ACNE

Introduction
 One of the commonest skin conditions seen
 Affects more than 80% people at some point in
their life
 Easily diagnosed
 May affect mental and social well being
 Successful management requires correct
etiological evaluation
Acne vulgaris

Definition:

Acne is a chronic inflammatory disease of the

pilosebaceous units, characterized by
seborrhoea, formation of comedones,
erythematous papules, pustules & less
frequently by nodules, cysts and scarring
Epidemiology

 Typically occurs around adolescence

 Physiological acne are considered as a normal
variant of maturation
 85% people in the age group of 12 to 24 have
some form of acne
 30% of them have acne of sufficient severity to
require some form of treatment
Pathogenesis of acne

 Increased sebum production

 Hypercornification of the pilosebaceous duct

 Colonisation of the duct with Propionibacterium

acnes

 Inflammation
1. Seborrhoea

 Increased androgenic sex hormones of gonadal

/ adrenal origin at puberty (and in women with
polycystic ovarian disease)

 Abnormal end-organ response to normal level

of hormones

 Abnormal composition of sebum

 Target organ sensitivity
 Six major enzyme systems are
involved in cutaneous androgen
metabolism, namely –

 1) steroid sulfatase
 2) 3 beta-hydroxysteroid dehydrogenase
 3) 3 alpha-hydroxysteroid dehydrogenase
 4) 17 -hydroxysteroid dehydrogenase
 5) 5 alpha–reductase type 2
 6) aromatase.
Normal sebum composition

 30 to 50% Triglycerides

 25 to 30% Wax ester

 15 to 30% Free fatty acids

 12 to 20% Squalene

 3 to 6% Cholesterol ester

 1.5 to 2.5% Cholesterol

 Functions of sebum
 In humans, sebum is important for –

 Photoprotection

 Antimicrobial activity

 Delivery of fat-soluble anti-oxidants to the

skin surface

 Pro- and anti-inflammatory activity exerted

by specific lipids
Sebum in acne gets
abnormal…
2. Comedogenesis
 Abnormalities in proliferation and differentiation
of ductal keratinocytes
 Retention of keratinocytes
 Increased cohesiveness
 Formation of the microcomedone
 (Brown)

(Yellow)
 Basic lesion in Acne -- Comedo

 Definition: A plug of keratin, sebum &

bacteria in a dilated pilosebaceous orifice

 Types:
closed (whiteheads)
open (blackheads) – black because of
oxidation of melanin
3. Propionibacterium acnes

 Resident Gram positive anaerobic bacteria which

colonises the pilosebaceous duct more & more in
the presence of seborrhoea
Propionibacterium acne
4. Inflammation
 Cytokines
 P.acnes & free fatty
 In moderate and severe cases there is rupture of
the duct and a macrophage giant cell foreign body
reaction
 Grades of Acne (Pillsburry’s classification)
 Grade I: comedones (open or closed), occ.
papules

 Grade II: papules, comedones, few pustules

 Grade III: predominant pustules,

abscesses

 Grade IV: mainly cysts, nodules, scars

With every grade of acne, the possibility of
scarring becomes greater.
White comedone --
Grade 1
White + Black comedone – Grade 1
Papules & PIH – Grade 2
Papules & scars – Grade 2
Pustules – Grade 3
Pustules – Grade 3
Nodules – Grade 4
Cysts – Grade 4
Cyst – Grade 4
Acne scars

Acne scars can be classified as :

 Depressed – Rolling , Box car, Ice pick

 Hypertrophic

 Keloids
Rolling scars
Boxcar
scars
 Ice-pick scars

Boxcar scars
Hypertrophic
scars
Keloids
Hyperpigmentation (PIH)

 In patients paticularly with type III / IV / V skin,

hyperpigmented macules (PIH) may persist
following the resolution of inflammatory acne
lesions

 Similar to scarring, incidence of PIH goes up

because of fiddling with the lesions which leads
to increased inflammation
PIH
PIH
 Uncommon Variants of Acne
 Acne excoriee  Late onset acne/endocrine
acne (PCOS)
 Acne conglobata
 Cosmetic/pomade acne
 Acne fulminans
 Acne mechanica
 Gram negative
folliculitis
 Tropical acne
 Pyoderma faciale
 Occupational
 Infantile acne acne/chloracne

 Drug induced acne/

acneiform eruption
Acne excoriee
Acne conglobata
Acne conglobata
Acne conglobata
Acne fulminans
Acne fulminans
Gram negative folliculitis
Pyoderma faciale
Pyoderma faciale
 Acne before puberty

 Neonatal acne

 Infantile acne

 Childhood acne
Neonatal acne
Infantile
Infantileacne
Acne
Childhood Acne
Acne with PCOS
PCOS
PCOS
Acne cosmetica
Pomade Acne
Acne mechanica
 Tropical acne
 Military personnel serving in the hot
climates, cooks, bakers etc are prone.

 Its onset is more abrupt and it is usually

more severe.

 The individual lesions are frequently of cystic

& deep-seated pustules develop, resulting in
deep scarring.

 Common on body
 Occupational acne
 Group 1 - petroleum  oil acne
and its derivatives,
especially all
compounds found in
crude oils, cutting oils,
metal working oils.

 Group 2 - certain coal-  coal-tar acne

tar products

 Group 3 - halogenated  chloracne.

aromatic compounds,
like polychlorinated
biphenyls
Drug induced acne
 Papules and pustules, comedones usually absent

 Drugs implicated:
◦ Halogens
◦ Androgens
◦ Steroids
◦ OC pills
◦ INH,Rifampcin
◦ Lithium
◦ Phenytoin
◦ PUVA
Cushingoid face with hypertrichosis with
subsiding acne
Nevus comedonicus
Nevus comedonicus
Senile comedones
Senile comedones
 Differential Diagnosis

 Rosacea  Tuberose sclerosis

 Pityrosporum  Milia
folliculitis
 Trichoepithelioma
 Pseudo-folliculitis
 Syringoma
 Sycosis barbae
 Keratosis pilaris
 Perioral dermatitis
Only flushing
Topical steroid
(used for
melasma)
induced Rosacea
Pityrosporum folliculitis
Pseudofolliculitis
barbae
Sycosis barbae
Perioral Dermatitis
Adenoma sebaceum- Tuberous sclerosis
Milia
Trichoepithelioma
Syringoma
Keratosis pilaris
KP Rubra
LMDF
Acne Keloidalis Nuchae
Hidradentis
suppurativa
Abscess with
scarring
 Guidelines of treatment of acne vulgaris

 Acne assessment ( for severity)

 Patient education

 Discussion of goals of treatment and patient

expectations

 Choice of therapy
Homoeopathic remedies
Berb aq
Bovista
Brom
Carbo ani
Calc sulp
Kali brom
Medorr
Nux vom
Psor
Pils
Sulp
 Management of acne scars

Non-surgical Surgical
 Subcision
 Chemical peel  Dermabrasion
 Cryo peel  Punch elevation
 Microdermabrasion  Punch graft
 Dermaroller  Punch excision

Laser – Ablative/ Non-ablative

Thank you