Acne
Acne: Excerpt from The 5-Minute Pediatric Consult
Marney Gundlach, MD, MPH
Acne - BASICS
Acne - description
Acne vulgaris is a disorder of pilosebaceous follicles (PSFs). PSFs are found on the face, chest, back, and upper arms. Acne lesions include microcomedones, closed comedones (whiteheads or CC), open comedones (blackheads or OC), inflammatory lesions (erythematous papules [Pap], pustules [Pus], nodules [Nod], or cysts), scars, and macules.
No universally accepted classification system for acne exists. One scheme is:
| | OC/CC | Pap/Pus | Nod | Scars |
| Mild | + | +/− | − | − |
| Moderate | + | + | +/− | +/− |
| Severe | + | + | + | + |
Other forms of acne:
- Acne conglobata: Large connecting cysts or abscesses causing severe scarring/disfigurement
- Acne fulminans: Severe acne associated with fever, arthritis, and systemic symptoms
- Acne rosacea: In adults; no comedones
- Steroid acne: Uniform papules or pustules occurring after use of topical or systemic steroids
- Neonatal acne: Inflammatory acne in up to 20% of neonates; resolves without treatment
Acne - epidemiology
Acne - prevalence
- Most common skin disorder in US
- More common in men during adolescence, and women during adulthood
- 85–100% of US teens have comedones
Acne - risk factors
Acne - genetics
Familial patterns exist, but no inheritance pattern demonstrated
Acne - pathophysiology
4 factors contribute to PSF obstruction:
- Increased sebum production:
- Adrenarche: Increased production of dehydroepiandrosterone sulfate (DHEAS) which is converted into free testosterone and dihydroxytestosterone (DHT)
- Androgens enlarge sebaceous glands and increase sebum production (highest during teens and decreases in the 20s).
- Hyperkeratinization—Epithelial cells lining the PSF do not shed properly. Obstruction of the PSF by cells and sebum creates a microcomedone.
- Propionibacterium acnes proliferation—Anaerobic, Gram + diphtheroid, colonizes PSFs and produces free fatty acids (FFAs).
- Inflammation
- P. acnes attract neutrophils (PMNs) to the PSF. PMNs ingest bacteria releasing hydrolytic enzymes that, with FFAs, damage follicle walls, causing inflammation.
- Acne severity is related to interactions of P. acnes with immune mediators, not absolute concentrations of P. acnes.
Acne - etiology
- Environmental factors (work grease exposure, hair grease use) may increase lesion numbers.
- Friction from athletic helmets, shoulder pads, chin straps, or bra straps may worsen acne.
Acne - associated conditions
- Polycystic ovarian syndrome (PCOS)
- SAPHO syndrome: Synovitis, acne, pustulosis, hyperostosis, and osteitis
- Adrenal tumors
- Late-onset congenital adrenal hyperplasia
Acne - DIAGNOSIS
Acne - signs & symptoms
Acne - history
- Age of onset (Early or late onset of acne may signal androgen excess.)
- Medications (including some oral contraceptive pills [OCPs], lithium, progestin implants, depot medroxyprogesterone, isoniazid, nicotine products, and steroids) may worsen acne.
- Menstrual history (Premenstrual flares may occur due to progesterone [androgen effects.])
- Androgen excess (history of or current)
- Prepubertal: Early onset acne or body odor, increased growth, adrenarche or pubarche, genital maturation, or clitoromegaly
- Postpubertal: Alopecia, hirsutism, truncal obesity, acanthosis nigricans, irregular menses
- Psychological impact: Ask about self-esteem, depression, and suicidal ideations in patients
Acne - physical exam
- Skin: OCs, CCs, and inflammatory lesions on the face, chest, and back. Consider diagramming facial lesions with global assessment of acne severity (number, size, extent, and scarring). Pomade acne may be seen around hairline.
- Note signs of androgen excess (see “History”).
Acne - tests
Acne - lab
- Consider only in patients who have early- or late-onset acne, signs of androgen excess, or acne unresponsive to traditional therapy.
- Most boys have normal hormone levels.
- Girls may have increased levels of free testosterone and DHEAS and decreased levels of sex hormone binding globulin (SHBG). Consider also total testosterone, FSH, and LH for PCOS.
- Lab monitoring while on isotretinoin should include triglycerides, cholesterol, transaminases, and complete blood counts.
Acne - imaging
Bone age in prepubertal children with signs of androgen excess
Acne - differencial diagnosis
- Adenoma sebaceum
- Gram-negative folliculitis
- Keratosis pilaris
Acne - TREATMENT
Acne - general measures
- Goal is to reduce number and severity of lesions and prevent scarring.
- Tell patients that 6–8 weeks (maturation time of microcomedone) are required for clinical improvement. Treat until no new lesions form.
- Scars warrant aggressive treatment targeting inflammation.
- In general, creams and lotions are less drying than solutions or gels. More drying formulations may be better for patients with excessively oily skin or for quick drying prior to makeup application; less drying formulations may be needed for patients with sensitive skin/eczema.
Acne - special therapy
Acne - comp alt-medicine
- Limited empirical studies on CAM and acne. RCTs of the following showed that they were not as effective as 5% benzoyl peroxide (BP), but less skin irritation:
- Tea tree oil: A mixture of terpenes and alcohols with antibiotic and antifungal properties; 5% solution may be effective at treating comedonal and inflammatory acne; may be associated with male gynecomastia
- Gluconolactone 14% solution may be effective at treating comedonal and inflammatory acne.
Acne - medication
Topical agents:
- BP: Bactericidal, decreases FFA concentration
- Useful for mild inflammatory and comedonal acne; adjunct with oral or topical antibiotics to prevent emergence of antibiotic resistance
- Available as lotions, creams, washes, and gels in 2.5–10%; 5% concentration up to twice daily effective for most patients; 10% solution does not increase effectiveness but does increase side effects.
- Side effects include drying, erythema, burning, peeling, stinging, and rarely contact dermatitis. Counsel patients that BP may bleach clothing and linens.
- Topical antibiotics (erythromycin, clindamycin, sulfacetamide) decrease P. acnes concentration and inflammatory mediators and may decrease FFAs.
- Useful for mild or moderate inflammatory acne; no comedolytic effects; applied once or twice daily. Do not use as monotherapy.
- Side effects: Well-tolerated but may include drying or irritation; patients may complain about the smell of sulfacetamide.
- Often combined with BP; combination products are more expensive. Can use separate generic prescriptions of BP and topical antibiotics together.
- Combining with topical retinoid in clinical trials yields faster results and greater clearing than topical antibiotics alone.
- Retinoids promote epidermal differentiation, epithelial shedding from the PSF, comedone drainage, prevent new comedone formation (by decreasing obstruction), and are anti-inflammatory.
- Side effects include erythema, dryness, and irritation, hypo or hyperpigmentation, and photosensitivity (patients should use a sunscreen with SPF 15–30).
- 1st-line therapy for most patients; may increase penetration of other topical agents by improving cell shedding
- Treatment started with a low strength (0.025% cream) formulation applied as a small amount every 3rd night and increased to nightly application over 3 weeks. Applying at night may decrease photosensitivity. Increase concentration as tolerated.
- Tretinoin
- Available as creams, gels, and liquids (increasing potency, respectively). May initially cause temporary worsening of acne before improvement. Approved for children ≥13 years.
- Sporadic reports of congenital malformations have occurred with tretinoin (pregnancy category C drug); important to discuss with women of childbearing age.
- Adapalene
- Cream, gel, solution, or pledgets
- Adapalene gel 0.1% is shown to be effective and better tolerated than tretinoin gel 0.025%.
- Approved for children ≥13 years
- Tazarotene
- Creams and gels
- More irritating than other retinoids
- Approved for children ≥12 years
- Teratogenicity concerns; contraindicated in pregnancy (Category X)
- Salicylic acid promotes comedolysis with drying and peeling, effective for comedonal acne:
- 0.5–5% cream, wash, lotion, or gel
- Less effective than topical retinoids at preventing new lesions, but less irritating
- Consider for patients with comedonal acne who cannot use retinoids or who have too large of a surface area to treat (e.g., back).
- Azelaic acid—Anticomedonal and antibacterial; decreases hyperpigmentation:
- 20% cream applied twice daily
- Side effects include itching, burning, tingling, stinging, and erythema.
- Consider for patients with comedonal acne who cannot use retinoids or who have too large of a surface area to treat (e.g., back).
Oral agents:
- Oral antibiotics (tetracycline, doxycycline, minocycline)—Same as topical antibiotics plus inhibit PMN chemotaxis, decrease FFAs in sebum:
- Use for moderate to severe acne, widespread acne, or treatment-resistant acne. Do not use as single agent.
- Antibiotic resistance may be seen in 25% of patients; limit treatment length as much as possible, and change antibiotic if no improvement is seen within 4 months.
- More effective than topical antibiotics, but more systemic effects
- Isotretinoin decreases sebum production, anti-inflammatory, and reduces P. acnes:
- Used for severe recalcitrant acne or acne with significant scarring only, given side effects.
- Dose starts at 0.5 mg/kg/d in 2 divided doses for 4 weeks, and is increased as tolerated up to 2 mg/kg/d; total course usually 20 weeks; total cumulative dose should not exceed 120–150 mg/kg
- For patients with severely inflamed acne, start at lower dose to prevent initial acne flares or pretreat with oral corticosteroids.
- FDA-mandated registry (iPledge; see https://www.ipledgeprogram.com/) for all patients on isotretinoin; prescribed only by physicians experienced with its use:
- Side effects:
- Teratogenicity (Obtain 2 negative pregnancy tests in women prior to starting treatment.)
- Depression and suicide have been reported in patients on isotretinoin (causality not established, but counsel about this risk).
- Other side effects: Hyperlipidemia, dry skin, pseudotumor cerebri, headaches, cheilitis
- OCPs for women:
- Combined OCPs work by estrogen increasing SHBG, which decreases free testosterone; decreasing gonadotropin secretion, which decreases ovarian androgen production; and androgen receptor blocking, which prevents DHT formation in the PSFs.
- Use OCPs with a low-androgen progestin. OCPs with ethinyl estradiol (35 mcg) and norgestimate, ethinyl estradiol (20 mcg) and levonorgestrel, or ethinyl estradiol (20-30-35 mcg) and norethindrone acetate shown in RCTs to improve acne
- May need 3–6 months to see improvement
- Side effects include nausea, breast tenderness, weight gain, breakthrough menstrual bleeding, myocardial infarction, ischemic stroke, and DVTs.
- Clostridium difficile pseudomembranous colitis may occur rarely with topical clindamycin.
- Do not use isotretinoin and tetracycline, minocycline, or doxycycline together due to increased risk of pseudotumor cerebri.
- BP inactivates tretinoin; when used together, apply BP in the morning and tretinoin at night.
- Tetracycline, minocycline, and doxycycline are Category D drugs (unsafe in pregnancy).
Acne - surgery
Dermatology: Manual comedone extraction, intralesional steroid injections, superficial peels, phototherapy, or laser treatments
Acne - FOLLOW UP
Follow-up should occur in 4–8 weeks.
Acne - disposition
Acne - issues for referral
Consider referral to a dermatologist for treatment failure, isotretinoin use, procedures, or significant scarring.
Acne - prognosis
Overall, good
Acne - complications
- Scarring may be permanent.
- Self-esteem: Acne severity correlated to social variables including embarrassment and lack of enjoyment in social activities among teenagers.
- Patients with mild to moderate acne showed clinical depression and >5% suicidal ideation.
- Suicide
Acne - bibliography
Arowojolu AO, Gallo MF, Lopez LM, et al. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev. 2007;(1):CD004425. DOI:10.1002/14651858.CD004425.pub2.Krowchuk DP. Managing adolescent acne: A guide for pediatricians. Pediatr Rev. 2005;26:250–261.Magin PJ, Adams J, Heading GS, et al. Topical and oral CAM in acne: A review of the empirical evidence and a consideration of its context. Complement Ther Med. 2006;14:62–76.Mancini AJ. Acne vulgaris: A treatment update. Contemp Pediatr. 2000;12:122.Strauss J, Krowchuck DP, Leyden JJ, et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. 2007;56:651–663.Zaenglein AL, Thiboutot DM. Expert committee recommendations for acne management. Pediatrics. 2006;188:1188–1199.
Acne - CODES
Acne - icd9
706.1 Other acne
Acne - PATIENT TEACHING-MED
Discuss common myths, medication compliance and proper use, time to expected results, and side effects. Web sites for patient education materials:
- http://www.skincarephysicians.com/acnenet/index.html
- http://www.aap.org/pubed/ZZZKRFFGL5C.htm?&sub_cat=2
Acne - FAQ
- Q: What treatment is recommended for patients with comedonal and inflammatory acne?
- A: Topical retinoid + topical/oral antibiotic + BP
- Web site with patient FAQs: http://www.skincarephysicians.com/acnenet/FAQ.html
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
More About Adult Acne
More Medical Textbooks Online about Adult Acne
Review other book chapters online related to Adult Acne:
Medical Books Excerpts
- Acne
- "In a Page: Signs and Symptoms" (2004)
- [ read ]
- Papular rash
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Pustular rash
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Acne
- "The 5-Minute Pediatric Consult" (2008)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
|
|
More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
|
|
» Next page: Surveys relating to Adult Acne
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
