INTRODUCTION–
It is the formation of comedones, pustules, papules, nodules or cysts, etc. due to obstruction and inflammation of hair follicles along with their sebaceous gland in the adjacent areas mostly on face and upper trunk of affected individuals in their adolescence years (also known as pilosebaceous units).
Pathophysiology of Acne Vulgaris-
It affects individuals either male or female mostly because of presence of four major factors as it is also known as one of the multifactorial disease, they are as follows-
1)Sebum production in excess by glands along hair follicles.
2) Hair Follicle getting obstructed or plugged by excess sebum as well as keratinocytes(cell of epidermis which produces keratin)
3) Cutibacterium acnes, it is a type of acne which is caused by proliferation of bacteria named as ‘cutibacterium’ (anaerobic gram positive bacteria) as a result of increased inflammation in the body.
4) In response to any other inflammatory process in body our immune system releases several inflammatory mediators like proinflammatory cytokines, etc. which also causes acne in the individuals.
Classification–
It is classified on the basis of inflammation into 2 types-
a)Papules and pustules- It is caused by C. acnes (Propionibacterium acnes) when they grew in the closed comedones which causes inflammatory response resulting into disruptive epithelium where inflamed follicle ruptures into the dermis either on their own or by some initiation by affected individual like by scrubbing where the contents filled in comedone causes further local inflammatory reaction on the surface resulting into papules( intense inflammation leads to purulent pustules in few cases too).
b)Nodules and cysts- Here nodules are lesions which are not on the epithelium but seated deep within involving more than one hair follicle while large fluctuant nodules forms cysts.
Etiology –
1)It is mostly triggered during growing age (adolescence) around puberty when sebum production is in excess under influence of androgen hormone, etc.
2)Other than puberty one can suffer from this due to various reasons, they are as follows-
a) Hormonal changes that occur with pregnancy or the menstrual cycle
Occlusive cosmetics, cleansers, lotions, and clothing
High humidity and sweating
Associations between acne exacerbations and inadequate face washing, masturbation, and sex are unfounded. Some studies suggest a possible association with milk products and high-glycemic diets. Acne may abate in summer months because of sunlight’s anti-inflammatory effects. Proposed associations between acne and hyperinsulinism require further investigation. Some drugs (eg, corticosteroids, lithium, phenytoin, isoniazid) worsen acne or cause acneiform eruptions.
Symptoms and Signs of Acne Vulgaris-
Skin lesions and scarring can be a source of significant emotional distress. Nodules and cysts can be painful. Lesion types frequently coexist at different stages.
Comedones appear as whiteheads or blackheads. Whiteheads (closed comedones) are flesh-colored or whitish palpable lesions 1 to 3 mm in diameter; blackheads (open comedones) are similar in appearance but with a dark center.
Manifestations of Acne-
Papules are actually inflamed blemish characterized by reddish elevation with size less than 5mm which often converts into pustules when they are more deeper than solid than later, whereas nodules are larger, deeper, and more solid than papules which lack true cystic nature but resemble to inflamed epidermoid cysts. In case of long-term cystic acne it leads to scarring which looks like tiny and deep pits (icepick scars), shallow depressions or hypertrophic scarring or keloids in some cases.
Some important types of acne are as follows-
1)Acne conglobate- It affects men more than women which is most severe of all the forms. It is known as basket of abscesses, draining sinuses, fistulated comedones including keloidal and atrophic scars. Mostly back and chest are affected while arms, abdomen, buttocks, and even the scalp are occasionally involved.
2)Acne fulminans- It is marked by the sudden appearance of confluent abscesses which leads to hemorrhagic necrosis. It is a type of acute, febrile, ulcerative acne which is present along with Leukocytosis and joint pain and swelling in the patient sometimes.
3)Rosacea fulminans/Pyoderma faciale- It is considered as analogous to ‘acne fulminans’ sometimes. It affects the midface of young women suddenly. It is marked by erythematous plaques and pustules over face involving cheeks, chin, etc.
Diagnosis–
It is done mainly by following certain procedure which involves-
1)First of all Determining the role of contributing factors either hormonal, mechanical, or drug-related, etc.
2) Degree of severity of the case (mild, moderate, severe).
3) Overview of psychosocial impact of the affected individual and their surrounding.
4)Differential diagnosis –
1) Rosacea (without comedones)
2) Corticosteroid-induced acne (no comedones but pustules are present in the same stage)
3) Perioral dermatitis (usually perioral and periorbital distribution other than acne sites).
Treatment–
Aim of treatment is to reduce-
1) The extent of parts affected by any type of acne as much as possible in optimum period of time.
2) If already scarring is there then it should to treated to make it less visible and if not then aim is to treat without any scar as most of the time scar causes more concern than acne itself to the patient.
3) Aim is to manage psychological distress and social taboo related to it as it is mostly occurred during adolescence.
Management involves different types of systemic (oral medication) as well as topical agents which are responsible for reduction of excess sebum production, to obstruct comodone to appear further during treatment, to reduce inflammation as well as controlling the bacterial growth and also last but not the least to reverse keratinization as much as possible.
In any system of medicine treatment is based on severity of the case (mild, moderate, severe).
Other tips which is to be including in daily routine is as follows-
1)Face or affected areas should be cleansed as well as scrubbing too if rawness is not there at least once a day by antibacterial soaps or face wash.
2) Diet during treatment consist of a lower glycemic diet, less spicy and fatty foods as well as milk should be taken in moderation especially for adolescence acne which are more resistant in nature..
3)Peeling agents such as sulfur, salicylic acid, glycolic acid, and resorcinol can be useful therapeutic adjuncts.
4) Different types of therapies according to case is used, with and without topical photosensitizers especially in case of inflammatory acne.
5) Management of any case should be done involving the patients and it should be feasible to patient economically as well as easy to follow in total duration of treatment so that they must not discontinue them in between the treatment.
6) Scars must be treated properly if it is already happened and also the aim of treatment is to avoid scarring post treatment as it has psychological impact on patients in their daily life. Here, small scars are easy to manage by chemical peels, laser resurfacing, or dermabrasion, etc. while deeper or discrete needed to be excised in some cases, also wide, shallow depressions can be treated with injection of collagen or another fillers like hyaluronic acid, etc. which are most of the time are temporary in nature and must be repeated for maintaining aesthetics.
Contributor- Dr. Apurva Varangi
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