ACNEACNEDisorders of sebaceous glandDisorders of sebaceous gland
Omar Abdulaziz Al-Sheikh, M.DOmar Abdulaziz Al-Sheikh, M.D..
College of MedicineCollege of Medicine
King Saud UniversityKing Saud University
DefinitionDefinition::
Is a chronic inflammatory disorder of the Is a chronic inflammatory disorder of the pilosebaceous apparatus of certain body pilosebaceous apparatus of certain body area (Face> Torso > rarely the Buttocks), area (Face> Torso > rarely the Buttocks), resulting in greasiness and polymorphic resulting in greasiness and polymorphic skin eruption. skin eruption.
Incidence:Incidence:
Acne affect all skin types, the male and Acne affect all skin types, the male and female ratio is virtually the same but tend female ratio is virtually the same but tend to be more severe in males.to be more severe in males.
85% affect the age group 12 – 24 years85% affect the age group 12 – 24 years
8% affect the age group 25 – 34 years 8% affect the age group 25 – 34 years
3% affect the age group 35 – 44 years3% affect the age group 35 – 44 years
Etiology:Etiology:1.1. Genetic Aspect, (Acne runs in family) Genetic Aspect, (Acne runs in family)
other example the case of severe acne other example the case of severe acne that is associated with XXY syndrome.that is associated with XXY syndrome.
2.2. Occupation (Environmental, Mechanical) Occupation (Environmental, Mechanical) e.g. exposure acnegenic mineral oil e.g. exposure acnegenic mineral oil (Pomade acne) dioxin(Pomade acne) dioxin
3.3. Drugs Oral and topical Hydrocortison Drugs Oral and topical Hydrocortison (Steroid acne) Lithium, Hydantoin, (Steroid acne) Lithium, Hydantoin, contraceptives contraceptives
4.4. Endocrine Factors (Recalcitrant Acne, Endocrine Factors (Recalcitrant Acne, POD/s, MARSH Syndrome) .POD/s, MARSH Syndrome) .
Pathogenesis: Pathogenesis: ( three main steps ( three main steps recognized and hypothesized)recognized and hypothesized)
1.1. Follicular Hyperkeratosis (the cause not Follicular Hyperkeratosis (the cause not fully understood) theory suggest:fully understood) theory suggest:
deficiency in Linoleic acid, deficiency in Linoleic acid, the effect off 5-the effect off 5-a a reductase enzyme on reductase enzyme on
converting Androgen (Testosterone) converting Androgen (Testosterone) hormone to the active acnegenic and hormone to the active acnegenic and potent (Dihydrotestosterone) DHT, potent (Dihydrotestosterone) DHT,
the direct effect of Interleukin-1 on the direct effect of Interleukin-1 on follicular hyperkeratosisfollicular hyperkeratosis
Perifollicular Hyperkeratosis histology
Fig 1Fig 1 Fig 2Fig 2
Fig 3Fig 3
2.2. Abnormal production of abnormal sebum Abnormal production of abnormal sebum increasing the ratio of wax easter to increasing the ratio of wax easter to cholesterol and cholesterol easter and is cholesterol and cholesterol easter and is believed to be the response of sebaceous believed to be the response of sebaceous glands to DHEAglands to DHEA
SeborrhoeaSeborrhoea is a common feature between is a common feature between patients with acne.patients with acne.
3. 3. Colonization of the affected unit with Colonization of the affected unit with bacteria bacteria PropionibacteriumPropionibacterium acneacne and yeast named Malassezia and yeast named Malassezia furfurfurfur
Propionibacterium Propionibacterium acneacne
Malassezia Malassezia furfurfurfur
Fig 4Fig 4 Fig 5Fig 5
P P acneacne is potent activator of complement is potent activator of complement via classical pathwayvia classical pathway
Fig 6Fig 6 Fig 7Fig 7
Propionobacterium Propionobacterium acne acne lipases act on sebaceous fatty lipases act on sebaceous fatty acid (Triglycrides) to release irritant free fatty acid acid (Triglycrides) to release irritant free fatty acid and low-molecular- weight peptide an extra cellular and low-molecular- weight peptide an extra cellular factor that penetrate the follicular wall and stimulate factor that penetrate the follicular wall and stimulate Polymorphs and Lymphocytes initiating inflammationPolymorphs and Lymphocytes initiating inflammation
Fig 8Fig 8
Hydrolytic enzymes released from the Hydrolytic enzymes released from the activated complement antibodies complex activated complement antibodies complex together with exoenzymes produced from together with exoenzymes produced from P P acneacne cause rupture of follicular wall cause rupture of follicular wall
Fig 9Fig 9
Once the wall is damaged Various agents Once the wall is damaged Various agents (prostaglandin-like substance, amino acid, (prostaglandin-like substance, amino acid, short chain fatty acid are) that are produced short chain fatty acid are) that are produced by the inflammatory cells and P acne extrude by the inflammatory cells and P acne extrude to the dermis causing more inflammationto the dermis causing more inflammation
Clinical features: Clinical features: (Acne and acne (Acne and acne related Disorders)related Disorders)
1.1. Acne Vulgaris:Acne Vulgaris:
Papules: (Less than 0.5 cm)Papules: (Less than 0.5 cm) Comedones (Open “Blackheads” or Comedones (Open “Blackheads” or
closed “Whitheads”)closed “Whitheads”)
Open Comedones (Blackheads)Open Comedones (Blackheads)
Open Comedones
Fig 10Fig 10 Fig 11Fig 11
Closed Comedones (Whitehead)Closed Comedones (Whitehead)
Closed Comedones
Fig 12Fig 12 Fig 13Fig 13
Inflammatory papulesInflammatory papules
Inflammatory papules
Fig 14Fig 14 Fig 15Fig 15
Pustules :Pustules :
Pustules
Fig 16Fig 16 Fig 17Fig 17
Nodule (more than 0.5 cm)Nodule (more than 0.5 cm)
Nodule
Fig 18Fig 18 Fig 19Fig 19
Cystic acne: the cysts are usually Cystic acne: the cysts are usually large 1-4cmlarge 1-4cm
Fig 21Fig 21Fig 20Fig 20
2.2. The nodules and cysts could be The nodules and cysts could be associated with sinuses as in Acne inverseaassociated with sinuses as in Acne inversea
Acne inversea (Hidradinitis supprativa “a Acne inversea (Hidradinitis supprativa “a misleading name”) because it is considered by misleading name”) because it is considered by some to be disorder of apocrine gland (Sweat some to be disorder of apocrine gland (Sweat gland) but gland) but In my opinion In my opinion Acne inversea affect Acne inversea affect primarily pilo Seb. Unit and affect secondarily the primarily pilo Seb. Unit and affect secondarily the sweat gland, hence the correct name Acne sweat gland, hence the correct name Acne inversea rather than Hidradinitis supprativa is inversea rather than Hidradinitis supprativa is preferred.preferred.
Fig 22Fig 22
Neonatal acne: cause unknown but some Neonatal acne: cause unknown but some believed is due to passing of believed is due to passing of Transplacental androgen other suggest Transplacental androgen other suggest the role of Mlalassezia the role of Mlalassezia furfurfurfur and and sympodalissympodalis . . affect 1 in 5 mainly affect 1 in 5 mainly inflammatory comedones on nose and inflammatory comedones on nose and cheeks affect new born between the 1cheeks affect new born between the 1stst and 6and 6thth week of age week of age
3.3. Neonatal Acne and Infantile AcneNeonatal Acne and Infantile Acne
Fig 23Fig 23
Infantile Acne: affect males more than Infantile Acne: affect males more than females, usually between 3 and 6 months females, usually between 3 and 6 months of age, and tend to be severer than the of age, and tend to be severer than the neonatal one and believed to be due to neonatal one and believed to be due to EndogenicEndogenic androgen from the infant’s androgen from the infant’s gonads.gonads.
Fig 24Fig 24
4. Recalcitrant Acne4. Recalcitrant Acne
Affect Women and associated with (Adrenal Affect Women and associated with (Adrenal hyperplasia "11-B- or 21-B hydroxlase hyperplasia "11-B- or 21-B hydroxlase deficiencies) acne is usually nodulocysticdeficiencies) acne is usually nodulocystic
5. Acne Fulminans5. Acne Fulminans
Affect youngsters 13 – 17 years of age, very Affect youngsters 13 – 17 years of age, very severe with ulceration and puss discharge, severe with ulceration and puss discharge, associated symptoms include (fever associated symptoms include (fever malase myalgia arthritis and bone pain) malase myalgia arthritis and bone pain) laboratory investigation shows ESR laboratory investigation shows ESR
Can be induced by starting the patient on Can be induced by starting the patient on high dose of isotretinion (Roaccutane).high dose of isotretinion (Roaccutane).
Fig 25Fig 25
6. Acne Conglobata6. Acne Conglobata
Very severe Acne, Nodulocystic form with Very severe Acne, Nodulocystic form with abscess formation, affect Torso more than abscess formation, affect Torso more than the face, usually associated with the face, usually associated with XYY XYY Syndrome. Syndrome.
Fig 26Fig 26
Fig 27Fig 27
7. Acne Agminata7. Acne Agminata (Lupus Milliaris Disseminatus (Lupus Milliaris Disseminatus
Faciei)Faciei)
Some believe it is form of Rosacea Some believe it is form of Rosacea (Granulomatous type), diagnosis is made (Granulomatous type), diagnosis is made at Histological base, Caseating at Histological base, Caseating Granulomata at the dermal level.Granulomata at the dermal level.
Fig 28Fig 28
8. Acne as part of other syndromes8. Acne as part of other syndromes
MARSH Syndrome (MARSH Syndrome (MMelsma, Acne, elsma, Acne, RRosacea, ,osacea, ,SSeborrhoeic eczema, and eborrhoeic eczema, and HHirsutism)irsutism)
Acne Conglobata Acne Conglobata Favre Racouchot syndrome elderly with elastosis Favre Racouchot syndrome elderly with elastosis
as part of Helioderma, sun exposure is a as part of Helioderma, sun exposure is a predisposing factor.predisposing factor.
Polycystic ovarian syndromePolycystic ovarian syndrome Atrophoderma vermiculatum as part of so called Atrophoderma vermiculatum as part of so called
Ulerythema ophryogenes triat in Ulerythema ophryogenes triat in Noonan SyndromeNoonan Syndrome, , de Lange Syndromede Lange Syndrome, and , and Rubinstein-Rubinstein-TaybiTaybi Syndrome Syndrome Not considered acne Not considered acne
9. Occupational 9. Occupational I EnvironmentalI Environmental
Chloracne rare forms of acne affect Chloracne rare forms of acne affect patients exposed to Halogenated patients exposed to Halogenated Hydrocarbons or who ingested Chlorinated Hydrocarbons or who ingested Chlorinated Phenols (Dioxin) Phenols (Dioxin)
Pomade acne or known as Oil Folliculitis Pomade acne or known as Oil Folliculitis Acne Aestivalis or so called Mallorca AcneAcne Aestivalis or so called Mallorca Acne
Occupational Occupational II mechanical acneII mechanical acne
Folicullitis Nuchae or so called Acne Folicullitis Nuchae or so called Acne Keloidalis Keloidalis
Pseudofollicultis barbaePseudofollicultis barbae Acne excoriee as part of PsychodermatosisAcne excoriee as part of Psychodermatosis
TRAETMENTTRAETMENT
Note: All medications used for the treatment of acne act as:
1. Anti comedonal
2. Anti inflammatory
3. Anti microbial
Topical KeratolyticTopical Keratolytic
Retinoid ( Retinoic acid 0.025, 0.05, 0.1%)Retinoid ( Retinoic acid 0.025, 0.05, 0.1%) Adapelene (Diffrine 0.1%)Adapelene (Diffrine 0.1%) Salicylic acid Salicylic acid Benzoic acidBenzoic acid Azelaic Acid (10, 15, 20 %)Azelaic Acid (10, 15, 20 %)
Topical AntibioticTopical Antibiotic
Topical clindamycin (Dalacin T)Topical clindamycin (Dalacin T) ErythromycinErythromycin Mupirocin (Bactroban)Mupirocin (Bactroban) Sodium Fusidic acid (less significant in the Sodium Fusidic acid (less significant in the
treatment) treatment)
Systemic therapySystemic therapy
Antibiotic (Macrolides and Tetracyline)Antibiotic (Macrolides and Tetracyline)
1.1. TetracyclineTetracycline
2.2. DoxycyclineDoxycycline
3.3. Minocycline (Photo sensitivity and LE)Minocycline (Photo sensitivity and LE)
4.4. ErythromycinesErythromycines
5.5. ClarythromycinesClarythromycines
6.6. AzithromycineAzithromycine
Systemic RetinoidSystemic RetinoidIsotretinoine caps (Roaccutane)Isotretinoine caps (Roaccutane)
New promising and potentially safe New promising and potentially safe medication medication SMT D002SMT D002
Phase I clinical trial Phase I clinical trial Is believed to treat Is believed to treat seborrhoeaseborrhoea a symptom a symptom
of Parkinson's disease and the primary of Parkinson's disease and the primary cause of acne cause of acne
Other form of therapyOther form of therapy
Systemic steroid (Prednisolone) acne Systemic steroid (Prednisolone) acne fulminans and intralesional steriods for fulminans and intralesional steriods for forms of cystic acne.forms of cystic acne.
Photodynamic therapy i.e. Laser therapy Photodynamic therapy i.e. Laser therapy and phototherapy (Less significant)and phototherapy (Less significant)
Hormonal therapy (Antiandrogen)Hormonal therapy (Antiandrogen)
Spironlacton (Potassium sparing agent) and Spironlacton (Potassium sparing agent) and Metformin as (Hypogylcemic agent) in Metformin as (Hypogylcemic agent) in treatment of POS have good results on treatment of POS have good results on acneacne
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.3Fig 4. Malassezia Fig 4. Malassezia furfur furfur www.doctorfungus.org/thefungi/Malassezia.htmwww.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 7
Fig 8 bacterial colonization www.healthcaresouth.com/pages/acnewhatis.htmFig 9 Breakage of follicular wall www.healthyskinbydesign.com/acne.cfm papule
Fig 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 http://www.virtualendocrinecentre.com/diseases.asp?did=860 (infantile)Fig 25Fig 26 Courtesy of Skin and allergy centre
Fig 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 João Borges da Costa, Sousa Coutinho V, L Soares de Almeida, M Marques Gomes PhDDermatology Online Journal 14 (2): 22
text:Moulin G, Thomas L, Vigneau M, Fiere A.[A case of unilateral Elastosis with cyst and Comedones of Favre-Racuchet syndrome]. Amn. Dermatol Venereol 1994, 121(10), 721-3
Sanchez-Yus E, DejRb E, Simon P, Requenal A, Vazquez H.[ The histopathology of close and open Comedones of Favre-Racuchet disease]. Arch dermatol 1997 Dec. 133 (12) 1592.
Zugerman C. [ Chloracne, clinical manifestation and etiology]. Dermatol clin. 1990 jan. 8 (1) 209-13.
Birian B. [ Peri orbital Comedones ]. J Am Acad Dermatol 2000. 42. 622-7 .
Khorsow Mehrany, Josedh M, Kist Roger H, Weenig, Patricia M, Witman. [ Acne Fulminana]. Inter. J. Dermatol 2005. 44 132.
Charles N, Ellis, Kent J, Krach. [ Uses and complications of isotretinoin therapy]. J Am Acad. Dermatol. 2001. 45: S1. 150-7.
Bedlow A J. Otter M. Marsder R A. [ Axillary acne agminata ( lupus Miliaria Desseminatus Facies)]. Clin. Exp. Dermatolo 1998 May. 22 (3) 125-8
Ogunbiyi A, George A. [ Acne keloidalis in female: Case report and review of literature]. Nati. Med assoc. 2005 Aug. 97 (8) 1178
Alfred L, Knable Jr, C William Hanke, Rene Gonin. [ Prevalence of acne Keloidalis Nuchae in Football players ]. J Am Acad Dermatol 1997. 37. 570-4
Shenefelt PD. [ Using hypnosis to facilitate resolution of psychogenic excoriation in Acne Excoriee]. Am. J. Clin. Hypn. 2004 Jan. 46 (3) 239-45
Griffiths WA. [The red face-an overview and delineation of the MARSH syndrome]Clin. Exp. Dermatol. 1999 Jan. 24(1):42-7
Thomas B Fitzpatreick, Richard Allen Johnson, Klaus Wolf, Dick Suurmond, [Disorders of Sebaceous and Apocrine glands]. Color Atlas of Synopsis of Clinical Dermatology by McGraw-Hill. 2001 . Page 2-17
Diane Thiboutot, MD Hershey, Pennsylvania [Acne: 1991-2001] . J Am Acad Dermatol July 2002 • Volume 47 • Number 1 • p109 to p117
Carolyn I. Jacob, MD,* Jeffrey S. Dover, MD, FRCPC, and Michael S. Kaminer, MD [Acne scarring: A classification system and review of treatment options] J Am Acad Dermatol 2001; 45:109-17
Susan C. Taylor, Fran Cook-Bolden, Zakia Rahman, and Dina Strachan. [Acne vulgaris in skin of color] J Am Acad Dermatol 2002; 46:S98-106
Jerry K. L. Tan, Kirsten Vasey, Karen Y. Fung, [Beliefs and perceptions of patients with acne] J Am Acad Dermatol 2001;44:439-45
Clement A. Adebamowo, Donna Spiegelman, William Danby,
.ALindsay Frazier, Walter C. Willett, Michelle D. Holmes. [High school dietary dairy intake and teenage acne]. J Am Acad Dermatol 2005; 52:207-14
Brian B. Adams, MD, Viziam B. Chetty, MD, and Diya F. Mutasim, MD Cincinnati. [Periorbital comedones and their relationship to pitch tar: A cross-sectional analysis and a review of the literature] J Am Acad Dermatol 2000;42:624-7
V. Goulden, G. I. Stables,W. J. Cunliffe. [Prevalence of facial acne in adults] J Am Acad Dermatol 1999; 41:577-80
Lowell A. Goldsmith, Jean L. Bolognia, Jeffrey P. Callen, Suephy C. Chen, Steven R. Feldman Henry W. Lim, Anne W. Lucky, Barbara R. Reed Elaine C. Siegfried, Diane M. Thiboutot, onald G. Wheeland.[American Academy of Dermatology Consensus Conference* on the Safe and Optimal Use of Isotretinoin: Summary and recommendations ] J Am Acad Dermatol 2004 june. Volume 50 number 6
Marvi Iqbal, Michael S. Kolodney, [Acne fulminans with synovitis-acne-pustulosishyperostosis- osteitis (SAPHO) syndrome treated with infliximab] . J Am Acad Dermatol 2005;52:S118-20.
Harold P. Lehmann, MD, PhD, Karen A. Robinson, MSc, John S. Andrews, MD,Victoria Holloway, MD, and Steven N. Goodman, MD, MHS, PhD. [Acne therapy: A methodologic review]. J Am Acad Dermatol 2002;47:231-40
Harald Gollnick, MD, and William Cunliffe, Diane Berson, Brigitte Dreno, Andrew Finlay, James J. Leyden, Alan R. Shalita, Diane Thiboutot. [Management of Acne A Report From a Global Alliance to Improve Outcomes in Acne]. J AM ACAD DERMATOL JULY 2003. VOLUME 49, NUMBER 1
Gary M. White. [Recent findings in the epidemiologic evidence, classification, and subtypes of acne vulgaris]. J Am Acad Dermatol 1998;39:S34-7John Y. M. Koo, Jennifer H. Do, Chai Sue Lee. [Psychodermatology]. J AM ACAD DERMATOL NOVEMBER 2000. VOLUME 43, NUMBER 5
Sharam S Yashar, Ali Moiin, .[ TREATMENT OF PSYCHODERMATOSES WITH SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS]. J AM ACAD DERMATOL MARCH 2004. P 33