Related Subjects:
|Nikolsky's sign
|Koebner phenomenon
|Erythema Multiforme
|Pyoderma gangrenosum
|Erythema Nodosum
|Dermatitis Herpetiformis
|Lichen Planus
|Acanthosis Nigricans
|Acne Rosacea
|Acne Vulgaris
|Alopecia
|Vitiligo
|Urticaria
|Basal Cell Carcinoma
|Malignant Melanoma
|Squamous Cell Carcinoma
|Mycosis Fungoides (Sezary Syndrome)
|Xeroderma pigmentosum
|Bullous Pemphigoid
|Pemphigus Vulgaris
|Seborrheic Dermatitis
|Pityriasis/Tinea versicolor infections
|Pityriasis rosea
|Scabies
|Dermatomyositis
|Toxic Epidermal Necrolysis
|Stevens-Johnson Syndrome
|Atopic Eczema/Atopic Dermatitis
|Psoriasis
Commonly begins during early puberty with increased activity
throughout the teens with spontaneous resolution thereafter
About
- Inflammation of the pilosebaceous unit of the skin
- Affecting mainly adolescents and may cause scarring
Aetiology
- Multifactorial but possibly a genetic component
- Males > Females in adolescence but reverse in adulthood
- Hormonal, inflammation, skin lipid composition and sebum production
- Overgrowth of Propionobacterium acnes
- Hyperproliferation of epithelial cells with obstructed ducts
- Pathology shows distension of pilosebaceous unit with neutrophils
Old myths
- It is caused by dirt or poor personal hygiene
- It is due to a poor diet
Causes/Exacerbating factors
- Congenital adrenal hyperplasia, Polycystic ovary syndrome
- Cushing's syndrome, high androgen levels
- Drugs - steroids, lithium, some antiepileptics
- Any cause of androgen excess
Clinical
- Primary lesion = microcomedo (clinically unrecognizable = microscopic
plugging of pilosebaceous unit)
- Open Comedones - "white heads" without surrounding inflammation
- Closed Comedones - "black heads" - due to oxidation of melanin pigment
- Papules, pustules and nodules and even cysts
- Can extend to torso, neck, chest and shoulders
- Can worsen with menstruation
Severity
- Mild: open and closed comedones with or without sparse inflammatory lesions
- Moderate acne: multiple widespread non-inflammatory lesions with many papules and pustules
- Severe acne: extensive inflammatory lesions, which may include nodules, pitting, and scarring
Investigations
- Very rarely needed except with unusual or very severe presentation
- FSH, LH, Prolactin, Sex hormone-binding globulin, Testosterone levels, 17(OH) progesterone
- Abdominal CT if adrenal tumour suspected
Differential
- Folliculitis, Acne rosacea, Adenoma sebaceum
Management
- Topical for mild to moderate disease
- Patients have often tried over the counter remedies - usually contain benzoyl peroxide, salicylic acid
- Topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid)
- Intralesional steroids for severe lesions
- Systemic therapies for moderate to severe disease
- Oral antibiotics: e.g. a tetracyclines: lymecycline, oxytetracycline, doxycycline. Avoid if pregnant or breastfeeding women or those under 12 years of age. Erythromycin may be used in pregnancy. Should be used for 3 months. Combine with topical Vitamin A derivatives (retinoids) to avoid antibiotic resistance or benzoyl peroxide. There is a risk of Gram-negative folliculitis as a complication of long-term antibiotic use - high-dose oral trimethoprim is effective if this occurs
- Some females may benefit from the oral contraceptive pill or cyproterone acetate. combined oral contraceptives (COCP) are an alternative to oral antibiotics in women as with antibiotics, they should be used in combination with topical agents
- Oral Vitamin A derivatives such as Isotretinoin ( Roaccutane) are severely teratogenic and is usually prescribed by specialists. Absolutely contraindicated in pregnancy and effective contraception is obligatory for fertile females. Patients must be counselled and formally consented. There have been suggestions of increased suicide risk in adolescents.
- Other treatments include dermabrasion, chemical peels, photodynamic therapy and laser treatments
- Address psychological issues. The prognosis is that it is usually self-limiting but may leave some scarring or hyperpigmentation or hypopigmentation in severe cases
Images online