Acne in the Spotlight: What Every Clinician Needs to Know

🚀 Learning Opportunities: Acne Vulgaris

Quick Overview

Acne vulgaris, a condition rooted in the pilosebaceous unit, is the #1 reason patients seek dermatological care. It is detrimental to people’s confidence, especially teenagers. Whether it’s mild comedones or severe inflammatory lesions, understanding acne is key to providing effective treatment.

Here’s what we’ll cover:

• What Is Acne Vulgaris?

• Etiology: What Causes It?

• Physical Exam: How to Identify It

• Types of Acne: From Neonatal to Hormonal

• General Treatment: Best Practices and Patient Tips

What Is Acne Vulgaris?

Acne vulgaris is a chronic inflammatory disease involving hair follicles and sebaceous glands. It presents as a mix of noninflammatory lesions (comedones) and inflammatory lesions (papules, pustules, nodules).

Its psychosocial impact can be profound —helping patients manage their condition can improve both their skin and self-esteem.

Etiology: What Causes It?

Four factors contribute to acne development —knowing them is pivotal in selecting appropriate therapy:

1. Follicular Plugging
   Epithelial cells* in the upper hair follicle become hyperkeratotic and block the follicle, creating microcomedones. These trapped cells collect keratin, oil (sebum), and bacteria. Androgen* stimulation worsens the issue by increasing and stimulating keratinocyte* formation.

   * Don’t forget to check the ABC section! 

2. Excess Sebum Production

   During puberty, elevated levels of androgen directly enlarge the sebaceous glands & increase sebum production. The follicular unit with its sebaceous glands is the potential powerhouse of androgen production. A weaker hormone DHEAS (Dehydroepiandrosterone sulfate) turns into DHT (Dihydrotestosterone), a stronger androgen that fuels this process.

3. Pro-inflammatory Mediators
   The sebaceous glands produce mediators that worsen inflammation, leading to red, swollen lesions.

4. Bacterial Overgrowth (P. acnes)
   Gram-positive, anaerobic bacteria P. acnes produce enzymes, such as lipases. This specific one cleaves triglycerides into fatty acids (FFA) and glycerol which is inflammatory and irritating to the skin. Teens with acne often have more P. acnes.

Debunking The Myth of Certain Foods

Cereal and milk? Donuts? Vanilla ice cream? Definitely not a good idea when having acne. There is significant data supporting the role of milk in acne.

Why? Milk contains anabolic steroids as well as growth hormones & other growth factors that can stimulate acne. 

In addition, foods with high sugar content yield a glycemic load that can affect serum insulin & insulin-like growth factors that increase the production of androgens. 

Though there is no resounding data supporting the age-old myths of chocolate, fried foods & soft drinks causing acne, a healthy and balanced diet is highly recommended.

Physical Exam: How to Identify It

When examining patients, think distribution: the face, chest, back, and shoulders are the most affected areas.

• Noninflammatory Lesions:

  • Open comedones (blackheads): Flat or slightly elevated lesions with a central dark impaction of keratin and lipids.

  • Closed comedones (whiteheads): Pale, slightly elevated papules without a central orifice. Stretching of the skin aids in detecting these lesions.

• Inflammatory Lesions:

  • Papules —red elevated lesions.

  • Pustules —red elevated lesions with a central orifice of pus.

  • Nodules (severe cases) —deep-seated dermal lesions that can feel like a cyst.

A few considerations:

• Clinical presentations are variable and patients may have strictly noninflammatory acne, inflammatory acne, or a combination of both. 

• It’s critical to identify the primary lesions, as each category of lesion has its appropriate treatment. 

• Comedones are also key in distinguishing features from other pustular eruptions, such as rosacea.

• Watch for signs of hormonal imbalances, such as hirsutism or virilization, which may indicate underlying endocrine issues, such as PCOS (Polycystic Ovary Syndrome).

• Look for obvious contributing factors. Example: football player with lesions on forehead and chin due to helmet padding and chin strap.

Types of Acne

• Neonatal Acne: Appears in 20% of healthy newborns, typically resolving within 3 months. They appear as small inflammatory papules along the nasal bridge and cheeks.

  

• Infantile Acne: Onset at 3–6 months; may persist up to 2 years and is most commonly seen in males. Papules and pustules appear in some cases. Scarring is rare. However, it may be caused by a transient elevation in DHEA produced by the immature adrenal gland.

• Hormonal Acne: Often linked to androgens, seen in teenagers and adults, particularly women.

  

General Treatment

Start Simple:

• Noninflammatory lesions? Focus on comedolytics like benzoyl peroxide or salicylic acid.

• Inflammatory acne? Combine topical retinoids with antimicrobial agents.

Patient Tips:

• Cleansing: Avoid abrasive scrubs or aids, such as Buf Puf® Pads; use gentle cleansers tailored to skin type. Overcleansing is as bad as not washing the face because it leads to increasing the skin’s pH and disrupting the skin barrier.

• Lifestyle: Educate patients to avoid picking lesions, minimize face-touching, and wash their face immediately after physical activity.

• Consistency is Key: Explain that visible results take weeks (up to 7 weeks); emphasize adherence to treatment plans.

What Every Clinician Should Remember

• KISS —Keep It Simple & Simultaneous.

• Target the acne grade: if the patient has only noninflammatory lesions, do not prescribe treatments for inflammatory acne.

• If a patient has a coexisting skin problem, such as atopic dermatitis, you must take that into account when prescribing therapy.

• For adolescents, the best times for treatment are: 

  • Before school & after school.

  • Night time before bed.

*ABCs

• Epithelial cells are the cells that cover and protect surfaces inside and outside the body, like skin, the lining of organs, and blood vessels. They act as a barrier and help with functions like absorption, secretion, and protection.

• Androgens are a group of hormones, like testosterone, that are responsible for male traits and reproductive activity. They are present in both men and women, influencing hair growth, muscle mass, and oil production in the skin.

• Keratinocyte are the primary type of cell found in the epidermis, the outermost layer of the skin. In humans, they constitute 90% of epidermal skin cells.

Summary: Acne Vulgaris

• Acne vulgaris is a common yet complex chronic inflammatory condition of the pilosebaceous unit. 

• It manifests as a range of lesions, from noninflammatory comedones to severe inflammatory nodules, and can significantly affect patients' self-esteem and quality of life. 

• Factors such as follicular plugging, excess sebum production, inflammation, and bacterial overgrowth contribute to its development. 

• Identifying the lesion type and underlying causes is key to tailoring effective treatments, which include topical and systemic options. 

• Nutrition and lifestyle also play a supportive role in managing this condition.

Ready to deepen your expertise? Explore comprehensive strategies to diagnose, treat, and support patients with acne vulgaris. From understanding hormonal influences to mastering the nuances of treatment options, you’ll empower your patients and refine your clinical practice. Continue your journey in skin science today!

↳ Check out our CE course on ‘Acne Vulgaris’ for in-depth strategies to enhance your clinical practice. 🧑🏻‍⚕️

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🔎 Research Highlight

Acne vulgaris: pathogenesis, treatment, and needs assessment

Knutsen-Larson, S., Dawson, A. L., Dunnick, C. A., & Dellavalle, R. P.

Acne vulgaris is a common skin condition with substantial cutaneous and psychologic disease burden. Studies suggest that the emotional impact of acne is comparable to that experienced by patients with systemic diseases, like diabetes and epilepsy. In conjunction with the considerable personal burden experienced by patients with acne, acne vulgaris also accounts for substantial societal and health care burden. The pathogenesis and existing treatment strategies for acne are complex. This article discusses the epidemiology, pathogenesis, and treatment of acne vulgaris. The burden of disease in the United States and future directions in the management of acne are also addressed.