Acne Vulgaris

INTRODUCTION

Acne is a common, usually self-limiting disease involving inflammation of the sebaceous follicles of the face and upper trunk.

CLINICAL PRESENTATION

Lesions usually occur on the face, back, upper chest, and shoulders. Severity varies from a mild comedonal form to severe inflammatory acne. The disease is categorized as mild, moderate, or severe, depending on the type and severity of lesions.

• Lesions may take months to heal completely, and fibrosis associated with healing may lead to permanent scarring. DIAGNOSIS
• Diagnosis is established by patient assessment, which includes observation of lesions and excluding other potential causes (e.g., drug-induced acne). Several different systems are in use to grade acne severity

TREATMENT

Goals of Treatment: The goals are to reduce the number and severity of lesions, slow disease progression, limit disease duration, prevent formation of new lesions, and prevent scarring and hyperpigmentation.

NONPHARMACOLOGIC THERAPY

• Encourage patients to avoid aggravating factors, maintain a balanced diet, and control stress.
• Patients should wash no more than twice daily with a mild, nonfragranced opaque or glycerin soap or a soapless cleanser. Scrubbing should be minimized to prevent follicular rupture.
• Comedone extraction results in immediate cosmetic improvement but has not been widely tested in clinical trials.

PHARMACOLOGIC THERAPY

Exfoliants (Peeling Agents)

• Resorcinol is less keratolytic than salicylic acid and, when used alone, is classified as the Food and Drug Administration (FDA) category II (not generally recognized as safe and effective). The FDA considers resorcinol 2% and resorcinol monoacetate 3% to be safe and effective when used in combination with sulfur 3% to 8%.
• Salicylic acid is keratolytic, has mild antibacterial activity against P. acnes, and offers slight anti-inflammatory activity at concentrations up to 5%.
• Sulfur is keratolytic and has antibacterial activity. It can quickly resolve pustules and papules, mask lesions, and produce irritation that leads to skin peeling. Sulfur is used in the precipitated or colloidal form in concentrations of 2% to 10%.

Topical Retinoids

• Tretinoin (retinoic acid and vitamin A acid) is available as 0.05% solution (most irritating); 0.01% and 0.025% gels; and 0.025%, 0.05%, and 0.1% creams (least irritating). Tretinoin should not be used in pregnant women because of risk to the fetus.
• Adapalene (Differin) is the topical retinoid of first choice for both treatment and maintenance therapy because it is as effective but less irritating than other topical retinoids. Adapalene is available as 0.1% gel, cream, alcoholic solution, and pledgets. A 0.3% gel formulation is also available.
• Tazarotene (Tazorac) is as effective as adapalene in reducing noninflammatory and inflammatory lesion counts when applied half as frequently. Compared with tretinoin, it is as effective for comedonal and more effective for inflammatory lesions when applied once daily. The product is available as a 0.05% and 0.1% gel or cream.

Topical Antibacterial Agents

acids, which are comedogenic and inflammatory triggers. It is useful for both noninflammatory and inflammatory acne.

Topical erythromycin and clindamycin have become less effective due to resistance by P. acnes.

Dapsone 5% topical gel (Aczone) is a sulfone that has anti-inflammatory and anti-bacterial properties that improve both inflammatory and noninflammatory acne.

Oral Antibacterial

Tetracyclines (minocycline and doxycycline) have antibacterial and anti-inflammatory effects.

Oral corticosteroids in high doses used for short courses may be of temporary benefit in patients with severe inflammatory acne.