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Acne Vulgaris

Definition

The skin manifestation of pilosebaceous unit or follicular duct plugging with excess sebum, cell debris, Propionibacterium acnes, staphylococcal bacteria, and perspiration.

History

Symptoms: Whiteheads, blackheads, pimples, and larger bumps of the face, chest, and/or back.

General: Usually unresponsive to over-the-counter (OTC) treatments.

Age: Typically adolescent or young adult, occasionally older adult; also an infantile form.

Onset: With puberty and the maturing function of sebaceous glands or sudden with significant physical or emotional stress.

Duration: Weeks, months, years, or longer.

Intensity: Anything from a few comedones to heavy coverage with scarring cysts.

Aggravating Factors: Physical stress including lack of sleep and poor diet, hormonal changes, fever, emotional stress and illness, scrubbing or rubbing hard, pinching, or any kind of pressure. Not specific to foods or touching.

Alleviating Factors: Sometimes from OTC medications or from improved physical/mental health and tincture of time.

Associated Factors: Chemical contact as in hair care chemicals, especially hairspray, and some medications especially Lithium. Genetically disposed skin.

Physical Examination

General: The patient is in no acute distress. Skin lesions may be readily apparent on exposed skin areas.

Skin: Open and closed comedones of any facial areas including ears, chest, and/or back. Red papules and/or pustules of face, chest, and/or back. Cystic nodules of any or all of the same areas. Occasional pit or small crater depression. Scars, usually on face or back. Rare keloid scars of jaw, neck, and/or back and chest.

Pathophysiology

Nerve energy or physical factors directly stimulate sebaceous glands. This increases size and sebum production which becomes too much for the follicular ducts. They plug with the excess sebum, cell debris from the duct and skin, and bacteria. A simple oil plug is either open or closed. An open duct oxidizes the oil and it turns dark, hence a blackhead. If the duct is covered with a thin membrane the oil dries white, hence whiteheads. Mixing with the microbes, cell debris or other chemicals yields red papules and pustules. Cysts are formed when the plug is so tight that the duct expands and breaks with continued sebum production and the body forms a wall around the collection.

Diagnostic Studies

None.

Differential Diagnosis

Traumatic: Not applicable.

Infections

Folliculitis due to bacteria or fungi: Will be more widespread including extremities and involve the scalp. Pustules tend to be uniform and smaller than acne vulgaris. No comedones or cysts.

Early impetigo: Exhibits pustules but spread into broader weepy crusted maculopapular plaques and may be anywhere on the body; also no comedones or cysts.

Metabolic

Steroid and chloracne: Marked by known systemic or contact exposure to offending drugs or chemical. The red papulopustules are in small group areas or more widespread over body.

Acne rosacea: Usually of middle aged adults. Inflammatory and confined to cheeks, nose, and forehead, with no significant comedones or cysts.

Neoplastic: Not applicable.

Vascular: Not applicable.

Congenital: Not applicable.

Acquired: Not applicable.

Acne Treatment

For comedones only, use Benzoyl peroxide 10 percent twice a day after wash. For treatment of all forms of acne, wash with some brand of acne soap or other mild soap (e.g., Purpose 2 to 3 times a day or more). For all inflammatory forms of acne add: Tetracycline 500 mg twice a day for 2 months minimum or Minocycline 100 mg every day for 2 months minimum, or Bactium DS with one tablet twice a day for 2 months minimum, or

Erythromycin 500 mg twice a day for 2 months minimum,or Doxycycline 100 mg every day for 2 months minimum. Oral medications take 6 to 8 weeks to reach full effectiveness in acne treatment., Some may flare the condition in the first 2 to 4 weeks. Also add or may use concurrently Topical antibiotic: Cleocin T solution, lotion or gel twice a day (or ATS, erygel, emgel, or benzamycin) after wash. Other preparations which may be helpful in early or late conditions: Retine A cream or gel thin layer on dry skin at bedtime. Inform the patient that a period of mild irritation and flakiness is normal which should pass in days to weeks.

Sulfacet R lotion or Novacet, at bedtime for active lesions. As a last resort for severe resistant, or severe scarring acne: Accutane 40 mg every day for 80 to 125 lbs. for 20 wks. Accutane 40 mg 2-1-2-1 alt. days for 125 to 170 lbs. for 20 wks. Accutane 40 mg twice a day for more than 170 lbs. for 20 wks.

Pediatric Considerations

Neonatal acne is attributed to a response to maternal androgens, and may be present at birth or, more commonly, appears by 4 to 6 weeks of age. The distribution is similar to adolescent acne, primarily on the face, chest, and back, and may last until age 4 to 6 months. Because it is self limited, no treatment other than reassurance is required.

Obstetrical Considerations

In the routine treatment of acne vulgaris with topical antiacne medications, there are no specific contraindications or known risks to the fetus, including the use of topical antibiotic preparations and the topical form of tretinoin (Retin-A). If oral medications are needed the antibiotic groups of the sulfonamides, erythromycin, and ciprofloxacin should be used with caution. Tetracycline is contraindicated. Isotretinoin (Accutane) is absolutely contraindicated in the pregnant patient due to high risk of spontaneous abortions, premasture births, and fetal death. This drug should not be administered to females of childbearing age unless the patient is using two approved forms of contraception (unless the patient has had a hysterectomy).

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