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Information on Acne vulgaris
Acne vulgaris
Acne vulgaris is a common chronic skin disease
involving blockage and/or inflammation of pilosebaceous units (hair follicles
and their accompanying sebaceous gland). Acne can present as noninflammatory
lesions, inflammatory lesions, or a mixture of both, affecting mostly the face
but
Acne vulgaris has a multifactorial
pathogenesis, of which the key factor is genetics.[2] Acne develops as a result
of an interplay of the following four factors: (1) follicular epidermal
hyperproliferation with subsequent plugging of the follicle, (2) excess sebum
production, (3) the presence and activity of the commensal bacteria
Propionibacterium acnes, and (4) inflammation.[3]
Essential update: FDA warns of rare but serious
reactions to OTC acne products
The FDA has issued a warning that certain
over-the-counter topical acne products, including Proactiv, Neutrogena,
MaxClarity, Oxy, Ambi, Aveeno, and Clean & Clear may cause rare but serious
and potentially life-threatening allergic reactions or severe irritation. Users
who experience hypersensitivity reactions such as throat tightness, difficulty
breathing, feeling faint, or swelling of the eyes, face, lips, or tongue or who
develop hives or itching should stop using the products and seek immediate
emergency medical attention.[4, 5]
Signs and symptoms
Acne vulgaris is characterized by
noninflammatory, open or closed comedones and by inflammatory papules,
pustules, and nodules. Acne vulgaris typically affects the areas of skin with
the densest population of sebaceous follicles (eg, face, upper chest, back).
Local symptoms of acne vulgaris may include pain, tenderness, or erythema.
Systemic symptoms are most often absent in acne
vulgaris. Severe acne with associated systemic signs and symptoms, such as
fever, is referred to as acne fulminans. Severe acne, characterized by multiple
comedones, without the presence of systemic symptoms, is known as acne
conglobata. This severe form of acne frequently heals with disfiguring scars.
Additionally, acne vulgaris may have a psychological impact on any patient,
regardless of the severity or the grade of the disease.[6]
Diagnosis
Examination in patients with acne vulgaris
includes the following features:
Comedonal acne: Presence of open and closed
comedones but usually no inflammatory papules or nodules
Mild acne: Presence of comedones and a few
papulopustules
Moderate acne: Presence of comedones,
inflammatory papules, and pustules; a greater number of lesions are present
than in milder inflammatory acne
Nodulocystic acne: Presence of comedones,
inflammatory lesions, and large nodules greater than 5 mm in diameter; scarring
is often evident
Laboratory tests
Acne vulgaris is a clinical diagnosis. However,
laboratory testing may be indicated in the following situations:
Female patients with dysmenorrhea or hirsutism:
Consider a hormonal evaluation with levels of total and/or free testosterone,
dehydroepiandrosterone sulfate, luteinizing hormone, and follicle-stimulating
hormone
Cases refractory to treatment or when
improvement is not maintained: Culture skin lesions to rule out gram-negative
folliculitis
See Workup for more detail.
Management
Treatment of acne vulgaris should be directed
toward the known pathogenic factors, including follicular hyperproliferation,
excess sebum, P acnes, and inflammation. The most appropriate treatment is
based on the grade and severity of the acne.
Pharmacotherapy
The following medications are used in the
treatment of Propionibacterium acne vulgaris:
Retinoid-like agents (eg, topical tretinoin,
adapalene, tazarotene, isotretinoin)
Antibiotics (eg, tetracycline, minocycline,
doxycycline, trimethoprim/sulfamethoxazole, clindamycin, topical clindamycin,
topical erythromycin, daptomycin)
Selective aldosterone antagonists (eg,
spironolactone)
Estrogen/progestin combination oral
contraceptive pills (eg, ethinyl estradiol, drospirenone, and levomefolate;
ethinyl estradiol and norethindrone; ethinyl estradiol and norgestimate;
ethinyl estradiol and drospirenone)
Acne products (eg, erythromycin and benzoyl
peroxide, clindamycin and tretinoin, clindamycin and benzoyl peroxide, azelaic
acid, benzoyl peroxide)
When a topical or systemic antibiotic is used,
it should be used in conjunction with benzoyl peroxide or topical retinoid to
reduce the emergence of resistance.
Nonpharmacotherapy
Diet therapy, such as a low-glycemic diet and
avoidance of “junk foods,” has been suggested as a nonpharmacologic measure to
manage acne vulgaris.
Procedures
Procedural treatments for acne vulgaris include
the following:
Manual extraction of comedones
Intralesional steroid injections
Superficial peels that use glycolic or
salicylic acid
See Treatment and Medication for more detail.
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