Acne
Acne Vulgaris is a chronic cutaneous inflammatory disorder of the pilosebaceous unit (hair follicle and sebaceous gland). Acne Vulgaris – StatPearls – NCBI Bookshelf. The conditions manifest with papules, pustules or nodules primarily on the face but can affect the upper arms, trunk and back. It develops through a complex multifactorial process driven largely by androgens (male hormones present in both men and women) that cause the excessive production of oil (sebum), leading to blockages of the hair follicles, bacterial growth and inflammation.
Acne Vulgaris is commonly observed in adolescents and young adults; its prevalence rates are estimated to be between 35% to 90% among adolescents and is more common in males than it is in females. Post-adolescent acne is more common in females. Acne prevalence and associations with lifestyle: a cross-sectional online survey of adolescents/young adults in 7 European countries – PubMed. Most cases will resolve by the third decade of life; however, there are instances where acne can persist into adulthood or even manifest for the first time in adulthood.
Risk factors for developing acne include the use of certain medications (lithium, steroids and anticonvulsants), endocrine disorders (polycystic ovarian syndrome), pregnancy, genetics, stress Study of psychological stress, sebum production and acne vulgaris in adolescents – PubMed and a high glycemic diet Etiology of Adult Female Acne-Systematic Review – PubMed.
What are the signs and symptoms?
Acne is classified into several forms (including acne conglobate, acne rosacea, acne fulminans and acne mechanica); acne vulgaris is the most prevalent form, accounting for 99% of all acne cases. Acne vulgaris: A review of the pathophysiology, treatment, and recent nanotechnology based advances – PMC. It manifests with both inflammatory and non-inflammatory cutaneous lesions, including:
- Blackheads are non-inflammatory acne lesions that develop on the skin due to excess oil and dead skin production. Blackheads are a mild acne form.
- Whiteheads are a further non-inflammatory lesion that develops on the skin when the hair follicles are blocked by oil, bacteria and dead skin cells.
- Papules, inflammation is the response of healthy skin tissue to bacteria, excess oil production and excess androgen activity. Papules show on the skin as a little pink lump, typically less than 5mm in diameter and not pus-filled.
- Pustules, inflammatory lesions that occur on the skin by clogging the pores with excess oil and dead skin. They contain pus in their centre and typically manifest as white pimples surrounded by red, irritated skin.
- Nodules are a severe form of inflammatory acne that develop when the pores become clogged by bacteria, excess oil and dead skin cells and appear as a red swollen bump. This type of combination usually causes whiteheads or blackhead comedones.
- Cyst, cystic acne is a severe kind of inflammatory acne that appears beneath the skin due to blocked pores. Cysts typically appear as large white/red painful lesions filled with pus and can sometimes lead to scars.
How is it diagnosed?
Acne is typically diagnosed based on clinical examination. Laboratory or radiological tests may be required for patients if there is a clinical concern for the presence of underlying hyperandrogenism (most commonly due to polycystic ovary syndrome).
The assessment of acne severity falls into 4 categories.
- Grade 1 (Mild). These are primarily whiteheads and blackheads (comedones) and are non-inflammatory lesions.
- Grade 2 (Moderate). A higher number of inflammatory papules and occasional pustules with erythema.
- Grade 3 (Moderate-Severe). Numerous papules and pustules along with several inflamed nodules and sometimes cysts.
Grade 4 (Severe). Many pustules, formed nodules and cysts.
How is it treated?
The management of acne vulgaris, regardless of its severity, encompasses a discussion about the nature of the disease, proper skincare practice, realistic treatment expectations, as well as assessing the physiological impact of the disease on the patient. Some cases may present with mild features, but the acne causes significant physiological distress due to cosmetic concerns, and this may necessitate a more aggressive treatment approach.
- Over-the-counter (OTC) and non-pharmacological methods.
Although acne is unavoidable for lots of patients, it can be effectively managed through various OTC and non-pharmacological measures. Regularly washing the face with a PH balancing cleanser such as benzoyl peroxide Benzoyl Peroxide – StatPearls – NCBI Bookshelf or salicylic acid face wash Effectiveness of a combination of salicylic acid-based products for the treatment of mild comedonal-papular acne: a multicenter prospective observational study – PubMed can help manage acne symptoms and can be purchased OTC. Avoiding high glycemic index foods and dairy-based products may help manage symptoms, along with managing stress levels.
- Mild Acne Vulgaris.
Acne vulgaris is considered mild when it presents with a few scattered comedones (whiteheads/blackheads) or with a few small inflammatory papules without scarring. The primary treatment approach is topical therapy, which commonly involves the use of topical retinoids (tretinoin, tazarotene, adapalene, and trifarotene), topical antibiotics (clindamycin and erythromycin) and benzoyl peroxide. Guidelines of care for the management of acne vulgaris – PubMed.
- Moderate-Severe Acne Vulgaris.
Acne vulgaris is considered moderate to severe when presenting with prominent comedones (blackheads/whiteheads), large inflammatory papules, pustules and nodules with associated scarring affecting multiple body areas. Topical and systemic therapies are the primary treatment. Systemic therapies for acne include oral antibiotics (primarily tetracyclines) and hormonal therapies (such as spironolactone or oral contraceptives for female patients). Systemic therapy is often combined with topical therapy, as already discussed for mild cases, except for oral isotretinoin, which is prescribed in isolation but occasionally with a course of oral steroids to avoid an isotretinoin-induced acne flare. The use of isotretinoin for acne – an update on optimal dosing, surveillance, and adverse effects – PubMed
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