Acne vulgaris is a disease of the pilosebaceous unit (i.e., the sebaceous glands and adjacent hair follicle).

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1 Dr. Ghassan Salah

2 Acne is a common, chronic inflammatory disorder of the pilosebaceous unit in which a microcomedo develops as the initial condition. The most common form of acne is acne vulgaris. Other variants of acne are neonatal acne, adult acne, acne cosmetica, and acne mechanica. Acne vulgaris is a disease of the pilosebaceous unit (i.e., the sebaceous glands and adjacent hair follicle).

3 Acne vulgaris is the result of a combination of several factors. The main processes involved are as follows: 1. Increased sebum production The pilosebaceous units in the dermis of the skin consist of a hair follicle and associated sebaceous glands. These glands secrete sebum a mixture of fats and waxes the function of which is to protect the skin and hair by retarding water loss and forming a barrier against external agents. The hair follicle is lined with epithelial cells, which become keratinised as they mature.

4 1. Increased sebum production

5 2. Hormonal changes During puberty, the production of androgenic hormones increases in both sexes and levels of testosterone rise. Testosterone is taken up into the sebaceous glands, where it is converted into dihydrotestosterone, stimulating the glands to secrete increased amounts of sebum.

6 2. Hormonal changes

7 3. If the orifice of the follicular canal opens sufficiently, the keratinous material is extruded through it and an open comedone results; this is also known as a blackhead because the keratinous material is dark in colour. Because this material can escape, the comedone does not become inflamed. If the follicular orifice does not open sufficiently, a closed comedone (whitehead) results, in which inflammation can occur. Most people with acne have a combination of both types of comedone.

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9 4. Bacterial growth and colonization The actions of microorganisms, principally Propionibacterium acnes, cause the follicular wall of closed comedones to disrupt and collapse, spilling their contents into the surrounding tissue and provoking an inflammatory response. In addition, bacterial enzymes bring about the decomposition of triglycerides in the sebum to produce free fatty acids, which also cause inflammation. In the more common, milder form of acne, this process leads to the formation of papules around the follicular openings; in the more severe form of acne, it leads to cyst formation in the deeper layers of the skin.

10 Acne lesions typically occur on the face, back, upper chest, and shoulder area. Acne vulgaris is described as mild, moderate, or severe, depending on the type and severity of lesions present.

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12 Acne lesions typically occur on the face, back, upper chest, and shoulder area. Acne vulgaris is described as mild, moderate, or severe, depending on the type and severity of lesions present.

13 Acne lesions typically occur on the face, back, upper chest, and shoulder area. Acne vulgaris is described as mild, moderate, or severe, depending on the type and severity of lesions present. LABORATORY TESTS There are no laboratory tests to diagnose acne vulgaris. Diagnosis is based on clinical signs.

14 SYMPTOMS Generally, the diagnosis of acne vulgaris consists of findings that include a mixture of lesions of acne (e.g., comedones, pustules, papules, nodules, and cysts) on the face, back, or chest. Although there is no precise definition for acne, many practitioners consider the presence of 5 to 10 comedones to be diagnostic.

15 SCARS Permanent scars may occur as a result of inflammatory acne lesions. RESIDUAL HYPERPIGMENTATION Inflammatory acne lesions may trigger noticeable hyperpigmentation that may persist weeks to months after resolution of the lesion.

16 Most therapeutic interventions function primarily to prevent the formation of new acne lesions and have minimal impact on existing lesions. Among the factors that may affect acne are genetics, climate, diet, environment, stress, and physical activity. Stress seems to aggravate, but not induce, acne. In response to stress, immunoreactive nerve fibers may stimulate sebaceous gland activity and provoke inflammatory reactions via mast cells.

17 Most treatments reduce or prevent new eruptions and may take up to 8 weeks to produce visible results. During the first few weeks of therapy, acne may appear to worsen as existing acne lesions may resolve more rapidly. Patients must understand the need to continue therapy for optimal outcome.

18 Patient education with emphasis on goals, realistic expectations, and dangers of overtreatment is important to optimize therapeutic outcomes. Treatment regimens are targeted to types of lesions and acne severity. Mild acne usually is managed with topical retinoids alone or with topical antimicrobials, salicylic acid, or azelaic acid. Moderate acne may be managed with topical retinoids in combination with oral antibiotics, and if indicated, benzoyl peroxide. Severe acne is often managed with oral isotretinoin.

19 Antibiotics such as tetracyclines and macrolides are the agents of choice for papulopustular acne. In severe papulopustular and nodulocystic, oral isotretinoin is the treatment of choice. Hormonal therapy represents an alternative effective regimen in female patients.

20 Topical treatment forms include creams, lotions, solutions, gels, and disposable wipes. Responses to different formulations may be dependent on skin type and individual preferences: Oily to normal skin types may tolerate gels, solutions, and lotions. Normal skin may tolerate gels, solutions, lotions, and creams. Normal to dry skin may tolerate lotions and creams. Note Ointments are not typically included in topical acne therapy due to their occlusive nature and possible induction of acne cosmetica..

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22 Topical retinoids tretinoin, adapalene, tazarotene Benzoyl Peroxide Topical Antimicrobial: Erythromycin and clindamycin. Oral antibiotics: 1. Macrolide antibiotics 2. Tetracyclines 3. Cotrimoxazole

23 Hormonal therapy is useful in treating acne in women with elevated or normal serum androgens. Hormonal therapy is absolutely contraindicated in women who want to become pregnant due to the risk of sexual organ malformation in a developing fetus Cyproterone Acetate Chlormadinone Acetate Spironolactone Estrogens Oral Contraceptives

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26 Acne lesions typically occur on the face, back, upper chest, and shoulder area. Acne vulgaris is described as mild, moderate, or severe, depending on the type and severity of lesions present.

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28 Topical retinoids tretinoin, adapalene, tazarotene, and in some countries topical isotretinoin, motretinide, retinaldehyde, and retinoyl- β-glucuronide9 should be used as first-line therapy for mild to moderate inflammatory acne and comedonal acne. They are also preferred agents for maintenance therapy to minimize antibiotic use in acne therapy

29 Tretinoin Tretinoin, a topical vitamin A analogue, is a comedolytic agent that increases cell turnover in the follicular wall and decreases cohesiveness of cells, leading to extrusion of existing comedones and inhibition of the formation of new comedones, and may reduce the number of inflammatory acne lesions.

30 A regimen of BPO each morning and tretinoin at bedtime may enhance efficacy and be less irritating than either agent used alone. By slowly increasing application frequency from every other day, to daily, and then twice daily, tolerance to tretinoin may be increased. Increased sensitivity to sun exposure, wind, cold, and other irritants may also be evident in patients using tretinoin. Adverse reactions to tretinoin such as skin irritation, erythema, and peeling will vary depending on individual skin type and dosage form used.

31 Allergic contact dermatitis is rare and much less common than with BPO. Teratogenicity risk with topical retinoids remains controversial. Two reformulations of tretinoin include a porous bead (0.01% gel) (microspheres) and liquid polymer (0.025% cream and 0.025% gel). These are less irritating than standard vehicles for tretinoin.

32 Adapalene Adapalene, a third-generation retinoid, is a retinoid-mimetic compound (a naphthoic acid derivative) available as 0.1% gel, cream, and alcoholic solution. It has selective affinity for retinoic acid receptor (RAR) subtypes RAR-β and RAR-γ found in the epidermis, and has comedolytic, keratolytic, and anti-inflammatory activity

33 Adapalene Adapalene is indicated for mild to moderate acne vulgaris. Adapalene 0.1% gel may be used as an alternative to tretinoin 0.025% gel to achieve better tolerability in some patients Adapalene coadministered with a topical or oral antibiotic represents a rational therapy for moderate forms of acne.

34 Tazarotene Tazarotene, a prodrug and a synthetic acetylenic retinoid, is converted to its active form, tazarotenic acid, after topical application. This new-generation retinoid also selectively binds to RARs and can alter expression of genes involved in cell proliferation, cell differentiation, and inflammation.

35 Tazarotene Once-daily tazarotene gel may be more effective than once-daily tretinoin in reducing papules and open comedones, with equal efficacy against closed comedones. Both 0.1% and 0.05% concentrations had acceptable tolerability profiles, with no serious adverse events. Dose-related local adverse effects include erythema, pruritus, stinging, and burning

36 Benzoyl Peroxide Superficial inflammatory acne is typically treated with benzoyl peroxide (BPO), a non-antibiotic antibacterial agent that is rapidly bacteriostatic and possibly bactericidal against P. acnes. Its antibacterial mechanism of action is uncertain, although BPO is decomposed on the skin by cysteine, liberating free oxygen radicals that oxidize bacterial proteins. BPO increases the sloughing rate of epithelial cells, loosens the follicular plug structure, and thus possesses some degree of comedolytic activity. An advantage to using topical BPO is that P. acnes resistance is not known to develop

37 Erythromycin Erythromycin in topical form in concentrations of 1% to 4% with or without the addition of zinc is effective against inflammatory acne. Zinc combination products possibly enhance penetration of erythromycin into the pilosebaceous unit. Topical erythromycin, usually applied twice daily, is formulated as a gel, lotion, solution, and disposable pad.

38 Clindamycin Topical clindamycin inhibits P. acnes and provides comedolytic as well as anti-inflammatory activity. It is available in gel, lotion, solution, and disposable pad formulations, and is usually applied twice daily. Combination with BPO increases efficacy. Though rare, diarrhea and pseudomembranous colitis may occur secondary to topical clindamycin

39 Azelaic Acid Azelaic acid has a dicarboxylic acid structure that confers antibacterial, anti-inflammatory, and comedolytic activity. Azelaic acid is useful for treating mild to moderate acne in patients who do not tolerate BPO. It is useful in treating postinflammatory hyperpigmentation since it also has skin-lightening properties. Azelaic acid has no likelihood of bacterial resistance, systemic adverse effects, or photosensitivity reactions. Although uncommon, adverse effects, usually transient, include burning, pruritus, stinging, and tingling. Azelaic acid is available in a 20% cream formulation. Application is usually twice daily on clean, dry skin.

40 Keratolytic Agents In addition to keratolytic activity, salicylic acid, sulfur, and resorcinol are mildly antibacterial. Corticosteroids Topical corticosteroids can be applied in very selected patients with very inflammatory acne for short periods of time. They may play a role in reducing flare-up reactions in severe conglobate acne and for reduction of granuloma like lesions under systemic isotretinoin treatment.

41 Isotretinoin As an oral retinoid, isotretinoin is the most effective 1. decreased sebum production and change in sebum composition, 2. inhibition of P. acnes growth within follicles, 3. inhibition of inflammation, 4. altered patterns of keratinization within follicles

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43 Macrolide Antibiotics The macrolide antibiotics (erythromycin, azithromycin, and clindamycin) exhibit antiinflammatory properties in patients with acne.

44 Tetracyclines The tetracyclines are effective in reducing P. acnes. In addition to their antibacterial effects, they reduce the amount of keratin in sebaceous follicles and inhibit chemotaxis, phagocytosis, complement activation (by the alternate pathway), and cell-mediated immunity

45 Tetracyclines Doxycycline is commonly used in the treatment of moderate to severe acne vulgaris. It is more effective and produces less resistance than tetracycline. The initial dosage is usually 100 or 200 mg daily, followed after improvement by 50 mg/day as a maintenance dose; It may be taken with food even though it is more effective when taken 30 minutes before meals.

46 Tetracyclines Minocycline is another commonly prescribed oral antibiotic used in the treatment of moderate to severe acne vulgaris. It is more effective than tetracycline because of greater lipid solubility and enhanced penetration into tissue and sebaceous follicles. Of the tetracyclines, minocycline has the most reported adverse effects. H.W S/E of minocycline

47 Cotrimoxazole Cotrimoxazole (trimethoprimsulfamethoxazole) or trimethoprim alone may be used for treating patients who do not tolerate tetracycline and erythromycin or in cases of resistance to these antibiotics. The adult dosage is usually 800 mg sulfamethoxazole and 160 mg trimethoprim twice daily.

48 Hormonal therapy is useful in treating acne in women with elevated or normal serum androgens. Hormonal therapy is absolutely contraindicated in women who want to become pregnant due to the risk of sexual organ malformation in a developing fetus Cyproterone Acetate Chlormadinone Acetate Spironolactone Estrogens Oral Contraceptives Dapsone

49 Top Skin Care Tips Avoid harsh soaps. Be gentle with cleansers because they can irritate and dry out your skin. Stop picking. Though it may be tempting to pick at acne, it can lead to secondary infection and scarring. Use sunscreen. Choose a sunscreen that's best suited for your skin type. Certain topical medications can make you sensitive to sunlight, so it's important that your skin is protected.

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