Acne ###etiology & management.....how we prevent acne? Management of acne

 Acne

Introduction

Acne is chronic inflammation of the pilosebaceous units.

Epidemiology

Acne is a very common facial rash occurring in over 85% of adolescents and frequently continuing into early and midadult life.

Etiology

The cause is multifactorial. Some important factors are-

■ Follicular epidermal hyperproliferation

■ Blockage of pilosebaceous units with surrounding inflammation

■ Increased sebum production

■ infection with 

Propionibacterium acnes

.

Pathophysiology

■ Severity of acne is associated with sebum excretion rate, which increases at puberty.

■ Both androgens and progestogens increase sebum excretion and oestrogens reduce it,

Clinical features

Acne presents in areas rich in sebaceous glands such as the face often the trunk (back and sternal area)

The three cardinal features are:

1. Open comedones (blackheads) or closed comedones (whiteheads)

2. Inflammatory papules

3. Pustules

■ The skin may be very greasy (seborrhoea).

■ A premenstrual exacerbation of acne is sometimes noticed.

• Occasionally it can cause profound psychological disturbance and depression.

• There is a tendency for spontaneous improvement over a number of years but acne can persist unabated into adult life

Management

The aims are-

■ decreasing sebum production

■ decreasing bacteria

■ normalizing duct keratinization and

■ decreasing inflammation.

i. Regular washing with acne soaps to remove excess grease is helpful (normal soaps can be comedogenic).

ii. ‘Picking’ should be discouraged.

A. First-line therapy- (for mild to moderate disease)

• Keratolytics (Azelaic Acid, 20%Benzoyl Peroxide, ) or Topical Retinoids

(Isotretinoin 0.05% Topical)

,Tretinoin Topical

or

• etinoid-like agents (Adapalene 0.1)

• Topical antibiotics, e.g. 

Erythromycin solution or Clindamycin 

Caution:

All topical agents can cause irritation.

B. Second-line therapy

1. Low-dose oral antibiotic therapy 

often helps but must be given for at least 3–4 months.

Oxytetracycline 500 mg twice daily is often used first.

2. Minocycline100 mg daily,

3. Erythromycin 500 mg twice daily

        or

4. Trimethoprim 100 mg twice daily are also used.

C. Third-line therapy

Third-line treatment with an oral retinoid drug (Isotretinoin) should be given if:

■ the above measures fail

■ there is nodulocystic acne with scarring

■ there is severe psychological disturbance.

Retinoids are synthetic vitamin A analogues that affect cell growth and differentiation.

        Caution

☞They are very teratogenic.

(Isotretinoin is a ‘hospital-only drug’ in most countries due to its teratogenicity)

☞Restricted to the use of dermatologists

 and a few trained family doctors.

☞A pregnancy test, contraceptive advice

☞signed consent are mandatory prior to its use in fertile women, and

☞pregnancy testing must be repeated monthly during therapy.

☞Patients must avoid pregnancy during therapy and for 1 month after stopping isotretinoin

☞This drug caun cause drying of the skin, especially of the lips and nasal mucosa.

☞Hair thinning and exercise-induced myalgia are not uncommon.

☞Blood count, liver biochemistry and fasting lipids need to be monitored during therapy.

☞In a few individuals retinoids may cause depression.

         It is given as a 4-month course at a dose of 0.5–1 mg/kg per day.

      Advantage-

■ Isotretinoin has revolutionised the treatment of moderate to severe acne that has not responded adequately to other therapies.

Over 90% of individuals will respond to this therapy and 65% of people will obtain a longterm ‘cure’.

D. Other Options for Acne Management

A number of physical techniques are currently under assessment-e.g.

>Lasers

>blue light

>microdermabrasion

Caution/Disadvantage-

>they are not as effective as isotretinoin

>Expensive as repeat treatment always required.