Transcript Acne

Scalp folliculitis “Acne
necrotica miliaris”
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epithelial cells in the infindibulum;
2. An increase in sebum production;
3. An accelerated growth of
Propiobacterium acnes;
4. The occurrence of inflammation;
Pathophysiology of Acne
 Abnormal keratinization of the cells in the
infundibulum results in obstruction of the
follicle with impacted cells and sebum to
form a plug;
 This plug will distend the follicle and form
a microcomedone
 Microcomedone is the initial pathologic
lesion of acne
Microcomedone
Pathophysiology of Acne
 As more sebum accumulate, the
microcomedone enlarges and becomes visible
as a closed comedo, or white head
 The whitehead: is a small pale nodule just
beneath the skin surface that may form a
precursor for other acne lesions
 An open comedo (blackhead) occurs: when the
desquamated epithelial cells and sebum
accumulate behind the plug and the orifice of the
follicular canal becomes distended, allowing the
plug to protrude
 The tip of the plug may darken because of
melanin NOT dirt;
Closed comedone (whitehead)
Open comedo (blackhead)
Pathophysiology of Acne
 Increase in the level of circulating androgens
stimulates production of sebum, which is prevented
from reaching the skin surface by the obstructing
plug;
 At same time; P. acnes colonizes the
pilosebaceous duct;
 Bacterial colony counts are higher in patients with
acne than in those without acne
 P. acnes: major contributor to causing inflammatory
acne lesions lipase: breakdown of sebum to
highly irritating free fatty acids
 The resultant inflammation: localized tissue
destruction
Pathophysiology of Acne
 Inflammatory acne begins with closed
comedones that distend the follicle, causing the
cellular lining of the walls to spread and become
thin;
 Primary inflammation results from disruption of
the epithelial lining + lymphocyte infiltration
 A severe inflammatory reaction happens if the
follicle wall ruptures spontaneously or is
ruptured by picking, squeezing, or attempted
expression with a comedo extractor
Pathophysiology of Acne
Contents are discharged into surrounding
tissue: abscesses scars or pits after
healing
Pits
Pustules or purulent nodules of
inflammatory acne are more likely to
cause scarring than those of noninflammatory acne
Exacerbating Factors for Acne
Several factors are known to exacerbate
existing acne or cause periodic flare-ups
of acne in some patients;
Some may have control over, while others
not (e.g. heredity);
Factors: environmental and physical
factors, cosmetic use, hormonal factors
and medication use
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decreases size of duct orifice and
prevents loosening of comedone. e.g. high
humidity environment or prolonged sweating and
occlusive clothing
Irritation and friction (
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clothing, headbands, helmets, resting chin or
cheek on hand etc
3. Occupational acne: exposure to dirt, vaporized
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Cosmetic Use
 Acne cosmetica: mild form of acne on the face,
cheek and chin;
 Typically: closed, non-inflammatory comedones;
 Occurs as a result of using oil-based products
on the skin that causes occlusion of the
pilosebaceous unit;
 Oil-based cosmetics may exacerbate acne or
even induce it;
 Moisturizers or tanning oils may contain
comedogenic oils (e.g. lanolin, mineral oil, cocoa
butter)
Rosacea
Pomade acne
pustule
Comedo extractor
Pustules (purulent
nodules)
Emotional Factors
Severe or prolonged periods of stress may
exacerbate acne; however they do not
induce acne!
Mechanism is not known
Hormonal Factors
Many women with acne experience a
premenstrual flare-up of symptoms (i.e.
ovulation, pregnancy).
OCP with high androgenic progestin are
implicated in the production of acne
Medication Use
P
Phenytoin
I
Isoniazid
M
Moisturizers
P
Phenobarbital
L
Lithium
E
Ethionamide
S
Steroids
Unsubstantiated Etiologic Factors
Little evidence supports link between: diet
and acne;
A rule of thumb: people should be advised
to avoid any particular food that seems to
exacerbate their acne;
Excessive scrubbing in attempt to open
blocked pores may exacerbate rather than
improve acne
“I know you're never supposed to squeeze
a zit, but I'm not about to leave the house
with a major eruption on my face. Isn't
there any good way to pop it?”
!!!!!
Can I pop a pimple?
!!
 Opinion differs (Some say popping a
pimple can scar, others say it can't scar)
 Most: lancing and gently squeezing
pimples that are at the surface and
white will usually not lead to
scarring.
However, trying to squeeze and pop
a pimple which is still below the
surface may lead to major problems.
Signs and Symptoms of Acne
 Non-inflammatory acne is characterized by
whiteheads or blackheads
 Inflammatory acne is characterized by pimples
(i.e. small, prominent inflamed elevations of the
skin) which may rupture to form a papule
 Papules are inflammatory lesions appearing as
raised, reddened areas on the skin, which may
enlarge to form pustules
 Pustules appear as raised reddened areas filled
with pus
Papule
pimple
whiteheads
pustule
blackheads
Very severe acne, cystic acne,
acne conglobata
Classification of Acne
Grade
of
Acne
Qualitative
Description
Quantitative Description
I
Comedonal acne
Comedones only, < 10 on face, none on
trunk, no scars, noninflammatory lesions only
II
Papular acne
10-25 papules on face and trunk, mild
scarring, inflammatory lesions < 5 mm in
diameter
III
Pustular acne
More than 25 pustules, moderate scarring,
size similar to papules but with visible
purulent core
IV
Severe persistent
pustulocyctis
acne
Nodules or cysts, extensive scarring,
inflammatory lesions > 5 mm in diameter
-
Recalcitrant
severe cystic
acne
Extensive nodules/cysts
Treatment of Acne
Non-pharmacologic therapy
Cleansing of Skin
Minimize Exacerbating factors
Pharmacologic Therapy
Pharmacologic Therapy
Benzoyl Peroxide
Salicylic acid
Sulfur
Sulfur-Resorcinol combination
products
Alpha-hydroxy acids
Benzoyl Peroxide
Available in variety of concentrations
(2.5%, 5% and 10%) and dosage forms
(lotions, gels, creams, cleansers, masks
and soaps);
MOA: (1) irritation & desquamationprevents closure of pilosebaceous duct.
Increase turnover rate of epithelial cells.
(2) Oxidizing potential-antibacterial
activity, decreasing P.acnes
Safety studies are ongoing
Benzoyl Peroxide
The most effective and widely used OTC
drug for non-inflammatory acne;
Clinical response to all concentrations is
similar in reducing the number of
inflammatory lesions
Different formulations are not equivalent:
alcohol gel is superior to lotion of the same
concentration;
Washes and cleansers: have little or no
comedolytic effect
Benzoyl Peroxide
Adverse Effects: excessive dryness,
peeling, some skin sloughing, erythema or
edema lower concentrations must be
used for shorter duration
Stinging/burning: non alarming unless
persist or worsen
Precautions: (1) bleach hair, clothes, bed
linens, (2)avoid excessive sun or sunlamps,
(3) alcohol-based products (e.g. after shave
lotion)( may exacerbate stinging/burning
Salicylic Acid
Available in wide range: 0.5%-2%
A milder, less effective alternative for
teretoin
MOA: acts as a surface keratolytic, mild
comedolytic agent
When used in cleansing preparations:
adjunctive treatment
Sulfur
Keratolytic and antibacterial (precipitated or
colloidal) 3%-10%
Generally: accepted as effective in
promoting the resolution of existing
comedones, but, on continued use, may
have a comedogenic effect
Alternative forms of sulfur: Na thiosulfate,
Zn sulfate, Zn sulfide NGRSE
Applied in thin film to skin 3 times daily
Have noticeable color and odor
Sulfur-Resorcinol combination
3-8% sulfur with resorcinol 2% (enhances
the effect of sulfur)
MOA: keratolytics, fostering cell turnover
and desquamation
Resorcinol produces a reversible dark
brown scale on some darker-skinned
individuals
Alpha-hyrdoxy Acids
They occur naturally in sugar cane, fruits
and milk products;
The most useful AHAs in dermatologic
practice are glycolic acid, lactic acid and
gluconic acid
MOA: facilitate desquamation of the
stratum corneum.
Effective in treatment of comedonal acne
Therapeutic Comparison
Benzoyl Peroxide Salicylic Acid
Sulfur
Bactericidal
Yes
-
-
Keratolytic
-
Yes
Yes
Comedolytic
-
Yes
Yes
Concentration
2.5%-20%
0.5%-2%
2%-10%
Frequency of use 1-2 times daily
Used mainly as
cleanser, then
rinsed off
1-3 times daily
Adverse effects
Potent keratolytic
at high
concentration
Color, unpleasant
odor
Bleached hair and
clothing
Product Selection Guidelines
Cosmetic appearance may influence
compliance
Cleansers (bars, liquids, suspensions,
lotions, creams, gels, and pads/wipes) are
not of much value (WHY?)
Lotions & creams with low fat content are
intended to counteract drying (astringent
effect) and peeling (keratolytic effect):
alternative to more effective gels for dry
sensitive skin or during winter weather
Patient Education:
The goal of self-treatment is to control mild
acne, thus preventing more serious form
from developing
Acne usually goes away on its own
Symptoms can usually be managed with
diligent and long term treatment
 Best approach is use cleansers and
medications to keep skin ducts and
orifices open
Patient Education:
Cleanse skin thoroughly but gently at least
twice daily to produce a mild drying effect
that loosens comedones, using soft wash
cloth, warm water and facial soap without
moisturizing oils
To prevent or minimize acne flare-ups,
avoid or reduce exposure to environmental
factors, such as dirt, dust, petroleum
products, cooking oils or chemical irritants
Patient Education:
To prevent friction or irritation that may
cause acne flare-ups, do not wear tightfitting clothes, headbands, or helmets,
avoid resting the chin on the hand;
To minimise acne related to cosmetic use,
do not use oil based cosmetics and
shampoos
Patient Education:
To prevent excessive hydration of the skin,
which can cause flare-ups, avoid areas of
high humidity and do not wear tight fitting
clothes that restrict air movement;
Try to maintain proper diet, although a link
between diet and acne is not found;
Avoid stressful situations. Stress may play
a role in acne flare-ups but it does not
cause acne
Selected websites for acne information
www.aad.org
www.acne.org
www.derm-infonet.com/acnenet
www.facefacts.com
www.fda.gov
www.nlm.nih.gov/medlinepluse/acne.html
www.rosacea.org
www.Skincarephysicians.com/acnenet
www.holisticonline.com/remedies/Acne.htm
Glossary:
 Comedo: A plug of keratin and sebum within the
dilated orifice of a hair follicle, frequently
containing the bacteria Propionibacterium
acnes, Staphylococcus albus and Pityrosporon
ovale, also called blackhead.
 Propiobacterium acnes: a gram positive
anearobic rod found on the skin
Pustule: a vesicle or an elevation of the
cuticle with an inflamed base, containing
pus.
Glossary:
 Blemish: Any mark of deformity or injury,
whether physical or moral; anything; that
diminishes beauty, or renders imperfect that
which is otherwise well formed
 Pimple: Any small acuminated elevation of the
cuticle, whether going on to suppuration or not
 Papule: A small circumscribed, superficial, solid
elevation of the skin