Acne vulgaris and treatment,

2. INDEX
• DEFINITION
• ACNE VULGARIS (an overview)
• EPIDEMEOLOGY
• ETIOLOGY AND PATHOGENESIS
• ACNE VARIANTS
• LABORATORY TESTS
• TREATMENT

3. DEFINITION
• Acne vulgaris is a common dermatological disorder of the
pilosebaceous unit that has a complex pathophysiology.
• it can be triggered by a number of factors such as,
abnormalities in sebum production
follicular desquamation
bacterial proliferation and inflammation
Prevalence
• 85% in adolescents
• 3.8% in 25 - 34 year old’s
• 4.3% in 35 - 44 year old’s

4. ACNE VULGARIS (an overview)
• Affects the Pilosebaceous unit
• Self-limited disorder that is seen primarily in
adolescents
Variety of lesions:
Comedones - (closed and open)Whiteheads and blackheads
Papules- Small or larger red or skin-colored acne bumps
Pustules- Bumps filled with white or yellow pus
Nodulocystic- Very large pus-filled, often painful acne lesions

5. EPIDEMIOLOGY
• Mild degrees of acne frequently seen at birth, resulting from
follicular stimulation by adrenal androgens in neonatal
period
• In the very young patients the predominant lesions are
Comedones
• Particularly in women, acne may persist through out the third
decade or even later
• Nodulocystic acne has been more common in white males
than in black males.

6. ETIOLOGY AND PATHOGENESIS
 Pathogenesis of acne
 Four basic steps have been identified
I. Follicular epidermal hyperproliferation (microcomedones)
II. Excess sebum production
III. Inflammation
IV. The presence and activity of Propionobacterium acnes

7. PATHOGENESIS OF ACNE

8. FACTORS AFFECTING KERATINOCYTE HYPERPROLIFERATION
• Androgen stimulation
• Decreased linoleic acid
• Increased interleukin (IL) 1a activity

9. EXCESS SEBUM PRODUCTION
• Excess sebum production from sebaceous glands
• Components of sebum :
1) Triglycerides – free fatty acids converted by p.acnes
2) Promote bacterial clumping and colonization of p.acnes,
incites inflammation.

10. INFLAMMATION
• Micromedo continues to expand with densely packed keratin sebum,
and bacteria.
• This distension causes follicular wall rupture.
• Extrusion of keratin, sebum and bacteria into the dermis results in a
brisk of inflammatory response.

11. CLINICAL FINDINGS
• Neonatal acne appears at approximately 2 weeks of age and infantile
acne develops at 3 to 6 months of age.
• Hyperandrogenism should be considered in the female patient whose
acne is severe, sudden onset, or associated with hirsutism or irregular
menstrual periods.

12. • Drug-induced acne may be caused by:
 Anabolic steroids
 Corticosteroids
 Corticotropin
 Phenytoin
 Lithium
 Isoniazid
• Vitamin B complexes - Prolonged use might cause an
irritation of the follicular epithelium and subsequently
produces an inflammatory reaction

13. Chemotherapy medication
Cancer drugs
Doxorubicin (Andriamycin)
Erlotinib (Tarceva)
Paclitaxel (Taxol)
Cetuximab (Erbitux)
EGFR-blocking agents playing a central role in the normal differentiation
and development of hair follicle.

14. SITES OF PREDILECTION
• Primary sites of acne are :
 Face
 Back
 Chest
 shoulders

15. NON INFLAMMATORY TYPES
 lesions are Comedones
 It may be either open (blackheads) or closed (whiteheads).

16. INFLAMMATORY TYPES
• Papules- Small or larger red or skin-coloured acne bumps
• Pustules- Bumps filled with white or yellow pus
• Nodulocystic- Very large pus-filled, often painful acne lesions

17. ACNE VARIANTS
• Neonatal acne - Lesions appear within 2 weeks and resolve in 3
months
• Infantile acne - 3 to 6 months of age marked by the presence of
comedones

18. • Acne Conglobata - Common in teenage males
• Acne Fulminans - Known as (acute febrile ulcerative acne) Treated
with systemic glucocorticoids and isotretinoin

19. SAPHO syndrome
• Synovitis Acne Pustulosis
Hyperrostosis Osteitis (SAPHO)
• Inflammatory bone disorder
PAPA syndrome
• PyogenicArthritis,
Pyodermagangrenosum and Acne
• Rare genetic disorder

20. Acne Excoriee des Jeunes Filles( Excoriated
acne)
• Mild acne accompanied by extensive
excoriations.
Acne Mechanica
• Acneiform eruption, observed after repetitive
physical trauma to the skin (rubbing,
occurring from clothing (belts and straps) or
sports equipments (football helmets and
shoulder pads)

21. Acne with Solid Facial Edema
• Known as Morbihan disease
Can be treated with,
• Isotretinoin (0.2 to 0.5 mg/kg/day)
• Oral glucocorticoids (1 to 2 mg/day)
• Clofazimine for 4 to 5 months
Acne with Associated Endocrinologic
Abnormalities
 Due to Irregular menstrual cycle
 Causes deepened voice
 hirsutism

22. TREATMENT OF ACNE VULGARIS
Non-inflammatory (Comedones) acne
Retinoids
1) Comedolytic and anti-inflammatory properties
2) Inactivated by concomitant use of benzoyl peroxide
3) Photolabile

23. RETIN A CREAM
• Tretinion - 0.05%
• Hyodrophilic base
• Butylated hydroxytoluene
• Isopropyl myristate
• Polyoxyl stearate
• Purified water
• Sorbic acid
• Stearic acid
• Stearyl alcohol
• Xanthan gum

24. Cleargel AP Gel
• Clindamycin phosphate -1.0%
• Adapalene - 0.1%
• Emmolient gel base
• Methyl paraben – 0.1%
• Phenoxyethanol – 0.25%

25. Azelaic acid
• Antimicrobial and comedolytic properties
• Competitive inhibitor of tyrosinase,
decreasing pigmentation
• Safe in pregnancy
Azelaic acid - 10% w/w
Tretion BP – 0.05%w/w
Phenoxyethanol IP – 0.5%w/w
Aloevera gel 3 glyceryl ascorbate

26. Benzoyl Peroxide
• antimicrobial
• Anti - comedonal
• safe in pregnancy
Glycolic acid cream
reduce wrinkles, acne scarring
and hyperpigmentation
• Promotes desquamation
• commonly used as a chemical
peel

27. INFLAMMATORY ACNE (PAPULAR)
Topical Retinoids
• Reduces keratinization
Benzoyl Peroxide
• antimicrobial
• Anti - comedonal
• safe in pregnancy

28. Sodium Sulfacetamide
Promotes desquamation
Topical antibiotic
• Anti-microbial spectrum

29. TREATMENT OF ACNE VULGARIS
,INFLAMMATORY (PUSTULAR)
 Pustular
Doxycycline
• Antibiotic spectrum
Minocycline
• Bacteriostatic antibiotic
Erythromycin
• Antimicrobial spectrum
Lymecycline
• Antibiotic spectrum

30. TREATMENT OF INFLAMMATORY ACNE VULGARIS
 Nodulocystic
Isotretinoin
Oral corticosteroids

31. HORMONALLY INDUCED ACNE
Oral contraceptives
Antiandrogens(Spironolactone)

32. TREATMENT OF HORMONALLY INDUCED ACNE
VULGARIS _ (CONT)
* Corticosteroids
* flutamide

33. INTRALESIONAL GLUCOCORTICOIDS
• Decrease the size of deep nodular lesions
• Injection of triamcinolone acetonide suspension

34. ADVERSE EFFECTS OF MEDICATIONS USED TO
TREAT ACNE
MEDICATIONS ADVERSE EFFECTS
TOPICAL RETINOIDS
EX: Tretinoin
Local irritation
photosensitivity
Adapalene Local irritation (slightly less than tretinoin)
photosensitivity
Isotretinoin Local irritation
Photosensitivity
Contraindicated in pregnancy and
nursing
Benzoyl peroxide Local irritation
Can bleach hair and clothing

35. TOPICAL ANTIBIOTICS
MEDICATIONS ADVERSE EFFECTS
Metronidazole
Tetracycline Can cause yellow staining of skin and clothing
Clindamycin Theoretically can cause pseudomembranous colitis
Erythromycin
Azelaic acid

36. ORAL ANTIBIOTICS
MEDICATIONS ADVERSE EFFECTS
Tetracycline Contraindicated in pregnancy and in children under
age 12 due to tooth discoloration
Doxycycline Photo toxicity
Oesophageal ulceration
Minocycline Vertigo
pseudotumour
Erythromycin Gastrointestinal compliants
Oral isotretinoin Teratogenecity (absolute contraindicated in pregnancy
and nursing )
Mucocutaneous effects
hypertriglyceridemia
Depression
Bone marrow supression

37. ACNEIFORM ERUPTIONS
Steroid Folliculitis
• Occur in adolescents and adults ,2 weeks after
the start of
steroids.
• Lesions have the same stage of development
Drug-Induced eruptions
 Glucocorticoids
 Phenytoin
 Lithium
 Isoniazid
 High-dose vitamin B complex

38. • Halogenated compounds
• Chemotherapy Induced eruptions,
Doxorubicin (Andriamycin)
Erlotinib (Tarceva)
Paclitaxel (Taxol)
Cetuximab (Erbitux

39. Epidermal Growth Factor Receptor Inhibitor-
Associated Eruption
• Used to treat
i. small cell lung cancer
ii. colorectal cancer
iii. breast cancer
• Highly expressed in the basal cell layer of the
epidermis
• follicular keratinocytes
• sebaceous epithelium, resulting in eruptions.
Occupational acne and Chloracne
 Due to tar derivatives
 Insoluble cutting oils
 Chlorinated hydrocarbons- (chloracne)

40. Gram- Negative Folliculitis
• Treated with long-term oral antibiotics
• Improves with oral Isotretinoin for 4 to 5 months
Radiation acne
• Ionizing radiation and UV radiation
• Lesions usually distributed at temporal and periorbital
areas
• Treated with oral or topical retinoids and extraction
Tropical acne
• Mainly on trunk and buttocks

41. ROSACEAE
Rosacea
• Mild, moderate, and severe
• Causes burning and stinging of the facial skin
• Sebaceous or glandular features characterized
by thickened skin and large follicular orifices
• Ocular rosacea may develop before cutaneous
symptoms up to 20%
• Severe cases - rosacea keratitis may lead to
vision loss

42. PERIORAL DERMATITIS
• Discrete and grouped erythematous papules,
vesicles, and pustules
• Unilateral and appear in the perioral, perinasal, and
periorbital regions
• Distinct of 5-mm clear zone at the vermilion edge
• In addition also appears on the ears, scalp, trunk and
extremities

43. OTHER DIFFERENTIAL DIAGNOSIS
Diagnosis is available most likely for,
Closed comedonal acne
• Milia
• Sebaceous hyperplasia
Open comedonal acne
• Dilated pore of Winer
• Favre- Racouchot syndrome
Inflammatory acne
• Rosacea
• Perioral Dermatitis
Neonatal acne
• Miliariarubra

44. ALWAYS RULE OUT:
Closed comedonal acne eruptions could be due to,
* Acne due to systemic agents (ex: corticosteroids)
* Contact acne (ex: occupational acne)
* Chloracne
Open comedonal acne eruptions could be due to,
* Acne due to systemic agents
* Contact acne
* Chloracne

45. • Inflammatory acne eruptions due to,
* Acne due to systemic agents
* Staphylococcal folliculitis
* Gram negative folliculitis
*Eosinophillic folliculitis
*Furuncle/carbuncle
• Neonatal acne eruptions due to,
*Candidal infections
*Benign neonatal cephalic pustulosis

46. COMPLICATIONS
• Acne lesions have the potential to resolve with sequelae.
• Acne lesions leave a transient macular erythema after resolution
causing,
1) post-inflammatory hyperpigmentation
2) Scarring
• Acne vulgaris also take a psychological toll
1) 30% to 50% adolescents have psychiatric disturbances due to acne

47. Sequelae:
4 general types of acne scars:-
• Ice pick- narrow, deep scars widest at the
surface of the skin and taper to a point in
the dermis.
• Rolling- shallow, wide scars that have
undulating appearance.
• Box scar – wide, sharply, demarcated scars.
• Hypertrophic- scars on the trunk

48. REFERENCES
• Fitzpatrick’s Dermatology in General Medicine Seventh
Edition(Volume 1, Chapter 78; pp 690-703)
• Sheretz EF. Acneiform eruption due to "megadose" vitamins B6 and
B12. Cutis. 1991 Aug,48(2): 119-20
• Adams DH, Nutt T. A case report and discussion of cetuximab-induced
folliculitis. Am J ClinDermatol 2006.

49. Thank
You