Acne and Its Development Factors

Acneiform Disorders

• Acne is a chronic disorder affecting the hair follicles.
• It affects males and females of all races and ethnicities.
• It's prevalent in adolescents and young adults, with 85% of 16-18 year-olds affected, but can occur in children and adults.
• Acne is caused by a combination of factors; exact mechanisms aren't fully understood.
• Factors include: familial tendency, endogenous and exogenous androgenic hormones, acne bacteria, innate immune activation with inflammatory mediators, and distension and occlusion of hair follicles.

Flares of Acne

• Flares can be triggered by: polycystic ovarian disease, drugs (steroids, hormones, anticonvulsants, epidermal growth factor receptor inhibitors), occlusive cosmetics, high environmental humidity, and diets high in dairy products and high glycemic foods.

Acne Diagnosis

• Routine tests are usually unnecessary for acne unless symptoms are atypical.
• If atypical, consider skin swabs for microscopy and culture, along with hormonal tests in females.

Acne Vulgaris

• Acne vulgaris is the most common type, characterized by a mixed eruption of inflammatory and non-inflammatory skin lesions.
• It affects both sexes and all races, though primarily affects adolescents but spans a wide age range.
• Further characterisation includes infantile acne, acne in children, and adult acne.
• The pathogenesis includes four important factors: excessive sebum production, hyperkeratinization of pilosebaceous follicles, hyperproliferation (with Cutibacteria acne), and inflammation.

Clinical Features of Acne Vulgaris

• Acne commonly affects the face, but can spread to the neck, chest, and back.
• Forms include inflammatory papules, pustules, and nodules, or non-inflamed comedones and pseudocysts.
• Appearance can be further classified by open and closed uninflamed comedones (blackheads and whiteheads), inflamed papules and pustules, nodules and pseudocysts in severe cases, post-inflammatory pigmentation, erythematous, and scars.
• Severity is classified as mild, moderate, or severe, based on total lesion count (<30, 30-125, >125 respectively).

Complications of Acne Vulgaris

• Complications of acne vulgaris include post-inflammatory hyperpigmentation, scarring (including keloid scars), and psychological effects.

Treatment for Acne Vulgaris

• Treatment depends on factors like patient's age, extent and severity of acne, and response to past treatments.
• Mild acne may include topical anti-acne preparations such as tretinoin, azelaic acid, adapalene, and benzoyl peroxide.
• Moderate acne may require antibiotics like tetracyclines and/or antiandrogens such as birth control pills.
• Severe acne may necessitate oral isotretinoin.

Nodulocystic Acne

• Nodulocystic acne is a severe form, affecting face and upper trunk, presenting with nodules and cysts that often scar.
• It is typically a disorder of adolescence and early adulthood, most common in males, but can occur in a juvenile form before age 6.
• Specific risk factors include genetic factors, drugs (anabolic steroids, etanercept, imatinib), dietary supplements such as whey, and haemodialysis.
• Clinical features include solitary or multiple inflammatory nodules and pseudocysts, firm, fluctuant, and/or tender lesions, and involvements of the face, neck, and trunk.

Acne Conglobata

• Acne conglobata is a rare, severe form of nodulocystic acne.
• Characterized by groups of multiple comedones and inflammatory papules, pustules, and nodules.
• Lesions involve the trunk, limbs, and buttocks.
• Interconnecting abscesses and draining sinuses are often present.
• Secondary infection may cause pain and malodour.
• Healing and scarring is typically slow, and the condition is persistent, lasting into the 30s or 40s.

Complications of Nodulocystic Acne

• Complications include psychological effects, keloid, hypertrophic and atrophic scars, and pyogenic granuloma.
• Diagnosis is clinical, although hormone studies might be considered for those with suggestive clinical features.
• Treatment for nodulocystic acne is often oral isotretinoin to lessen scarring, with a minimum five-month course, and possible further treatments depending on need.
• Intralesional steroids may also be used for individual persistent or large inflammatory nodules or cysts.

Acne Fulminans

• Acne fulminans is a severe, rare form of acne conglobata associated with systemic symptoms.
• Nearly always affects adolescent males.
• Potential causes include increased androgens (male hormones), genetic and autoimmune complex disease, and hypersensitivity reaction to bacteria (Cutibacteria acnes).
• The condition can be precipitated by testosterone and anabolic steroids, either legitimately prescribed or illegally taken.
• Clinical features include abrupt onset, inflammatory and ulcerated nodular acne on chest and back (painful), crusty ulcerations on the upper trunk, severe acne scarring, fluctuating fever, painful joints (sacroiliac joints in 20% of cases and ankles, shoulders, and knee joints), malaise, loss of appetite and weight loss, and an enlarged liver and spleen.
• Treatment involves systemic corticosteroids (prednisone, 20-60mg/day), anti-inflammatory medications (salicylates, aspirin), dapsone (50-100mg/day), ciclosporin, high doses of oral antibiotics (erythromycin 2g/day) for secondary infections, isotretinoin, and tumour necrosis factor (TNF-α) inhibitors.

Acne Mechanica

• Acne mechanica develops from repeated friction or pressure against the skin.
• This includes tight-fitting clothing such as shirts with collars, sports gear, accessories (hats and bras), medical equipment (casts and surgical tape), and repeated skin contact with hands and seating, for instance, chairs and car seats.
• Acne mechanica is characterized by inflammatory lesions, including papules, pustules, and nodules.
• Treatment involves removing the source of friction or pressure, along with localised treatment such as topical benzoyl peroxide, antibiotics (where indicated based on suspected bacteria), and vitamins (retinoids and nicotinamide).

Occupational Acne

• Occupational acne stems from physical contact with industrial chemicals (such as halogenated polycyclic hydrocarbons, coal tar derivatives, wood preservatives), and can be characterized by comedones predominantly.
• This condition sometimes has unusual sites of lesions and is more common in middle-aged males.

Acne Excoriee

• Acne excoriee describes the condition where people pick pus-filled acne pimples, causing a more aggravated form of the condition.
• This is often seen as a means to resolve pimples, leading to an increase in inflamed lesions and potential scarring.
• Patients may have no active acne spots but only scratch marks, sores, pigmentation, and scars from picking, which is a form of anxiety, potentially body dysmorphic disorder.
• Treatment entails breaking the habit of picking (psychosocial interventions and potentially medications) and using topical treatments (if inflammatory lesions persist) for existing acne.

Drug-Induced Acne

• Drug-induced acne can be caused by systemic corticosteroid use (topical can also contribute) as well as various medications, including halogens (iodides, chlorides), antiepileptics, ciclosporin, lithium, and B vitamins, etc.
• Characterized by lesions appearing after medication administration.