Acne vulgaris

Last Updated: 2021-10-15

Author(s): -

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

 

light

medium-difficult

heavy

Akne

comedonica

papulopustulosa

papulopustulosa

papulopustulosa nodosa

conglobata

1st choice

Topical retinoid

Basic therapeutic

Combination of basic therapeutic agents

Basic therapeutic & topical antibiotic

Combination of basic therapeutics

Basic therapeutic & topical antibiotic

Basic therapeutic & oral antibiotic

Oral antibiotic

& 1-2 basic therapeutics

Oral antibiotic & azelaic acid

 

Alternatives

Azelaic acid

Azelaic acid

if necessary in combination with basic therapeutics or top. Antibiotics

Azelaic acid & basic therapeutics

oral antibiotic

& azelaic acid

Oral isotretinoin

Oral isotretinoin

Women

s.o.

s.o.

Oral antiandrogenic contraceptive

& 1st choice

Oral antiandrogenic contraceptive

& 1st choice

Oral antiandrogenic contraceptive

& 1st choice

In case of pregnancy

Azelaic acid

Azelaic acid

Top. Erythromycin & BPO

Oral erythromycin

& azelaic acid

Oral erythromycin

& BPO

Oral erythromycin

& azelaic acid

& BPO

Oral erythromycin

& azelaic acid

& BPO

possibly oral prednisolone short-term

Maintenance therapy

         

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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