IADVL Digital Lecture Series

Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 1

Introduction
One of the commonest skin conditions seen, which can be easily
diagnosed. Though not fatal acne may affect mental and social well being.
Multiple therapeutic options are available but requires skill to treat.
Successful management requires tailormade treatment.

Definition

Acne is a chronic inflammatory disease of the pilosebaceous units,

characterized by seborrhoea, formation of comedones, erythematous
papules, pustules & less frequently by nodules, cysts and scarring.

Epidemiology

Acne is a disease of adolescence, and can be considered a normal variant of

maturation
It may present later in life and also early in infancy. Acne persisting beyond 25
years of age is likely to persist for another 10-20 yrs.

Pathogenesis of acne

The following four factors are implicated in acne :

1. Increased sebum production
2. Hypercornification of the pilosebaceous duct
3. Colonisation of the duct with Propionibacterium acnes
4. Inflammation
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 2

Seborrhoea

Seborrhoea can be a result of :

1. Increased androgenic sex hormones of gonadal / adrenal origin

2. Abnormal end-organ response to normal level of hormones

Sebum in acne patients show increased levels of squalene and wax esters
Lower levels of linoleic acid in the sebum leads to ductal hypercornification.

Comedogenesis

Comedogenesis occurs due to abnormalities in proliferation and

differentiation of ductal keratinocytes,
retention of hyperproliferating ductal keratinocytes or increased
cohesiveness of ductal keratinocytes
These lead to formation of the microcomedo which is the precursor of all acne
lesions.

Propionibacterium acnes

Propionibacterium acnes is a resident anaerobe which colonises the

pilosebaceous duct in the presence of seborrhoea. It hydrolyses the
triglycerides in sebum to produce free fatty acids. P.acnes produces
mediators of inflammation like lipase ,phosphatase etc. The cell wall of
P.acnes also is a potent chemoattractant.
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 3

Inflammation

Inflammation plays a key role in the pathogenesis of acne.

Sebum and ductal keratinocytes produce cytokines like interleukin-1,TNF.
Cytokines produced by P.acnes and free fatty acids also contribute to the
inflammation.
Cytokines attract neutrophils and mononuclear cells.
In moderate and severe cases there is rupture of the duct and a macrophage
giant cell foreign body reaction occurs.

Co-factors
The following factors are known to aggravate acne :
Premenstrual flare
Stress
Sweating
Smoking
Frequent washing (leads to irritation )
Diet *

Grades of Acne (Pillsburrys classification)

(Pilsbury has classified acne in various grades to facilitate the choice of

treatment modalities
Grade I : comedones (open or closed), occasional papules
Grade II : papules, comedones, few pustules
Grade III: predominant pustules, nodules, abscesses
Grade IV: mainly cysts, abscesses, scars
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 4

Scarring

The most dreaded complication of acne is scarring which results as a

consequence of abnormal resolution or wound healing following the
inflammation. Acne may leave behind ice-pick ,rolling, box-car or
hypertrophic scars
Ice-pick scars are seen in most patients with grades I and II acne while
depressed or hypertrophic scars are seen in nodulocystic acne

Hyperpigmentation

In patients with Type III/ IV skin, hyperpigmented macules may persist

following the resolution of inflammatory acne lesions.

Uncommon variants of Acne

Depending upon the causation and morphology there are several variants of
acne , which are as follows :
Acne excoriee : predominantly in females who fiddle with and exacerbate
the smallest of lesions

Acne conglobata : severe form; often seen in males ; characterised by

multiple inflammatory papules and tender nodules which fuse to form
multiple sinuses ; mutilating scars may be seen

Acne fulminans : young males who suddenly develop extensive

inflammatory lesins on the trunk associated with fever, polyarthropathy,
marked leucocytosis, malaise, painful splenomegaly.
Contd...
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 5

Uncommon variants of Acne

Acne mechanica : acne occurs at site of friction or physical trauma eg. On

the neck in violin players, beneath headbands and tight bra-straps.

Drug induced acne/ Acneiform eruption : lacks comedones , monomorphic

lesions ,temporal relation with drug intake

Occupational acne/ chloracne : acne in areas exposed to oils, crude tars,

chlorinated hydrocarbons.

Pyoderma faciale : sudden eruption of pustules and nodules on the face of

post adolescent women having mild acne ;often following a period of stress ;
no systemic symptoms ; associated with facial flushing.
Late onset acne/endocrine acne : acne occurring beyond 25 years of age

Cosmetic acne : due to use of potentially comedogenic cosmetics usually in

the perioral area

Pomade acne : pomades are greasy preparations used to defrizz curly hair ;
consists of many non-inflamed lesions on the forehead

Gram-negative folliculitis sudden exacerbaton of lesions in a patient on

long term antibiotics for acne

Acne scarring may be confused with acne keloidalis (keloidal lesions seen
commonly at the nape of neck), varioliform scarring (secondary to varicella,
papulonecrotic tuberculid ) and porphria cutanea tarda.
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 6

Drug induced acne

Drugs which cause acne are :

- Halogens
- Androgens
- Steroids
- INH, Rifampcin
- Lithium
- Phenytoin
- PUVA
Drug induced acne usually causes monomorphic rash, devoid of comedones.

Psychosocial aspects

The psychological impact created by acne cannot be overstressed .

It may lead to :
Increased anger and anxiety
Social embarrassment
Lack of self confidence
Depression
Dysmorphophobia false perception of their physical appearance. Acne
may be mild but the patients symptoms are out of proportion to the physical
signs.
Stress can further aggravate the existing lesions as well.
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 7

Differential Diagnosis

Though easily diagnosed some conditions may mimic acne, such as

Rosacea Occurs in older patients ,lacks comedones, nodules, cysts or
scarring . Facial flushing and telangiectasia are also seen.
Milia infraorbital and are whiter
Pseudofolliculitis erythematous papules on the beard area due to
ingrowth of closely shaved hair.
Pityrosporum folliculitis Pruritic, seen as ill-defined plaques with
scattered papules and pustules on the upper trunk
Plane warts - multiple, smooth, flat, round or polygonal skin coloured
papules on the face ,dorsa of hands and shins
Adenoma sebaceum reddish brown dome-shaped papules associated
with telangiectasia in a symmetric butterfly distribution over the nose,
nasolabial folds and cheeks; ash leaf macules and shagreen patch also seen.
Epilepsy and mental retardation may also be present.

Guidelines of Treatment

First and foremost the severity of acne should be assessed to decide on the
treatment mode and for monitoring the response to the treatment which
includes:
Extent of the inflammatory and comedonal lesions
Presence of scarring
Psychological effects
Degree of success or failure with previous treatment.
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 8

Guidelines of Treatment

Appropriate patient expectations would be little improvement after 1 month of

therapy,20% improvement at 2 months,60% at 6 months and 80%at 8 months
Other factors should be assessed before starting therapy : drug history,
evidence of PCOD

Topical therapy

Various topical therapies are available such as

Topical antibiotics - erythromycin, clindamycin, tetracycline, clarithromycin,
doxycycline
Benzoyl peroxide anti-bacterial, anti-inflammatory action.
Azelaic acid

The above three agents can be employed for predominantly inflamed acne

Predominantly for non-inflammatory acne

Topical retinoids - retinoic acid, adapalene, tazarotene.

Topical therapy should be prescribed alone for mild acne inconjuction with
appropriate oral therapy for moderate acne ,and as maintenance therapy
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 9

Oral therapy

Oral therapy is resorted to in the following groups:

Moderate and severe acne
Mild acne if patient is significantly depressed
Patients with body dysmorphic disorder
Patients with scarring or those prone to scarring /post inflammatory
pigmentation
1 Antibiotics :
Erythromycin(500 qid )
Azithromycin (pulse dosing) 500mg/day for 3 consecutive days in a week
constitutes a pulse
Tetracycline (1 g /day)
Doxycycline(100 mg/day)
Minocycline (50-100 mg )
Trimethoprim
Dapsone (100-200mg)
Oral therapy should be given in combination with topical therapy for a
minimum of 6 months. However, if there is no improvement after 2-3 months ,
then alternative therapy is necessary.
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 10

Side effects of oral antibiotics

Antibiotic therapy may be associated with the following side effects:

Doxycycline - onycholysis, oesophagitis with ulceration, fixed drug
eruptions, photosensitivity etc.
Minocycline - benign intracranial hypertension, papilloedema, blue-black
pigmentation and rarely hypersensitivity reactions.
Macrolide group - gastritis, diarrhoea
Trimethoprim - severe drug reactions
Dapsone - hemolytic anemia, dapsone syndrome etc.

Hormonal therapy
Hormonal therapy may be tried when
- Standard antibiotic regimens have failed
- Concomitant menstrual cycle control or contraception is required
- Oral isotretinoin is inappropriate or not available

Antiandrogens cyproterone acetate(50-100 mg/day)

Oral contraceptives - 35 mcgs ethinyl estradiol plus 2 mgs cyproterone

acetate

Levonorgestrel-ethinyl estradiol(100+20 mcgs)

Other regimens - prednisolone plus oestrogen, spironolactone and

antiandrogens

Drosperinone novel progestin derived from spironolactone

 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 11

Side effects of Hormonal therapy

These also may have their own side effects :

* weight gain
* menstrual irregularity
* occasional fluid retention
* melasma
* hypertension
* thrombophlebitis
* pulmonary embolism
* ? breast cancer
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 12

Isotretinoin

Isotretinoin may be considered as a boon for severe cases and those

intractable to oral antibiotics:
Mechanism of action:
Decreases the size of sebaceous glands
80% reduction in sebum
Alters the composition of sebum
Reduces comedogenesis
Lowers P.acnes concentration and has anti inflammatory activity

Isotretinoin is indicated for :

- Nodulocystic / severe Acne
- Pyoderma faciale
- Acne recalcitrant to routine treatment
- Excessive seborrhoea
- Depression/Dysmorphophobia
- Acne conglobata/other unusual variants
- Scarring

Contd...
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 13

Isotretinoin

It is given in dose of 0.5 1 mg/ kg/day is given after meals .

Total cumulative dose should not cross 120-150 mgs / kg
Side effects
- Teratogenicity
- Mucocutaneous side effect dryness of skin and mucosa, cheilitis
- Elevation of serum lipids
- Neurological : pseudotumor cerebri, optic neuritis, depression, mood swing
- Arthritis, myalgia
- Acne flares

Physical modalities

Some people may require physical modalities for better , faster treatment and
to minimise scarring which include :
Comedo expression
Superficial electrocautery
Aspiration of cystic lesions
Intralesional steroids : triamcinolone aceonide 0.05-0.25 ml of 10mg/ml
Cryotherapy
Alpha-hydroxy acids
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 14

Newer options

Laser and lights with photodynamic therapies are new entrant in acne therapy.
Though not curative they have excellent additive properties

* Photodynamic therapy using blue red light

* Low fluence pulsed dye laser light

* Dermabrasion / CO2 laserbrasion (ice-pick scars)

* Erbium-Yag laser for atrophic / hypertrophic scars

* Punch grafting / punch floats (for depressed scars)

* New anti inflammatory agents such as 5-lipooxygenase inhibitors *

Acne treatment plan

Recommendations:
Grade 1 acne may be treated with only topical therapy.
Moderate to severe acne has to be treated with oral antibiotics.
Avoid monotherapy and dissimilar antibiotics.
Combination of antibiotics with topical retinoids improves efficacy and with
benzoyl peroxide decreases resistance
Duration of treatment is 4-6 months and any treatment should be continued for
at least 6 weeks.

Contd...
 IADVL Digital Lecture Series
Indian Association of Dermatologists, Venereologists and Leprologists

Acne Page - 15

Acne treatment plan

Hormonal therapy is used for patients with moderate acne who also need
contraception, or those who need hormonal therapy to regulate hormonal
irregularities.
Compliance should be stressed upon and patients should be educated about
the potential side effects.

Poor response to therapy

Sometimes inspite of all efforts the patients fail to respond .

This could be due to :
Poor compliance
Inadequate instructions
Side effects
Resistance of P. acnes
Inadequate dosage
Folliculitis due to staphylococci, gram negative enterobacteria or malassezia