Your next patient is a 16 year old William Slater who has suffered from facial skin problems for the last 12 months and it is not getting better. (See provided picture-acne vulgaris)YOUR TASK IS TO:• To take a history• Examine the patient • Arrange for appropriate investigations• Discuss the diagnosis and management with the patientHOPC: Will noticed about one year ago a few “blackheads” and “whiteheads” (comedones), and circumscribed, solid elevation of the skin with no visible fluid, varying in size from a pinhead to 1 cm (papules). Over the last few months they have become worse and spread all over his face, forehead and also on his shoulders. Sometimes he accidentally scratches the papules and they then become infected and crusty. Recently he also developed pimples (pustules, small elevations of the skin containing cloudy or purulent material usually consisting of necrotic inflammatory cells. These can be either white or red.)
PHx.: unremarkable
FHx.: his father had severe acne as a teenager
SHx: high school student, lives with his parents and two younger sisters, no problems, no alcohol, non smoker, no recreational drugs, NKA.
EXAMINATION: except for the obvious acne he looks quite well and healthy, normal vital signs.
INVESTIGATIONS:
DIAGNOSIS: ACNE VULGARIS
Acne vulgaris is a common skin problem, affecting most adolescents and many adults with formation of comedones, papules, pustules, nodules, and/or cysts as a result of obstruction and inflammation of pilosebaceous units (hair follicles and their accompanying sebaceous oil gland). It most often affects adolescents.
Diagnosis is by examination. Treatment is a variety of topical and systemic agents intended to reduce sebum production, infection, and inflammation and to normalize keratinization.
Pathophysiology:
Acne occurs when pilosebaceous units become obstructed with plugs of sebum and desquamated keratinocytes, then colonized and sometimes infected with the normal skin anaerobe Propionibacterium acnes or Corynebacterium acne They produce lipase with the result of free fatty acids which can provoke inflammation or infection.
Comedones, uninfected sebaceous plugs impacted within follicles, are the signature of noninflammatory acne. They are termed open or closed depending on whether the follicle is dilated or closed at the skin surface.
Inflammatory acne comprises papules, pustules, nodules, and cysts.
Papules are circumscribed, solid elevation of skin with no visible fluid, varying in size from a pinhead to 1 cm. They can be either brown, purple, pink or red in colour. The papules may open when scratched and become infected and crusty
Pustules occur when active P. acnes infection causes inflammation within the follicle. Nodules and cysts occur when rupture of follicles due to inflammation, physical manipulation, or harsh scrubbing releases free fatty acids, bacteria, and keratin into tissues, triggering soft-tissue inflammation.
AETIOLOGY:
The most common trigger is puberty, when surges in androgen stimulate sebum production and hyperproliferation of keratinocytes. Other triggers include hormonal changes that occur with pregnancy or throughout the menstrual cycle; occlusive cosmetics, cleansing agents, and clothing; and humidity and sweating. Associations between acne exacerbation and diet (eg, chocolate), inadequate face washing, masturbation, and sex are unfounded. Some studies question an association with milk products. Acne may improve in summer months because of sunlight's anti-inflammatory effects. Proposed associations between acne and hyperinsulinism require further investigation.
Symptoms and Signs:
Cystic acne can be painful; other types cause no physical symptoms but can be a source of significant emotional distress. Lesion types frequently coexist at different stages.
Comedones appear as whiteheads or blackheads. Whiteheads (closed comedones) are flesh-colored or whitish palpable lesions 1 to 3 mm in diameter; blackheads (open comedones) are similar in appearance but with a dark center.
Papules and pustules are red lesions 2 to 5 mm in diameter. In both, the follicular epithelium becomes damaged with accumulation of neutrophils and then lymphocytes. When the epithelium ruptures, the comedone contents elicit an intense inflammatory reaction in the dermis. Relatively deep inflammation produces papules. Pustules are more superficial.
Nodules are larger, deeper, and more solid than papules. Such lesions resemble inflamed epidermoid cysts, although they lack true cystic structure.
Cysts are suppurative nodules. Rarely cysts become infected and form abscesses. Long-term cystic acne can cause scarring that manifests as tiny, deep pits (“icepick scars”), larger pits, shallow depressions, or areas of hypertrophic scar.
ACNE CONGLOBATA is the most severe form of acne vulgaris, affecting men more than women. Patients have abscesses, draining sinuses, fistulated comedones, and keloidal and atrophic scars. The back and chest are severely involved. The arms, abdomen, buttocks, and even the scalp may be affected.
ACNE FULMINANS is acute, febrile, ulcerative acne, characterized by the sudden appearance of confluent abscesses leading to hemorrhagic necrosis. Leukocytosis and joint pain and swelling may also be present.
DIFFERENTIAL DIAGNOSIS:
• Rosacea (in which no comedones are seen)
• corticosteroid-induced acne (which lacks comedones and in which pustules are usually in the same stage of development)
• perioral dermatitis (usually with a more perioral and periorbital distribution)
• and acneiform drug eruptions.
Acne severity is graded mild, moderate, or severe based on the number and type of lesions:
Classification of Acne Severity:
Severity Definition
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
Prognosis
Acne of any severity usually remits spontaneously by the early to mid-20s, but a substantial minority of patients, usually women, may have acne into their 40s; options for treatment may be limited because of childbearing. Many adults occasionally develop mild, isolated acne lesions. Noninflammatory and mild inflammatory acne usually heals without scars. Moderate to severe inflammatory acne heals but often leaves scarring. Scarring is not only physical; acne may be a huge emotional stressor for adolescents who may withdraw, using the acne as an excuse to avoid difficult personal adjustments. Supportive counseling for patients and parents may be indicated in severe cases.
MANAGEMENT :reducing sebum production, comedone formation, inflammation, and infection:
• Support and counseling: factual patient education about acne (see above) and acne should not be dismissed as minor problem but dealt with in a sympathetic manor and the patient should be reassured that treatment is available!
• Mild inflammatory acne:
a) unblock the pores (follicular ducts) with benzoyl peroxide, sulphur compounds, salicylic acid (5-10%) or retinoid acid (tretinoin) gel, cream or lotion, improvement should happen in 1-2 months!
b) Topical antibiotics (clindamycin, erythromycin)
• Moderate acne: as above and the addition of oral antibiotics (tetracyclin, clindamycin, erythromycin, doxycyclin) for 3-6 months. Consider oral hormones (combined OCP) for female patients.
• Severe cystic or recalcitrant acne:
Oral isotretinoin (Roccutane, teratogenic, photosensitivity!!!)
Affected areas should be cleansed daily, but extra washing, use of antibacterial soaps, and scrubbing confer no added benefit. Changes in diet are also unnecessary and ineffective, although moderation of milk intake might be considered for treatment-resistant adolescent acne.
How various drugs work in treating acne.
Treatment should involve educating the patient and tailoring the plan to one that is realistic for the patient. Treatment failure can frequently be attributed to lack of adherence to the plan and also to lack of follow-up. Consultation with a specialist may be necessary.
Scarring: Small scars can be treated with chemical peels, laser resurfacing, or dermabrasion. Deeper, discrete scars can be excised. Wide, shallow depressions can be treated with subcision or collagen injection. Collagen implants are temporary and must be repeated every few years.
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