Acne & Acneiform Eruptions

Introduction
Sebaceous glands develop in the human body along with the hair and, hence, constitute the pilosebaceous unit. In some situations, the hair is lost and only the gland remains, eg, on the prepuce and on the nose. The main function of sebaceous glands is production of a material called sebum which has anti-bacterial and anti-fungal properties. One of the important constituents of sebum is fatty acids. These glands are distributed maximally on the scalp, face, axillae, chest and back. Diseases particular to sebaceous glands are maximally located in these areas. The glands are hormonally controlled, being stimulated by androgens and progesterone and inhibited by oestrogens. They, therefore, function most from puberty onwards. This is approximately the time when acne first appears. Acne begins with formation of a plug in the pilosebaceous opening described as a comedone (blackhead). It appears black because of oxidative changes in melanin and dirt accumulated from the outside environment. Should skin grow over the pilosebaceous opening, it may appear as a whitehead. Blackheads, and their variation whiteheads, should be considered within the physiological range of normality. With secondary breakdown of fatty acids by lipases contained in bacteria and fungi, inflammation in these comedones occurs and the acne is then described as inflammatory acne. This may go on to pus formation or develop into cysts (pilar cysts), which, owing to secondary infection, give rise to abscesses tunnelling below the skin surface of the affected sites. Lesions of acne may occur along with hydradenitis of the axillary region or wherever apocrine glands occur. Severe degrees of acne are seen with XYY chromosomal combinations and with immunoglobulin deficiencies. Healing of acne, particularly on the chest, may be accompanied by keloidal changes. Rosacea is a disorder characterised by easy ability to blush, which ultimately leads to forms of erythema and hyperplasia of skin tissue, eg, rhinophyma. Rosacea tends to be produced with emotional disturbances and is aggravated by solar exposure in the tropics and the mite Demodexfolliculorum, hence, the often dramatic respons~ to the application of crotamiton. Rosacea and acne may overlap and may at times simulate each other. The treatment of acne is based on control of bacterial population on the face with systemic administration of tetracyclines, erythromycin, cotrimoxazole and adequate local therapy. Oral retinoeic acid is advised in the most severe form of disease. Surgical drainage of abscesses, removal of comedones and use of peeling agents should be considered. Avoiding contact with mineral oils as in the treatment of oil acne or stopping the administration of corticosteroids in steroid-induced acne are the specific measures carried out in these situations.

Acne & Acneiform Eruptions

8.1 Acne vulgaris (grade I) Oily face with follicular plugs described as blackheads and called comedones. Acne vulgaris - papular (grade II) Small, erythematous folliculopapules on the face. Note the scarring, suggestive of recurrent attacks. Acne vulgaris (grade II) Erythematous, papular and pustular lesions on the chest. Lesions at this site, if irritated, tend to beconie keloidal. Papulopustular acne (grade II) Inflamed papules and pustules over the face are associated with scarring.

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Acne & Acneiform Eruptions

8.5 Acne vnlgaris - advanced stage Multiple papular and pustular lesions along with a few comedones, abscesses and scars of healed lesions. All stages of acne are present in this picture, hence, the difficulty in grading the disorder. Acne (grade III) Severely inflamed, widespread acne with scarrmg. Acne vnlgaris (grade IV) Prominent pustular acne. Note the grouping and coalescence. Acne vnlgaris - nodnlopnstnlar (grade IV) The differential diagnosis of this is pyoderma faciale.

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Acne & Acneiform Eruptions

3.9 Acne vulgaris - dominantly nodular Note the inflammatory nodules on the face. Shaving becomes difficult for such patients. Keloidal acne Keloids developing in a milieu of acne. This form of keloidal change following acne is common in the coloured population. Acne need not reach nodulo-cystic proportions to produce this effect. Oil acne Prominent follicular papules on the forearm of a motor mechanic. The most common cause of oil acne is contact with cutting oil and petroleum products, thus constituting an occupational hazard. Vegetable oils may rarely produce this. Oil acne Follicular papules, comedones and pustules over the thigh of a motor mechanic. Note the broken hair, a result of friction.

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Acne & Acneiform Eruptions

8.13 Steroid acne Folliculopapular acneiform eruptions on the trunk and arm of a subject on systemic corticosteroid therapy. Rosacea Erythematous, papular and nodular lesions on the face. Note telangiectasia on the tip of the nose.

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8.15 Acne mimicking rosacea Multiple, erythematous papules and pustules of acne mimicking rosacea.

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Rhinophyma This may be the result of long-standing rosacea or arise sui generis and probably has nothing to do with alcoholism. Demodex folliculorum is often isolated from these follicles.

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