ACNE
Tattvamasi Parikh PGY1 Pediatrics
ACNE
• Acne is the most common skin disorder in the United States
• Affecting approximately 85% of young people between 12 and 24 years of
age.
Introduction
• Acne vulgaris (acne) is the most common skin disorder in the United States.
• The severity can vary from mild comedonal acne to fulminant systemic
disease that affects multiple organ systems.
• Acne often is a cause of permanent scarring, emotional distress, and
decreased self-esteem.
Epidemiology
• Acne vulgaris affects 40 million to 50 million individuals each year ; most common Adolescents.
• Approximately 85% of people between 12 and 24 years of age will have acne
• Adolescent acne usually begins with the onset of puberty, occurring earlier in girls than boys.
• Early on, blackheads and whiteheads predominate, and the midface, known as the T zone, is
involved typically.
• Later, inflammatory lesions become more prevalent, and the lateral aspects of the cheeks, jaw, back,
and chest are affected.
• Unfortunately, contrary to previous dogma, not all patients outgrow the condition.
Pathogenesis
• Acne is a chronic inflammatory process of the pilosebaceous unit.
• These units are concentrated on the face, back, and chest.
Pathogenesis of acne.
Basak S A , and Zaenglein A L Pediatrics in Review
2013;34:479-497
©2013 by American Academy of Pediatrics
Abnormal Keratinization
• Individual acne lesions begin with obstruction of the pilosebaceous unit in a process
known as comedogenesis.
• In acne lesions, overproduction and abnormal cohesiveness of these desquamated
epithelial cells leads to their retention within the follicle and subsequent obstruction of
the ostium. Termed microcomedones.
• Interleukin 1 and tumor necrosis factor α are produced by keratinocytes that become
activated in response to the disrupted epithelium caused by accumulating sebum →
Inflammatory process.
Abnormal Keratinization
• Comedones can be divided into open and closed subtypes (blackheads and
whiteheads, respectively).
• The open comedone is an easily visible, small, dome-shaped papule with a widely
dilated, black-appearing orifice.
• Closed comedones are small, white or flesh-colored papules with no surrounding
erythema.
• When they rupture, lead to the pustules, nodules, cysts, and scars seen in inflammatory acne.
Hormonal Stimulation of Sebum Production
• Production of sebum is controlled primarily by gonadal and adrenal androgen hormone
stimulation.
• Levels of dehydroepiandrosterone sulfate (DHEAS), testosterone, and
dihydrotestosterone notably increase at adrenarche, resulting in bigger sebaceous glands
that produce more sebum.
• As the sebum accumulates, microcomedones enlarge into visible comedones.
• Although hormones play a critical role in the pathogenesis of acne, most patients with
acne have normal circulating hormone levels.
Inflammation
• Inflammation leads to the characteristic papules and pustules of acne.
• Pustules
• Greater than 5 mm in diameter
• Nodules : tend to be seated deeper in the dermis.
• They may coalesce into sinus tracts.
• A person’s innate immunity plays a large role in acne, with factors such as β-defensins and
cathelicidins all contributing to resultant inflammation, which is a key determinant of scar
formation.
Bacteria
• Propionibacterium acnes
• These gram-positive, nonmotile rods are found deep within the sebaceous follicle.
• They produce chemotactic factors, proinflammatory mediators, and lipolytic enzymes
that break down sebum into immunogenic components.
• All of these agents serve to intensify inflammation at ruptured comedones.
• Hypersensitivity to P acnes also may play a part in the more severe forms of acne.
Environmental and Exacerbating Factors
• Stress
• activation of the hypothalamic-pituitary-adrenal axis and subsequent increase in androgen
production.
• Mechanical factors, such as skin occlusion from sports gear
• Premenstrual flares are common.
• Topically applied occlusive preparations, such as pomades and cocoa butter.
• Oils or greases in the work environment also can cause obstructive lesions
• Several medications worsen acne, including anabolic steroids, progestins, lithium,
isoniazid, hydantoin, and gold.
MYTHS and MISCONCEPTIONS
• Patients frequently are concerned about the effect of their diet on their acne.
• Diet’s role in acne currently is a hotly debated topic among acne researchers.
• Although substantiated dietary culprits may emerge in the future, several controlled studies to date
have refuted the value of dietary restrictions in limiting acne eruptions.
• Elimination of chocolate, soft drinks, milk, fatty foods, ice cream, and iodides; literature currently does
not support restrictions.
• A patient occasionally will insist on an apparent relationship btw a particular food and acne flare-ups.
• Another common misperception is that frequent face washing will improve acne.
Acne
Misconceptions
Corrected Myth Reality
Acne is infectious Acne is not contagious.
Make-up makes acne worse Noncomedogenic products are fine.
Squeezing pimples makes them go away increases the risk of scarring and can prolong
faster their presence by inciting inflammation
People of all ages can be affected by acne,
Acne only affects teenagers
and it may persist well beyond the teen years.
Clinicians often underestimate the
psychological effect of acne. For many
Acne is cosmetic patients with acne, it is devastating. Rare
subtypes of acne can be associated with
systemic illness.
Clinical Presentation
• Acne can occur at any age
• presentations can vary widely.
• clinical manifestations include comedones, pustules, papules, nodules, scars,
and dyspigmentation.
Neonatal Acne
• Affecting up to 20% of healthy neonates; Involvement usually is limited to the face
• Most often presents within the first 30 days of life
• This acneiform eruption is thought to be related to stimulation of sebaceous glands by maternal androgens
and colonization with yeast species.
• Malassezia furfur and Malassezia sympodialis
• Many pediatric dermatologists prefer the term neonatal cephalic pustulosis
• Most cases resolve spontaneously in several weeks and do not require treatment.
• In pronounced cases, ketoconazole cream, 2% or hydrocortisone cream, 1%, can be used.
• If true comedones or nodular lesions are noted, the child should be treated for infantile acne.
Neonatal acne.
Basak S A , and Zaenglein A L Pediatrics in Review
2013;34:479-497
©2013 by American Academy of Pediatrics
Infantile Acne
• Infantile acne usually has an age of onset between 3 and 6 months of life.
• An admixture of comedones, papules, and pustules is observed on the face
• Infantile acne results from physiologic increased production of adrenal and
gonadal androgens.
• Most infants have no hyperandrogenism.
• However, a complete hormonal evaluation is indicated in any infant with unusually
severe or persistent acne or other signs of hyperandrogenism.
• Most cases resolve by 2 to 3 years of age, with some lasting up to age 5 years.
Infantile acne.
Basak S A , and Zaenglein A L Pediatrics in Review
2013;34:479-497
©2013 by American Academy of Pediatrics
Infantile Acne
• Treat even mild cases of infantile, 50% of these infants can develop pitted scars on their cheeks .
• Treatment
• mild retinoid with benzoyl peroxide cream.
• washes and alcohol-based gels, should be avoided due to risk of irritation of skin and eyes.
• Treatment of more severe inflammatory lesions: oral erythromycin, azithromycin, or
trimethoprim-sulfamethoxazole
• For the rare cases of nodulocystic acne: referral to a dermatologist for oral isotretinoin is appropriate.
Mid-Childhood Acne
• In children between 1 and 7 years of age, new-onset acne is unusual.
• Hyperandrogenism should be ruled out
• Evaluation for causes of hyperandrogenism
• Congenital adrenal hyperplasia
• Gonadal or adrenal tumors
• Cushing syndrome
• Precocious puberty.
• Treatment is similar to that for adolescent acne
• Exception : tetracyclines due to the risk of teeth staining
Preadolescent Acne
• In children 7 years and older
• Acne often is the first sign of impending puberty, especially in girls.
• Acne can precede pubic hair, areolar budding in girls, testicular enlargement in boys.
• Most affected children have comedonal lesions that involve the T-zone.
• Therapy of acne in this age group follows the same algorithm as adolescent
acne.
Preadolescent acne.
Basak S A , and Zaenglein A L Pediatrics in Review
2013;34:479-497
©2013 by American Academy of Pediatrics
Adolescent Acne
• Comedonal acne
• Consists primarily of noninflammatory blackheads and whiteheads on face and, occasionally, back and chest.
• Papulopustular acne
• Characterized by erythematous papules and pustules 1 to 5 mm in diameter.
• Nodulocystic acne subtype
• Acne cysts that contain pus and serosanguinous fluid develop deeper within the skin --> nodulocystic acne
subtype
• Acne conglobata
• Severely afflicted patients, these lesions coalesce into complex cystic plaques, abscesses, and sinus tracts.
Adolescent Acne
• Acne fulminans: Rare and severe variant
•Occurring almost exclusively in boys between 13 and 16 years of age.
• Characterized by the abrupt onset of nodular and suppurative acne in association with systemic
manifestations, including fever, arthralgias, osteolytic bone lesions, myalgias, hepatosplenomegaly, and
severe fatigue.
• Laboratory abnormalities include leukocytosis and an increased erythrocyte sedimentation rate.
• Emergent evaluation by a dermatologist for initiation of therapy with systemic corticosteroids and
isotretinoin
• Refractory cases, systemic treatment with dapsone, infliximab, cyclosporine, and azathioprine has been
used as an alternative or adjunctive therapy.
Complications
• Postinflammatory hyperpigmentation and persistent macular erythema often
complicate the treatment of lesions and tend to persist for many months
• Topical retinoids can speed resolution of postinflammatory hyperpigmentation.
• Scarring is permanent -->results from fibrous contraction
• Scars on the face - sharply punched-out deep or shallow pits.
• On the trunk, residual lesions typically are small hypopigmented macules.
• Hypertrophic and keloidal scars can occur in susceptible patients.
Evaluation
• History
• Physical examination: include the back, chest, and facial skin.
• The general severity of acne can be categorized as mild , moderate , or severe.
Predominant
Grading Distribution Scarring Other Factors
Lesion Type
Few to several
comedones, few <1/4th face,
Mild None None
Evaluation scattered
papules
mostly T zone
of Acne Many papules
Severity Moderate
and pustules,
variable Roughly 1/2 face Few, shallow
Involvement of
the chest and
comedones, 1-2 back
nodules
Numerous
papules and
Moderate to
pustules and Drainage,
Face, back, extensive,
Severe nodules; variable
and/or chest hypertrophic
hemorrhage,
comedones; pain
and/or deep
sinus tracts
and/or cysts
Treatment algorithm for adolescent acne.
Basak S A , and Zaenglein A L Pediatrics in Review
2013;34:479-497
©2013 by American Academy of Pediatrics
Mild acne.
Basak S A , and Zaenglein A L Pediatrics in Review
2013;34:479-497
©2013 by American Academy of Pediatrics
Moderate acne.
Basak S A , and Zaenglein A L Pediatrics in Review
2013;34:479-497
©2013 by American Academy of Pediatrics
Severe acne.
Basak S A , and Zaenglein A L Pediatrics in Review
2013;34:479-497
©2013 by American Academy of Pediatrics
Therapy
• There is no single most appropriate therapy for acne vulgaris.
• Rather, treatment must be individualized
• Response to previously attempted therapies; degree of activity of the acne, patient distress,
likelihood of patient compliance, and severity of scarring.
• Patient education is vital.
• Debunking myths
• The essential need for prolonged adherence to therapy
• Emphasize the delayed and gradual nature of improvement.
Topical Treatments
• Topical treatments often are the first line of therapy for mild-to-moderate acne
• Are useful as part of combination therapy for more severe acne.
• topical medicines include antimicrobials, antibiotics, retinoids, and salicylic
acid.
• Topical medications are preventive and require 8 to 12 weeks of use to judge their
efficacy.
• The entire area affected by acne must be treated, not just current lesions, and
long-term therapy usually is required.
Fixed-dose combination therapies
• Several fixed-dose combination therapies are available to treat acne
• benzoyl peroxide– clindamycin
• benzoyl peroxide–erythromycin
• adapalene benzoyl peroxide
• tretinoin-clindamycin
Benzoyl Peroxide
• Is bactericidal for P acnes
• Comedolytic properties
• An excellent medication for patients with mild comedonal or inflammatory acne.
• Also prevents the emergence of antibiotic-resistant P acnes
• Available both with and without a prescription
• In concentrations ranging from 2.5% to 10%.
• For most patients, a single daily application of 5% is sufficient.
• Increasing to 10% occasionally provides greater efficacy but also increases adverse effects, which include
dryness, irritation, and erythema
Benzoyl Peroxide Adverse Reaction
• Adverse reactions include : stinging after application, erythema, peeling skin, and dry
skin.
• Contact dermatitis
• Will bleach clothing, towels, and bedding.
• The drug is rated pregnancy category C
Topical Retinoids
• Effective in promoting normal desquamation
• Will benefit patients who have both comedones and inflammatory lesions.
• Anti-inflammatory effect: inhibiting leukocyte activity and the release of proinflammatory
cytokines.
• They help in the penetration of other active ingredients, such as benzoyl peroxide and
antibiotics.
• Preferred agents in maintenance therapy.
• In patients with purely comedonal acne, they may be the only antiacne medication required.
Types of Retinoids
• Tretinoin, a vitamin A derivative
• Classified as pregnancy category C and generally is avoided during pregnancy.
• Adapalene
• Adapalene also is classified as pregnancy category C.
• Tazarotene
• Designated as pregnancy category X, tazarotene is contraindicated in pregnancy.
• Contraceptive counseling should be provided for all women of childbearing potential who are prescribed this
medication.
Retinoid Adverse Affect
• Most common: Irritation, redness, and dryness, all peaking at approximately 2 weeks of
use.
• In darker skin types, this inflammation can result in hyperpigmentation that can persist
for months.
• Patients must be warned that temporary worsening of acne can occur within the first
month of starting treatment and does not indicate medication failure.
• They should continue to treat through this phase, which will resolve spontaneously with
continued medication use.
• They also may have increased sensitivity to sunlight and should be diligent about sun
protection.
Topical Antibiotics
• Reduce concentrations of P acnes and inflammatory mediators
• Useful in treating mild to moderate inflammatory acne.
• clindamycin and erythromycin
• Sodium sulfacetamide is useful in patients whose acne has a rosacea component.
• Dapsone gel : is a newer topical agent
• Temporary orange or yellow discoloration of skin may occur if applied
concomitantly with benzoyl peroxide .
Topical Antibiotics
• Should not be used as monotherapy
• because of increasing antibiotic resistance.
• Should be used with concurrent therapy with benzoyl peroxide
• These combination demonstrate greater efficacy than either drug alone.
Salicylic Acid
• OTC formulations: washes, gels, creams, and pads.
• Salicylic acid is primarily a gentle comedolytic that can be useful in mild
comedonal acne.
• It is less effective than topical retinoids but also better tolerated.
Systemic Antibiotics
• They are effective for treating moderate or severe inflammatory acne.
• Antibiotics act via several mechanisms: decreasing P acnes, inhibiting bacterial lipases,
suppressing neutrophil chemotaxis, and reducing free fatty acid concentrations in
sebum.
• Tetracycline-class antibiotics are prescribed most commonly because they have
documented efficacy and a long history of use in acne.
• Other antibiotics, including erythromycin, clindamycin, trimethoprim-sulfamethoxazole,
azithromycin, and cephalexin, should be reserved.
General guidelines for oral antibiotic
• Avoiding the oral agent if a topical agent will suffice
• Avoiding concomitant oral and topical treatment with dissimilar antibiotics to avoid emergence of
cross-resistant P acnes.
• Oral antibiotics require 8 to 12 weeks
• Once disease activity has diminished and an effective topical combination routine is established, use of the
antibiotic can be discontinued.
• In patients who do not respond to oral antibiotics
• the possibility of resistant P acnes should be considered.
• To avoid development of resistant strains, patients should concomitantly use a benzoyl peroxide product while taking oral
antibiotics.
• A multipronged approach to acne using benzoyl peroxide, a topical retinoid, and an oral antibiotic often is
referred to as triple therapy.
Tetracycline-class antibiotics
• The most commonly adverse effect : gastrointestinal upset
• The medication cannot be taken with milk or food for adequate amounts to be absorbed into the body (ie, take at least
30 minutes before a meal or 2 hours after a meal).
• There is a risk of phototoxicity, esophagitis and vaginitis or perianal itching secondary to Candida albicans occurs in roughly 5%
of patients.
• To reduce the incidence of esophagitis, all of the tetracycline-class antibiotics should be taken with a full glass of water well before
bedtime or lying down.
• Pseudotumor cerebri can be a complication of tetracycline-class therapy, but rarely.
• Not approved for use in children younger than 9 years or pregnant women because these drugs can cause tooth discoloration
and bony abnormalities.
• For those patients who cannot take tetracyclines erythromycin can be considered. Gastrointestinal discomfort is common.
Doxycycline
• Photosensitivity
• patients must be cautioned to use meticulous sun protection.
• One advantage of doxycycline is that it can be taken with food, significantly
increases its tolerability and hence patient adherence.
Minocycline
• Minocycline also can be taken with food, and photosensitivity is rare.
• However, vertigo, dizziness, and headaches may occur.
• Rarely, a bluish dyspigmentation of oral tissues, nails, scars, teeth, and sclera can occur.
• Adverse effects ( rare and reversible ) : lupuslike syndrome, drug hypersensitivity reactions,
autoimmune hepatitis, and serum sickness–like reactions.
Oral Contraceptive Pills
• Combined oral contraceptive pills that contain estrogen and progesterone are another treatment
option for female patients with acne
• regardless of whether serum androgen levels are abnormal.
• The primary goal of these therapies is to oppose the effects of androgens on the sebaceous
glands.
• Results often take at least 3 months
• Acne may be exacerbated by endocrine disorders
• polycystic ovarian syndrome or metabolic syndrome
• Use of long-acting progestin implants or depot medroxyprogesterone acetate may actually worsen
acne.
Isotretinoin
• Orally administered vitamin A derivative
• Highly effective in treating recalcitrant nodulocystic acne and is the only acne therapy that
has curative potential.
• isotretinoin markedly inhibits sebum synthesis, decreases P acnes concentration,
inhibits neutrophil chemotaxis, and has comedolytic effects.
• Potent teratogen
• Is the most effective drug for treatment of severe acne unresponsive to conventional
therapy and can clear even severe acne in a 5- to 6-month treatment course.
• Many patients will remain clear after finishing therapy.
Isotretinoin Adverse Effect
• Nearly all patients will experience generalized skin dryness while using
isotretinoin, and cholesterol and liver enzyme abnormalities are common.
• serious adverse events:
• Suicidal ideation
• major depressive disorder
• inflammatory bowel disease
Scar Treatments
• many patients are concerned about scarring
• Actual scars will continue to remodel for several years, gradually becoming
subtler and less noticeable, although they will not disappear fully.
• For deeper scars:
• Options include chemical peels, microdermabrasion, injections, punch excision, or laser
resurfacing.
• Acne should be well controlled before scar-reducing procedures are pursued.
Miscellaneous Therapy
• Intralesional corticosteroid injections are effective in individual acne nodules.
• Physical modalities such as glycolic acid peels can be of benefit.
• Newer laser and intense pulsed light treatments can help with acne control.
• Limited data suggest that complementary therapies are of benefit.
• herbal agents such as tea tree oil (which may be effective topically but can cause contact dermatitis; oral ingestions can
produce confusion and ataxia)
• guggul (which is derived from the resin of a tree and has benefits in treating inflammatory acne)
• aloe vera (which helps diminish acne scars)
• witch hazel (an astringent agent)
• calendula (marigold)
• tea (used as a compress)
• lemon juice or cider vinegar (used as a face wash).
Follow-up and Maintenance
• Most patients with acne should be seen 3 to 4 months after initiating a
therapeutic regimene.
• Topical acne medications are safe to use indefinitely and are the preferred
long-term maintenance medications.
• Oral antibiotics generally should be used for up to 6 to 12 weeks.
Emotional Considerations
Questions?
Thank you!!!
