Our first topic is going to be one of the
most common dermatologic presentations
that we find in United States.
Many of us have gone through
this, especially during puberty.
Our topic, obviously,
being acne vulgaris.
Now, the acne vulgaris here that you’re
seeing could be of different types.
You could have pustules,
you could have vesicles.
So, in terms of description, it
could be all over the place.
And notably, as I said, we
talked about pathogenesis.
We’ll be focusing upon
the puberty years.
Demographics: 80% of people seek
medical care for acne in life.
Take a look at this pie; 80% with
acne vulgaris with demographics.
It’s the most common found in
teens and early adulthood.
So, you’re thinking about
those pubertal ages.
Let’s take a look at etiology.
Here, as soon as you hear
about acne vulgaris,
it’s a fact that you’re thinking
about your androgens playing a role.
Hence, andrenarche increases
Think about your patient, a teenager,
perhaps, going through puberty.
And so therefore, at this point, there is
going to be increased levels of hormones,
especially our androgens.
So, during andrenarche,
increases sebum production.
Next, what happens?
Well, then you had
What’s a comedone?
A comedone is basically the type of
lesion that you expect to see with acne.
Now, you’ve heard of
blackhead and white head.
And if it’s a blackhead, this would
then mean that the comedone,
so think about the lesion that occurs
and think of this kind of
being like a volcano, please,
and that would be the
best description here.
And if you’ve heard of blackhead,
that basically means that here,
the volcano has erupted, in other
words, the comedone is now exposed.
So, the overlying skin or the
cover has been now removed.
Once it’s removed, the inner
contents of your comedone
then gets exposed to the environment
resulting in oxidation.
This oxidation then causes what’s
known as blackish discoloration,
and you call this a blackhead.
Whereas a whitehead, as you can imagine,
the skin then is intact over the comedone.
And if it is intact,
then please understand what then
appears upon gross examination
is going to be a whitehead.
So, comedone forms due to accumulation of
lipid and keratin in the follicular unit,
So, think about where you are,
maybe perhaps on your face,
and you have a follicular unit,
which is now undergoing this type of
accumulation of lipid and keratin.
An important point here would be bacteria
known as propionibacterium acnes.
The particular bacteria that you
want to make sure that you memorize
overgrow in abundance
of such “oil”.
And by oil, what are
you referring to?
That sebum and lipid accumulation
within your comedone.
The bacteria convert the
sebum into fatty acids
that elicited an
And as soon as you think
about inflammatory response,
then you know that you have your WBC such
as neutrophils that are going to come in.
All part of your etiology
pathogenesis acne vulgaris.
Let’s talk about the morphology.
If you have an open comedone,
what does that mean to you?
Remember, you have that lesion
that you’re looking for.
And instead of it being
covered, it is now open.
So therefore, the overlying skin or
epidermis is not intact,
Once this type of
exposure is taking place,
the inner content of your particular
lesion is now at risk for oxidation.
Now, what is it going to do?
It will oxidize your keratin
plug, and therefore,
the coloration that it then gives
or provides is a blackhead.
Whereas, if the epidermis over
the comedone remains intact.
So now you have a papule
without the oxidation
because now you don’t
have such exposure.
And therefore, upon gross
examination, it appears being white.
Now, you could have acne vulgaris
in which, unfortunately,
it might get a
little bit bigger.
And so therefore, now you’re
thinking about a nodule.
And this will then arise from the follicle,
rupture, and may then cause an
inflammatory type of dermis.
You’re getting the dermis
involved with nodules.
Then you have a more serious
type of acne vulgaris.
You can call it nodulocystic lesion.
And this can then yield
a systemic symptom,
most often seen with teenager
boys or teenagers that are males.
Here, you want to memorize
So here, what you want
to do is try to then
make your particular “infection,”
if you want to call it as such.
Remember, bacteria could also be involved.
And so therefore, you try to keep
things as sterile as possible.
Antiseptics, it prevents the comedones,
and perhaps, decreases bacterial count.
Also, it depends on
Most commonly, doxycycline,
may cause photosensitivity.
Keep that in mind.
Or minocycline that may
cause a drug-induced lupus.
Keep that in mind for this
type of tetracyclines.
All tetracyclines can cause a
condition or an adverse effect
known as pseudotumor cerebri.
Remember, this is a patient that is
then going to present with headaches,
and there would be measurement of
increased intracranial pressure.
Upon fundoscopic examination,
there would be papilledema.
On imaging study, there would be
nothing because this is a pseudotumor.
We talked about this earlier.
Continue our discussion
Here, we have our
vitamin A derivatives.
In other words, retinoids, and we
have tretinoin as being a drug.
Prevents a comedone and may
decrease the inflammation.
Oral retinoid, known
reserved for severe
nodulocystic scarring acne.
Remember now, you’re
talking about a nodule
that has also taken on a
cystic type of appearance
and could also have
Remember those young teenage
boys we were talking about
most commonly may be seen with.
Now, with that, you need
to make sure that you have
minimal type of
scarring taking place.
Something that you want to keep
in mind with side effects.
It is, as you know with the
retinoids, a huge teratogen.
Here also, as your tetracycline,
pseudotumor cerebri could be
a possible side effect, SE.
accumulation of lipid.
Now, keep all this in mind
when dealing with retinoids.
And with tetracycline,
the common denominator between the
two drugs is an adverse effect,
As a differential diagnosis now,
what we will do as we go through
dermatology is rule things
in or rule things out.
So at this point, our topic
is still acne vulgaris.
Many of your skin conditions would be --
well, they might look quite similar, huh?
And so therefore, what kind of things you
want to know about as clinical pearls
so that you can either rule
things in or rule things out?
Our topic here would be differential
diagnosis of acne vulgaris.
A differential diagnosis.
Our topic here is acne rosacea.
I emphasized rosacea,
not acne vulgaris
but acne rosacea.
Well, how do you know if a patient
has a rosacea versus vulgaris?
Usually, with the rosacea, adult
of Northern European heritage,
maybe perhaps, Scandinavian.
You’re going to look for a patient
that has particular triggers
such as stress, spice,
so on and so forth.
Then, there is going to be
erythema, and specifically,
the flushing that you’re
going to find on the face,
and hence, the differential
There is going to be a background erythema,
which is redness, but that’s nonspecific.
But then you have telangiectasia.
We’ll talk more about
rosacea, and when we do,
we’ll talk about something
And basically, you have a
bulbous nose with rosacea
and could also be
associated with alcoholism.
Not always, huh? Not always.
And comedone is not a
feature of rosacea.
Our topic, differential
diagnoses of acne vulgaris.
Here are some clinical pearls so that you
know that you’re dealing with rosacea
These would occur in specific areas
and may follow topical steroid use.
Here, we have monophormic
in its appearance,
and inflammatory papules
Once again, comedone would be more
as high in your differential,
either blackhead or whitehead as being
acne vulgaris in that teenage population,
and you’re looking for andrenarche
type of issues, right?
Here, comedone is not present
with your dermatitis
of periocular or
perioral type of lesion.
A differential diagnosis for
vulgaris would also be folliculitis.
Allow the name to speak to you.
So, we’re talking about the
follicular unit, right?
And with the follicular unit, you know that
there is hair that is being also expressed.
So therefore now, the follicle or the
follicular unit is undergoing infection,
the hair follicle.
And related, in many
could you have follicle
involvement with acne vulgaris?
Sure, you could.
But with folliculitis,
specifically, is an infection,
predominantly, on the
trunk and extremities.
So, it doesn’t have to be on
the face with folliculitis.
Occurs at any age, any age.
May progress to what’s known as
furuncles, carbuncles, and abscesses.
Topics that we’ll take
a look at in due time.
But at this point, please know that
folliculitis, if not properly addressed,
may go on to develop
or perhaps even, abscesses
of that entire region.