Acne Vulgaris

Acne vulgaris on a very oily skin[1]

Acne vulgaris a common skin disorder characterized by noninflammatory comedones, inflammatory papules, pustules, nodules and possibly scarring, usually seen in adolescents and young adults.

Presentation

Acne vulgaris presents the following signs and symptoms:

  • Acne vulgaris usually develops on the face in 90% of the cases. The acne occurs along with papules, comedones and pustules. 
  • Acne can get painful and may be tender to touch. The affected area becomes hot.
  • The skin of the affected area turns greasy with development of blackheads and whiteheads.
  • Acne vulgaris, regardless of severity especially in the face can impair patients psychologically in most cases [7].

Workup

Acne vulgaris is diagnosed using the grading scale system. Here, the lesions are compared with standard photographs for determining the grade of the condition.

Acne is categorized into 3 categories namely: mild, moderate and severe acne. Individuals with <20 comedones and< 15 inflammatory lesions are known to have developed mild acne. Those with 20 to 100 comedones and 15 to 50 inflammatory lesions are known to have developed moderate acne. Severe acne is described as having > 5 pseudocysts, total comedones greater than 100 and inflammatory lesions beyond 50.

Severe and persistent acne with a high rate of suspicion for a secondary gram negative bacterial infection may warrant culture and sensitivity tests [8].

Treatment

Treatment of acne vulgaris depends on extent of severity of the disease and age of the individual. Various medications exist for treating this skin disorder. These include oral medications and topical creams and ointments to be applied on the affected area.

Medications that include benzoyl peroxide, antibiotics, hormones, salicyclic acid and retinols are administered. Benzoyl peroxide usually forms the primary line of treatment which causes the skin to shed its layer of dead skin [9]. Oral antibiotics are given to treat infections, if they are the source of acne vulgaris development. Contraceptives are given if antibiotics do not work. These are method of choice when hormonal imbalance is the cause of acne breakouts.

In case of severe acne, retinoids are the treatment regime [10]. Such medications work by reducing the sebum production of the sebaceous glands of the skin.

Prognosis

The prognosis of the condition is generally good and with appropriate medications it should generally fade off within some years. However, in certain cases, the acne may continue to go on for several years together.

Complications

The following are the complications of acne:

  • Acne can cause permanent scarring which is a grave cause of depression and lowered self-esteem among the affected individuals.
  • It is can also cause social morbidity, anxiety and suicidal ideation.
  • Patients can suffer from post–inflammatory hyperpigmentation.
  • Treatment with medications such as erythromycin or tetracycline can cause long term effects such as development of gram negative folliculitis.

Etiology

Acne is a common complaint amongst the adolescents which points towards the fact that the onset of puberty is one of the major reasons for development of such a skin disorder. Other causes include:

  • Hormonal changes during the menstrual period which trigger the development of acne.
  • Heredity is yet another reason for acne vulgaris [2].
  • Cosmetic moisturizers which are oily in nature.
  • Overproduction of sebaceous glands of the skin increases the oil production giving rise to acne [3].
  • Certain medications such as steroids.
  • Diseases such as polycystic ovarian syndrome and Crushing’s syndrome.

Epidemiology

Acne vulgaris is a common disorder of the skin affecting about 80 to 90% of teenagers in the United States and in other Western nations [4]. The year 2010 witnessed a high incidence of acne vulgaris and it was in this year that this skin disease was ranked as the 8th most common disorder worldwide. It has also been estimated that about 650 million globally develop acne vulgaris.

Acne vulgaris is more common in males during adolescence but tends to be more frequent in women during adulthood [5]. In majority of the cases, acne tends to get better and then gradually disappear as one ages. However, in some individuals, the acne worsens and continues to haunt then till adulthood years.

Sex distribution
Age distribution

Pathophysiology

The skin contains oil producing glands known as sebaceous glands. These glands produce sebum (natural oil). Due to overproduction of sebum, the hair follicles in the skin get blocked with the oil and dead skin cells. As a result the oil and dead skin gets trapped in the hair follicles giving rise to a spot which is known as acne. In some cases, the normal microflora of the skin can also cause inflammation of the skin causing development of acne. It is not an infectious condition, and therefore does not spread by contact. Although the anaerobic bacterium known as Propionibacterium acnes has been found to activate the proinflammatory mediators at the follicular walls causing an inflammatory type of acne [6].

Prevention

Keeping skin clean and free from excess of oil can help to a great extent in preventing acne breakouts. The skin should be washed at least twice in a day with a mild, fragrance free soap. Individuals should remember not to use to harsh scrubs for removing dead skin.

Summary

Acne vulgaris, also commonly referred to as acne, is a skin disease characterized by development of scaly reddish skin along with pimples, papules and nodules. Acne vulgaris may present as an inflammatory lesion, non-inflammatory lesion, or combination of both occurring in the face, chest and back [1]. It is common among the teenage population.

Acne vulgaris in some cases takes a more severe turn when one reaches adulthood. In rare cases, even newborn babies develop acne during the first few weeks. The disorder causes scarring and leaves behind marks which can be a cause of depression and low self-esteem among the affected individuals.

Patient Information

Definition

Acne vulgaris is defined as the development of spot along with pimples, papules, nodules and comedones on the skin. It is a major condition affecting millions of teenagers across the globe. With advancing age, acne disappears but may leave behind permanent scars which are a great cause of depression, anxiety and low self esteem amongst individuals. 

Cause

Overproduction of sebaceous glands is one of the major reasons for development of acne vulgaris. In addition, certain types of medications may also trigger acne breakouts. Hormonal changes during menstruation are also a major cause for acne vulgaris.

Symptoms

Acne usually develops in conjugation with comedones, papules and pustules. The area is painful and tender to touch. Inflammation may also be noticed along with reddish scaly skin. Face is the most common area for development of acne.

Diagnosis

The acne is compared with the standard pictures and diagnosis is made accordingly. There are three grades of acne which are dependent on the number of comedones and inflammatory lesions.

Treatment

Treatment of acne vulgaris is directed towards treating the cause of the condition. In case of increased production of sebaceous glands, oral administration of medications containing retinoids is given that work by reducing the oil production. Oral antibiotics are given to reduce infection if they are the source of acne breakout. In addition to oral medications, topical ointments and creams are given to be applied on the affected area.

Self-assessment

References

  1. Dawson AL, Dellavalle RP. Acne vulgaris. BMJ. May 8 2013; 346:f2634. 
  2. Goulden V, McGeown CH, Cunliffe WJ. The familial risk of adult acne: a comparison between first-degree relatives of affected and unaffected individuals. Br J Dermatol. Aug 1999; 141(2):297-300.
  3. Thiboutot D, Gollnick H, Bettoli V, Dréno B, Kang S, Leyden JJ, 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. May 2009; 60(5 Suppl):S1-50.
  4. Collier CN, Harper JC, Cafardi JA, Cantrell WC, Wang W, Foster KW, et al. The prevalence of acne in adults 20 years and older. J Am Acad Dermatol. Jan 2008; 58(1):56-9.
  5. Shaw JC, White LE. Persistent acne in adult women. Arch Dermatol. Sep 2001; 137(9):1252-3. [
  6. Kim J, Ochoa MT, Krutzik SR, et al. Activation of toll-like receptor 2 in acne triggers inflammatory cytokine responses. J Immunol. Aug 1 2002; 169(3):1535-41.
  7. Kellett SC, Gawkrodger DJ. The psychological and emotional impact of acne and the effect of treatment with isotretinoin. Br J Dermatol. Feb 1999; 140(2):273-82.
  8. Strauss JS, Krowchuk DP, Leyden JJ, et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. Apr 2007; 56(4):651-63.
  9. Eichenfield LF, Krakowski AC, Piggott C, Del Rosso J, Baldwin H, Friedlander SF, et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics. May 2013; 131 Suppl 3:S163-86.
  10. Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, Leyden JJ, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. Jul 2003; 49(1 Suppl):S1-37.

  • Of Photodynamic Therapy with Topical 5‐Aminolevulinic Acid and Intense Pulsed Light versus Intense Pulsed Light Alone in the Treatment of Acne Vulgaris: - MAV Santos, VG Belo, G Santos - Dermatologic surgery, 2005 - Wiley Online Library
  • Of Photodynamic Therapy with Topical 5‐Aminolevulinic Acid and Intense Pulsed Light versus Intense Pulsed Light Alone in the Treatment of Acne Vulgaris: - MAV Santos, VG Belo, G Santos - Dermatologic surgery, 2005 - Wiley Online Library
  • A comparison of the efficacy and safety of adapalene gel 0.1% and tretinoin gel 0.025% in the treatment of acne vulgaris: a multicenter trial. - A Shalita, JS Weiss, DK Chalker, CN Ellis - Journal of the , 1996 - ukpmc.ac.uk
  • Acne vulgaris and the quality of life of adult dermatology patients - RJ Lasek, MM Chren - Archives of dermatology, 1998 - Am Med Assoc
  • A prospective survey of pediatric dermatology clinic patients in Kuwait: an analysis of 10,000 cases - A Nanda, F Al‐Hasawi, QA Alsaleh - Pediatric dermatology, 2002 - Wiley Online Library
  • Acne in zinc deficiency - MT Baer, JC King, T Tamura, S Margen - Archives of Dermatology, 1978 - Am Med Assoc
  • A comparison of the efficacy and safety of adapalene gel 0.1% and tretinoin gel 0.025% in the treatment of acne vulgaris: a multicenter trial. - A Shalita, JS Weiss, DK Chalker, CN Ellis - Journal of the , 1996 - ukpmc.ac.uk
  • Action of isotretinoin in acne rosacea and gram-negative folliculitis - G Plewig, J Nikolowski, HH Wolff - Journal of the American Academy of , 1982 - Elsevier
  • Blind, controlled trials of 2219 subjects to compare the combination clindamycin/tretinoin hydrogel with each agent alone and vehicle for the treatment of acne vulgaris - JJ Leyden, L Krochmal, A Yaroshinsky - Journal of the American Academy , 2006 - Elsevier
  • A pilot study of ICG laser therapy of acne vulgaris: photodynamic and photothermolysis treatment - VV Tuchin, EA Genina, AN Bashkatov - Lasers in surgery , 2003 - Wiley Online Library
  • Acne vulgaris - HC Williams, RP Dellavalle, S Garner - The Lancet, 2012 - Elsevier
  • Blind, controlled trials of 2219 subjects to compare the combination clindamycin/tretinoin hydrogel with each agent alone and vehicle for the treatment of acne vulgaris - JJ Leyden, L Krochmal, A Yaroshinsky - Journal of the American Academy , 2006 - Elsevier
  • Acne in infancy and acne genetics - MI Herane, I Ando - Dermatology, 2003 - content.karger.com

Media References

  1. Acne vulgaris on a very oily skin, CC BY-SA 4.0

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