Acne

Overview

Definition

Acne vulgaris is a disease of the skin manifested by comedones and inflammatory lesions. Essentially all adolescents are affected, while only about 3% of the population aged 35 to 44 years suffer from some degree of acne. Severity of disease is greater in males, but more persistent in females. Acne affects areas of the skin containing the largest sebaceous glands, including the nose, central forehead, medial cheeks, middle chin, back, and trunk.

A less common disorder, acne rosacea, is now classified as an acneiform as it bypasses the comedo stage. It involves dilation of small blood vessels that leave a prolonged facial redness. It is more prevalent in fair-skinned men and women, occurs later in life, and predominately afflicts those of Celtic and Northern European backgrounds.

Neonatal acne begins in the first six weeks of life, resolves within three months with no scarring, and is not predictive of later acne. Infantile acne begins at three to six months of age, may result in scarring, and is associated with increased risk of acne vulgaris.

Etiology

Acne vulgaris is caused by increased production in the sebaceous gland in response to elevated androgen activity with subsequent pathophysiologic responses. The precise etiology of acne rosacea is unproven but thyroid dysfunction and other triggers seem to provoke the skin condition.

Risk Factors

Acne vulgaris:

Greasy/oily cosmetic or hair products containing vegetable or animal fats

Genetic predisposition

Acne at age 10 is predictive of severe acne at age 15

Humid climates

Sun exposure

Occlusion of skin pores

Oral contraceptive use

Constipation

Acne rosacea:

Genetic predisposition

Personal triggers—diet (cheese, meat, spicy foods, caffeine, alcohol, hot soup or drink), cold, sun, wind, exercise, stress, menopause

Signs and Symptoms

Acne vulgaris:

Open comedo ("blackheads")

Closed comedo ("whiteheads")

Inflamed papule

Cysts and nodules

Nodulocystic lesions

Scarring

Acne rosacea:

Prolonged facial redness

Pustules, papules

Ocular rosacea, conjunctivitis, stye formation

Rhinophyma (enlargement of the nose resulting from tissue overgrowth)

Differential Diagnosis

Flat warts

Folliculitis

Dermatitis

Lupus erythematous—for rosacea

Fungal infection—for rosacea

Diagnosis

Physical Examination

Comedones, papules, pustules, and scarring may all be visible. Emotional upset of patient may also be evident and should be addressed.

Pathology/Pathophysiology

Acne vulgaris:

· Overactive sebaceous glands drain into follicular canal, becoming plugged with keratinous debris that contains Propionibacterium acnes (comedo)

· Sebaceous gland increases production in response to increased androgen activity during puberty; girls with severe acne have significantly higher serum dehydroepiandrosterone sulfate (DHEA-S)

· P. acnes (or possibly Staphylococcus epidermidis or Pityrosporon ovale) organisms mix with sebum and produce lipolytic enzymes that convert the sebum to free fatty acids

· Patulous pilosebaceous orifice—open comedo

· Follicular wall ruptures high in the dermis, contents extruded into subadjacent dermis, induces a neutrophillic inflammatory response—pustules form if inflammation stays near surface; nodules form if inflammation develops deeper

· Liquefied masses of inflammatory debris may develop from suppuration and reaction to giant cells

· Pathogenesis unknown for acne flares one week prior to menstruation

Acne rosacea:

Erythema

Vasodilation

Telangiectasia (permanent dilation of preexisting blood vessels)

Sebaceous hyperplasia and tissue overgrowth results in rhinophyma

Treatment Options

Treatment Strategy

Acne cannot be cured but often can be well controlled. Treatment focuses on curtailing lesions and avoiding scarring. Acne vulgaris is usually self-limiting.

Drug Therapies

Acne vulgaris:

Tretinoin (Retin-A)—for comedones; a retinoid that normalizes follicular keratinization; side effects include photosensitivity, erythema, and peeling; pustule flares possible at beginning of treatment; response in three to six months; typically 0.025% cream; at least one study shows addition of polyolprepolymer-2 reduces cutaneous irritation with comparable efficacy

Isotretinoin—for nodulocystic acne, reduces sebum excretion, decreases inflammation, antibacterial properties for P. acnes; only drug that alters the course, effect lasts beyond administration; 0.5 to 1.0 mg/kg/day for 16 to 20 weeks; side effects include dry or inflamed skin, eyes, and mucous membranes, muscle and joint aches; rule out preexisting liver disease; potent teratogen

Benzoyl peroxide—a topical keratolytic that dissolves keratin plugs and follicular debris, allowing sebaceous secretion outflow, antibacterial properties for P. acnes; prescription (10%) and OTC preparations (2.5% and 5%) may be used in the morning (begin every other day) with a retinoid in the evening

Oral antibiotics—inhibit bacterial lipases, reduce free fatty acids; enhanced by benzoyl peroxide and tretinoin; commonly, tetracycline (500 mg/bid)—must not be taken with food; side effects include phototoxicity, gastrointestinal problems, Candida vaginitis, teratogenic, decreases contraceptive effectiveness

Topical antibiotics—less effective than oral; enhanced by benzoyl peroxide and tretinoin

Oral contraceptives—inhibit sebum production; must be estrogen-containing

Acne rosacea:

Antibiotics—tetracycline (500 to 1000 mg/bid)

Isotretinoin—0.5 to 1 mg/kg/day

Topical metronidazole 0.75% gel

Cosmetic and sunscreen protection

Surgical Procedures

Glucocorticoid intralesional injections—for painful nodulocystic lesions; 3 mg/ml

Dermabrasion—decreases depth of scars

Scar excision

Focal chemical peeling, carbon dioxide laser, scar excision, punch grafting, and dermabrasion—effective combined treatment

Complementary and Alternative Therapies

Herbal remedies may be effective at balancing hormones and improving digestion in order to stimulate androgen metabolism. Proper nutrition supports skin health.

Nutrition

Eliminate allergenic foods (especially dairy), caffeine, sugars, alcohol, and refined foods. Iodine may exacerbate outbreaks. Decrease pro-inflammatory fats (i.e., animal products) and increase anti-inflammatory oils (i.e., cold-water fish, nuts, and seeds). Include carotene-rich orange, yellow, and leafy green vegetables. High consumption of water.

Vitamin A (10,000 IU/day) or beta carotene (25,000 IU/day), vitamin E (400 IU/day), and zinc (15 to 30 mg/day) for skin health.

Vitamin B6 (pyridoxine). Take 50 to 100 mg/day for PMS-associated acne.

Acidophilus (one capsule with meals) to restore normal bowel flora.

HCl and pancreatic enzymes may be beneficial especially with acne rosacea or with concurrent constipation.

Herbs

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes). For the following herbs, take 20 to 30 drops tincture bid to tid, or drink two to three cups tea daily.

For both acne vulgaris and rosacea, include the following herbs in equal parts: cleavers (Galium aparine), red clover (Trifolium pratense), calendula (Calendula officinalis), and coneflower (Echinacea purpurea).

For acne vulgaris, add yellowdock (Rumex crispus) and burdock root (Arctium lappa). For severe cases, substitute Oregon grape (Berberis aquafolium) for burdock.

For acne rosacea add: blue flag (Iris versicolor) and yarrow (Achillea millefolium). For vasomotor instability, substitute oatstraw (Avena sativa) for yarrow.

An bitters [e.g., dandelion (Taraxacum officinale), greater celandine (Chelidonium majus)] plus milk thistle (Silybum marianum) to stimulate digestive tract.

For increased testosterone levels, add saw palmetto (Serenoa repens) 200 mg bid to tid.

Homeopathy

An experienced homeopath would consider the individual's constitution. Some of the most common acute remedies are listed below. Acute dose is three to five pellets of 12X to 30C every one to four hours until symptoms resolve.

Belladonna for flushes of heat to the face or inflamed pustular acne that is better with cold applications

Calcarea carbonica for severe acne in those with a tendency toward constipation and dairy allergies, as well as those who are easily chilled

Rhus tox for acne rosacea that is generally aggravated by cold, wet weather

Sulphur for ruddy complexion with enlarged veins on the cheeks or nose, or for those who are easily overheated

Kali bromatum for deep acne in chilled patients and for those who are suffering from insomnia

Physical Medicine

External wash bid:

Calendula soap or tea (1 tsp. herb per cup water) for gentle cleansing

Tea tree oil (15 to 20 ml per cup water) for severe acne

Acupuncture

May be useful in resolving hormonal or constitutional imbalances and facilitating detoxification.

Massage

Stimulates circulation and helps to eliminate toxins.

Patient Monitoring

Ensure drug treatment compliance

Other Considerations

Prevention

Isotretinoin—only preventive drug for acne vulgaris

Avoid triggers to prevent rosacea

Complications/Sequelae

The potentially serious psychological and social impact of severe acne, especially during adolescence, warrants prompt and continuing treatment.

Squeezing of lesions causes local inflammation and ruptures intact lesions.

Prognosis

Vulgaris—symptoms generally diminish after adolescence

Rosacea—requires ongoing management

Pregnancy

Tetracycline and isotretinoin—contraindicated during pregnancy as they are teratogenic

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References

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· Whang KK, Lee M. The principle of a three-staged operation in the surgery of acne scars. J Am Acad Dermatol. 1999; 40(1): 95–97.

· White GM. The evolving role of retinoids in the management of cutaneous conditions. J Am Acad Dermatol. 1998; 39(2).