Acne vulgaris pimples cystic acne

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Acne Vulgaris (Pimples)
Acne or pimples is a common skin condition, usually occuring at the age of puberty. The skin lesions consist of blackheads, whiteheads, and sometimes deeper boil-like lesions called nodules or cysts. The disease varies in severity and disease may continue beyond teen years.
What causes acne ?
There are four factors which cause acne
1.Increased male hormones at puberty
2. When hormone levels increase , the skin of the acne- prone person reacts by producing excess sebum (oils).
3.The bacteria called propionibacrteria on the skin increase in acitivity and alter these oils to produce substances that cause acne.
4. The hair follicle, the site of acne may get plugged with dead skin cells. Sebum and bacteria may accumulate and cause pimples.

A blackhead occurs when the trapped sebum and bacteria reaches the surface
of the skin and opens up.
Either way, blackheads and whiteheads are filled with trapped sebum and bacteria. The treatment advice is the therefore the same for both whiteheads and blackheads.
What are the types of acne ?
These include blackheads, whiteheads (comedones), the larger papules (pimples) and later, pustules and large cysts. Scars occur after papules, pustules and cysts.
Why should acne be treated?
Though acne is considered physiological , the lesions may heal with formation of different types of scars which may be permanent and often need expensive treatments. Hence all cases should be taken seriously and treated. Do not wait thinking that can will go by itself!!.
What should I do when I have acne ?
Consult your doctor early. Treatment depends on the type and severity of the acne. Follow the doctor's instructions.
Some antibiotics (tetracycline or erythromycin), which are effective for acne need to be taken on an 'empty stomach, to improve absorption. Some lotions or creams may make the skin red or flaky but usually this effect is temporary . Go back to see your doctor if the lotions or creams cause excessive redness and itchiness. Do not squeeze or scratch pimples. Do not attempt to cover pimples on the forehead with a fringe.
What are topical acne medications ?
They consist of peeling agents (sulphur), topical antibiotics (erythromycin, clindamycin, benzoyl peroxides) and topical vitamin A, ( Retino A ).

What are the oral treatments”?
For acne not responding to local creams, the following treatments are available:

Oral antibiotics such as tetracyclins, erythromycins, azithromycin are used. Note that these antibiotics are safe, and can b sued for long periods of time.
Oral hormones: Drugs containing oestrogens, antiandroegens are useful in girls who have acne with exessive hair and menstrual abnormalities.
For severe acne , isotretinoin( a drug related vitamin A) is very useful. This drug not clears acne even in most sever cases, but also may prevent acne.
Not that these drugs will have to be taken for several weeks or even months.

Can 'diet' cause acne ?
There is no concrete evidence that food causes acne. Following the strictest diet will not by itself clear your acne. On the other hand, a few people find that their acne seem to worsen when they eat certain foods, particularly chocolates, fried food and chillies. These people should avoid the foods that clearly aggravate their acne.
How should I clean my face ?
Remove surface oil from the face by washing with soap and water or with medicated cleansers. There is no need to use special soaps. Ordinary toilet soaps will do. Wash frequently when the face is oily, about three times a day. Continue washing even when you acne is cured. Do not wash with harsh soaps or brushes.
Can I use cosmetics when I have acne ?
Avoid oily and greasy cosmetics. Use water-based, oil-free cosmetics sparingly. You can use eyeliners, eyeshadows and lipsticks.
What if I have severe cystic acne ?
Do not despair. A new oral drug, isotretinoin, is available for the treatment of severe cystic acne. This medication can cause side effects and should be taken under the supervision of a dermatologist

Can acne be cured?
The new drug Isotretinoin can prevent acne for prolonged periods offering a near cure.

Is there any new treatment for acne?
There are new machines for treating acne-lasers and machine called Light and heat energy machine.These are effective in healing lesions quickly without any drug therapy.

Instructions: Do not squeeze pimples . Repeated cleaning will not help to remove acne.

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Acne vulgaris pimples cystic acne

Acne Vulgaris

What is acne vulgaris?
Acne vulgaris is called simply 'acne' or 'zits'. Acne is the most common skin problem people have. It occurs in almost all teenagers. As they grow older, their acne usually gets better. Sometimes people in their 20s, 30s, and 40s can get acne, but the older you are, the less likely you are to develop it

What are the symptoms of acne vulgaris?
People with acne usually have oily skin. They get marks, called 'eruptions', on their skin. These can be blackheads, whiteheads, or pimples with pus. Acne usually occurs on the face, chest, and back. If not treated, acne can leave lasting scars. This is why treatment is so important.

What tests are needed?
Your doctor will examine the acne. Most of the time, this is all that is necessary. Sometimes a sample of your blood will be taken and sent to a laboratory to be analyzed. This is done to learn if there are any unusual reasons for the acne or to help your doctor decide what kind of medicine is best for you.

What treatment is needed?

Many acne medicines are available. Your doctor may prescribe pills, cream, ointment, or lotion to apply to your skin. If the treatment doesn't work, your doctor may refer you to a dermatologist - a doctor who specializes in treating skin problems.
Do

Do wash your face gently twice daily with a mild soap cleanser
Do also wash after activities such as sports or exercise that make you sweat
Do use hair products, skin care products, and make-up that have 'oil-free' on the label
Do eat a healthy diet rich in fish, fruits, and vegetables. This can help make your skin less oily

Don't

Don't scrub your face with a washcloth
Don't squeeze or 'pop' the pimples, because this can leave scars
Don't wear tight clothes that rub against your skin, or use sporting equipment such as shoulder pads, helmets, and chin straps

Recovery time
Acne medicine should make your acne improve within a month, and your skin should clear up within 2-3 months.
Acne is worse between the ages of 16 and 18, and lessens as you grow older.

Source: http://svpediatrics.com/Documents/NelsonPtHandouts/Acne%20Vulgaris.doc

Further information on acne vulgaris can be found from:
American Academy of Dermatology
Link http://www.aad.org/

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Acne Vulgaris

Most common skin disease, affecting 80% of persons between 11 to 30 years old at some point
4.8 million patient visits per year
It can persist for years resulting in disfigurement and permanent scarringà emotional problems, societal withdrawal and depression

Pathophysiology

Begins in the prepubertal period, the adrenal glands mature (adrenarche) and secrete increasing amounts of androgensà increased sebum production
Sebaceous follicles located primarily on the face and trunk become obstructed by excessive amounts of sebum as well as excessive numbers desquamated epithelial cells from the wall of the follicle
The obstruction causes formation of a microcomedo which may develop into a comedones or inflammatory lesion
Propionibacterium acnes, an anaerobic organism, proliferates well in the obstructed follicleà chemotactic factors and proinflammatory mediators
With the development of gonads, androgen production and activity of the sebaceous gland increases
Most patients with acne probably have sebaceous glands which are hyper responsive to androgens
However patients with androgen excess (PCOS) frequently develop acne

Clinical manifestations

Earliest clinical expression of acne is usually noninflammatory comedones (blackheads and whiteheads) typically found on the central forehead, chin, nose and paranasal area
This usually occurs in preteen or early teenage years prior to colonization with P. acnes
Next, a mild form of inflammatory acne occurs in many early teenage patients in which there are scattered small papules and pustules with minimal inflammation
The inflammatory acne typically evolves into a more generalized eruption first on the face then on the trunk
A minority of patients will go on to develop a more destructive type of inflammatory acne associated with large deep nodules and cystsà potential scarring

Differential Dx

Acne vulgaris
Rosacea (note: absence of comedones and presence of telangiectasias)
Acne fulminans (d/o of adolescent malesà severe inflammatory acne, leukocytosis, elevated ESR, proteinuria and osteolytic lesions)
Pyoderma faciale (AKA rosacea fulminans) (d/o of abrupt appearance of many large pustules and furunculiod nodules; usually affects women under severe stress)
Adrenal excess (Cushing’s)
PCOS

Therapies

No topical therapies influence production of sebum (only hormonal and antiandrogen therapies)
Soaps, detergents and astringents remove sebum from the surface but do not alter production
Vigorous scrubbing can aggravate acneà inflammation and worsening
Gentle nonabrasive cleansing is best
Dietary factors do not influence sebum production and therefore have no role in the treatment of acne
Oil based cosmetics and hair products can worsen acne and should be avoided

Comedonal acne

Goal is prevention of progression
Topical retinoids: mechanism: normalize follicular keritinization and thus prevent new comedones
May cause local skin irritation so lowest strength should be used

Topical tretinoin (Retin A)

Can increase photosensitivity so should be used at night with sun screen

Adapalene (Differin): causes less irritation but is weaker
Salicylic acid: OTC
Tazorac

Contraindicated in pregnancy

Mild Inflammatory acne

Most patients respond to a topical antibiotic such as benzoyl peroxide or benzoyl peroxide plus erythro or clinda
The antibiotic have both anticomedomal and anti-inflammatory properties
Used BID for 2-4 weeks

Inflammatory acne

If inflammatory lesions are present along with comedonesà topical retinoid used q day along a topical or systemic antibiotic
If systemic antibiotics are used they should be continued for 2-4 months and weaned slowly while topical abx are applied

Tetracycline is preferred because of its low cost and high efficacy; usual dose is 500 BID

Must be taken on an empty stomach: Absorption is inhibited by food, dairy products and antacids
Contraindicated in pregnancy and in children <12 yo

Doxycycline and minocycline are other options

Can be taken at lower dose and with food
Doxy can cause photosensitivity and esophageal ulcerations

If acne persists:

Systemic isotretinion (Accutane)

Indicated for severe nodular cystic acne, acne without improvement after 6 months of oral abx, scarring or relapsing acne
Usual duration: 20 weeks
80 % will have a stable longterm remission after one course
Very teratogenic: every female must have 2 negative pregnancy test before starting and q monthly tests while on therapy
Sexually active women need two form of birth control while on therapy
Many Side effects: photosensitivity, dry skin depression (increased suicide risk), arthalgias, myalgias, pseudo tumor cerebri, decreased night vision, corneal opacities, hypertriglyceridemia and bone marrow suppression
Serum triglycerides, cholesterol, LFTs, CBC must be drawn prior to therapy and at regular intervals during therapy

OCPs: Decrease sebum production

Preparations which contain estrogen or antiandrogen progrestin are most effective
Must be used for 3-6 months

Antiandrogen: spironalactoneà decrease sebum production

Used at doses of 50-150 mg/day
Must monitor BP and potassium

Source: http://pediatrics.uchicago.edu/medpeds/documents/lectures%20(word%20files%20for%20future%20edit)/Acne%20Vulgaris.doc

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Acne vulgaris

The term "acne" was derived from a Greek word "acme". It means eruption of all sorts,. The word also means "peak" or "point".
Acne vulgaris is a skin disease and is caused by the clogging of pores with dead skin cells and oil. It is most common in teenagers, but may occur at any age. Most commonly it affects Face however other areas of the body may be affected with acne

Back
Chest
Legs.
Neck
Scalp
Shoulders
Upper arms

History
Early sources told us that acne has been a common factor effecting the skin in past. Even, records of acne occurrences were found in ancient Egypt. Even the Pharaohs of their time were noted to have had acne experiences. During the ancient times, several methods to cure acne have been found in ancient times. Remedies and treatments for acne were also common during that time.
In19th century, at the time of the Roman Empire, skin specialists used hot sulfurous mineral water to treat the acne lesions. This method was based on the fact that sulfur can dry the skin and can result into acne riddance for good.
several treatments for acne which were developed during past are being widely used at present. Examples are:

Benzoyl Peroxide is an early acne treatment dating back to the 1920's
Laxatives came out during the 1930's
Oral antibiotics were popular in the 1950's
1960 - 1980’s Vit A, Retin A, Accutane and Roaccutane
Laser treatment in the 1990's
In the new millennium era, spas and blue or red light therapy became more prevalent

Types of Acne Vulgaris
There are 2 different types of acne vulgaris, These are Noninflammatory and Inflammatory.

Noninflammatory lesions are called comedos and can result into whiteheads or blackheads. Whiteheads formed when trapped sebum and skin cells stay just below the skin's surface. Blackheads occur when the trapped sebum breaks through the skin's surface. This trapped sebum oil turns black when expose to dirt. Whiteheads and blackheads not contact to bacteria.

Inflammatory acne result into pimples and zits (papules and pustules) and in worst cases, nodules and cysts. Nodules are large, painful, solid lesions and lodged deep within the skin. Cysts also lay deep within the skin and filled with pus. Both types can produce scarring.

Symptoms of Acne
In non-inflammatory acne, only a few whiteheads and blackheads are present on the face. It can be treated effectively with nonprescription medicines. The majority of people with acne have this type of acne.
With inflammatory acne, whiteheads become inflamed, and red pimples and pustules develop. In its most severe case, inflammatory acne causes disfiguring cysts and deep, pitting scars of the face, neck, back, chest and groin

Stages of Acne vulgaris:
Mild acne: Fewer than 20 comedones, or Fewer than 15 inflammatory lesions, or total lesion count fewer than 30
Moderate acne: 20–100 comedones, or 15–50 inflammatory lesions, or total lesion count 30–125
Treatment: Mild and moderate acne is managed well by over-the-counter preparations such as:

Benzoyl peroxide dries up the oil; it works up by killing the bacteria P acnes.
Salicylic acid stop the shedding of the skin cells which lines the oil glands.
Rercinol and sulfur breakup the pimples.

Severe acne: More than 5 nodules, or Total inflammatory count greater than 50, or Total lesion count greater than
Treatment: oral medication, isotretinoin and is a synthetic derivative (made from chemicals) of vitamin A

It is the effective treatment for severe acne.
After four to six months of the treatment, the acne had disappeared in up to 90% of those treated.
But some times the acne may recur in some people, and another course of the treatment may be required.

Girls, Puberty and Acne:
In Girls many psychological changes takes place during puberty. These changes comprise of body composition, fat distribution, menstruation, cyst spurts, body and facial hair growth, body odor and skin changes. During puberty girls experience an augmented severity of acne from the bigger amount of oil secretions in the skin.

Factors effecting Acne Vulgaris:

Hormonal activity, such as menstrual cycles
Stress, which increases production of hormones from the adrenal (stress) glands
growth of dead cells of skin
Bacteria in pores,due to which the body becomes 'allergic'
Skin irritation or scratching of any type will activate inflammation
Use of anabolic steroids
Any drug contain halogens (iodides, chlorides, bromides), lithium, barbiturates, or androgens
contact to high levels of chlorine compounds, mainly chlorinated dioxins, causes severe, long-lasting acne, known as Chloracne
Diet

Hormonal effect:
Hormones are chemical messengers move from glands to cells and other parts of the body; it triggers biological reactions and functions. They play a role in adolescence during puberty.
Androgens trigger hair growth, libido, kidney functions, and sebum (oil) secretion in males.
Hormonal Acne:
acne first appears during adolescence, hormonal acne usually begins in the early-to-mid twenties and can carry on well into adulthood. When some oil producing hormones are triggered, acne breakouts occure. Typically, female skin tends to break out before or during the menstrual cycle. This is due to changes in hormonal levels. Adult hormonal acne causes much distress for many women, leading them to try acne scars cream. If the root cause of acne is known then internal treatments is possible.
The Biochemical Cause:
Hormones affect
Acne breakouts in women are due to the hormone androgen. Nearly half of all women experience acne flare-ups and increased facial oiliness during the week foregoing menstruation. As androgens are released previous to the menstrual cycle, sebaceous glands are stimulated and sebum is produced. If this sebum becomes trapped in the pores, pimples may result.
From the beginning of the menstrual cycle, estrogen levels in the female body increases. Approximately 36 hours before ovulation, these levels will reach to peak. This Androgen levels rise, converted into estrogen by the ovaries. This is why many women observe acne breakouts right before their menstrual cycles. The body needs the extra estrogen for ovulation to occur, and it is the male hormone, androgen that makes this extra hormonal kick possible.
Whenever hormones in the body alter, such as prior to menstruation, menopause, or during pregnancy, acne breakouts caused by increased androgen levels.
Treatments :There are several treatments available for women with hormonal acne, including topical retinoids, topical antimicrobials (such as benzoyl peroxide and antibiotics), and oral antibiotics that are prescribed when the inflammation is more harsh. Anti-androgen medication is also offered.
Oral contraceptive pills are also used for treating hormonal acne. They contain estrogen, which regulates the menstrual cycle and decreases the androgen activity which causes acne.

Stress:
In stress, adrenal glands secrete excessive hormones, norepinephrine and epinephrine. Stress also increases the male hormones secretion by adrenal cortex and these male hormones are responsible for triggering the sebaceous gland creating more sebum and this is linked to the formation of acne.
Secondly, during stress condition, immune system is down and the ability to recover the wounds and lesions is decreases so stress has double impact on acne. With the increased production of the oily substance during stressful times our skin becomes very oily.

Treatments
If possible to completely avoid stress.
Learn to cope with stress effectively and pay very close attention to skin care when experiencing more stress than usual.
When stress attacks, cleanse your skin at least once a day with a gentle acne cleanser.
A ZENO acne zapper is a good way to treat blemishes that arise due to stress.

Diet effect
A high glycemic load diet and cow's milk have been associated with worsening acne. Other products such as chocolate and salt are not supported by the evidence.
Diet has a direct effect on our body's insulin levels. Insulin is our master hormone and affects all of our other hormones, including our androgens (male hormones). Scientists suspected that hormonal fluctuations, particularly in our androgen levels, can result in acne flare ups.

Accumulation of dead skin cells

The skin is an interesting organ in a lot of ways and has an equally important function. Like all organs, it is made up of tissues that are made up of cells. These cells are tough and water-tight as a protective layer to keep all sorts of things out of your body.
Cells are regularly dying and new cells are forming so that the skin remain fresh and continues to function as a protective barrier. But some problems occur due to gathering of dead skin cells. If skin is don’t wash properly, those cells can build up, clog the pores, and lead to pimples.
Treatments :
Soap is not useful because it only cleans the surface of the skin
The most valuable way to wash your face with a wash cloth or sponge. These materials helps to hold the dead skin cells and wash them off and it takes to keep the dead skin cells from becoming a problem.

No harsh chemicals and irritants are used to clear the acne, Oxycerin is backed by prescription grade clinical proof, but does not have the high prescription prices or inconvenience. Basically speaking, it uses clinically proven 5% tea tree oil. This has been clinically proven effective since the early 1900’s and it has been specifically compared to 5% benzoyl peroxide, in which it showed the same level of results with no side effects. So that’s definitely an improvement.
Use the aloe vera, white willow bark, licorice root, MSM, and hyaluronic acid, all of which are meant to calm and heal the skin.
If acne problems is fixed, the 12 hour miracle acne treatment is carried out. It works deep into the skin pores to attack acne dissolving the sebum that is the source and clear the skin of all acne causing bacteria

Activity Of Normal Skin Bacteria

Although acne is not caused by a bacterial infection, bacteria play a role in making the worse situation. The bacterium Propionibacterium acnes (P. acnes), is a normal flora of the skin surface. It protected the skin from being invaded by harmful bacteria.
When oil is trapped in the hair follicles, this bacteria will grow in the blocked pore and causes destruction of the lining of the follicle. The bacteria produce chemicals that modify the composition of the oil, which makes it more infuriating to the skin and causes inflammation.

Inflammation

Inflamed skin appear red, enlarge, warmth and discomfort. Inflammation occurs because the body's immune system is acting to free itself of a foreign substance. In the case of acne, this substance is either bacteria or the irritating compounds they have produced.
Acne Treatment With Topical Antibiotics
Topical antibiotics work by killing the Propionibacterium acnes bacteria. They not only diminish the small infections in the pores, but also keeps the pores open. Topical antibiotics have been used without many changes to the formulations. All topical antibiotics must be prescribed by a health care provider.
Acne Treatment with Clindamycin

The most commonly used topical antibiotic for acne
presented as a solution, lotion, or gel at 1% strength
Applied twice a day to all acne prone areas
Generally well tolerated but may cause some irritation
Should not be used by people with regional enteritis, ulcerative colitis, or a history of antibiotic-induced colitis

Acne Treatment with Erythromycin

Second most frequently used topical antibiotic used for acne
Available as a solution, gel, and ointment at 2% strength.
Applied twice a day to all acne level areas
Generally well tolerated but may cause some irritation
Safe for use by pregnant women

Acne Treatment with Tetracycline

Not used very frequently as a topical treatment
Available as an gel and solution at different strengths
Contains sodium bisulfite, a sulfa derivative, and can cause allergic reactions
May also source of yellowing of the skin

Acne Treatment with Metronidazole

Used frequently for acne
Available as a gel at 0.75% strength
Applied once or twice a day
Generally well tolerated but can cause irritation

Steroids
When sebaceous glands are enlarging in the skin then these glands increase sebum (oil) production. The increased sebum leads to plug formation and serves as "food" for bacteria.
Steroids effect of boosting androgens in the body. Androgens are the male hormones that are also present in small quantities in females. Testosterone is the most important androgen and when increase in testosterone, the sebaceous glands is stimulated. This results in more sebum secretion in the skin and ultimately it breaks out as acne. The effect is such that pimples burst not only on the face but also the chest, back and neck. This is what is called as steroid acne. Higher the dose of steroids, more are the chances and harshness of zits.
Treatment
To reduce the intake of steroids or turn to milder ones that doesn’t cause side effects like acne.

For females, anti-androgen treatments are widely used. The most common are:
* Topical inocoterone acetate
* Spironolactone
* Cyproterone acetate
* Flutamide
* 5-alpha reductase inhibitors
Prevalence
Many factors influence the prevalence of acne vulgaris. The onset of acne is usually in adolescence, earlier in girls than in boys (Daniel et al., 2000). The peak incidence and severity occur between fourteen and seventeen years in females; and sixteen and nineteen years in males, where 40 percents and 35 percents in these age groups are affected respectively. Acne is a very common condition worldwide, even the prevalence varies from one country to another. Many researchers have studied acne in adolescents and their findings are consistent, with little variations. The prevalence of facial acne in Peruvian adolescents is related to their ethnicity of adolescent health. It has been estimated that teenage acne is associated with physical and psychological morbidity in up to 90 percent of adolescents and young adults (White, 1998).
In conference of dermatology, in Pakistan, it was demonstrated that 200 acne patients between ages of 13-30 years were treated, 100 were treated with typical benzoyl peroxide 4 percents and 100 with adapalene 0.1 percents for 12 weeks. This treatment was well tolerated leading to non-compliance in only 10 patients due to side effects. Efficiency was recorded 90 percents in both groups. It was noted that benzoyl peroxide is more effect than adapalene (Usma and Atif, 2008).

How Should People With Acne Care for Their Skin?

Clean Skin Gently: In case of acne, wash the face gently with a mild cleanser, once in the morning and once in the evening.

Avoid Frequent Handling of the Skin: Do not rub and touch skin lesions. Squeezing, pinching or picking blemishes can lead to the development of scars or dark blotches.

Choose Cosmetics Carefully Duringacne treatment, change some of the cosmetics. All cosmetics, such as foundation, blush, eye shadow, moisturizers, and hair-care products should be oil free.

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Acne Vulgaris

Acne are small, localized infections in the pores commonly in the face, neck and back. Some factors that cause acne are:

Oil Based skin and hair products
Menstuation in girls
Popping or touching pimples
Hard scrubbing of the skin

Some common myths that do not cause acne are:

Dirt
Greasy foods
Sexual Activity

Also known as "zits," acne is especially frequent amongst teenagers as during puberty, both boys and girls produce more androgens (male sex hormones), which inspire oil production. Acne is often genetic, so if your parents had pimples, you're more likely to as well.

Some tips to help and avoid acne are:

Do not use skin cleansers with oil in them. Look for “oil free” which also contain benzol peroxide or stalatic acid.

Do not over wash your face. Only wash twice per day and pat dry gentley.

Source: http://imet.csus.edu/imet7/bernal/Anatomy/Unit%203/eposters/Acne_Vulgaris3.doc

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Acne Vulgaris, Folliculitis, and Acne Rosacea

Sonya K. Brown, M.D., and Alan R. Shalita, M.D.
Acne vulgaris, folliculitis and acne rosacea are common disorders of the pilosebaceous units, which consist of sebaceous glands and their associated hair follicles. The most common anatomic sites of involvement are those that have the largest and greatest density of sebaceous glands: the face, neck, upper chest and back, and upper arms.
Acne vulgaris is a common disorder that peaks in incidence around the time of puberty. The pathogenesis of acne vulgaris is multifactorial. Abnormal keratinization in the upper canal of the hair follicle causes formation of hyperkeratotic, adherent plugs that are derived from desquamated epithelial cells, resulting in comedones (appearing clinically as whiteheads and blackheads), the noninflammatory lesions of acne vulgaris. Androgens stimulate the secretion of lipid-rich sebum from the sebaceous glands; sebum, in turn, provides a growth substrate for the commensal Propionibacterium acnes, an anaerobic diphtheroid. Proliferation of P. acnes is particularly facilitated by the anaerobic environment of the follicles that are plugged by comedones. This results in the production of proinflammatory mediators that are largely responsible for the appearance of the inflammatory lesions of acne vulgaris: papules, pustules, and nodules. (Figure 1 and Figure 2)
Treatments for acne vulgaris target one or more of its pathogenetic factors. Topical agents alone may be used for mild cases of acne, whereas systemic agents are generally reserved for patients with moderate to severe involvement. Comedolytic agents act primarily against comedones and include tretinoin and adapalene, both of which are available only as topical preparations. By diminishing the growth of P. acnes, antibiotics and antibacterials, available in various topical and systemic preparations
(Table 1), are effective against the inflammatory lesions of acne vulgaris. Antiandrogens, administered orally, diminish sebum production, which results in the improvement of inflammatory lesions. Isotretinoin (13-cis-retinoic acid) is a potent systemic agent that affects all of the major pathogenetic factors of acne vulgaris. However, because it can cause a variety of adverse effects, some of which are potentially serious (Table 2), isotretinoin is generally reserved for the treatment of severe, treatment-resistant acne.
Folliculitis
Folliculitis is a somewhat nonspecific term that refers to inflammation of the hair follicle (in clinical practice, this term does not include acne vulgaris). The most common etiology of folliculitis is bacterial infection, often due to Staphylococcus aureus. The usual clinical presentation is superficial pustules and/or papules in the distribution of the hair follicles. The face, chest, back, thighs, and buttocks are often involved. Folliculitis is frequently initiated by mild physical injury to the follicles, such as friction caused by tight-fitting garments, or by ingrown hairs in the beard area in men. Less commonly, folliculitis is caused by infection by fungi, such as dermatophytes or Pityrosporum. Folliculitis due to Pseudomonas aeruginosa ("hot tub folliculitis") may occur in patients exposed to water sources that are contaminated by that organism. Treatment of folliculitis is aimed at eliminating the offending agent(s), and includes topical and/or systemic antibacterial or antifungal preparations.
Acne Rosacea
Rosacea is an inflammatory disorder of uncertain etiology that most commonly affects adults of northern European ancestry, between 30 and 50 years of age. The earliest manifestation of this disease can be recurrent episodes of flushing and blushing, often triggered by stimuli such as ingestion of hot beverages, spicy foods, and ethanol or exposure to ultraviolet radiation. Clinical findings in the fully developed eruption include papules, pustules, erythema, and telangiectasias. The central face, including the nose, forehead, chin and cheeks, is involved predominantly. Chronic inflammation may lead to permanent enlargement (phyma) of the affected areas due to sebaceous gland and soft tissue hypertrophy; rhinophyma("W. C. Fields nose") refers to enlargement of the nose. Involvement of the eye may lead to conjunctivitis and/or blepharitis. Rosacea may clinically resemble acne vulgaris; however, in contrast to acne, comedones are absent. Treatments of mild rosacea include topical metronidazole gel, lotion or cream, or a combination of sodium sulfacetamide and sulfur. In moderate to severe cases, oral antibiotics, of which the tetracyclines are the most widely used, may be added. Isotretinoin may be used in severe, recalcitrant cases.
References

Rothman KF, Lucky AW. Acne vulgaris. Adv Dermatol 1993; 8: 347-74.
Brown SK and Shalita AR. Acne vulgaris. Lancet 1998; 351:1871-76.
Habif T. Bacterial infections. In: Clinical Dermatology. St. Louis: Mosby Co., 1996, pp. 248-58.
Wilkin JK. Rosacea: pathophysiology and treatment. Arch Dermatol 1994; 130: 359-62.

Figure Legends

Figure 1. Multiple closed comedones (whiteheads; A) and open comedones (blackheads; B) in two patients with papular and cystic acne vulgaris. Note the acne scarring in the second patient.

Figure 2. Post-inflammatory hyperpigmentation in a patient with papular and cystic acne.

Figure 3. Erythema of the central face (cheeks, nose, and chin) in a patient with acne rosacea. Scattered papules are also present.
Table 1: Antibacterial/antibiotic agents used in the treatment of acne vulgaris
Topical
Benzoyl peroxide
Clindamycin
Erythromycin
Sodium sulfacetamide with or without sulfur
Systemic
Tetracycline
Doxycycline
Minocycline
Erythromycin
Trimethoprim/sulfamethoxazole
Table 2: Adverse effects of isotretinoin
Teratogenicity: craniofacial, cardiovascular, central nervous system, and thymic malformations
Mucocutaneous: cheilitis; photosensitivity; dryness of skin and mucous membranes
Gastrointestinal: nausea/vomiting; acute pancreatitis (due to hypertriglyceridemia)
Psychiatric: possible mood changes
Laboratory: hypertriglyceridemia; elevated liver function tests, increased muscle enzymes

Questions - Acne Vulgaris, Folliculitis, and Acne Rosacea
1. A 16-year-old African-American girl presents with numerous comedones on the face. Papules and pustules are absent. Appropriate initial treatment would be:
A) Adapalene
B) Tetracycline
C) Clearasil
D) Topical steroids
E) Oral isotretinoin
2. The same patient subsequently develops a moderate number of pustules on her face. The addition of what topical or oral medication should be considered in this case?
A) Adapalene
B) Tetracycline
C) Clearasil
D) Topical steroids
E) Oral isotretinoin
2a. Why would isotretinoin NOT be considered as first-line therapy in this case?
3. A 30-year-old Asian male presents with papules and pustules around the hair follicles on his legs. What is the most likely etiology?
A) Lubricating lotion
B) Staphylococcus aureus
C) Fungus infection
D) Hot oil treatment
E) Pseudomonas aeruginosa
3a. What is the most likely diagnosis in this case?
3b. What topical or oral medication should be prescribed?
4. A 45-year-old, Irish-American man presents with papules, pustules and diffuse erythema on his face. Comedones are absent. What is the most likely diagnosis?
A) Photosensitivity
B) Rosacea
C) Lupus erythematosous
D) Acne vulgaris
E) Contact dermatitis
4a. What topical or systemic medication could be prescribed?

Answers - Acne Vulgaris, Folliculitis, and Acne Rosacea

1. A 16-year-old African-American girl presents with numerous comedones on the face. Papules and pustules are absent. Appropriate initial treatment would be:
            A) Adapalene
            B) Tetracycline
            C) Clearasil
            D) Topical steroids
            E) Oral isotretinoin
Answer: A) Adapalene
2. The same patient subsequently develops a moderate number of pustules on her face. The addition of what topical or oral medication should be considered in this case?
            A) Adapalene
            B) Tetracycline
            C) Clearasil
            D) Topical steroids
            E) Oral isotretinoin
Answer: B) Tetracycline
2a. Why would isotretinoin NOT be considered as first-line therapy in this case?
Answer: Oral isotetinoin is reserved for the treatment of severe treatment-resistent acne.
3. A 30-year-old Asian male presents with papules and pustules around the hair follicles on his legs. What is the most likely etiology?
            A) Lubricating lotion
            B) Staphylococcus aureus
            C) Fungus infection
            D) Hot oil treatment
            E) Pseudomonas aeruginosa
Answer: B) Staphylococcus aureus
3a. What is the most likely diagnosis in this case?
Answer: Fiolliculitis
3b. What topical or oral medication should be prescribed?
Answer: Antibiotics
4. A 45-year-old, Irish-American man presents with papules, pustules and diffuse erythema on his face. Comedones are absent. What is the most likely diagnosis?
        A) Photosensitivity
        B) Rosacea
        C) Lupus erythematosous
        D) Acne vulgaris
        E) Contact dermatitis
Answer: B) Rosacea
4a. What topical or systemic medication could be prescribed?
Answer: Topical metronidazole and/or oral antibiotics (teracyclene)

Source: http://web1.neton-line.com/education/students/_doc/AcneVulgaris.doc
Web site: http://web1.neton-line.com
Authors: Sonya K. Brown, M.D., and Alan R. Shalita, M.D.

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