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 :

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