6-27: Acne Vulgaris

Kanade Shinkai; Lindy P. Fox

Key Clinical Updates in Acne Vulgaris

It may take 3 months or more for truncal acne to resolve with oral antibiotic treatment.

Side effects from isotretinoin that are almost universal are cheilitis, dry skin, and photosensitivity.

ESSENTIALS OF DIAGNOSIS

Almost universal in puberty; may begin in premenarchal girls and present or persist into the fourth or fifth decade.
Comedones are the hallmark. Severity varies from purely comedonal to papular or pustular inflammatory acne to cysts or nodules.
Face, neck, and upper trunk may be affected.
Scarring may be a sequela of the disease or picking by the patient.

GENERAL CONSIDERATIONS

Acne vulgaris is polymorphic. Open and closed comedones, papules, pustules, and cysts are found.

In younger persons, acne vulgaris is more common and more severe in males. It does not always clear spontaneously when maturity is reached. Twelve percent of women and 3% of men over age 25 have acne vulgaris. This rate does not decrease until the fourth or fifth decade of life. The skin lesions parallel sebaceous activity. Pathogenic events include plugging of the infundibulum of the follicles, retention of sebum, overgrowth of the acne bacillus (Propionibacterium acnes) with resultant release of and irritation by accumulated fatty acids, and foreign-body reaction to extrafollicular sebum. Antibiotics may help control acne because of their antibacterial or anti-inflammatory properties.

Hyperandrogenism may be a cause of acne in women and may or may not be accompanied by hirsutism or irregular menses. Polycystic ovary syndrome (PCOS) is the most common identifiable cause. Acne may develop in patients who use systemic corticosteroids or topical fluorinated corticosteroids on the face. Acne may be exacerbated or caused by cosmetic creams or oils.

CLINICAL FINDINGS

There may be mild tenderness, pain, or itching. The lesions occur mainly over the face, neck, upper chest, back, and shoulders. Comedones (tiny, flesh-colored, white or black noninflamed superficial papules that give the skin a rough texture or appearance) are the hallmark of acne vulgaris. Inflammatory papules, pustules, ectatic pores, acne cysts, and scarring are also seen (Figure 6–19) (eFigure 6–53).

eFigure 6–53.

Acne vulgaris. (Reproduced, with permission, from Bondi EE, Jegasothy BV, Lazarus GS [editors]. Dermatology: Diagnosis & Treatment. Originally published by Appleton & Lange. Copyright © 1991 by The McGraw-Hill Companies, Inc.)

A photo illustrating acne vulgaris shows dense red pimples on the cheeks and neck of a man's face.

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Figure 6–19.

Acne vulgaris, severe papulopustular and nodular cystic form with scarring. (Used, with permission, from Richard P. Usatine, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H, Tysinger J. The Color Atlas of Family Medicine. McGraw-Hill, 2009.)