Acne Vulgaris

Acne Vulgaris

Acne Vulgaris, also called as common acne is  a common inflammatory pilosebaceous disease characterized by comedones, papules, pustules, inflamed nodules and cysts, with occasional scarring.
Acne vulgaris is commonly seen in face, neck, upper chest and back, which has more severe progression in males than females.

 

Pathogenesis
Androgens stimulate increased sebum production. Sebum is comedogenic, an irritant, and is converted to free fatty acids by microbial lipases made by anaerobic diphtheroid called Propionibacterium acne.
Free fatty acids along with bacteria causes inflammation and delayed
hypersensitivity reaction causing hyperkeratinization of follicle lining with resultant plugging.

 

Exacerbating factors

  • Menstruation
  • Oral contraceptive pill (OCP) (low estrogen formulations)
    corticosteroids
  • Lithium, Iodides, Bromides
  • Comedogenic topical agents – some cosmetics, sunscreens, moisturizers, greases, tars

Treatment based on severity of Acne Vulgaris

4 types of severity of Acne Vulgaris

  • Type I – Comedonal. Few lesions. No scarring
  • Type II – Papular. Moderate number of lesions. Little scarring
  • Type III – Pustular. Lesions > 25. Moderate scarring
  • Type IV – Nodulocystic. Severe scarring

 

Treatment

  • Type I – Non-inflammatory : 
    • Benzoyl Peroxide (2.5%, 5%, 10%) – bactericidal
    • Adapalene gel/cream
      • not irritating, no interaction with sun
      • expensive
    • +/– Tretinoin (Retin-A)
      • comedolytic more sun-sensitive
      • start with 0.01% and increase to 0.025% after one month
  • Type I – Inflammatory :
    • Benzoyl Peroxide
    • Tretinoin/ Adapalene gel/cream
    • Topical Antibiotic (clindamycin, erythromycin)
      • bacteriostatic and anti-inflammatory
  • Type II :
    • Topical Antibiotic
    • Benzoyl Peroxide
    • Tretinoin/ Adapalene gel/cream
  • Type III –
    • Topical Antibiotic
    • Benzoyl Peroxide
    • Tretinoin
    • Oral Antibiotic (tetracycline, minocycline, erythromycin)
  • Type IV –
    • Isotretinoin (Accutane)
      • 0.5 to 1.0 mg/kg/day for 3-4 months
      • baseline CBC, pregnancy tests, LFT, TG, and cholesterol prior to start of therapy
      • repeat tests at 2/6/10/14 weeks
        • Side effects : Teratogenic, skin and mucous membrane dryness, hyperlipidemia, reversible alopecia, abnormal LFT

Other treatments

  • cryotherapy (for cysts)
  • Intralesional steroids (for cysts)
  • Dermabrasion
    Spironolactone – antiandrogen
  • Diane-35 OCP (cyproterone acetate + ethinyl estradiol)
  • high-estrogen OCP

Differential Diagnosis

  • Rosacea
  • Folliculitis
  • Perioral dermatitis
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