Acne

Digital Lecture Series : Chapter 10

Dr Sanjay Khare
Associate Professor, Department of Dermatology,
Venereology & Leprology,
Mahatma Gandhi 
Memorial Medical College, Indore 
 CONTENTS

 Introduction  Treatment guidelines

 Acne Vulgaris  Topical treatment
 Epidemiology  Oral antibiotics
 Pathogenesis  Hormonal therapy
 Grading  Isotretinoin
 Variants  Physical modalities
 Psychosocial aspects  Newer options
 Polycystic ovarian syndrome  MCQs
 Adult acne  Photoquiz
 Differential diagnosis
 Introduction

 Common skin condition

 Readily diagnosable

 May affect mental and social well being

 Affects more than 90% people at some point in their life

 Acne Vulgaris

Definition :

 Acne is a chronic, self limiting, inflammatory disease of pilo-

sebaceous unit, presenting with pleomorphic lesions like comedones,
papules, nodules, and in severe case with cyst

 Scarring is common
 Epidemiology

 Age of onset, puberty or a few months earlier

 Peak incidence
• Women : 14 to 17 yrs
• Men : 16 to 19 years
 More common and more severe in men
 More common in urban boys
 Genetic factors influence the susceptibility
 Pathogenesis of acne

 Altered keratinization within sebaceous follicle

 Androgen activity

 Quantity and quality of sebum secretion

 Colonization by follicular microbial flora

 Immunological factors

 Environmental factors
 Altered keratinization within sebaceous follicle

 Micro-comedones are initial lesions of acne

 Increased production of follicular-ductal keratinocyte

 Increased adhesion of follicular-ductal keratinocytes

 Retention of hyperproliferating ductal keratinocytes

 Androgen activity

 Spurt of hormones during puberty correlates with onset of acne

 Increase in androgen-estrogen ratio
 Androgen increases sebum secretion and sebaceous gland hyperplasia
 Increased sebum :
• Excessive production by gonads / adrenal
• Decreased sex hormone binding globulin
• Increased responsiveness of sebaceous glands
 Quantity and quality of sebum secretion

 Sebum is acnegenic

 Change in quality of sebum – irritation of ducal keratinocytes

 Colonization by follicular microbial flora

 Resident bacterial flora: Propionibacterium acnes, Propionibacterium

granulosum, Pityrosporum ovale, and Staphylococcus epidermidis

 increased count of P. acnes

 Resident flora secretes enzymes and pro-inflammatory chemokines

 Lipases – sebum to free fatty acids – follicular irritation – keratinocyte

hyperproliferation

 Chemokines – inflammation
 Immunological factors

 Inflammation precedes microcomedone

 Interleukin – 1 initiates keratinocyte hyper- proliferation
 P. acnes activates classical and alternate complement pathways
 Environmental factors

 Hot & humid climate– aggravates

 Emotional stress – aggravates
 High-glycemic load diet – hyperinsulinemia – free IGF 1 – increased
sebum, altered keratinization, excess gonadal androgens
 Milk & dairy products – contains IGF 1 as well as increases endogenous
production of IGF 1
 Natural light – beneficial
 Acne Vulgaris

 Pathogenesis
 Grades of Acne (Pillsbury, Shelley and Kligman)
- earliest published grading system

 Grade I : Comedones, occasional papules

 Grade II : Comedones, many papules, few pustules

 Grade III : Predominant pustules, nodules, abscesses

 Grade IV : Mainly cysts, abscesses, scars

 Grades of Acne

 Other grading systems have been also defined similar to Pillsbury by

James & Tisserand and Tutakne & Chari
 In 1997, Doshi, Zaheer and Stiller devised a global acne grading system;
this system utilizes six areas - forehead, each cheek, nose, chin and
chest and back, and assigns a factor to each area on the basis of size
 The global acne grading system

Location Factor

Forehead 2

Right cheek 2

Left cheek 2

Nose 1

Chin 1

Chest and upper back 3

 The global acne grading system

Note : Each type of lesion is given a value depending on severity :

no lesions = 0, comedones = 1, papules = 2, pustules = 3 and
nodules = 4.
The score for each area (Local score) is calculated using the formula : Local
score = Factor × Grade (0-4).
The global score is the sum of local scores, and acne severity was graded
using the global score.
A score of 1-18 is considered mild; 19-30, moderate; 31-38, severe; and
>39, very severe
 Acne Vulgaris

Grade 1 - Open and close comedones

 Acne Vulgaris

Grade 2 - comedones,papules with few pustules

 Acne Vulgaris

Grade 3 - papules, few nodules & deep pustules

 Acne Vulgaris

Grade 4 - large nodulocystic lesion on the cheeks

 Scarring
 Consequence of abnormal
resolution or wound healing
following the inflammation

 Ice-pick scars are seen in most

patients with grades I and II acne
while depressed or hypertrophic
scars are seen in nodulocystic
acne
 Hyperpigmentation

 In patients particularly with

type III/IV skin, hyperpigmented
macules may persist following the
resolution of inflammatory acne lesions
 Variants of Acne

 Drug induced acne/ acneiform eruption

 Acne excoriee
 Acne conglobata
 Acne fulminans
 Acne mechanica
 Occupational acne/chloracne
 Pyoderma faciale
 Late onset acne/endocrine acne
 Cosmetic/pomade acne
 Tropical acne
 Gram negative folliculitis
 Acne excoriee

Excoriated papular lesions on forehead with hyperpigmentation.

Acne conglobata
 Chloracne

 Multiple comedones,
occupational dermatosis due to
aromatic hydrocarbon
 Should be investigated for
systemic complication
(ophthalmic, neurological,
hepatic, lipoprotein abnormality)
 Drug induced acne

 Papules and pustules , comedones usually absent

 Drugs implicated:
• Halogens
• Androgens
• Steroids
• Isoniazide, Rifampcin
• Lithium
• Phenytoin
• PUVA
 Acneiform eruption

Post steroidal Acneiform eruption

 Psychosocial aspects

 Stress induces acne

 Increased anger and anxiety

 Social embarrassment

 Lack of self confidence

 Depression

 Dysmorphophobia
 Polycystic Ovary syndrome and Acne

 Persistent, severe, acne of late onset in females

 Other associated features may be
• Hirsutism
• Acanthosis nigricans
• Patterned hair loss
 Key etiological feature of PCOS are increased androgen secretion and
insulin resistance
 Hormonal therapy along with lifestyle modifications (e.g. weight reduction)
are helpful treatment options
 Adult Acne

 Acne above 25 years of age

• Persistence of adolescent acne, or
• First appearing in the age above 25 years
 May last in sixth decade
 Familial cases are very common
 Hormonal or drug induced causes are more commonly associated
 Hormonal causes-PCOS, Congenital adrenal hyperplasia, Cushing Syndrome
 Differential diagnosis

 Rosacea

 Pityrosporum folliculitis

 Pseudo folliculitis

 Milia

 Plane warts

 Tuberous sclerosis

 Acne scarring may be mistaken for acne keloidalis, varioliform, atrophy and
porphyria cutanea tarda.
 Rosacea

Absent comedones, erythematous papulopustules

on central part of face & cheeks
 Pityrosporum folliculitis

Itchy papulopustular lesion on seborrheic areas

 Guidelines of treatment

 Acne assessment (of severity)

 Patient education

 Discussion of goals of treatment and patient expectations

 Choice of therapy
 Topical agents

 Topical antibiotics - erythromycin, clindamycin, tetracycline, clarithromycin

 Benzoyl peroxide – 2.5 to 10%, gel/cream/lotion; comedolytic; no effect on

sebum production

 Azelaic acid – effective; safe during pregnancy

 Topical retinoids - retinoic acid, adapalene, tazarotene

 Topical dapsone
 Oral therapy

 Antibiotics :

• Erythromycin

• Azithromycin (pulse dosing)

• Tetracycline

• Doxycycline

• Minocycline

• Trimethoprim

• Dapsone
 Side effects of oral antibiotics

 Doxycycline - onycholysis, oesophagitis with ulceration, fixed drug

eruptions, photosensitivity

 Minocycline - benign intracranial hypertension, pappiloedema, blue-black

pigmentation and rarely hypersensitivity reactions

 Macrolide group - gastritis, diarrhoea

 Co-trimoxazole - severe drug reactions

 Dapsone - hemolytic anemia, dapsone syndrome

 Hormonal therapy

 Antiandrogens – cyproterone acetate(50-100 mg/day)

 Oral contraceptives - 35 mcgs ethinyl estradiol plus 2 mgs cyproterone

acetate

 Levonorgestrel+ethinyl estradiol (100+20 mcgs)

 Other regimens - prednisolone plus oestrogen, spironolactone and

antiandrogens

 Drosperinone – novel progestin derived from spironolactone

 Oral contraceptives containing androgenic progesterones such as

norethisterone must be avoided.
 Side effects of Hormonal therapy

 Weight gain

 Menstrual irregularity

 Occasional fluid retention

 Melasma

 Hypertension

 Thrombophlebitis

 Pulmonary embolism
 Isotretinoin

13-cis-retinoic acid (Vitamin A derivative)

 Mechanism of action:
• Decreases the size of sebaceous glands
• 80% reduction in sebum
• Alters the composition of sebum
• Reduces comedogenesis
• Lowers P. acnes concentration and has anti-inflammatory activity
 Isotretinoin

 Indicated for :
• Nodulocystic/ severe Acne
• Pyoderma faciale
• Acne recalcitrant to routine treatment
• Excessive seborrhoea
• Depression / Dysmorphophobia
• Acne conglobata / other unusual variants
• Scarring
 Isotretinoin

 Dose : 0.1 – 2 mg/ kg per day is given after meals. Ideal would be 1
mg/kg/day
 Cumulative dose : 120-150 mgs/kg
 Side effects
• Teratogenicity
• Mucocutaneous side effects, dryness
• Elevation of serum lipids
• Neurological : pseudotumor cerebri, optic
• Neuritis, depression, mood swing
• Arthritis, myalgia
• Acne flares
 Physical modalities

 Comedone expression

 Superficial electrocautery

 Aspiration of cystic lesions

 Intralesional steriods

 Cryotherapy

 Alpha-hydroxy acids or salicylic acid peels

 Newer options

 Photodynamic therapy using blue red light

 Low fluence pulsed dye laser light

 Dermabrasion / CO2 laserbrasion (ice-pick scars)

 Erbium-YAG laser for atrophic /hypertrophic scars

 Punch grafting / punch floats (for depressed scars)

 New anti inflammatory agents such as 5-lipooxygenase inhibitors

 Selection of treatment modality

 Mild involvement (comedones only)

• Benzoyl peroxide
• Azelaic acid
• Salicylic acid in cleanser or face wash

 Mild to moderate involvement (comedones and some papules/pustules)

• Benzoyl peroxide
• And topical retinoids
• Topical antibacterial – inflammatory lesions

Continue…
 Selection of treatment modality

 Moderate or severe (many inflammatory papules, pustules and/or

scarring)
• Oral antibiotics
• If oral does not respond – isotretinoin or hormonal therapy
 Cystic acne (more than two nodules, cysts, abscesses, bridging scar)
• Aspiration of cyst and intralesional steroid injection
• Systemic antibiotics
• Dapsone or hormonal or isotretinoin
• Adjuvant therapy : comedone expression, peel, acne surgery for scar
 Poor response to therapy

 Poor compliance

 Inadequate instructions

 Side effects

 Resistance of P. acnes

 Inadequate dosage

 Folliculitis due to staphylococci, gram negative enterobacteria or

malassezia
Before After 10 weeks

Topical Clindamycin gel and benzoyl Peroxide 2.5% gel

Before After 8 weeks

Oral Isotretinoin and topical clindamycin gel

Before After 12 weeks

Oral Minocycline and Benzoyl peroxide 2.5 % gel and topical

clindamycin gel (young married female – no isotretinoin was used)
 MCQ’S

Q.1) Acne is caused by

A. Propionibacterium acne
B. Malassezia furfur
C. M. tonsurans
D. Cornyebacterium

Q.2) Stage 1 of acne is :

E. Severe pustules and nodules
F. Few pustules with scars
G. Few comedones mainly
H. Pustules with comedones
 MCQ’S

Q.3) Acne is basically disease of :

A. Pilosebaceous gland
B. Epidermis
C. Eccrine gland
D. Estrogens and progesteron imbalance

Q.4) Side effects of Minocycline include all except :

E. Benign cranial hypertension
F. Pigmentation
G. Hemolytic anaemia
H. Photosensitivity
 MCQ’S

Q.5) The following is not the feature of steroidal acne

A. Absence of comedone
B. Absence of nodulocystic lesion
C. Polymorphous eruption
D. Occasional puritus
 Photo-quiz

Give differential diagnosis

Grade the acne and outline
management options
Thank You!