Acne Vulgaris



About


Inflammation of the pilosebaceous unit of the skin.
Affecting mainly adolescents and may cause scarring.

Etiology


Multifactorial but possibly a genetic component.

Males > Females in adolescence but reverse in adulthood.

Hormonal, inflammation, skin lipid composition and sebum production.

Overgrowth of Propionobacterium acnes.

Hyperproliferation of epithelial cells with obstructed ducts.

Pathology shows distension of pilosebaceous unit with neutrophils.


Old myths
It is caused by dirt or poor personal hygiene.
It is due to a poor diet.


Causes

Congenital adrenal hyperplasia.

Polycystic ovary syndrome.

Cushing’s syndrome.

Drugs – steroids, lithium, some antiepileptics.

Any cause of androgen excess.

Clinical

File:Acne vulgaris on a very oily skin.jpg - Wikimedia Commons

Open Comedones – “white heads” without surrounding inflammation.

Closed Comedones – “black heads” – due to oxidation of melanin pigment.

Papules, pustules and nodules and even cysts.

Can extend to torso, neck, chest and shoulders.

Can worsen with menstruation.

  • Investigations
  • Very rarely needed except with unusual or very severe presentation.
  • FSH, LH, Prolactin, Sex hormone binding globulin, Testosterone levels, 17(OH) progesterone.
  • Abdominal CT if adrenal tumor suspected.
  • Differential
  • Folliculitis.
  • Acne rosacea.
  • Adenoma sebaceum.

Management:

  • Topical for mild to moderate disease.
  • Patients have often tried over the counter remedies – usually contain benzoyl peroxide, salicylic acid.
  • Topical antibiotics.
  • Topical Vitamin A derivatives.
  • Intralesional steroids for severe lesions.
  • Combinations of the above treatments.
  • Systemic therapies for moderate to severe disease.
  • Systemic antibiotics.
  • Some females may benefit from the oral contraceptive pill or cyproterone acetate.
  • Oral Vitamin A derivatives such as Isotretinoin ( Roaccutane) are severely teratogenic and is usually prescribed by specialists. Absolutely contraindicated in pregnancy and effective contraception is obligatory for fertile females. Patients must be counselled and formally consented. There have been suggestions of increased suicide risk in adolescents.
  • Other treatments include dermabrasion, chemical eels, photodynamic therapy and laser treatments.
  • Address psychological issues.
  • Prognosis is that it is usually self limiting but may leave some scarring or hyperpigmentation or hypopigmentation in severe cases.