Acne Vulgaris

Risk factors/Triggers

1. Food/Diet

Foods such as nuts, cola, milk, cheese, fried foods and iodised salts have been concerned as triggers of acne vulgaris; however, the connections in the middle of nutrition and acne has not absolutely been proven as they are rarely supported by good analytical, epidemiological or therapeutic studies [4, 5]. On the other hand, recurrent acne as noted by Niemeier et al (2006) may be a cutaneous sign of an basal eating disorder.

2. Genetics

A genetic background is supported by a case control study by Goulden et al, as noted by Rzany et al (2006). This stated that the risk of adult acne vulgaris in relatives of patients with acne as compared with those of patients without acne is significantly higher [4].

3. Hormones

According to Rzany et al (2006), hormonal influences on acne vulgaris are undisputed as shown by the higher incidence of acne in male adolescents. Premenstrual flare has also been recorded as causing acne [5].

4. Nicotine

Smoking has also been named as a risk factor for acne vulgaris; however, conflicting data exists as to the link in the middle of smoking and acne. Some citizen based studies have found links in the middle of smoking and acne whilst some others have not [4].

Important!

Contrary to popular misconceptions by young patients and occasionally their parents, acne does not come from bad behaviour nor is it a disease of poor hygiene. It also has nothing to do with lack of cleanliness [2].

Types of acne vulgaris

There are two main types of acne vulgaris, inflammatory and non-inflammatory; these can be manifested in distinct ways,

1. Comedonal acne, which is a non-inflammatory acne

2. Papules and pustules of inflammatory acne

3. Nodular acne (inflammatory acne)

4. Inflammatory acne with hyperpigmentation (this occurs more ordinarily in patients with darker skin complexions) [1]

Clinical manifestations

In general, acne is petite to the parts of the body, which have the largest and most abundant sebaceous glands such as the face, neck, chest, upper back and upper arms. Among dermatologists, it is roughly universally approved that the clinical manifestation of acne vulgaris is the succeed of four significant processes as described below [1, 6],

1. Increased sebum production in the pilosebaceous follicle. Sebum is the lipid-rich secretion goods of sebaceous glands, which has a central role in the amelioration of acne and also provides a increase medium for Propionibacterium acnes (P acnes), an anaerobic bacterium which is a normal constituent of the skin flora. Compared with unaffected individuals, citizen with acne have higher rates of sebum production. Apart from this, the severity of acne is often proportional to the amount of sebum produced [1, 6].

2. Abnormal follicular differentiation, which is the earliest structural change in the pilosebaceous unit in acne vulgaris [1].

3. Colonisation of serum-rich obstructed follicle with Propionibacterium acnes (P acnes). P acnes is an anaerobic bacterium which is a normal constituent of the skin flora and which populates the androgen-stimulated sebaceous follicle [androgen is a steroid hormone such as testosterone or androsterone, that controls the amelioration and maintenance of masculine characteristics]. Individuals with acne have higher counts of P acnes compared with those without acne [1, 6].

4. Inflammation. This is a direct or indirect succeed of the rapid and excessive increase of P acnes [1].

Non-inflammatory acne lesions comprise open and fulfilled, comedones, which are thickened secretions plugging a duct of the skin, particularly sebaceous glands. Open comedones, also known as blackheads, "appear as flat or slightly raised brown to black plugs that distend the follicular orifices". fulfilled, comedones, also known as whiteheads, "appear as whitish to flesh-coloured papules with an apparently fulfilled, overlying surface" [1].

Inflammatory lesions on the other hand comprise papules, pustules, and nodules; papules and pustules "result from superficial or deep inflammation related with petite rupture of comedones". Nodules are large, deep-seated abscesses, which when palpated may be compressible. In expanding to the typical lesions in acne, other features may also be present. These comprise scarring and hyperpigmentation, which can succeed in stupendous disfigurement [1].

Psychological Aspects

Numerous psychological problems such as diminished self-esteem, collective embarrassment, collective withdrawal, depression and even unemployment stem from acne. However, differential prognosis from a psychosomatic point of view indicates two serious psychological problems, which can arise from acne. These are,

1. Psychogenic excoriation, and

2. Body dysmorphic disorder (Bdd)

Psychogenic excoriation also referred to as neurotic excoriation, pathological or compulsive skin picking "is characterised by excessive scratching or picking of normal skin or skin with minor irregularities" [5]. According to Niemeier et al (2006) it is estimated to occur in 2% of dermatological patients. Patients with this disorder can also have psychiatric disorders such as mood and anxiety disorders, as well as related disorders such as obsessive compulsive disorder, substance abuse disorder, obsessive compulsive personality disorder, compulsive buying, eating disorder, and borderline personality disorder, to mention a few [5].

Body dysmorphic disorder (Bdd) "is a condition characterised by an greatest level of dissatisfaction or preoccupation with a normal appearance that causes disruption in daily functioning" [3]. Niemeier et al (2006) described it as "a syndrome characterised by distress, secondary to imagined or minor defects in one's appearance." The onset of Bdd is commonly during adolescence, and it occurs equally in both male and female. Tasteless areas of concern comprise the skin, hair and nose, with acne being one of the most Tasteless concerns with Bdd patients [3].

According to the Diagnostic and Statistics by hand of reasoning Disorders (2000), Bdd has three diagnostic criteria,

1. A preoccupation with an imagined defect in appearance; where a petite corporal anomaly is present, the person's concern is markedly excessive,

2. The preoccupation causes clinically significant distress or impairment in social, occupational, or other prominent areas of functioning,

3. The preoccupation is not caused by another reasoning disorder (e.g. Anorexia Nervosa)

Characteristic behaviours comprise skin picking, mirror checking, and camouflaging by wearing a hat or excessive make up. Apart from these, patients often seek reassurance oftentimes by asking questions such as "Can you see this pimple?" or "Does my skin look okay?" Some patients also have a tendency to physician shop, which is essentially going from one expert to another in crusade of a dermatologist or plastic surgeon, willing to carry out a desired course or dispense a certain drug, to improve their perceived defect [3, 5].

Although it is a relatively Tasteless disease, Bdd is still an under diagnosed psychiatric disorder and is estimated to influence 0.7 to 5% of the normal population. Other psychiatric conditions related with Bdd comprise major depression, anxiety, and obsessive compulsive disorder. It is also related with high rates of functional impairment and suicide attempts, high levels of perceived stress, and markedly poor quality of life [3, 5, 8].

Acne Treatment

1. Topical treatment, particularly for individuals with non-inflammatory comedones or mild to moderate inflammatory acne (See types of acne vulgaris). Medications comprise tretinoin (available as gels, creams, and solutions), adapalene gel, salicylic acid (available as solutions, cleansers, and soaps), isotretinoin gel, azelaic acid cream, benzoyl peroxide (available as gels, lotions, creams, soaps, and washes), to mention a few [1, 2].

2. Oral treatment, particularly for acne that is resistant to topical treatment or which manifests as scarring or nodular lesions. Medications comprise oral antibiotics (e.g. Tetracycline, doxycycline, minocycline, erythromycin, and co-trimoxazole), oral isotretinoin, and hormonal agents (e.g. Oral contraception, oral corticosteroid, cyproterone acetate, or spironolactone) [1, 2].

3. Physical or surgical methods of treatment, which are sometimes beneficial as adjuvant to medical therapy. Methods comprise comedo extraction, intralesional injections of corticosteroids, dermabrasion, chemical peeling, and collagen injections, to mention a few [1, 9].

4. Sun exposure, reported by up to 70% of patients to have a beneficial succeed on acne [10].

5. Light therapy, which is becoming more popular due to the growing request for a convenient, low risk and sufficient therapy, as many patients fail to reply adequately to treatment or compose side effects, from the use of discrete oral and topical treatments available for the treatment of acne [11]. Methods comprise the use of visible light (e.g. Blue light, blue/red light combinations, yellow light, and green light), laser treatment and monopolar radiofrequency [11]. Many of these light therapy treatments can be used at home.

Baker University

Tuesday, September 4, 2012

Acne Vulgaris

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