Acne Skin Condition : What Is It ? Treatment and Advice For Patient ( 5 )
Acne is a disorder of the pilosebaceous unit which may present with comedones, inflammatory papules or pustules. Nodules and scarring can also occur. The precursor lesion of all acne lesions is the microcomedone which, under the influence of androgens, develops into non-inflammatory lesions (comedones) and inflammatory lesions (papules and pustules).
Lesions of acne vary considerably with time, but in acne vulgaris comedones are always present and are a diagnostic sign. Most patients notice a fluctuation in the number and severity of spots. In young women, this is often related to the menstrual cycle.
Approximate age group
The first problems are usually encountered in adolescence. In girls, this may be as early as 10 years. In both sexes, incidence peaks at 13–16 years, although it may continue into the 40s.
Exceptions to this are:
• infantile/juvenile acne, typically seen in infants and children at 3–12 months: lesions usually subside after 4−5 years, but adolescence often heralds a severe aggravation
• late-onset acne, where first signs develop in the 20s: this is more commonly seen in women and often has a marked premenstrual exacerbation; there will be endocrine involvement, such as polycystic ovary syndrome, in some individuals.
Presentation
Acne occurs on the face, chest and back depending on the distribution of sebaceous follicles in the individual.
Type of lesion
Non-inflammatory lesions:
• open comedones (blackheads)
• closed comedones (whiteheads).
Inflammatory lesions:
• Papules and pustules – the majority of patients with comedonal acne develop papules and pustules. They are the well known little red spots or pustules on a red base. They may be itchy or quite painful.
Papules develop rapidly over a few hours and frequently become pustular as they evolve. They generally resolve over a few days.
• Nodules and cysts – as the inflammation within the pilosebaceous unit progresses and extends deeper into the dermis, the size of visible and palpable lesions increases, resulting in deep-seated nodules.
Secondary lesions:
• Scars - the inflammatory process of acne can cause scarring. Characteristically, small, deep “ice-pick” scars occur, but more severe disease will leave gross changes with atrophy or keloid formation.
• Individual lesions usually last less than two weeks but deeper papules may persist for months. The average “acne life” is 12 years.
Treatment
Treatment depends on severity (consider the possibility of scarring).
Comedonal acne – topical agents such as: Adapalene; Benzoyl Peroxide; Isotretinoin; Tretinoin.
Acne with inflammatory lesions and comedones, topical agents such as: Benzoyl Peroxide; antibiotics (erythromycin, tetracycline, clindamycin); Adapalene; Azelaic acid.
Application of topical agents – the aim is to cleanse, moisturise and treat. Before going to bed, the patient should cleanse the skin with soap and water or medicated wash then apply the weakest strength of topical agent.
The strength may be built up gradually. If the skin becomes sore, stop the treatment for a few days then restart on alternate nights. This allows the patient to adapt to the treatment and any irritation quickly resolves. If the skin feels dry in the morning, apply a non-greasy moisturiser.
In moderate to severe acne or unresponsive acne, systemic treatments are usually required in combination with topical treatments. These include antibiotics, anti-androgens and systemic retinoids. Referral to GP or dermatologist is indicated.
Advice to patient
Squeezing comedones should be avoided as it can convert comedone to an inflammatory lesion or papule and increases the potential for scarring.
There is no evidence that diet influences acne and it is not caused by over indulgence in chocolate or “junk food”.
Traffic light
Systemic symptoms (acne fulminans) – this rare condition is almost always seen in young men.
Symptoms include severe nodulocystic acne accompanied by fever, malaise and joint pain and swelling.
Psychological impact – the condition generally involves people in their teens and twenties, a time when the psychological impact may be profound (note that the psychological impact is not always related to the degree of severity).
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