ACNE VULGARIS

What is it?

0Disorder of pilosebaceous complex which predominantly affects the peripubertal population and manifest as comedones, papules, nodules, pustules and cysts and heals with scars.

ETIOLOGY

0 Increased sebum secretion.0Follicular duct hypercornification.0 Increased colonization with Propionibacterium.0 Inflammation.

PATHOGENESIS

0Occlusion of pilosebaceous orifice.

0 Increased sebum secretion.

0Microbial colonization.0Release of

inflammatory mediators.

OCCLUSION OF PILOSEBACEOUS ORIFICE

Occluded by keratinous plug induced by chemicals and reduced level of linoleic acid in sebum

Retention of sebum encouraging growth of microbes.

Distended follicle rupture, releasing proinflammatory chemicals into dermis

Stimulate inflammation.

INCREASED SEBUM SECRETION

0Occurs due to end organ sensitivity to androgens.Increased activity of 5α reductase in sebaceous

gland.

Converts testosterone to 5 α testosterone

Binds to receptors in sebaceous gland

Increase sebaceous secetion.

Microbal colonization0 Organisms involved-Propionibacterium , Malassezia

furfur,Staph epidermidis

Bacteria thrive

Inflammation results

Chemotactic factors attract neutrophils

Depending on conditions

Non-inflammatory open/closed comedones

Inflammatory papule/pustule/nodule

EPIDEMIOLOGY

0PREVELANCE -affects all adolescents.0AGE- Onset-12-14 years.0GENDER- Both sexes equally but nodulocystic acne common in males.

FACTORS

1. GENETIC PREDISPOSITION Found to be familial Identical twins shows greater concordance of severity of acne.2) DIETHigh glycemic diet.3. COSMETICSSeen in women using oil based cosmetics for long time.Follows facial massage.4. MENSTRUAL CYCLEPremenstrual edema of pilosebaceous duct.5. PSYCHOLOGICAL FACTORS

MORPHOLOGY

0Polymorphic eruption consisting of papules, pustules, nodules, cysts, and pathognomic open and closed comedones on a background of oilness.

COMEDONES0Hyperkeratotic plug made of sebum and keratin in

follicular canal.0Pathognomic lesions of acne vulgaris.02 types:1. Open comedones.2. Closed comedones.

OPEN COMEDONES0Also known as Black head.0Due to plugging of pilosebaceous orifice by keratin

and sebum on the skin surface.

CLOSED COMEDONES

0Due to keratin and sebum accretions plugging the pilosebaceous ducts below the skin surface.

0SUBMARINE COMEDONES-deep seated and seen by stretching the skin.

Grades of Acne (Pillsburry’s classification)

Grade I: Comedones (open or closed), occasionally pustules or papules; no scarring.

Grade II: papules, comedones, few pustules; mild scarring.

Grade III: predominant pustules, nodules, abscesses;

moderate scarring.

Grade IV: mainly cysts, abscesses, scars; severe scarring.

SCARS

0Acne scars can be:Depressed scars1. Ice pick scars- deep pits.2. Box car scars-superficial/deep3. Rolling scarsHypertrophic and keloidal scars.

VARIANTS

ACNE CONGLOBATA0Severe form of acne characterised by

intercommunicating abscess, cysts, and sinuses loaded with serosanguinous fluid or pus.

0Multiporous comedones.0Lesions take months to heal and on healing leave

behind deep pitted or hypertrophic scars.

OCCUPATIONAL ACNE

0Caused by exposure to industrial chemicals (tar, chlorinated hydrocarbons) and cutting oils.

0Predominantly comedones

COSMETIC ACNE

0Seen in women using cosmetics(oil based ones)0Comedones0Frequently on the chin

DRUG INDUCED ACNE

0Steroids, androgens, oral contraceptives, antitubercular drugs, iodides, bromides and anticonvulsants.

0Lesions are monomorphic, consisting of papules and pustules

0Site- trunk especially back.

INFANTILE ACNE0Due to presence of maternal hormones in child.0Common in males.

LATE ONSET ACNE

0Onset after 25 years of age.0Predominantly women.0Deep seated persistent lesions on lower half of face.

ACNE EXCORIEE0Seen in young girls, who obsessively pick their mild

acne.0Results in discrete excoriations on face, while

comedones, and papules are few and far between.

ACNE FULMINANS0Acute onset.0Crusted ulcerated lesions.0Associated with fever, myalgia and arthralgia.

ACNE AFTER FACIAL MASSAGE

03-6 weeks later as acneiform eruption.0 Indolent deep seated nodules with vey few

comedones.0Predominantly on cheeks along the mandible.

DIFFERENTIAL DIAGNOSIS0Rosacea0Folliculitis0Acne scarring may be mistaken for acne keloidalis,

varioliform, atrophy and porphyria cutanea tarda

TREATMENT

0General measures0Topical therapy0Systemic therapy0Physical therapy

GENERAL MEASURES

1. Local hygiene Regular cleansing with soap and water and avoiding use of oil based cosmetics.2. Diet Avoid use of high glycemic diet.3. Stress

TOPICAL THERAPY

0RetinoidsMost frequently used agent in acne.Effective against comedones and inflammatory acne.Reduces formation of microcomedo.Side effects include irritation and photosensitivity.

0Benzoyl peroxide Powerful antimicrobial which decrease population of Propionibacterium acnes.Used in both inflammatory acne and non inflammatory acne.Side effects include irritation and bleaching of hair.

0Topical antibiotics Clindamycin(1-2%) and erythromycin(2-4%)Used in inflammatory acne since it suppress P.acnes.Side effect: antibiotic resistance. So should be combined with retinoids or benzoyl peroxide.

Systemic treatment

0AntibioticsMostly Doxycycline and minocycline; Erythromycin and azithromycin.Inhibit growth of P.acnes and has direct anti inflammatory effect.

ADVERSE EFFECTS

Doxycycline - onycholysis, oesophagitis with ulceration, fixed drug eruptions, photosensitivity etc.

Minocycline - benign intracranial hypertension, pappiloedema, blue-black pigmentation and rarely hypersensitivity reactions

Macrolide group - gastritis, diarrhoea.

HORMONES

0Act by decreasing sebum secretion rate.0Used only in females with late onset acne and

menstrual irregularities.

Adverse effects of hormonal therapy

Weight gainMenstrual irregularityOccasional fluid retentionMelasmaHypertensionThrombophlebitis Pulmonary embolism

ISORETINOIN

13-cis- retinoic acid (Vitamin A derivative )Mechanism of action:◦ Inhibiting sebum secretion.◦ Alters the composition of sebum◦ Lowers P.acnes concentration and has anti-

inflammatory activity

Indicated for :◦ Nodulocystic/ severe Acne◦ Pyoderma faciale◦ Excessive seborrhoea◦ Depression / Dysmorphophobia◦ Acne conglobata / other unusual variants◦ Scarring

Dose: 0.5 – 1 mg/ kg per day is given after meals. Cumulative dose: 120-150 mgs/kg

Side effects◦ Teratogenicity◦ Mucocutaneous side effects, dryness◦ Elevation of serum lipids◦ Neurological : pseudotumor cerebri Optic Neuritis, depression, mood swing◦ Arthritis, myalgia◦ Acne flares

PHYSICAL MODALITIES

0 Intralesional corticosteroids0Cryotherapy0Laser therapy0Photodynamic treatment0Dermabrasion0Fillers

Thank You…..