SKINIPEDIA - Skin Encyclopedia: Acne, Treatment & Diagnosis
Diagnosis and Treatment of Acne
STEVEN FELDMAN, M.D., PH.D., RACHEL E. CARECCIA, M.D., KELLY L. BARHAM, M.D., and JOHN HANCOX, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina
Acne can cause significant embarrassment and anxiety in affected patients. It is important
for family physicians to educate patients about available treatment options and
their expected outcomes. Topical retinoids, benzoyl peroxide, sulfacetamide, and azelaic
acid are effective in patients with mild or moderate comedones. Topical erythromycin or
clindamycin can be added in patients with mild to moderate inflammatory acne or mixed
acne. A six-month course of oral erythromycin, doxycycline, tetracycline, or minocycline
can be used in patients with moderate to severe inflammatory acne. A low-androgen
oral contraceptive pill is effective in women with moderate to severe acne. Isotretinoin is
reserved for use in the treatment of the most severe or refractory cases of inflammatory
acne. Because of its poor side effect profile and teratogenicity, isotretinoin (Accutane)
must by prescribed by a physician who is a registered member of the manufacturer’s
System to Manage Accutane-Related Teratogenicity program. (Am Fam Physician 2004;69:
2123-30, 2135-6. Copyright© 2004 American Academy of Family Physicians).
Acne is a disease of pilosebaceous units in the skin. It is thought to be caused by the interplay of four factors.
Excessive sebum production secondary to sebaceous gland hyperplasia is the first abnormality to occur.1 Subsequent
hyperkeratinization of the hair follicle prevents normal shedding of the follicular keratinocytes, which then obstruct the follicle and form an inapparent microcomedo.2 Lipids and cellular debris soon accumulate within the blocked follicle. This microenvironment encourages colonization of Propionibacterium acnes, which provokes an immune response through the production of numerous inflammatory mediators. Inflammation is further enhanced by follicular rupture and subsequent
leakage of lipids, bacteria, and fatty acids into the dermis.
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The diagnosis of acne is based on the history
and physical examination. Lesions most commonly
develop in areas with the greatest concentration
of sebaceous glands, which include
the face, neck, chest, upper arms, and back.
Acne vulgaris may be defined as any disorder
of the skin whose initial pathology is
the microscopic microcomedo.3 The microcomedo
may evolve into visible open comedones
(“blackheads”) or closed comedones
(“whiteheads”). Subsequently, inflammatory
papules, pustules, and nodules may develop.
Nodulocystic acne consists of pustular lesions
larger than 0.5 cm. The presence of excoriations,
postinflammatory hyperpigmentation,
and scars should be noted.
Acne may be triggered or worsened by
external factors such as mechanical obstruction
(i.e., helmets, shirt collars), occupational
exposures, or medications. Cosmetics and emollients
may occlude follicles and cause an acneiform eruption.
Topical corticosteroids may produce
perioral dermatitis, a localized erythematous
papular or pustular eruption.5
Endocrine causes of acne include Cushing’s
disease or syndrome, polycystic ovary syndrome,
and congenital adrenal hyperplasia.6
Clinical clues to possible hyperandrogenism
in women include dysmenorrhea, virilization
(i.e., hirsutism, clitoromegaly, temporal balding),
and severe acne.
Classification
In 1990, the American Academy of Dermatology
developed a classification scheme
for primary acne vulgaris.7 This grading scale
delineates three levels of acne: mild, moderate,
and severe. Mild acne is characterized by the
presence of few to several papules and pustules,
but no nodules (Figure 1). Patients with
moderate acne have several to many papules
and pustules, along with a few to several nodules
(Figure 2). With severe acne, patients have
numerous or extensive papules and pustules,
as well as many nodules (Figure 3).
Acne also is classified by type of lesion—
comedonal, papulopustular, and nodulocystic.
Pustules and cysts are considered inflammatory
acne.
Diagnosis and Treatment of Acne, Part 2, Acne Therapy is HERE.