A Case Of Acne Vugaris In An Adolescent Boy

An adolescent boy presents with complains of severe acne on face. The picture is shown above.How would you approach to this case:

Case Discussion:

Acne Vulgaris:  This adolescent is suffering from acne vulgaris.

Pathophysiology: Acne happens in the sebaceous follicles instead of hair follicles. They have large and abundant sebaceous glands and usually lack hair. Obstruction of the follicular opening results in the clinical lesions of acne. Diet, soaps and sex do not have much role in its causation. Acne often improves in summer while flare up during winter.

Whiteheads or closed comedones are likely to progress to inflammatory acne (pustule and nodule formation). So, obviously they are more problematic than blackheads or open comedones.

Causes Of Neonatal Acne: Maternal androgens cross the placental barrier and reach the fetus causing
the enlargement of the sebaceous glands which become more active leading to increased sebum production and thereby causing acne in the neonate.

Several factors are incriminated in its pathogenesis as :

• increased sebum secretion because of increased end-organ sensitivity to androgens, 
• follicular duct hypercornification and
• increased colonization with a bacterium called Propionibacterium acnes. These commensal bacteria play a vital role in its causation and have been found in increased number in acne.

Clinical Features: Its onset is usually around 12-14 years of age. It often consists of a polymorphic eruption consisting of papules, pustules, nodules, cysts and typically open and closed comedones on a background of oilness. The lesions heal with pitted or hypertrophic scars.


Open Comedome or Black Head: Obstruction at the opening of the sebaceous follicle mouth is characterized by a lesion with a wide patulous opening filled with a plug of stratum corneum cells. Such a lesion is called an open comedone or blackhead. It is the predominant lesion in adolescent acne. It does not progress to inflammatory acne.

Closed comedones or whiteheads are caused by obstruction just beneath the follicular opening in the neck of the sebaceous follicle. It results in the cystic swelling of the follicular duct beneath the epidermis, and resulting lesion is an enlarging sphere just beneath the skin surface. Closed comedones usually progress to inflammatory acne.

Usual sites of its affection are face, upper trunk and deltoid region.

Management
Preventive Measures: Oil-based cosmetics, face creams or hair sprays should be avoided in patients
with acne as they will aggravate acne by further obstructing the partially occluded sebaceous follicles. Their discontinuation may greatly help these patients.

Treatment: Acne cannot be cured but can be controlled and scarring can be avoided by early treatment. Its management depends on the predominant type of the lesion and the severity.

1. In mild comedonic acne, comedolytic agents as retinoic acid (0.025-0.1%), adaplene (0.1%) and benzoyl peroxide are used. Systemic agents are not necessary in it.

2. In moderately severe predominantly comedonic acne, a combination of retinoic acid and benzoyl peroxide is used. If moderate acne is predominantly inflammatory then oral antibiotics or topical antibiotics are used in addition to topical retinoic acid or benzoyl peroxide.

3. In severe cases retinoic acid/glycolic acid/azelaic acid/mometasone can be used once daily sequentially. Severe acne is managed by a combination of retinoic acid or benzoyl peroxide and oral antibiotics or anti-androgens (in females) or oral retinoids.

Retinoic acid and benzoyl peroxide gel are 2 potent keratolytic agents that are most efficacious for the management of acne. Either of these agents can be used once daily. Oral retinoids are most efficacious but are used for the management of severe acne.

Combination therapy is better. A popular and effective combination is use of benzoyl peroxide gel in the morning and tretinoin at night.

Retinoic acid is a potent keratolytic agent. It is used for the management of acne, scars, pits, post-inflammatory marks and wrinkles. It often causes drying of skin as a side effect. It is applied once daily at night after drying soap washed skin. It should not be applied in day as sun exposure may cause problem. It can be used for long term without problem. It also works as an anti-aging agent.

Benzoyl peroxide 2.5% gel is used once in morning. It is especially used, if lesions are infected.

Other drugs that help topically are :

• adapalene, 
• azelaic acid, 
• glycolic acid and
• topical antibiotics (erythromycin and clindamycin).

Adapalene 1% gel may be more effective than 0.025% tretinoin gel and may have fewer side effects. It is a derivative of naphthoic acid. It is comedolytic and anti-inflammatory.

Azelaic acid has antimicrobial and keratolytic properties. A 20% cream is as effective as 0.05% tretinoin cream.

Topical antibiotics include clindamycin and erythromycin, they may be applied once or twice daily. Although not as effective as orally administered antibiotics or benzoyl peroxide. They serve as a useful therapeutic adjunct by inhibiting growth of P. acnes. The effectiveness of a topical antibiotic is enhanced by concurrent use of benzoyl peroxide or tretinoin.

Tetracycline or Doxycycline are 2 commonly used systemic antibiotics in acne. Systemic antibiotics: especially tetracycline and its derivatives are used if:
 patients cannot tolerate topical medications,
 those who have not responded to topical medications,
 those who have moderate to severe inflammatory papulopustular andnodulocytic acne, and
 those who have a propensity for scarring.

Tetracyclines and erythromycin are especially concentrated in the sebum. So, they are very effective in the management of inflammatory acne.