Dr. Naji Majid Ahmed naji_dr@yahoo.com Acne vulgaris

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Disorders Of SebaceousDisorders Of Sebaceous
And Apocrine GlandsAnd Apocrine Glands
(Acne Vulgaris)

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Acne Vulgaris And Cystic Acne
 An inflammation of pilosebaceous units, very
common
 Appears in certain body areas (face, trunk,
rarely buttocks)
 Most frequently in adolescents
 Manifests as comedones, papulopustules,
nodules, and cysts
 Results in pitted, depressed, or hypertrophic
scars

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EpidemiologyEpidemiology
• Age of Onset :
Puberty—10 to 17 years in females.
14 to 19 in males; however, may appear first
at 25 years or older.
• Sex : more sever in Males > females.
(why???)

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Genetic Aspects
• Multifactorial genetic background.
• Familial predisposition: majority of
individuals with cystic acne have parent(s)
with a history of severe acne. Severe acne
may be associated with XYY syndrome.

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PATHOGENESIS
Hypertrophy --
hyperkeratinization –
obs. Of s. gland –
accumulationof sebum –
comedons formation

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Microcomedone
• hyperkeratotic
infundibulum
• cohesive
corneocytes
• sebum secretion
Comedone
• accumulation
of
shed
corneocytes
and sebum
• dilation of
follicular
ostium
Inflammatory
papule/
pustule
• further expansion
of follicular unit
• proliferation of
Propionibacterium
acnes
perifollicular
inflammation
Nodule
• rupture of
follicular wall
• marked
perifollicular
inflammation
• scarring

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Contributory Factors
• Acnegenic mineral oils, rarely dioxin and
others.
Drugs :
Lithium, hydantoin, isoniazid, glucocorticoids, oral
contraceptives, iodides, bromides and
androgens (e.g., testosterone), danazol.

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Others
Emotional stress can definitely cause
exacerbations.
Occlusion and pressure on the skin,
such as by leaning face on hands, very
important and often unrecognized
exacerbating factor ( acne mechanica ).
Acne is not caused by chocolate or
fatty foods or, in fact, by any kind of
food.

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Clinical Manifestation
• Duration : Weeks to Months .
• Season: Often worse in fall and winter.
• Skin Symptoms :
 Pain in lesions (especially nodulocystic
type).

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Skin Lesions
1. Comedones :
open (blackheads) or closed (whiteheads);
comedonal acne

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2. Papules and papulopustules :
i.e., a papule topped by a pustule;
papulopustular acne

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3. Nodules or cysts :
1–4 cm in diameter ; nodulocystic acne .

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Sites of Predilection
Face
Neck
Trunk
Upper Arms
Buttocks.

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Special Forms :
1. Acne Conglobata :
Severe cystic acne with more involvement
of the trunk than the face.
• Coalescing nodules, cysts, abscesses,
and ulceration; occurs also on buttocks .
• Spontaneous remission is long delayed.
• acne conglobata seen in - XYY genotype
- the polycystic ovary syndrome.

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Acne
Conglobata
In this severe
nodulocystic acne,
There is
postulation, scarring
and lesions are
very painful.

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Acne conglobata Inflammatory nodules and cysts have coalesced,
forming abscesses and even
leading to ulceration. There are multiple comedones and many recent
red scars following resolution of inflammatory
lesions on the upper chest, neck, and arms.

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 2. Acne Fulminans
• Teenage boys (ages 13 to 17).
• Acute onset , severe cystic acne with
concomitant suppuration and always
ulceration ;
• also present are malaise, fatigue, fever,
generalized arthralgias, leukocytosis, and
elevated erythrocyte sedimentation rate.

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3. SAPHO Syndrome:
Synovitis, acne, acne fulminans,
palmoplantar pustulosis , hidradenitis
suppurativa, hyperostosis, and osteitis.
Rare.
4. PAPA Syndrome:
Sterile pyogenic arthritis, pyoderma
gangrenosum acne. An inherited
autoinflammatory disorder; very rare.

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5. Tropical Acne:
Flare of acne, usually with severe folliculitis,
inflammatory nodules, and draining cysts
on trunk and buttocks in tropical climates;
secondary infection with Staphylococcus
aureus .

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6. Acne with Facial Edema :
Associated with recalcitrant, disfiguring
midline facial edema. Woody induration
with and without erythema.

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7. Acne in the Adult Woman:
Persistent acne in an (often) hirsute female
with or without irregular menses needs an
evaluation for hypersecretion of adrenal
and ovarian androgens:
• total testosterone, free testosterone,
and/or dehydroepiandrosterone sulfate
(DHEAS) (e.g., in the polycystic ovary
syndrome).

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8. Recalcitrant Acne:
Can be related to congenital adrenal
hyperplasia (11β- or 21β- hydroxylase
deficiencies).
9. Acne Excoriée:
Mild acne, usually in young women,
associated with extensive excoriations and
scarring due to emotional and
psychological problems (obsessive
compulsive disorder).

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10. Occupational Acne:
Due to exposure to tar derivatives, cutting
oils, chlorinated hydrocarbons (see
“Chloracne,” below). Large comedones,
inflammatory papules and cysts; not
restricted to predilection sites of acne but
can appear on other (covered) body sites.

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• 11. Acne Cosmetica :
Due to comedogenic cosmetics.

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Acne-Like Conditions:
• Steroid Acne: Following systemic or
topical glucocorticoids. Monomorphous
folliculitis small erythematous papules and
pustules without comedones.
• Drug-Induced Acne: Monomorphous
acnelike eruption due to phenytoin,
lithium, isoniazid, high-dose vitamin B
complex, epidermal growth factor
inhibitors

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• Acne Aestivalis : Papular eruption after
sun exposure (“Mallorca acne”). Usually
on forehead, shoulders, arms, neck, and
chest. No comedones. Pathogenesis
unknown.
• Gram-Negative Folliculitis: Multiple tiny
yellow pustules develop on top of acne
vulgaris as a result of long-term antibiotic
administration.

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Diagnosis And Differential Diagnosis
• Note : Comedones are required for
diagnosis of any type of acne. Comedones
are not a feature of acne-like conditions
(above) and of the conditions listed below.
• Face S. aureus folliculitis,
pseudofolliculitis barbae, rosacea, perioral
dermatitis.

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• Trunk: Malassezia folliculitis, “hot-tub”
pseudomonas folliculitis, S. aureus
folliculitis, and acne-like conditions (see
above).

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Laboratory Examination
No laboratory examinations required.
If there is suspicion of an endocrine
disorder, free testosterone, follicle-
stimulating hormone …etc

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Course
• Acne most often clears spontaneously by the
early twenties but can persist to the fourth
decade or older. Flares occur in the winter and
with the onset of menses

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Complications of acne:
1- Scarring.
2-Psychological impact

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Scarring: can also occur if you pick or
squeeze your spots, so it's important not to do this.

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There are three main types of acne scars:
1)ice pick scars – small, deep holes in the surface of
your skin that look like the skin has been punctured with a
sharp object

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2) rolling scars – caused by bands of scar
tissue that form under the skin, giving the surface
of the skin a rolling and uneven appearance.

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3) boxcar scars : round or oval
depressions, or craters, in the skin .

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1.General measures:
• Reassurance.
• Education.
• Avoidence of comedogenic factors .
• Avoid squeezing the lesions.
• Gentle cleansing.
• Pillow changes
• Less sun exposure
• Less use makeup
Management

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2. Mild Acne:
• Topical antibiotics :
(clindamycin and erythromycin)
• Benzoyl peroxide gels: (2%, 5%, or 10%)
• Topical retinoids (tretinoin, adapalene)

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3. Moderate Acne:
Oral antibiotics are added to the above
regimen. Most effective antibiotic is:
• minocycline, 50 –100 mg twice daily
• or doxycycline, 50 – 100 mg twice daily,

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• In females, moderate acne can be
controlled with high doses of oral estrogens
combined with progesterone or
antiandrogens, but recurrences are the rule
after cessation of treatment.
Cerebrovascular accidents are a serious
risk.

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 3. Severe Acne:
• In addition to the topical treatment outlined
above, systemic treatment with isotretinoin
is indicated for cystic or conglobate acne
or for acne refractory to treatment.
**This retinoid inhibits sebaceous gland
function and keratinization and is very
effective

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Other Systemic Treatments for Severe
Acne :
• Systemic glucocorticoids: may be required in
severe acne conglobata, acne fulminans, and
the SAPHO and PAPA syndromes.
• The TNF-α inhibitor infliximab and anakinra are
investigational drugs in these severe forms and
show promising effects. Note : For inflammatory
cysts and nodules, intralesional triamcinolone
(0.05 mL of a 3 to 5 mg/mL solution) is
indicated.

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Differential diagnosis of acne:
1- Rosocea.
2-Perioral dermatitis.
3-Pitrosporum folliculitis.
4-Folliculitis barbae and
Psudofolliculitis barbae.
5-Acneform drug eraption
6-Acneform secondary syphilis.

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Acne Rosacea
Onset Adolescence Thirties To Fifties
Sex Male>.F Females.>Males
Site Face,upper Tunck, Upper
Arms
Face
Flushing&teleangectasia _ +
Comedons + _
Eye Complecations _ +
Rhinophyma _ +
Responce To
Treatment
Slow Rapid

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• SOURCE: From FITZPATRICK’S COLOR ATLAS
AND SYNOPSIS OF CLINICAL DERMATOLOGY
SIXTH EDITION

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