acne andrews' chapter 13 ben adams, d.o

AcneAcne

Andrews’ Chapter 13Andrews’ Chapter 13

Ben Adams, D.O.Ben Adams, D.O.

1-18-051-18-05

Acne VulgarisAcne Vulgaris

Chronic inflammatory disease of the Chronic inflammatory disease of the pilosebaceous folliclespilosebaceous follicles

Comedones, papules, pustules, cysts, Comedones, papules, pustules, cysts, nodules, and often scarsnodules, and often scars

Face, neck, upper trunk, and upper Face, neck, upper trunk, and upper armsarms

Disease of the adolescentDisease of the adolescent 90% of all teenagers90% of all teenagers May also begin in twentiesMay also begin in twenties Usually involution by 25Usually involution by 25 Occurs primarily in oily{seborrheic} Occurs primarily in oily{seborrheic}

areas of the skinareas of the skin Face occurs; cheeks> Face occurs; cheeks>

nose>forehead>chinnose>forehead>chin Ears; comedones in concha, cysts in Ears; comedones in concha, cysts in

lobuleslobules Retroauricular and nuchal cystsRetroauricular and nuchal cysts

DHT, the prominent hormonal effector on the sebaceous glandDHT, the prominent hormonal effector on the sebaceous gland

ComedoComedo

Commonly known as the Commonly known as the blackhead blackhead Basic lesion of acne Basic lesion of acne Produced by hyperkeratosis of the Produced by hyperkeratosis of the

lining of the follicles lining of the follicles Retention of keratin and sebumRetention of keratin and sebum

ComedoComedo

Plugging produced by the comedo Plugging produced by the comedo dilates the mouth of the follicle dilates the mouth of the follicle

Papules are formed by inflammation Papules are formed by inflammation around the comedonesaround the comedones

Severity of AcneSeverity of Acne

Typical mild acne; comedones Typical mild acne; comedones predominate predominate

More severe cases; pustules and More severe cases; pustules and papules predominate, heal with scar papules predominate, heal with scar if deep if deep

Acne Conglobata; suppurating cystic Acne Conglobata; suppurating cystic lesions predominate, and severe lesions predominate, and severe scarring resultsscarring results

TypesTypes

Acne comedo; mild case were Acne comedo; mild case were eruption is composed almost entirely eruption is composed almost entirely of comedones on an oily skin of comedones on an oily skin

Papular acne; inflammatory papules, Papular acne; inflammatory papules, most common in young men with most common in young men with coarse, oily skincoarse, oily skin

Atrophic acne; residual atrophic pits Atrophic acne; residual atrophic pits and scars and scars

EtiologyEtiology

Keratin plug in lower infindibulum of Keratin plug in lower infindibulum of hair follicle hair follicle

Androgenic stimulation of sebaceous, Androgenic stimulation of sebaceous, proliferation of propionbacterium proliferation of propionbacterium acnes which metabolizes sebum to acnes which metabolizes sebum to produce free fatty acids produce free fatty acids

PathogenesisPathogenesis

Disruption of the follicular epithelium Disruption of the follicular epithelium permits discharge of the follicular permits discharge of the follicular contents into the dermis contents into the dermis

Causes the formation of Causes the formation of inflammatory papules, pustules, and inflammatory papules, pustules, and nodulocystic lesionsnodulocystic lesions

FFA are chemotactic to components FFA are chemotactic to components of inflammationof inflammation


Effects of tetracycline are obtained Effects of tetracycline are obtained by the reduction of FFA by the reduction of FFA

Antibiotics do not produce involution Antibiotics do not produce involution of the inflammatory lesions present, of the inflammatory lesions present, but inhibit the formation of new but inhibit the formation of new lesions lesions

Topical retinoic acid acts on Topical retinoic acid acts on keratinization, causing horny cells to keratinization, causing horny cells to lose their stickiness lose their stickiness


Androgens enlarge the sebaceous Androgens enlarge the sebaceous glands glands

In women consider hyperandrogenic In women consider hyperandrogenic statestate

HistologyHistology

Acne is characterized by perifollicular Acne is characterized by perifollicular inflammation around comedones inflammation around comedones

Exudate of lymphocytes and PMNsExudate of lymphocytes and PMNs Plasma cells, foreign body giant cells, Plasma cells, foreign body giant cells,

and proliferation of fibroblasts and proliferation of fibroblasts Large cysts and epithelial-lined sinus Large cysts and epithelial-lined sinus

tracts tracts

TreatmentTreatment

Topical medications to systemic Topical medications to systemic therapytherapy

No evidence that dietary habits No evidence that dietary habits influence acne influence acne

AntibacterialsAntibacterials

Tetracycline since 1951Tetracycline since 1951 Safest and cheapest choiceSafest and cheapest choice 250 to 500mg QD to QID250 to 500mg QD to QID Gradual reduction in doseGradual reduction in dose Take on empty stomachTake on empty stomach Calcium and iron decrease absorptionCalcium and iron decrease absorption Constant or intermittent tx months to Constant or intermittent tx months to

yearsyears

TetracyclinesTetracyclines

Tetracylines as sole treatment will Tetracylines as sole treatment will give a positive response in 70% give a positive response in 70%

May take 4-6 weeks for response May take 4-6 weeks for response Vaginitis and perianal itching in 5% Vaginitis and perianal itching in 5%

due to Candida albicansdue to Candida albicans Staining of growing teeth precludes Staining of growing teeth precludes

use in pregnancy and children < 9 or use in pregnancy and children < 9 or 1010

MinocyclineMinocycline

More effective than tetracycline in More effective than tetracycline in acne vulgaris acne vulgaris

50 to 100mg QD or BID50 to 100mg QD or BID Absorption less affected by milk and Absorption less affected by milk and

foodfood

AntibacterialsAntibacterials

Doxycycline; Doxycycline; P.ancesP.ances resistant to resistant to erythromycin, photosensitivity can occur erythromycin, photosensitivity can occur

Erythromycin; consider in young and Erythromycin; consider in young and pregnant who cannot use tetracyclinepregnant who cannot use tetracycline

Clindamycin; works well, but can cause Clindamycin; works well, but can cause pseudomembranous colitis pseudomembranous colitis

Sulfonamides; phototoxicity, Scalded skinSulfonamides; phototoxicity, Scalded skin

Bacterial ResistanceBacterial Resistance

Worsening clinical condition Worsening clinical condition correlates with a high MIC for correlates with a high MIC for erythromycin and tetracycline for P. erythromycin and tetracycline for P. acnes acnes

Resistance lost after 2 months after Resistance lost after 2 months after withdrawal of antibioticwithdrawal of antibiotic

Avoid use of different oral and topical Avoid use of different oral and topical antibiotics at the same timeantibiotics at the same time

Oral Contraceptives Oral Contraceptives

Estradiol suppresses the uptake of Estradiol suppresses the uptake of testosterone by the sebaceous glandstestosterone by the sebaceous glands

Oral contraceptives containing Oral contraceptives containing androgenic progesterones may androgenic progesterones may exacerbate acneexacerbate acne

EES and Norgestimate is approved for txEES and Norgestimate is approved for tx (Ortho Tri-cyclen, Estrostep, Yazmine) (Ortho Tri-cyclen, Estrostep, Yazmine)

Hormonal TherapyHormonal Therapy

Spironolactone 25mg to 300mg/d , Spironolactone 25mg to 300mg/d , antiandrogenic antiandrogenic

Steroids for severe inflammatory Steroids for severe inflammatory acneacne

IsotretinoinIsotretinoin

0.5 to 1 mg/kg/day qd or bid for 15 to 0.5 to 1 mg/kg/day qd or bid for 15 to 20 weeks20 weeks

Leads to a remission that may last Leads to a remission that may last months to years months to years

teratogenicteratogenic


Retinoids exert their physiologic Retinoids exert their physiologic effects through two distinct families effects through two distinct families of nuclear receptorsof nuclear receptors

RARs and retinoid X receptors (RXRs)RARs and retinoid X receptors (RXRs) Affects sebum production, Affects sebum production,

comedongenesis, P. acne, comedongenesis, P. acne, keratinization, not related to RAR and keratinization, not related to RAR and RXR affinity RXR affinity


Hypertriglyceridemia, dry mucosa Hypertriglyceridemia, dry mucosa Nasal colonization with S.aureus in Nasal colonization with S.aureus in

90%90% Worsening of acne common in first Worsening of acne common in first

monthmonth Monitor HCG, lipids, LFT’sMonitor HCG, lipids, LFT’s

Topical TreatmentTopical Treatment

Benzoyl peroxideBenzoyl peroxide Topical retinoidsTopical retinoids Topical antibacterialsTopical antibacterials Salicyclic acid, Azeleic acidSalicyclic acid, Azeleic acid

Benzoyl PeroxideBenzoyl Peroxide

Available as gels, lotions, washes and Available as gels, lotions, washes and barsbars

2.5% to 10%2.5% to 10% Potent antibacterial effectPotent antibacterial effect May decrease antibacterial May decrease antibacterial

resistanceresistance Decrease frequency of application if Decrease frequency of application if

irritation occursirritation occurs

Topical RetinoidsTopical Retinoids

Creams, gels, liquidsCreams, gels, liquids 0.01%, 0.025%, 0.04%, 0.05% and 0.01%, 0.025%, 0.04%, 0.05% and

0.1%0.1% Cream base may be less irritating Cream base may be less irritating Affect follicular keratinizationAffect follicular keratinization ComedolyticComedolytic Apply qhs, may take 8 to 12 weeksApply qhs, may take 8 to 12 weeks

Topical AntibacterialsTopical Antibacterials

Clindamycin 1% effective against Clindamycin 1% effective against pustules and small papulopustular pustules and small papulopustular lesions lesions

Erythromycin 3%Erythromycin 3% Both equally effective, combined Both equally effective, combined

with bezoyl peroxide can decrease with bezoyl peroxide can decrease resistance resistance

Other TopicalsOther Topicals

Azeleic Acid; low adverse reactionsAzeleic Acid; low adverse reactions Salicylic acidSalicylic acid Abrasive cleaners, astringents make Abrasive cleaners, astringents make

the skin dry and susceptible to the skin dry and susceptible to irritantsirritants

Surgical TreatmentSurgical Treatment

Comedone extractor brings about Comedone extractor brings about quick resolution of comedones and quick resolution of comedones and pustulespustules

In Isotretinoin pts macrocomedones In Isotretinoin pts macrocomedones present at week 10 to 15 of therapypresent at week 10 to 15 of therapy

Intralesional CorticosteroidsIntralesional Corticosteroids

Effective in reducing inflammatory Effective in reducing inflammatory papules, pustules, and smaller cystspapules, pustules, and smaller cysts

Kenalog-10 (triamcinolone 10mg/ml)Kenalog-10 (triamcinolone 10mg/ml) Diluted with NS to 5 or 2.5mg/mlDiluted with NS to 5 or 2.5mg/ml

Complications of AcneComplications of Acne

Scarring can occur despite best Scarring can occur despite best treatmenttreatment

Pitted scars, wide-mouthed Pitted scars, wide-mouthed depressions and keloidsdepressions and keloids

Chemical peels, CO2 Laser Chemical peels, CO2 Laser resurfacing, scar excision,resurfacing, scar excision,

Acne ConglobataAcne Conglobata

Conglobate: shaped in a rounded Conglobate: shaped in a rounded mass or ballmass or ball

Severe form of acne characterized by Severe form of acne characterized by numerous comedones, large numerous comedones, large abscesses with sinuses, grouped abscesses with sinuses, grouped inflammatory nodulesinflammatory nodules

SuppurationSuppuration Cysts on forehead, cheeks, and neck Cysts on forehead, cheeks, and neck

Acne ConglobataAcne Conglobata

Occurs most frequently in young menOccurs most frequently in young men Follicular Occlusion Triad: acne Follicular Occlusion Triad: acne

conglobata, hidradenitis suppurativa, conglobata, hidradenitis suppurativa, cellulitis of the scalpcellulitis of the scalp

Heals with scarringHeals with scarring Treatment; oral isotretinoin for 5 Treatment; oral isotretinoin for 5

months months

Acne FulminansAcne Fulminans

Rare form of extremely severe cystic Rare form of extremely severe cystic acneacne

Teenage boys, chest and backTeenage boys, chest and back Rapid degeneration of nodules Rapid degeneration of nodules

leaving ulcerationleaving ulceration Fever, leukocytosis, arthralgias are Fever, leukocytosis, arthralgias are

commoncommon Tx; oral steroids, isotretinoinTx; oral steroids, isotretinoin

SAPHO SyndromeSAPHO Syndrome

Synovitis, Acne, Pustulosis, Synovitis, Acne, Pustulosis, Hyperostosis, and OsteomyelitisHyperostosis, and Osteomyelitis

Acne fulminans, acne conglobata, Acne fulminans, acne conglobata, pustular psoriasis, and palmoplantar pustular psoriasis, and palmoplantar pustulosispustulosis

Chest wall is most site of Chest wall is most site of musculoskeletal complaintsmusculoskeletal complaints

Tropical AcneTropical Acne

Nodular, cystic, and pustular lesions Nodular, cystic, and pustular lesions on back, buttocks, and thighson back, buttocks, and thighs

Face is sparedFace is spared Young adult military stationed in Young adult military stationed in

tropicstropics

Premenstrual AcnePremenstrual Acne

Papulopustular lesions week priorPapulopustular lesions week prior Estrogen-dominant contraceptive Estrogen-dominant contraceptive

pills will diminishpills will diminish

Preadolescent AcnePreadolescent Acne

NeonatalNeonatal InfantileInfantile ChildhoodChildhood

Neonatal AcneNeonatal Acne

First four weeks of life First four weeks of life Develops a few days after birthDevelops a few days after birth Facial papules or pustules Facial papules or pustules

Infantile AcneInfantile Acne

Cases that persist beyond 4 weeks or Cases that persist beyond 4 weeks or have an onset afterhave an onset after

R/O acne cosmetic, acne venenata, R/O acne cosmetic, acne venenata, drug-induced acne drug-induced acne

Acne VenenataAcne Venenata

Contact with acnegenic chemicals Contact with acnegenic chemicals can produce comedonescan produce comedones

Chlorinated hydrocarbons, cutting Chlorinated hydrocarbons, cutting oils, petroleum oil, coal taroils, petroleum oil, coal tar

Radiation therapyRadiation therapy

Acne CosmeticaAcne Cosmetica

Closed comedones and Closed comedones and papulopustules on the chin and papulopustules on the chin and cheekscheeks

May take months to clear after May take months to clear after stopping cosmetic productstopping cosmetic product

Pomade Acne; blacks, males, due to Pomade Acne; blacks, males, due to greases or oils applied to hair greases or oils applied to hair

Acne DetergicansAcne Detergicans

Patients wash face with comedogenic Patients wash face with comedogenic soapssoaps

Closed comedonesClosed comedones TX; wash only once or twice a day TX; wash only once or twice a day

with non-comedogenic soap with non-comedogenic soap

Acne AestivalisAcne Aestivalis

Aka; Mallorca acneAka; Mallorca acne Rare, females 25-40 yrsRare, females 25-40 yrs Starts in spring, resolves by fallStarts in spring, resolves by fall Small papules on cheeks, neck, Small papules on cheeks, neck,

upper bodyupper body Comedones and pustules are sparse Comedones and pustules are sparse

or absentor absent Tx; retinoic acid, abx don’t help Tx; retinoic acid, abx don’t help

Excoriated AcneExcoriated Acne

Aka; picker’s acneAka; picker’s acne Girls, minute or trivial primary lesions Girls, minute or trivial primary lesions

are made worse by squeezingare made worse by squeezing Crusts, scarring, and atrophyCrusts, scarring, and atrophy TX; eliminate magnifying mirror, r/o TX; eliminate magnifying mirror, r/o

depression depression

Acneiform EruptionsAcneiform Eruptions

Originate from skin exposure to Originate from skin exposure to various industrial chemicalsvarious industrial chemicals

Papules and pustules not confined to Papules and pustules not confined to usual sites of acne vulgarisusual sites of acne vulgaris

Chlorinated hydrocarbons, oils, coal Chlorinated hydrocarbons, oils, coal tartar

Oral meds; iodides, bromides, Oral meds; iodides, bromides, lithium, steroids (steroid acne)lithium, steroids (steroid acne)

Gram Negative FolliculitisGram Negative Folliculitis

Occurs in patients treated with Occurs in patients treated with antibiotics for acne over a long-termantibiotics for acne over a long-term

Enterobactor, Klebsiella, Proteus Enterobactor, Klebsiella, Proteus Anterior nares colonizedAnterior nares colonized Tx; isotretinoin, AugmentinTx; isotretinoin, Augmentin

Acne KeloidalisAcne Keloidalis

Folliculitis of the deep levels of the hair Folliculitis of the deep levels of the hair follicle that progresses into a perifolliculitisfollicle that progresses into a perifolliculitis

Occurs at nuchal area in blacks or Asian Occurs at nuchal area in blacks or Asian menmen

Not associated with acne vulgarisNot associated with acne vulgaris Hypertrophic connective tissue becomes Hypertrophic connective tissue becomes

sclerotic, free hairs trapped in the dermis sclerotic, free hairs trapped in the dermis contribute to inflammation contribute to inflammation

Tx; intralesional Kenalog, surgeryTx; intralesional Kenalog, surgery

Hidradenitis SuppurativaHidradenitis Suppurativa

Disease of the apocrine gland Disease of the apocrine gland Axillae, groin, buttocks, also areolaAxillae, groin, buttocks, also areola Obesity and genetic tendency to Obesity and genetic tendency to

acneacne Tender red nodules become fluctuant Tender red nodules become fluctuant

and painfuland painful Rupture, suppuration, formation of Rupture, suppuration, formation of

sinus tracts sinus tracts


Most frequently axillae of young Most frequently axillae of young women women

Men usually groin and perianal areaMen usually groin and perianal area Follicular keratinization with plugging Follicular keratinization with plugging

of the apocrine duct; dilation and of the apocrine duct; dilation and inflammationinflammation

DDx; Furuncles are unilateral, and not DDx; Furuncles are unilateral, and not associated with comedones, Bartholin associated with comedones, Bartholin cyst, scrofuloderma, actinomycosis, cyst, scrofuloderma, actinomycosis, granuloma inguinale granuloma inguinale


Oral antibiotics, culture S. aureus, Oral antibiotics, culture S. aureus, gram-negativesgram-negatives

Intralesional steroids, surgeryIntralesional steroids, surgery Isotretinoin helpful in some casesIsotretinoin helpful in some cases

Perifolliculitis Capitis AbscedensPerifolliculitis Capitis Abscedens

Aka; Aka; Dissecting cellulitis of the scalp Dissecting cellulitis of the scalp Uncommon suppurative disease Uncommon suppurative disease Nodules suppurate and undermine to Nodules suppurate and undermine to

form sinusesform sinuses Scarring and alopeciaScarring and alopecia Adult black men most common, Adult black men most common,

vertex and occiput vertex and occiput

Perifolliculitis Capitis AbscedensPerifolliculitis Capitis Abscedens

Tx; intralesional steroids, Tx; intralesional steroids, isotretinoin, oral abx, surgical isotretinoin, oral abx, surgical incision and drainageincision and drainage

Acne vs. RosaceaAcne vs. Rosacea

acneacne rosacearosacea

RosaceaRosacea

Chronic inflammatory eruption of the Chronic inflammatory eruption of the flush areas of the faceflush areas of the face

Erythema, papules, pustules, Erythema, papules, pustules, telangiectasia, hypertrophy of the telangiectasia, hypertrophy of the sebaceous glandssebaceous glands

Usually mid-faceUsually mid-face Women ages 30-50Women ages 30-50

RosaceaRosacea

Ocular RosaceaOcular Rosacea

Blepharitis, conjunctivitisBlepharitis, conjunctivitis Keratitis, iritis, episcleritisKeratitis, iritis, episcleritis C/o gritty, stinging sensationC/o gritty, stinging sensation

Ocular rosacea occurs in Ocular rosacea occurs in about 58% of rosacea patientsabout 58% of rosacea patients

Chronically inflamed eyelid Chronically inflamed eyelid margins may be confused with margins may be confused with

seborrheic dermatitisseborrheic dermatitis

Granulomatous RosaceaGranulomatous Rosacea

Midface, perioral, lateral mandible Midface, perioral, lateral mandible areasareas

Noncaseating granulomasNoncaseating granulomas

Rosacea EtiologyRosacea Etiology

Vasomotor liabilityVasomotor liability Hot liquids, ETOH, steroids (oral and Hot liquids, ETOH, steroids (oral and

topical) ie: perioral dermatitistopical) ie: perioral dermatitis Demodex folliculorumDemodex folliculorum not causative not causative

Differential Diagnosis RosaceaDifferential Diagnosis Rosacea

Acne VulgarisAcne Vulgaris Lupus erythematosusLupus erythematosus Bromoderma, ioderma Bromoderma, ioderma Papular syphilidPapular syphilid

Inflammatory rosaceaInflammatory rosacea

Papules and Papules and pustules are pustules are characteristiccharacteristic

Rosacea TreatmentRosacea Treatment

Long-term oral tetracycline is Long-term oral tetracycline is suppressive, required for ocular suppressive, required for ocular rosacearosacea

Topical metronidazoleTopical metronidazole Sunscreens, avoidance of flushing Sunscreens, avoidance of flushing

triggerstriggers Flash lamped pumped dye laser for Flash lamped pumped dye laser for

telangiectasiastelangiectasias

RosaceaRosaceaRhinophymaRhinophyma

RhinophymaRhinophyma

Men over 40Men over 40 Pilosebaceous gland hyperplasia with Pilosebaceous gland hyperplasia with

fibrosis, inflammation, and fibrosis, inflammation, and telangiectasia telangiectasia

Treatment is surgeryTreatment is surgery

Pyoderma FacialePyoderma Faciale

Postadolescent girls, reddish cyanotic Postadolescent girls, reddish cyanotic erythema with abscesses and cystserythema with abscesses and cysts

Distinguished from acne by absence Distinguished from acne by absence of comedones, rapid onset, fulminant of comedones, rapid onset, fulminant course and absence of acne on the course and absence of acne on the back and chest back and chest

Tx; oral steroids followed by Tx; oral steroids followed by isotretinoinisotretinoin

Perioral DermatitisPerioral Dermatitis

Papulosquamous eruptionPapulosquamous eruption Clear zone around vermillion borderClear zone around vermillion border Women 23-35yrsWomen 23-35yrs Etiology; ?topical steroids, Etiology; ?topical steroids,

fluorinated toothpastefluorinated toothpaste Tx; d/c topical steroids, oral tcn if Tx; d/c topical steroids, oral tcn if

pustules pustules

acne andrews' chapter 13 ben adams, d.o

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