Acne: A Review of Diagnosis and Treatment

5 Mar
2010

Acne

Abstract

Acne vulgaris (acne) is probably the most common derma-tological complaint in the U.S. Acne has a range of presentations and manifestations, thus apparently comprising many disease states. Although acne is not an infectious disease, specimens of bacteria such as Propionibac-terium acnes, Propionibacterium granulosus, and Staphylococcus epidermidis can be obtained for culture from the eruptions of acne. Other common associations of acne include hormonal imbalances and follicular hyperkeratinization.

Therapies for acne are varied. The most cost-effective treatment option; for comedonal acne, the most effective therapy consists of retinoids. Isotretinoin canadian remains the most potent therapy. Other treatments include oral and topical antibiotics, topical sulfur agents, topical azelaic acid, and oral contraceptives.

Introduction

Acne vulgaris (acne) affects almost all humans at some point in their lives. Acne is the most common condition treated by American dermatologists. Approximately seven million new cases are diagnosed each year in the U.S. The cost of prescription and over-the-counter (OTC) medications exceeds $1 billion annually.

Acne engenders substantial psychosocial morbidity. A study from England notes that people with severe acne have a higher rate of unemployment than those with clearer skin. Other studies have indicated an adverse impact on social relationships. Teenagers with acne are at an increased risk of depression (odds ratio, 2.04), anxiety (odds ratio, 2.3), and suicide attempts (odds ratio, 1.83).

Acne commonly afflicts people between adolescence and the end of life. It is more common in boys than in girls during puberty (ages 10 to 12). Between the ages of 21 and 45 years, acne is more common in women than in men of a similar age. In one community-based study from the United Kingdom, the estimated prevalence of facial acne was 14% in adult women between 26 and 44 years of age. By age 45 years, 5% of both men and women still experience a range of acne lesions; however, comedones are common in the elderly, even independent of solar elastosis.

In a study of hospitalized patients in geriatric wards, Kumar and Marks found a prevalence rate of 26% for senile comedones. Acne rarely occurs in prepubes-cent children as a result of an en-docrinopathy; more commonly, it occurs in neonates as a transient eruption caused by circulating maternal hormones.

Stages of Acne

Morphologically, acne is divided into inflammatory and noninflammatory subtypes that can overlap. Papules, pustules, and nodules characterize inflammatory lesions; comedones (open and closed) characterize non-inflammatory lesions.

Acne is graded on a scale of mild, moderate, and severe, with intermediate grades and severe variants:

  • Mild acne can present simply with comedonal or mild papulopustular lesions, with or without the presence of a few papulopustules.
  • Moderate acne presents with numerous comedones, few to numerous pustules, and few small nodules, without residual scarring.
  • In severe acne, papulopustules are numerous, many nodules appear, inflammation is manifested, and scarring is present.
  • Very severe acne is characterized by sinus tracts, grouped comedones, numerous deeply located nodules, and severe inflammation and scarring.

Mild or moderate non-inflammatory acne can be treated with topical retinoids. Non-inflammatory acne of a moderate-to-severe or greater grade is best treated with oral (Accutane canadian, Roche).

Inflammatory acne of any grade can benefit from the use of topical benzoyl peroxide (e.g., Galderm; Benzagel, Aventis). The initial treatment of mild inflammatory acne can be OTC benzoyl peroxide without the need for intervention by a medical doctor. Mild inflammatory acne that does not respond to benzoyl peroxide can benefit from a variety of topical treatments.

For moderate comedonal and mild-to-moderate papulo-pustular acne, combination therapy with either canadian benzoyl peroxide or topical retinoids plus topical antibiotics such as erythromycin (e.g., Akne-Mycin, DPT Laboratories) or clin-damycin phosphate (T, Pfizer) has proved effective. Six to eight weeks should be allowed for most treatments to work before the regimen is altered.

Moderate inflammatory acne is best treated with oral medications that include antibiotics, oral contraceptives for female patients, and isotretinoin for patients who have not responded to other oral medications.

Clinical Presentation

As a polymorphic disease with non-inflammatory and inflammatory aspects, acne has a wide spectrum of clinical manifestations, including papules, pustules, open or closed comedones, and/or cysts. Most men and women with acne manifest a mixture of non-inflammatory and inflammatory lesions; however, some patients have predominantly one type of lesion or the other type.

The lesions appear in characteristic locations and possess a typical appearance. Acne is most commonly manifested on the face, chest, and back; it can appear on the lower back as well. It usually spares the neck, the scalp, and the skin behind the ears.

Comedones are typically present only on the face, whereas papules and pustules of acne can appear on the face, chest, and back. Milia and cysts, although distinct from acneiform eruptions, commonly occur with these eruptions.

Common symptoms include pain, tenderness, and erythema in the areas where acne cysts and swollen skin are present. In particular, these cysts, if inflamed, can be painful. In some cases, acne appears to be related to excess sebum production and oily skin.

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