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Acne Vulgaris

Acne Vulgaris

Acne vulgaris, also known as acne, is a common disorder of the pilosebaceous units Pilosebaceous Units Hidradenitis Suppurativa in adolescents and young adults. The condition occurs due to follicular hyperkeratinization, excess sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis production, follicular colonization Colonization Bacteriology by Cutibacterium acnes, and inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation. Acne can present as open or closed comedones, papules, pustules, nodules, or cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change. The diagnosis is based on clinical exam. Management depends on the severity, but includes skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions care techniques, topical therapies, antibiotics, and retinoids Retinoids Retinol and derivatives of retinol that play an essential role in metabolic functioning of the retina, the growth of and differentiation of epithelial tissue, the growth of bone, reproduction, and the immune response. Dietary vitamin A is derived from a variety of carotenoids found in plants. It is enriched in the liver, egg yolks, and the fat component of dairy products. Fat-soluble Vitamins and their Deficiencies.

Last updated: 29 Nov, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Contents

Overview

Epidemiology

  • The most common skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions disease in the United States
  • Affects approximately 80% of people at some point in life:
    • Frequently occurs in preadolescence, but can develop in adulthood
    • Often resolves by the 4th decade, but can persist in some patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
    • 20% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship will develop severe acne and scarring Scarring Inflammation.
  • Demographics:
    • Boys are more commonly affected in adolescence.
    • Women are more likely to be affected as adults.
    • People of Asian and African descent more frequently suffer from severe acne.
    • Caucasians Caucasians Esophageal Cancer more often have mild acne.

Etiology

  • Genetic predisposition (heritability: 50%–90%)
  • Cutibacterium acnes (formerly known as Propionibacterium Propionibacterium A genus of gram-positive, rod-shaped bacteria whose cells occur singly, in pairs or short chains, in V or y configurations, or in clumps resembling letters of the chinese alphabet. Its organisms are found in cheese and dairy products as well as on human skin and can occasionally cause soft tissue infections. Dog and Cat Bites acnes)
  • Aggravating factors:
    • Hormonal variation:
      • During puberty Puberty Puberty is a complex series of physical, psychosocial, and cognitive transitions usually experienced by adolescents (11-19 years of age). Puberty is marked by a growth in stature and the development of secondary sexual characteristics, achievement of fertility, and changes in most body systems. Puberty or menstrual cycle Cycle The type of signal that ends the inspiratory phase delivered by the ventilator Invasive Mechanical Ventilation
      • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
      • Congenital Congenital Chorioretinitis adrenal hyperplasia Hyperplasia An increase in the number of cells in a tissue or organ without tumor formation. It differs from hypertrophy, which is an increase in bulk without an increase in the number of cells. Cellular Adaptation
      • Polycystic ovarian syndrome Polycystic ovarian syndrome Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder of reproductive-age women, affecting nearly 5%-10% of women in the age group. It is characterized by hyperandrogenism, chronic anovulation leading to oligomenorrhea (or amenorrhea), and metabolic dysfunction. Polycystic Ovarian Syndrome
    • Mechanical occlusion:
      • Underwire bras
      • Headbands
      • Shoulder pads
    • Cosmetics
    • Stress
    • Medications:
      • Lithium Lithium An element in the alkali metals family. It has the atomic symbol li, atomic number 3, and atomic weight [6. 938; 6. 997]. Salts of lithium are used in treating bipolar disorder. Ebstein’s Anomaly
      • Steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors
      • Anticonvulsants
    • Diet:
      • Dairy (due to hormonal components in milk)
      • High glycemic index foods

Pathophysiology

Acne vulgaris is a disorder of the pilosebaceous unit (which includes the hair follicle Hair follicle A tube-like invagination of the epidermis from which the hair shaft develops and into which sebaceous glands open. The hair follicle is lined by a cellular inner and outer root sheath of epidermal origin and is invested with a fibrous sheath derived from the dermis. Follicles of very long hairs extend into the subcutaneous layer of tissue under the skin. Cowden Syndrome and sebaceous gland Sebaceous Gland Small, sacculated organs found within the dermis. Each gland has a single duct that emerges from a cluster of oval alveoli. Each alveolus consists of a transparent basement membrane enclosing epithelial cells. The ducts from most sebaceous glands open into a hair follicle, but some open on the general surface of the skin. Sebaceous glands secrete sebum. Hordeolum (Stye)) and is characterized by 4 pathogenic factors:

  • Follicular hyperkeratinization: corneocyte cohesiveness → hyperkeratotic plugging in the upper follicle, causing retention of sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis and leading to a microcomedo
  • Excessive sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis production:
    • Androgens Androgens Androgens are naturally occurring steroid hormones responsible for development and maintenance of the male sex characteristics, including penile, scrotal, and clitoral growth, development of sexual hair, deepening of the voice, and musculoskeletal growth. Androgens and Antiandrogens ↑ sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis production
    • Sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis accumulates with keratin Keratin A class of fibrous proteins or scleroproteins that represents the principal constituent of epidermis; hair; nails; horny tissues, and the organic matrix of tooth enamel. Two major conformational groups have been characterized, alpha-keratin, whose peptide backbone forms a coiled-coil alpha helical structure consisting of type I keratin and a type II keratin, and beta-keratin, whose backbone forms a zigzag or pleated sheet structure. Alpha-keratins have been classified into at least 20 subtypes. In addition multiple isoforms of subtypes have been found which may be due to gene duplication. Seborrheic Keratosis → comedo formation
  • Colonization Colonization Bacteriology of follicles by C. acnes:
    • Sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis acts as a nutrient and growth medium for C. acnes.
    • C. acnes produce enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body’s constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes that degrade keratin Keratin A class of fibrous proteins or scleroproteins that represents the principal constituent of epidermis; hair; nails; horny tissues, and the organic matrix of tooth enamel. Two major conformational groups have been characterized, alpha-keratin, whose peptide backbone forms a coiled-coil alpha helical structure consisting of type I keratin and a type II keratin, and beta-keratin, whose backbone forms a zigzag or pleated sheet structure. Alpha-keratins have been classified into at least 20 subtypes. In addition multiple isoforms of subtypes have been found which may be due to gene duplication. Seborrheic Keratosis and stimulate inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation.
  • Inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation:
    • C. acnes trigger Trigger The type of signal that initiates the inspiratory phase by the ventilator Invasive Mechanical Ventilation an innate immune response Innate Immune Response Immunity to pathogens is divided into innate and adaptive immune responses. The innate immune response is the 1st line of defense against a variety of pathogens, including bacteria, fungi, viruses, and parasites. In essentially the same form, the innate type of immunity is present in all multicellular organisms. Innate Immunity: Barriers, Complement, and Cytokines → proinflammatory cytokine release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology → activation of neutrophils Neutrophils Granular leukocytes having a nucleus with three to five lobes connected by slender threads of chromatin, and cytoplasm containing fine inconspicuous granules and stainable by neutral dyes. Innate Immunity: Phagocytes and Antigen Presentation → mild perifollicular inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation → inflammatory papule Papule Elevated lesion < 1 cm in diameter Generalized and Localized Rashes or pustule Pustule Blister filled with pus Generalized and Localized Rashes development
    • Neutrophils Neutrophils Granular leukocytes having a nucleus with three to five lobes connected by slender threads of chromatin, and cytoplasm containing fine inconspicuous granules and stainable by neutral dyes. Innate Immunity: Phagocytes and Antigen Presentation and C. acnes release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body’s constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes → follicular rupture into the dermis Dermis A layer of vascularized connective tissue underneath the epidermis. The surface of the dermis contains innervated papillae. Embedded in or beneath the dermis are sweat glands; hair follicles; and sebaceous glands. Skin: Structure and Functions → a more marked and deeper inflammatory response → inflammatory nodule Nodule Chalazion (also called a cyst) development
Acne vulgaris pathogenesis illustrated

Pathogenesis of acne vulgaris:
Image depicting the pathogenic factors leading to comedo, pustule Pustule Blister filled with pus Generalized and Localized Rashes, and nodule Nodule Chalazion development. Plugging of the follicle by corneocytes results in sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis accumulation. C. acnes colonization Colonization Bacteriology triggers Triggers Hereditary Angioedema (C1 Esterase Inhibitor Deficiency) an inflammatory response, which may lead to follicular rupture.

Image by Lecturio.

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Acne Vulgaris

Clinical Presentation

Classification and presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor of acne lesions

Noninflammatory acne (comedones):

  • Hyperkeratotic plug composed of corneocytes in the lower portion of the follicular infundibulum Infundibulum Uterus, Cervix, and Fallopian Tubes: Anatomy
  • Open comedones:
    • Commonly called “blackheads”
    • Dilation and plugging at the follicular orifice on the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions surface
    • Contains brown or black keratotic material (due to oxidization of fatty acids Fatty acids Organic, monobasic acids derived from hydrocarbons by the equivalent of oxidation of a methyl group to an alcohol, aldehyde, and then acid. Fatty acids are saturated and unsaturated. Fatty Acids and Lipids)
    • < 5 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma
  • Closed comedones:
    • Frequently called “whiteheads”
    • Plugging occurs at the follicular orifice below the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions surface.
    • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions-colored, white, or gray papules
    • Smooth
    • < 5 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma
    • Precursor lesion to inflammatory acne
  • Open comedones or blackheads

    Open comedones on the nose Nose The nose is the human body’s primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Nose and Nasal Cavity: Anatomy

    Image: “Blackheads” by Elecbullet. License: Public Domain
  • Closed comedones

    Closed comedones at the nasolabial folds

    Image: “Comedos Nose Nose The nose is the human body’s primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Nose and Nasal Cavity: Anatomy 01” by M. Sand, D. Sand, C. Thrandorf, V. Paech, P. Altmeyer, F. G. Bechara. License: CC BY 2.0

Inflammatory acne:

  • Papulopustular acne:
    • < 5 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma
    • Superficial papules or pustules
    • Inflamed
  • Nodular acne:
    • Tender
    • Inflamed
    • Much deeper
  • Acne vulgaris with typical lesions

    Acne vulgaris with typical lesions, such as comedones, papules, and pustules on the face

    Image: “Clinical characteristics and epidermal barrier function of papulopustular rosacea Papulopustular Rosacea Rosacea: A comparison study with acne vulgaris” by Pakistan Journal of Medical Sciences. License: CC BY 3.0
  • Severe acne vulgaris

    Severe acne vulgaris:
    A cutaneous papular outbreak over the neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess and lower jaw Jaw The jaw is made up of the mandible, which comprises the lower jaw, and the maxilla, which comprises the upper jaw. The mandible articulates with the temporal bone via the temporomandibular joint (TMJ). The 4 muscles of mastication produce the movements of the TMJ to ensure the efficient chewing of food. Jaw and Temporomandibular Joint: Anatomy, with a coalescence of numerous inflamed papules

    Image: “20482” by Glen Lambert. License: Public Domain

Common locations

  • Face
  • Neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess
  • Upper chest
  • Back
  • Shoulders

Sequelae

  • Postinflammatory hyperpigmentation Hyperpigmentation Excessive pigmentation of the skin, usually as a result of increased epidermal or dermal melanin pigmentation, hypermelanosis. Hyperpigmentation can be localized or generalized. The condition may arise from exposure to light, chemicals or other substances, or from a primary metabolic imbalance. Malassezia Fungi:
    • Results at the site of an active or resolving lesion
    • Increased risk in those with darker skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions pigmentation
    • Can persist for months
    • Resolves spontaneously
  • Scarring Scarring Inflammation:
    • More likely to occur with inflammatory acne
    • Types:
      • Atrophic (“ice pick” or “boxcar” scars)
      • Hypertrophic
      • Keloids
Atrophic acne scarring

Atrophic acne scarring Scarring Inflammation in a patient with severe acne vulgaris

Image: “Novel Technology in the Treatment of Acne Scars: The Matrix-tunable Radiofrequency Technology” by Ramesh M, Gopal M, Kumar S, Talwar A. License: CC BY 2.0

Severe variants

The following variants are rare forms of acne that more often affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment adolescent boys and men.

  • Acne fulminans:
    • Large, inflammatory, painful nodules
    • Friable plaques with:
    • Commonly occurs on the trunk
    • Can be associated with systemic signs and symptoms:
      • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
      • Malaise Malaise Tick-borne Encephalitis Virus
      • Arthralgias
      • Splenomegaly Splenomegaly Splenomegaly is pathologic enlargement of the spleen that is attributable to numerous causes, including infections, hemoglobinopathies, infiltrative processes, and outflow obstruction of the portal vein. Splenomegaly
      • Erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion nodosum
  • Acne conglobata:
    • Aggregates of blackheads may be seen.
    • Nodules coalesce to form sinus tracts (large, fluctuant Fluctuant Dermatologic Examination, linear lesions).
    • May drain foul-smelling discharge
    • Tender
    • Large, irregular scars form.
    • Increases in severity over time
    • Common locations:
      • Back
      • Chest
      • Buttocks
  • Acne fulminans

    Large, hemorrhagic ulcerations on the face of a patient with acne fulminans

    Image: “Successful Treatment of Facial Acne Fulminans: Antimicrobial Agents and Oral Prednisolone Prednisolone A glucocorticoid with the general properties of the corticosteroids. It is the drug of choice for all conditions in which routine systemic corticosteroid therapy is indicated, except adrenal deficiency states. Immunosuppressants as Promising Regimes” by Case Reports in Dermatological Medicine. License: CC BY 4.0
  • Acne conglobata

    Acne conglobata:
    A rare form of acne vulgaris that causes extensive scarring Scarring Inflammation, and a coalescence of developing inflammatory cutaneous nodules.

    Image: “19117” by Richard S. Hibbets. License: Public Domain

Diagnosis and Management

Diagnosis

The diagnosis is clinical and based on the physical examination. No laboratory or skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma is required.

Patient counseling

  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions care:
    • Use gentle skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions cleansers.
    • Use non-comedogenic cosmetics and skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions care products.
    • Avoid picking at lesions or aggressively scrubbing skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions.
  • Patient education:
    • Acne vulgaris is a long-term condition.
    • Improvement is often slow and requires consistency Consistency Dermatologic Examination with the treatment regimen.
    • Response to treatment regimens vary.

Medical therapy for mild disease

These treatments are indicated for all patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with inflammatory disease in order to prevent sequelae and complications.

  • Topical retinoids Retinoids Retinol and derivatives of retinol that play an essential role in metabolic functioning of the retina, the growth of and differentiation of epithelial tissue, the growth of bone, reproduction, and the immune response. Dietary vitamin A is derived from a variety of carotenoids found in plants. It is enriched in the liver, egg yolks, and the fat component of dairy products. Fat-soluble Vitamins and their Deficiencies:
    • Normalizes follicular hyperproliferation and minimizes inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
    • Also helps with postinflammatory hyperpigmentation Hyperpigmentation Excessive pigmentation of the skin, usually as a result of increased epidermal or dermal melanin pigmentation, hypermelanosis. Hyperpigmentation can be localized or generalized. The condition may arise from exposure to light, chemicals or other substances, or from a primary metabolic imbalance. Malassezia Fungi
    • Options:
      • Tretinoin
      • Adapalene
      • Tazarotene
  • Topical benzoyl peroxide Benzoyl peroxide A peroxide derivative that has been used topically for burns and as a dermatologic agent in the treatment of acne and poison ivy dermatitis. It is used also as a bleach in the food industry. Molluscum Contagiosum:
    • Has antibacterial Antibacterial Penicillins properties
    • Should not be used simultaneously with topical retinoids Retinoids Retinol and derivatives of retinol that play an essential role in metabolic functioning of the retina, the growth of and differentiation of epithelial tissue, the growth of bone, reproduction, and the immune response. Dietary vitamin A is derived from a variety of carotenoids found in plants. It is enriched in the liver, egg yolks, and the fat component of dairy products. Fat-soluble Vitamins and their Deficiencies
  • Topical antibiotics:
    • Not used as monotherapy due to antibiotic resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing
    • Options:
      • Clindamycin Clindamycin An antibacterial agent that is a semisynthetic analog of lincomycin. Lincosamides
      • Minocycline Minocycline A tetracycline analog, having a 7-dimethylamino and lacking the 5 methyl and hydroxyl groups, which is effective against tetracycline-resistant staphylococcus infections. Tetracyclines
      • Erythromycin Erythromycin A bacteriostatic antibiotic macrolide produced by streptomyces erythreus. Erythromycin a is considered its major active component. In sensitive organisms, it inhibits protein synthesis by binding to 50s ribosomal subunits. This binding process inhibits peptidyl transferase activity and interferes with translocation of amino acids during translation and assembly of proteins. Macrolides and Ketolides
  • Salicylic acid:
    • May be used as an alternative to topical retinoids Retinoids Retinol and derivatives of retinol that play an essential role in metabolic functioning of the retina, the growth of and differentiation of epithelial tissue, the growth of bone, reproduction, and the immune response. Dietary vitamin A is derived from a variety of carotenoids found in plants. It is enriched in the liver, egg yolks, and the fat component of dairy products. Fat-soluble Vitamins and their Deficiencies
    • Targets follicular hyperproliferation and abnormal desquamation Desquamation Staphylococcal Scalded Skin Syndrome (SSSS)
  • Azelaic acid:
    • May also be used as an alternative to topical retinoids Retinoids Retinol and derivatives of retinol that play an essential role in metabolic functioning of the retina, the growth of and differentiation of epithelial tissue, the growth of bone, reproduction, and the immune response. Dietary vitamin A is derived from a variety of carotenoids found in plants. It is enriched in the liver, egg yolks, and the fat component of dairy products. Fat-soluble Vitamins and their Deficiencies
    • Comedolytic and anti-inflammatory, and has antibacterial Antibacterial Penicillins properties
    • Also helps with postinflammatory hyperpigmentation Hyperpigmentation Excessive pigmentation of the skin, usually as a result of increased epidermal or dermal melanin pigmentation, hypermelanosis. Hyperpigmentation can be localized or generalized. The condition may arise from exposure to light, chemicals or other substances, or from a primary metabolic imbalance. Malassezia Fungi

Medical therapy for moderate and severe disease

In addition to the above measures, the following may be added:

  • Oral contraceptives and/or spironolactone Spironolactone A potassium sparing diuretic that acts by antagonism of aldosterone in the distal renal tubules. It is used mainly in the treatment of refractory edema in patients with congestive heart failure, nephrotic syndrome, or hepatic cirrhosis. Its effects on the endocrine system are utilized in the treatments of hirsutism and acne but they can lead to adverse effects. Potassium-sparing Diuretics:
    • Used in women
    • Reduces androgen effects in order to minimize sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis production
  • Oral antibiotics:
    • Used if a patient is not a candidate for other systemic therapies
    • Options:
      • Tetracyclines Tetracyclines Tetracyclines are a class of broad-spectrum antibiotics indicated for a wide variety of bacterial infections. These medications bind the 30S ribosomal subunit to inhibit protein synthesis of bacteria. Tetracyclines cover gram-positive and gram-negative organisms, as well as atypical bacteria such as chlamydia, mycoplasma, spirochetes, and even protozoa. Tetracyclines (preferred)
      • Cephalosporins Cephalosporins Cephalosporins are a group of bactericidal beta-lactam antibiotics (similar to penicillins) that exert their effects by preventing bacteria from producing their cell walls, ultimately leading to cell death. Cephalosporins are categorized by generation and all drug names begin with “cef-” or “ceph-.” Cephalosporins
      • Macrolides Macrolides Macrolides and ketolides are antibiotics that inhibit bacterial protein synthesis by binding to the 50S ribosomal subunit and blocking transpeptidation. These antibiotics have a broad spectrum of antimicrobial activity but are best known for their coverage of atypical microorganisms. Macrolides and Ketolides
      • Penicillins Penicillins Beta-lactam antibiotics contain a beta-lactam ring as a part of their chemical structure. Drugs in this class include penicillin G and V, penicillinase-sensitive and penicillinase-resistant penicillins, cephalosporins, carbapenems, and aztreonam. Penicillins
      • Trimethoprim Trimethoprim The sulfonamides are a class of antimicrobial drugs inhibiting folic acid synthesize in pathogens. The prototypical drug in the class is sulfamethoxazole. Although not technically sulfonamides, trimethoprim, dapsone, and pyrimethamine are also important antimicrobial agents inhibiting folic acid synthesis. The agents are often combined with sulfonamides, resulting in a synergistic effect. Sulfonamides and Trimethoprim-sulfamethizole (TMP-SMX)
  • Isotretinoin:
    • Targets all 4 pathogenic factors
    • Indicated for severe or resistant acne (including acne fulminans and acne conglobata)
    • Requires close monitoring due to the risk of: 
    • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship must use 2 forms of contraception while on therapy and for 1 month post-therapy.

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Acne Vulgaris
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Complications and Prognosis

Complications

  • Psychosocial impacts due to the appearance of the affected skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions:
    • Low self-esteem
    • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder and depression
  • Folliculitis: 
    • May develop with prolonged use of topical antibiotics
    • Often results from gram-negative organisms
  • Morbihan disease: 
    • Rare
    • Soft tissue Soft Tissue Soft Tissue Abscess edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema and erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion of the face
  • Acne fulminans can occur from isotretinoin use (despite also being a treatment for the condition).

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

  • Acne vulgaris is a long-term condition.
  • Most cases will eventually clear spontaneously.
  • In some patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, acne may persist throughout adulthood.
  • Overall, the prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas is good with treatment.

Differential Diagnosis

  • Rosacea Rosacea Rosacea is a chronic inflammatory disease of the skin that is associated with capillary hyperreactivity. This condition is predominantly seen in middle-aged women, and is more common in fair-skinned patients. Rosacea: a chronic inflammatory disease of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions associated with capillary hyperreactivity Capillary Hyperreactivity Rosacea, usually seen in middle-aged women. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with facial erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion, telangiectases, papules, pustules, and phymatous changes. The absence of comedones distinguishes rosacea Rosacea Rosacea is a chronic inflammatory disease of the skin that is associated with capillary hyperreactivity. This condition is predominantly seen in middle-aged women, and is more common in fair-skinned patients. Rosacea from acne vulgaris. The diagnosis is clinical, and management involves avoiding triggers Triggers Hereditary Angioedema (C1 Esterase Inhibitor Deficiency), gentle skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions care, topical and/or oral antibiotics, and laser or surgical therapies.
  • Folliculitis: a common skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions condition characterized by inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of hair follicles due to an infectious Infectious Febrile Infant agent (most commonly Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. Staphylococcus aureus). Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with pruritis, follicular pustules, and erythematous papules. There are no comedones. The diagnosis is clinical. Management is generally supportive, but may involve topical or oral antibiotics for severe cases.
  • Hidradenitis suppurativa Hidradenitis suppurativa Hidradenitis suppurativa (HS) is a chronic skin condition due to the inflammation of apocrine sweat glands and hair follicles. Most commonly, it occurs due to occlusion of the follicular component of pilosebaceous units (PSUs). Hidradenitis Suppurativa: a chronic inflammatory condition of the hair follicle Hair follicle A tube-like invagination of the epidermis from which the hair shaft develops and into which sebaceous glands open. The hair follicle is lined by a cellular inner and outer root sheath of epidermal origin and is invested with a fibrous sheath derived from the dermis. Follicles of very long hairs extend into the subcutaneous layer of tissue under the skin. Cowden Syndrome and associated structures. The condtion leads to follicular occlusion and rupture which, in turn, causes abscesses, sinus tracts, and scarring Scarring Inflammation, which commonly occur in axillary, groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination, and inframammary regions. The diagnosis is clinical. Management is based on the severity, and can include topical or oral antibiotics, intralesional corticosteroids Corticosteroids Chorioretinitis, oral retinoids Retinoids Retinol and derivatives of retinol that play an essential role in metabolic functioning of the retina, the growth of and differentiation of epithelial tissue, the growth of bone, reproduction, and the immune response. Dietary vitamin A is derived from a variety of carotenoids found in plants. It is enriched in the liver, egg yolks, and the fat component of dairy products. Fat-soluble Vitamins and their Deficiencies, debridement Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Stevens-Johnson Syndrome or surgical excision, and immunosuppressive medications.
  • Keratosis pilaris Keratosis Pilaris Ichthyosis Vulgaris: a common condition that causes small, pointed, follicular papules on the extensor surfaces of the upper arms or thighs secondary to keratinization. Erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion may be present. The diagnosis is clinical. Management is unnecessary, but salicylic acid and retinoids Retinoids Retinol and derivatives of retinol that play an essential role in metabolic functioning of the retina, the growth of and differentiation of epithelial tissue, the growth of bone, reproduction, and the immune response. Dietary vitamin A is derived from a variety of carotenoids found in plants. It is enriched in the liver, egg yolks, and the fat component of dairy products. Fat-soluble Vitamins and their Deficiencies may be used.
  • Periorificial dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema): a condition that causes an erythematous, papulopustular eruption that starts at the nasolabial folds and spreads periorally. Comedones are not present. The diagnosis is clinical. Management involves avoiding causative agents (such as steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors or fluoride Fluoride Inorganic salts of hydrofluoric acid, hf, in which the fluorine atom is in the -1 oxidation state. Sodium and stannous salts are commonly used in dentifrices. Trace Elements) and topical or oral antibiotics.
  • Sebaceous hyperplasia Hyperplasia An increase in the number of cells in a tissue or organ without tumor formation. It differs from hypertrophy, which is an increase in bulk without an increase in the number of cells. Cellular Adaptation: a common condition caused by enlargement of sebaceous glands. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with a history of “oily skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions” may develop umbilicated, skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions-colored, or yellowish papules, frequently involving the forehead Forehead The part of the face above the eyes. Melasma, nose Nose The nose is the human body’s primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Nose and Nasal Cavity: Anatomy, and cheeks Cheeks The part of the face that is below the eye and to the side of the nose and mouth. Melasma. The diagnosis is clinical, although biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma may be performed to rule out basal cell Basal Cell Erythema Multiforme carcinoma (due to its similar appearance). Management is not necessary, but dermabrasion Dermabrasion The mechanical planing of the skin with sandpaper, emery paper, or wire brushes, to promote reepithelialization and smoothing of skin disfigured by acne scars or dermal nevi. Actinic Keratosis, laser therapy Laser Therapy The use of photothermal effects of lasers to coagulate, incise, vaporize, resect, dissect, or resurface tissue. Glaucoma, isotretinoin, or surgical removal may be done for cosmetic reasons.

References

  1. Thiboutot, D., Zaenglein, A. (2019). Pathogenesis, clinical manifestations, and diagnosis of acne vulgaris. In Ofori, A.O. (Ed.). UpToDate. Retrieved February 23, 2021, from https://www.uptodate.com/contents/pathogenesis-clinical-manifestations-and-diagnosis-of-acne-vulgaris
  2. Graber, E. (2021). Acne vulgaris: Overview of management. In Ofori, A.O. (Ed.). UpToDate. Retrieved February 23, 2021, from https://www.uptodate.com/contents/acne-vulgaris-overview-of-management 
  3. Keri, J.E. (2020). Acne vulgaris. MSD Manual Professional Version. Retrieved March 2, 2021, from https://www.merckmanuals.com/professional/dermatologic-disorders/acne-and-related-disorders/acne-vulgaris
  4. Rao, J., and Chen, J. (2020). Acne vulgaris. In James, W.D. (Ed.). Medscape. Retrieved March 2, 2021, from https://emedicine.medscape.com/article/1069804-overview
  5. Sutaria, A.H., Masood, S., and Schlessinger, J. (2020). Acne vulgaris. StatPearls. Retrieved March 2, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK459173/
  6. Zito, P.M., and Badri, T. (2020). Acne fulminans. StatPearls. Retrieved March 2, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK459326/
  7. Hafis, W., and Badri, T. (2020). Acne conglobata. StatPearls. Retrieved March 2, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK459219/
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