ACNE AND ROSACEA

Acne vulgaris
Acne is chronic inflammation of the pilosebaceous units.
The condition is extremely common; it generally starts after puberty and there are reports of it affecting
over 90% of adolescents
It is usually most severe in the late teenage years but can persist into the thirties and forties, particularly in
females .
• It is a polymorphic disorder (comedons, papules, pustules, nodules, pseudocysts, and
sometimes scarring)
• The sites of predilection are face, upper trunk and upper arms.
• It usually affect adolescent
• Darker skinned patients at increased risk for developing post-inflammatory hyper-
pigmentation and keloids.
Patients can experience significant psychological morbidity and, rarely, mortality due to suicide

Pathophysiology

Follicular keratinocytes exhibit increased cohesiveness (do not shed normally)

↓
Leading to retention and accumulationof sebum.
↓
Androgens stimulate enlargement of sebaceous glands and increased sebum production
The abnormal keratinaceous material and sebum collect in the microcomedon. (Socommedon
formed which is non-inflammatoryacne)
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Bacterial proliferation (Propionibacterium acnes)
↓
Infection and inflammation

Aetiology
The key components are increased sebum production; colonisation of pilosebaceous ducts by
Propionibacterium
acnes, which in turn causes inflammation; and hypercornification and occlusion of pilosebaceous ducts

Severity of acne is associated with sebum excretion rate, which increases at puberty.
I. Both androgens and progestogens increase sebum excretion and
II. oestrogens reduce it,
  although the hormonal effects may also reflect end-organ sensitivity, as most patients have
normal hormone profiles.
 There may be a positive family history; there is high concordance in monozygotic twins and it
is likely that genetic factors are important in some families, but candidate genes have not been
confirmed.

Clinical features
Acne usually affects the face and often the trunk.
Greasiness of the skin may be obvious (seborrhoea).
The hallmark is the comedone:
1ry lesion
I. open comedones (blackheads) are dilated keratin-filled follicles, which appear as black papules
due to the keratin debris;
II. closed comedones (whiteheads) usually have no visible follicular opening and are caused by
accumulation of sebum and keratin deeper in the pilosebaceous ducts.

2ry lesion
I. Inflammatory papules, nodules and cysts occur and may arise from comedones
II. Scarring may follow deep-seated or superficial acne and may be keloidal.

Acne Varients- summary

• Neonatal acne
• Persistant acne
• Late onset acne (chin of female)
• Acne conglobata (nodulocysticacne)
• Fulminante acne (fever + acne)
• Acne excorié(hairepilation)
• Gram negative folliculitis. ( S.E. of tetracycline )
• Cosmetic Acne (make up)
• Drug induced acne (steroid acne)
• Endocrine acne

There are distinct clinical variants:

Type Lesions present Complication
• Acne characterised by comedones, nodules, It may be associated with
conglobata abscesses, sinuses and cysts, usually with  hidradenitis suppurativa (a chronic,
marked scarring. inflammatory disorder of apocrine
It is rare, usually affecting adult males, glands, predominantly affecting axillae
and most commonly occurs on trunk and and groins),
upper limbs.  scalp folliculitis
 pilonidal sinus.

Acne a rare but severe presentation of acne, Costochondritis

fulminans associated with fever, arthralgias and can occur
systemic inflammation, with raised
neutrophil count and plasma viscosity. It is
usually found on the trunk in adolescent
males
• Acne describes self-inflicted excoriations due to It usually affects teenage girls and
excoriée compulsive picking of pre-existing or underlying psychological problems are
imagined acne lesions. common.

Secondary .Predominantly pustular acne can occur in comedonal acne can be caused by greasy
acne: patients cosmetics or occupational exposure to oils,
 using : tars or chlorinated aromatic hydrocarbons
 systemic or topical corticosteroids,
 oral contraceptives,
 anticonvulsants,
 lithium or
 antineoplastic drugs, such as :
the epidermal growth factor receptor
(EGFR) inhibitor,
cetuximab.

Most patients with acne do not have an

underlying
endocrine disorder. However, acne is a
common
feature of polycystic ovary syndrome
which should be suspected if acne is
moderate to
severe and associated with hirsutism and
menstrual
irregularities.
Virilisation should also raise suspicion of
an androgen-secreting tumour.

Steroid Acne
1. History of steroid drugs use
2. No comedones
3. Wide spread
4. Rapid oncet
5. Monomorphic

Local symptoms:Pain especially if acute inflammation

Systemic symptoms: Most often absent

Classification according to severity:

• Comedonal acne: Only comedons
• Mild acne: Less than 20 pustules.
• Moderate to severe acne: More than 20 pustules (Sever acne contain cysts, sinuses, scaring)

Investigations
Investigations are not required in typical acne vulgaris.
Secondary causes and suspected underlying endocrine disease or virilisation should be investigated

Management
Mild to moderate disease
 Mild disease is usually managed with topical therapy
If comedones predominate, then topical benzoyl peroxide or retinoids should be used.
Treatment should initially be applied at low concentrations for short duration and increased as
tolerated.
Azelaic acid may also be useful for mild acne.
Patients with mild inflammatory acne should respond to topical antibiotics, such as :
I. erythromycin or
II. clindamycin, which can be used in combination with other treatments.

 For moderate inflammatory acne,:

 a systemic tetracycline, such as oxytetracycline or lymecycline, should be used at adequate dose
for 3–6 months in the first instance
If the case fails to respond, then alternatives include erythromycin or trimethoprim.
Oestrogen-containing oral contraceptives or a combined oestrogen/anti-androgen (such as
cyproterone acetate) contraceptive may provide additional benefit in women.
Patients should be referred for consideration of isotretinoin (13 cis-retinoic acid) if there is a
failure to respond adequately to 6 months of therapy with these combined systemic and topical
approaches

Moderate to severe disease

Isotretinoin has revolutionised the treatment of moderate to severe acne that has not responded
adequately to other therapies.
 It has a multifactorial mechanism of action, with reduction in sebum excretion by over 90%,
follicular hypercornification and P. acnes colonisation.
 A typical course lasts for 4 months.
 Sebum excretion usually returns to baseline over the space of a year after treatment is stopped,
although clinical benefit is
 usually longer-lasting.
 Many patients will not require further treatment, although a second or third course of isotretinoin
may be required.
A low-dose continuous or intermittent-dose regimen may be considered for a longer duration,
in patients who relapse after a higherdose regimen.
Combination with systemic steroid may be required in the short term for severe acne, in order
to minimise the risk of disease flare early in the treatment course.
Thorough screening and monitoring are required, given the side-effect profile of isotretinoin

Other treatments and physical measures

 Intralesional injections of triamcinolone acetonide may be required for inflamed acne nodules or
cysts, which can also be incised and drained, or excised under local anaesthetic.
 Scarring may be prevented by adequate treatment of active acne.
 Keloid scars may respond to intralesional steroid and/or silicone dressings.
 Carbon dioxide laser, microdermabrasion, chemical peeling or localised excision can also be
considered for scarring.
 UVB phototherapy or PDT can occasionally be used in patients with inflammatory acne who are
unable to use conventional therapy, such as isotretinoin.
There is no convincing evidence to support a causal association between diet and acne.
The psychological impact of acne must not be underestimated and should be considered in management
decisions

Summary notes
A. General measures:
• Improve hygiene
• Gentle cleansing
• Avoidness of comedogenic applications.
• Reassurance

B. Topical treatments:
1. Those directed towards microorganisms.
2. Those directed towards comedogenesis.

1. Topical treatments directed towards microorganisms:

Topical antibiotics:erythromycin (1.5-2% gel or cream), clindamycin (1% lotion), Benzyl
peroxide.

2. Topical treatment directed towards comedogenesis:

 • Retinoids:
Anti-seborrheic effect
Anti-comedonal effect
Anti-inflammatory effect
Inhibiting the growth of propionobacterium acne

- Tretinoin may be used as solution, cream or gel. It is available in 0.025% ,

0.05% and 0.1% concentration
- Tazarotene(0.1% gel) applied once daily.
- Adapalene:Adapalene (0.1% gel).

• Azelaic acid: cream with 20%

C. Systemic Treatment of acne:
1. Those directed against microorganisms (antibiotics).
2. Those directed against comedogenesisand seborrhea (retinoids).
3. Those acting on hormonal bases (antiandrogens).

1. Systemic antibiotic
Indications
• Moderate or severe inflammatory acne.
• Acne resistant to topical treatment.
• Acne that covers large area of the body.

Tetracycline: Tetracycline dose for an adult is 250 mg four times daily.

Doxycycline: It is usually given in a dose of 100 mg once or twice daily.
Minocycline: The usual dose is 50-100 mg once or twice daily.
Erythromycin and Azithromysin
Clindamycin: In a dose of 75-150 mg. (may cause pseudomembranous colitis)

2. Isotretinoin(Vitamin A derivative):is the single most effective treatment.

Indications:
• Severe acne.
• Moderate unresponsive acne.
• Acne with scarring.
• Acne with severe depression or dysmorphophobia.
• High sebum excretion rate.
• Some unusual variants, such as acne fulminans, gram-negative folliculitis.

Side Effect of Isotretenoin

• Teratogenic (contraindicated to be pregnant)
• Dryness of skin and mucous membrane (lip, face, and body nose – bleeding)
• Conjunctivitis
• Hair loss
• Impetiginization
• Photosensitivity
• Arthralgia and myalgia
• Depression
• Headache

3. Hormonal therapy
Indicated for:
Acne is not responding to conventional therapy.
If there are signs of hyperandrogenism(PCOS, Hirsutism)
 A. Androgen production inhibitors
Glucocorticoids and oral contraceptives
B. Androgen receptor blockers: cyproterone acetate, spironolactone and flutamide.

Rosacea:‫داءالوردية‬

Rosacea (latin: “like roses”) is a chronic inflammatoy disorder of the facial pilosebaceous units, with an
increased reactivity of capillaries to heat, leading to flushing and telangiectasia...

Rosacea is distinct from acne vulgaris; sebum excretion is normaland comedones are absent. The relative
contribution of
Demodex mite and cutaneous vasomotor instability to the pathogenesis of rosacea remains poorly defined.

Clinically

Stages of evolution

Episodic (flushing) in response to (hot liquids), spicy foods; alcohol ,exposure to sun, heat and
emotional stress.

Stage i: persistent erythema with telangiectases

Stage ii: persistent erythema, telangiectases, papules, tiny pustules

Stage iii: persistent deep erythema, dense telangiectases, papules, pustules, nodules;

• marked sebaceous hyperplasia edema of the central part of the face "glandular rosacea“causing
disfigurement of the nose (Rhinophyma) (enlarged nose) }

• Age of incidence between 30 to 50 years,

• Sex females predominantly;

• Race WHITE peoples.

• Distribution characteristic is a symmetrical localization on the face

 Eye lesions “red” eyes :

Chronic blepharitis, conjunctivitis, and episcleritis. Rosacea keratitis

Facial lymphoedema can be an added complication

Differential diagnosis

• Acne: (note: in rosacea no comedones)

• Perioral dermatitis

• Folliculitis

• SLE ( no papule and pustule )

Course :

• Prolonged.

• Recurrences are common.

• After a few years, the disease tends to disappear spontaneously.

Management

Reduction of alcoholic and hot beverages.

Topical :

• Metronidazole gel or cream, 0.75 %, twice daily

• orTopicalantibiotics (e.g., erythromycin gel).

• Systemic: oral antibiotics:

• Tetracycline, 250mg 4td. until clear; then gradually reduce to once-daily doses of 250 to 500 mg.

• Minocycline and doxycycline: 50 to 100 mg twice daily.

• Oral Isotretinoin

• Rhinophyma, is treated successfully by surgery or laser surgery.

N.B “:

Mild disease may respond to topical antimicrobials, such as metronidazole or azelaic acid.
Tetracycline or erythromycin for 3–6 months is usually effective in inflammatory pustular disease
resistant to topical
therapy
Relapse may require intermittent or chronic antibiotic use.
Erythema and telangiectasiae do not respond well to antibiotics but laser therapy can be effective.
Systemic isotretinoin may be helpful in severe resistant disease and rhinophyma may need laser
therapy or surgery