ACNE VULGARIS

Acne Vulgaris is a chronic and common skin condition that most often affects adolescents. This condition forms different types of presentations on the skin including, spots, redness and inflammation.

Epidemiology

Acne is one of the most common skin conditions in the UK leading to 3.5 million visits to primary care every year.
Acne is the most common skin disease in the US and affects 80% of the population at some point in life [1]
Acne is more common in males during adolescence but in adulthood, higher in women [2]
The Global Burden of Disease Study 2010 found that acne vulgaris is the eighth most common skin disease, with an estimated global prevalence of 38% [3]
Approximately 85% of people between the ages of 12 and 24 experience at least minor acne [4]

Acne Vulgaris

In darker skin, redness and inflammatory acne can be harder to notice

Acne Vulgaris

Small bumps and pus-filled lesions (areas of damage) as well as dark flat marks

Pathophysiology

Medical Student
- Can be split into non-inflammatory and inflammatory acne
  - Non-inflammatory acne present with comedones (impacted plugs within follicles which can be termed open or closed)
  - Inflammatory acne presents with papules (formed by comedones’ contents stimulating an inflammatory reaction) and pustules (formed by further inflammation) [5]
- Excess sebum production and follicular plugging
  - Sebum holds an important role in anti-bacterial, anti-oxidant, and light and friction protection.
  - Increased sebum production, caused by hormonal changes such as puberty and pregnancy contributes to the development of acne.
  - If sebum interrupts the process of keratinisation in follicles within the pilosebaceous unit, the blockage can occur in the pores of the skin. Therefore, contributing to acne formation. [6]
- Cutibacterium acnes involvement
  - Uncertain the specific mechanisms and relationships between C acnes and acne development.
  - C acnes have been labelled as a low risk of disease causation (low virulence). It has also been considered an opportunistic pathogen paired with soft tissue and invasive skin infections.
  - The production of C acnes has also been associated with increased inflammatory triggers and host tissue damage. Thus contributing to acne formation. [7]
- Release of inflammatory mediators
  - The event of acne lesion development can lead to an increase in inflammatory mediators such as:
    - E selectin (recruits leukocytes to the site of injury; triggered by cytokines IL-1 and TNK- alpha macrophages)
    - Vascular adhesion molecules
    - Interleukins
    - Integrin
    - CD3+ and CD4+ T cells and macrophages [8]
Patients
- Excess sebum production and blockage
  - Sebum holds an important role in the protection of the skin.
  - Increased sebum production, caused by hormonal changes such as puberty and pregnancy contributes to the development of acne.
  - Sebum can stop the process of hair and skin formation, causing a blockage in the pores of the skin. Therefore, contributing to acne formation. [9]
- Cutibacterium acnes (c acnes) involvement
  - Uncertain the specific relationships between C acnes and acne development.
  - C acnes has been labelled as a low risk of disease causation but it has also been associated with soft tissue and skin infections.
  - The production of C acnes has also been associated with increased inflammation and skin damage. Thus contributing to acne formation. [7]
- Release of inflammatory substances
  - The event of acne development can lead to an increase in inflammatory substances that contribute to the process [8]

Source: Mind The Gap

Acne Vulgaris
Nodulo-cystic acne (a severe form of acne)

Source: DermNetNZ.org

Acne Vulgaris
Acne found on the back

Causes [10]

Blocked hair follicles
Testosterone
Acne in families
Periods
Pregnancy
Polycystic Ovary Syndrome
Certain medications- steroids, lithium, anti-epileptics
Smoking
High glycaemic index
Cosmetics

Risk factors
- Skin trauma (eg. usage of soaps, detergent, or other agents)
- Food habits (high glycemic index)
- Stress
- Insulin resistance
- Increased BMI
- Endocrine disorders
- Greasy skin
- Genetics
- Age (12-24) [11,12]

Presentations [5]

Involves the neck, chest, back and other parts of the body
Blackheads (open comedones) and whiteheads (closed comedones)
Small, tender red bumps
Yellow or white spots
Swelling
Redness
Dark/red marks
Scarring

Investigations [12]
- Clinical diagnosis (risk factors and presentation of acne)
- Hormonal evaluation
- Bacterial cultures
Differential diagnosis [1]
- Rosacea
- Peri-oral (around the mouth) dermatitis
- Folliculitis (inflammation of the follicles) and boils
- Drug-induced acne
- Keratosis pilaris (a dry skin condition caused by keratin build-up)

Source: Waikato District Health Board

Acne Vulgaris
Mild acne

Source: VisualDx and Skinsight

Acne Vulgaris
Multiple bumps of inflammatory acne with a faint redness

Management [1]
- Students
  - Give advice to patients personalised to their condition/case:
    - The possible causes of the acne
    - Treatment pathways and its pros and cons
  - Discuss the use of contraception or alternatives for possible childbearing patients
  - Discuss childbearing possibilities that cover topical retinoids and oral tetracyclines (contraindicated in pregnancy)
  - To advise the person on lifestyle choices:
    - Avoid over-cleaning the skin
    - To use pH neutral or slightly acidic cleansing product on acne-prone skin
    - Avoid oil-based products such as make-up sunscreen and skin care
    - Constant contact with the skin can increase the risk of scarring
    - To take the steps needed to reduce the risk of skin irritation caused by treatment types (eg. alternate day usage or gradually increase treatment application time)
  - For people with mild to moderate acne:
    - Offer a 12-week course of one of the following:
      - Topical adapalene with topical benzoyl peroxide
      - Topical tretinoin with topical clindamycin
      - Topical benzoyl peroxide with topical clindamycin
    - Consider topical benzoyl peroxide as an isolated treatment (monotherapy) if some topical medications are contraindicated or if topical retinoid or an antibiotic is not preferred by the patient.
    - Creams/ lotions can be used for dry or sensitive skin
    - Gels with less grease can be used for oily skin
    - Advise patients on taking the steps needed to reduce the risk of skin irritation caused by treatment types (eg. alternate day usage or gradually increase treatment application time)
  - For people with moderate to severe acne:
    - Offer a 12-week course of one of the following:
      - Topical adapalene with topical benzoyl peroxide
      - Topical tretinoin with topical clindamycin
      - Topical adapalene with topical benzoyl peroxide to be applied with either oral lymecycline or oral doxycycline
      - Topical azelaic acid with either oral lymecycline or oral doxycycline
        Consider topical benzoyl peroxide as an isolated treatment (monotherapy) if some topical medications are contraindicated or if topical retinoid or an antibiotic is not preferred by the patient.
        For patients who cannot tolerate/contraindications to oral lymecycline or oral doxycycline, consider replacing these with trimethoprim or with an oral macrolide
      - Combined oral contraceptives (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women.
        Co-cyprindiol (Dianette®) or other ethinylestradiol/cyproterone acetate-containing products may be considered in moderate to severe acne where other treatments have failed.
  - Refer to a consultant dermatologist-led team with expertise in scarring management if acne-related scarring is severe and persists a year after acne has cleared.
  - Do not use the following to treat acne:
    - Monotherapy with a topical or oral antibiotic.
    - A combination of a topical and oral antibiotic.
    https://cks.nice.org.uk/topics/acne-vulgaris/management/primary-care-management/
- Patients
  - Advice can be given based on individual condition/case:
    - The possible causes of the acne
    - Treatment pathways and its pros and cons
  - Discuss the use of contraception or alternatives for possible childbearing patients as certain medications pose potential risks to pregnancies
  - Advice on lifestyle choices:
    - Avoid over-cleaning the skin
    - To use pH neutral or slightly acidic cleansing product on acne-prone skin
    - Avoid oil-based products such as make-up sunscreen and skin care
    - Constant contact with the skin can increase the risk of scarring
    - To take the steps needed to reduce the risk of skin irritation
  - For people with mild to moderate acne:
    - Offer a 12-week course of one of the following:
      - Topical (applied to the skin) adapalene with topical benzoyl peroxide
      - Topical tretinoin with topical clindamycin
      - Topical benzoyl peroxide with topical clindamycin
    - Consider topical benzoyl peroxide on its own if some topical medications pose harm to the patient (contraindicated) or if topical retinoid or an antibiotic is not preferred by the patient.
    - Creams/ lotions can be used for dry or sensitive skin
    - Gels with less grease can be used for oily skin
    - Advise patients on taking the steps needed to reduce the risk of skin irritation
  - For people with moderate to severe acne:
    - Offer a 12-week course of one of the following:
      - Topical adapalene with topical benzoyl peroxide
      - Topical tretinoin with topical clindamycin
      - Topical adapalene with topical benzoyl peroxide to be applied with either oral lymecycline or oral doxycycline
      - Topical azelaic acid with either oral lymecycline or oral doxycycline
        Consider topical benzoyl peroxide on its own if some topical medications pose harm to the patient (contraindicated) or if topical retinoid or an antibiotic is not preferred by the patient.
        For patients who cannot tolerate oral lymecycline or oral doxycycline, consider alternatives
      - Combined oral contraceptives (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women.
        Stronger medication can be used in moderate to severe acne where other treatments have failed.
      - Refer to a consultant dermatologist-led team with expertise in scarring management if acne-related scarring is severe and persists a year after acne has cleared.
  - Do not use the following to treat acne:
    - Monotherapy with a topical or oral antibiotic.
    - A combination of a topical and oral antibiotic.
Complications [10]
- Self-image and depression
- Scarring
  - Ice pick scars- small, deep holes in the skin
  - Rolling scars- rolling or uneven appearance found in the skin
  - Boxcar scars- round or oval pits in the skin
    - Can be treated as a type of cosmetic surgery but is not usually funded under the NHS (exceptions have included cases which can cause significant psychological distress)

Source: DermNetNZ.org

Acne Vulgaris
Post-inflammatory pigmentation due to acne

Myths behind Acne [13,14]

Acne will clear more quickly if you scrub your skin clean
Wearing makeup causes acne breakouts
Acne will clear once the teenage year has finished
Tanning helps clear up acne
Squeezing/popping pimples will be rid of acne quicker
Chocolate is bad for your skin
Eating greasy foods can cause acne
Cutting out gluten will help clear the skin
Dairy can cause acne

Questions you may want to ask your doctor
- What are the possible reasons for my acne flares?
- Is there a long-term treatment to manage my acne and prevent exacerbations?
- Are there any changes I need to make to my skincare routines?
- Should I avoid certain foods to help manage acne?
Support
- The British Association of Dermatologists
- Talkhealth
- Acne Support

Bibliography

[1] https://cks.nice.org.uk/topics/acne-vulgaris/background-information/prevalence/#:~:text=An

[2] https://pubmed.ncbi.nlm.nih.gov/23657180/

[3] https://www.nature.com/articles/s41598-020-62715-3

[4] https://pubmed.ncbi.nlm.nih.gov/23210645/

[5] https://www.msdmanuals.com/en-gb/professional/dermatologic-disorders/acne-and-related-disorders/acne-vulgaris?query=acne

[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051853/

[7] https://www.nature.com/articles/s41598-022-25436-3#:~:text=Cutibacterium

[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3780801/

[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051853/

[10] https://www.nhs.uk/conditions/atopic-eczema/causes/

[11] https://www.almirall.com/your-health/your-skin/skin-conditions/acne/risk-factors