Incidence:Occurs mostly in teenagers.
Peak: Late teenagers but may persist till third decade and beyond especially in females.
Elevated sebum excretion:
- Sebum excretion is necessary for the development of acne but is not sufficient to cause acne on its own.
- The main determinants of sebum excretion are hormonal, which accounts for the onset of acne in the teenagers.
- Androgens and progestogens increase sebum excretion but estrogens reduce it.
- It colonises the pilosebaceous ducts and acts on lipids to produce a number of pro-inflammatory factors.
- Occlusion or blockage of the pilosebaceous unit.
Site: Usually limited to the face, shoulders, upper chest and back.
- Open comedones (blackheads) due to plugging by keratin and sebum of the pilosebaceous orifice,
- Closed comedones (whiteheads) due to accretions of sebum and keratin deeper in the pilosebaceous ducts are evident.
- Inflammatory papules, nodules and cysts may occur with some lesion.
The lesion may be followed by scarring.
- Dominated by presence of comedones.
- May be due to exogenous substances like oily cosmetics, chlorinated hydrocarbons, tars, etc
- Pustular rash may also be seen in those treated with steroids, lithium, OCP and anticonvulsants.
Moderate or Severe form:
May have systemic disorder. E.g- polycystic ovarian disease, Androgen secreting tumors
Clinical variants of Acne:
1. Conglobate acne:
severe acne with many abscesses and cysts, marked scaring and sinus formation.
2. Acne fulminans:
severe acne accompanied by fever, joint pains and markers of systemic inflammation ( raised ESR)
2. Acne excoriee:
effect of scratching or pricking, mostly seen on the face of teenage girls with acne.
3. Infantile acne:
Rare. It is due to sebotropic effects of maternal hormones on the infant.
Investigation: Rarely required.
It is important to enquire about the details of previous treatments and their duration.
1. Topical benzoyl peroxide:
- Benzoyl peroxide is a broad spectrum bactericidal agent which is effective due to its oxidizing activity.
- The drug has an anti-inflammatory, keratolytic, and comedolytic activities, and is indicated in mild-to-moderate acne vulgaris.
It can induce irritant dermatitis with symptoms of burning, erythema, peeling, and dryness.This occurs within few days of therapy and mostly subsides with continued use.
2. Topical retinoids:
- Topical retinoids target the microcomedo–precursor lesion of acne. There is now consensus that topical retinoid should be used as the first-line therapy, alone or in combination, for mild-to-moderate inflammatory acne and is also a preferred agent for maintenance therapy.
- It targets the abnormal follicular epithelial hyperproliferation, reduces follicular plugging and reduces microcomedones and both noninflammatory and inflammatory acne lesions.
The main adverse effects with topical retinoid is primary irritant dermatitis, which can present as erythema, scaling, burning sensation and can vary depending on skin type, sensitivity, and formulations.
3- Topical Anti-biotics therapy:
Local antibiotics: Clindamycin or Erythromycin.
Clindamycin and erythromycin were both effective against inflammatory acne in topical form in combination of 1–4% with or without the addition of zinc.
- Oxytetracycline 1.5g per day on empty stomach.
- If the response is inadequate:
- Minocycline ( both must be continued till 3 months to see if the antibiotics have worked or not)
- If little response after 3 months treatment: Erythromycin 1g/day.
- Topical clarithromycin, azithromycin, and nadifloxacin are available in India, but trials for their efficacy and safety are lacking.
- In women, oestrogen containing OCP can be used as a adjunct in therapy. ( oral estrogen reduces sebum production)
Adverse effect: Side effects though minor includes erythema, peeling, itching, dryness, and burning, pseudomembranous colitis which is rare, but has been reported with clindamycin.
A most important side effect of topical antibiotics is the development of bacterial resistance
4- If these topical agents fails to produce an adequate clinical response within 3-6 months;
Systemic retinoids— Isotretinoin (decreases follicular keratinization, Sebum production, bacterial count)
Both open and closed comedones can be removed mechanically with comedone extractor and a fine needle or a pointed blade.
b) Active deep inflammatory lesions:
Aspiration of deep inflamed lesion may be needed in few cases which are followed by IL steroid injection in cysts and sinus tract.
It is a chronic disorder affecting the facial convexities, characterized by frequent flushing, persistent erythema and telangiectasia, interspersed by episodes of inflammation during which swelling, papules and pustules are evident.
- The areas characteristically affected are the central convex areas of the face (nose, forehead, cheeks and chin) . Occasionally, the scalp, upper chest, back and even the limbs may be involved.
- In cases of rosacea showing the classical pattern of progression, the onset is most often marked by vascular changes, notably episodic flushing usually unaccompanied by sweating.
- Erythema, which is often accompanied by a burning sensation, gradually becomes more persistent, is easily triggered by minor irritants, and is associated with increasingly prominent telangiectasia.
- More advanced cases show follicular and nonfollicular papules and pustules, without comedones, followed by persisting tissue thickening due to oedema, fibrosis and glandular hyperplasia, leading ultimately to a peau d’orange appearance and phymas.
Factors which trigger flushing: Include emotion and stress, hot drinks, alcohol and other vasodilating drugs, and spicy food.
Aggravating factors: Include the use of topical steroids on those occasions when they are used (usually in error) to treat rosacea.
- Sun exposure may worsen or improve rosacea.
- Rhinophyma, with erythema, sebaceous gland hyperplasia and overgrowth of the soft tissue of the nose, is sometimes associates.
- There may be complications like blepharitis and conjunctivitis.
- Oral oxytetracycline can be used for the pustular component of rosacea.
- Topical metronidazole can also be used.
- Erythema and telangiectasia don’t respond to antibiotic therapy.