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Acne

ACNE

HUDA ALI HAMEED

Member of The Health Committee

Acne, also known as acne vulgaris, is a long-term skin disease that occurs when hair follicles are clogged with dead skin cells and oil from the skin. It is characterized by blackheads or whiteheads, pimples, oily skin, and possible scarring. It primarily affects areas of the skin with a relatively high number of oil glands, including the face, upper part of the chest, and back. The resulting appearance can lead to anxiety, reduced self-esteem and, in extreme cases, depression or thoughts of suicide.

Genetics is thought to be the primary cause of acne in 80% of cases. The role of diet and cigarette smoking is unclear, and neither cleanliness nor exposure to sunlight appear to play a part. In both sexes, hormones called androgens appear to be part of the underlying mechanism, by causing increased production of sebum. Another frequent factor is excessive growth of the bacterium Cutibacterium acnes, which is normally present on

Classification

  • The severity of acne vulgaris can be classified as mild, moderate, or severe as this helps to determine an appropriate treatment regimen. There is no universally accepted scale for grading acne severity. Mild acne is classically defined by the presence of clogged skin follicles (known as comedones) limited to the face with occasional inflammatory lesions.
  • Moderate severity acne is said to occur when a higher number of inflammatory papules and pustules occur on the face compared to mild cases of acne and are found on the trunk of the body.
  • Severe acne is said to occur when nodules (the painful ‘bumps’ lying under the skin) are the characteristic facial lesions and involvement of the trunk is extensive.Large nodules were previously referred to as cysts, and the term nodulocystic has been used in the medical literature to describe severe cases of inflammatory acne.

What are the clinical features of acne vulgaris?

  • Acne most often affects the face, but it may spread to involve the neck, chest and back, and sometimes even more extensively over the body.
  • Individual lesions are centred on the pilosebaceous unit, ie the hair follicle and its associated oil gland. Several types of acne spots occur, often at the same time. They may be inflamed papules, pustules and nodules; or non-inflamed comedones and pseudocysts.
  • Superficial lesions
  • Open and closed comedones (blackheads and whiteheads)
  • Papules (small, tender red bumps)
  • Pustules (white or yellow “squeezable” spots)
  • Nodules (large painful red lumps)

Secondary lesions

Excoriations (picked or scratched spots)

Erythematous macules (red marks from recently healed spots, best seen in in fair skin)

Pigmented macules (dark marks from old spots, mostly affecting those with dark skin)

Scars or various types

Individual acne lesions usually last less than 2 weeks but the deeper papules and nodules may persist for months. Many acne patients also have oily skin (seborrhoea).

Differential diagnosis

  • Acne rosacea: usually presents in middle age or later in life.
  • Folliculitis and boils: may present with pustular lesions similar to those seen in acne.
  • Milia: small keratin cysts that may be confused with whiteheads. They tend to be whiter than acne whiteheads and are most commonly seen around the eyes.
  • Perioral dermatitis.

Pityrosporum folliculitis: predominates on the trunk

Causes:

  • Four main factors cause acne:
  • Excess oil production
  • Hair follicles clogged by oil and dead skin cells
  • Bacteria
  • Excess activity of a type of hormone (androgens)
  • Acne typically appears on your face, forehead, chest, upper back and shoulders because these areas of skin have the most oil (sebaceous) glands. Hair follicles are connected to oil glands.
  • The follicle wall may bulge and produce a whitehead. Or the plug may be open to the surface and darken, causing a blackhead. A blackhead may look like dirt stuck in pores. But actually the pore is congested with bacteria and oil, which turns brown when it’s exposed to the air.
  • Pimples are raised red spots with a white center that develop when blocked hair follicles become inflamed or infected with bacteria. Blockages and inflammation that develop deep inside hair follicles produce cystlike lumps beneath the surface of your skin. Other pores in your skin, which are the openings of the sweat glands, aren’t usually involved in acne.

Factors that may worsen acne

  • These factors can trigger or aggravate acne:
  • Androgens are hormones that increase in boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum. Hormonal changes related to pregnancy and the use of oral contraceptives also can affect sebum production. And low amounts of androgens circulate in the blood of women and can worsen acne.
  • Certain medications. Examples include drugs containing corticosteroids, testosterone or lithium.
  • Studies indicate that certain dietary factors, including skim milk and carbohydrate-rich foods — such as bread, bagels and chips — may worsen acne. Chocolate has long been suspected of making acne worse. A small study of 14 men with acne showed that eating chocolate was related to a worsening of symptoms. Further study is needed to examine why this happens and whether people with acne would benefit from following specific dietary restrictions.
  • Stress can make acne worse.

Risk factors

Risk factors for acne include:

  • People of all ages can get acne, but it’s most common in teenagers.
  • Hormonal changes. Such changes are common in teenagers, women and girls, and people using certain medications, including those containing corticosteroids, androgens or lithium.
  • Family history. Genetics plays a role in acne. If both parents had acne, you’re likely to develop it, too.
  • Greasy or oily substances. You may develop acne where your skin comes into contact with oily lotions and creams or with grease in a work area, such as a kitchen with fry vats.
  • Friction or pressure on your skin. This can be caused by items such as telephones, cellphones, helmets, tight collars and backpacks.
  • Stress doesn’t cause acne, but if you hFirst-line and Alternative Treatment Options

Treatment

  • First-line treatment for mild acne vulgaris includes benzoyl peroxide or a topical retinoid, or a combination of topical medications consisting of benzoyl peroxide and an antibiotic (erythromycin or clindamycin), retinoid, or both.
  • First-line treatment for moderate acne vulgaris includes a combination of benzoyl peroxide and a topical antibiotic (erythromycin or clindamycin), topical retinoid, or both; benzoyl peroxide, an oral antibiotic, and topical retinoid; or benzoyl peroxide, oral and topical antibiotics, and a topical retinoid. Alternative treatments to be considered include a different combination of medications; changing the oral antibiotic; adding a combined oral contraceptive or spironolactone in females; or oral isotretinoin.
  • First-line treatment for severe acne vulgaris includes an oral antibiotic, benzoyl peroxide, and a topical antibiotic (erythromycin or clarithromycin), topical retinoid, or both. Oral isotretinoin can also be considered as a first-line option. Alternative treatment options to consider include changing the oral antibiotic; adding a combined oral contraceptive or spironolactone in females; or starting oral isotretinoin.

HORMONAL AGENTS

  • Spironolactone can be of benefit in some females, and combined oral contraceptives containing estrogen are recommended in females with inflammatory acne. It should be noted that a Papanicolaou smear and bimanual pelvic examination are not required to prescribe combined oral contraceptives; however, the risks associated with them should be taken into consideration (e.g., cardiovascular problems, breast or cervical cancer).
  • In the short term, adding an oral corticosteroid when initiating the usual acne therapy in persons with severe inflammatory acne can be beneficial. Low-dose oral corticosteroids are recommended for persons with adrenal hyperandrogenism.

HORMONAL AGENTS

  • Spironolactone can be of benefit in some females, and combined oral contraceptives containing estrogen are recommended in females with inflammatory acne. It should be noted that a Papanicolaou smear and bimanual pelvic examination are not required to prescribe combined oral contraceptives; however, the risks associated with them should be taken into consideration (e.g., cardiovascular problems, breast or cervical cancer).
  • In the short term, adding an oral corticosteroid when initiating the usual acne therapy in persons with severe inflammatory acne can be beneficial. Low-dose oral corticosteroids are recommended for persons with adrenal hyperandrogenism.

ISOTRETINOIN

  • Oral isotretinoin, which is best absorbed when taken with meals, is recommended for severe nodular acne, and is appropriate for moderate acne in which other therapies have failed or for acne that results in scarring or causes patient distress. Low doses are effective while also decreasing related adverse effects, but it should be noted that intermittent dosing is not indicated. Common adverse effects of isotretinoin, which generally resolve when the medication is stopped, are usually related to hypervitaminosis A symptoms affecting the mucocutaneous, musculoskeletal, and ophthalmic systems. A liver function test and serum cholesterol and triglyceride measurements should be performed initially to obtain a baseline and repeated until the patient responds to treatment; however, it is not necessary to routinely perform complete blood counts. Patients should also be monitored for inflammatory bowel disease and depression.
  • If patients are taking isotretinoin,Females of childbearing age should receive information about contraception

ROLE OF DIET

  • Specific changes in diet are not recommended to treat acne, but developing information indicates that acne may be related to a high glycemic index and limited data indicate that some dairy, especially skim milk, can worsen acne. There is insufficient evidence to endorse recommendations related to antioxidants, probiotics, and fish oil.ave acne already, it may make it worse.

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