What is Acne Vulgaris?
Acne Vulgaris is a common skin disorder majorly affecting adolescents, though it may occur at any age. Acne is multifactorial chronic inflammatory disease of pilosebaceous units.
It commonly occurs in males than in females and vary in severity. In 99% of cases face is affected, the back in 60% cases and the chest in 15% cases. The severity of the condition varies from individual to individual.
The four main mechanisms of Acne are – increased sebum production, follicular hyperkeratinization, Propionibacterium acne colonization, and the inflammatory products.
Acne can lead to severe psychological problem that may erode self-esteem.
- Oil glands are plugged for unknown reasons and they are infected by bacteria normally present in glands. Acne is not caused by dirt, masturbation or foods and sexual activity has no effect on it.
- Genetic factors and a positive family history is often a factor causing acne.
- Acne occur in adolescence, when hormones are in a state of flux.
- In girls it may flare up in premenstruation.
- Acne may be caused due to polycystic ovarian syndrome.
- Acne can result from abnormal production of androgens. This might occur in testosterone replacement therapy, anabolic steroids overuse, Cushing’s disease or in virilising tumours in women, for example arrhenoblastoma.
- Other triggers include hormonal changes in pregnancy or menstrual cycle; cosmetics, cleansers, lotions, clothing, humidity and sweating.
- The high prevalence of acne in adults may be related to treatment with antibiotic or oral contraceptives or cosmetic use.
Symptoms and Signs
- Cystic acne may be painful; other types do not have physical symptoms. Lesion type acne coexist at different stages.
- Comedones appear as whiteheads or blackheads. Whiteheads (closed comedones) are flesh-colored or whitish palpable lesions; blackheads (open comedones) have a dark center.
- Papules and pustules are red lesions. The follicular epithelium is damaged with accumulation of neutrophils and lymphocytes. Once the epithelium ruptures, the comedone contents cause inflammatory reaction in the dermis. Papules occur due to deep inflammation and Pustules are superficial.
- Nodules are larger, deeper, raised areas and more solid than papules.
- Cysts are nodules associated with discharge. Rarely cysts form deep abscesses. Scarring can be caused by long-term cystic acne.
- Acne conglobata is a severe form of acne vulgaris, affects men more than women. It is characterised by abscess, draining sinuses, fistulated comedones, keloidal and atrophic scars. The back and chest are largely involved. Arms, abdomen, buttocks, and scalp may be affected.
- Acne fulminans is acute, febrile and ulcerative acne with sudden appearance of confluent abscesses leading to hemorrhagic necrosis. Leukocytosis, joint pain and swelling may also occur.
- Pyoderma faciale (rosacea fulminans) occurs on the midface of women. It may resemble acne fulminans. The eruption consists of erythematous plaques and pustules, covering chin, cheeks, and forehead.
- Acne rosacea: usually occur in middle age.
- Folliculitis and boils: may be present with pustular lesions similar to those seen in acne.
- Milia: small keratin cysts. They are whiter than whiteheads and are commonly seen around the eyes.
- Perioral dermatitis.
- Pityrosporum folliculitis: appears on trunk.
Acne severity is classified into mild, moderate, or severe based on the number and type of lesions. A standardized system is mentioned in following table:
Classification of Acne Severity
|Mild||< 20 comedones, or < 15 inflammatory lesions, or < 30 total lesions|
|Moderate||20 to 100 comedones, or 15 to 50 inflammatory lesions or 30 to 125 total lesions|
|Severe||> 5 cysts, or total comedone count > 100, or total inflammatory lesion count
> 50 or > 125 total lesions
Treatments include reduction of sebum production, come done formation, inflammation, and bacterial infection. The type of treatment depend on severity.
Affected areas are needed to be cleansed daily. Excess washing, use of antibacterial soaps or scrubbing do not provide added benefit. A diet that do not affect blood glucose level and moderation of milk intake might be considered for treatment-resistant adolescent acne.
Treatment involve guiding the patient and customizing the plan that is realistic nad beneficial to the patient. Treatment failure can be due to lack of adherence to the treatment plan or lack of follow-up. Consultation with specialist is necessary.
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