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acne

Etiology: 1) inflammation of the pilosebaceous unit 2) factors influencing incidence & severity of acne a) genetic factors, cosmetics, microflora, endocrine status, immune status - women may have premenopausal flares [2] b) occupational: oils, greases, chlorinated hydrocarbons 3) pharmacologic causes: a) anabolic steroids & androgens c) glucocorticoids f) progesterone b) bromides d) iodides e) lithium f) phenytoin g) thiouracil h) isoniazid Epidemiology: 1) extremely common among teenagers & remains a problem until the fifth decade of life 2) keratinization is influenced by genetic factors, thus acne tends to run in families Pathology: 1) altered keratinization of epithelial cells in the hair follicle infundibulum 2) the resulting plug along with free fatty acids released with infection by Propionibacterium acnes, results in inflammation 3) the initial lesion is a comedone Clinical manifestations: 1) comedones (non-inflammatory) a) open comedones are blackheads b) closed comedones are whiteheads 2) papules, pustules, papulopustular, nodules (inflammatory) 3) cystic lesions a) true cysts do not occur with acne b) cystic lesion represent advanced lesions with foreign material & inflammatory cells in the dermis c) sinus tracts may connect deep cystic lesions [2] 4) distribution: face, neck, upper torso 5) women may have premenstrual flare ups [2] * images [12] Laboratory: - serum dehydroepiandrosterone sulfate - may be useful in assessing a systemic basis Differential diagnosis: 1) primary skin disorders a) Staphylococcal pyoderma &/or folliculitis - papules, pustules, occasional furuncles on hair-associated skin - scalp, buttocks & thigh common - common in athletes b) gram-negative folliculitis - results from prolonged systemic antibiotics for acne - presents as exacerbation of pre-exisiting acne - acute pustular eruption on areas other than face, upper trunk - cultures often positive for E coli c) rosacea: > 18 years, erythematous lesions of the central face d) sebaceous hyperplasia e) drug-induced acneiform eruption - glucocorticoid associated [2] - occurs after topical glucocorticoid use - eruption lacks comedones f) pustular contact dermatitis g) skin neoplasm - appendageal & adnexal tumors - basal cell carcinoma - epidermal cysts - fibrofolliculoma - trichodiscoma h) osteoma cutis i) periorificial dermatitis 2) systemic disorders a) Cushing's disease b) 21-hydroxylase deficiency c) polycystic ovary disease (hyperandrogenism) - severe, cyclical, unresponsive to therapy [2] d) cryptococcosis e) Behcet's disease Management: 1) general a) establish realistic expectations b) most treatments require 8-12 weeks for improvement [2] c) avoid adverse effects, antibiotic resistance 2) topical therapy a) benzoyl peroxide most cost effective treatment [4,5,7] - 2.5%, 4%, 5%, 10% - bactericidal & keratolytic - many preparations are drying to skin b) topical salicylic acid [2] c) topical azelaic acid [2] d) topical retinoid [2] - agents - 13-cis retinoic acid (Accutane) - all-trans retinoic acid (Retin-A) - tazarotene (pregnancy category X) - adapalene - comedolytic - 1st line agent for mild to severe acne & post-inflammatory hyperpigmentation [2] - topical retinoids have acne preventive effects [2] - may be standard of care for acne treatment [2] - consider other topical agents during pregnancy - all topical retinoids & oral isotretinoin contraindicated during pregnancy [2] e) erythromycin topical - 1.5-3% - may be used in combination with benzoyl peroxide (Benzamycin) f) clindamycin topical - up to 1% - rarely associated with pseudomembranous colitis - may be used in combination with benzoyl peroxide (Benzaclin) g) tetracycline less effective than erythromycin h) combination therapy (adapalene/clindamycin ...) - topical retinoid + topical antibiotic 1st line [2] i) dapsone (Aczone) not recommended [7] j) topical acne agents may be associated with rare, but serious hypersensitivity reactions [10] k) do not use topical antibiotics as monotherapy for acne [2] - combine with topical benzoyl peroxide [2] l) topical metronidazole indicated for rosacea, but not acne [16] 3) oral agents a) effective in management of moderate to severe acne - acne not responding to appropriate topical treatment [18] - acne involving large surface area rendering topical treatment impractical b) limit oral antibiotic therapy to 3-6 months [15]; 3 months (ACP) [2] - tetracycline 500 mg - 2 g QD divided BID - erythromycin 1 g QD divided BID - doxycycline 100 mg BID - minocycline 50 - 100 mg BID c) isotretinoin is the most effective treatment [20] - treatment of recalcitrant nodular acne [2] - 0.5-1.0 mg/kg/day for 16-20 weeks - mandatory risk management program (iPLEDGE) for women of child-bearing age [2] - at least 2 forms of birth control - prolonged remissions 1-3 years in 40% of patients [2] d) hormonal therapy (women) - prednisone 5 mg QD (suppresses adrenal androgens) - spironolactone 150-200 mg BID (androgen antagonist) - may be useful for women with flares during menstrual cycle when topical agents have failed [2,17] - excellent choice for adult female acne (pregnancy category C) [16] - oral contraceptives - ethinyl estradiol/norethindrone acetate - ethinyl estradiol/norgestimate - estrogens suppress adrenal androgens - avoid progesterone - 1st line in women with androgen excess [2] - requires average of 5 cycles for 50% improvement 4) triple therapy with topical retinoid, topical antibiotic & benzoyl peroxide - second most effective treatment after oral isotretinoin [20] - topical metronidazole indicated for rosacea, but not acne [16] 5) intralesional injection of triamcinolone acetonide 2.5 mg/mL a) reduces size & inflammation of large lesions b) skin atrophy is side effect 6) investigational - topical silymarin with nonablative laser therapy may reduce inflammation & postinflammatory hyperpigmentation [19] 7) treating acne using vitamins & minerals [21] (video)

Related

acneiform eruption chloracne

General

sebaceous gland disease sign/symptom chronic skin disease (chronic dermatologic disorder, chronic dermatopathy, chronic dermatosis)

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 932
  2. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2022 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 294 - Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
  4. Journal Watch 25(4):32, 2005 Ozolins M, Eady EA, Avery AJ, Cunliffe WJ, Po AL, O'Neill C, Simpson NB, Walters CE, Carnegie E, Lewis JB, Dada J, Haynes M, Williams K, Williams HC. Comparison of five antimicrobial regimens for treatment of mild to moderate inflammatory facial acne vulgaris in the community: randomised controlled trial. Lancet. 2004 Dec 18;364(9452):2188-95. PMID: 15610805
  5. Prescriber's Letter 12(3): 2005 Comparison of Antimicrobial Treatments for Mild to Moderate Acne Detail-Document#: 210310 (subscription needed) http://www.prescribersletter.com
  6. Strauss JS, Krowchuk DP, Leyden JJ, Lucky AW, Shalita AR, Siegfried EC, Thiboutot DM, Van Voorhees AS, Beutner KA, Sieck CK, Bhushan R; American Academy of Dermatology/American Academy of Dermatology Association. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. 2007 Apr;56(4):651-63. Epub 2007 Feb 5. Review. PMID: 17276540 http://www.aad.org/NR/rdonlyres/8D4D2DDB-7176-4202-808E-28D67334B3E4/0/AcneVulgaris.pdf
  7. Prescriber's Letter 16(1): 2009 COMMENTARY: New Drug: Aczone (Dapsone) Gel 5% GUIDELINES: Acne Vulgaris Management GUIDELINES: Recommendations for Acne Management Detail-Document#: 250112 (subscription needed) http://www.prescribersletter.com
  8. Thiboutot DM. Overview of acne and its treatment. Cutis. 2008 Jan;81(1 Suppl):3-7. PMID: 18338651
  9. Lolis MS, Bowe WP, Shalita AR. Acne and systemic disease. Med Clin North Am. 2009 Nov;93(6):1161-81 PMID: 19932324
  10. FDA MedWatch. June 25, 2014 Over-The-Counter Topical Acne Products: Drug Safety Communication - Rare But Serious Hypersensitivity Reactions. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm402722.htm
  11. Acne (image) American Academy of Dermatology https://www.aad.org/public/diseases/acne-and-rosacea/acne
  12. DermNet NZ. Acne (images) http://www.dermnetnz.org/acne/acne.html
  13. Thiboutot D, Gollnick H, Bettoli V et al New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne group. J Am Acad Dermatol. 2009 May;60(5 Suppl):S1-50 PMID: 19376456
  14. Zaenglein AL et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016 Feb 15 PMID: 26897386 Free Article
  15. Barbieri JS et al. Duration of oral tetracycline-class antibiotic therapy and use of topical retinoids for the treatment of acne among general practitioners (GP): A retrospective cohort study. J Am Acad Dermatol 2016 Dec; 75:1142. PMID: 27502311 - Zaenglein AL et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016 May; 74:945. PMID: 26897386 Free Article
  16. Zaenglein AL Clinical Practice: Acne Vulgaris N Engl J Med 2018; 379:1343-1352. Oct 4, 2018 PMID: 30281982 https://www.nejm.org/doi/full/10.1056/NEJMcp1702493
  17. Santer M et al. Effectiveness of spironolactone for women with acne vulgaris (SAFA) in England and Wales: Pragmatic, multicentre, phase 3, double blind, randomised controlled trial. BMJ 2023 May 16; 381:e074349. PMID: 37192767 Free article https://www.bmj.com/content/381/bmj-2022-074349
  18. NEJM Knowledge+ Dermatology
  19. Brunk D Topical Antioxidants With Nonablative Laser May Prevent Acne Scars, Study Results Suggest. Medscape. April 27, 2023
  20. Huang CY, Chang IJ, Bolick N, et al. Comparative Efficacy of Pharmacological Treatments for Acne Vulgaris: A Network Meta-Analysis of 221 Randomized Controlled Trials. Ann Fam Med. 2023 Jul-Aug;21(4):358-369. PMID: 37487721 PMCID: PMC10365865 Free PMC article https://www.annfammed.org/content/21/4/358.long
  21. Barbieri J Treating Acne Using Vitamins and Minerals VuMedi. 2024. Jan 18 https://www.vumedi.com/video/treating-acne-using-vitamins-and-minerals/ - Lim SK, Ha JM, Lee YH, Lee Y, Seo YJ, Kim CD, Lee JH, Im M. Comparison of Vitamin D Levels in Patients with and without Acne: A Case-Control Study Combined with a Randomized Controlled Trial. PLoS One. 2016 Aug 25;11(8):e0161162. PMID: 27560161 PMCID: PMC4999291 Free PMC article. Clinical Trial.
  22. National Institute of Arthritis and Muscluloskeletal and Skin Diseases (NIAMS) Acne https://www.niams.nih.gov/health-topics/acne