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Definition :

  • Acne Vulgaris is a disease of pilosebaceous gland.
  • This is most commonly found in face, front, back of the chest.
  • Moreover this is also present in the gluteal area and buttock.

Age and other factors :

  • Acne vulgaris is extremely common malady in the teenagers.
  • About 80% of he teenagers are affected by acne vulgaris.
  • Most of the cases suffer only to a limited extent.
  • In such cases the patient treat themselves or by nondermatologists.
  • When the disease does not subside on itself or becomes complicated then the patient reports to the dermatologists.

Course of the disease :

  • Early lesion is a comedone which may be close or open.
  • The primary lesions are microcomedone are not visible with the naked eye.
  • But the microcomedones microscopically shows visible dilatation of the intrafollicular sebaceous ducts and sebaceous glands.
  • The enlarged sebaceous gland starts secreting large amounts of the sebum into the dilated follicle.
  • The enlarged sebaceous gland contains large amounts of bacteria.
  • The sebum contains esterified and also free fatty acids which is produced by action of enzymes associated with the action of P.acne.
  • This acts as the primary substance causing irritation.
  • With the increased production of triglycerides P.acne multiplies large in number.
  • They produce lipases in larger quantity that are responsible for hydrolysis of triglycerides to free fatty acid fraction leading to follicular hyperkeratosis.
  • And also this leads to rupture of the follicles.

Etiology :

  • Firstly, Increase sebum production.
  • Secondly, Colonization of P.acne
  • Thirdly, Hypercornification of ducts.
  • Inflammation
  • Production of androgens in body
  • Dihydrotestosterone converted from testosterone by the enzyme 5 alpha reductase
  • P.acne is a gram positive bacteria.
  • And also it is a pleomorphic and anaerobic rod.
  • Moreover its role in the sebum production is accepted as positive chemotactic effect on the neutrophils.
  • This leads to breakdown of sebum to free fatty acids by bacterial lipases.
  • But this bacteria is not involved in the formation of comedones but induces the inflammation immunologically.

Grading :

Grade 1 Comedones
Grade 2 Papules, Comedones, Few papules
Grade 3 Mostly Pustules
Grade 4 Nodules, Cysts, Abscess and Scarring
Sequelae Hypermelanosis, Hypertrophic keloidal scar

Clinical diagnosis :

  • Acne vulgaris may be present in various forms.
  • That is they may be Open and closed comedones, Papule, Pustule, Nodule, Cysts, Sinus, Scars, and conglobate lesions.
  • A comedone is most pathognomonic in acne.
  • Moreoever it is raised conical lesion with a broad base and plugged apex.
  • The plug maybe black (due to oxidized melanin).
  • Extraction of such comedones is easy.
  • Or this can be whitehead which is a close comedone and also extraction remains difficult.

Treatment :

  • Treatment of acne is of two types. They are
    • Local
    • Internal
  • Local treatment :
    • Objective
      • Aims to minimize the lesions as eradication of lesions completely is not possible.
    • Principle
      • Elimination of P.acne as far as possible to reduce lipase.
      • To remove obstruction of the follicles.
      • To reduce inflammation and also to decrease the activity of the sebaceous glands.
      • Moreover, To correct the overactivity of androgens if any.
  • Topical therapy :
    • Cleansers, Soap and also Water is sufficient in majority cases.
    • Deep cleansers may be used to remove the plugs.
    • Topical preparation are anticomedogenic, antiseborrheic and antibacterial.
    • Some Vitamin – A analogues like Retino – A cream .025 – 05% is used topically as a comedolytic agent.
    • But it is strong irritant to facial skin.
    • Topical Benzoyl peroxide in gel or lotion (2.5/5%) is an oxidizing agent and also bacteriostatic on P.acne and reduces hydrolysis of triglycerides.
    • Topical antibiotics are antiinflammatory in nature.
    • They inhibit P.acne but better act in combination with benzoyl peroxide gel.

Topical agents :

  • Tretinoin
    • It is Transretinoic acid – Vitamin A acid.
    • This came into use of about 25 years ago.
    • Moreover this is not used as Vitamin A in its therapeutic effect.
    • This causes,
      • Firstly, Increase in epidermal cell turn over,
      • Secondly, Decreases adhesiveness of epidermal cells,
      • Thirdly, Inhibits new comedone formation,
      • Eliminates old comedones,
      • Decreases total number of cell layer,
      • Decreases epidermal barrier function,
      • Finally, Increases penetration of other topical agents used together or subsequently.
    • Since it produces severe irritation patient must be cautioned regarding the irritation and also advise to use it in the alternative evenings.
  • Adapheline
    • Adalpheline – derivative of naphthoic acid and also selective retinoic acid analogue, used as a gel 0.1% gel.
    • It is not phototoxic in nature.
    • And also it does not degrade on sunlight.
    • It can be used along with the Benzoyl peroxide.
    • This also produces less irritation than the tretinoin and also reduces the inflammatory and non inflammatory lesions.
    • It reacts with only nuclear retinoic binding receptors RAR and also RXR belonging to thyroid and steroid receptors.
    • Whereas Tretinoin interacts both with cytoplasmic and also nuclear retinoic acid binding protein.
  • Tazarotene
    • After topical application it gets converted into tazarotenic acid and binds to nuclear retinoic acid receptor RAR beta and Gamma.
    • Moreover it reduces keratinocyte proliferation and also blocks proinflammatory and hyperproliferative transcription factors AP – 1.
    • And also Side effects are like Tretinoin.
  • Antibacterials
    • Acts by bacteriostatic action and also by suppressing the antiinflammatory actions.
    • It also minimizes the papules and pustules but no significant action to reduce cysts or comedones.
    • Erythromycin, Clindamycin and also Nadoxin are commonly used in cream or lotion.
    • All the local antibiotics must be used along with the oral antibiotics inorder to avoid the resistant strains.
    • And the antibiotic creams should not be used for a period more than 3 months.
  • Other topical agents like Azelaic acid may be used.
  • It reduces microbes, comedones, inflammation and also hyperpigmentation.
  • Moreover, Azelaic acid acts better when used along with the Benzoyl peroxide or Retinoids.

Acne surgery :

  • Comedone expression :
    • Gentle pressure with the comedo extractor rempves the comedones.
    • And also sometimes opening of the follicular and pustular lesions with a number 11 scalpel if done judiciously may help to heal the lesions.
    • Similarly judicious incision may shorten the duration of the lesion.
  • Microdermoabrasion :
    • Using aluminium oxide crystals and a dermabrader – reduces acne scar.
  • Ultraviolet rays :
    • Exposure to UVB may help in some patient.

Oral Medication :

  • Antibiotics when in use should be in full dose and also treatment of more than three months is not useful in grade 2,3,4 acne.
  • Common antibiotics are tetracycline 250/500 mg six hourly for 4 – 6 weeks, Doxycycline 1 gm a day, Minocycline 50 mg twice a day is helpful.
  • Moreover this antibiotic is lipid – soluble and penetrates sebaceous glands easily.
  • It causes blue discolouration of cysts after eight months.
  • Erythromycin 1gm a day is also effective all antibiotics have side effects like GI symptoms, Vaginitis, and also adverse drug reaction.

Oral Retinoids

  • Isoretinoin 1 gm/kg is highly effective in grade 3/4 acne vulgaris, it acts by reducing number of P.acne, by altering the follicular keratinization.
  • Drug induced acne – Drugs like steroid, INH, Lithium, Phenytoin, Cyclosporine A, Halogens may be produce acne form lesions.
  • Acne excoriee :Psychotherapy, Trifluoperazine may help in such cases.

Foods to be taken to control Acne :

  • Kale
  • Sweet Potatoes
  • Lemon
  • Pumpkin
  • Berries
  • Legumes
  • Papapya
  • Quinoa
  • Salmon
  • And also Cauliflower 
  

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