Definition
Acne vulgaris is an inflammatory pilo-sebaceous disease characterized by comedones (horny plugs), papules, pustules, nodules and cysts which may get inflamed and cause tissue destruction and scar formation.
Any hair bearing area can develop acne but it is commonly seen on face, neck, chest (upper part) and back. It is more severe in males but is more persistent in females and keeps flaring up periodically from before menarche till menopause.
Mechanism
Androgens stimulate production of Sebum, which is comedogenic and irritant and is converted to free fatty acids by the action of lipases produced by Propionibacterium acnes. The bacteria along with free fatty acids cause inflammation and delayed hypersensitivity reaction. This reaction leads to hyperkeratinization of follicles resulting in their plugging.
Drugs containing Androgens and Glucocorticoids, lubricating and cutting oils, complex chlorinated compounds and picking and squeezing may lead to acne and its exacerbation.
Important Note
Oral contraceptive pills may lead to acne but only slight alteration in the progesterone and estrogen proportion may alleviate the problem.
There is no evidence of the role of any foodstuffs (including oils) in causing acne.
Treatment
The person must be reassured because the lack of knowledge and understanding about the physiology leads to depression among certain individuals, especially skin conscious females.
Benefits of the use of soaps for washing is not established. If used, they should be mild. The skin must be kept clean and dry.
Mostly water or gel based topical formulations and oral medications are used in the treatment. The treatment is based on reducing bacterial population (by antimicrobial agents), promote shedding of plugs (by comedolytic agents), reducing rate of sebum production (by anti-androgens) and reducing damaging effect of inflammation (by anti-inflammatory agents).
Treatment of Comedonal Acne
1. Tretinoin (0.025% cream) or Adapalene gel (0.1%) applied twice daily half an hour after washing the face.
Note: (i) In place of Tretinoin and Adapalene, Renova, Retin A etc may be used. (ii) The disease may flare during first month of treatment (iii) These drugs are contraindicated in pregnancy.
2. Benzoyl peroxide 2.5% is as effective as higher concentrations and less irritating.
Treatment of Papular inflammatory acne
Mild acne (Moderate number of lesions and little or no scarring)
1. A combination of Clindamycin or Erythromycin with Benzoyl peroxide as topical gel applied twice daily. Or Clindamycin or Erythromycin applied twice daily and Benzoyl peroxide applied in the morning.
2. Addition of tretinoin may enhance efficacy.
Moderate Acne (more than 25 lesions and moderate scarring and pustular variety)
1, Tetracycline 500 mg/ Erythromycin 500 mg/ Doxycycline 100 mg/ Minocycline 50 mg twice daily. Taper the daily dose after every two months if the skin is clear.
Note: Tetracycline, Minocycline and Doxycycline are contraindicated in pregnancy.
2. Oral contraceptives (high estrogen) and Spironolactone any one 50 mg daily may be given as an anti-androgen.
Severe Acne (Severe scarring and nodulo-cystic)
1. Antibiotics as in Moderate acne.
2. Isotretinoin (Accutane) must ideally be used before severe scarring occurs. Dose - 0.5 to 1 mg/kg/day for 5 months.
Note: (i) Obtain consent in every case for use of isotretinoin. (ii) Strictly contraindicated in pregnancy and use of more than one contraceptive techniques must be advocated. (iii) High doses derange cholesterol, triglyceride and liver function, so they must be periodically monitored.
Other procedures
1. Comedo extractor may be used to remove comedones but medical treatment is required to prevent recurrence.
2. Triamcinolone acetonide injections hasten resolution of deep papules and cysts.
3. Cryotherapy is done for cysts.
4. Dermabrasion provides cosmetic improvement.
Note
1. The disease may flare intermittently inspite of treatment.
2. Other conditions like Acne rosacea, bacterial folliculitis, tinea and other forms of dermatitis must be excluded.
Acne vulgaris is an inflammatory pilo-sebaceous disease characterized by comedones (horny plugs), papules, pustules, nodules and cysts which may get inflamed and cause tissue destruction and scar formation.
Any hair bearing area can develop acne but it is commonly seen on face, neck, chest (upper part) and back. It is more severe in males but is more persistent in females and keeps flaring up periodically from before menarche till menopause.
Mechanism
Androgens stimulate production of Sebum, which is comedogenic and irritant and is converted to free fatty acids by the action of lipases produced by Propionibacterium acnes. The bacteria along with free fatty acids cause inflammation and delayed hypersensitivity reaction. This reaction leads to hyperkeratinization of follicles resulting in their plugging.
Drugs containing Androgens and Glucocorticoids, lubricating and cutting oils, complex chlorinated compounds and picking and squeezing may lead to acne and its exacerbation.
Important Note
Oral contraceptive pills may lead to acne but only slight alteration in the progesterone and estrogen proportion may alleviate the problem.
There is no evidence of the role of any foodstuffs (including oils) in causing acne.
Treatment
The person must be reassured because the lack of knowledge and understanding about the physiology leads to depression among certain individuals, especially skin conscious females.
Benefits of the use of soaps for washing is not established. If used, they should be mild. The skin must be kept clean and dry.
Mostly water or gel based topical formulations and oral medications are used in the treatment. The treatment is based on reducing bacterial population (by antimicrobial agents), promote shedding of plugs (by comedolytic agents), reducing rate of sebum production (by anti-androgens) and reducing damaging effect of inflammation (by anti-inflammatory agents).
Treatment of Comedonal Acne
1. Tretinoin (0.025% cream) or Adapalene gel (0.1%) applied twice daily half an hour after washing the face.
Note: (i) In place of Tretinoin and Adapalene, Renova, Retin A etc may be used. (ii) The disease may flare during first month of treatment (iii) These drugs are contraindicated in pregnancy.
2. Benzoyl peroxide 2.5% is as effective as higher concentrations and less irritating.
Treatment of Papular inflammatory acne
Mild acne (Moderate number of lesions and little or no scarring)
1. A combination of Clindamycin or Erythromycin with Benzoyl peroxide as topical gel applied twice daily. Or Clindamycin or Erythromycin applied twice daily and Benzoyl peroxide applied in the morning.
2. Addition of tretinoin may enhance efficacy.
Moderate Acne (more than 25 lesions and moderate scarring and pustular variety)
1, Tetracycline 500 mg/ Erythromycin 500 mg/ Doxycycline 100 mg/ Minocycline 50 mg twice daily. Taper the daily dose after every two months if the skin is clear.
Note: Tetracycline, Minocycline and Doxycycline are contraindicated in pregnancy.
2. Oral contraceptives (high estrogen) and Spironolactone any one 50 mg daily may be given as an anti-androgen.
Severe Acne (Severe scarring and nodulo-cystic)
1. Antibiotics as in Moderate acne.
2. Isotretinoin (Accutane) must ideally be used before severe scarring occurs. Dose - 0.5 to 1 mg/kg/day for 5 months.
Note: (i) Obtain consent in every case for use of isotretinoin. (ii) Strictly contraindicated in pregnancy and use of more than one contraceptive techniques must be advocated. (iii) High doses derange cholesterol, triglyceride and liver function, so they must be periodically monitored.
Other procedures
1. Comedo extractor may be used to remove comedones but medical treatment is required to prevent recurrence.
2. Triamcinolone acetonide injections hasten resolution of deep papules and cysts.
3. Cryotherapy is done for cysts.
4. Dermabrasion provides cosmetic improvement.
Note
1. The disease may flare intermittently inspite of treatment.
2. Other conditions like Acne rosacea, bacterial folliculitis, tinea and other forms of dermatitis must be excluded.
Priti Kaushik
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