ACNE VULGARIS
- This is a chronic inflammation of the sebaceous unit/glands and the associated hair follicles affecting mainly the face, the neck, the back and chest of the adolescents and the young adults.
- It is characterized by plugging of the pillosebacceous follicles by keratin and sebum resulting in an expanded follicle called comedones-primary acne lesions
PREDISPOSING FACTORS
- Family history
- Hormonal changes during puberty
- Diet –chocolate, cola, fried foods
- Anxiety/stress disorders
- Some chemicals e.g. soruazid
- Exercise vigorous leading to sweat
AETIOLOGY
- No known cause.
- Androgenic hormones
- Genetic predisposition
- Bacterial factors
- Follicular obstruction/plugging.
- All genders are equally affected and esp. adolescents and ladies who use androgen.
NB Acne is aggravated by picking and squeezing the lesion, stress, nervous tension, insufficient sleep, chronic illness, menstruation and some diets
PATHOPHYSIOLOGY
- At puberty, the presence of androgens stimulates sebaceous gland causing them to enlarge and produce sebum.
- In childhood , sebaceous glands are small and non-functional due to low levels of androgens
- Acne develops when there is an alteration in keratinisation within the follicles, leading to plugging of the pillosebacious a canal by a mass of keratin and sebum.
- This leads to accumulation of sebum in the follicles and the normal saprophytes propionibacterium acne breaks this sebum into free fatty acids which imitates and eventually break down follicular walls.
- The free fatty acids then invade the surrounding tissues causing inflammatory reactions
- CLINICAL FEATURES.
- In mild forms, only non-inflammatory lesions are present known as open comedones (white heads) closed comedones (black heads) Their dark colour is due to oxidation of surface keratin. (accumulation of lipids, bacterial, and epithelia debris)
- Papules and pustules are 2-4mm in diameter and have slightly erythematous base.
- Nodules are deeper erythematous lesions from 6-20mm in diameter.
- There may appear and a few superficial pustules
- In most severe forms there are deep nodules , deep pustules and also abscess.
DIAGNOSIS
- Basically clinical through physical examination and history taking.
- Biopsy of lesion is seldom necessary for a definitive diagnosis
MANAGEMENT
- Goal is to reduce bacterial colonies to decrease sebaceous gland activity, prevent the follicle from becoming plugged, reduce inflammation, combat secondary infection, minimize scarring and eliminate factors that predispose the person.
- Therapeutic regime depends on the types of lesion/comedonal/popular and may be topical, systemic, intralesional or surgical and includes the following;
- Hormone therapies i.e. give estrogens to suppress effects of androgens (for female).
- Nutritional therapy elimination of specific food products associated with acne e.g chocolate, cola, fried foods, milk products.
- Skin hygiene in mild cases washing the faces at least three times daily with a cleansing soap, but vigorous scrubbing should be avoided.
- Topical pharmacological therapy –this is designed to obtain a mild exfoliation (peeling). Common medication are sulphur-zinc losion, benzoyl peroxide wash gel – depresses sebum production and promote breakdown of comedo plugs , Vitamin A acid (retirioic acid) –has comedolytic effects and also increases the rate of cell production within the hair follicle hence pushing out of the plug itself. (Increases rate of desquamation of epidermis as well as reduce sebum production).
- Systemic pharmacological therapy esp. in severe case of abscess formation oral antibiotics (erythromycin, tetracycline, doxycycline, minocin, penicillins trimethoprim, sulfamethazone).
- Intralesional corticosteroid therapy- cysts should be drained and injected with triamcinolone solution.
- Topical application –use of comedolytics e.g. vitamin A benzoacid (benzoy peroxide) which has antibacterial effects .
- Topical antibiotics e.g. Tetracycline, clindamycin and erythromycin ointment –suppresses multiplication of propillumbacteria
- Oral retinoids e.g. synthetic vitamin A compounds in patients with nodular cystic acne not responding to other treatment.
NB these medications are potentially irritating and frequency should be gradually increased
- Surgical management
- Open comedones may be removed with a comedo extractor, incision and drainage of cystic regions.
- Dermabresion- damage epidermis and superficial dermis scars are removed.
- Cryosurgery- freezing with liquid nitrogen
HEALTH EDUCATION
- The patient should be assured that the disease is not related to uncleanness and in description of any other misconceptions.
- Advice the pt to abide to the treatment regimen as it’s normally long term (4-blocks for any results to be realized).
- Advice the patient to avoid scrubbing the or squeezing pimples (comedones)
- To stop using cosmetics on face –lotions, creams, shaving etc. instead use oil free cosmetics
- Activities causing occlusion such as tight collar shirts should be avoided
- Advice on the need to avoid stress.
- Reduce the junk foods –chips, chocolate, fried food, milk product.