Acne- a disfiguring skin problem

A common skin problem of adolesence. Acne often disfigures and scar the skin to an extent that may cause depression and low self-confidience among people.

• Acne is almost always seen in the teenage years
• severity of disease differs per individuals
• Peak severity is in the late teenage years But acne may persist into the third decade and beyond, particularly in females.

Main Problem- issues relate to under-treatment and lack of clinical interest or insight into the patient’s condition.

Aetiology or Causes-
There are three pathogenetic factors :

  1. Increased sebum excretion. There is a clear relation between severity of acne and sebum excretion rate. In the complete absence of sebum, acne does not occur, however, acne may improve in the third and fourth decades despite high sebum excretion. Sebum excretion is therefore necessary for the development of acne but is not sufficient to cause acne on its own.
  2. Infection with Propionibacterium acnes. This bacterium colonises the pilosebaceous ducts and acts on lipids to produce a number of pro-inflammatory factors.
  3. Occlusion or blockage of the pilosebaceous unit.

Clinical features
Lesions are usually limited to

  • face,
  • shoulders,
  • upper chest and back.
  • upper arms

Seborrhoea (greasy skin) is often clinically obvious.

    • Open comedones (blackheads) due to plugging by keratin and sebum of the pilosebaceous orifice, or closed comedones (whiteheads) due to accretions of sebum and keratin deeper in the pilosebaceous ducts, are usually evident.
    • Inflammatory papules, nodules and cysts occur , with one or two types of lesion predominating.
    • Scarring may follow.

Scars ( Source Wikipedia)
Physical acne scars – “Icepick” scars. This is because the scars tend to cause an indentation in the skin’s surface. There are a range of treatments available. Although quite rare, the medical condition Atrophia Maculosa Varioliformis Cutis also results in “acne-like” depressed scars on the face.
Ice pick scars: Deep pits, that are the most common and a classic sign of acne scarring.
Box car scars: Angular scars that usually occur on the temple and cheeks, and can be either superficial or deep, these are similar to chickenpox scars.
Rolling scars: Scars that give the skin a wave-like appearance.
Hypertrophic scars: Thickened, or keloid scars.

Before treatment.

Clinical variants of acne.

Conglobate acne refers to severe acne with many abscesses and cysts, marked scarring and sinus formation.
Acne fulminans refers to the presence of severe acne accompanied by fever, joint pains and markers of systemic inflammation such as a raised ESR.
Acne excoriée refers to the effects of scratching or picking, principally on the face of teenage girls with acne.
Infantile acne is rare and is thought to be due to the sebotrophic effects of maternal hormones on the infant.

  • A mild form of acne dominated by the presence of comedones may be due to exogenous substances such as tars, chlorinated hydrocarbons or oily cosmetics.
  • A primarily pustular rash may also be seen in those being treated with corticosteroids, lithium, oral contraceptives and anticonvulsants. These forms of acne are usually clinically distinct from the usual variety developing in adolescence.
  • Individuals with moderate or even severe acne very rarely have any other systemic disorder. However, individuals with polycystic ovary syndrome are more likely to have severe acne, and clinical hints-for instance, menstrual irregularities-require investigation. If there is associated cutaneous virilism or other features of an androgen-secreting tumour, further investigations and expert endocrinological assessment are warranted.

Investigations
– rarely required.

Management

  • Tretinoin cream.
  • Benzoyl peroxide.
  • Local antibiotics (clindamycin or erythromycin) are used more widely than previously
  • The principal oral antibiotic is oxytetracycline, taken on an empty stomach not with food, in a dose of up to 1.5 g a day if tolerated. In general, oxytetracycline has a good safety profile even with long-term use.
  • Minocycline may be used if the response to oxytetracycline is inadequate or because of the ease of dosing. It is, however, associated with autoimmune hepatitis and remains a second- rather than first-choice drug.
  • Before an antibiotic is deemed not to have worked, the individual must be treated continuously for up to 3 months. If after 3 months there is little response to oxytetracycline the patient should be changed to erythromycin up to 1 g per day in divided doses. Patients need to remain under review.
  • In women, oestrogen-containing oral contraceptives can be a useful adjunct in therapy. There is a small reduction in sebum secretion with oral oestrogens. An oral anti-oestrogen, cyproterone acetate, is occasionally added in doses of 50-100 mg daily on days 5-14 of the cycle to enhance the effects of sebum reduction. If these topical and systemic agents fail to produce an adequate clinical response within 3-6 months the patient should be referred for specialist opinion and consideration for treatment with isotretinoin (13 cis-retinoic acid).
  • Isotretinoin has revolutionised the treatment of severe or moderate acne in patients unresponsive to other therapy.

Physical measures

  1. Cysts can be incised and drained under local anaesthetic.
  2. Intralesional injections of triamcinolone acetonide (0.1-0.2 ml of a 10 mg/ml solution) hasten the resolution of stubborn cysts.
  3. Scarring following acne is seen a lot less commonly if patients receive adequate care. Small, deep acne scars can be excised and other forms of more extensive but shallower scars can be treated by carbon dioxide laser.
  4. Dermabrassion

Photo Therapy

  1. Red and Blue light
  2. Photodynamic therapy
  3. Laser treatment.

 

Home Remedies have been used conventionally with following items-

1. Tomatoes/Tomato Pulp
2. Honey and Cinnamon
3. Potato
4. Lemon Juice
5. Apple Cider Vinegar
6. Garlic
7. Cucumber
8. Olive Oil

 

Current Scenario-

1. Hormonal Therapy with  Oral Contraceptive – Estrogen combined with progestin to avoid the risk of endometrial cancer. Anti-acne effect  by decreasing level of circulatory androgens.

2. Spironolactone-They functions primarily as a steroidal androgen receptor blocker.

3.Cyproterone acetate- It is the first androgen receptor blocking agent to be well studied and found to effective in acne in females

4. Flutamide- It is useful in acne when given in females with hirsuitism

 

Physical Treatment-

1.Lesion Removal- comedones- mechanically with comedone extractor and a fine needle or a pointed blade.

2.Active deep inflammatory lesions- Aspiration of deep inflamed lesion may be needed in few cases which are followed by IL steroid injection in cysts and sinus tract.

3. Phototherapy.

 

SUBMITTED- DR. S. M. PALIKHE

4 Comments
  1. April 11, 2011
  2. December 14, 2011
  3. April 24, 2014
  4. June 1, 2014

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