CMS250 - Wk 2, Acne

• Acne is a common skin disorder and burdensome disease worldwide
• Acne is a multifactorial inflammatory condition centred on the pilosebaceous gland

Pathogenesis

• Follicular hyperkeratinization
• Colonization of Cutibacterium acnes
• Sebum production
• Complex inflammatory mechanisms involving both innate and acquired immunity
• Hormones, diet, and genetic factors contribute to acne

Epidemiology

• Acne vulgaris impacts 85% of Canadians aged 12–24
• Acne may persist into adulthood, specifically affecting 12% of women and 3% of men, which can continue until the 5th decade of life.

Associated Factors

• The onset typically correlates with puberty
• Acne prevalence in females is generally higher
• Acne severity tends to be greater in males
• An increased risk of more severe acne is linked to parent education level
• Parental acne history shows a strong correlation with acne in their offspring
• Skin sebum levels are associated with acne, particularly in oily and mixed skin types
• Geography, diet, and ethnicity factors into acne, though in a complex relationship
• African American and Latin American populations have a slightly higher acne rate versus Asian and Caucasian populations
• In populations outside Canada and the US, there is less acne, suggesting the influence of the standard American diet

Definitions

• Papule: A small, raised, solid, circumscribed lesion less than 1 cm in diameter
• Nodule: A palpable, raised, solid, circumscribed lesion greater than 1 cm in diameter
• Pustule: A small, circumscribed, inflamed, pus-filled lesion
• Comedo: A dilated hair follicle filled with keratin, bacteria, and sebum; plural is comedones
• Closed Comedo: A obstructed opening with inflammatory response, also called a whitehead
• Open Comedo: Opening is not obstructed with a pigmented mass of skin debris, otherwise known as a blackhead

Diagnosis

• Clinical diagnosis is made by the presence of comedones, papules, pustules, and nodules on the face, chest, or upper back
• Hyperpigmentation is more frequent in skin of colour patients compared to fairer-skinned patients
• Diagnosing and testing rarely requires additional testing
• Workup for hyperandrogenism is appropriate for polycystic ovary disease, virilization, or atypical presentation
• There are no detectable endocrinological disturbances for most acne patients

Severity Classification

• Severity is classified to facilitate treatment approaches

Acne Severity Classification

• Grade 1 (Mild): Open and closed comedones with few inflammatory papules and pustules
• Grade 2 (Moderate): Papules and pustules, mainly on the face
• Grade 3 (Moderately Severe): Numerous papules and pustules, and occasional inflamed nodules, also on the chest and back
• Grade 4 (Severe): Many large, painful nodules and pustules

Objective Outcomes

• There is no one objective standard; approximately 24 classifications exist
• Mild acne is generally viewed as comedonal, which is characterized by primarily uninflamed comedones
• Severe acne is classified by the presence of nodules

Quality of Life.

• Quality of life is not always correlated with acne severity
• Even mild acne may impact daily activities, emotions, social activities, study/work dynamics, interpersonal relationships
• Higher rates of anxiety, depression, and suicidal ideation occur in people with acne when compared to people without acne

Prognosis

• Acne eventually remits spontaneously, date unclear
• Acne may persist throughout adulthood and lead to severe scarring if not treated
• Flare and relapse rates are dependent on treatments applied
• In some instances, acne is chronic and flares intermittently despite treatment

Additional Classification of Acne

• This can involve specific predisposing or causative agents and behaviours
• Acne vulgaris is incorrectly treated in specific scenarios, exacerbating the condition
• Patients with atypical presentations should be referred to a dermatologist
• Types of acne include:
• Drug-induced
• Occupational
• Chemical
• Mechanical

Drug-induced Acne

• Can be induced by topical and systemic corticosteroids
• Topical corticosteroids may cause acneiform eruptions over the skin where the topical preparations is applied
• Steroid acne are monomorphous papulopustules, located mainly on the trunk and extremities, with less involvement of the face
• Typically occurs after systemic administration of corticosteroids
• Acute generalized pustular is caused by antibiotics like penicillins and macrolides
• Is typically associates with fever and leukocytosis
• Cotrimoxazole, doxycycline, ofloxacin, and chloramphenicol are additional causes

Other drugs associated with acneiform eruptions:

• Anticonvulsants (phenytoin)
• Antipsychotics (olanzapine, lithium)
• Antidepressants
• Antituberculosis drugs
• Antifungals
• Naproxen
• Chemotherapy drugs
• Hydroxychloroquine

Occupational Acne

• Occupational acne is secondary to exposure to halogenated aromatic hydrocarbons
• It is often referred to as 'chloracnegens'
• Historically, it’s described within the context of dioxin exposure
• Very rare because of restrictions on causative agents.

Chemical Acne

• Also called Acne cosmetica
• It is linked to the use of heavy oil-based hair products and cosmetics
• It resolves once those products discontinue

Mechanical Acne

• It's also called acne mechanica
• Results from pressure and friction that induce acneiform eruptions
• It is identified acne in specific, more localized areas
• Commonly caused by restrictive clothing, prolonged contact with synthetic clothing fibers, and sports equipment usage

Childhood Acne

• Classified into three groups differences in association, clinical, and pathogenetic factors

Neonatal Acne

• Present in approximately 20% of newborns
• Occasionally present at the time of birth
• Most commonly presents at 2 weeks, but can develop any time before 6 weeks
• It is caused by exposure to hormones in utero or breastmilk
• Typically spontaneously resolves in a few weeks to months without sequelae

Milia

• Common skin condition resulting in small (1 – 2mm) papules caused by keratin retention
• Occurs in 40 – 50% of newborns
• Can also occur in adults
• Occurs mostly on the forehead, cheeks, nose, and chin
• Newborns typically only have the condition for a few weeks
• Adults may have it do to cosmetic products
• Often misdiagnosed as acne

Miliaria

• Results from sweat retention caused by partial closure of eccrine structures
• Affects up to 40% of infants and usually appears during the first month of life

Miliaria Subtypes

• The two subtypes include Miliaria crystallina and Miliaria rubra
• Miliaria crystallina is caused by superficial eccrine duct closure.
• 1–2 mm vesicles (without surrounding erythema) appear on the head, neck, and trunk
• Miliaria rubra is caused by deeper level of sweat gland obstruction
• Also referred to as a heat rash
• The lesions are small erythromatous papules and vesicles on covered portions of the skin

Infantile Acne

• Acne that occurs after 6 weeks of age
• Most commonly develops between 3 and 6 months
• Can last up to 2 years
• Most often caused by temporary, physiologic imbalances in androgen products
• Immature adrenals can produce elevated DHEAS, which typically normalizes by 6 months
• From 6–12 months LH levels surge in males, which results in increased gonadal testosterone production
• It can also be caused by cosmetic products (moisturizers, etc.)
• Potentially more worrying because more care needs to be taken

Mid-childhood Acne

• Presents in children between 1–7 with comedones and inflammatory lesions over the forehead, cheeks, and nose
• Children 1–7 do not produce significant androgens, so acne in this age group suggests an endocrine abnormality that requires a pediatric endocrinologist's evaluation
• Acne in this age group is very rare

Preadolescent Acne

• Acne in this group (7–12) may signify the onset of puberty
• Comedones will present on the T-zone of the face (central forehead, nose, and lips)
• Caused by an increase of rise in androgen levels

Differential Diagnosis

• Acne can occur as a primary dermatological disorder or as the symptom of another disorder
• Many skin conditions that cause papules or pustules are difficult to separate from acne vulgaris
• Conditions that cause hyperandrogenism lead to the potential to cause acne -Majority of these cases are due to polycystic ovary syndrome
• Hyperprolactinemia, Adrenal hyperplasia, Cushing’s Disease, and Certain cancers can cause acne.

Systemic Disorders

• In some cases, acne can be a component of more extensive systemic disorders such as SAPHO and PAPA syndrome
• SAPHO is an inflammatory disorder of bone, joints, and skin characterized by synovitis, acne, pustulosis, hyperostosis, and osteitis
• PAPA syndrome is a rare autosomal dominant disorder caused by mutations in the CD2-binding protein; characterized by pyogenic sterile arthritis, pyoderma gangrenosum, and acne
• PASH syndrome is a rare hereditary autoinflammatory disorder characterized by pyoderma gangrenosum, acne, and hidradenitis suppurativa
• PAPSH is a rare autoinflammatory disorder characterized by pyogenic arthritis, acne, pyoderma gangrenosum, and hidradenitis suppurativa
• PAPA, PASH, and PAPASH share common pathophysiologic mechanisms. They involve the over-activation of the immune system resulting in increased production of the IL-1 family and neutrophil-rich cutaneous inflammation

Severe Rare Forms of Nodulocystic Acne.

• Acne conglobata: Presents with painful, tender, disfiguring, double or triple interconnecting comedones, cysts, inflammatory nodules, and deep burrowing abscesses
• Cysts often discharge purulent, foul-smelling material

Differential Diagnosis of Acne Conglobata

• Acne conglobata may occur in isolation or with a systemic inflammatory condition (SAPHO, PAPA, PASH, or PAPASH syndrome)
• Related to thyroid hormone and halogenated aromatic hydrocarbons exposure
• Anabolic steroids and sudden discontinuation of anabolic steroids

Acne Fulminans(aka Acne Maligna)

• A very rare skin disorder presenting as a painful, ulcerating, and hemorrhagic clinical form of acne with a very sudden onset
• May or may not be associated with symptoms such as fever and polyarthritis
• May cause bone lesions

Difference Between Acne Conglobata and Fulminans

• The two are often confused as triggers and clinical presentation share certain similarities
• Acne fulminans is very rare. Less than 200 cases have been reported
• Acne conglobata is also quite uncommon; Most cases occur in the US and involve anabolic steroid use in athletes
• Fulimans occurs more often with cysts and acutely inflamed lesions and polyporous comedones.

Acne Excoriée.

• Involves an uncontrollable desire to pick, scratch, or rub acne lesions
• Excoriation disorders are a distinct entity within the group of obsessive-compulsive and related disorders
• Presents as recurrent skin picking, resulting in skin lesions
• Diagnostic parameters:
  • Repeated decline to decrease behavior
  • Skin picking that causes clinically significant distress or impairment in various areas of functioning
  • Not attributable to the physiological effect of a substance or another medical condition
  • Not better explained by symptoms of another mental disorder

Acne with Solid Facial Edema.

• It’s a rare condition associated with longstanding acne
• Clinically presenting as localized, symmetric, non-pitting, non-painful edema over the glabellar region, midface, nasal saddle, and infraorbital regions
• Reported mostly in males who are in their late teens/twenties with a multi-year history of acne followed by a recent start of persistent edema

Acne-Like Conditions

• Rosacea is sometimes mistaken for acne
  • However, they are distinct conditions
  • Rosacea presents a long-term inflammatory skin condition that reddens skin and includes rash
  • May also cause eye problems like ocular rosacea -Usually presents with rash in the center of the body parts around the face

Rosacea Symptoms

• Facial redness(that looks like flushing or blushing) that becomes more persistent over time
• May include tingling or burning sensations Rash in the areas of facial redness that develops into acne-like bumps
• Telangiectasia
• Skin thickening, especially on the nose
• Eye irritation presenting as sore, red, itchy, watery, dry and potential eyelid swelling

Perioral Dermatitis

• A common acneiform eruption that affects women, though all adults and children can be affected
• Presents with monomorphic papules and pustules on an erythematous with scale distributed around the mouth
• Causes a clear zone with the vermillion border

Folliculitis

• Is a disorder of the hair can affect all ages
• Presents with follicular-based pustules
• Occurs on any hair-bearing region, but commonly occurs on the trunk, thighs, face, and scalp
• Etiologies can be infectious or non-infectious
• Is Bacteria most being the most common (like staph and strep)
• Mechanical folliculitis is a result of hair removal, tight clothing and ingrown hairs