ACNE VULGARIS

by
Dr. Majid Suhail
prof Dermatology
 ACNE:WHY DO WE CARE
•Affects
>80% of adolescents
>40% of adults over than 25
•Genetics plays a role
•Associated with
Disfigurement
Pain
Loss of confidence
Depression
•Effects on quality of life are comparable to
those suffering from chronic diseases like
asthma, seizures and diabetes
 How you will define Acne
Vulgaris?
A multifactorial chronic
inflammatory disorder of the
pilosebaceous apparatus.
Characterized by
Papules:
Non-inflammatory
(comedones).
Inflammatory.
Pustules.
Nodules.
Cysts.
 Etiology
 Genetic background
 More than one member of the family is
affected.
 Influence the development of lesions.
 Influence the course and severity of the
disease.
 Factors which aggravate acne
 Menstruation:
– 70% of women complain of a flare 2-7 days
premenstrually.
 Stress. acne among university students was associated
with exam stress
 Sweating: 15% of patients notice that sweating
deteriorates acne.
 Cosmetics & hair pomade.
 Friction and pressure
 Medications: iodides, antiepileptics, stroides. INH
 Congenital adrenal hyperplasia, PCO.
 What is the Pathophysiology of
acne ?
P. acnes Androgen &
Sebum
Production

ACNE

Inflammation with leakage Follicular hyper

of Sebum proliferation & plugging
Pathogenesis
Evolution of Acne Lesions
 Mediators of inflammation
 Inflammation is due to the
biologically active mediators rather
than the direct bacterial infection.
CLINICAL PICTURE
Black Heads (open
comedones)
White Heads (closed
comedones)
Inflamed lesions
Papules and pustules
Nodules
Cystic Acne
Pigmented acne macules
Post-acne Atrophic Scars
Hypertrophic scars
 Distribution
 Affects the areas of skin
with the densest
population of sebaceous
follicles:
– Face.
– The upper part of the
chest.
– The back.
 CLINICAL FEATURES
 SYMPTOMS. Acne usually causes social
embarrassment more than the physical
disability
1. Signs. Greasy (oily) skin
2. Noninflammatory lesions. Comedones
3. Inflammatory lesions. Papules and
pustules, Nodules, Cysts, sinuses,
Abscesses
4. Scars, Keloids, Pigmentation
 Clinical spectrum
A spectrum of lesions
comedones, papules, pustules,
and erythematous macules
and scars at site of resolving
leisons.
 Classification of acne
Type of lesions & extent

Mild Acne. Predominantly

Comedones, Papules and
pustules may be present.
(generally <10).
 Classification of acne
Moderate acne
 Moderate
numbers of
papules and
pustules (10–40)
and Comedones
(10–40) are
present.
 Classification of acne
moderately severe

Predominantly
papules and
pustules are present
(40–100), & deeper
nodular inflamed
lesions (up to 5)
involving the face,
chest, and back .
 Classification of acne
severe
 Severe Nodulocystic acne and acne
 Differential Diagnosis and
Variants of Acne

Gram-Negative
Folliculitis.
Pustules are
centered around
the anterior nares.
 Acne Rosacea

Persistent erythema,
telangiectasia, red
papules, and tiny
pustules.
Midface
Acne Rosacea
Acne Rosacea
What is Perioral dermatitis?
Infantile acne
 Excoriated Acne

Girls, minute or trivial

primary lesions are made
worse by squeezing
Crusts, scarring, and
atrophy
Acne cosmetica
Pomade acne occurs on
skin that comes into
contact with the
pomade, such as the
scalp, forehead and
temples.
ACNE MECHANICA
 Acne in Adult women
 Late onset Acne in Women . hirsute female with or
without irregular menses needs an endocrinal
evaluation . (e.g., polycystic ovary syndrome).
STEROID ACNE
 Tropical acne
Nodular, cystic, and
pustular lesions on back,
buttocks, and thighs
Face is spared
Young adult military
stationed in tropics
 What is Acne conglobata?

Severe form of acne in

young men
characterized by numerous
comedones, large abscesses
with sinuses, grouped
inflammatory nodules
Suppuration
Cysts on forehead, cheeks,
and neck
 What is Acne Fulminans?
 Rare form of extremely
severe cystic acne
 Teenage boys, chest and
back
 Rapid degeneration of
nodules leaving
ulceration
 Fever, leukocytosis,
arthralgias are common
 Tx; oral steroids,
isotretinoin
 What is pyoderma faciale ?
Pyoderma faciale affects mainly
female patients (age from 20-30
years old). It is characterised by
the sudden onset of painful cysts
with minimal comedones on the
face, especially on the central
part of the face. The trunk is
usually spared. In some cases,
there are interconnecting sinus
tracts.
 ASSESSMENT
Several points regarding severity, etiology and therapy
should be considered with each patient
 FEMALES
Menstrual regularity, hirsutism require endocrinal
evaluation.
 SEASONAL OR OCCUPATIONAL FACTORS
Exposure to heavy oils or greases or Hot, humid
climate or working conditions.
 MEDICINES OR COSMETICS. Greasy occlusive
make ups
 SEVERITY / TYPES OF ACNE
D/D of Facial Rash
 Treatment
 Patient Education
 Removal of Aggravating Factors
 Pharmaceutical treatment
 Adjunct Therapies
 Maintenance treatment
 Patient Education

Acne is
 Not infectious or contagious
 Not caused by poor hygiene
 Not to prick or scratch lesions
 Acne may worsen premenstrually
 Improvement may take 4-6 weeks
 Worsening may occur during early weeks
 Role of diet
 Patient Education
 Dispel the Myths
1. Marriage will improve acne
2. Acne should not be treated
3. Spicy foods ,eggs, mangoes cause acne
4. Betnovate , archi, stillmans improve
acne
 Encourage to continue the therapy
 Whole face needs to be treated and not
the visible spots only
 Acne

Mild Moderate Severe

Topical & Systemic

Topical
Systemic isotretinoin
Treatment
 Topical Therapies
1. Retinoids
 Tretinoin ,Adapalene ,Tazarotene
2. Antimicrobials
Benzoyl peroxide,Clindamycin, erythromycin
singly or in combination
3. Other topical agents
Azelaic acid, sodiumsulfacetamide, sulfur,
salicylic acid.
T
 Oral

Antibiotics Hormones Rtenoides Steroides

Tetracycline Estrogen +prednisolone

Minocycline Cyproterone a + Ethinyl
Erythromycin E
Isotertinoin Prednisolone
Sulphonamides Sprionolactone
 Systemic Therapies
1. Antibiotics
 Tetracycline,Doxycycline,Minocycline
 Trimethoprim–sulfamethoxazole
 Erythromycin. Azithromycin
2. Hormonal agents
 Spironolactone 50–200 mg in divided doses
 Estrogen-containing oral contraceptives , Diane 35
3. Oral retinoid
 Isotretinoin
Severe Acne response after Isotretinoin
Severe Acne response after Isotretinoin
 Adjunct Therapies
 Skin Care
Normal washing twice a day
Avoid Physical scrubs
Anti acne soaps are not much effective
 Comedo extractor
 Bleaching agents like hydroquinone for
pigmented acne macules
 Chemical peeling
 Microdermabrasion, Blue light / Laser/ IPL
 Patient FAQs
 Soaps, detergents
remove sebum but do
not alter production
 Avoid occlusive
clothing
 Water based
cosmetic better than
oil based
 Diet modification no
role in rx
 Course & Prognosis
 Mostly clears by early twenties
 Some may continue in third / fourth
decade
 Residual scarring & pigmentation
Acne Scars
 Acne Icepick Scars. 60-70%
Icepick: narrow (2 mm), punctiform,
and deep scars are known as icepick
scars. opening is typically wider than
the deeper infundibulum (forming a
“V” shape) . 60%–70% of total scars
Acne Boxcar scars. 20-30%
 Acne Scars
rolling scars along the chin and cheeks

.
Rolling scars occur from dermal
tethering of otherwise relatively
normal-appearing skin and are
usually wider than 4 to 5 mm.
Abnormal fibrous anchoring of the
dermis to the subcutis leads to
superficial shadowing and a rolling
or undulating appearance to the
overlying skin
Management of Acne Scarring
CROSS Technique
Application of TCA 100% with a
wooden toothpick, keeping the skin
stretched till frosting occurs
 100% TCA before and after
six courses of treatment CROSS Technique
 Pigmentary problems
 Treating PIH.
 Erythema
 Question
 A 22 years old female presented with comedones
and papulo pustular lesions and scars on
forehead, cheeks and shoulders.
 What is the likely diagnosis?
 Name the topical agents used to treat this
disease
 This patient has planned to get married in 6
months but is refractory to conventional
treatment and developed nodules and cyst with
risk of facial disfigurement. How are you going
to manage?
 Name the single most important drug and single
most important precaution to be observed during
 Question
Q. The enzyme responsible for conversion
of testosterone to dihydrotestosterone in
androgen dependent tissues is
a. 5-alpha –reductase
b.21-hydroxylase
c.21-dehydroxylase
d.11 hydroxylase
e.11 dehydroxylase
Do any drug cause or
aggravate acne?
What are the scenarios When
systemic steroids can be given
in Acne?
What is the difference between acne vulgaris and acne
rosacea?

They share in common the presence of papules and pustules on

the face. Differences are
1. Patients with acne tend to have oily skin. Comedones are
common. In more severe cases, patients develop cysts and
nodules that may heal leaving scars. Lesions are frequently
seen on the chest, back, and upper arms as well as the face.
The patients are generally younger than those with rosacea .
2. Rosacea typically begins after the age of 30 years and peaks
between 40 and 50 years of age. Lesions are usually limited to
the central face. Comedones are absent and scarring is rarely
seen. Rosacea is commonly associated with diffuse erythema
and flushing and blushing. There may be prominent
telangiectasias, phyma formation, and ocular involvement.
When can teenager with acne
expect their acne to resolve ?
What are the teratogenic effects of systemic
isoterinoin?
How long the contraception to be continued in
acne patients treated with systemic
isoterinoin?
How you will monitor the patients on
Isoterinoin?
 SEQ. what is your diagnosis?
Ms A is a 22-year-old
accountant presented with a
two week history of explosive
acne. She describes her
complexion as "spotless" prior
to that and now her face
erupted with scores of
pustules, nodules and cysts.
On Examination:
She was afebrile. Extensive
erythematous nodules,
pustules and papules were
noted on the cheeks and
forehead. Few cysts and
comedones were noted