Acne: Comprehensive Overview and Diagnosis - PDF

Acne CMS250 Dr. Adam Gratton MSc ND Learning Outcomes Analyze the essentials of Acne Vulgaris, including its definition and etiology. Evaluate and comprehend the prevalence, presentation, and epidemiology of acne vulgaris across different age groups, skin types, and populations, emphasizing t...

Acne CMS250 Dr. Adam Gratton MSc ND Learning Outcomes Analyze the essentials of Acne Vulgaris, including its definition and etiology. Evaluate and comprehend the prevalence, presentation, and epidemiology of acne vulgaris across different age groups, skin types, and populations, emphasizing the differences in acne vulgaris in skin of color populations compared to fairer-skinned populations. Distinguish the clinical findings, presentations, and key features of acne vulgaris, including the different types and severity levels of acne vulgaris, typical locations of acne lesions, and the different types of acne lesions (comedones, papules, pustules, nodules, and cysts). Critique the differential diagnosis of acne vulgaris (including drug-induced, occupational, chemical, and mechanical acne), how to differentiate it from other conditions with similar presentations, and when investigations may be necessary. Evaluate and comprehend the relationship between various factors and acne vulgaris, including diet, genetic and environmental factors, and psychological stress. Appraise the variability in the age of onset, distribution, severity, and age of resolution of acne vulgaris and understand the chronic course and self-limiting nature of the disease. Learning Outcomes Assess the potential physical and psychological impacts of acne vulgaris, including its impact on quality of life, potential long-term health implications, and the potential sequelae of acne, such as scarring, dyspigmentation, and low self-esteem. Investigate the general considerations, disease highlights, evidence-based diagnosis, and prognosis of acne vulgaris. Analyze the clinical presentation and causes for acne variants and acneiform eruptions, including neonatal acne, infantile acne, mid-childhood acne, acne conglobata, acne fulminans, SAPHO syndrome, PAPA, PASH, and PAPSH syndromes, acne excoriée, acne mechanica, acne with solid facial edema, acne with associated endocrinology abnormalities, and others. Diagnose the indications for consultation in patients with acne, acneiform eruptions, rosacea, and perioral dermatitis, comprehend the clinical course and prognosis of these conditions, and classify them based on clinical presentation. Appraise the importance of interprofessional collaboration in the evaluation, counseling, and provision of effective care for patients with acne vulgaris from diverse racial backgrounds. Interpret common medications, endocrine causes, and external factors that may cause or affect acne, and evaluate the role of occupational exposure and mechanical factors in the development of acneiform eruptions. Introduction Acne vulgaris is one of the most common skin disorders Multifactorial inflammatory disease centred on the pilosebaceous gland of the skin Understanding of the pathogenesis continues to evolve Key features include follicular hyperkeratinization, microbial colonization with Cutibacterium acnes, sebum production, and complex inflammatory mechanisms involving both innate and acquired immunity Hormones, diet, and genetic factors contribute to acne pathogenesis Epidemiology Acne vulgaris is one of the most burdensome diseases globally In Canada, it is estimated to affect 85% of those aged 12 – 24 years Acne may persist into adulthood affecting 12% of women and 3% of men and these rates persist until the 5th decade of life Associated Factors Onset typically correlates with the onset of puberty Prevalence is higher in females Severity is higher in males Parent’s education level and family education level are associated with an increased risk of more severe acne Parental history of acne strongly correlated with acne in their offspring Skin sebum levels associated with acne and most strongly associated with oily and mixed skin types Associated Factors Geography, diet, and ethnicity seemed to be associated but the relationship is complex African American and Latin American populations have a slightly higher prevalence of acne compared to Asian American and Caucasian populations However, geographically, many populations outside of Canada and the United States see less prevalence of acne which has implicated a standard American diet as an influencing factor in acne pathogenesis 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 – dilated hair follicle filled with keratin, bacteria, and sebum. Plural = comedones. Closed comedo – opening is obstructed and accompanied by an inflammatory response. Commonly called a whitehead Open comedo – opening is not obstructed and capped with a pigmented mass of skin debris. Commonly called a blackhead Diagnosis Diagnosis is typically made clinically with the presence of comedones, papules, pustules and nodules on the face, chest, or upper back. Hyperpigmentation occurs more frequently in skin of colour patients compared to fairer-skinned patients Additional testing is rarely required Workup for hyperandrogenism is appropriate when there are signs of polycystic ovary disease, virilization, or atypical presentation There are no detectable endocrinological disturbances in the majority of patients with acne Severity Classification Typically classified by severity to facilitate treatment approaches Grade Severity Clinical findings 1 Mild Open and closed comedones with few inflammatory papules and pustules 2 Moderate Papules and pustules, mainly on face 3 Moderately severe Numerous papules and pustules, and occasional inflamed nodules, also on chest and back 4 Severe Many large, painful nodules and pustules Severity Classification Other terminology associated with severity classification includes: Comedonal Mild papulopustular Moderate papulopustular Severe papulopustular/nodular Objective Outcomes There are around 24 different methods of classifying severity in trials related to acne An objective standard does not exist which complicates making a clinical severity determination challenging General agreement at the mild end of the severity spectrum is comedonal acne characterized by primarily uninflamed comedones. The presence of nodules results in a classification of severe Quality of Life Quality of life is not entirely correlated with acne severity Even mild acne is associated with a significant impact on daily activities, emotions, social activities, study/work dynamics, and interpersonal relationships Prevalence of anxiety, depression, and suicidal ideation are significantly higher with people who have acne versus people who do not Prognosis Acne vulgaris eventually remits spontaneously, but when this will occur cannot be predicted May persist throughout adulthood and may lead to severe scarring if left untreated Flare and relapse rates are dependent on the specific treatments used In some instances, it can be chronic and flare intermittently despite treatment Additional Classification Additional classification can involve predisposing or causative agents and behaviours Erroneously treating these specific scenarios as acne vulgaris exacerbates the condition Patients with atypical presentations should be referred to a dermatologist Drug-induced acne Occupational acne Chemical acne Mechanical acne Drug-induced Acne Topical and systemic corticosteroids Topical corticosteroids may cause acneiform eruptions over the skin under which the topical preparation is applied or in/around the nose or mouth in the case of inhaled steroids Steroid acne presents as monomorphous papulopustules located mainly on the trunk and extremities, with less involvement of the face, and typically occurs after systemic administration of corticosteroids Drug-induced Acne Antibiotics like penicillins and macrolides can cause acute generalized pustular eruptions without comedones. Typically associated with fever and leukocytosis Can also be caused by cotrimoxazole, doxycycline, ofloxacin, and chloramphenicol Drug-induced Acne Other drugs associated with the development of acneiform eruptions include Anticonvulsants (phenytoin) Antidepressants Antipsychotics (olanzapine, lithium) Antituberculosis drugs Antifungals Naproxen Chemotherapy drugs Hydroxychloroquine Occupational Acne Secondary to exposure to halogenated aromatic hydrocarbons Often referred to as ‘chloracnegens’ Historically described within the context of dioxin exposure Very rare with restrictions on the use of the vast majority of causative agents Chemical Acne Also called Acne cosmetica Associated with the use of heavy oil-based hair products and cosmetics and resolves with discontinuation of these products Mechanical Acne Also called acne mechanica Results from pressure and friction that induce acneiform eruptions Presence of acne in very specific highly localized areas Common in areas of restrictive clothing, prolonged contact with synthetic clothing fibers, use of sports equipment, etc. Childhood Acne Acne in childhood is divided into three groups, based on age at presentation, differences in clinical presentations, associated conditions, and pathogenetic factors Neonatal Acne Presents in about 20% of newborns It is occasionally present at the time of birth Most commonly presents at about 2 weeks of age but can develop any time before 6 weeks of age Likely caused be exposure to hormones in utero or via breastmilk Typically, spontaneously resolves in a few weeks to months without sequelae Milia Common skin condition resulting in small (1 – 2 mm) white or yellow papules under the surface of the skin caused by keratin retention Present in 40 – 50% of newborns Can also occur in adults Milia occur most often on the forehead, cheeks, nose, and chin, but they may also occur on the upper trunk, limbs, penis, or mucous membranes In newborns, the condition only lasts a few weeks and disappears spontaneously within the first month of life In adults, the condition may be related to various cosmetic products and practices Often misdiagnosed as acne as it looks very similar to closed comedones Miliaria Results from sweat retention caused by partial closure of eccrine structures Miliaria affects up to 40% of infants and usually appears during the first month of life Miliaria Two clinically distinguishable subtypes: Miliaria crystallina Caused by superficial eccrine duct closure Consists of 1 – 2 mm vesicles without surrounding erythema most commonly on the head, neck, and trunk Miliaria rubra Also referred to as a heat rash Caused by deeper level of sweat gland obstruction Lesions are small erythematous papules and vesicles usually occurring on covered portions of the skin Infantile Acne Acne occurring after 6 weeks of age Most commonly develops between 3 and 6 months of age 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 of age LH levels surge between 6 and 12 months of age resulting in increased gonadal testosterone production in males Sometimes caused by cosmetic products (moisturizers, etc.) Infantile Acne Potentially more worrisome than neonatal acne and may require referral to a pediatric endocrinologist Especially true when Tanner stages are not consistent with age, increased height velocity, hirsutism, etc. Mid-childhood Acne Presents in children of one to seven years of age with comedones and inflammatory lesions typically distributed over the forehead, cheeks, and nose Because children aged one to seven years do not produce significant amounts of androgens, acne in this age group suggests an endocrine abnormality that warrants evaluation by a pediatric endocrinologist Acne in this age group is very rare Preadolescent Acne Acne can be the first sign of puberty and it is common to find acne in this age group (7 – 12 years of age) Often presents as comedones in the ‘T-zone’ of the face (central forehead, nose, and lips) Associated with rise in androgen levels associated with onset of puberty Differential Diagnosis Acne can occur as a standalone dermatological disorder or as a symptom of another disorder Many skin conditions cause the formation of papules or pustules and can be difficult to separate from acne vulgaris Differential Diagnosis Any condition that causes hyperandrogenism has the potential to cause acne The majority of these cases are due to polycystic ovary syndrome Other causes include adrenal hyperplasia, insulin resistance, hyperprolactinemia, Cushing’s disease, and certain cancers. The presence of other systemic factors related to hyperandrogenism should be explored before making a diagnosis of acne vulgaris Differential Diagnosis Acne is also considered a component of more extensive systemic disorders SAPHO syndrome A rare inflammatory disorder of bone, joints, and skin characterized by the presence of synovitis, acne, pustulosis, hyperostosis, and osteitis Differential Diagnosis PAPA syndrome A rare autosomal dominant disorder caused by mutations in the CD2-binding protein characterized by pyogenic sterile arthritis, pyoderma gangrenosum, and acne PASH syndrome A rare hereditary autoinflammatory disorder characterized by pyoderma gangrenosum, acne, and hidradenitis suppurativa PAPSH syndrome A rare autoinflammatory disorder characterized by pyogenic arthritis, acne, pyoderma gangrenosum, and hidradenitis suppurativa Differential Diagnosis PAPA, PASH, and PAPASH all share common pathophysiologic mechanisms involving the over-activation of the immune system leading to increased production of the IL-1 family and neutrophil-rich cutaneous inflammation Differential Diagnosis Severe rare forms of nodulocystic acne Acne conglobata Presents with tender, disfiguring, double or triple interconnecting comedones, cysts, inflammatory nodules, and deep burrowing abscesses on the face, shoulders, back, chest, upper arms, buttocks, and thighs Cysts often contain purulent, foul-smelling material that is discharged on the skin surface Part of a group of related diseases involving dysfunction of the follicular unit Differential Diagnosis Acne conglobata may occur in isolation or present with a systemic inflammatory condition, including SAPHO syndrome, PAPA syndrome, PASH syndrome, or PAPASH syndrome Also related to the use of thyroid hormone, exposure to halogenated aromatic hydrocarbons (occupational acne), and the use of, or sudden discontinuation of, anabolic steroids Differential Diagnosis Acne fulminans aka acne maligna A very rare skin disorder presenting as, painful, ulcerating, and hemorrhagic clinical form of acne with a very sudden onset May or may not be associated with systemic symptoms such as fever and polyarthritis May cause bone lesions May be triggered by the use of high doses of isotretinoin when initiating treatment in patients with severe acne Also associated with anabolic steroid use Acne conglobata vs fulminans The two conditions are often confused as there are significant similarities between triggers and presentation Acne fulminans occurs is very rare Less than 200 cases are known to have occurred Acne conglobata is also quite uncommon Most cases have been described within the US and most of those cases involve the use of anabolic steroids in athletes Acne conglobata vs fulminans Acne fulminans typically involves cysts and acutely inflamed lesions Acne conglobata involves polyporous comedones which are not present in acne fulminans Acne excoriée An excoriation disorder in which patients have a conscious, repetitive, and uncontrollable desire to pick, scratch, or rub acne lesions Excoriation disorders are a distinct entity within the group of obsessive- compulsive and related disorders Recurrent skin picking, resulting in skin lesions All of the following must be met to diagnose the condition Repeated attempts to decrease picking behavior Skin picking causes clinically significant distress or impairment in social, occupational, or other areas of functioning Skin picking is not attributable to the physiologic effect of a substance (e.g. cocaine) or another medical condition (e.g. scabies) Skin picking is not better explained by symptoms of another mental disorder (e.g. delusions or tactile hallucinations in a psychotic disorder) Acne with solid facial edema Solid facial edema is a rare condition associated with longstanding acne vulgaris Clinical presentation is consistent with localized, symmetric, non-pitting, non-painful edema over the glabellar region, midface, nasal saddle, and infraorbital regions Most reported cases are males in their late teens or early twenties who present with a multi-year history of acne followed by a recent onset of persistent edema Differential Diagnosis Rosacea Sometimes referred to as acne rosacea, but the acne has been dropped so as not to add confusion to this diagnosis It is not acne Rosacea is a long-term inflammatory skin condition that causes reddened skin and a rash, usually on the nose and cheeks It may also cause eye problems – ocular rosacea It usually affects the center of the face, but in rare cases, it can extend to other parts of the body, such as the sides of the face, the ears, neck, scalp, and chest Differential Diagnosis Symptoms include: Facial redness (that looks like flushing or blushing) but becomes more persistent over time. It is sometimes accompanied by a tingling or burning sensation. Rash in the areas of facial redness that can develop bumps that resemble acne Telangiectasia Skin thickening, especially on the nose Eye irritation presenting as sore, red, itchy, watery, dry, or feel as if something is in them. Possible eyelid swelling and development of styes. Differential Diagnosis Perioral dermatitis A common acneiform eruption that usually affects women 20–45 years of age but can affect all adults and children Presents with discrete monomorphic papules and pustules on an erythematous base with or without scale distributed symmetrically around the mouth with a clear zone between the vermilion border and the affected skin It can extend to the nasolabial folds and skin around the lateral canthi (periorbital dermatitis) It is often triggered and or exacerbated by the use of topical corticosteroids Differential Diagnosis Folliculitis Common disorder of the hair follicle that can affect individuals of all ages Folliculitis typically presents with follicular-based pustules and/or inflammatory papules on any hair-bearing area, but most commonly on the trunk, buttocks, thighs, axillae, face, and scalp Differential Diagnosis Can be caused by infectious or non-infectious etiologies Bacteria are the most common cause (Staphylococcus aureus, Streptococcus, Pseudomonas aeruginosa) Fungal folliculitis caused by Malassezia is common and can become chronic if not treated Mechanical folliculitis can be caused by hair removal practices, tight clothing, and ingrown hairs References Shinkai K, Fox LP. Acne Vulgaris. In: Papadakis MA, McPhee SJ, Rabow MW, McQuaid KR. eds. Current Medical Diagnosis & Treatment 2023. McGraw Hill; 2023. Accessed May 13, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=3212&sectionid=269146777 Stein S. Acne Vulgaris. In: Stern SC, Cifu AS, Altkorn D. eds. Symptom to Diagnosis: An Evidence- Based Guide, 4e. McGraw Hill; 2020. Accessed May 13, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=2715&sectionid=249061788 eCPS chapter on acne Elbuluk N, David J, Barbosa V, Taylor SC. Acne Vulgaris. In: Kelly A, Taylor SC, Lim HW, Serrano A. eds. Taylor and Kelly's Dermatology for Skin of Color, 2e. McGraw Hill; 2016. Accessed May 13, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=2585&sectionid=211766114 Goh C, Cheng C, Agak G, Zaenglein AL, Graber EM, Thiboutot DM, Kim J. Acne Vulgaris. In: Kang S, Amagai M, Bruckner AL, Enk AH, Margolis DJ, McMichael AJ, Orringer JS. eds. Fitzpatrick's Dermatology, 9e. McGraw Hill; 2019. Accessed May 13, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=2570&sectionid=210419885 References Zaenglein AL, Graber EM, Thiboutot DM. Acne Variants and Acneiform Eruptions. In: Kang S, Amagai M, Bruckner AL, Enk AH, Margolis DJ, McMichael AJ, Orringer JS. eds. Fitzpatrick's Dermatology, 9e. McGraw Hill; 2019. Accessed May 13, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=2570&sectionid=210420249 Gao Y, Farah R. Acne, Rosacea, and Related Disorders. In: Soutor C, Hordinsky MK. eds. Clinical Dermatology: Diagnosis and Management of Common Disorders, 2e. McGraw Hill; 2022. Accessed May 13, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=3171&sectionid=266027525 Nair PA, Salazar FJ. Acneiform Eruptions. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459207/ Acne Vulgaris Article (statpearls.com) https://www.statpearls.com/articlelibrary/viewarticle/17101/ Oge' LK, Broussard A, Marshall MD. Acne Vulgaris: Diagnosis and Treatment. Am Fam Physician. 2019 Oct 15;100(8):475-484. PMID: 31613567. https://www.aafp.org/pubs/afp/issues/2019/1015/p475.html Feldman S, Careccia RE, Barham KL, Hancox J. Diagnosis and treatment of acne. Am Fam Physician. 2004 May 1;69(9):2123-30. PMID: 15152959. References Winters RD, Mitchell M. Folliculitis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547754/ Hafsi W, Arnold DL, Kassardjian M. Acne Conglobata. [Updated 2023 Jun 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459219/ Zito PM, Badri T. Acne Fulminans. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459326/ Smith EJ, Allantaz F, Bennett L, Zhang D, Gao X, Wood G, Kastner DL, Punaro M, Aksentijevich I, Pascual V, Wise CA. Clinical, Molecular, and Genetic Characteristics of PAPA Syndrome: A Review. Curr Genomics. 2010 Nov;11(7):519-27. doi: 10.2174/138920210793175921. PMID: 21532836; PMCID: PMC3048314. Niv D, Ramirez JA, Fivenson DP. Pyoderma gangrenosum, acne, and hidradenitis suppurativa (PASH) syndrome with recurrent vasculitis. JAAD Case Rep. 2017 Feb 4;3(1):70-73. doi: 10.1016/j.jdcr.2016.11.006. PMID: 28203623; PMCID: PMC5294749. Cugno M, Borghi A, Marzano AV. PAPA, PASH and PAPASH Syndromes: Pathophysiology, Presentation and Treatment. Am J Clin Dermatol. 2017 Aug;18(4):555-562. doi: 10.1007/s40257-017-0265-1. PMID: 28236224.