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ACNE VULGARIS (COMMON ACNE) AND CYSTIC ACNE ICD-10: L70.0

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  • An inflammation of pilosebaceous units, which is very common.

  • Appears on the face, trunk, and rarely buttocks.

  • Occurs most frequently in adolescents.

  • Manifests as comedones, papulopustules, nodules, and cysts.

  • Results in pitted, depressed, or hypertrophic scars.

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EPIDEMIOLOGY

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OCCURRENCE VERY common, affecting approximately 85% of young people.

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AGE OF ONSET Puberty; may appear for the first time around 25 years or older.

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SEX MORE severe in males than in females.

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RACE Lower incidence in Asians and Africans.

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GENETIC ASPECTS Multifactorial genetic background and familial predisposition. Most individuals with cystic acne have a parent(s) with history of severe acne. Severe acne may be associated with XYY syndrome (rare).

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PATHOGENESIS

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Key factors are follicular keratinization, androgens, and Propionibacterium acnes (see Fig. 1-4).

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Follicular plugging (comedone) prevents drainage of sebum; androgens (quantitatively and qualitatively normal in serum) stimulate sebaceous glands to produce more sebum. Bacterial (p. acnes) lipase converts lipids to fatty acids and produces proinflammatory mediators (IL-I, TNF-α), which lead to an inflammatory response. Distended follicle walls break; sebum, lipids, fatty acids, keratin, and bacteria enter the dermis, provoking an inflammatory and foreign-body response. Intense inflammation leads to scars.

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CONTRIBUTORY FACTORS Acnegenic mineral oils, rarely dioxin, and others listed below.

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Drugs. Lithium, hydantoin, isoniazid, glucocorticoids, oral contraceptives, iodides, bromides and androgens, and danazol.

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Others. Emotional stress can cause exacerbations. Occlusion and pressure on the skin, such as leaning the face on the hands, is a very important and often unrecognized exacerbating factor (acne mechanica). Acne is not caused by any kind of food.

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CLINICAL MANIFESTATION

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DURATION OF LESIONS Weeks to months.

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SEASON Often worse in fall and winter.

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SYMPTOMS Pain in lesions (especially the nodulocystic type).

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SKIN LESIONS Comedones—open (blackheads) or closed (whiteheads); comedonal acne (Fig. 1-1). Papules and papulopustules—i.e., a papule topped by a pustule; papulopustular acne (Fig. 1-2). Nodules or cysts—1 to 4 cm in diameter; nodulocystic acne (Fig. 1-3). Soft nodules result from repeated follicular ruptures and re-encapsulations with inflammation, abscess formation (cysts), and foreign-body reaction (Fig. 1-4). Round, isolated single nodules and cysts coalesce to linear mounds and sinus tracts (Figs. 1-3 and 1-5). Sinuses: draining epithelial-lined tracts, usually with nodular acne. Scars: atrophic depressed (often pitted) or hypertrophic (at times, keloidal). Seborrhea of the face and scalp are often present and sometimes severe.

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Figure 1-1

Acne vulgaris: comedones Comedones are keratin plugs that form within follicular ostia and are frequently associated with surrounding erythema and pustule formation. Comedones associated with small ostia are referred to as ...

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