1. Acne vulgaris is a chronic skin condition caused by abnormal desquamation of follicular epithelium leading to obstruction of pilosebaceous canals and inflammation. 2. Factors such as overactive sebaceous glands, bacteria, hormones, and environment can exacerbate acne. 3. Treatment involves topical and oral medications tailored to the type and severity of lesions, ranging from topical retinoids and antibiotics for mild noninflammatory acne to oral isotretinoin for severe nodular cystic acne resistant to other therapies.

1. ACNE VULGARIS
Prepared By :- Dr Monther Fadel Nagi
Dermatology Resident

2. ACNE VULGARIS

3. Definition
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• Acne vulgaris is a chronic disorder of the pilosebaceous
apparatus caused by abnormal desquamation of follicular
epithelium leading to obstruction of the pilosebaceous
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canal, inflammation, and subsequent formation of
comedones, papules, pustules, nodules, and scarring.
Based on their appearance, the acne lesions can
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be divided into inflammatory (presence of papules,
pustules, and nodules) and noninflammatory (open and
closed comedones). For inflammatory acne, lesions
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can be classified as papulopustular, nodular, or both.

4. Definition
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The American Academy of Dermatology classification
scheme for acne denotes the following three levels:
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1. Mild acne: characterized by the presence of
comedones (noninflammatory lesions), few papules and
pustules (generally <10), but no nodules.
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2. Moderate acne: presence of several to many papules
and pustules (10–40) along with comedones (10–40). The
presence of more than 40 papules and pustules along
with larger, deeper, nodular, inflamed lesions (up to 5)
denotes moderately severe acne.
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3. Severe acne: presence of numerous or extensive
papules and pustules as well as many nodular lesions.

5. Etiology
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• Acne is a follicular disease, with the principal
abnormality being comedo formation.
•
• Overactivity of the sebaceous glands and blockage
in the ducts result in acne vulgaris. The obstruction
leads to the formation of comedones, which can become
inflamed because of overgrowth of Propionibacterium
acnes. The condition can be exacerbated by
environmental factors (hot, humid, tropical climate),
medications (e.g., iodine in cough mixtures, hair greases),
and industrial exposure to halogenated hydrocarbons.
Mechanical or frictional forces can aggravate existing
acne (e.g., excessive washing by some patients to help
rid them of their blackheads or oiliness).

6. Clinical Manifestation(s)
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• Various stages of development and severity may be
present concomitantly.
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• Common distribution of acne is on the face, back, and
upper chest.
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Physical Examination
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• Open comedones (blackheads), closed comedones
(whiteheads).
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• Inflammatory papules, pustules , and ectatic pores.
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• Inflammatory and noninflammatory acneiform cysts.
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• Greasiness (oily skin)
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• Presence of scars from prior acne lesions.

7. Diagnostic Tests
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• Laboratory evaluation is generally not helpful.
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• Patients who are candidates for therapy with isotretinoin
(Accutane) should have baseline liver enzymes, cholesterol,
and triglycerides checked because this medication may result
in elevation of lipids and liver enzymes.
•
• Negative urine or serum pregnancy test must be obtained in
female patients one month prior to, upon initiation of, and
monthly when taking isotretinoin.
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• In female patients, if hyperandrogenism is suspected, levels
of dehydroepiandrosterone sulfate (DHEAS), testosterone
(total and free), and androstenedione should be measured.
Generally, for women with regular menstrual cycles, serum
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androgen measurements are not necessary.

8. DIFFERENTIAL DIAGNOSIS
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• Gram-negative folliculitis
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• Staphylococcal pyoderma
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• Acne rosacea
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• Drug eruption
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• Sebaceous hyperplasia
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• Angiofibromas, basal cell carcinomas, osteoma cutis
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• Occupational exposures to oils or grease
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• Steroid acne
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• Flat warts

9. TREATMENT
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First Line
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• Treatment generally varies with the type of lesions (comedones,
papules, pustules, cystic lesions) and the severity of acne.
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• Comedones (noninflammatory acne) can be treated with retinoids or
retinoid analogs. Topical retinoids are comedolytic and normalize
follicular keratinization. Commonly available agents are adapalene
(0.1% gel or cream, applied once or twice daily), tazarotene (0.1%
cream or gel applied daily), and tretinoin (0.1%, 0.5%, or 0.025%
cream or gel applied once nightly). Tretinoin is inactivated by UV light
and oxidized by benzoyl peroxide; therefore, it should only be applied
at night and not used concomitantly with benzoyl peroxide. Tretinoin
is pregnancy category C; tazarotene is pregnancy category X.

10. First Line cont…..
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• Salicylic acid preparations (e.g., 2% wash) have
keratolytic and antiinflammatory properties and are also
useful in the treatment of comedones. Large open
comedones (blackheads) may be expressed.
•
• Benzoyl peroxide gel (2.5% or 5%) may be added if the
comedones become inflamed or form pustules. The most
common adverse effects are dryness, erythema, and
peeling.
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• Topical antibiotics (erythromycin, clindamycin lotions or
pads) can also be used in
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patients with significant inflammation. They reduce P.
acnes in the pilosebaceous
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follicle and have some antiinflammatory effects.

11. First Line cont…..
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Combination products containing 5% benzoyl peroxide with
topical antibiotics (3% erythromycin or 1% clindamycin)
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are highly effective in patients who have a mixture of
comedonal and inflammatory acne lesions. Fixed-dose
combinations of clindamycin phosphate 1.2% and tretinoin
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0.025% are also available and are more effective than either
product used alone; however,
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they are much more expensive than the individual generic
components.
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• Pustular acne can be treated with tretinoin and benzoyl
peroxide gel applied on alternate evenings; drying agents (sulfa
containing products) are also effective when used in
combination with benzoyl peroxide.
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• Azelaic acid, a bacteriostatic dicarboxylic acid, is used to
normalize keratinization and reduce inflammation. It may be
preferred in pregnancy (pregnancy category B).

12. Second Line
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• Oral antibiotics (doxycycline 50–100 mg QD-BID or
minocycline 50–100 mg QDBID) are effective in patients
with moderate to severe pustular acne. Erythromycin
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may also be used but has high rates of bacterial
resistance. It is pregnancy category B.
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• Patients with nodular cystic acne should be treated with
systemic agents, including antibiotics (erythromycin,
tetracycline, doxycycline, minocycline), isotretinoin, and/or
oral contraceptives. Periodic intralesional triamcinolone
injections are also effective for individual painful lesions.
The possibility of endocrinopathy should be considered in
patients responding poorly to therapy.

13. Second Line cont…..
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• Oral contraceptives reduce androgen levels and therefore sebum
production. They represent a useful adjunctive therapy for some types
of acne in women and adolescent girls but are not considered first-
line therapy and should not be used as monotherapy for acne
vulgaris. Commonly used agents are norgestimate/ethinyl estradiol
and drospirenone/ethinyl estradiol.
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• Spironolactone 100 to 200 mg/day can be administered to women
only and has been shown to be particularly effective for adult-onset or
“beard distribution” acne.
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• Blue light can be used for treatment of moderate inflammatory acne
vulgaris. Light in the violet/blue range can cause bacterial death by a
photoreaction in which porphyrins react with oxygen to generate
reactive oxygen species, which damage the cell membranes of P.
acnes. Treatment usually consists of 15-minutes of exposure
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twice weekly for 4 weeks

14. Third Line
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• Isotretinoin is indicated for acne resistant to antibiotic
therapy, severe acne, and scarring acne. Dosage is 0.5 to
1 mg/kg/day, and duration of therapy is generally
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20 weeks for a cumulative dose 120 to 150 mg/kg. Before
using this medication, patients should undergo baseline
laboratory evaluation as described previously.
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Isotretinoin is absolutely contraindicated during pregnancy
because of its teratogenicity. Patients, providers,
pharmacies, and distributors of the drug must register
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in the iPLEDGE program prior to initiation of therapy.