There are many disorders of the sebaceous glands. Acne is the most relevant condition in the field of dermatology that is tested in medical examinations. Acne vulgaris is also considered one of the most common skin diseases. The clinical picture of these conditions as well their treatment is covered in this article. 
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Schema zeigt die Bildung von Akne

Image: “Acne formation” by OpenStax College. License: CC BY 3.0


Overview of Sebaceous Glands

Haarwurzel mit Talgdrüse oil gland

Image: “Hair root with sebaceous gland (oil gland)” by Don Bliss. License: Public Domain

Sebaceous glands (Lat. glandula sebacea) can be found almost in areas of the body. Rich in sebaceous glands are the head, face, back and also the upper body. The produced tallow, also referred to as sebum, consists of triglycerides, fatty acids and wax esters. The production is stimulated by androgen hormones.

Nevus Sebaceous Glands (Nevus Sebaceous)

The nevus sebaceous gland is also called organoid nevus and consists of sebaceous glands, ectopic glands and malformed hair follicle residues. Nevus sebaceous occurs at an early age but is usually inherited.

Clinic of nevus sebaceous

Naevus Sebaceus am Scheitel

Image: “Nevus sebaceous on the scalp” by Phrontis. License: CC BY-SA 3.0

It presents as a flat, white-yellowish, waxy tumor without hair and most frequently occurs in the hair area where, it may develop alopecia. Sebaceous glands nevus occurs mostly solitary on the face and neck.

In old age, the nevus may evolve into a benign or malignant adnexal tumor. The most common one is trichoblastoma.

The therapy of nevus sebaceous

In dermatology cryotherapy is a proven treatment method. Here, low temperatures are usually used locally, to destroy pathological tissue.

Excision of a nevus sebaceous can be performed for cosmetic reasons or even to avoid complications such as the development of tumors.

Sebostasis

Sebostasis means a reduction in sebaceous glands activity. The result is dry skin (xerosis cutis) and brittle hair.

The etiology of sebostasis

Sebostasis is age-related and has an occurrence of about 80 % in older people. Mechanical or chemical degreasing such as frequent washing or very dry hair can also cause sebostasis.

Clinic of sebostasis

The clinical symptoms show a scaly, rough skin and the patient often suffers from itching and an unpleasant tightness of the skin.

The dry skin often leads to barrier disorder. Therefore, secondary inflammation and super infection by bacteria may result. Consequently, the skin cracks and forms an eczema craquele, also named drying eczema or asteatotic eczema.

Typical symptoms of sebostasis are Brittle and scrubby hair.

Treatment of sebostasis

Consistent anti-sebostatic cleaning serving as prophylactic treatment is recommended. It is necessary to maintain the skin regularly with fatty externa, special fatty acids and urea.

The patient should shower, if possible, only briefly under warm, but not hot water. Alcoholic lotions must be avoided, as they cause the skin to dry out.

Seborrhea

Seborrhoische Dermatitis bei einem Mann

Image: “Seborrhoeic dermatitis” by Roymishali. License: CC BY-SA 3.0

Seborrhea means, “tallow flow” and refers to a strongly increased sebum production, which leads to oily skin and greasy lankly hair. Seborrhea is often a predisposition for acne, rosacea and seborrhoeic eczema.

Etiology of Seborrhea

In 80 % of cases seborrhea occurs at adolescence. This suggests that hormonal changes play a decisive role. Responsible for sebum production, is an increase of androgen production and a higher density of androgen receptors. Thus, hormonal medicines, such as anabolic steroids or contraceptives, can affect sebaceous glands.

Systemic diseases such as Parkinson’s, acromegaly or polycystic ovarian syndrome can go hand in hand with Seborrhea.

Clinical presentation of seborrhea

A greasy shine of the face, scalp and hair are the consequence of increased sebum production. Partially large pores are visible.

An increase in lipid secretion favors the conditions for Propionibacterium acnes and yeast fungi (e.g. Malassezia furfur) to propagate.

Treatment of Seborrhea

A prophylactic anti-seborrheic skin care is recommended. For cleaning and care, disinfectants (e.g. benzoyl peroxide) and soap-free synthetic detergents, as well as low-fat externa (lotions and gels) can be used.

Topical and systemic retinoids work anti-inflammatory and against abnormal keratinization. In severe cases of acne the use of oral retinoids, such as Isoretinoid, are proven to be highly effective.

Note: Retinoids are teratogenic and contraindicated in pregnancy. Women can use a systemic anti-androgens against Seborrhea. Topical application of estradiol for men can lead to systemic side effects.

Acne vulgaris

Acne vulgaris is a common chronic inflammatory disease of the sebaceous glands. Acne presents itself, depending on the shape and characteristics, with comedones, pustules or papules. Particularly affected are the areas rich in sebaceous glands such as the face, scalp, as well as back and chest. Frequently, acne vulgaris occurs over the age of 12.

Akne auf der Stirn eines Teenagers

Image: “puberal acne in a young boy” License: Public Domain

Note: 65 % of young people suffer from acne!

The etiology of acne vulgaris

In most cases acne vulgaris appears with the beginning of puberty. By the end of the third life decade, the skin disease usually ends by itself. Boys and girls are affected to the same extent. Typical for girls is deterioration before and during menstruation.

Note: For young people, the disease can be, psychologically, very stressful. Acne often leads to a feeling of distortion. The typical comedones (“blackheads”) are the result of a faulty tallow drain in the closure of the follicle excretory ducts.

Androgens enlarge sebaceous glands and increase their activity. This may, as already described above, lead to Seborrhea.

The increase of sebum production and thus, an increase in bacteria such as Propionibacterium acnes, results in a bacterial super infection. The bacteria split the fat into free fatty acids, which induce the secretion of pro-inflammatory mediators and release an inflammatory response.

Nicotine abuse leads to a phospholipase-induced inflammation.

Clinical presentation of acne vulgaris

The clinical picture of acne vulgaris shows in particular comedones, papules, and pustules and in severe forms of acne, scars formation.

Acne vulgaris can be divided into 3 stages

  1. Non-flammable stage

    Grafik zeigt normale und verstopfte Poren

    Image: “Acne” by BruceBlaus. License: CC BY-SA 3.0

Here we find acne comedonica, which appears centrofacial and is characterized by open (black head) and closed (white head) comedones.

  1. Flammable stage

The clinical picture of acne papulopustulosa includes pustules and papules. Often affected is the face, back and upper torso. Acne nodosa forms up to 1 cm large knots that decline very slowly. The next stage is either acne conglobata or a transition to the defect stage. Acne conglobata is the most severe form of inflammatory acne and appears as deep, inflammatory nodes in the face, chest and back. This form is especially common in young men.

  1. Defect stage

Acne comedonica and papulopustulosa heal usually without scarring. Typical in the defect stage, are scars, cysts and abscessed fistula gears.

Treatment of acne vulgaris

To prevent exacerbation of chronic acne and scar formation a stage-related treatment of acne vulgaris is necessary. The following forms of therapy are to be considered:

  • Topical therapy: is applied in cases of papulopustulosa or acne comedonica, Benzoyl peroxide (BPO) 5 – 10 % can be used as a washing suspension to clean the skin.

Effective are topical retinoids, such as adapalene and Isotretinoin. However, retinoids work well with teratogenics. Therefore, special clarification for women within childbearing age has to take place. Oral contraception – one month before the treatment and up to one month after treatment – plus additional contraceptive methods (condoms) are necessary. Clindamycin or in combination with benzoyl peroxide, as well as topical antibiotics, can be used.

  • Systemic therapy: is used against pustulosa or acne conglobata. Considered as systemic treatment methods are tetracyclines, hormones (contraceptives with anti-androgenic effect) and retinoids.
  • Peelings etc.: e.g. peelings with fruit acids can have supportive effects. Also treatment with dermabrasion or hyaluronic acid injection can reduce acne scars.

Special forms of acne

  • Acne neonatorum: is already present at birth or occurs in the first weeks of life. The sebaceous glands are stimulated by maternal androgens.
  • Acne infantum: is typical in the 3rd – 6th Month of life by testosterone influence
  • Acne exocrine: is a surface ulceration caused by constant manipulation and excoriation mild acne papulopustulosa
  • Acne tarda: acne, which occurs after puberty through androgen effects. Hormonal disorders must be excluded
  • Acne venenata: might develop through contact with tar, oils, halogens (chlorine) or cosmetics

Acne aestivalis (Mallorca acne): arise in warm, humid climate in combination with application of oily sun creams

Rosacea

Rosazea im Gesicht

Image: “Rosacea. Erythema and telangiectasia are seen over the cheeks, nasolabial area and nose. ” License: CC BY 2.0

Rosacea is a chronic inflammatory, non-infectious disease of the sebaceous glands and connective tissues. It has a relapsing course in the central facial area. In contrast to acne – rosacea forms no comedones.

Etiology of rosacea

So far the etiology of this disease is largely unexplained. But there are certain factors known which seem to deteriorate rosacea. UV exposure, hot drinks, alcohol and spicy food, as well as hormonal influences or temperature changes can affect the disease activity.

Clinical presentation of rosacea

  • Stage I: Typical for rosacea is a flat redness on the face – the flush. In addition, there are telangiectasia and persistent erythema present.
  • Stage II: facial pustules and papules, partially exceed the forehead-hair line
  • Stage III: The Rhinophym is a tuberous hypertrophy of sebaceous glands in the nose.

Diagnosis of rosacea

For the diagnosis of rosacea, knowing the typical clinical picture is crucial. Ophthalmorosacea occurs in up to 50 % of cases and should therefore be excluded.

Treatment of rosacea

Particularly relevant for the treatment of rosacea is the avoidance of aggravating factors.

Stage I is treated with 0.75 % Metronidazole-containing externa. Stage II combines the therapy of the first stage with a systemic antibiosis (doxycycline) or retinoids (low dose) over the course of several weeks. Rhinophym can be treated using operational or laser surgical resection.

Perioral dermatitis

Perioral dermatitis is an inflammatory skin disease. It appears in perioral and periocular regions due to excessive skin care. This dermatosis mostly affects young women.

Etiology of Perioral dermatitis

Periorale dermatitis

Image: “Perioral dermatitis in a child who had a habit of licking their lips” by James Heilman, MD. License: CC BY-SA 4.0

The etiology of this disease is still unclear. Factors that can trigger perioral dermatitis are excessive cosmetic care, the use of external corticosteroids, fluorinated toothpastes, soaps as well, being exposed to stress situations and hormonal disturbances.

The result of excessive care could lead to swelling of the horny layer. This disrupts the skin barrier and creates room for super infections. This effect is often reinforced by topical glucocorticoids.

Clinical presentation of perioral dermatitis

Small bound follicular papules and pustules appear around the mouth and eyes. Burning and the feeling of skin tension are also typical symptoms.

Perioral dermatitis therapy

The treatment of Perioral dermatitis is “zero-therapy“. This means that the patient should avoid all external causes of the condition. Initially, it usually comes to a deteriorated condition in the first two weeks. For patients with the habit of using cosmetics, zero therapy is often very difficult to achieve. The patient should be informed on probable deterioration.

Popular Exam Questions

The correct answers can be found beneath the references.

1. Which form of acne occurs in hot climates in combination with the use of oily sun creams?

  1. Acne vulgaris
  2. Acne nodosum
  3. Acne papulopustulosa
  4. Acne tarde
  5. Acne aestivalis

2. Which clinical manifestation determines the second Stage of rosacea?

  1. Flush
  2. Telangiectasia
  3. Pustules
  4. Rhinophym
  5. Comedones

What is the recommended treatment for perioral dermatitis?

  1. Topical glucocorticoids
  2. Prophylactic anti-seborrheic skin care and cleaning
  3. Zero therapy
  4. 0.75 % Metronidazole-containing externa
  5. Systemic antibiosis
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