ACNE VULGARIS

                                     ACNE VULGARIS






• Acne vulgaris is a common, usually self-limiting, multifactorial disease involving inflammation of the sebaceous follicles of the face and upper trunk.

• The four primary factors involved in the formation of acne lesions are increased sebum production, sloughing of keratinocytes, bacterial growth, and inflammation.
• Increased androgen activity at puberty triggers growth of sebaceous glands and enhanced sebum production. Sebum consists of glycerides, wax esters, squalene, and cholesterol. 
• The primary lesion, the comedo, forms as a result of plugging of the pilosebaceous follicle.
• If the follicular wall is damaged or ruptured, follicle contents may extrude into the dermis and present as a pustule.
• A primary factor in the development of acne is an alteration in the pattern of keratinization within the follicle. Increased production and sloughing of keratinocytes correlate with comedo formation. 


CLINICAL PRESENTATION

• Acne lesions typically occur on the face, back, upper chest, and shoulders. Severity varies from a mild comedonal form to severe inflammatory necrotic acne. The disease is categorized as mild, moderate, or severe, depending on the type and severity of lesions
. • Lesions may take months to heal completely, and fibrosis associated with healing may lead to permanent scarring

DIAGNOSIS

 Diagnosis is established by observation of acne lesions (e.g., comedones, pustules, papules, nodules, cysts) on the face, back, or chest. The presence of five to 10 comedones is usually considered to be diagnostic.


TREATMENT 

• Patient education about goals, realistic expectations, and dangers of overtreatment is important to optimize therapeutic outcomes.
✓ Mild acne usually is managed with topical retinoids alone or with topical antimicrobials, salicylic acid, or azelaic acid. 
✓ Moderate acne can be managed with topical retinoids in combination with oral antibiotics and, if indicated, benzoyl peroxide. 
✓ Severe acne is often managed with oral isotretinoin
• Initial treatment is aimed at reducing lesion count and may last from a few months to several years; chronic indefinite therapy may be required to maintain control in some cases.
• Topical treatment forms include creams, lotions, solutions, gels, and disposable wipes. Responses to different formulations may depend on skin type and individual preference.
• Antibiotics such as tetracyclines and macrolides are the agents of choice for papulopustular acne
. • Oral isotretinoin is the treatment of choice in severe papulopustular acne and nodulocystic/conglobate acne. Hormonal therapy may be an effective alternative in female patients..


NONPHARMACOLOGIC THERAPY

• Surface skin cleansing with soap and water has a relatively small effect on acne because it has minimal impact within follicles.
 • Skin scrubbing or excessive face washing does not necessarily open or cleanse pores and may lead to skin irritation
. • Use of gentle, nondrying cleansing agents is important to avoid skin irritation and dryness during some acne therapies.


TOPICAL PHARMACOTHERAPY

Benzoyl Peroxide
• Benzoyl peroxide may be used to treat superficial inflammatory acne. It is a nonantibiotic antibacterial that is bacteriostatic against P. acnes

Tretinoin 
• Tretinoin (a retinoid; topical vitamin A acid) is a comedolytic agent that increases cell turnover in the follicular wall and decreases cohesiveness of cells, leading to extrusion of comedones and inhibition of new comedo formation. It also decreases the number of cell layers in the stratum corneum from about 14 to about five.

Adapalene
• Adapalene (Differin) is a third-generation retinoid with comedolytic, keratolytic, and antiinflammatory activity. It is available as 0.1% gel, cream, alcoholic solution, and pledgets. A 0.3% gel formulation is also available.

Tazarotene
• Tazarotene (Tazorac) is a synthetic acetylenic retinoid that is converted to its active form, tazarotenic acid, after topical application

Erythromycin
• Erythromycin in concentrations of 1% to 4% with or without zinc is effective against inflammatory acne. Zinc combination products may enhance penetration of erythromycin into the pilosebaceous unit. 

Azelaic Acid
• Azelaic acid (Azelex) has antibacterial, antiinflammatory, and comedolytic activity.

Salicylic Acid, Sulfur, and Resorcinol
• Salicylic acid, sulfur, and resorcinol are second-line topical therapies. They are keratolytic and mildly antibacterial agents. Salicylic acid has comedolytic and antiinflammatory action

SYSTEMIC PHARMACOTHERAPY

Isotretinoin
 • Isotretinoin (Accutane) decreases sebum production, changes sebum composition, inhibits P. acnes growth within follicles, inhibits inflammation, and alters patterns of keratinization within follicles


Oral Contraceptives
• Oral contraceptives containing both an estrogen and progestin are used as an alternate treatment for moderate acne in women.