Acne vulgaris
Acne vulgaris: Excerpt from Handbook of Diseases
An inflammatory disorder of the sebaceous glands, acne vulgaris is the most common skin problem in adolescents, although lesions can appear as early as age 8. Although acne is more common and more severe in boys than girls, it usually occurs in girls at an earlier age and tends to last longer, sometimes into adulthood. The prognosis is good with treatment.
Causes
Many factors contribute to acne, but theories regarding dietary influences appear to be groundless. Research now centers on follicular occlusion, androgen-stimulated sebum production, and Propionibacterium acnes as possible primary causes.
Certain drugs, including corticosteroids, glucocorticoids, phenobarbital, phenytoin, isoniazid, lithium, and halogens can cause acne.
Other precipitating factors include exposure to industrial compounds, trauma or rubbing from tight clothing, cosmetics, emotional stress, and unfavorable climate.
Androgens stimulate sebaceous gland growth and production of sebum, which is secreted into dilated hair follicles that contain bacteria. The bacteria — usually P. acnes and Staphylococcus epidermidis, which are normal skin flora — secrete lipase. This enzyme interacts with sebum to produce free fatty acids, which provoke inflammation. Also, the hair follicles produce more keratin, which joins with the sebum to form a plug in the dilated follicle.
Signs and symptoms
The acne plug appears as a closed comedo, or whitehead (if it doesn’t protrude from the follicle and is covered by the epidermis), or as an open comedo, or blackhead (if it does protrude and isn’t covered by the epidermis). The black coloration is caused by the melanin or pigment of the follicle.
Rupture or leakage of an enlarged plug into the dermis produces inflammation and characteristic acne pustules, papules or, in severe forms, cysts or abscesses. Chronic, recurring lesions produce acne scars.
Diagnosis
The appearance of characteristic acne lesions, especially in an adolescent parms the presence of acne vulgaris.
Treatment
Commonly, acne is treated topically with an antibacterial (such as benzoyl peroxide, clindamycin, or erythromycin), alone or in combination with tretinoin (retinoic acid), a keratolytic, or salicylic acid. Benzoyl peroxide and tretinoin may irritate the skin.
Systemic therapy consists primarily of an antibiotic, usually tetracycline, to decrease bacterial growth until the patient is in remission; then a lower dose is used for long-term maintenance. Tetracycline is contraindicated during pregnancy and childhood because it discolors developing teeth. Erythromycin is an alternative for these patients. Exacerbation of pustules or abscesses during either type of antibiotic therapy requires a culture to identify a possible secondary bacterial infection.
Oral isotretinoin combats severe acne by inhibiting sebaceous gland function and abnormal keratinization. Because of its severe adverse effects, the 16- to 20-week course of isotretinoin is limited to those with severe papulopustular or cystic acne who don’t respond to conventional therapy. (See Risks of isotretinoin therapy.)
Females may benefit from taking birth control pills (such as Ortho Tri-Cyclen) or spironolactone because these drugs produce antiandrogenic effects. (See Hormonal therapy.)
Other treatments for acne vulgaris include intralesional corticosteroid injections, exposure to ultraviolet light (but never when a photosensitizing agent, such as tretinoin, is being used), cryotherapy, and acne surgery.
Special considerations
Check the patient’s drug history because certain drugs may cause an acne flare-up.
Try to identify in the patient predisposing factors that may be eliminated or modified.
Explain the causes of acne to the patient and his family. Make sure they understand that the prescribed treatment is more likely to improve acne than a strict diet and fanatic scrubbing with soap and water. Provide written instructions regarding treatment.
Instruct the patient receiving tretinoin to apply it at least 30 minutes after washing the face and at least 1 hour before bedtime. Warn against using it around the eyes or lips. After treatments, the skin should look pink and dry. If it appears red or starts to peel, the preparation may have to be weakened or applied less often.
Advise the patient to avoid exposure to sunlight or to use a sunscreen. If the prescribed regimen includes tretinoin and benzoyl peroxide, avoid skin irritation by using one preparation in the morning and the other at night.
Instruct the patient to take tetracycline on an empty stomach and not to take it with an antacid or milk because tetracycline interacts with the metallic ions of both substances and is then poorly absorbed.
If the patient is taking isotretinoin, tell him to avoid vitamin A supplements, which can worsen any adverse reactions. Also, discuss with him how to deal with the dry skin and mucous membranes that usually occur during treatment.
Warn the female patient about the severe risk of teratogenesis.
Monitor the patient’s liver function and lipid levels.
Pay special attention to the patient’s perception of his physical appearance, and offer emotional support. Pictures
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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