Acne vulgaris

Is the formation of comedones, papules, pustules, nodules, and/or cyst as a result of obstruction and inflammation of pilosebaceous units (hair follicles and their accompanying sebaceous gland). Treatment is a variety of topical and systemic agents intended to reduce sebum production, bacterial counts, and inflammation and to normalize keratinization

Pathophysiology
Acne occurs when pilosebaceous units become obstructed with plugs of sebum and desquamated keratinocytes then colonized with the normal skin anaerobe P.acne. Comedones, uninfected sebaceous plugs impacted within folliclessignature of noninflammatory acne Inflamatory acne comprises papules, pustules, nodules and cyst

 Papules lipases from P.acne metabolize triglycerides into FFA, which irritate the follicular wall Pustules active P.acnes infection causes inflammation within the follicle. Nodules & cyst rupture of follicle

Etiology
Puberty Androgen stimulate sebum, hyperproliferation of keratinocytes Hormonal Cosmetics, cleanser, lotion sweating

Diagnosis
Assesment for contributing factors Determination of severity Assesment of psychosocial impact

Classification
Mild
< 20 comedones, or < 15 inflammatory lesions, or < 30 total lesions

Moderate
20 to 100 comedones, or 15-50 inflammatory lessions, or 30 to 125 total lesions

Severe
> 5 cysts, or total comedone count > 100, or total inflammatory lesion count > 50, or > 125 total lesions

Treatment
Comedones: Topical tretionin Mild inflammatory acne: Topical antibiotics, benzoyl peroxide, or both Moderate acne: Oral antibiotics Severe acne: Oral isotretionin Cystic acne: Intralesional triamcinolon

Mild
Should be continued 6 week or until lesions respond Topical tretionin Adapalene gel, taxarotene cream or gel, azelaic acid cream, glycholic Mild papulopustular: dual therapy combination tretionin with benzoyl peroxide, a topical antibiotics (erythromicyn or clindamycin) or both.

Moderate
Oral systemic therapy with antibiotics ( tetracycline, minocycline, erythromycin, doxycycline) Full benefit takes Tetracycline first choice 250-500mg bid 4wk Minocycline 50 or 100 mg bid causes fewer GI adverse effects, easier to take Erithromycin and doxycycline are considered 2nd line therapy Ampicilin is an alternative treatment for gramnegative folliculitis

Severe
Oral isotretionin 1mg/kg once/day for 16 to 20 wk, maybe increased to 2 mg/kg once/day Limited by adverse effects, including dryness of conj., mucosae of the genitals, chapped lips, arthralgias, depression, elevated lipid levels, birth defect during pregnancy Intralesional injection of 0.1 ml triamcinolone acetonide suspension2.5 mg/ml