Continuing Education Activity

Acne vulgaris is an inflammatory disorder of pilosebaceous unit, which runs a chronic course and it is self-limiting. Acne vulgaris is triggered by propionibacterium acnes in adolescence, under the influence of normal circulating dehydroepiandrosterone. It is a very common skin disorder which can present with inflammatory and non-inflammatory lesions. This activity reviews the etiology, evaluation, and management of acne vulgaris and highlights the role of the interprofessional team in caring for patients with this condition.

Objectives:

• Describe the epidemiology of acne vulgaris.
• Identify some of the topical and systemic treatment options for acne vulgaris.
• Outline some of the complications of acne vulgaris.
• Describe how interprofessional team members can collaborate to improve the evaluation, management, and counseling of patients with acne vulgaris.

Introduction

Acne vulgaris is an inflammatory disorder of the pilosebaceous unit, which runs a chronic course and it is self-limiting. Acne vulgaris is triggered by Cutibacterium acnes in adolescence, under the influence of normal circulating dehydroepiandrosterone (DHEA). It is a very common skin disorder which can present with inflammatory and non-inflammatory lesions chiefly on the face but can also occur on the upper arms, trunk, and back.[1][2][3]

Etiology

Acne occurs by hypersensitivity of the sebaceous glands to a normal circulating level of androgens, which are aggravated by P. acnes and inflammation.[4] Causes of acne include the following:

• Use of medications like lithium, steroids, and anticonvulsants
• Exposure to excess sunlight
• Use of occlusive wear like shoulder pads, headbands backpacks, and underwire brassieres
• Endocrine disorders like polycystic ovarian syndrome and even pregnancy
• Genetic factors affect the percentage of branched fatty acids in sebum. Heritability estimates range from 50-90% 

Epidemiology

Acne may appear in adolescence, and it persists through the early thirties. Acne is more common in males than in females. Urban populations are more affected than rural populations. About 20% of the affected individuals develop severe acne, which results in scarring. Some races appear to be more affected than others. Asians and Africans tend to develop severe acne, but mild acne is more common in the white population. In general, populations with darker skin also tend to develop hyperpigmentation. Acne can also develop in neonates but in most cases, resolves spontaneously.[5]

Pathophysiology

During puberty, under the influence of androgens, sebum secretion is increased as 5-alpha reductase converts testosterone to more potent DHT, which binds to specific receptors in the sebaceous glands increasing sebum production. This leads to an increased hyperproliferation of follicular epidermis, so there is retention of sebum. Distended follicles rupture and release pro-inflammatory chemicals into the dermis, stimulating inflammation. C. acnes, Staphylococcus epidermis, and Malassezia furfur induce inflammation and induce follicular epidermal proliferation.[6]

Factors aggravating acne include:

• Food with a high glycemic number like dairy products (which also contain hormones), junk food, and chocolates which cause insulin-like growth factors that stimulate follicular epidermal hyperproliferation
• Oil-based cosmetics and facial massage
• A premenstrual flare-up in acne seems to follow edema of the pilosebaceous duct. This occurs in 70% of female patients.
• Severe anxiety and anger may aggravate acne, probably by stimulating stress hormones.

Histopathology

The acne lesion will usually show a dilated follicle with a plug of keratin. In advanced cases, one may see a dilated follicle, which results in an open comedone. When the thin follicle wall ruptures, bacteria and signs of inflammation may be evident. Large acne lesions that are traumatized can develop fibrosis and scarring.

History and Physical

Acne occurs on centrofacial areas of the back, upper trunk, and deltoid region. Acne presents as polymorphic lesions starting with comedones.

• Grade 1: Comedones. They are of two types, open and closed. Open comedones are due to plugging of the pilosebaceous orifice by sebum on the skin surface. Closed comedones are due to keratin and sebum plugging the pilosebaceous orifice below the skin surface.
• Grade 2: Inflammatory lesions present as a small papule with erythema.
• Grade 3: Pustules.
• Grade 4: Many pustules coalesce to form nodules and cysts.

Acne can leave various scars after healing, which may present as depressed scars or hypertrophic and keloidal scars. Depressed scars may be gentle contour (boxcar scars) or ice pick scars, which are deep pits. Acne is associated with seborrhoea and in the case of hyperandrogenism associated with hirsutism, acanthosis nigricans, irregular menstrual period, and weight gain.

Evaluation

Acne vulgaris is diagnosed clinically. However, in women of childbearing age, one should ask for a history of hirsutism or dysmenorrhea. If positive, then levels of testosterone, LH, FSH, and DHEA should be ordered.[7]

Treatment / Management

Topical Therapy

• Topical retinoids like retinoic acid, adapalene, and tretinoin are used alone or with other topical antibiotics or benzoyl peroxide. Retinoic acid is the best comedolytic agent, available as 0.025%, 0.05%, 0.1% cream, and gel.[8]
• Topical clindamycin 1% to 2%, nadifloxacin 1%, and azithromycin 1% gel and lotion are available. Estrogen is used for Grade 2 to Grade 4 acne.
• Topical benzoyl peroxide is now available in combination with adapalene, which serves as comedolytic as well as antibiotic preparation. It is used as 2.5%, 4%,and 5% concentration in gel base.[9]
• Azelaic acid is antimicrobial and comedolytic available 15% or 20% gel. It can also be used in postinflammatory pigmentation of acne.
• Beta hydroxy acids like salicylic acid are used as topical gel 2% or chemical peel from 10% to 20% for seborrhoea and comedonal acne, as well as, pigmentation after healing of acne.
• Topical dapsone is used for both comedonal and papular acne, though there are some concerns with G6PD deficient individuals.

Systemic Therapy

• Doxycycline 100 mg twice a day as an antibiotic and anti-inflammatory drug as it affects free fatty acids secretion and thus controls inflammation.
• Minocycline 50 mg and 100 mg capsules are used as once a day dose.
• Other antibiotics such as amoxicillin, erythromycin, and trimethoprim/sulfamethoxazole are sometimes used, and if bacterial overgrowth or infection is masquerading as acne, other antibiotics such as ciprofloxacin may be used in pseudomonas related 'acne.' 
• Isotretinoin is used as 0.5 mg/kg to 1 mg/kg body weight in daily or weekly pulse regimen. It controls sebum production, regulates pilosebaceous epidermal hyperproliferation, and reduces inflammation by controlling P. acnes. It may give rise to dryness, hairless, and cheilitis.
• An oral contraceptive containing low dose estrogen 20 mcg along with cyproterone acetate as anti-androgens are used for severe recurrent acne.
• Spironolactone (25 mg per day) can also be used in males. It decreases the production of androgens and blocks the actions of testosterone. If given to females, then pregnancy should be avoided because the drug can cause feminization of the fetus.[10]
• Scars are treated with submission, trichloroacetic acid, derma roller, microneedling, or fractional CO2 laser.[11][12]

Differential Diagnosis

• Acne conglobata
• Acne fulminans
• Acne Keloidalis nuchae
• Acneiform eruptions
• Folliculitis
• Perioral Dermatitis
• Rosacea
• Sebaceous Hyperplasia
• Syringoma
• Tuberous Sclerosis

Prognosis

Acne may not be life-threatening but it has lifelong psychosocial effects. People with acne and acne scars often develop anxiety and depression. The acne scars are almost impossible to correct. A study from Sweden suggests that acne in teenager boys may be a risk factor for prostate cancer development late in life.

The overall prognosis of acne is good with treatment.

Complications

• Scars
• Depression
• Anxiety
• Socially withdrawn
• Poor facial aesthetics
• Lack of self-esteem

Postoperative and Rehabilitation Care

Change in the diet has been suggested to avoid recurrence of acne. Some experts recommend avoiding chocolate, spicy foods, junk foods, and cola beverages.

One study found that a high protein- low glycemic diet lowered the risk of acne lesions.

If the patient is treated with spironolactone, levels of electrolytes should be measured regularly.

Pearls and Other Issues

Acne is unavoidable but can be controlled by regular washing of the face by a pH balancing wash which is available as benzoyl peroxide and salicylic acid face wash. Avoidance of high glycemic index and/or dairy-based food plays a role. Management of stress and early detection and treatment of underlying causes like PCOD helps to control acne and preventing disfigurement.

Even though retinoids are excellent agents for acne, their use in women of childbearing age is limited because the agents are teratogenic. There is a registry for all individuals who are prescribed or dispensed retinoids like isotretinoin.

Enhancing Healthcare Team Outcomes

The American Academy of Dermatology has evidence-based guidelines on the management of acne. [13]  [Level V] Hence all healthcare workers including the primary care provider and nurse who manage acne must know these guidelines and how to stratify treatment. If the healthcare worker decides to use an oral contraceptive to manage acne, then they should follow the guidelines established by the WHO. Finally, determining the type of bacteria causing acne is only of academic importance and should not alter the treatment of acne. 

If the acne is severe, then a consult with a dermatologist is highly recommended. The pharmacist should be fully aware of the adverse effects of medications especially isotretinoin and its potential teratogenic effects. The pharmacist should never dispense retinoids to a female of childbearing age without first speaking to the dermatologist. The pharmacist should educate the patient on the potential teratogenic effects of retinoids and adhere to the iPLEDGE risk management program. [14] [15][Level V] Dermatology and plastic surgery nurses are involved in patient and family education, monitoring of response to therapy, and provide feedback to the team.

Outcomes

For the most part, most patients have a good outcome after treatment. But in many patients, acne does leave residual scars. These can be avoided by educating the patient on not manipulating the lesions and seeking timely care. Once established, the treatment of acne scars is not optimal. [16](Level V)