This document defines acne vulgaris and discusses its pathogenesis, clinical presentation, treatment, and complications. Key points include: - Acne is caused by abnormalities in sebum production, desquamation, P. acnes proliferation and inflammation within pilosebaceous units. It commonly affects adolescents. - Lesions include non-inflammatory comedones and inflammatory papules, pustules, and nodules. Variants include neonatal, infantile, nodulocystic, and hormonally-induced forms. - Treatment involves topical and oral antibiotics, retinoids, and isotretinoin depending on severity. Hormonal therapies may be used for severe acne

1. Acne Vulgaris

2. Definition Multi-factorial disease characterized by abnormalities in sebum production, follicular desquamation, bacterial proliferation and inflammation.Prevalence 85% adolescents

3. 8% of 25 - 34 yr olds

4. 3% of 35-44 yr oldsAcne vulgarisOverviewwww.bilkent.edu Affects the Pilosebaceous unit

5. Self-limited disorder that is seen primarily in adolescentswww.bilkent.eduVariety of lesions:Comedones- (closed and open): Whiteheads and blackheads)Papules- Small or larger red or skin-colored acne bumpsPustules- Bumps filled with white or yellow pusNodulocystic- Very large pus-filled, often painful acne lesions

6. Course of acne maybe self-limiting Sequelae will be life-long, with pitted or hypertrophic scar formation

7. Epidemiology www.gatoveramce.com Mild degrees of acne frequently seen at birth, resulting from follicular stimulation by adrenal androgens neonatal periodIn the very young patients the predominant lesions are comedones.imresidents.mhri.orgimresidents.mhri.orgClosed comedo(whiteheads & blackheads)

8. Epidemiology cont…Particularly in women, acne may persist through out the third decade or even later.www.bilkent.eduNodulocystic acne has been more common in white males than in black males.

9. Etiology and PathogenesisPathogenesis of acneFour basic steps have been identifiedFollicular epidermal hyperproliferation (microcomedones) Excess sebum productionInflammationThe presence and activity of Propionobacterium acnes

10. Pathogenesis of Acnebrownskin.netMicrocomedoneHyperkeratoticinfundibulum

11. Cohesive corneocytes

12. Sebum secretionNodule Rupture of follicular wall

13. Marked perifollicular inflammation

14. Scarring Inflammatory papule/pustuleFurther expansion of follicular unit

15. Proliferation of Propionobacterium acnes

16. PerifollicularinflammationComedoneAccumulation of shed corneocytes and sebum

17. Dilation of follicular ostiumI. Factors affecting keratinocyte hyperproliferationAndrogen stimulationDecreased linoleic acidIncreased interleukin (IL)-1a activitywww.nature.com

18. Factors affecting keratinocytehyperproliferationDihydrotestosterone (DHT) is a potent androgen that may play a role in acne17B-hydroxysteroid dehydrogenaseand 5a-reductase are enzymes responsible for converting DHEAS to DHTCompared to epidermal keratinocytes, follicular keratinocytes show increased 17B-hydroxysteroid dehydrogenaseand 5a-reductase activities. DHT may stimulate follicular keratinocyte proliferation and regulated by linoleic acid.Fitzpatrick’s Dermatology in General Medicine Seventh Edition(Volume 1; Chapter 78; pp 690-703)

19. Factors affecting keratinocytehyperproliferationLinoleic acidis an essential fatty acid in the skin subnormal level of it may induce follicular keratinocyte hyperproliferation and produce pro-inflammatory cytokineswww.nature.comIL-1 contributes to keratinocytehyperproliferationwww.nature.com

20. II. Sebum Production and P. acnesExcess sebum production from the sebaceous glandComponents of sebum:Triglycerides  free fatty acids converted by P. acnes

21. Promote bacterial clumping and colonization of P. acnes  incites inflammationwww.nature.comwww.nature.com

22. III. Inflammationbrownskin.netMicromedo continues to expand with densely packed keratin, sebum, and bacteria.brownskin.netThis distension causes follicular wall rupture.brownskin.netExtrusion of keratin, sebum and bacteria into the dermis results in a brisk of inflammatory response.

23. Clinical Findings www.gatoveramce.comHistory Neonatal acneappears at approximately 2 weeks of age and infantile acne develops at 3 to 6 months of age.www.wedmd.comten.wikipedia.orgHyperandrogenismshould be considered in the female patient whose acne is severe, sudden onset, or associated with hirsutism or irregular menstrual periodsten.wikipedia.orgten.wikipedia.org

24. History cont…Drug-induced acne may be caused by: Anabolic steroidsCorticosteroids CorticotropinPhenytoinLithium IsoniazidVitamin B complexes Prolonged use might cause an irritation of the follicular epithelium and subsequently produces an inflammatory reactionChemotherapy medication Cancer drugsDoxorubicin (Andriamycin)Erlotinib (Tarceva)Paclitaxel (Taxol)Cetuximab (Erbitux)EGFR-blocking agents playing a central role in the normal differentiation and development of hair follicle

25. ten.wikipedia.orgSites of PredilectionPrimary sites of acne are the face, back, chest, and shoulderswww. healthline.com/imageten.wikipedia.orgwww. healthline.com/imagewww. healthline.com/image

26. Non-Inflammatory Types:lesions are comedones, which may be either open (blackheads) or closed (whiteheads)imresidents.mhri.orgimresidents.mhri.orgimresidents.mhri.org

27. Inflammatory Typesten.wikipedia.orgPapules- Small or larger red or skin-colored acne bumpsPustules- Bumps filled with white or yellow pusNodulocystic- Very large pus-filled, often painful acne lesions

28. Acne Variantswww.gatoveramce.comNeonatal acneLesions appear within 2 weeks and resolve in 3 monthsInfantile acne3 to 6 months of age marked by the presence of comedoneswww.getacnehomeremedies.info

29. Acne Variants cont…..Acne ConglobataCommon in teenage malesAcne FulminansKnown as (acute febrile ulcerative acne)Treated with systemic glucocorticoids and isotretinointen.wikipedia.orgten.wikipedia.org

30. Acne Variants cont..SAPHO syndromeSynovitis Acne PustulosisHyperrostosisOsteitis (SAPHO)Inflammatory bone disorderten.wikipedia.orgPAPA syndromePyogenicArthritis, Pyodermagangrenosum and AcneRare genetic disorderten.wikipedia.orgten.wikipedia.org

31. Acne Variants cont….Acne Excoriee des JeunesFilles( Excoriated acne)Mild acne accompanied by extensive excoriationswww. chelseaderm. com/physician_service/acneAcne MechanicaAcneiform eruption, observed after repetitive physical trauma to the skin (rubbing, occurring from clothing (belts and straps) or sports equipments (football helmets and shoulder pads)www. chelseaderm. com/physician_service/acne

32. Acne Variants cont…Acne with Solid Facial EdemaKnown as (Morbihan disease)Isotretinoin (0.2 to 0.5 mg/kg/day)Oral glucocorticoids (1 to 2 mg/day)Clofazimine for 4 to 5 monthswww. chelseaderm. com/physician_service/acneAcne with Associated Endocrinologic AbnormalitiesIrregular menstrual cycle , deepened voice , increased libido, and hirsutismten.wikipedia.org

33. Laboratory TestsLaboratory workup is not indicated for patients with acne unless hyperandrogenism is suspected.Elevated serum levels of androgens (severe cystic acne) and in acne associated with a variety of endocrine conditions:Congenital adrenal hyperplasia (CAH; 11B- and 21B- hydroxylase deficiencies)Ovarian or adrenal tumorsPolycystic ovarian disease

34. Treatment of Acne VulgarisNon-inflammatory (Comedones) acneimresidents.mhri.orgRetinoidsComedolytic and anti-inflammatory properties

35. Inactivated by concomitant use of benzoyl peroxide

36. PhotolabileTreatment of Acne Vulgaris (Non-inflmmatory)Salicylic acid Promotes desquamationAzelaic acid Antimicrobial and comedolytic properties

37. Competitive inhibitor of tyrosinase decreasing pigmentation

38. Safe in pregnancyTreatment of Acne Vulgaris (Non-Inflammatory)Benzoyl Peroxide antimicrobial

39. anticomedonal

40. safe in pregnancyGlycolic acid reduce wrinkles, acne scarring and hyperpigmentation

41. Promotes desquamation

42. commonly used as a chemical peelTreatment of Acne Vulgaris Inflammatory AcnePapularTopical Retinoids Reduces keratinization Benzoyl Peroxide antimicrobial

43. anticomedonal

44. safe in pregnancyTreatment of Acne Vulgaris (Inflammatory)Azelaic acid Antimicrobial and comedolytic properties Competitive inhibitor of tyrosinase decreasing pigmentation

45. Safe in pregnancySodium Sulfacetamide Promotes desquamationTopical antibioticsantimicrobial spectrum Treatment of Acne Vulgaris (Inflammatory)Oral antibiotics PustularDoxycyclineAntibiotic spectrumMinocyclineBacteriostatic antibioticErythromycinAntimicrobial spectrumLymecyclineAntibiotic spectrumteknolohistangpinoy.wordpress.compharmacyeu.net4rx.compharmacyeu.net

46. Treatment of Acne Vulgaris (Inflammatory)NodulocysticIsotretinoinOral corticosteroids

47. Treatment of Acne Vulgaris Hormonally induced-acneOral contraceptivesMechanism of Action:Inhibits the production of androgens by gonadal tissue via a negative feedback loop on pituitary gonadotropin releaseRegulating genes that suppress sebaceous gland growth or lipid productionAntiandrogens (Spironolactone)

48. Treatment of Acne Vulgaris Hormonally Induced AcneCorticosteroids Flutamide

49. IntralesionalGlucocorticoidsDecrease the size of deep nodular lesionsInjection of triamcinolone acetonide suspension

50. Treatment Summary ofAcne Vulgarisimresidents.mhri.org

51. Medications use to treat Acne

52. Medications use to treat Acne

53. Medications use to treat Acne

54. Acneiform Eruptions Steroid FolliculitisOccur in adolescents and adults 2 weeks after the start of steroids

55. Lesions have the same stage of development Drug-Induced AcneGlucocorticoids

56. Phenytoin

57. Lithium

58. Isoniazid

59. High-dose vitamin B complex

60. Halogenated compounds

61. Epidermal growth factor receptor inhibitors

62. Chemotherapy Induced AcneDoxorubicin (Andriamycin)Erlotinib (Tarceva)Paclitaxel (Taxol)Cetuximab (Erbitux)mons.wikimedia.org

63. Epidermal Growth Factor Receptor Inhibitor-Associated EruptionTreat non-small cell lung cancer, colorectal cancer, and breast cancerHighly expressed in the basal cell layer of the epidermis, follicular keratinocytes, and the sebaceous epitheliumten.wikipedia.orgOccupational acne and ChloracneTar derivatives Insoluble cutting oilsChlorinated hydrocarbons- (chloracne) found in fungicides, insecticides, and wood preservativesten.wikipedia.org

64. Gram- Negative FolliculitisTreated with long-term oral antibioticsImproves with oral Isotretinoin for 4 to 5 monthsten.wikipedia.orgRadiation acneIonizing radiation and UV radiationLesions usually distributed at temporal and periorbital areasTreated with oral or topical retinoids and extractionten.wikipedia.orgTropical acne

65. Mainly on trunk and buttocksten.wikipedia.org

66. RosaceaMild, moderate, and severePresents with burning and stinging of the facial skinSebaceous or glandular features characterized by thickened skin and large follicular orificesOcular rosacea may develop before cutaneous symptoms up to 20% Severe cases  rosaceakeratitis may lead to vision loss Granulomatous rosacea only true rosacea variantsYellow-brown or red papules or nodules that are monomorphic and located on the cheeks and periorificial facial skinApple-jelly-like change in color similar to sarcoidosis or lupus vulgaris

67. Perioral DermatitisDiscrete and grouped erythematous papules, vesicles, and pustulesUnilateral and appear in the perioral, perinasal, and periorbital regionsDistinct of 5-mm clear zone at the vermilion edgeIn addition also appears on the ears, scalp, trunk, labia majora, and extremities

68. Other Differential DiagnosisMost likely Closed comedonal acne

69. Milia

70. Sebaceous hyperplasia

71. Open comedonal acne

72. Dilated pore of Winer

73. Favre- Racouchot syndrome

74. Inflammatory acne

75. Rosacea

76. Perioral Dermatitis

77. Neonatal acne

78. MiliariarubraAlways Rule OutClosed comedonal acne

79. Acne due to systemic agents(ex. Corticosteroids)Contact acne (ex. Occupational acne)

80. Chloracne

81. Open comedonal acne

82. Acne due to systemic agents

83. Contact acne

84. Chloracne

85. Inflammatory acne

86. Acne due to systemic agents

87. Staphylococcal folliculitis

88. Gram-negative folliculitis

89. Eosinophilicfolliculitis

90. Furuncle/ Carbuncle

91. Neonatal acne

92. Candidal infections

93. Benign neonatal cephalic pustulosisConsiderClosed comedonal acne

94. Osteoma cutis

95. Tricoepitheliomas

96. Tricodiscomas

97. Fibrofolliculomas

98. Eruptive vellus hair cysts,steatocystoma multiplexColloid miliaComplications Acne lesions have the potential to resolve with sequelaeAcne lesions leave a transient macular erythema after resolutionpost-inflammatory hyperpigmentationscarringAcne vulgaris also take a psychological toll30% to 50% adolescents have psychiatric disturbances due to acne

99. Sequelae: 4 general types of acne scarswww.nature.comIce pick- narrow, deep scars, widest at the surface of the skin and taper to a point in the dermisRolling- shallow, wide scars that have undulating appearance www.nature.comBox scar – wide, sharply demarcated scarswww.nature.comHypertrophic- scars on the trunk www.nature.com

100. ReferencesFitzpatrick’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): 119-20Adams DH, Nutt T. A case report and discussion of cetuximab-induced folliculitis. Am J ClinDermatol. 2006;7(5):333-6.