Basics

Description

  • Acne vulgaris is a disorder of the pilosebaceous units. It is a chronic inflammatory dermatosis notable for open/closed comedones, papules, pustules, or nodules.
  • Systems affected: skin/exocrine

Geriatric Considerations
Favre-Racouchot syndrome: comedones on face and head due to sun exposure

Pregnancy Considerations
  • May result in a flare or remission of acne
  • Typically improves 1st trimester; may worsen 3rd trimester (1)
  • Topical benzoyl peroxide, azelaic acid, erythromycin or clindamycin, and oral erythromycin or cephalexin can be used in pregnancy; use topical agents when possible (1).
  • Isotretinoin is teratogenic; pregnancy Category X
  • Avoid topical tretinoin and adapalene as they may cause retinoid embryopathy (1); class C
  • Contraindicated: isotretinoin, tazarotene, tetracycline, doxycycline, minocycline
Pediatric Considerations
  • Neonatal acne (neonatal cephalic pustulosis)
    • Newborn to 8 weeks; lesions limited to face; responds to topical ketoconazole 2% cream (2)
  • Infantile acne
    • Newborn to 1 year; lesions on face, neck, back, and chest; no Rx required (2)
  • Early–mid childhood acne
    • 1 to 7 years; rare; consider hyperandrogenism (2).
  • Preadolescent acne
    • 7 to 11 years; common, 47% of children, usually due to adrenal awakening
  • Do not use tetracyclines in those <8 years of age (2); other therapies similar to adolescent acne

Epidemiology

  • Predominant age: early to late puberty, may persist in 20–40% of affected individuals into 4th decade
  • Predominant sex
    • Male > female (adolescence)
    • Female > male (adult)

Prevalence
  • 80–95% of adolescents affected. A smaller percentage will seek medical advice.
  • 8% of adults aged 25 to 34 years; 3% at 35 to 44 years
  • African Americans 37%, Caucasians 24%

Etiology and Pathophysiology

  • Androgens (testosterone and dehydroepiandrosterone sulfate [DHEA-S]) stimulate sebum production and proliferation of keratinocytes in hair follicles (3).
  • Keratin plug obstructs follicle os, causing sebum accumulation and follicular distention.
  • Propionibacterium acnes, an anaerobe, colonizes and proliferates in the plugged follicle.
  • P. acnes promote proinflammatory mediators, causing inflammation of follicle and dermis.

Genetics
  • Familial association in 50%
  • If a family history exists, the acne may be more severe and occur earlier.

Risk Factors

  • Increased endogenous androgenic effect
  • Oily cosmetics, cocoa butter
  • Rubbing or occluding skin surface (e.g., sports equipment such as helmets and shoulder pads), telephone, or hands against the skin
  • Polyvinyl chloride, chlorinated hydrocarbons, cutting oil, tars
  • Numerous drugs, including androgenic steroids (e.g., steroid abuse, some birth control pills)
  • Endocrine disorders: polycystic ovarian syndrome, Cushing syndrome, congenital adrenal hyperplasia, androgen-secreting tumors, acromegaly
  • Stress
  • High-glycemic load and possibly high-dairy diets may exacerbate acne (3).
  • Severe acne may worsen with smoking.

Commonly Associated Conditions

  • Acne fulminans, pyoderma faciale
  • Acne conglobata, hidradenitis suppurativa
  • Pomade acne
  • SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis)
  • Pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA) and seborrhea, acne, hirsutism, and alopecia (SAHA) syndromes
  • Behçet syndrome, Apert syndrome
  • Dark-skinned patients: 50% keloidal scarring and 50% acne hyperpigmented macules

Diagnosis

History

  • Ask about duration, medications, cleansing products, stress, smoking, exposures, diet, and family history.
  • Females may worsen 1 week prior to menses.

Physical Exam

  • Closed comedones (whiteheads)
  • Open comedones (blackheads)
  • Nodules or papules
  • Pustules (“cysts”)
  • Scars: ice pick, rolling, boxcar, atrophic macules, hypertrophic, depressed, sinus tracts
  • Consistent grading scale is useful; no specific universal grading system is recommended per guidelines (4).
  • Grading system (American Academy of Dermatology, 1990) (3)
    • Mild: few papules/pustules; no nodules
    • Moderate: some papules/pustules; few nodules
    • Severe: numerous papules/pustules; many nodules
    • Very severe: acne conglobata, acne fulminans, acne inversa
  • Most common areas affected are face, chest, back, and upper arms (areas of greatest concentration of sebaceous glands) (3).

Differential Diagnosis

  • Folliculitis: gram-negative and gram-positive
  • Acne (rosacea, cosmetica, steroid-induced)
  • Perioral dermatitis
  • Chloracne
  • Pseudofolliculitis barbae
  • Drug eruption
  • Verruca vulgaris and plana
  • Keratosis pilaris
  • Molluscum contagiosum
  • Sarcoidosis
  • Seborrheic dermatitis
  • Miliaria
  • Lupus erythematosus

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)
Only indicated if additional signs of androgen excess; if so, test for free and total testosterone and DHEA-S and consider LH and FSH (PCOS).

Treatment

  • Comedonal (grade 1): keratinolytic agent (see as follows for specific agents)
  • Mild inflammatory acne (grade 2): benzoyl peroxide or topical retinoid or benzoyl peroxide +/− topical antibiotic +/− topical retinoid (4)
  • Moderate inflammatory acne (grade 3): Add systemic antibiotic to grade 2 regimen.
  • Severe inflammatory acne (grade 4): as in grade 3, or isotretinoin
  • Topical retinoid plus a topical antimicrobial agent is first-line treatment for more than mild disease.
  • Topical retinoid + antibiotic (topical or PO) is better than either alone for mild/moderate acne.
  • Topical retinoids are first-line agents for maintenance. Avoid long-term antibiotics for maintenance.
  • Avoid topical antibiotics as monotherapy (4)[A].
  • Can use isotretinoin for treatment of resistant moderate acne (4)
  • Recommended vehicle type
    • Dry or sensitive skin: cream, lotion, or ointment
    • Oily skin, humid weather: gel, solution, or wash
    • Hair-bearing areas: lotion, hydrogel, or foam
  • Apply topical agents to entire affected area, not just visible lesions.
  • Mild soap daily to control oiliness; avoid abrasives.
  • Avoid drying agents with keratinolytic agents.
  • Gentle cleanser and noncomedogenic moisturizer help decrease irritation.
  • Oil-free, noncomedogenic sunscreens
  • Stress management if acne flares with stress

Medication

ALERT
Most prescription topical medications are very expensive, costing from $100 to several hundred dollars per tube.

  • Keratinolytic agents (alpha-hydroxy acids, salicylic acid, topical retinoids, azelaic acid) (side effects include dryness, erythema, and scaling; start with lower strength, increase as tolerated)
  • Tretinoin (Retin-A, Retin-A Micro, Avita, Atralin) varying strengths and formulations: Apply at bedtime; wash skin; let skin dry 30 minutes before application.
    • Retin-A Micro, Atralin, and Avita are less irritating and stable with BP.
    • May cause an initial flare of lesions; may be eased by 14-day course of oral antibiotics
    • Avoid in pregnant and lactating women.
  • Adapalene (Differin): 0.1%, apply topically at night.
    • Effective; less irritation than tretinoin or tazarotene
    • May be combined with benzoyl peroxide (Epiduo)—very effective in skin of color
    • First FDA-approved retinoid much less expensive than other Rx retinoids
  • Tazarotene (Tazorac): Apply at bedtime.
    • Most effective and most irritating; teratogenic
  • Azelaic acid (Azelex, Finevin): 20% topically, BID
    • Keratinolytic, antibacterial, anti-inflammatory
    • Reduces postinflammatory hyperpigmentation in dark-skinned individuals
    • Side effects: erythema, dryness, scaling, hypopigmentation
    • Effective in postadolescent acne
  • Salicylic acid: 2%, less effective and less irritating than tretinoin
  • Alpha-hydroxy acids: available over-the-counter
  • Topical antibiotics and anti-inflammatories
    • Topical benzoyl peroxide
      • 2.5% as effective as stronger preparations
      • Gel penetrates better into follicles.
      • When used with tretinoin, apply benzoyl peroxide in morning and tretinoin at night.
      • Side effects: irritation; may bleach clothes; photosensitivity
  • Topical antibiotics: Do not use as monotherapy (4)[A].
    • Erythromycin 2%
    • Clindamycin 1%
    • Metronidazole gel or cream: Apply once daily.
    • Azelaic acid (Azelex, Finevin): 20% cream: enhanced effect and decreased risk of resistance when used with zinc and benzoyl peroxide
    • Benzoyl peroxide-erythromycin (Benzamycin): especially effective with azelaic acid
    • Benzoyl peroxide-clindamycin (BenzaClin, DUAC, Clindoxyl)
    • Benzoyl peroxide-salicylic acid (Cleanse & Treat, Inova): similar in effectiveness to benzoyl peroxide-clindamycin
    • Sodium sulfacetamide (Sulfacet-R, Novacet, Klaron): useful in acne with seborrheic dermatitis or rosacea
    • Dapsone (Aczone) 5% gel: useful in adult females with inflammatory acne; may cause yellow/orange skin discoloration when mixed with benzoyl peroxide; very rare methemoglobinemia
  • Oral antibiotics: use for shortest possible period, generally needs 8 to 12 weeks of therapy, reevaluate for discontinuation at 12 to 16 weeks duration (4); indicated when acne is more severe, trunk involvement, unresponsive to topical agents, or at greater risk for scarring (5)[A]
    • Tetracycline: 500 to 1,000 mg/day divided BID; high dose initially, taper in 6 months, less effective than doxycycline or minocycline (4), side effects: photosensitivity, esophagitis
    • Minocycline: 100 to 200 mg/day, divided daily—BID; side effects include photosensitivity, urticaria, gray-blue skin, vertigo, hepatitis, lupus.
    • Doxycycline: 20 to 200 mg/day, divided daily—BID; side effects include photosensitivity.
    • Erythromycin: 500 to 1,000 mg/day; divided BID–QID; decreasing effectiveness as a result of increasing P. acnes resistance
    • Trimethoprim-sulfamethoxazole (Bactrim DS, Septra DS): 1 daily or BID
    • Azithromycin (Zithromax): 500 mg 3 days/week × 1 month, then 250 mg every other day × 2 months
  • Oral retinoids
    • Isotretinoin: 0.5 to 1.0 mg/kg/day divided BID to maximum 2 mg/kg/day divided BID for very severe disease; 60–90% cure rate; usually given for 12 to 20 weeks; maximum cumulative dose = 120 to 150 mg/kg; 20% of patients relapse and require retreatment (3)[A], 0.25 to 0.40 mg/kg/day in moderately severe acne
      • Side effects: teratogenic, pancreatitis, excessive drying of skin, hypertriglyceridemia, hepatitis, blood dyscrasias, hyperostosis, premature epiphyseal closure, night blindness, erythema multiforme, Stevens-Johnson syndrome, suicidal ideation, psychosis
      • Avoid tetracyclines or vitamin A preparations during isotretinoin therapy due to risk of pseudotumor cerebri.
      • Monitor for pregnancy, psychiatric/mood changes, complete blood count (CBC), lipids, glucose, and liver function tests at baseline and every month.
      • Patient and provider must be registered and adhere to manufacturer’s iPLEDGE program (www.ipledgeprogram.com), two forms of effective contraception required.
  • Medications for women only
    • FDA-approved oral contraceptives (in order of effectiveness) (6)[B]
      • Drospirenone/ethinyl estradiol (Yaz, Yasmin), or drospirenone/ethinyl estradiol/levomefolate (Beyaz, Safyral) > norgestimate/ethinyl estradiol (Ortho Tri-Cyclen) > norethindrone acetate/ethinyl estradiol
      • Most combined contraceptives also effective.
  • Spironolactone (Aldactone); 25 to 200 mg/day; antiandrogen; reduces sebum production

Issues For Referral

Consider referral/consultation to dermatologist.

  • Refractory lesions despite appropriate therapy
  • Consideration of isotretinoin therapy
  • Management of acne scars

Additional Therapies

  • Acne hyperpigmented macules
    • Topical hydroquinones (1.5–10%)
    • Azelaic acid (20%) topically
    • Topical retinoids
    • Corticosteroids: low dose, suppresses adrenal androgens
    • Dapsone 5% gel (Aczone): topical, anti-inflammatory; use in patients >12 years.
    • Sunscreen for prevention
  • Light-based treatments
    • Ultraviolet A/ultraviolet B (UVA/UVB), blue or blue/red light; pulse dye, KTP, or infrared laser
    • Photodynamic therapy for 30 to 60 minutes with 5-aminolevulinic acid × 3 sessions is effective for inflammatory lesions.
      • Greatest use when used as adjunct to medications or if can’t tolerate medications

Surgery/Other Procedures

  • Comedo extraction after incising the layer of epithelium over closed comedo
  • Inject large cystic lesions with 0.05 to 0.30 mL triamcinolone (Kenalog 2 to 5 mg/mL); use 30-gauge needle, inject through pore, slightly distend cyst.
  • Acne scar treatment: retinoids, steroid injections, cryosurgery, electrodessication, micro/dermabrasion, chemical peels, laser resurfacing

Complementary and Alternative Medicine

  • Evidence suggests tea tree oil, seaweed extract, Kampo formulations, Ayurvedic formulations, rose extract, basil extract, epigallocatechin gallate, barberry extract, gluconolactone solution, and tea extract may be useful (4).
  • Limited data on use of dermocosmetics for acne Rx

Ongoing Care

Follow-up Recommendations

Use oral or topical antibiotics for 3 months; taper as inflammatory lesions resolve.

Diet

Data suggests that high-glycemic index foods and skim milk may influence acne (4)[B].

Patient Education

  • There may be a worsening of acne during first 2 weeks of treatment.
  • Results are typically seen after a minimum of 4 weeks of treatment.

Prognosis

Gradual improvement over time (usually within 8 to 12 weeks after beginning therapy)

Complications

  • Acne conglobata: severe confluent inflammatory acne with systemic symptoms
  • Facial scarring and psychological distress, including anxiety, depression, and suicidal ideation (3)
  • Postinflammatory hyperpigmentation, keloids, and scars are more common in skin of color.

Additional Reading

  • Asai Y, Baibergenova A, Dutil M, et al. Management of acne: Canadian clinical practice guideline. CMAJ. 2016;188(2):118–126. [PMID:26573753]
  • Fisk WA, Lev-Tov HA, Sivamani RK. Botanical and phytochemical therapy of acne: a systematic review. Phytother Res. 2014;28(8):1137–1152. [PMID:25098271]
  • Fox L, Csongradi C, Aucamp M, et al. Treatment modalities for acne. Molecules. 2016;21(8):E1063. [PMID:27529209]

See Also

Codes

ICD-10

  • L70.0 Acne vulgaris
  • L70.1 Acne conglobata
  • L70.4 Infantile acne
  • L70.8 Other acne

ICD-9

  • 706.0 Acne varioliformis
  • 706.1 Other acne

SNOMED

  • 13277001 Cystic acne (disorder)
  • 238744006 Comedonal acne
  • 403359004 acne nodule (disorder)
  • 42228007 Acne conglobata
  • 88616000 Acne vulgaris (disorder)

Clinical Pearls

  • Full results for changes in therapy take 8 to 12 weeks.
  • Decrease topical frequency to every day or to every other day for irritation.
  • Use BP every time a topical or oral antibiotic is used.

Authors


Gary I. Levine, MD

Figures

Figure 1-2

Inflammatory acne lesions. Papules, pustules, and closed comedones are all present on this patient.
Figure 1-3

Severe cystic acne. This patient was subsequently treated with isotretinoin (Accutane).

Bibliography

  1. Chien AL, Qi J, Rainer B, et al. Treatment of acne in pregnancy. J Am Board Fam Med. 2016;29(2):254–262.  [PMID:26957383]
  2. Admani S, Barrio VR. Evaluation and treatment of acne from infancy to preadolescence. Dermatol Ther. 2013;26(6):462–466.  [PMID:24552409]
  3. Dawson AL, Dellavalle RP. Acne vulgaris. BMJ. 2013;346:f2634.  [PMID:23657180]
  4. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945.e33–973.e33. [PMID:26897386]
  5. Del Rosso JQ, Kim G. Optimizing use of oral antibiotics in acne vulgaris. Dermatol Clin. 2009;27(1):33–42.  [PMID:18984366]
  6. Lortscher D, Admani S, Satur N, et al. Hormonal contraceptives and acne:a retrospective analysis of 2147 patients. J Drugs Dermatol. 2016;15(6):670–674.  [PMID:27272072]


© Wolters Kluwer Health Lippincott Williams & Wilkins
Acne Vulgaris is a sample topic from the 5-Minute Clinical Consult.

To view other topics, please or purchase a subscription.

Medicine Central™ is a quick-consult mobile and web resource that includes diagnosis, treatment, medications, and follow-up information on over 700 diseases and disorders, providing fast answers—anytime, anywhere. Learn more.

Citation

* When formatting your citation, note that all book, journal, and database titles should be italicized* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Acne Vulgaris ID - 116006 Y1 - 2019 PB - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116006/all/Acne_Vulgaris ER -