Acne vulgaris

ACNE VULGARIS INTRODUCTION Acne most commonly presents as follicle-based comedones, inflammatory papules or pustules on the face, neck, chest and back Most patients with acne are teenagers, but neonatal acne and adult acne are common also According to some dermatologist, acne causes profound negative psychological and social effects on the quality of life of patients Lots of adolescent patients have reported that lack of confidence and depression leading to a lower quaity of life The potential for hyperpigmentation and scarring into adulthood affects later quality of life as well Thus, more patients are presenting to health care provider seeking treatment and prevention This report will help us capture more information about acne DEFINITION Acne is the most common skin condition characterized by red pimples on the skin, especially on face, due to inflamed or infected sebaceous glands and prevalent cheifly among adolescents The onset of acne is usually around puberty, but in a minority of cases it may also start sooner or later Figure 01 Two patients exhibited acne vulgaris Acne vulgaris is a chronic inflammatory disease of the pilosebaceous unit (comprising hair follicle, hair shaft and sebaceous gland, so acne vulgaris sometimes call folliculitis) Acne vulgaris is the most common form of acne and among the most common dermatological conditions worldwide with an estimated 650 million people affected Acne vulgaris is considered a chronic disease owing to its prolonged course, pattern of recurrence and relapse Moreover, acne vulgaris causes profound negative psychological and social effects on the quality of life patient ANATOMY & PHYSIOLOGY The skin & its accessory structure (hair, nails and glands) make up the integumentary system of the body The skin has many important function: (1) As a protective membrane over the entire body; (2) Containing types of glands that produce important secretions (sebaceous glands produce sebum and sweat glands produce sweat); (3) Sensing for pain, temperature, pressure and touch; (4) Thermoregulation Figure 02 Skin (A) Three layers of the skin; (B) Epidermis Epidermis is the outermost layer or the surface epithelium of the skin, totally cellular layer of the skin, containing keratin The cells in the basal layer, or the deepest layer of the epidermis, are constantly growing and multiplying and are the source of other cells in the epidermis As the basal layer cells divide, they are pushed upward by a stream of younger cells Cells in the most superficial layer of the epidermis, or stratum corneum, flatten, shrink, lose their nuclei and die, becoming filled with keratin (so these cells are also called keratinocytes) Figure 03 Skin under the microscope (A) Epidermis; (B) Dermis and Hypodermis Dermis, directly below the epidermis, is composed of blood and lymph vessels and nerve fibers, as well as other accessory organs of the skin, which are the hair follicles, sweat glands and sebaceous glands The dermis is composed of interwoven elastic and collagen fiber - Hair follicle is a sac within which each hair grow - Sweat glands are small glands found on almost all body surface, deep in the dermis and straightens out to extend up through the epidermis The tiny opening on the surface is a pore Sweat is almost pure water, with dissolved materials Sweat cools the body as it evaporates into the air - Sebaceous glands are located in the dermis over the entire body, with the exception of the hands, feet and lips They secrete an oily substance called sebum, containing lipids, lubricates the skin and minimizes water loss Sebaceous glands are closely associated with hair follicles, and their ducts open into hair follicle through which the sebum is released The sebaceous glands are influenced by sex hormones, which cause them to hypertrophy at puberty and atrophy in old age Increased production of sebum is one of the reasons can cause acne formation Hypodermis, or subcutaneous layer, is the deepes layer of the skin, specializes in the formation of fat EPIDEMIOLOGY Most people experience acne during adolescence, with over 95% of teenage boys and 85% of teenage girls affected About 20% of them have moderate-to-severe acne, and as many as 50% continue to suffer from acne in adulthood About 12% of women and 3% of men will continue to have clinical acne until age 44 According to the analysis for the Global Burden of Disease study indicated that acne was the eight most prevalent disease globally in 2010 Acne is most common in facial skin (about 85%), next is dorsal skin (about 50%) and chest (about 25%) PATHOPHYSIOLOGY CLASSIFICATION When we classified based on dermal acne density, according to Global Evaluation, acne vulgaris can be divided into groups: - Level There is no lesion; residual pigmentation and erythema may be seen - Level Almost no lesion; with a few scattered open or closed comedones and very few papules - Level Mild acne, in which < 50% of the face (or other part) is involved with a few comedones, papules and pustules - Level Moderate acne, in which > 50% of the face (or other part) is involved with many papules, pustules, comedons and a maximum of one nodule - Level Severe acne, in which the entire (or > 75% other part) is involed, covered with many papules, pustules, comedones and some nodules When we classified based on the degree of inflammation of acne, acne vulgaris can be divided into groups: - Group 1: Non-Inflammatory Acne This group of acne comprises of blackheads and whiteheads They are also called closed comedones (whiteheads) and opened comedones (blackheads) Blackheads are tiny, dark bumps; and whiteheads are tiny, white or skin colored bumps They are mild, non-inflammatory acne - Group 2: Inflammatory Acne This group of acne comprises of papules, pustules, nodules and cystic acne Papules (also known as pimples) are raised, red bumps with no white pus Pustules are raised, red bumps with white pus Nodules are hard and large red painful lumps Cystic acne are hard, large and red painful lumps with presence of cysts They are moderate-to-severe, inflammatory acne Figure Classification of acne based on the degree of inflammation of acne SYMPTOMS & DIAGNOSIS Acne signs and symptoms vary depending on the severity of disease: Non-inflammatory acne - Whiteheads Whiteheads, also called closed comdones, are small, round and white bumps on the skin’s surface This type of acne occurs when a pore becomes clogged with sebum, dead skin cells and debris In the case of whiteheads, these comedones have small opening at the top of the skin Air is not able to enter the follicle, melanin is not oxidized so the pores have white color Whiteheads commonly appear on the face, neck, chest and back - Blackheads Blackheads, also called opened comedones, are small bumps that appear on your skin due to clogged hair follicles Blackheads look like black dots that have formed on your skin In the case of blackheads, these comedones have its follicles with very large opening Melanin is oxidized and turns the clogged pores a black color This form of acne is often found on face, back, chest, neck, arms, shoulders, etc Inflammatory acne - Papules Papules are small, inflammatory, irritated pimples or swelling on the skin More distension of the comedones results in follicular rupture and inflammatory lesions such as papules Papules are hard when you touch them Papules not have pus because only some leukocytes present at this stage - Pustules Pustules are small pimples on the skin containing pus In the case of pustules, inflammatory reaction increases, lots of leukocytes present and attack the bacteria which cause infection and then release pus into the follicles to form pustules Pustules are similar to papules except yellowish, liquid pus - Nodules and cysts Nodules are very large, inflammatory pimples When inflamed follicles erupts along the bottom, nodules will be formed If the lesions are filled with large amount of pus due to inflammatory reaction, the cysts will be formed Inflammatory lesions can be very painful and potentially lead to permanent scarring The diagnosis of acne vulgaris is based on the prehistory, physical examination and clinical symptoms Lesions most commonly develop in areas with the greatest concentration of sebaceous glands include the face, neck, chest, upper arms and back The doctor has to look at all of these parts to diagnose acne vulgaris Androgen level test sometimes is used to diagnose whether the patient has Cushing’s syndrome or PCOS Proper diagnosis leads to higher treatment efficacy COMPLICATION Acne can cause many complications that affect the quality of life of the patients Hyperpigmentation Post-inflammatory hyperpigmentation (also known as PIH) is a type of hyperpigmentation that can affect the face and body It appears as flat spots of discolouration, from pink to red, brown to black, depending on the skin tone and the depth of discolouration PIH often affects people with acne Acne is a type of folliculitis This inflammation triggers melanocytes, or melanin-producing cells, to release excessive melanin The excessive melanin darken and discolor the wounded area, remaining there long after the wound has recovered Scars Scars are important permanent sequelae of acne Up to 95% of patients with acne have scars, with 30% developing severe scars Scars are important permanent sequelae of acne211,212 Up to 95% of patients with acne have scars, with 30% developing severe scars TREATMENT The approach to treating acne vulgaris depends on its presentation and severity Some studies suggests treating acne vulgaris as a chronic disease, such that early, aggressive and maintainance therapy leads to better outcomes According to different factors of pathology which contribute acne, other therapies are used, include: medical therapy, physical modalities, psychological therapy, lifestyle management, etc - Medical therapy A topical medication is a medication that is applied to particular place on or in the body An oral medication is a medication that can be taken orally and swallowed through the mouth that will be absorbed in the gastrointestinal tract Because a topical medication works at the affected sites, it works quickly and effectively Before application, the face should be washed with warm water or a topical cleanser and dried carefully • Mild acne Mild acne can be treated with over-the-counter (OTC) medications such as gels, soaps, creams, and lotions, that are applied to the skin For noninflammatory acne, tropical retinoid and salicylic acid or azelaic acid could be used to treat For inflammatory acne, the doctor should combine these medicine • with some low-effective antibiotics Moderate-to-severe acne The doctor should combine oral antibiotic, topical retinoid and benzoyl peroxide to treat moderate-to-severe acne If there is no effect, alternative medications should be used For acne caused by hormonal disease (Cushing’s syndrome, PCOS in women, etc.), the doctor carefully use hormonal therapy (oral contraceptives, spironolactone, dexamethasone, etc.) to treat the symptoms Isotretinoin is approved only for severe cystic acne - Physical modalities Logical surgical treatment is helpful in quickly resolving the comedones Light electrode desiccation can be used to treat acne The use of photodynamic therapy and various forms of light, laser or radiofrequency energy, which are capable of destroying sebaceous glands and killing P acnes, is under investigation These methods is an efficient, cost-effective, safe, no pain - Psychological therapy For stressed patients, psychological therapy is considered the best one Different methods of stress reduction such as doing yoga, listening to music, taking a deep sleep, etc should be used to help stressed patients When stress is reduced, acne also decreases - Lifestyle managements Changing the patient’s diet is the simpliest and easiest way to treat mild acne Heat-treated foods, such as vegetables, fruits, greentea, etc should be added to the diet MEDICATION There are many kinds of medicine for treating acne, they are divided into groups: - Group 01: Salicylic acid Salicylic acid helps to correct the abnormal shedding of dermocytes For mild acne, salicylic acid helps unclog the pores to resolve, so the sebum will be easier to escape and prevent the acne lesion formation It does not have any effect on sebum production and it does not kill bacteria The effects will stop when you stop using it, that means the pores will clog up again and the acne maybe returns Figure Salicylic acid medicine - Group 02: Antibiotic medicine Because bacteria as Propionibacterium acnes can cause acne vulgaris, some medicines attack and destroy the bacteria associated with acne can be used to treat acne and maybe prevent its development Because it does not affect on sebum production or the skin follicle cells are shed When you stop using it, the acne maybe comes back • Benzoyl peroxide Benzoyl peroxide is believed that this compound works by destroying the bacteria associated with acne It usually takes at least weeks to • work and it must be used continously to keep acne at bay Topical antibiotics Topical clindamycin and erythromycine are available in a number of formulations In general, they are well tolerated and are effective in mild inflammatory acne They should be combined with benzoul peroxide or • topical retinoid and applied directly to the skin Oral antibiotics Some oral antibiotics are often used include: doxycycline, minocycline and tetracycline, all of which are quite effective in many cases of acne vulgaris Oral erythromycine is also available Using antibiotics to treat acne maybe leads to antibiotic resistance, limiting its usefullness, so be careful when you use antibiotics - Group 03: Retinoid (Vitamin A3) Retinoid works to keep pimples from being able to form It effects the growth of cells and decreases swelling and inflammation Your acne may appear to get worse before it gets better because it will work on the pimples that have already started forming beneath your skin So, it must be used continously and maybe to 12 weeks to get results - Group 04: Hormonal medicines Hormonal medicines usually are used carefully to treat symptoms of hormone disorders, including acne Women with PCOS, late-onset adrenal hyperplasia, late-onset acne, severe acne and acne unresponsive to other oral and topical therapies are good candidates for hormonal treatment • Oral contraceptives Birth control pills contain female hormones (estradiol, progesterone, etc.) that work by counteracting the effect of male hormones on acne through negative feedback The oral contraceptives block both adrenal and ovarian androgens which cause acne vulgaris The adverse reaction asso- • ciated with oral contraceptives: vomiting, weight gain, breast tenderness, etc Spironolactone Spironolactone is an oral drug that can block the action of the other hormones on sebaceous glands, so it will inhibit sebum production It it especially helpful for women who have acne that worsens around the time • of menstruation Dexamethasone Dexamethasone reduces androgen excess and ma alleviate cystic acne Tại mụn gây ảnh hưởng đến chất lượng sống? .. .Acne vulgaris is a chronic inflammatory disease of the pilosebaceous unit (comprising hair follicle, hair shaft and sebaceous gland, so acne vulgaris sometimes call folliculitis) Acne vulgaris. .. colored bumps They are mild, non-inflammatory acne - Group 2: Inflammatory Acne This group of acne comprises of papules, pustules, nodules and cystic acne Papules (also known as pimples) are raised,... Cystic acne are hard, large and red painful lumps with presence of cysts They are moderate-to-severe, inflammatory acne Figure Classification of acne based on the degree of inflammation of acne