Clinical Features

CHRONIC INFLAMMATORY DISEASE -

PILOSEBACEOUS FOLLICLES
Characterized by:
Comedones
Papules
Pustules
Nodules
Often scars
Comedo - Primary Lesion
Open comedones (blackhead) may be
seen as a flat or slightly elevated papule
with a dilated central opening filled with
blackened keratin
Closed comedones (whiteheads) are
usually 1-mm yellowish papules that may
require stretching of the skin to visualize.
Papules and Pustules
1 to 5 mm in size, and
are caused by
inflammation, so there
is erythema and edema.

They may enlarge,
become more
NODULAR, and
coalesce into plaques of
several centimeters that
are indurated or
fluctuant, contain sinus
tracts, and discharge
semsanguinous or
yellowish pus.

Light Skinned - lesions
often resolve with a
reddish-purple macule
that is short lived.

Dark-skinned - macular
hyperpigmentation
results and this may
last several months
Heterogeneous in
appearance.
Morphologies
Temples & Cheeks -
deep, narrow ice-pick
scars
Face - canyon-type
atrophic lesions
Trunk & Chin - whitish-
yellow papular scars
Neck & Trunk -
hypertrophic and keloidal
elevated scars
Primarily affects:
Face
most frequently on the
cheeks
lesser degree on nose,
forehead and chin
Ears - with large
comedones in the concha,
cysts in the lobes
Neck
Nuchal area large cystic
lesions
Upper trunk (picture)
Upper arms
Primarily a disease of the ADOLESCENT - 85% affected between 15
and 18.
Typically begins at PUBERTY FIRST SIGN of increased sex hormone
production.
8 to 12 years - comedonal in character, affecting primarily the forehead and
cheeks.
Middle Teenage Years - more severe inflammatory pustules and
nodules occur, with spread to other sites
Young Men - oilier complexion and more severe widespread disease
than young women.
Women - may experience a flare of their papulopustular lesions a
week or so before menstruation.
Before Age 25 General Involution

Neonatal Acne
Common condition that
develops a few days
after birth, has a male
sex preponderance
transient facial papules
or pustules - clear
spontaneously in a few
days or weeks

Infantile Acne

Includes those cases that persist beyond the neonatal period or have
an onset after the first 4 weeks of life
It can extend into childhood, pubety or adult life
Childhood Acne
May evolve from
persistent infantile
acne or begin after age
2.
Uncommon and has a
male predominance.
Grouped comedones,
papules, pustules, and
nodules can occur
alone or in any
combination, usually
limited to the face
Often, has a strong
family history of severe
acne
Pathogenesis
Follicular disease
Principle abnormality - COMEDO formation.
Produced by the impaction and distension of the follicles
Androgens, alterations in lipid composition, and an abnormal
response to local cytokines are all hypothesized to be important.
Acne begins after sebum secretion increases and women with
hyperandrogenlc states often manifest acne
Mechanical or frictional forces can aggravate existing acne
retained cells block the follicular opening

lower portion of the follicle is dilated by entrapped sebum

disruption of the follicular epithelium

discharge of the follicular contents into the dermis

combination of keratin, sebum & microorganisms (Propionibacterium acnes)

release of proinflammatory mediators and the accumulation of T-helper
lymphocytes, neutrophils, and foreign body giant celIs

causes the formation of inflammatory papules, pustules, and nodules
Treatment General principles
Corticosteroids, anabolic steroids, neuroleptics, lithium, and cyclosporin
may WORSEN acne.
Lack of compliance most common cause of failure of treatment
Avoidance of specific foods is NOT necessary.
Scrubbing of the face will not only Increase irritation but may worsen
acne due to friction.
Utilization of only the prescribed medications and AVOIDANCE of
potential drying over-the-counter products, such as astringent, harsh
cleansers or antibacterial soaps, should be emphasized
Explaining how lesions form and the expected response to and duration
and possible side effects of treatment is key
Medical therapy
Systemic and topical Retinoids
Systemic and topical Antimicrobials
Systemic Hormonal Therapy
Topical treatment
As all topical treatments are
preventative - 6 to 8 weeks is
required to judge their efficacy.
The entire acne affected area is
treated, not just the lesions, and long-
term usage is the rule

Topical Retinolds
effective in promoting NORMAL
DESQUAMATION of the follicular
epithelium - thus they reduce
comedones and inhibit the
development of new lesions.
marked anti-inflammatory effect
Tretinoin
0.025% and .05% cream base
was the first of this group of agents to be used for acne.
Less irritating than gels and liquids
may take 8 to 1 2 weeks before improvement occurs.

Adapalene
well-tolerated retinoid-like compound which has efficacy equivalent to the lower
concentrations of tretinoin

Tazarotene
comparatively strong in its action, but also relatively irritating.
it should be applied once at night or every other night

Benzoyl Peroxide.
potent antibacterial effect.
Its concomitant use during treatment with antibiotics will limit the development of
resistance, even if only given for short 2- to 7-day pulses.



Topical Antibacterials

Topical clindamycin and erythromycin
Well tolerated and are effective in mild-to-moderate inflammatory acne.
Use of topical antibiotics alone, however, is not recommended because of
increasing antibiotic resistance.
Concomitant use with a topical retinoid will hasten the response and allow for
more rapid discontinuance of them antibiotic.

Sulfur sodium, Resorcin & SSA
Useful and moderately helpful if newer medications are not tolerated

Azeleic Acid
Free from adverse actions and has mild efficacy in both inflammatory and
comedonal acne.
Oral Antibiotics
moderate-to-severe acne
Topical combinations have
failed or are not tolerated
It generally takes 6 to 8
weeks to judge efficacy
Starting at a high dose and
reducing it after control is
preferred
Working it eventually
control with topical retinoids
is ideal
Tetracycline
safest and cheapest choice
positive response in approximately 70% of patents.
given usually at an initial dose of 250 to 500 mg one to four times a day
best taken on an empty stomach, at least 30 min before meals and 2 hours
afterwards
Doxycycline.
The usual dose is 50 to 100 mg once or twice a day depending on the disease
severity.
Photosensitivity reactions are common
anti-inflammatory activity is being utilized but no antibiotic resistance results
because of the low dose.


Minocycline.
most effective oral
antibiotic in treating acne
vulgaris
alternatives for patients
whose P. acnes develops
tetrarcycline resistance
usual dose is 50 to 100 mg
once or twice a day
Side Effects: Pigmentation
in areas of inflammation, of
oral tissue in post acne or
scars, shin, sclera, nailbed,
ear, cartilage, teeth may be
seen

Erythromycin.
who cannot take tetracyclines because of side effects or in pregnant women
requiring oral antibiotic thempy
efficacy is low
initial dose is 250 to 500 mg two to four times a day


Clindamycin
excellent response in the treatment of acne
the potential for the development of pseudomembranous colitis and the
availability of retinoids has limited its use
initial dose is 150 mg three times a day

Bacterial Resistance
Strategies to prevent antibiotic resistance include limiting the
duration of treatment, stressing the importance:
good compliance
restricting the use of antibiotics to inflammatory acne
encouraging retreatment with the same antibiotic unless it has lost
its efficacy
avoiding the use of dissimilar oral and topical antibiotics at the
same time
Hormonal Therapy
Hormonal interventions in women may be beneficial in
the absence of abnormal laboratory tests.
Women with normal laboratory values often respond to
hormonal therapy
Oral Contraceptives
These agents block both adrenal and ovarian androgens.
Spironolactone
As pregnancy while on antiandrogen treatment will result in
feminization of a male fetus, spironolactone is usually
prescribed in combination with oral contraceptives
Effective in doses 25-200 mg/day

Dexamethasone
in doses from 0.125 to 0.5 mg given
once at night reduced androgen excess
and alleviated cystic acne

Prednisone
Although steroids may produce steroid
acne, they are also effective anti-
inflammatory agents in severe and
intlractable acne vulgaris.
Oral Retinoid Therapy
Isotretinoin
This drug is approved only for severe cystic acne
HOWEVER; it is useful in less severe forms of acne so as to prevent the need
for continuous treatment and the repeated office visits that many patients
require.
Dose is .5 to 1 mg/kg/day
Major advantage, only acne therapy that is not open ended ( open ended -
leads to remission, which may last many months to years)
Major side effect severe damage to fetus if given during pregnancy
* women should not become pregnant until off medication for at least a month
Psychological effects
Dry lips, skin, nasal and oral mucosa
Liver function should be checked at regular intervals
Intralesional Corticosteriods
Effective in reducing inflammatory nodules
Kenolog-10 ( Triamcinolone acetonide 10mg/ml) is best diluted with
sterile NSS to 2.5 mg/ml
Injecting less than 0.1 ml directly into center of the nodule will help
safeguard against ATROPHY and HYPOPIGMENTATION
Physical Modalities
Local surgical treatment is
helpful in bringing about quick
resolution of the comedones,
clinicians wait until after 2 or
more months of topical
retinoids to extract those that
remain.

Complications
Even with the excellent
treatment options available,
scarring may occur.
Pitted scan, and wide mouthed
depressions and keloids,
primarily seen along the jawline
and chest, are common types
Clinical Features
Persistent erythema:
convex surfaces of the face
cheeks and nose - most
frequently affected
brow and chin
Rosacea occurs most often in
light-skinned women between the
ages of 30 and 50
severe phymatous changes occur
in men.
Additional features commonly
manifested
telangiectasia
flushing
erythematous papules and
pustules.
Erythrotelangiectatic Type
Prominent history of a prolonged
(over 10 min)
Flushing reaction to various stimuli
emotional stress
hot drinks, alcohol, spicy foods
exercise
cold or hot weather
hot baths and showers
Burning or stinging sensation
accompanies the flush
The skin:
fine texture
may have a roughness
scaling of the affected central facial
sites
easily irritated
Papulopustular Subset
Strikingly red central face
Accompanied by erythematous
papules often surmounted by a
pinpoint pustule
History of flushing is also present in
most patients, but
Usually symptoms of irritancy are
not prominent

Glandular Rosacea
Men with thick sebaceous skin
predominate.
Papules are edematous
Pustules are often 0.5 to 1.0 cm in
size, and nodulocystic lesions
Tend to cluster in the central face
In affected women the chin is favored.
There is frequently a history of
adolescent acne and typical scar may
be seen.
Rhinophyma
Hypertrophic, hyperemic, large
nodular masses are centered
over the distal half of the nose.
Hugely dilated follicles contain
long vermicular plugs of sebum
and keratin
The histologic features:
pilosebaceous gland hyperplasia
with fibrosis
inflammation
telanglectasia.
ETIOLOGY
Remains UNKNOWN.
Most patients have ABNORMAL VASOMOTOR RESPONSE to thermal
and other stimuli
CHRONIC SOLAR DAMAGE is an important contributor in producing
damage to the dermal matrix and ground substance.
CHRONIC VASODILATION, EDEMA, and COMPROMISE of LYMPHATIC
DRAINAGE occur and lead to telangiectasia and fibrosis.
Other Clinical Considerations
Ocular Findings
Blepharitis
Conjunctivitis
Complaints of stinging, burning
and itchy sensation
Extrafacial Lesions
Flushing ears, lateral facial
contours, neck, upper chest, scalp
Pustules, and papules may be
present in scalp
Topical steroid use
Persistent erythema, papules and
pustules areas of application
Perioral dermatitis
Granulomatous lesions

Differential Diagnosis
Polycythemia vera
Carcinoid
Mastocytosis
Connective tissue disease

These conditions do not have associated papules and pustules, will manifest a
variety of systemic symptoms and extra facial signs, and specific laboratory
markers are available to confirm clinical suspicions.
TREATMENT
Topical products
Papulospustular patients and some with erythrotelangiectatic type
Tacrolimus scaly, irritated, erythrotelangiectatic skin
Retinoid repair sun damaged skin

Oral Antibiotics
Tetracycline control more aggressive papular and pustular lesions and aid in ocular lesions

Sunscreen
Applied each morning
Physical blockers are better than chemical blockers
*If induced by a specific trigger avoidance

Surgical approach
Reshaping rhinophyma heated scalpel, electrocautery, dermabrasion, laser abrasion

Laser
Usefeul treating erythema and telangiectasia
Treatment of Rosacea By Subset