoulder
areas.
The usual types of acne occur after puberty.
Since puberty manifests earlier nowadays in some children
especially young girls, brief discussion of different types of acne
are included in this chapter.
Etiology
Increase
in the activity of
sebaceous glands and occlusion of the pilosebaceous orifices are the
main factors of acne pathogenesis.
Hormones :
Androgens increase the activity of sebaceous
gland in both sexes.
Estrogens antagonize the effect of androgens.
ACTH increases the activity of the sebaceous
glands due to its stimulation of production androgens.
Infections: Corynebacterium acnes and
staphylococci are considered important in the pathogenesis of acne.
Diet: The effect of diet is variable. Some
types of diet such as high carbohydrate, fatty foodstuffs,
chocolate, diets rich in iodides such as seafood may have some
effect on exacerbation and not the pathogenesis of acne in certain
individuals.
Drugs: acniform eruption results due to
different systemic and topical medications. Tetracyclines ,
corticosteroids, certain vitamins with mineral supplements such as
iodides and other drugs may be accompanied by acniform eruptions.
Stress and lack of sleep may have some role.
Pathogenesis
Two factors play an important role in the
formation of acne. These include increased activity of sebaceous
glands with production of excess sebum and the other is the
occlusion of the pilo sebaceous orifices.
( A)
(B)
(C)
Stages of acne
pathogenesis. (A)
Normal follicle; (B) open comedo (blackhead); (C)
closed comedo (whitehead);
Hormones :
Fig.
Acne vulgaris : (Black heads &papulopustules)
Increased activity of sebaceous glands and
occlusion of the cornfied hypertrophic pilosebaceous follicles lead
to retention of sebum into the follicles, which dilate and rupture
by time. Anaerobes such as Corynebacterium acne, Pityrosporon ovale
and Staphylococci cause split of the sebum into fatty acids and
triglycerides which act as an important irritating factors .This
will lead to the formation of the different clinical types of acne
which varies from papules, pustules ,cysts and comedones.
CLINICAL TYPES OF ACNE
NEONATAL ACNE
Skin lesion begins shortly after birth as small
papules on the seborrheic areas mainly on the forehead and cheeks
due to increase in the activity of sebaceous glands. The role of
circulating androgen and estrogen may have some role.
There is usually a family history of severe acne
.
The condition resolves spontaneously within few
weeks . Persistent cases may need antiseptic lotions such as
Clindamycin or Erythrocin topically .
Fig. 389. Neonatal Acne |
Fig. 390. Neonatal Acne
|
JUVENILE ACNE
This type of acne affects mainly males, presents
as facial acne at around three months and may last up to five years
of age .
Etiology
-
Transplacental stimulation of the
adrenals.
-
Drugs
-
Virilizing tumour or congenital adrenal
hyperplasia.
Treatment
Erythromycin 125 mg three times daily.
|
Fig. 391. Juvenile Acne |
Topical preparations: erythromycin (Eryderm) or
Clinamycin lotion (Dalacin). Pufexamac (Parfenac or Flogocid cream)
may have good effect especially when there is erythema or
irritations of lesions by previous medications.
Benzoyl peroxide or vitamin A acid is useful
medications .These preparations are better used for adults since
they may cause irritation in some patients especially when applied
to extensive areas.
POST-PUBERTAL ACNE (Acne Vulgaris)
This is the
most common type of acne. Papular and
pustular lesions appear on the seborrheic areas mainly on the face,
forehead, upper chest , back and shoulders.
|
Fig. 392. Acne Vulgaris |
CYSTIC ACNE
Cysts containing thick , viscid or blood tinged
fluid . The most common sites involved are the face and the back. This
type has to be differentiated from the cysts of neurofibromatoses,
which has other manifestations such as the café
au lait macules, and the cysts of neuro fibromatoses are more soft
392c papulo-pustular
and scarring acne
Fig. 392b. Cystic , Black dot and Keloidal acne
ACNE CONGLOBATA
This is a severe type of acne that may affect the
face and back. The lesions are boggy and heal in some cases by scar
formation . This type is more common in girls.
|
Fig. 393. Acne Conglobata |
SOLAR ACNE
Solar comedones (senile comedones). These are not
uncommon in elderly people, especially in the periorbital areas.
Most patients have had high exposure to UV radiation and the solar
damage to the supporting dermis allows the pilo sebaceous duct to
become more easily distended .
Fig.394b. Solar acne
DETERGENT ACNE
This uncommon form of acne develops in patients
who wash many times daily, hoping to moderate their existing lesion.
Certain bacteriostatic soaps contain weak acnegenic compounds, such
as hexachlorophene which may lead to pustular and papular lesions .
ACNE KELOIDALIS
This is due to pyogenic infection of the
sebaceous glands leading to more destruction and disfiguration of
tissues with formation of keloids.
Fig. 394b. Acne keloidalis nuchae
|
Fig. 394. Acne Keloidalis |
ACNE EXCORIATA
This type is common in neurotic patients, who
play by picking or squeezing the lesions. This may lead to crust and
pitted scarring.
|
Fig. 395. Acne Excoriata |
TROPICAL ACNE
Hot humid environment leads to excessive
sweating. Occlusion of the pores of the sweat glands leads to
miliaria and this may be accompanied by occlusion of the pilo
sebaceous orifices .
|
Fig. 396. Tropical Acne |
ACNE ROSACEA
The manifestations are erythema of the face
usually has the appearance of butterfly where papules and papules
are embedded in the erythematous patches of the face.
Fig. 397b. Acne rosacea
ACNIFORM ERUPTIONS
Papules mainly and to lesser extent pustules
simulating acne vulgaris appear suddenly. The lesions are not
necessarily located on the seborrheic areas. These may be
distributed on the chest ,trunk and extremities. Different factors
may cause acniform eruption. These include:
|
Fig. 397. Acniform Eruption |
Drugs: such as Tetracycline, Minocycline,
Doxycycline and corticosteroids. Topical corticosteroids especially
when occluded may cause acniform eruption.
Iodides and bromides in vitamins and mineral
supplements .
Other drugs such as isonicotine hydrazine (INH),
ACTH, Chloral hydrates and pro-banthin can cause acniform eruption.
Chemicals: Chloracne, which is due to excess
chlorination of swimming pool.
Chloronaphthalines, cutting oils, crude coal tar,
petrol and its derivatives may cause acniform eruption.
ACNE FRONTALIS (Acne necrotica)
Follicular papulopustules appear on the
forehead which has a central depressed surface due to central necrosis. The
lesions may heal with pitted scars resembling the late lesions of
Variola (Acne varioliformis)
|
Fig. 398. Acne Frontalis
|
MECHANICAL ACNE
This type of acne is due to physical trauma,
which may lead to licheinification , occlusion of the pilo sebaceous
orifices and pigmentation. Tight caps especially in young babies and
children, pressing bands and headgears may lead to such type. Head
bands and tight under wears are other causes. Continuous friction
from turtleneck sweaters may localize acne to the neck.
|
Fig. 399.Mehanical acne (Acne of the cural area
)
|
Acne Scar:
Certain types of acne may be accompanied by
severe scarring, especially with secondary bacterial infection,
repeated playing in the lesions and excoriations in neurotic
patients.
|
Fig. 400. Acne Scar |
Immobility Acne
Adolescent patients lying in bed for a long time,
as in the orthopedic ward, frequently develop a flare of acne - the
so-called “immobility acne.”
This is probably due to a change in the environment of the skin,
which may enhance bacterial colonization of the duct.
COSMETIC ACNE
The lesions characteristically occur as a result
of continuous use of cosmetic creams and powders and kept for a long
time without cleaning and removal. Preparations containing lanolin,
petrolatum, certain vegetable oils, butylstearate, lauryl alcohol
and oleic acid, are comedogenic.
Fig.401b. Cosmetic acne&contact
dermatitis(Clindamycin)
Grease that is applied to the scalp may cause
acne.
ENDOCRINE ACNE
Endocrine abnormality such as Cushing‘s
disease, adrenogenital syndrome and the polycystic ovarian syndrome
are associated with acne besides the other systemic manifestations.
OCCUPATIONAL ACNE
Certain workers in petrol products as those who
wash cars, drivers, and mechanics may have acniform eruption due to
continuous exposure to petrol and its products. Cutting oils
,industry of chlorine , bromine and swimming pools maintenars may
have the same effect.
|
Fig. 401. Occupational Acne |
TREATMENT OF ACNE
General Considerations
Dealing with acne lesion may be simple and very
difficult at the same time.
Too many preparations whether pharmaceutical,
cosmetic, herbal, traditional, over the counter, body shop
preparations and many others are available. The patients are some
times confused and shift from one medication to another by himself ,
according to the advice of others and prescriptions from different
centers.
In most cases such patients will loose a lot of
time , money and have their lesions usually exacerbated or
accompanied by unwanted complications.
The easiest way is to abide with the instructions
of your physician.
Playing in your lesion and spending a long time
looking in your mirror and try to squeeze the pimples or pustules
may lead to hazardous effect complicated by scars.
Cosmetics
such as powders, creams and others used
as camouflage , sun blocks especially if left for a long time may
lead to occlusion of the pilo sebaceous orifices leading to more and
more complications.
Hot humid environment should be avoided if
possible.
Excessive washing of the affected areas may do
harmful effects, especially if certain detergents are used.
Facial cleaning , peeling and others should be
done by professionals and not by hairdressers, coiffeurs and
inexperienced technicians.
Neonatal, juvenile acne and mild types usually
need no medications and if this is indicated gentle washing and mild
topical preparation can be used.
Regulation of sleep, stress and other
negative triggering
factors, should be avoided.
Irritating diet
if proved to have exacerbating
factors should be avoided.
Direct exposure to sunlight may have a good
beneficial effect on acne lesion.
Active Treatment
Topical medications
Washing the area once or twice daily with mild
anti seborhea soap (Acne-aid, Neutrogena soap). Some lesions may be
irritated especially young age and those with sensitive skin. Mild
soaps with pH balanced such as (Seba med or Numis med soap) can be
used.
Erythrocin lotion
(Eryderm), Clindamycin
lotions (Dalacin lotion) are antibacterial . These are usually
effective in pustular acne.
Benzyl peroxide
is effective
medication .This can be applied for long standing lesions and care should be
taken because of the possibility of irritation.
Retinoic acid
preparations such as (Retin A
gel or cream, Eudyna gel). These preparations may be effective in
clearing acne lesions but they may cause severe irritation if were not used properly.
We begin usually with the gel form at night
because it has low concentration(Retin A gel, Eudyna gel). The
patient is instructed not to be exposed to direct sun light after
application of such medications . The area is simply washed with
water or mild soap before application of the Retin A gel.
Retinoic acid preparations are rarely needed in
the juvenile acne and are reserved for older age groups.
Systemic Medications
Different systemic medications, which are used in
the adults, are not indicated for children. Eerythrocin suspension
may be used for juvenile acne.
Juvenile types:
If the lesions are extensive , Erythrocin
suspension can be used .
Adult acne:
Different systemic medications are used in acne
affecting adults. The type of medication depends on the severity of
the lesion , age and sex.
The cause of acne should be discussed and the
potential success of therapy be highlighted. Patient instruction
leaflets are helpful.
Mild acne requires only topical therapy. Patients
with moderate or severe acne need both oral and topical therapy
besides other lines of medical and cosmetic procedures.
Oral antibiotics must be given for 6 months but
topical therapy will be required throughout the duration of the
disorder.
These medications include the following:
Tetracycline: Tetracyclines are given for a
long time .Usually 250mg. is given four times daily for 10 days and
the dose is reduced to twice daily for 20 days. A single daily dose
may be given for 1-6 months.
Tetracycline and erythromycin are bacteriostatic,
especially in larger doses. In smaller doses (500mg per day or less)
they do not reduce the number of organisms but they affect their
function . Tetracyclines decrease the split of fats to fatty acids
and triglycerides which play an important role in the inflammatory
manifestations of acne.
The antibiotics can also inhibit various enzyme
activities and affect chemotaxis and lymphocyte functions.
Care should be taken for the side effects of
tetracycline.
Erythromycin
:This is an effective medication
especially in young age and the childbearing age in females.
The major disadvantage of tetracycline (and less
so of erythromycin) is the need to take the tablet with water (not
milk) half an hour before food: otherwise there is reduced
absorption.
Zithromax is an effective medication but it is
more expensive than erythromycin.
Doxycycline and minocycline
Doxycycline (100mg/day) and minocycline
(100mg/day) are effective medications but they are more expensive.
We found that
Doxycycline tablets are accepted
well by patients, more effective than Minocycline and has fewer side
effects. The dose is 100mg twice daily for ten days . The dose is
reduced to 100mg daily for twenty days and 100mg every other day for
three months or for a longer period depending on the lesions
response. Doxycycline tablets are preferred than the capsule due to
its less gastro-intestinal irritation.
Oral therapy should be given for a minimum of 6
months in combination with topical therapy.
Trimethoprim
(400-600 mg/day), which is
equally effective, can be reserved as a third-line antibiotic.
Clindamycin: these are helpful because of its
lipid solubility and should not be used routinely because of the
possible risk of pseudomembranous colitis.
Treatment of resistant adult acne lesions
Change the antibiotic to Trimethoprim
Prednisone 2.5 mg
in the morning and 5 mg at
the bed time to suppress renal androgens may help severe cases not
responding to the usual lines of treatment. Suppression of adrenal
androgens lead to decrease in the sebum secretions.
Oral
Contraceptives
There is compelling evidence that oral contraceptives (OCs) are
effective in the management of mild-moderate acne vulgaris, as well as
cumulative evidence that elevated levels of androgens in acne
patients, relative to appropriate controls, are an underlying
pathophysiological factor in acne. All low dose OCs reduce serum free
testosterone (T) to a similar extent, which is contrary to the
traditional concept that a patient who has acne should not use an OC
containing a progestin with androgenic properties
Anti androgens
such as Diane may be effective
in controlling severe acne lesions in young girls.
Cyproterone acetate (CPA)
(2 mg) combined
with 50-microgram ethinyl oestradiol
Dianette (35 micro g. ethinyl estradiol and 2
mg CPA) appears to be of value in women with acne resistant to other
therapies.
Oral spironolactone 100-200 mg for 6 months, is
of considerable benefit in old females.
In males 25 mg CPA has been used with success .
Isotretinoin
is more effective than Diane for
acne patients. For the patient with intractable moderate or severe
acne, or if anti-androgens are unavailable, isotretinoin is the
treatment of choice.
Isotretinoin was restricted to adult patients with severe
nodulocystic acne. Patients with less severe but scarring acne
who are not responding to the traditional therapies may
be given oral isotretinoin as a safe and effective treatment for
severe nodulocystic acne unresponsive to conventional therapy.
The usual procautions,side effects amd
contra-indications should be always taken into consideration before
prescribing isotretinoin to adult patients.
Isotretinoin produces a striking benefit and is
superior both to conventional treatment and anti-androgens.
Isotretinoin is teratogenic and it is of prime
importance that females using the drug should be under adequate
contraception.
The precautions and
contra-indications of these
drugs especially in adult females should be strictly considered.
Fetal abnormalities and other complications may occur with these
medication. Warning to the patient that pregnancy should be at least
after one or two months after stopping the drug.
Pregnancy test should be negative before using
the medication and to be on the safe side it is advised that
medication can be started on the second day of the next period.
Recommended doses and duration of treatment
varies . The recommended dose of isotretinoin is 0.5 -1 .0 mg/kg for
younger patients and for a period of four months.
Isotretinoin influences all the major factors
involved in acne, in doses of 0.5-2.0mg/kg .
Action of Isotretinoin
-
It reduces sebum secretion.
-
The populations of surface and ductal
bacteria, especially of P. acnes fall gradually and ductal
cornification.
-
It stimulates the T-helper cells with a
consequent increase in Immunoglobulins , including IgE and reduces
chemotaxis.
-
It has an effect on bacteria, ductal
corneocytes and inflammation and comedon formation.
-
It affects cellular differentiation possibly
as a result of interference with endogenous vitamin A metabolism.
Treatment of Post Acne Scars
Peeling by fruit acids such as Glycolic acid.
These preparations are available in different concentrations of
10%-70%.Low concentration of 10% can be used by the patient
according to the instruction of the attending physician.
Peeling can give very good results for
superficial scars and superficial wrinkles .
Ultraviolet light is useful in some cases
especially in mixed acne lesions of papules and pustules. PUVA can
induce superficial peeling leading to improvement of skin lesions.
Deep scars need
surgical repair or local
collagen injection or fat tissue.
Laser skin resurfacing
by CO2 Laser is used
recently to smoothen and correction of superficial scars.
|
Fig. 402. Skin resurfacing of
Acne Scar by Co2 laser
|
Fig. 403. Skin resurfacing of Acne Scar by Co2 laser
|
Dermabrasion: This is a technique, which was
used for a long time for treatment of post acne scars. It is done
with a rotating brush applied on the scars. This method needs more
keen and attention during the operation due to the unwanted results
that may result. |
Fig.404. Acne scar
Fig.404c. Acne scar
|
Fig.405. Treatment of acne scar
by Co2 laser
|
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