Acne Vulgaris
Basics
Acne is an inflammatory condition of the skin. This is the most common skin conditions a health care professional will encounter. Acne usually begins to occur in females around the age of 14-16 years and in males around the age 16-20 years old. Acne also begins to clear around the ages of 40 in females and in the mid 20s in males. Acne is generally considered as a hormone mediated inflammation of the sebaceous glands and hair follicles.
Acne is caused by several factors:
- Increased sebum secretion.
- Follicular hyperkeratinization – Normally, the cells in the hair follicule will detach and desquamate at a certain interval. However, in follicular hyperkeratinization, the cells lining the inside of the hair follicle adhere to one another and they are not shed onto the surface of the skin. The cohesion of cells blocks the hair follicle or sebaceous/oil ducts. The end result is the formation of a microcomedone. Retinoids, assist with the normalization of follicular keratinization and hence prevent the formation of microcomedones.
- Colonization by a bacteria called Cutibacterium acnes (formerly called Propionibacterium acnes).
- There is also an associated inflammatory response.
Classification
- Non-Inflammatory
- Comedones – Non-inflamed lesions
- Closed Comedones – These are the whiteheads that are caused by the distension of the pilosebaceous ducts.
- Open Comedones – These are the blackheads that are caused by the hyperkeratinization of the duct. Remember the “black” is due to melanin and not due to dirt.
- Comedones – Non-inflamed lesions
- Inflammatory
- Papules
- Pustules
- Nodules
- Cysts
Grading
Acne is graded as mild, moderate, and severe depending on the criteria that the health care professional uses. Acne with predominant comedones is referred to as being mild, while those with predominantly inflammatory lesions are referred to as being more moderate-severe acne.
- Mild Acne: Predominantly non-inflammatory comedones
- Moderate Acne: Mixture of non-inflammatory comedones and inflammatory papules and pustules.
Severe Acne: There is the presence of nodules, cysts as well as papules and pustules.
Management
The management of acne aims to reverse the etiological factors. For instance, acne occurs due to increased sebum production resulting in increased “oiliness”. This means that our first aim would be to decrease the amount of oil secreted onto the skin. Secondly, we want to normalize follicular keratinization and open the pore. Thirdly, we want to use agents that can act against the bacteria, and finally, we need to decrease the ongoing inflammation.
| Mild | Moderate | Severe | Maintenance | |
|---|---|---|---|---|
| Retinoid | Topical Retinoid | Topical Retinoid | Isotretinoin | Topical Retinoids |
| Antimicrobial | Benzoyl peroxide/topical antibiotics | Benzoyl peroxide/topical antibiotics | Benzoyl peroxide/topical antibiotics | Benzoyl peroxide/topical antibiotics |
| Antimicrobial | Oral antibiotic | Oral antibiotic | ||
| Hormonal treatment | Hormonal Treatment | Hormonal Treatment |
General
- Educate the patient to not squeeze any of the lesions.
Medical
- Topical Retinoids:
- This is a very important agent in the treatment of Acne. As stated previously, it normalizes the process of keratinization and helps opens the pores. This means that it is very useful in the management of comedones. Retinoids make the skin more sensitive the UV rays. The sunlight also decreases the efficacy of the retinoid. For this reason, the patient should be advised to apply the retinoid at night.
- Prescription: Tretinoin topical is applied at night to the affected areas for at least 6 weeks.
- Precautions: Do not use it if the patient is pregnant or planning a pregnancy. Limit the exposure to sunlight. If sunburn occurs then discontinue the agent until the skin recovers. The acne may worsen in the first few weeks.
- This is a very important agent in the treatment of Acne. As stated previously, it normalizes the process of keratinization and helps opens the pores. This means that it is very useful in the management of comedones. Retinoids make the skin more sensitive the UV rays. The sunlight also decreases the efficacy of the retinoid. For this reason, the patient should be advised to apply the retinoid at night.
- Isotretinoin (roaccutane, acnetane)
- This is indicated when there is moderate or severe acne but the treatment is not working, there is severe scarring, there is resistance to oral antibiotics, chronic relapsing acne. These patients should be initiated by a dermatologist. Patients should be done a lipid profile and LFTs as well as a pregnancy test.
- Side effects: Teratogenic, photosensitivity, conjunctivitis, muscle pains
- Benzoyl Peroxide:
- This agent is very effective at treating acne. It has three modes of action as it is sebostatic, and comedolytic (releases free radicals that break down keratin), and is also able to inhibit the growth of C. acnes. Some side effects include skin irritation, erythema, and burning.
- Prescription: Benzoyl peroxide 5% gel applied in the morning to affected areas as tolerated. Wash off in the evenings. If the prescription is ineffective and the patient can tolerate it, one may increase the frequency to be applied 12 hourly.
- Precautions: Avoid contact with the mucous membranes, eyes, mouth, and angle of the nose.
- Topical antimicrobials:
- These are good alternatives to benzoyl peroxide. For instance, you may want to prescribe Clindamycin or Erythromycin topical antibiotics. For instance, one can prescribe Erythromycin (solution) to be applied in a small quantity to the affected area(s) 12 hourly.
- Oral Antibiotics:
- First line: Doxycycline 100mg daily (EML) PO for a duration of 3 months. Taken with meals.
Hormonal Therapy
- Indications:
- The patient is not responsive to conventional treatment
- In females – There is evidence that the patient has clinical features suggestive of an excess amount of androgens (hirsutism, seborrhea, menstrual abnormalities, obesity)
- Options:
- Contraceptive pills such as Diane 35, Minerva, Yaz, and Tasmin. However, in order to prescribe these agents one should exclude any contraindications.
- On the EML, it is advised to prescribe Cyproterone acetate 2mg plus Ethinyl estradiol 35mcg PO OD (Combined Oral Contraceptive Pill).
- Should be discussed with the dermatologist.
Differentials
- Folliculitis
- Pseudofolliculitis barbae
Complications
- Scaring, Keloids
- Deformity
- Post Inflammatory Hyperpigmentation
2. Notes: Dr. Noluvuyo Qikani-Mamane's (Walter Sisulu University) notes on Acne Vulgaris (2020).
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