Case of the Week

Acne Vulgaris
By Dr Sam Manger

Case
A 15 year old woman, Justine, presents to you with her
mother. She reports painful and worsening acne of her
face over the past 6-9 months. It was initially very mild for
years but now it is quite marked and she is worried about
permanent scarring.

She has no other medical history, but she is on some

supplements, she cannot remember what they are. She
has no allergies.

Question 1 adolescent ages is for men and • Treatments attempted so far

How common is acne vulgaris in
adolescents and other age groups?
Question 2
What further assessment do you
want to obtain?
Question 3
What is the pathogenesis of acne
vulgaris?
Question 4
What role do external factors like
diet, BMI, family history, insulin
resistance, and stress play?
Question 5
What variants of acne vulgaris exist?
Question 6
What are your differential diagnoses
to acne vulgaris?
Question 7
What are the treatment options?
Answer 1
Estimates of the prevalence of acne
vulgaris in adolescents range from 35
to over 90%. Prevalence in post-
women respectively:
• 20 to 29 years: 43 and 51%
• 30 to 39 years: 20 and 35%
• 40 to 49 years: 12 and 26%
• Ages 50 and older: 7 and 15%
Of interesting note: Infantile acne
(with typical onset at age three to six
months) occurs as a result of elevated
levels of androgens produced by the
immature adrenal glands and testes.
Androgen levels fall by age one to
two and acne improves.
Answer 2
Acne is relatively easy to spot
diagnose, though there are important
differentials to consider as listed
below in question 6. Note the
question asked for assessment, not
just history.
• Duration
• Sites
• Severity and type
• Scarring
• Post-inflammatory
hyperpigmentation
• Skin type – oily/dry
• Current skin care regime
• Menstrual cycle triggers
• Medications, supplements, herbs
and OTC
• Family history
• Diet
• Stress
• Systemic symptoms – e.g. signs of
PCOS
• Impact and mental health
• Expectations of treatment
Acne can contribute to significant
psychological morbidity including
depression and anxiety, and rarely
mortality due to suicide. Hence it
may be important to ask a few
screening questions about the impact
of the acne on her mental health, her
thoughts, her social life, schooling,
employment and general wellbeing.
Answer 3
Acne vulgaris is a common
inflammatory disorder of the
pilosebaceous unit. It typically affects
those areas of the body that have the
largest, hormonally-responsive
sebaceous glands, including the face,
neck, chest, upper back, and upper
arms. In addition to the typical
lesions of acne vulgaris (e.g comedos
Case of the Week
and inflammatory lesions), scarring
and post-inflammatory
hyperpigmentation can occur.
Six main factors are involved:
1. Follicular hyperkeratinization
2. Increased sebum production –
This provides a rich growth
medium for p.acnes
3. Propionibacterium acnes (also
known as Cutibacterium acnes)
4. Inflammation
5. Androgens
6. External factors – e.g. skin care,
diet, stress, BMI, family history,
medications
Androgens are produced in the
adrenal glands, gonads and in the
sebaceous glands themselves. The
pathway is DHEA-S is converted to
testosterone, which is then converted
to 5-alpha-dihydrotestosterone
(DHT). Testosterone and DHT bind
to androgen receptors of
keratinocytes, and stimulate the
growth and secretory function of
sebaceous glands. DHEA-s serum
levels can correlate with severity of
acne.
The comedo is considered the
precursor for the clinical lesions of
acne vulgaris, including closed
comedos (whitehead), open comedos
(blackhead, dark due to oxidisation of
the lipids), and inflammatory papules,
pustules, and nodules.
Nodules are tender inflammatory
acne lesions that are larger than 5mm
in diameter. Nodular acne is
sometimes inaccurately referred to as
"cystic" or "nodulocystic" acne. In
reality, true cysts are rare.
Signs of severe acne include;
inflammatory and nodular acne, and,
non-nodular numerous
pustules/papules with scarring,
severe impact e.g. mental illness.
Answer 4
Skin care - Soaps, detergents, and
astringents remove sebum from the
skin surface but do not alter sebum
production and their pH is higher
than normal skin pH. Repetitive
mechanical trauma caused by
scrubbing with these agents may
worsen the disorder by rupturing
comedos, promoting the
development of inflammatory
lesions. Certain products are
comedogenic (e.g. oily moisturisers,
cosmetics, sunscreen).
Diet – for many years it was taught
that diet had little role in acne.
However, a large retrospective
Nurse’s Health Study of >45,000
women have demonstrated an
association between milk and acne
due to the natural hormonal
components of milk, possibly in
particular skin and low fat milk. This
has been replicated in multiple
smaller studies.
Other foods that worsen acne include
high glycaemic index foods and
saturated fats and trans-fats – as well
as a deficiency of omega-3
polyunsaturated fatty acids. There
are very small studies suggesting
chocolate and protein supplements
may worsen acne.
Data on favourable effects of dietary
factors such as zinc, omega-3 fatty
acids, antioxidants, vitamin A, and
dietary fibre on acne vulgaris are
limited but under further study.
Stress - Small studies show increased
stress is linked to worsening acne.
This may be stimulated by the release
of corticotropin releasing hormone
(CRH) and its action on sebaceous
glands.
Family history - Case-control studies
have demonstrated a more than
three-fold risk among individuals with
affected first-degree family members.
BMI - Small studies have shown an
increasing incidence of acne with
increasing BMI.
Insulin resistance - IR may play a role
in acne. Insulin resistance may
stimulate increased androgen
production and is associated with
increased serum levels of insulin-like
growth factor-1 (IGF-1), a finding
linked to increased facial sebum
excretion. A key example of acne,
insulin resistance and hyper-
androgenism is PCOS, though the
pathophysiology is not fully
understood.
Answer 5
Occasionally, patients with acne
vulgaris may exhibit variants of the
disease, some of which require
aggressive treatment.
Acne fulminans is a disorder
characterized by an acute eruption of
large, inflammatory nodules, crusts
and ulcers and it may be associated
with systemic symptoms (fever,
arthralgia etc), often in males and can
be triggered by oral isotretinoin
treatment.
Acne conglobata – a severe form of
more widespread nodular acne.
There are other very rare syndromes,
not discussed here.
Answer 6
Differential diagnoses include:
1. Acne cosmetica
2. Acne mechanica
3. Rosacea
4. Perioral dermatitis
5. Sebaceous hyperplasia
6. Folliculitis
Case of the Week
7. Hidradenitis suppurativa – usually
in flexures e.g. groin, axilla
8. Medications
9. Topical acne – response to
extreme heat
10. Occupational acne - occupational
chemicals
Acne cosmetica is associated with the
use of occlusive, oil-based hair
products.
Bra straps, orthopaedic casts and
helmets etc may all cause acne
mechanica, in which occlusion of
pilosebaceous follicles leads to
comedone formation.
Known medication causes of acne or
acneiform eruptions include
glucocorticoids, phenytoin, lithium,
isoniazid, androgens, and vitamins
B2, B6, and B12 may also cause drug-
induced acne.
Answer 7
General skin care is recommended
included washing with a gentle non-
soap cleanser (e.g. cetaphil) or
combined cleanser and antiseptic
wash (e.g. benzac AC wash) with
warm water. Do not aggressively
scrub the skin; gentle massage with
the fingertips is sufficient.
Moisturises are not routinely needed
but may reduce dryness associated
with treatment (usually apply on top
of the treatment). Use water based
moisturisers and cosmetics and avoid
comedogenic and oily skin creams.
Advise them to refrain from rubbing
their faces or picking their skin.
Dermnet NZ suggests expressing non-
infected comedones may help.
Specific treatments include:
1. Follicular hyperkeratinisation –
topical and oral retinoids, azelaic
acid, salicylic acid, hormonal
therapy
2. Sebum production – oral
isotretinoin, hormonal therapy
3. C. acnes – benzoyl peroxide,
topical and oral antibiotics
4. Inflammation – azelaic acid,
topical/oral retinoids, oral
tetracyclines
5. Androgens – hormonal therapy
6. External factors – hygiene, diet,
stress, BMI, medications
Topical retinoids (vitamin A
derivatives) can cause skin dryness
and irritation. Consider reducing
frequency to every 2nd/3rd day. Oral
retinoids are generally only
prescribed by dermatologists due to
the rare but serious risks. Do not use
retinoids in pregnancy.
The general guidelines of treatment
might include:
Mild acne –
• General skin care
• Remove aggravating factors
• Improve lifestyle factors
• Monotherapy with topical
antibiotics (e.g. benzoyl peroxide,
clindamycin, erythromycin), or
topical retinoids (e.g. tretinoin,
adapalene) or topical
azelaic/salicylic acid
• If there is no response after 6
weeks, use a topical
antibiotic/benzoyl peroxide in
combination with a topical
retinoid OR topical salicyclic acid
(avoid retinoids and salicyclic acid
together).
This may include morning and night
facial wash, with antibiotic
preparation in the morning and
retinoid at night (due to
photolability).
Due to the preventive effect of
topical retinoids on acne, the
medication should be applied to the
entire affected area, not as spot
treatment of individual lesions. A
pea-sized amount of medication is
usually sufficient to cover the face.
Moderate acne – as above +
combined topical benzoyl
peroxide/antibiotic/retinoid +/- oral
antibiotics (tetracyclines), +/-
hormonal therapy (e.g. COCP).
Only prescribe antibiotics when
necessary. The duration of treatment
should be limited (ideally three to
four months) and review at 6 weeks.
Once the acne is under reasonable
control, these can be ceased and
topical agents used. They should be
used in combination with benzoyl
peroxide as it reduces bacterial
resistance. Oral tetracyclines should
not be used in children.
Severe acne – as above + may require
oral retinoids like isotretinoin. Some
dermatologists will use oral steroids
to control the inflammation initially
however the use of steroids should
be limited to specialists only.
Oral hormonal therapy is an
alternative to oral antibiotic therapy
in post-menarchal females with
moderate to severe acne, even in the
absence of a hyperandrogenic state.
Premenstrual acne in particular
seems to benefit from hormonal
therapies. Combined oral
contraceptives more likely to improve
acne are those containing
cyproterone acetate, desogesterel,
dienogest, drospirenone or
jestodene. Clinically, nearly all
hormonal therapies are effective.
Onset of improvement is slow and
will take 3-6 months.
Post-inflammatory hyper-
pigmentation - both topical retinoids
and azelaic acid accelerate the
resolution.
Case of the Week

Scarring – although a variety of

therapies may reduce the References
prominence of acne scars, no therapy 1. Thiboutot et al, Pathogenesis, clinical
removes scars completely. Options manifestations, and diagnosis of
include minor surgical procedures, acne vulgaris, UpToDate, 2017
laser therapy, chemical peels, 2. Kurt Gabauer, Acne in Adolescents,
RACGP AFP, 2017
injectable soft tissue fillers etc.
3. Emmy Graber, Treatment of Acne
Vulgaris, UpToDate, 2017
Patients should be given realistic 4. Dover et al, Light-based, adjunctive
expectations regarding timelines for and other therapies for acne
improvement. At least two to three vulgaris, UpToDate, 2017
months of consistent adherence to a 5. Amanda Oakley, Acne management,
therapeutic regimen is often Dermnet NZ, 2014
necessary prior to concluding that 6. Titus et al, Diagnosis and Treatment
treatment is ineffective. of Acne, AAFP (USA), 2012
7. Cook et al, Acne, RACFP AFP, 2010
Other treatments to note include:
1. Dapsone 5% and 7.5% gels are an
effective treatment. The 5%
formulation is applied twice daily,
while the 7.5% formulation is
applied once daily. Do not use
with benzoyl peroxide.
2. Spironolactone
3. Tea tree oil products – supported
by 2 RCTs (200 people total)
4. Alpha hydroxy acids (glycolic acid
and lactic acid) - low-quality
evidence is available. A
synergistic effect has been
observed when combined with
topical retinoids.
5. Sulfur - Prescription products that
combine sulfur
with sulfacetamide, an ingredient
with antibacterial properties, are
available and have been effective
in open-label but small studies
6. Light and laser therapies - there
have been small studies
published supporting its efficacy
and safety, high-quality, peer-
reviewed data are lacking
7. Gold microparticles – early
evidence suggests topical gold
microparticles may be of use
8. Data on favourable effects of
dietary factors such as zinc,
omega-3 fatty acids, antioxidants,
vitamin A, and dietary fiber on
acne vulgaris are limited but
under further study