Acne vulgaris

Pimples

Common, inflammatory disease of the skin regions rich in hair follicle glands.

• Occurrence mainly in adolescents (12-24 yrs).
• About 35-90% (depending on the study) of all adolescents suffer from acne vulgaris, 17% of those affected have severe acne vulgaris with a tendency to scarring.
• Women < men.
• Post-adolescent acne
  • 20-29 yrs 43% (males) / 51% (females)
  • 30-39 y. 20% (men) / 35% (women)
  • 40-49 y. 12% (men) / 26% (women)
  • ≥ 50 7% (men) / 15% (women)

1. Acne comedonica
2. Acne papulopustulosa
3. Acne conglobata

Acne fulminans is considered a separate condition, as are multiple other forms of acne, differentiated by age of onset, clinic and/or underlying triggers.

• Genetic predisposition, polygenic disease
• Nutrition
  • Data is inconclusive. Several studies suggest an association of dairy intake and exacerbation of acne
  • High insulin like growth factor (IGF)-1 correlates with the number of acne lesions (note: milk also leads to increased serum IGF levels)
• Stress
• Body mass index (underweight people have more, overweight people less acne vulgaris)
• Androgens
• Bacterial colonisation of the skin (Propionibacterium acnes, Staphylococcus epidermidis)
• Nicotine abuse

• Medications:
  • Anticontraceptives with a restandrogenic component
  • Anabolic steroids
  • Vitamin B preparations
  • Lithium

• Androgens lead to seborrhoea. Due to follicular keratinisation disorders, the excretory duct is blocked. Sebum backs up into the follicle and bacteria in the infundibulum eventually cause inflammation.

• Nutrition
  • The role of diet remains controversial according to the DDG S2 guideline. The only food with an association with acne is skimmed milk.
  • Omega-3 fatty acids could have a positive influence on the course of acne. These are significantly reduced in the "Western diet".
  • IGF-1 (insulin-like growth factor) plays a role in the pathogenesis of acne. Since IGF-1 can be induced by foods with a high glycaemic index (e.g.: milk), a diet with a ↓ glycaemic index could be recommended
    • Hereby would be to avoid:
      • Milk and dairy products (incl. chocolate).
      • Carbohydrate-rich foods (white bread, rice, potatoes, wheat pasta).

• Depending on the clinic, a distinction is made between:
  • Acne comedonica
    • Mostly comedones
  • Acne papulopustulosa
    • Mostly papules and pustules
  • Acne conglobata
    • Mostly abscesses, fistulas, scars and keloids
• Note: Comedones are divided into open (black heads) and closed comedones (white heads)

• Primary efflorescences:
• Non-inflammatory lesions:
  • Closed/open comedones
• Inflammatory lesions:
  • Papules
  • Pustules
  • Nodules (>5 & ≤ 10 mm Ø)
  • Nodules (> 10 mm Ø)

• Secondary efflorescences:
  • Cysts
  • Fistula comedones
  • Draining sinuses
  • Crusts
  • Scars

• Clinical picture: is usually sufficient for diagnosis
• Bacterial smear to exclude folliculitis, if necessary
• If necessary, hormonal work-up: if underlying hormonal disease is suspected

• Face
• Chest (décolleté)
• Back
• Rare:
  • Perianal region
  • Gluteal region
  • Genital region
  • Inguinal region
  • Axillae

• Pain, influence on quality of life
• Age of onset
• Medication history
• Association with stress
• Suicidal tendencies
• Eating behaviour
• Manipulation of skin lesions

• Scarring and disfigurement, associated with: depression, unemployment, difficulties in finding a partner.
• Impetiginisation.
• Occurrence of the other diseases within the acne tetrad
• Gram-negative folliculitis with prolonged antibiotic therapy (never without antiseptics)

Acne tarda is still prevalent in double-digit percentages, especially in women over 30 years of age.

Basic Therapy

• Cleansing wash solutions (benzoyl peroxide)

Acne comedonica:

wash solution (benzoyl peroxide), topical retinoids (adapalene)

Acne papulopustulosa light:

wash solution (benzoyl peroxide), topical retinoids (adapalene), azelaic acid, topical antibiotics (erythromycin, clindamycin) 

Acne papulopustulosa moderate:

wash solution (benzoyl peroxide), topical retinoids (adapalene), azelaic acid, topical antibiotics (erythromycin, clindamycin), oral tetracyclines (limecycline 300 mg daily, doxycycline 1x 100 mg , minocycline 50mg 2x daily for 12 weeks

Acne papulopustulosa severe:

Isotretinoin: low-dose (10-30mg daily), in severe cases use 1mg per kg body weight.

Consensus therapy algorithm of the German Acne Guidelines Group

Source: Nast, A. (2016). S2 guideline: treatment of acne. Awmf.org. Retrieved 1 June 2016, from http://www.awmf.org/leitlinien/detail/ll/013-017.html

Hormones - prescribed by gynaecologists

• Cyproterone acetate & estrogen, several alternatives.

Chemical Peels

• AHA (Alpha Hydroxy Acid)
  • Superficial chemical peel
  • Maintenance therapy for superficial post-inflammatory hyperpigmentation
  • For the reduction of comedones
• Salicylic acid peels
  • Postacne conditions with follicular keratinisation
  • Postinflammatory hyperpigmentation
  • Superficial scarring
• Trichloroacetic acid (TCA)
  • Focal application for single, deep, worm-like scars

     

Pregnancy

• In case of need for treatment indicated:
  • Benzoyl peroxide, azelaic acid
• Systemic: Systemic therapy may be discussed in the 1st trimester, recommended from the 2nd trimester onwards --> consult obstetrics

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