Question

    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].

    Entire body system
    Noncompliance
    • The first, and essentially universal, side effect of isotretinoin is cheilitis and its absence is often considered a marker of noncompliance or insufficient dosage.[intechopen.com]
  • more...
  • Face, Head & Neck
    Facial Scar
    • Facial scarring due to acne affects up to 20% of teenagers.[ncbi.nlm.nih.gov]
    • Permanent facial scars or pitting of the skin.[nmihi.com]
    • Prognosis Gradual improvement over time (usually within 8 to 12 weeks after beginning therapy) Complications Acne conglobata: severe confluent inflammatory acne with systemic symptoms Facial scarring and psychological distress, including anxiety, depression[unboundmedicine.com]
  • more...
  • Skin
    Acneiform Eruption
    • Acne variants and acneiform eruptions also exist, many of which have an identifiable and reversible etiology.[accessmedicine.mhmedical.com]
    • Webster Drug and acneiform eruptions Deeptej Singh, Alan R.[routledge.com]
    • Additionally, true acne vulgaris should be differentiated from acneiform eruptions.[clinicaladvisor.com]
    • Acne vulgaris and acneiform eruptions.[positivehealth.com]
    • The skin of the thorax, back, and legs is most commonly affected. acne urticaria An acneiform eruption of itching wheals. acne varioliformis Vesiculopustular folliculitis that occurs mostly on the temples and frontal margins of the scalp but may be seen[medical-dictionary.thefreedictionary.com]
    Eruptions
    • An inflammatory eruption affecting the face, upper back, and chest, consisting of blackheads, cysts, papules, and pustules, and occurring primarily during puberty and adolescence. acne ac·ne (āk'nē) n.[dictionary.reference.com]
    • Also called acne vulgaris [vuhl- gair -is, - gar -] /vʌlˈgɛər ɪs, -ˈgær-/ ( Show IPA ) . 1820-30; New Latin Late Greek aknás, a manuscript error for akmás, accusative plural of akmḗ facial eruption, probably to be identified with Greek akmḗ acme British[dictionary.com]
    • . acne [ ak ne ] a disorder of the skin with eruption of papules or pustules; more particularly, acne vulgaris . acne congloba ta ( conglobate acne ) severe acne, seen almost exclusively in males, with many comedones, marked by suppuration, cysts, sinuses[medical-dictionary.thefreedictionary.com]
    • Redness and inflammation around eruptions.[nmihi.com]
    • This is a polymorphic eruption primarily of the face, which usually occurs in adolescents during puberty.[gpnotebook.co.uk]
    Facial Skin Lesion
    • The sixth-century Greek physician Aëtius of Amida is credited with coining the term "ionthos" (ίονθωξ,) or "acnae", which is believed to have been a reference to facial skin lesions that occur during "the 'acme' of life" (puberty).[en.wikipedia.org]
    • skin lesions that occur during "the ' acme ' of life" ( puberty ). [118] In the 16th century, the French physician and botanist François Boissier de Sauvages de Lacroix provided one of the earlier descriptions of acne.[en.wikipedia.org]
    Hirsutism
    • However, laboratory testing may be indicated in the following situations: Female patients with dysmenorrhea or hirsutism: Consider a hormonal evaluation with levels of total and/or free testosterone, dehydroepiandrosterone sulfate, luteinizing hormone[emedicine.medscape.com]
    • […] congenital adrenal hyperplasia, which may have the following features: Clinical features in childhood include precocious puberty, acne and accelerated bone age Clinical features in adolescent and adult females include persistent acne, moderate-severe hirsutism[pcds.org.uk]
    • Women with PCOS frequently also suffer from acne, central obesity, hirsutism, alopecia and infertility.[clinicaladvisor.com]
    • Conditions Acne fulminans, pyoderma faciale Acne conglobata, hidradenitis suppurativa Pomade acne SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) Pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA) and seborrhea, acne, hirsutism[unboundmedicine.com]
    • Clues that help the doctor diagnose hormonally influenced acne are adult-onset acne, hirsutism (excessive growth of hair or hair in unusual places), premenstrual acne flares, irregular menstrual cycles, and elevated blood levels of certain androgens.[multiplan.com]
    Papule
    • The acne occurs along with papules, comedones and pustules. [symptoma.com]
    • Definition / general Common skin disease of seborrhea (scaly red skin), comedones (blackheads and whiteheads), papules (pinheads), pustules (pimples), nodules (large papules) and possibly scarring Typically affects skin with densest sebaceous follicles[pathologyoutlines.com]
    • Pustules and Papules Pustules and papules are moderate forms of acne that are accompanied by inflammation and present themselves as bumps on the surface of the skin.[exposedskincare.com]
    • Papules on the nose and related rosacea in the surrounding areas of the face are often observed.[stanfordmedicine25.stanford.edu]
    • ACNE PAPULOSA acne papulosa Acne characterized by formation of papules with very little inflammation.[medical-dictionary.thefreedictionary.com]
    Pruritus
    • However, it often induces signs of chronic hypervitaminosis A, including cheilitis, dry eyes, generalized xerosis, pruritus and paronychia, and, most problematic of all, it is a proven and potent human teratogen.[apps.who.int]
    Pustular Lesion
    • Folliculitis and boils : may present with pustular lesions similar to those seen in acne.[patient.info]
  • more...
  • 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.

    Complications

    Acne Vulgaris
    • Acne vulgaris presents the following signs and symptoms: Acne vulgaris usually develops on the face in 90% of the cases.[symptoma.com]
    • There is no Indian study on the profile of acne vulgaris, markers of severe forms of acne vulgaris and a possible correlation between acne vulgaris and markers of androgenicity in females.[dx.doi.org]
    • Acne Vulgaris Treatments: There is no cure for acne vulgaris, but it can be treated.[acne.about.com]
    • Acne vulgaris is so common that skin specialists say that three-quarters of teens and adults will experience acne vulgaris.[adult-acne.net]
    Cushing's Disease
    • This may occur in testosterone replacement therapy, abuse of anabolic steroids, Cushing's disease or in virilising tumours in women, such as arrhenoblastoma.[patient.info]
    • Polycystic ovarian syndrome, anovulation, Cushing's disease, and androgen-secreting tumors cause these sudden changes.[brownskin.net]
    Erythema Multiforme
    • multiforme, Stevens-Johnson syndrome, suicidal ideation, psychosis Avoid tetracyclines or vitamin A preparations during isotretinoin therapy.[unboundmedicine.com]
    Folliculitis
    • .• Face - S. aureus folliculitis, pseudofolliculitis barbae, rosacea, perioral dermatitis.• Trunk -Malassezia folliculitis, “hot-tub” pseudomonas folliculitis, S. aureus folliculitis, and 21.[slideshare.net]
    • Types: Severe subtypes Consider in refractory cases Referral usually indicated Conditions Gram Negative Folliculitis Severe, inflammatory acne Onset months after starting oral antibiotics Acne Fulminans Rapidly progressive, severe inflammatory acne Associated[fpnotebook.com]
    • Folliculitis is a skin condition that causes small red bumps to form around the hair follicles.[medicinenet.com]
    • Pityrosporum folliculitis: predominates on the trunk.[patient.info]
    Furunculosis
    • […] of useful medicinal plant extracts for the topical treatment of acne, which include: Myrrh ( Commiphora myrrha ) , is stated to possess antimicrobial, astringent, carminative, antiseptic and vulnerary properties, and has been traditionally used for furunculosis[positivehealth.com]
    Hidradenitis Suppurativa
    • Commonly Associated Conditions Acne fulminans, pyoderma faciale Acne conglobata, hidradenitis suppurativa Pomade acne SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) Pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA) and[unboundmedicine.com]
    • Acne inversa (L. invertō, "upside down") and acne rosacea (rosa, "rose-colored" -āceus, "forming") are not true forms of acne and respectively refer to the skin conditions hidradenitis suppurativa (HS) and rosacea.[en.wikipedia.org]
    • suppurativa , miliaria [6] Treatment Lifestyle changes, medications, medical procedures [7] [8] Medication Azelaic acid , benzoyl peroxide , salicylic acid , antibiotics , birth control pills , isotretinoin [8] Frequency 633 million (2015) [9] [ edit[en.wikipedia.org]
    • Acne conglobata is included in the follicular occlusion tetrad along with hidradenitis suppurativa, dissecting cellulitis of the scalp and pilonidal cysts.[clinicaladvisor.com]
    Polycystic Ovary Syndrome
    • Disturbed stress responses in women with polycystic ovary syndrome.[resultsrna.com]
    • Congenital adrenal hyperplasia, polycystic ovary syndrome, and other endocrine disorders with excess androgens may trigger the development of acne vulgaris.[streetdirectory.com]
    • ovary syndrome or those with excess cortisol (e.g. steroid use) are prone by age 40 years, 1% of men and 5% of women still have lesions (3) acne has clear detrimental effects on a psychosocial level and can lead to permanent scarring a common presenting[gpnotebook.co.uk]
    • Ehrmann DA Insulin-lowering therapeutic modalities for polycystic ovary syndrome.[archderm.jamanetwork.com]
    Pyoderma
    • Fulminans Rapidly progressive, severe inflammatory acne Associated findings Fever Arthralgia Bone diathesis Acne conglobata Severe Cystic Acne Associated with dissecting scalp Cellulitis Associated with Hydradenitis suppurativa Aggressive treatment required Pyoderma[fpnotebook.com]
    • Commonly Associated Conditions Acne fulminans, pyoderma faciale Acne conglobata, hidradenitis suppurativa Pomade acne SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) Pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA) and[unboundmedicine.com]
    • Pyoderma faciale (also called rosacea fulminans) occurs suddenly on the midface of young women.[merckmanuals.com]
    • Treatment involves oral glucocorticoids, which concomitantly helps treat the arthritis, pyoderma gangrenosum and acne conglobata.[clinicaladvisor.com]
    Rosacea
    • The pimples only show up in what is called Papulopustular Rosacea, or stage 2 Rosacea.[supernaturalacnetreatment.com]
    • Acne rosacea (commonly referred to as rosacea) is a common skin disease which is characterized by redness, papules, pustules, and swelling.[stanfordmedicine25.stanford.edu]
    • Acne Rosacea Rosacea is a common long-term and non-curable skin condition that is also called adult acne or acne rosacea because of the similar appearance with acne vulgaris.[adult-acne.net]
    Urticaria
    • […] mg/day divided BID; high dose initially, taper in 6 months, less effective than doxycycline or minocycline ( 4 ), side effects: photosensitivity, esophagitis Minocycline : 100 to 200 mg/day, divided daily—BID; side effects include photosensitivity, urticaria[unboundmedicine.com]
    • The skin of the thorax, back, and legs is most commonly affected. acne urticaria An acneiform eruption of itching wheals. acne varioliformis Vesiculopustular folliculitis that occurs mostly on the temples and frontal margins of the scalp but may be seen[medical-dictionary.thefreedictionary.com]
    • They provided, as they wrote, 'an important linkage of emotion with cutaneous outbreaks of erythema, urticaria and dermatitis by way of the physiology and bacteriology of the gastrointestinal tract'.[gutpathogens.biomedcentral.com]
  • more...
  • 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
    • Acne in zinc deficiency - MT Baer, JC King, T Tamura, S Margen - Archives of Dermatology, 1978 - Am Med Assoc
    • 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
    • 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
    • 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
    • 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

    Languages

    Self-assessment