Acne vulgaris is a common skin condition affecting hair follicles on the face, neck and upper trunk. It is characterized by non-inflammatory lesions like closed and open comedones as well as inflammatory lesions including papules, pustules, nodules and cysts. It most commonly affects adolescents and young adults between 12-35 years of age. The causes are multifactorial including hormonal factors like androgens, obstruction of hair follicles, genetics, bacteria P. acnes, and other environmental factors. Treatment involves topical and oral medications like retinoids, antibiotics, and isotretinoin depending on the severity of acne.

1. ACNE VULGARIS
By dr vishwarath

2. Definition
• Acne vulgaris is a common follicular disorder affecting susceptible
hair follicles found on Face, neck and upper trunk. It is characterised
by comedones , both closed and open , and by papules , pustules ,
nodules and cysts.

3. INCIDENCE
• AGE GROUP- 12-35
• Sexes – both genders are equally affected , but onset is seen early in
girls.

5. ETIOLOGY
• MULTIFACTORIAL
• RESULT OF BLOCKAGE IN FOLLICLES,FORMATION OF PLUG OF KERATIN AND
SEBUM
• HORMONAL – hormonal activities such as menstrual cycle , puberty ,
pregnancy and PCOD may contribute to formation pf acne. The male
hormone androgen can over stimulate production of sebum in some
people
• GENETIC
• INFECTIOUS - Propionibacterium acnes is the anaerobic bacteria.
• DIET- high glycaemic load diet
• DRUGS- lithium , isoniazid , halogens , phenytoin , corticosteroids
• OTHERS – exposure to sun, oil , stress , anxiety .

6. TYPES
• Non inflammatory
• inflamatory

7. Non inflammatory
• These are comedones and result in white heads or blackheads.

8. inflamatory
• Consists of papules , pustules , nodules and cysts.

9. PATHOPHYSIOLOGY

11. Histo pathology
• The acne lesion will usually show a dilated follicle with a plug of
keratin. In advanced cases, one may see a dilated follicle, which
results in an open comedone. When the thin follicle wall ruptures,
bacteria and signs of inflammation may be evident. Large acne lesions
that are traumatized can develop fibrosis and scarring

12. • Grade 1: Comedones. They are of two types, open and closed. Open
comedones are due to plugging of the pilosebaceous orifice by sebum
on the skin surface. Closed comedones are due to keratin and sebum
plugging the pilosebaceous orifice below the skin surface.
• Grade 2: Inflammatory lesions present as a small papule with
erythema.
• Grade 3: Pustules.
• Grade 4: Many pustules coalesce to form nodules and cysts

13. • Acne can leave various scars after healing, which may present as
depressed scars or hypertrophic and keloidal scars. Depressed scars
may be gentle contour (boxcar scars) or ice pick scars, which are deep
pits. Acne is associated with seborrhea and in the case of
hyperandrogenism associated with hirsutism, acanthosis nigricans,
irregular menstrual period, and weight gain.

14. Evaluation
• Acne vulgaris is diagnosed clinically. However, in women of
childbearing age, one should ask for a history of hirsutism or
dysmenorrhea. If positive, then levels of testosterone, LH, FSH, and
DHEA should be ordered.

15. Treatment / Management
• Topical Therapy
• Topical retinoids like retinoic acid, adapalene, and tretinoin are used alone or with other topical
antibiotics or benzoyl peroxide. Retinoic acid is the best comedolytic agent, available as 0.025%,
0.05%, 0.1% cream, and gel.
• Topical clindamycin 1% to 2%, nadifloxacin 1%, and azithromycin 1% gel and lotion are available.
Estrogen is used for Grade 2 to Grade 4 acne.
• Topical benzoyl peroxide is now available in combination with adapalene, which serves as
comedolytic as well as antibiotic preparation. It is used as 2.5%, 4%,and 5% concentration in gel
base.
• Azelaic acid is antimicrobial and comedolytic available 15% or 20% gel. It can also be used in post
inflammatory pigmentation of acne.
• Beta hydroxy acids like salicylic acid are used as topical gel 2% or chemical peel from 10% to
20% for seborrhoea and comedonal acne, as well as, pigmentation after healing of acne.
• Topical dapsone is used for both comedonal and papular acne, though there are some concerns with
G6PD deficient individuals.

16. Systemic Therapy
• Doxycycline 100 mg twice a day as an antibiotic and anti-inflammatory drug as it affects free fatty
acids secretion and thus controls inflammation.
• Minocycline 50 mg and 100 mg capsules are used as once a day dose.
• Other antibiotics such as amoxicillin, erythromycin, and trimethoprim/sulfamethoxazole are
sometimes used, and if bacterial overgrowth or infection is masquerading as acne, other antibiotics
such as ciprofloxacin may be used in pseudomonas related 'acne.'
• Isotretinoin is used as 0.5 mg/kg to 1 mg/kg body weight in daily or weekly pulse regimen. It
controls sebum production, regulates pilosebaceous epidermal hyperproliferation, and reduces
inflammation by controlling P. acnes. It may give rise to dryness, hairless, and cheilitis.
• An oral contraceptive containing low dose estrogen 20 mcg along with cyproterone acetate as anti-
androgens are used for severe recurrent acne.
• Spironolactone (25 mg per day) can also be used in males. It decreases the production of androgens
and blocks the actions of testosterone. If given to females, then pregnancy should be avoided
because the drug can cause feminization of the fetus.
• Scars are treated with submission, trichloroacetic acid, derma roller, microneedling, or fractional
CO2 laser.

17. • Differential Diagnosis
• Acne conglobata
• Acne fulminans
• Acne Keloidalis nuchae
• Acneiform eruptions
• Folliculitis
• Perioral Dermatitis
• Rosacea
• Sebaceous Hyperplasia
• Syringoma
• Tuberous Sclerosis

18. • Prognosis
• Acne may not be life-threatening but it has lifelong psychosocial
effects. People with acne and acne scars often develop anxiety and
depression. The acne scars are almost impossible to correct. A study
from Sweden suggests that acne in teenager boys may be a risk factor
for prostate cancer development late in life.
• The overall prognosis of acne is good with treatment

19. • Complications
• Scars
• Depression
• Anxiety
• Socially withdrawn
• Poor facial aesthetics
• Lack of self-esteem

20. • Acne is unavoidable but can be controlled by regular washing of the
face by a pH balancing wash which is available as benzoyl peroxide
and salicylic acid face wash. Avoidance of high glycemic index and/or
dairy-based food plays a role. Management of stress and early
detection and treatment of underlying causes like PCOD helps to
control acne and preventing disfigurement.
• Even though retinoids are excellent agents for acne, their use in
women of childbearing age is limited because the agents are
teratogenic. There is a registry for all individuals who are prescribed
or dispensed retinoids like isotretinoin.

21. Few neet pg questions

22. Staph aureus causes –
a) Erythrasma
b) Chancroid
c) Acne vulgaris
d) Bullous impetigo
.

23. • Correct Answer - D
Ans. is 'd' i.e., Bullous impetigo Impetigo is divided into two types :? i)
Non-bullous impetigo (Impetigo contagiosum) :- Caused by
staphylococcus aureus and streptococcus pyogenes. ii) Bullous
impetigo :- Caused by staphylococcus aureus.

24. •Maximum cumulative dose of isotretinoin
shouldn't exceed for acne treatment ?
• a) 30-60 mg/kg
• b) 60-90 mg/kg
• c) 90-120 mg/kg
• d) 120-150 mg/kg

25. • Correct Answer - D
• Ans., D. 120-150 mg/kg Isotretinoin is recommended for severe
nodulocystic acne and also for the patients with milder disease who
don't respond to conventional treatment. Treatment regimens usually
begin at 0.5-1.0mg/kg/day for the duration of between 16 and 20
weeks. Cumulative dose amount to a total of at least 12O mg/kg, but
there is no added benefit when 150 mg/kg is exceeded.

26. •9. True about rhinophyma:
• a) Premalignant
• b) Common in alcoholics
• c) Acne rosacea
• d) Fungal etiology

27. • Correct Answer - C
Rhinophyma is a slow-growing benign tumor which occurs due to
hypertrophy of the sebaceous glands° of the tip of the nose. Seen in
long standing cases of acne rosacea. Mostly affects men past middle
age. Presents as a pink, lobulated mass over the nose. Treatment
Paring down the bulk of the tumor with a sharp knife, or carbon
dioxide laser or scalpel (dermabraions), and the area is allowed to re-
epithelize. Sometimes tumor is completely excised and the raw area is
covered with skin graft

28. •1653. Difference in acne rosacea & acne
vulgaris
• a) Pustule
• b) Erythema
• c) Papule
• d) Absence of comedone

29. • Correct Answer - D
• Ans. is 'd' i.e., Absence of comedone

30. •Which hormone is responsible for acne ?
• a) Estrogen
• b) Thyroid
• c) Testosterone
• d) Gonadotropins

31. • Correct Answer - C Ans. is 'c' i.e., Testosterone Predisposing factors for
Acne vulgaris Genetic factors Hormones -4 Androgens,
glucocorticoids. Psychological stress and depression. Environmental
factors High temperature & humidity. Cosmetics -3 Containing lenolin,
petroleum, vegetable oils. Infection --> Propionibacterium,
Pityrosporum, Staph. epidermidis. Menstural cycle -4 Premenstural
aggravation. Hyperkeratosis of pilosebaceous ostia. Drugs
Antepileptics (Carbamazepine, phenytoin, phenobarbitone),
antitubercular (INH, rifampin, ethionamide), antidepressants,
cyclosporine, Vitamin B12.Cough syrups containing halogens (Iodides,
bromides)

32. • . Treatment of nodulocystic acne is
• a) Erythromycin
• b) Tertacycline
• c) Isoretinonine (Retinoic acid)
• d) Steroids

33. • Correct Answer - C
• C i.e. Isoretinonine

34. • Lithium causes all except
• a) Polyuria
• b) Nephropathy
• c) Ebstein's anomaly
• d) Hyperthyroidism

35. • Side effects of lithium
• 1. Neurological: - Tremor is the commonest side effect of lithium.
Other CNS side effects are giddiness, ataxia, motor incoordination,
hyperreflexia, mental confusion, nystagmus.
• 2. Renal: - Nephrogenic diabetes insipidus with polyuria & polydipsia.
Amiloride is the DOC for Lithium induced nephrogenic DI.
• 3. Cardiovascular: - Effects are similar to hypokalemia. The most
common ECG change is T wave depression.
• 4. Endocrine: - Goitre, hypothyroidism
• 5. GIT: - Nausea, vomiting, diarrhea, metallic test, abdominal pain.
6. Dermatological : - Acneiform eruptions, papular eruption,
exacerbation of psoriasis.
• 7. Teratogenicity: - Ebstein's anomaly in the fetus.