Acne and Acne related disordersDisorders of sebaceous glands and Rosacea

Fahad Al Sudairy , M.D.

Objectives

• Acquiring knowledge of the etiology and pathogenesis of acne and acne related disorders.

• Understanding the disease spectrum and various types of clinical presentations.

• Knowing the differential diagnosis of acne and related disorders.

• Acquiring knowledge of the therapeutic options and their indications.

• to be familiar with the etiology, clinical types and treatment of rosacea.

Acne Vulgaris

• AV, is a common chronic skin disease involving blokage and/or inflammation of pilosebaceous units (hair follicles & their accompanying sebaceous gland)

• Acne can present as noninflammatory lesions, inflammatory lesions, or a mixture of both, affecting mostly the face but also the back and chest.

Etiology:Not 100% understood BUT there are some theories : 1. Genetic Aspect, (Acne runs in family) .

2. Occupation (Environmental, Mechanical) .

3. Drugs , Oral and topical .

4. Endocrine Factors .

• The 4 factors that contribute to development of ACNE are

: 1. production of excessive sebaceous gland secretion

( Follicular Hyperkeratosis ).2. obstruction to outflow of this sebum at the mouth of

the pilosebaceous canal 3. inflammation arising as a result of leakage of contents

of the pilosebaceous follicle into the surrounding dermis 4. excessive colonization or infection of the pilosebaceous

ducts with P.acnes

Clinical features ( morphology ) : (Acne and acne related Disorders)

1. Acne Vulgaris:Papules: (Less than 0.5 cm)

• Comedones (Open “Blackheads” or closed “Whiteheads”)

• The early lesions of acne are open and closed comedones which can develop into papules and pustules

Open Comedones (Blackheads)

Open Comedones

It is a special sign of Acne Vulgaris The lesion ( as the figure show ) opens to the outside ( on skin surface ) so any discharge will

get out and it wont accumulate

Closed Comedones (Whitehead)

Closed Comedones

It has the same color of the skin It is covered by the skin surface So the discharge will be trapped and accumulate leading to

formation of Inflammatory Acne So it has worse prognosis than the previous type

• Inflammatory papules

Inflammatory papules

• Pustules :

Pustules

It is due to collection of Pus due to Nutrophills infiltration

• Nodule (more than 0.5 cm) this occure in sever form of Acne

Nodule

Stages of acne: (A) Normal follicle.

)B( open comedo (blackhead) .

(C) closed comedo (whitehead) .

(D) papule .(E) pustule.

• Cystic acne: the cysts are usually large 1-4cm this occure in sever form of Acne

Nodule and cystic acne has high chance of scar formation

• Neonatal acne: • Cause unknown but some believed is due to passing of

Transplacental androgen , other suggest the role of organisms (Malassezia furfur) .

• Affect 1 in 5 • Mainly inflammatory comedones on nose and cheeks • Affect new born between the 1st and 6th week of age

Neonatal Acne and Infantile Acne

• Infantile Acne: • affect males more than females• usually between 3 and 6 months of age• tend to be severer than the neonatal one and believed

to be due to Endogenic androgen from the infant’s gonads.

Acne Fulminans

• Affect youngsters 13 – 17 years of age• very severe with ulceration and pus discharge

• associated symptoms include (fever, malaise, myalgia, arthritis and bone pain)

• laboratory investigation shows ESR • Can be induced by starting the patient on high

dose of isotretinion (Roaccutane).

Acne Conglobata

• Very severe Acne, Nodulocystic form with abscess formation

• Affect Trunk more than the face• Usually associated with XYY Syndrome.

This type resistance to treatment need to treat the underlying cause

TREATMENT

• Note: All medications used for the treatment of acne act as:

1. Anti comedonal

2. Anti inflammatory

3. Anti microbial

• The main aim of treating acne is to prevent scaring

Topical Keratolytic

• Retinoid ( Retinoic acid 0.025, 0.05, 0.1%)• Adapalene (Differin 0.1%)• Salicylic acid Also treat post inflamatory

pigmentations• Benzoyl peroxide (peeling agent and

antimicrobial)• Azelaic Acid (10, 15, 20 %)

Topical Antibiotic

• Used in mild to moderate cases

• Topical clindamycin (Dalacin T)• Erythromycin

Systemic therapy

• Antibiotic 1. Tetracycline2. Doxycycline the best choice (( safe )) -- but it

has teratogenicity 3. Minocycline (blue grey discoloration )4. Erythromycin

Usually combination therapy is useful : give Abx + creams (( ex, tretinoin ))

• Systemic Retinoids :

Isotretinoin caps (Roaccutane): 0.5 – 1 mg/kg The most effective drug for acne.

Indicated for severe forms, but also for milder forms associated with scarring or with significant psychological impact.

Relapse is minimal with cumulative dose of 120 – 150 mg/kg.

Teratogenicity : Retinoid - induced embryopathy.

Pregnancy must be prevented during treatment and for at least 1 month after discontinuing the drug.

• Mild Acne• topical antibiotic . Ex. Clindmaycin .• topical keratolytic

• Moderate acne• Topical benzoyl peroxide• Oral Tetracycline or erythromycin • If no response refer for systemic retinoic acid

• Severe acne • Controlled in almost all cases by isotretinoin (females should take

contraceptive pills)

Rosacea- A controversial topic in dermatology largely because of

its uncertain pathophysiology and clinical variation.- Erythema of the central face that has persisted for

months or more.- Primary features : flushing, papules pustules and

telangiectases.- Secondary features : burning, stinging, edema, plaques,

dry appearance, phyma, peripheral flushing and ocular manifestations.

Epidemiology

• Common in caucasian population• Fair skinned individuals• women>men• Onset typically begins after age 30

Etiology and pathogenesis

• Not 100% understood But there are some theories : 1) Vascular reactivity:• Rosacea is induced by chronic repeated triggers of flushing

exposure, they include:

• 1) Hot or cold temperature 7) Sunlight • 2) Hot drinks• 3) Spicy foods• 4) Alcohol 8) Emotional disteress• 5) Certain cosmetics 9) Topical irritants• 6) Medications• there appears to be a hyper responsive blood supply to the

pilosebaceous follicles

Etiology and pathogenesis

2) Dermal matrix degeneration and endothelial damage• Inherent problems with vessels permeability • Delayed clearance of inflammatory mediators and waste

products• Photodamaged connective tissue (solar elastosis is a

common background on which rosacea histologic features are superimposed

Etiology and pathogenesis

• The role of microbe – induced follicle based inflammation• Commensal organisms which reside in hair follicles and

sebaceous glands may trigger folliculocentric inflammatory papules.

• Demodex folliculorum (mite) or associated bacteria (bacillus oleronius).

Sub-type classification

Sub types were defined by the National Rosacea Society (NRS) expert committee in 2002.

1) Erythematotelangiectatic : persistent erythema and telangiectasias on the central face.

2) Papulopustular: papules and pustules predominate on convex areas on a background of persistent erythema

3) Phymatous: patulous follicular orifices, thickened skin and nodularity

Most often affect the nose (rhinophyma)Almost exclusively in men4) Ocular: Blepharitis is the most common feature (mebomian gland

dysfunction)Conjuctivitis, iritis, scleritis, keratitis

Erythematotelangiectatic Rosacea

begin typically on the forehead , the bridge of the nose , and cheeks , they call it butterfly area of the face

Papulopustular Rosacea

Rhinophyma

Rosacea variantsGranulomatous rosacea: Rosacea variant characterised by

monomorphic yellow brown or red papules/ nodules located on the cheeks and periorificial skin.

Granulomas on histologyThe background facial skin is otherwise normal

Differential DiagnosisFull and detailed history (including medications)is required,Medications that induce flushing include : all vasodilators, calcium

channel blockers, nicotinic acid, morphine, amyl and butyl nitrite, cholinergic drugs, bromocriptine, tamoxifen, cyproterone acetate, systemic steroids and cyclosporine.

Diagnosis is made clinicallyDifferential diagnosis include: Seborrheic dermatitis Steroid folliculitis/Perioral Dermatitis Acne vulgaris Erythromelanosis faciei and keratosis pilaris rubra Lupus erythematosus Lupus miliaris disseminatus faciei

Treatment

• Sunscreens• Avoidance of aggravating factors.• Topical medications include:• Metronidazole .• Sodium sulfacetamide and sulfur• Azelaic acid• Benzoyl peroxide• Tretinoin• Erythromycin and Clindamycin

• Oral medications include:• Tetracyclines:• Tetracyclines are the most commonly prescribed oral

medications for the treatment of rosacea.• They act by their anti-inflammatory effects• Erythromycin (for children with granulomatous perioral

dermatitis)• Isotretinoin

Laser and light therapy Laser and Intense Pulsed light IPL is useful in treating

persistent erythema and telangiectasiasPulsed dye laser (585 or 595 nm)Potassium-titanyl phosphate laser KTP 532nm, for

superficial small telangiectasias. • Deep facial vessels require longer wavelengths : Diode laser (810)• The long pulsed alexandrite laser (755nm)• Long pulse ND:YAG (1064nm)

Treatment of Phymatous Rosacea

Early to moderate Phymatous changes could be treated with Isotretinoin.

Advanced phyma is treated with surgery or surgery followed by isotretinoin.

Electrosurgery Laser CO2 ablation.

Fig 1, 2 www.scf-online.com/.../keratinization38_e.htm keratinization of the duct of the hair follicle.www.nlm.nih.gov/.../ency/imagepages/2087.htm open (Blackheads) comedones, Medical EncyclopediaFig.3Fig 4. Malassezia furfur www.doctorfungus.org/thefungi/Malassezia.htm Closed comedones Skin and allergy centre.Fig 5Fig 6 www.ohiohealth.com/bodymayo.cfm?id=6&action=t... Mayo Foundation for Medical and research.Fig 7Fig 8 bacterial colonization www.healthcaresouth.com/pages/acnewhatis.htmFig 9 Breakage of follicular wall www.healthyskinbydesign.com/acne.cfm papuleFig 10 open comedones www.healthcaresouth.com/pages/acnewhatis.htmFig 11Fig 12 closed comedones www.healthcaresouth.com/pages/acnewhatis.htmfig www.dermalogix.net/acne/acne.html open and closed comedones schematic pictureswww.dermalogix.net/acne/acne.html proriobionacterium acne in pilosabaceous unitwww.healthyskinbydesign.com/acne.cfm. follicular hyperkeratosis in acneFig 13Fig 14Fig 15Fig 16 www.healthyskinbydesign.com/acne.cfm pustuleFig 17. Courtesy of Skin and allergy centreFig 18 www.healthyskinbydesign.com/acne.cfm noduleFig 19 nodule www.acnekil.com/What's_Acne/photo_gallery2.htmFig 20Fig 21 Courtesy of Skin and allergy centreFig 22 Courtesy of Skin and allergy centreFig 23 www.adhb.govt.nz/.../BenignLesions.htm at neonatal dermatology benign lesions Auckland district health board.Fig 24 Courtesy of Polonia, second editionFig 25Fig 26 Courtesy of Skin and allergy centreFig 27 Acne conglobata www.consultantlive.com/showArticle.jhtml?arti... Fig 28 acne Agminata Granulomatous rosacea in infants. Report of three cases and discussion of the differential diagnosis

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