ACNEACNEDisorders of sebaceous glandDisorders of sebaceous gland

Omar Abdulaziz Al-Sheikh, M.DOmar Abdulaziz Al-Sheikh, M.D..

College of MedicineCollege of Medicine

King Saud UniversityKing Saud University

DefinitionDefinition::

Is a chronic inflammatory disorder of the Is a chronic inflammatory disorder of the pilosebaceous apparatus of certain body pilosebaceous apparatus of certain body area (Face> Torso > rarely the Buttocks), area (Face> Torso > rarely the Buttocks), resulting in greasiness and polymorphic resulting in greasiness and polymorphic skin eruption. skin eruption.

Incidence:Incidence:

Acne affect all skin types, the male and Acne affect all skin types, the male and female ratio is virtually the same but tend female ratio is virtually the same but tend to be more severe in males.to be more severe in males.

85% affect the age group 12 – 24 years85% affect the age group 12 – 24 years

8% affect the age group 25 – 34 years 8% affect the age group 25 – 34 years

3% affect the age group 35 – 44 years3% affect the age group 35 – 44 years

Etiology:Etiology:1.1. Genetic Aspect, (Acne runs in family) Genetic Aspect, (Acne runs in family)

other example the case of severe acne other example the case of severe acne that is associated with XXY syndrome.that is associated with XXY syndrome.

2.2. Occupation (Environmental, Mechanical) Occupation (Environmental, Mechanical) e.g. exposure acnegenic mineral oil e.g. exposure acnegenic mineral oil (Pomade acne) dioxin(Pomade acne) dioxin

3.3. Drugs Oral and topical Hydrocortison Drugs Oral and topical Hydrocortison (Steroid acne) Lithium, Hydantoin, (Steroid acne) Lithium, Hydantoin, contraceptives contraceptives

4.4. Endocrine Factors (Recalcitrant Acne, Endocrine Factors (Recalcitrant Acne, POD/s, MARSH Syndrome) .POD/s, MARSH Syndrome) .

Pathogenesis: Pathogenesis: ( three main steps ( three main steps recognized and hypothesized)recognized and hypothesized)

1.1. Follicular Hyperkeratosis (the cause not Follicular Hyperkeratosis (the cause not fully understood) theory suggest:fully understood) theory suggest:

deficiency in Linoleic acid, deficiency in Linoleic acid, the effect off 5-the effect off 5-a a reductase enzyme on reductase enzyme on

converting Androgen (Testosterone) converting Androgen (Testosterone) hormone to the active acnegenic and hormone to the active acnegenic and potent (Dihydrotestosterone) DHT, potent (Dihydrotestosterone) DHT,

the direct effect of Interleukin-1 on the direct effect of Interleukin-1 on follicular hyperkeratosisfollicular hyperkeratosis

Perifollicular Hyperkeratosis histology

Fig 1Fig 1 Fig 2Fig 2

Fig 3Fig 3

2.2. Abnormal production of abnormal sebum Abnormal production of abnormal sebum increasing the ratio of wax easter to increasing the ratio of wax easter to cholesterol and cholesterol easter and is cholesterol and cholesterol easter and is believed to be the response of sebaceous believed to be the response of sebaceous glands to DHEAglands to DHEA

SeborrhoeaSeborrhoea is a common feature between is a common feature between patients with acne.patients with acne.

3. 3. Colonization of the affected unit with Colonization of the affected unit with bacteria bacteria PropionibacteriumPropionibacterium acneacne and yeast named Malassezia and yeast named Malassezia furfurfurfur

Propionibacterium Propionibacterium acneacne

Malassezia Malassezia furfurfurfur

Fig 4Fig 4 Fig 5Fig 5

P P acneacne is potent activator of complement is potent activator of complement via classical pathwayvia classical pathway

Fig 6Fig 6 Fig 7Fig 7

Propionobacterium Propionobacterium acne acne lipases act on sebaceous fatty lipases act on sebaceous fatty acid (Triglycrides) to release irritant free fatty acid acid (Triglycrides) to release irritant free fatty acid and low-molecular- weight peptide an extra cellular and low-molecular- weight peptide an extra cellular factor that penetrate the follicular wall and stimulate factor that penetrate the follicular wall and stimulate Polymorphs and Lymphocytes initiating inflammationPolymorphs and Lymphocytes initiating inflammation

Fig 8Fig 8

Hydrolytic enzymes released from the Hydrolytic enzymes released from the activated complement antibodies complex activated complement antibodies complex together with exoenzymes produced from together with exoenzymes produced from P P acneacne cause rupture of follicular wall cause rupture of follicular wall

Fig 9Fig 9

Once the wall is damaged Various agents Once the wall is damaged Various agents (prostaglandin-like substance, amino acid, (prostaglandin-like substance, amino acid, short chain fatty acid are) that are produced short chain fatty acid are) that are produced by the inflammatory cells and P acne extrude by the inflammatory cells and P acne extrude to the dermis causing more inflammationto the dermis causing more inflammation

Clinical features: Clinical features: (Acne and acne (Acne and acne related Disorders)related Disorders)

1.1. Acne Vulgaris:Acne Vulgaris:

Papules: (Less than 0.5 cm)Papules: (Less than 0.5 cm) Comedones (Open “Blackheads” or Comedones (Open “Blackheads” or

closed “Whitheads”)closed “Whitheads”)

Open Comedones (Blackheads)Open Comedones (Blackheads)

Open Comedones

Fig 10Fig 10 Fig 11Fig 11

Closed Comedones (Whitehead)Closed Comedones (Whitehead)

Closed Comedones

Fig 12Fig 12 Fig 13Fig 13

Inflammatory papulesInflammatory papules

Inflammatory papules

Fig 14Fig 14 Fig 15Fig 15

Pustules :Pustules :

Pustules

Fig 16Fig 16 Fig 17Fig 17

Nodule (more than 0.5 cm)Nodule (more than 0.5 cm)

Nodule

Fig 18Fig 18 Fig 19Fig 19

Cystic acne: the cysts are usually Cystic acne: the cysts are usually large 1-4cmlarge 1-4cm

Fig 21Fig 21Fig 20Fig 20

2.2. The nodules and cysts could be The nodules and cysts could be associated with sinuses as in Acne inverseaassociated with sinuses as in Acne inversea

Acne inversea (Hidradinitis supprativa “a Acne inversea (Hidradinitis supprativa “a misleading name”) because it is considered by misleading name”) because it is considered by some to be disorder of apocrine gland (Sweat some to be disorder of apocrine gland (Sweat gland) but gland) but In my opinion In my opinion Acne inversea affect Acne inversea affect primarily pilo Seb. Unit and affect secondarily the primarily pilo Seb. Unit and affect secondarily the sweat gland, hence the correct name Acne sweat gland, hence the correct name Acne inversea rather than Hidradinitis supprativa is inversea rather than Hidradinitis supprativa is preferred.preferred.

Fig 22Fig 22

Neonatal acne: cause unknown but some Neonatal acne: cause unknown but some believed is due to passing of believed is due to passing of Transplacental androgen other suggest Transplacental androgen other suggest the role of Mlalassezia the role of Mlalassezia furfurfurfur and and sympodalissympodalis . . affect 1 in 5 mainly affect 1 in 5 mainly inflammatory comedones on nose and inflammatory comedones on nose and cheeks affect new born between the 1cheeks affect new born between the 1stst and 6and 6thth week of age week of age

3.3. Neonatal Acne and Infantile AcneNeonatal Acne and Infantile Acne

Fig 23Fig 23

Infantile Acne: affect males more than Infantile Acne: affect males more than females, usually between 3 and 6 months females, usually between 3 and 6 months of age, and tend to be severer than the of age, and tend to be severer than the neonatal one and believed to be due to neonatal one and believed to be due to EndogenicEndogenic androgen from the infant’s androgen from the infant’s gonads.gonads.

Fig 24Fig 24

4. Recalcitrant Acne4. Recalcitrant Acne

Affect Women and associated with (Adrenal Affect Women and associated with (Adrenal hyperplasia "11-B- or 21-B hydroxlase hyperplasia "11-B- or 21-B hydroxlase deficiencies) acne is usually nodulocysticdeficiencies) acne is usually nodulocystic

5. Acne Fulminans5. Acne Fulminans

Affect youngsters 13 – 17 years of age, very Affect youngsters 13 – 17 years of age, very severe with ulceration and puss discharge, severe with ulceration and puss discharge, associated symptoms include (fever associated symptoms include (fever malase myalgia arthritis and bone pain) malase myalgia arthritis and bone pain) laboratory investigation shows ESR laboratory investigation shows ESR

Can be induced by starting the patient on Can be induced by starting the patient on high dose of isotretinion (Roaccutane).high dose of isotretinion (Roaccutane).

Fig 25Fig 25

6. Acne Conglobata6. Acne Conglobata

Very severe Acne, Nodulocystic form with Very severe Acne, Nodulocystic form with abscess formation, affect Torso more than abscess formation, affect Torso more than the face, usually associated with the face, usually associated with XYY XYY Syndrome. Syndrome.

Fig 26Fig 26

Fig 27Fig 27

7. Acne Agminata7. Acne Agminata (Lupus Milliaris Disseminatus (Lupus Milliaris Disseminatus

Faciei)Faciei)

Some believe it is form of Rosacea Some believe it is form of Rosacea (Granulomatous type), diagnosis is made (Granulomatous type), diagnosis is made at Histological base, Caseating at Histological base, Caseating Granulomata at the dermal level.Granulomata at the dermal level.

Fig 28Fig 28

8. Acne as part of other syndromes8. Acne as part of other syndromes

MARSH Syndrome (MARSH Syndrome (MMelsma, Acne, elsma, Acne, RRosacea, ,osacea, ,SSeborrhoeic eczema, and eborrhoeic eczema, and HHirsutism)irsutism)

Acne Conglobata Acne Conglobata Favre Racouchot syndrome elderly with elastosis Favre Racouchot syndrome elderly with elastosis

as part of Helioderma, sun exposure is a as part of Helioderma, sun exposure is a predisposing factor.predisposing factor.

Polycystic ovarian syndromePolycystic ovarian syndrome Atrophoderma vermiculatum as part of so called Atrophoderma vermiculatum as part of so called

Ulerythema ophryogenes triat in Ulerythema ophryogenes triat in Noonan SyndromeNoonan Syndrome, , de Lange Syndromede Lange Syndrome, and , and Rubinstein-Rubinstein-TaybiTaybi Syndrome Syndrome   Not considered acne Not considered acne

9. Occupational 9. Occupational I EnvironmentalI Environmental

Chloracne rare forms of acne affect Chloracne rare forms of acne affect patients exposed to Halogenated patients exposed to Halogenated Hydrocarbons or who ingested Chlorinated Hydrocarbons or who ingested Chlorinated Phenols (Dioxin) Phenols (Dioxin)

Pomade acne or known as Oil Folliculitis Pomade acne or known as Oil Folliculitis Acne Aestivalis or so called Mallorca AcneAcne Aestivalis or so called Mallorca Acne

Occupational Occupational II mechanical acneII mechanical acne

Folicullitis Nuchae or so called Acne Folicullitis Nuchae or so called Acne Keloidalis Keloidalis

Pseudofollicultis barbaePseudofollicultis barbae Acne excoriee as part of PsychodermatosisAcne excoriee as part of Psychodermatosis

TRAETMENTTRAETMENT

Note: All medications used for the treatment of acne act as:

1. Anti comedonal

2. Anti inflammatory

3. Anti microbial

Topical KeratolyticTopical Keratolytic

Retinoid ( Retinoic acid 0.025, 0.05, 0.1%)Retinoid ( Retinoic acid 0.025, 0.05, 0.1%) Adapelene (Diffrine 0.1%)Adapelene (Diffrine 0.1%) Salicylic acid Salicylic acid Benzoic acidBenzoic acid Azelaic Acid (10, 15, 20 %)Azelaic Acid (10, 15, 20 %)

Topical AntibioticTopical Antibiotic

Topical clindamycin (Dalacin T)Topical clindamycin (Dalacin T) ErythromycinErythromycin Mupirocin (Bactroban)Mupirocin (Bactroban) Sodium Fusidic acid (less significant in the Sodium Fusidic acid (less significant in the

treatment) treatment)

Systemic therapySystemic therapy

Antibiotic (Macrolides and Tetracyline)Antibiotic (Macrolides and Tetracyline)

1.1. TetracyclineTetracycline

2.2. DoxycyclineDoxycycline

3.3. Minocycline (Photo sensitivity and LE)Minocycline (Photo sensitivity and LE)

4.4. ErythromycinesErythromycines

5.5. ClarythromycinesClarythromycines

6.6. AzithromycineAzithromycine

Systemic RetinoidSystemic RetinoidIsotretinoine caps (Roaccutane)Isotretinoine caps (Roaccutane)

New promising and potentially safe New promising and potentially safe medication medication SMT D002SMT D002

Phase I clinical trial Phase I clinical trial Is believed to treat Is believed to treat seborrhoeaseborrhoea a symptom a symptom

of Parkinson's disease and the primary of Parkinson's disease and the primary cause of acne cause of acne

Other form of therapyOther form of therapy

Systemic steroid (Prednisolone) acne Systemic steroid (Prednisolone) acne fulminans and intralesional steriods for fulminans and intralesional steriods for forms of cystic acne.forms of cystic acne.

Photodynamic therapy i.e. Laser therapy Photodynamic therapy i.e. Laser therapy and phototherapy (Less significant)and phototherapy (Less significant)

Hormonal therapy (Antiandrogen)Hormonal therapy (Antiandrogen)

Spironlacton (Potassium sparing agent) and Spironlacton (Potassium sparing agent) and Metformin as (Hypogylcemic agent) in Metformin as (Hypogylcemic agent) in treatment of POS have good results on treatment of POS have good results on acneacne

Fig 1, 2 www.scf-online.com/.../keratinization38_e.htm keratinization of the duct of the hair follicle.

www.nlm.nih.gov/.../ency/imagepages/2087.htm open (Blackheads) comedones, Medical EncyclopediaFig.3Fig.3Fig 4. Malassezia Fig 4. Malassezia furfur furfur www.doctorfungus.org/thefungi/Malassezia.htmwww.doctorfungus.org/thefungi/Malassezia.htm Closed comedones Skin and allergy centre.Fig 5Fig 6 www.ohiohealth.com/bodymayo.cfm?id=6&action=t... Mayo Foundation for Medical and research.Fig 7

Fig 8 bacterial colonization www.healthcaresouth.com/pages/acnewhatis.htmFig 9 Breakage of follicular wall www.healthyskinbydesign.com/acne.cfm papule

Fig 10 open comedones www.healthcaresouth.com/pages/acnewhatis.htmFig 11Fig 12 closed comedones www.healthcaresouth.com/pages/acnewhatis.htmfig www.dermalogix.net/acne/acne.html open and closed comedones schematic pictureswww.dermalogix.net/acne/acne.html proriobionacterium acne in pilosabaceous unitwww.healthyskinbydesign.com/acne.cfm. follicular hyperkeratosis in acneFig 13Fig 14Fig 15Fig 16 www.healthyskinbydesign.com/acne.cfm pustuleFig 17. Courtesy of Skin and allergy centreFig 18 www.healthyskinbydesign.com/acne.cfm noduleFig 19 nodule www.acnekil.com/What's_Acne/photo_gallery2.htmFig 20Fig 21 Courtesy of Skin and allergy centreFig 22 Courtesy of Skin and allergy centreFig 23 www.adhb.govt.nz/.../BenignLesions.htm at neonatal dermatology benign lesions Auckland district health board.Fig 24 http://www.virtualendocrinecentre.com/diseases.asp?did=860 (infantile)Fig 25Fig 26 Courtesy of Skin and allergy centre

Fig 27 Acne conglobata www.consultantlive.com/showArticle.jhtml?arti... Fig 28 acne Agminata Granulomatous rosacea in infants. Report of three cases and discussion of the differential diagnosis João Borges da Costa, Sousa Coutinho V, L Soares de Almeida, M Marques Gomes PhDDermatology Online Journal 14 (2): 22

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