Acne

Case

A 13 year old male comes to your office for a high school entry exam. He is in good health and has no problems. His physical exam is normal except for some pimples on his face. After discussing other teenage issues such as safety, school, drugs, and sexually transmitted diseases, you need to recommend a treatment plan for his acne.

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Epidemiology

  • ~17 million Americans have acne, including 85% of adolescents ages 15 to 17 years. 
  • Adolescent acne correlates best with pubertal stage, although lesions may become evident before secondary sexual characteristics appear.
  • Early in puberty, blackheads and whiteheads predominate, and the midface (midforehead, nose, and chin) typically is involved.
  • Later, inflammatory lesions become more prevalent, and the lateral cheeks, lower jaw, back, and chest are affected.

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Pathogenesis

  1. Obstruction of the pilosebaceous unit by abnormal keratinization and increased production of sebum secondary to the increased androgen production during puberty.  
  2. There is proliferation of bacteria, primarily Propionbacterium acnes on the skin
  3. Inflammatory reaction secondary to sebum in follicles rupturing into surrounding tissue and production of free fatty acids produced by lipases from the bacteria acting on triglycerides in the sebum.
  4. Blackheads are "open comedones" and the darkness is from melanin not dirt. Usually not associated with inflammation.
  5. Whiteheads are "closed comedones" with only microscopic opening of pores and are the forerunners of "pimples" The rupture of the pore wall leads to an inflammatory reaction because of expelling of sebum. Near the surface this becomes a pustule, below the surface becomes either a papule or nodule.

 

Patient Education 

  1. Acne is not caused by dirt, thus frequent washing will not improve the condition. To control oily skin, patients may be advised to wash once or twice daily using a mild nondrying soap or cleanser.

  2. For most adolescents, diet plays no role in acne. 

  3. Picking at acne lesions may increase inflammation, prolong resolution of lesions, and increase the likelihood of scar formation.

  4. Cosmetics, sunscreens, and moisturizers, particularly those containing oils, may worsen acne. Patients should be advised to use products that are labeled noncomedogenic or nonacnegenic

  5. Encouragement and discuss that time is important and not to expect immediate changes

  6. The face may look "worse" before there is improvement

 

Drugs used in acne treatment

Biggest obstacle to successful treatment of acne in teenagers is compliance. Teens want rapid results and are often discouraged by time it takes to see results. Also, side effects of the medications are sometimes deterrents to further use of drugs. Encouragement and frequent visits to monitor progress is important.

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Psychosocial impact of Acne

Skin conditions such as acne have often been considered as benign diseases and have sometimes been dismissed as insignificant, even trivial, when compared to other diseases of childhood.  Research however has shown that even clinically mild to moderate facial acne is associated with significant depression and suicidal ideation. In another study, patients with severe acne reported levels of psychosocial and emotional problems that were as great as those reported with chronic disabling asthma, epilepsy, diabetes, back pain and arthritis. Complaints of acne should thus be taken seriously by the pediatrician.

  1. Benzoyl peroxide- comedolytic by causing follicular desquamation and antibacterial action vs. P.acnes. Can be bought over the counter and has drying effect causing irritation and redness. Begin qod. Adjust concentration as go along.
  2. Tretinoin (Retin-A)- Need Rx. Reduces hyperkeratosis. Irritating to skin and suggest starting qod. Follow directions and drying will be less if used about 30 minutes after washing face. Must use sunblock and moisturizer. The creams are milder than the gels. May use with Benzoyl peroxide. Very expensive
  3. Systemic antibiotics- Eliminate bacteria from the skin and inhibit lipase causing decrease concentration of FFA and decrease in neutrophile chemotaxis and follicular inflammation.
    1. Tetracylcline
    2. Erythromycin
    3. Clindamycin
  4. Topical Antibiotics
    1. Products containing clindamycin or erythromycin are available and have comparable efficacy
    2. Sodium sulfacetamide, with or without sulfur, also is available
  5. Isoretinoin (Accutane) Useful for severe pustulocystic acne. Should be under care of dermatologist if the patient needs Isoretinoin. Teratogenic so must make sure patient isn't and doesn't plan to become pregnant while on the drug. 

 

Conditions That May Mimc Adolescent Acne 

Condition Description Differentiating Features
Adenoma sebaceum Erythematous papules or nodules that appear in the nasolabial folds or on the cheeks of individuals who have tuberous sclerosis. Lesions often appear during childhood (earlier than the lesions of acne); comedones are absent.
Acne rosacea Erythematous papules, pustules, and scaling that involve the central face. Typically occurs in adults; comedones are absent.
Gram-negative folliculitis Sudden appearance of papules, pustules, and nodules in a patient being treated with oral antibiotics for acne. Sudden worsening of acne in a patient who has been receiving long-term antibiotic treatment for acne vulgaris.
Keratosis pilaris Small, rough-feeling, skin-colored or erythematous papules centered about follicles. A keratin plug emerging from the follicular orifice can be observed or palpated. The presence of a central keratin plug differentiates keratosis pilaris from acne. Lesions also may be located on the upper outer arms, thighs, or buttocks.
Pityrosporum folliculitis Erythematous papules and pustules that occur on the chest, shoulders, and upper back. Lesions spare the face; a potassium hydroxide preparation performed on a pustule roof demonstrates budding yeast.
Steroid acne Dome-shaped erythematous papules appearing on the face and trunk weeks after systemic corticosteroids have been begun. Lesions have a monomorphous appearance (eg, only papules without comedones). There is a temporal relationship between the onset or worsening of acne and corticosteroid therapy.
Steroid rosacea Erythematous papules or pustules that appear around the mouth and eyes. Often occurs in individuals who have applied potent topical corticosteroids to the face or have used inhaled corticosteroids. Lesions are concentrated around the mouth (or eyes), and comedones are absent.

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Adenoma sebaceum 
http://picsfair.com/adenoma-sebaceum.html

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Steroid acne 
http://skincare-system.info/acne/severe-acne-from-steroids-pict.html

 

 

References

  1. Krowchuk, Daniel. Managing Adolescent Acne: A Guide for Pediatricians. Pediatrics in Review Vol. 26 No. 7 July 1, 2005, pp. 250 -261.
  2. Hurwitz, Sidney. Acne Update. Pediatrics in Review Vol. 15, #2 February 1994 pp. 47-52.
  3. Hurwitz, Sidney. Acne Treatment in the 90's. Contemporary Pediatrics August 1995.
  4. Strasberger VC. Acne: What Every Pediatrician Should Know About Treatment. Pediatric Clinics of North America. 1997; 44(6):1505-1523.
  5. Mancini Anthony Acne Vulgaris: A Treatment Update.  Contemporary Pediatrics December 2000
  6. Leyden J. Therapy for Acne Vulgaris.  NEJM Vol 336 pg 1156 April 17, 1997
  7. Krowchuk D. Managing Adolescent Acne Pediatrics in Review July 2005
  8. Zaenglein A.L. et al. Expert Committee Recommendations for Acne Management. Pediatrics September 2006
  9. New Insights into the Management of Acne.  J of American Academy of Dermatology. 2009;60:S1-50
  10. Gupta MA & Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. British Journal of Dermatology. 2002. Volume 139 Issue 5, Pages 846 - 850
  11.   Mallon E, Newton JN, Klassen A et. Al. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. British Journal of Dermatology. 2001. Volume 140 Issue 4, Pages 672 – 676.

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