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.

1. Conraths H. [Unilateral acne necroticans in monozygotic twins]. Z Haut Geschlechtskr 1955;18:169-70.
2. Krauspe C, Stelzner F. [Pyodermia fistulans sinifica. On the clinical and histopathological changes in fistulous dermatitis with remarks on the relation to so-called hidradenitis suppurativa and acne conglobata]. Chirurg 1962;33:534-8.
3. Mueller H. [Contribution to the Therapy of Acne Necroticans (Boeck)]. Dermatol Wochenschr 1964;149:495-500.
4. Fulton JE. Gram-Negative Folliculitis in Acne Vulgaris. Arch Dermatol 1968;98:349.
5. Heller J, Erbertova B. [Effect of a polysan preparation for the treatment of acne on the growth of Corynebacterium acnes and Staphylococcus pyogenes aureus]. Cesk Dermatol 1975;50:235-40.
6. Sjolin KE. Acne aestivalis. A histopathological study. Acta Derm Venereol Suppl (Stockh) 1979;59:171-6.
7. Goodfellow A, Alaghband-Zadeh J, Carter G, et al. Oral spironolactone improves acne vulgaris and reduces sebum excretion. Br J Dermatol 1984;111:209-14.
8. Friedman SJ, Fox BJ, Albert HL. Solid facial edema as a complication of acne vulgaris: Treatment with isotretinoin. Journal of the American Academy of Dermatology 1986;15:286-9.
9. Lucky AW. Acne vulgaris in premenarchal girls. An early sign of puberty associated with rising levels of dehydroepiandrosterone. Archives of Dermatology 1994;130:308-14.
10. Bassukas ID, Hundeiker M. Acne inversa (pyodermia fistulans sinifica) and smoking. J Am Acad Dermatol 1997;36:1029.
11. Chu A, Huber FJ, Plott RT. The comparative efficacy of benzoyl peroxide 5%/erythromycin 3% gel and erythromycin 4%/zinc 1.2% solution in the treatment of acne vulgaris. Br J Dermatol 1997;136:235-8.
12. Cunliffe W, Caputo R, Dreno B, et al. Efficacy and safety comparison of adapalene (CD271) gel and tretinoin gel in the topical treatment of acne vulgaris. A European multicentre trial. Journal of Dermatological Treatment 1997;8:173-8.
13. Wood AJJ, Leyden JJ. Therapy for Acne Vulgaris. New England Journal of Medicine 1997;336:1156-62.
14. Dunlap, Mills, Tuley, Baker, Plott. Adapalene 0·1% gel for the treatment of acne vulgaris: its superiority compared to tretinoin 0·025% cream in skin tolerance and patient preference. British Journal of Dermatology 1998;139:17-22.
15. Itoh Y, Ninomiya Y, Tajima S, Ishibashi A. Photodynamic Therapy for Acne Vulgaris With Topical 5-Aminolevulinic Acid. Arch Dermatol 2000;136.
16. Cordain L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller J. Acne Vulgaris. Arch Dermatol 2002;138.
17. Taylor SC, Cook-Bolden F, Rahman Z, Strachan D. Acne vulgaris in skin of color. Journal of the American Academy of Dermatology 2002;46:S98-S106.
18. Burkhart CN, Burkhart CG. Microbiology's principle of biofilms as a major factor in the pathogenesis of acne vulgaris. International Journal of Dermatology 2003;42:925-7.
19. Elman M, Slatkine M, Harth Y. The effective treatment of acne vulgaris by a high‐intensity, narrow band 405–420 nm light source. Journal of Cosmetic and Laser Therapy 2003;5:111-7.
20. Leyden JJ. A review of the use of combination therapies for the treatment of acne vulgaris. Journal of the American Academy of Dermatology 2003;49:S200-S10.
21. Amichai B, Shemer A, Grunwald MH. Low-dose isotretinoin in the treatment of acne vulgaris. Journal of the American Academy of Dermatology 2006;54:644-6.
22. Margolis DJ, Hoffstad O, Bilker W. Association or lack of association between tetracycline class antibiotics used for acne vulgaris and lupus erythematosus. Br J Dermatol 2007;157:540-6.
23. Hædersdal M, Togsverd-Bo K, Wulf HC. Evidence-based review of lasers, light sources and photodynamic therapy in the treatment of acne vulgaris. Journal of the European Academy of Dermatology and Venereology 2008;22:267-78.
24. Melnik B. Acne vulgaris. Hautarzt 2010;61:115-25.
25. Plewig G. Wie entsteht Acne vulgaris? Hautarzt 2010;61:99-106.
26. Sakamoto FH, Lopes JD, Anderson RR. Photodynamic therapy for acne vulgaris: A critical review from basics to clinical practice. Journal of the American Academy of Dermatology 2010;63:183-93.
27. Woolery-Lloyd H, Baumann L, Ikeno H. Sodium L-ascorbyl-2-phosphate 5% lotion for the treatment of acne vulgaris: a randomized, double-blind, controlled trial. Journal of Cosmetic Dermatology 2010;9:22-7.
28. Kawashima M, Hashimoto H, Alio Sáenz AB, Ono M, Yamada M. Is benzoyl peroxide 3% topical gel effective and safe in the treatment of acne vulgaris in Japanese patients? A multicenter, randomized, double-blind, vehicle-controlled, parallel-group study. The Journal of Dermatology 2014;41:795-801.
29. Nast, A. (2016). S2-Leitlinie: Behandlung der Akne. Awmf.org. Retrieved 1 June 2016, from http://www.awmf.org/leitlinien/detail/ll/013-017.html