Andrews Chap 13-Acne

Acne

Neonatal Acne

  • Common condition developing days after birth.

  • Predominantly affects males.

  • Characterized by:

    • Transient facial papules or pustules.

    • Spontaneous clearance within days or weeks (Fig. 13.7).

Neonatal Cephalic Pustulosis (Infantile Acne)

  • Cases persisting beyond the neonatal period or occurring after 6 weeks.

  • Most cases remit by age 1 year but some extend into childhood and puberty.

  • Treatments for prolonged cases include:

    • Topical benzoyl peroxide, erythromycin, retinoids.

    • Severe cases may require oral erythromycin (125 mg twice daily) or trimethoprim (100 mg twice daily).

    • Oral isotretinoin effective in infantile acne.

Midchildhood Acne

  • Can evolve from persistent infantile acne or initiate after age 1.

  • More common in males.

  • Characteristics include:

    • Grouped comedones, papules, pustules, nodules.

    • Usually limited to the face (Fig. 13.8).

    • Duration can range from weeks to several years, occasionally leading to severe pubertal acne.

  • Often strong family history of acne; endocrine evaluation indicated for:

    • Preadolescent acne (ages 7-12).

Pathogenesis of Acne Vulgaris

  • Exclusive follicular disease primarily characterized by comedo formation:

    • Comedo formation occurs due to keratinous plug in follicles.

    • Triggered by hyperproliferation and abnormal keratinocyte differentiation.

    • Key factors:

      • Androgen stimulation of sebaceous glands.

      • Altered lipid composition.

      • Abnormal cytokine response.

  • Acne onset coincides with increased sebum secretion, particularly in women with hyperandrogenism.

Clinical Features of Acne Vulgaris

  • Primary lesions:

    • Comedones (blackheads and whiteheads):

      • Open comedones (blackheads): flat or elevated papules with dilated openings.

      • Closed comedones (whiteheads): yellowish papules requiring skin stretching.

  • Inflammatory lesions:

    • Papules and pustules of 1-5 mm in size.

    • Nodules and cysts can occur, leading to plaques with pus discharge.

  • Resolution may leave post-inflammatory hyperpigmentation (Fig. 13.4).

  • Acne Scarring:

    • Includes various types: ice pick scars, atrophic scars, hypertrophic scars, and keloids.

Distribution of Acne

  • Affects the face, neck, upper trunk, and arms.

  • Begins at puberty, with common initial sites being cheeks, forehead, and nose.

  • Young men tend to experience more severe cases compared to young women.

  • Women may have cyclic exacerbation pre-menstruation.

  • Adult acne can occur, especially in women aged 20-35, often with hormonal aspects.

Diagnostic Considerations

  • Hormonal disorders:

    • Consider evaluations for deficiencies or excesses if acne occurs severely or early.

    • Diagnoses include:

      • Polycystic ovarian syndrome (PCOS): need for criteria fulfillment (irregular menses, hirsutism, etc.).

    • Tests may include hormone levels and ultrasound evaluations.

  • Go for workup in patients with acne onset between 1-7 age unless external factors identified.

Treatment Principles

  • Detailed history-taking of previous treatments including OTC products.

  • Understand potential worsening agents:

    • Corticosteroids, anabolic steroids, neuroleptics, and various antihypertensives can provoke acne.

    • Family history and prior scarring needs evaluation.

Topical Treatments

  • Topical retinoids are effective for prevention and treating current lesions.

  • Benzoyl peroxide known for antibacterial effects without developing resistance.

  • Combo Therapies:

    • Use of dual-action products combining retinoids with anti-inflammatories or antibiotics to limit irritation.

    • Isotretinoin as a systemic option for severe cases and persistent acne.

  • Hormonal Treatments:

    • Useful for women (e.g., oral contraceptives, spironolactone).

Dietary Influences and Skin Care Recommendations

  • Diets high in glycemic index or dairy may exacerbate symptoms.

  • Avoid using abrasive cleansers or scrubs which might worsen acne.

  • Non-comedogenic cosmetics recommended to prevent further clogging of pores.

Psychological Considerations

  • Acne has psychological implications; depression may arise from stigma associated with visible lesions.

  • Support from family or mental health professionals advised.