Acne Pathogenesis and Development

Acne Pathogenesis

• Acne pathogenesis involves follicular hyperkeratinization, increased sebum production, inflammation, and bacterial colonization.

Acne Question

• The answer to "Which of the following does NOT contribute to the pathogenesis of acne?" is D. Hyperpigmentation,

Acne Vulgaris Comedo Development:

• Progression of acne involves changes to the pilosebaceous unit.
• A normal follicle contains lipid droplets, sebaceous glands, an infundibulum, and an apocrine sweat gland.
• Microcomedo formation includes keratinocytes and a developing epithelial plug, remaining beneath the skin's surface.
• Closed comedones (whiteheads) are full of sebum, and are located beneath the skin's surface.
• Open comedones (blackheads) are hair follicles containing sebum.
• Inflamed papules also include edema and polymorphonuclear leukocytes in the follicle.
• Pustules involve follicular dissolution and blood vessels.

Acne Grading and Classification:

• Mild acne includes few erythematous papules, occasional pustules, and comedones.
• Moderate acne involves many erythematous papules and pustules, with prominent scarring.
• Severe acne is characterized by extensive pustules, erythematous papules, and multiple nodules on an inflamed background.

Acne Treatment Goals:

• Decrease the number and severity of lesions.
• Prevent future lesions, scar formation, and hyperpigmentation.
• Improve quality of life.

Acne Self-Treatment Exclusions:

• Moderate to severe acne based on Table 2
• Exacerbating factors like comedogenic drugs
• Possible rosacea

Non-Pharmacologic Therapies: Cleansing

• Cleanse skin gently with a mild, oil-free cleanser and warm water twice daily to loosen comedones for removal.
• Micellar water is an herbal-infused water that cleanses skin, removes makeup without rinsing or scrubbing, and is gentle for sensitive skin.
• Micelles in micellar water are tiny cleansing oil molecules suspended in soft water.

Non-Pharmacologic Therapies: Toners

• Use toners after cleansing and before moisturizing, to remove excess dirt and oil.

Non-Pharmacologic Therapies: Pimple Patch

• Avoid picking or squeezing pimples to prevent skin irritation, infection, worsening acne, and scarring.
• Pimple patches act as bandages that prevent touching, absorb fluid, and promote moist healing.

Non-Pharmacologic Therapies: Environmental factors

• Avoid or reduce exposure to environmental factors such as dirt, dust, petroleum products, cooking oils, or chemical irritants.
• Prevent friction that may cause acne flares by avoiding tight-fitting clothes, headbands, or helmets and resting the chin on the hand.

Non-Pharmacologic Therapies: Cosmetic

• Minimize acne from cosmetics using noncomedogenic, oil-free makeup and cleaning cosmetic brushes frequently.
• Avoid environments with high humidity to prevent excessive skin hydration, which can cause acne flares.
• Manage stress to prevent it from worsening acne.

OTC Pharmacologic Therapies:

• Differin Gel (Adapalene 0.1%) is a retinoid.
• Benzoyl Peroxide products include Proactiv Repairing Treatment (2.5%), Neutrogena Rapid Clear Stubborn Acne Cleanser (10%), and Clearasil Ultra Rapid Action Vanishing Treatment Cream (10%).
• Salicylic Acid products include Neutrogena Oil-Free Acne Stress Control Power Cream Wash and Clean & Clear Advantage Acne Spot Treatment (2%).

Adapalene 0.1% (Differin Gel): How it Works

• Adapalene 0.1% normalizes skin cell development, reducing acne symptoms.

Adapalene 0.1% (Differin Gel): When to Expect Effects

• Acne can worsen temporarily at the start of the treatment.
• Expect noticeable clinical improvement with adapalene after 8-12 weeks of treatment.
• If acne worsens or shows no improvement after three months of appropriate adapalene use, medical advice should be sought.

Adapalene 0.1% (Differin Gel): Counseling Points

• Increases susceptibility to sunburn.
• Avoid contact with eyes, lips, mouth, nose, cuts, scrapes, and abrasions.
• Redness, itching, dryness, scaling, and burning diminish after the first treatment month.

Benzene Contamination in Acne Products:

• A recent FDA testing shows elevated levels of benzene contamination in some acne products.
• FDA is alerting the public and industry about these findings.
• Retailers will remove affected products from shelves, since the recalls are at the retail level, and not the consumer level.

Benzoyl Peroxide (Proactiv): How it Works

• Benzoyl peroxide inhibits bacterium Cutibacterium acnes growth, along with unclogging pores through a mild peeling effect.

Benzoyl Peroxide (Proactiv): When to Expect Effects

• Applications can be increased after 1-2 weeks of treatment, with slight improvement in days, though maximum effectiveness may take up to 3-6 weeks.
• If tolerated, benzoyl peroxide strength may increase to 5% after one week or 10% after two weeks.
• Treatment should continue post-lesion clearance to prevent new formations.

Benzoyl Peroxide (Proactiv): Counseling Points

• It may increase susceptibility to sunburn.
• Contacts with eyes, lips, mouth, and nose, as well as cuts, scrapes, and other abrasions should be avoided,
• Contact with hair and dyed fabrics may be bleached by it.
• Redness, burning, itching, peeling, or swelling may occur.
• The occurrence of dryness and peeling increases with multiple products.

Salicylic Acid 2% (Neutrogena Oil-Free Acne Wash)

• Salicylic acid helps unclog pores causing slight peeling.
• It is less effective than benzoyl peroxide and adapalene.

Salicylic Acid 2% (Neutrogena Oil-Free Acne Wash): When to Expect Effects

• Salicylic acid can be used 1–3 times daily as a cleanser or as a topical gel.
• Medical referral is needed if there is a lack of response after 6 weeks.

Salicylic Acid 2% (Neutrogena Oil-Free Acne Wash): Counseling Points

• Gel formulations should be applied to the affected area only.
• Limit use if excessive peeling occurs to once daily or every other day.
• Sun sensitivity may occur, requiring sunscreen use (SPF 15 or higher) and limited sun exposure.

Ultraviolet (UV) Radiation:

• UVC barely reaches Earth, and is absorbed by the ozone layer.
• UVB is partially absorbed by the ozone layer, and is mainly responsible for sunburns and skin cancer.
• UVA penetrates deeper, requiring 20x more exposure to burn.
• UVA is responsible for wrinkling, leathering, and sagging, also worsening carcinogenic effects of UVB.

Sun Protection Factor (SPF) and Broad Spectrum

• SPF measures a sunscreen's ability to protect the skin from UVB damage
• SPF spectrum includes SPF 15 (93% blockage), SPF 30 (97% blockage), and SPF 50 (98% blockage).
• Broad spectrum sunscreens protect against both UVA and UVB.

Signs and Symptoms of Melanoma

• Asymmetry means that one part of a mole or birthmark does not match the other.
• Irregular border means that the edges are ragged, notched, or blurred.
• Color variation means that the color is not uniform and may include shades of brown or black, or patches of pink, red, white, or blue.
• Diameter larger than 6mm.
• Elevated surface.

Sunscreen to Use?

• The best sunscreen is a product of the intended use and the patient's characteristics.
• Select a product with SPF 30 or greater, that is broad-spectrum (UVA & UVB protection), and water-resistant.
• Sunscreen sticks are good around the eyes, and creams are preferred over sprays.
• Do not spray face, especially in children.
• Select a sunscreen for sensitive skin and inorganic blockers are the best for kids.

Sunscreen Types

• Inorganic agents act as "Physical Blockers" and reflect or scatter UV rays.
• The photostability of inorganic blockers are better, preferred for kids, and aesthetic concerns until recently reformulated have occurred.
• Organic agents act as "Chemical absorbers" that absorb and convert UV rays into heat energy.
• Organic agents protect against UVB and or UVA.

Sunscreen Environmental Effects

• Sunscreens can have environmental effects on areas like Hawaii, Key West, and the U.S. Virgin Islands.
• Oxybenzone, octinoxate, and octocrylene have been banned in sunscreens.
• Approved forms of physical sunscreen products such as zinc oxide and titanium dioxide—appear to be safer for aquatic life.
• Products with a particle size less than 100 nanometers should be avoided.

Inorganic Sunscreens:

• Zinc Oxide provides better UVA protection.
• Titanium Dioxide provides superior UVB protection, and whiter tone from high refractive index,.

Exclusions for Sun Protection Product

• Less than 6 months old

Sunscreen Counseling

• To Protect From The Sun: Seeking shade, especially between 10AM and 4PM, avoiding tanning and UV tanning booths, covering up skin with clothing, keeping newborns out of the sun, use sunscreen on babies over six months old, examine your skin every month, and broad spectrum sunscreen every day.