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Acne vulgaris, also known as acne, is a multifactorial disorder of the pilosebaceous unit.  The clinical scenario can vary from small pimple to a fulminating systemic disease. Although groups of all ages can be affected by this disease, this is commonly a disease of adolescence.
This condition has an undeniable impact on the psychological factor, affecting the patient who suffers, causing isolation, depression, even to suicidal thoughts.

Acne vulgaris affects approximately 40 to 50 million people each year, only in the United States. With an increase in the appearance in adolescence, this disorder affects 85% of the young population between the ages of 12 to 24 years. Although studies conducted agree that 35% of women and 20% of men usually suffer in their 30s. Boys and men of Caucasian origin have the more severe nodulocystic disease than other groups.

One of the first steps in the emergence of acne is the formation of micro blackhead. This begins with the keratosis coating of the upper portion of the follicle. Due to this phenomenon, it appears is a bottleneck effect, where sebum accumulates and lose keratinocytes.

It often causes blackheads, whiteheads or pimples, usually located on the cheeks, chin, forehead, chest, back, and shoulders. This disorder is very common in teenagers, although it affects people of all ages.

There are treatments to treat this condition, but it can be persistent. Pimples and lumps slowly heal, and when one begins to disappear, others seem to arise.

Acne Symptoms

The signs and symptoms of acne vary depending on the severity of your condition:

  • Closed plugged pores (whiteheads)
  • Open pores plugged (black spots or Blackheads )
  • Papules (small red and sensitive lumps)
  • Pustules (pimples), which are papules with pus on their tips.
  • Nodules (large, solid, painful lumps) beneath the surface of the skin.
  • Cystic lesions, (painful, lumps filled with pus) under the surface of the skin
Common acne. If the pore becomes infected with bacteria, inflammation results.
Cystic acne — the most severe form of acne — occurs when oil and dead skin cells build up deep within hair follicles. The resulting rupture within your skin may form boil-like infections.

When to see a doctor

You should not self-medicate, this can make your situation worse. Consult your primary care doctor. He can prescribe appropriate medications. If acne persists or is severe, you may want to seek medical treatment from a doctor specializing in dermatology.

For many women, acne can persist for decades, accentuating the signs a week before menstruation. This type of condition tends to disappear without treatment in women who use contraceptives.

In older adults, a sudden onset of severe acne may signal an underlying disease requiring medical attention.

Four main factors cause acne:

  •    Hair follicles clogged by oil and dead skin cells
  •    Excess production of oil from the sebaceous glands
  •    Bacterium
  •    Excess activity of one type of hormone (androgens).

Acne usually appears on your face, forehead, chest, upper back and shoulders because these areas of the skin have the most sebaceous glands. The hair follicles are connected to the sebaceous glands. The wall of the follicle can bulge and produce a white spot. Or the pore may be open and darken, causing a pimple. The pimple may look like dirt adhering to the pores. But in reality, the pore is congested with bacteria and oil, which turns brown when exposed to air. Pimples are red bumps with a white center that develops when the blocked hair follicles become infected with bacteria and inflamed. The blockages and inflammation that develop inside the hair follicles produce cyst-shaped lumps beneath the surface of the skin. Other pores in your skin, which are the openings of the sweat glands, are generally not involved in acne.

Factors that can make acne worse

  • Certain hormones (androgens) can trigger the productive increase of sebum, on the part of the sebaceous glands. This is common in puberty and pregnancy, so when the patient uses certain contraceptives.
  • Certain medications Examples include medications that contain corticosteroids, testosterone, or lithium.
  • Diet. Studies indicate that certain dietary factors, such as skimmed milk and carbohydrate-rich foods, such as bread, rolls, and chips, can make it worse. It has long been suspected that chocolate makes acne worse.
  • Stress. Stress can make acne worse.

Risk factors

Risk factors for acne include:

  • Age. While people of all ages can get acne, but it’s most common in teenagers.
  • Hormonal changes. Such changes are common in teenagers, women, and girls, and people using certain medications, including those containing corticosteroids, androgens or lithium.
  • Family history. Genetics plays a role in acne. If both parents had, you’re likely to develop it, too.
  • Greasy or oily substances. You can develop acne where they clog pores due to lotions and oily creams or with grease in a work area, such as mechanical workshops
  • Stress. Stress does not cause acne, but it makes it worse if you already have it.

Acne Variants.

Post Adolescent: Inflammatory acne that persists beyond 25 years of age, mainly in women, usually appears during the weeks preceding menstruation. This disorder usually appears in papular forms on the lower part of the face, jaw, and neck. and is mainly associated with signs of hyperandrogenism. But despite hormone levels of androgens, hormone therapy is effective.

Acne fulminans: It is the most severe, characterized by the abrupt development of nodular and suppurative lesions, associated with systemic manifestations. This uncommon variate mainly affects males between the ages of 13 and 16 years. Patients usually suffered from acne vulgaris, which suddenly erupted, inflamed, painfully festering injuries or covering with hemorrhagic crusts.

Cystic acne (Conglobata): It is a severe form of nodulocystic acne, which may have an eruptive appearance but without systemic manifestations. this recalcitrant variant is part of the follicular occlusion, along with dissecting cellulitis of the scalp, hidradenitis suppurativa, and pilonidal cyst.

Solid facial edema: it is another unusual and disfiguring complication of vulgar acne. From the clinical point of view, it is a distortion of the midline of the face and cheeks due to the soft tissue inflammation. the hardening may be accompanied by erythema.

Mechanica: This appears when the friction and mechanical obstruction of the pilosebaceous outputs occurs and the blackhead is formed. objects such as helmets, necklaces. A typical example of mechanical acne is the neck of the violinist, where the trauma can be appreciated by the repetitive placement of the violin in the lateral part of the neck. It is usually cured by eliminating the causes.

Acne excoriée

Ecoriée des jeunes filles: As its name implies, it occurs in young women, typical pimples and inflamed papules are systematically excoriated systematically, causing a crust-like erosion that can leave a scar. Linear erosion suggests self-manipulation and an underlying psychological aspect must be considered. Therefore individuals with anxiety, disorder or obsessive-compulsive personality are particularly at risk for this disease.  The doctor should indicate antidepressants and psychotherapy in these patients.

Drug-induced acne due to Isoniazid Drug-induced: acne or eruptive acneiform lesion can be seen as a side effect of e number of medications (Table 1). An abrupt, monomorphic eruption of inflammatory papules and pustules are frequently observed in drug-induced acne, in contrast to the heterogeneous lesions seen in common acne. That is why some clinicians use the terms Folliculitis.

Occupational: Exposure to insoluble substances, which obtrudes the follicles present in the workplace is responsible for the occurrence of occupational acne.
Frequently the causative agents are oils, derived from petroleum, aromatic hydrocarbons and coal derivatives. Blackheads and blackheads predominate in this type of acne.

Infantile Acne

Neonatal: Occurs in more than 20% of newborns. The lesions usually appear at 2 weeks of age and disappear at approximately three months of age. Small papulopustules without pimples emerge on the cheeks and the bridge of the nose. Although the forehead, chin and upper torso can be affected.

This is triggered by the passive transfer of maternal forms to the newborn at the time of delivery.

Table 1: Cause of Drug-Induced Acne

Acne Treatment.

TREATMENT OF ACNE VULGARIS
Mild Moderate Severe
Comedonal Papular/Pustular Papular/Pustular Nodular Conglobata/Fulminans
First Line Topical retinoid Topical Retinoid + topical antimicrobial Oral antibiotic + topical retinoid ± BPO Oral antibiotic + topical retinoid ± BPO Oral isotretinoin (may require concurrent oral corticosteroid, esp. for acne fulminans)
Second Line Alternative topical retinoid.

Azelaic acid.

Salicylic acid.

Alternative topical retinoid + alt. Topical antimicrobial.

Azelaic acid.

Salicylic acid.

Oral antibiotic + topical retinoid ± BPO / azelaic acid. Oral isotretinoin.

Alternative oral antibiotic + alt.  topical retinoid ± BPO/ azelaic acid

Dapsone.

High dose oral antibiotic + topical retinoid ± BPO

Option for female patients Oral contraceptive/ antidrogen Oral contraceptive/ antidrogen Oral contraceptive/ antidrogen
Surgical option Comedon extraction Comedon extraction Comedon extraction

Intralesional corticosteroid

Intralesional corticosteroid
Refractory to treatment Exclude Gram-negative folliculitis Exclude Gram-negative folliculitis

Female patient: Exclude adrenal or ovarian dysfunction.

Exclude use of anabolic steroid or other acne exacerbating medications.

Maintenance: Topical retinoid ± BPO Topical retinoid ± BPO Topical retinoid ± BPO

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