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Acne Vulgaris definition 

Acne is a skin condition that occurs when your hair follicles become plugged with oil and dead skin cells, it is characterized by non-inflammatory and inflammatory legions and it affects mainly teenagers, though it occurs at any age.

Acne causes

The main cause of acne is genetic predisposition; all other factors are aggravating factors.

Aggravating factors of acne

There is many factors aggravate and increase the severity of acne such as; heat, humidity, pressure on acne legions, friction of the legions, some cosmetics and some drugs such as corticosteroids.

Is diet related to acne?

There is foods induce and increase the severity of acne in most patients; eg: dairy products and foods with high glycemic index.

 

Also some foods may trigger acne in some patients but not in all patients (vary between patients such as; chips, bagels and chocolate).

Is hygiene related to acne?

No, hygiene never related to acne, even aggressive washing worsen acne legions because aggressive washing removes the sebum from the face resulting in increased sebum production.

Pathogenesis of acne vulgaris

There are 4 steps of developing acne 

 

1- Increased sebum production.

 

2- Hyperproliferation of ductal epidermis.

 

3- Colonization of P.Acne.  

 

4- Inflammation.  

 

Sites of acne legions

 In most patients acne develops in the face, but some patients may suffer of acne on their chest, shoulder or upper back.

 

Types of acne legions 

• Non-inflammatory legions: closed comedons (white heads) and opened comedons (black heads).
  
• Inflammatory acne legions: papules, pustules, nodules and cysts.

Classification of acne

According to severity of acne, acne is classified into 3 classes: Mild, moderate and severe acne.

• Mild acne :

Also called comedonal acne, develops only in the face.

 

It is characterized by non-inflammatory legions (white and black heads) and some inflammatory legions.  

 

• Moderate acne :

This type of acne may develop in the face and may develop in any other areas. 

 

It is characterized by greater number of inflammatory legions than mild acne.

 

• Severe acne :

Also called nodulocystic acne and it is characterized by nodules or cysts.

 

Acne complications 

1-      Hyperpigmentation of the inflammatory legions. 

 

2-      Risk of scaring.

Acne treatment and management

All antiacne drugs target one of/or the 4 pathogenesis steps of acne.

 

Most antiacne drugs affect the legions that yet not developed.

Patient counseling for acne patients 

1-      Avoid aggressive washing of the face. 

 

2-      Avoid the triggers of acne (pressure on legions, friction of the legions, foods aggravate the legions and comedogenic cosmetics). 

 

3-      Avoid manipulation or squeezing of acne legions.

 

4-      Use oil free, non comedogenic cosmetics.

Pharamacological treatment of acne 

•  Comedonal acne :
  

Comedonal acne includes mainly black and white heads, so drugs used in those patients target the 2 first steps (increased sebum production and hyperproliferation of ductal epidermis).

 

How to manage mild acne?

 

This type of acne is treated by topical drugs such as; Topical retinoids, topical azealic acid and topical salicylic acid

 

 According to guidelines; the first line therapy for induction of remission for comedonal acne is topical retinoid.

 

If the patient is pregnant or could not tolerate the adverse effects of topical retinoid, she can go for topical azealic or salicylic acid (alternatives).

 

Maintenance therapy: topical retinoids are the preferred drugs for maintenance of mild acne.

 

• Maculopapular acne (moderate acne) :

Drugs used for treatment of this type of acne must have antibacterial and anti-inflammatory effects.

 

How to manage moderate acne?

 

According to guidelines the patient should start with benzoyl peroxide alone or in combination with topical retinoid, if the patient is not responding to this combination he should add topical antibacterial such as; clindamycin or erythromycin.

 

If yet not responding even on this combination, replace topical antibacterial by systemic antibacterial such as; tetracyclines (minocycline, doxycycline and tetracycline) or clindamycin or sulfamethoxazole or macrolides (erythromycin and azithromycin).

 

If yet not responding, go for oral isotretinoin (isotretinoin is very effective therapy). 

 

Maintenance therapy: topical retinoid + benzoyl peroxide. 

 

• Nodulocystic acne (severe acne) :

This type of acne increase the risk of scaring and has very bad psychological impact on the patient, so the patient should start with very effective therapy such as oral isotretinoin.

 

How to manage severe acne?

 

According to guidelines, the patient should start with oral isotreinoin, specially those with very bad psychological impact.

 

Severe acne also can be managed as discussed above in moderate acne.

 

Maintenance therapy: topical retinoid + benzoyl peroxide.

 

• Reference :-

 

Pharmacotherapy principles and practice 4 edition.