1. Acne Vulgaris in Primary care
Dr Olusegun Omosini
ST2 GPVTS

2. epidermiology
Almost every teenager can expect to experience acne to some degree during the adolescent years.
They tend to "grow out of it" by the early 20s but it can persist rather longer.
Being mediated by androgens, it tends to affect boys more than girls.
Acne tends to occur in adolescence, when hormones are in a state of flux. In girls it may flare up when they are pre-menstrual.
The severity of the problem is probably less related to androgen levels as to end-organ sensitivity. ‘it remains a conundrum why a condition that so undermines self assurance and self esteem should strike at such a vulnerable time in life.’

3. pathology
This is a disorder of the pilosebaceous follicles found in the face and upper trunk.
It is characterized by the obstruction of the follicle with keratin plugs.
At puberty, androgens increase the production of sebum from enlarged sebaceous glands that become blocked and infected with Propionibacterium acnes causing an inflammatory reaction.
The primary lesion is the comodone which is a follicle impacted and distended by incompletely desquamated keratinocytes and sebum.
Comedones are seen as small white nodules below the skin surface.

4. sebum
Mixed with lipids (from the surface skin cells), sweat and environmental material,makes the covering oil of skin surface
Sebum is produced by sebaceous glands,found over most of the body.
sebaceous glands consists of lobes connected by ducts, which are lined with cells similar to those on the skin surface.
Most sebaceous glands open out into the hair follicle. Some free sebaceous glands open directly onto the skin surface. These include Meibomian glands on the eyelids and fordyce spots on the upper lip or genitals.
Sebaceous glands on the mid-back, forehead and chin are larger and more numerous than elsewhere (up to glands per square centimetre).
Sebum production is under the control of Androgens i.e increased by Androgens

5. pathogenesis
Patients with acne often have increased production of sebum,hence oily skin. This may be because of:
High overall levels of sex hormones (mainly the androgen, testosterone).
Hyperandrogenism in females
Increased free testosterone because of low levels of circulating sex-hormone-binding-globulin (SHBG).
More active conversion of weaker androgens to stronger androgens such as dihydroxytestosterone (DHT) by the enzyme 5-reductase within the skin.
Higher sensitivity of the skin to DHT.

6. Aetiology Normal physiological reaction in puberty
Disease of the ovaries
Polycystic ovarian syndrome
Benign or malignant ovarian tumors
Disease of the adrenal gland
Partial deficiency of the adrenal enzyme 21 Hydroxylase
Benign or malignant adrenal tumors
Disease of the pituitary gland
Cushing’s syndrome due to excessive adrenocorticotrophic hormone
Acromegaly due to excessive growth hormone production
Adenoma of the adrenal gland especially prolactinoma
Obesity and the metabolic syndrome
Medication-phenytoin,steroids,barbiturates,OCPills.

7. presentation The primary lesions are comedomes.
They present at the time of puberty and continue for a variable number of years thereafter, usually stopping in late teens or early 20s but uncommonly continuing well into adulthood.
They may extend beyond the face to the shoulders, back and chest (seborrhaeic areas).
They tend to run a variable course with marked fluctuations, often being worse in girls who are pre-menstrual.
The severity of the condition varies enormously between individuals.
It is unsightly but the degree of psychological distress does tend to be disproportionate.

8. Types of acne lesions Non-inflammatory/primary lesions:
Open comedones (blackheads)
Closed comedones (whiteheads)

9. Closed comedone (whitehead)

10. Open comedones (blackheads)

11. Close up of blackhead

12. Inflammatory lesions Papules (small red bumps)
Pustules (white or yellow ‘squeezable’ spots)
Inflamed nodules (large red lumps)

13. cause of inflammatory acne?
Chemicals produced by P. acnes diffuse into the surrounding skin (dermis) and attract white blood cells (polymorphonucleocytes and monocytes).
The cells lining the sebaceous ducts also produce inflammatory mediators so pimples may occur in the absence of bacteria.
Foreign body reaction White blood cells (macrophages and giant cells) removing the debris may cause a more severe granulomatous inflammatory reaction.
Irritation by lipids Free fatty acids and sebum penetrate the dermis after the duct has ruptured
Hypersensitivity (allergy) to P. acnes

15. Secondary lesions Excoriations (picked or scratched spots)
Erythematous macules (red marks from recently healed spots, mostly in fair skin)
Pigmented macules (dark marks from old spots, mostly in dark skin)
Scars

16. Acne scar

17. Acne conglobata Unpleasant form of nodulocystic acne
Interconnecting abscesses and sinuses, which result in unsightly hypertrophic (thick) and atrophic (thin) scars.
There are groups of large macrocomedones and cysts that are filled with smelly pus.
It is occasionally associated with hidradenitis suppurativa,

18. Acne conglobata

19. Acne fulminans Allergic reaction to P. acne Abrupt onset
Inflammatory and ulcerated nodular acne on chest and back
Severe acne scarring
Fluctuating fever
Painful joints
Malaise (ie. the patient feels unwell)
Loss of appetite and weight loss
Raised white blood cell count.

20. Acne fulminans

21. Infantile acne Infantile acne
Generally affects the cheeks, and sometimes the forehead and chin, of children aged six months to three years.
More common in boys and is usually mild to moderate in severity. In most children it settles down within a few months.
The acne may include comedones inflamed papules and pustules, nodules and cysts. It may result in scarring.

22. Infantile acne

23. What is the cause of infantile acne?
The cause of infantile acne is unknown.
It is thought to be genetic in origin.
Hormone abnormalities in older children with acne may be associated with the following conditions:
Congenital adrenal hyperplasia
Cushing's Disease
21-Hydroxylase deficiency
Precocious puberty
Androgen-secreting tumors

24. Should any tests be done?
In most babies with acne, no investigations are necessary.
In older children, or if there are other signs of virilisation, the following screening tests may be useful.
Blood tests: DHEAS, testosterone, 17-hydroxyprogesterone, LH, FSH, prolactin

25. Solar comedones

26. What tests should be done?
About 50% of females with acne have an imbalance of hormones although this is usually only mild.
Any symptoms suggestive of primary cause should be investigated in full.
Otherwise, not necessary

27. General principles of treatment
Acne can be effectively treated, but response is usually slow
Face washing bed-rock of management
Where possible, avoid excessively humid conditions
Ultraviolet light helps.
Try not to apply irritant oils or cosmetics to the affected skin.
Abrasive skin treatments can aggravate acne
Try not to scratch or pick the spots
No relationship between particular foods and acne has been proven

28. Treatment mild acne
Wash affected areas twice daily with a mild cleanser and water or an antiseptic wash.
Acne products should be applied to all areas affected by acne, rather than just put on individual spots.
A thin smear should only be applied to dry clean skin at nighttime.
Acne products may work better if applied in the morning as well.
They often cause dryness particularly in the first 2-4 weeks of use. This is partly how they work. The skin usually adjusts to this.
Apply an oil-free moisturizer only if the affected skin is obviously peeling.

29. Topical medication
retinoid preparations eg tretinoin %, isotretinoin 0.05%, adapalene 0.1%.
treatment of choice for comedonal acne
anti-inflammatory effect
prevents comedone formation
application at bedtime (retinoids inactivated
by light)
azelaic acid is an allternative anticomedonal preparation
benzoyl peroxide % eg benzamycin gel
salicyclic acid
Tea tree oil products

30. Topical antibiotics clindamycin 1%
Erythromycin 2% and 4% with zinc acetate 1.2% - most useful when inflammatory lesions predominate
topical antibiotics should be used in combination with retinoids to prevent antibiotic resistance

31. Treatment of moderate acne
Step 1 plus oral antibiotics
an adequate dose of antibiotic should be given for at least three months before deciding that a patient has failed to respond
after three months therapy then a reduction of acne lesions by per cent should have occurred(pt assessment)
Good response? continued for a further three months and then the patient maintained on an appropriate topical regimen
Poor response to oral antibiotic therapy then an alternative antibiotic may be substituted

32. Oral antibiotics First line - Tetracycline,
2nd line-Erythromycin, doxycycline, minocycline(causes SLE),
Trimethoprim is increasingly used by dermatologists

33. Oral antiandrogen:
cyproterone acetate 2mg with ethinyloestradiol 35 mug (Diannette) dly
Similar efficacy as oral antibiotics but also contraceptive and controls hirsutism
risk of venous thromboembolism is high
conventional low-dose second- or third-generation COCs are more appropriate

34. NSAIDS
Some patients are helped by nonsteroidal anti-inflammatory agents such as ibuprofen or naproxen

35. Treatment severe acne
Many patients will be treated with oral isotretinoin.
If this is not suitable, the following may be used:
High dose oral antibiotics for six months or longer
In females, especially those with polycystic ovary syndrome, oral antiandrogens such as Diannette or spironolactone may be suitable long term. Systemic corticosteroids are sometimes used for their antiandrogenic effect.
Flutamide and finasteride also been reported to be of benefit in hyperandrogenic women, though not liscenced

36. Physical treatments for acne
Sunlight is anti-inflammatory and can help briefly.o skin cancer.
Cryotherapy
Intralesional steroid injections
Comedones can be expressed by cautery or diathermy.
Microdermabrasion can help mild acne.
Lasers and light systems (blue light)
X-ray treatment-no longer recommended for acne as it may cause skin cancer.

37. Who to refer Immediate referral indicated (within a day):
have a severe variant of acne such as acne fulminans or gram-negative folliculitis
Urgent referral
have severe or nodulocystic acne and could benefit from oral isotretinoin
have severe social or psychological problems, including a morbid fear of deformity

38. Routine referral
At risk of or are developing scarring despite management
have moderate acne that has failed to respond to treatment which has included two courses of oral antibiotics, each lasting three months.
are suspected of having an underlying endocrinological cause for the acne (such as polycystic ovary syndrome) that needs assessment