Acne Vulgaris (Grading and Treatment)

Acne Vulgaris is the most common type of acne. It is an inflammatory disorder and it is usually self limiting. In this blog you will learn about the different variants of this disorder and how it is managed. 

Learning about this topic is going to be extremely helpful for your Dermatology preparation. 

Let’s begin. 

Etiopathogenesis

• Increase androgens
• Increase IL-1alpha activity
• Decrease Linoleic acid

Due to all these factors, there is hyperproliferation of keratinocytes in the duct of sebaceous glands. Sebocytes, which are on the inner side of sebaceous gland, secretes sebum, while keratinocytes only line the duct. Due to hyperproliferation, more and more keratinocytes are proliferating, causing blockage in the duct of sebaceous gland. Sebocyte is secreting sebum, but due to blockage more and more sebum is accumulating that causes an increase in sebum collection also known as seborrhea. Sebum is a very good culture media for bacteria. So when there is excess sebum, there is increased proliferation of bacteria called Propionibacterium acne. Once there is proliferation of bacteria, it releases lipase enzyme. The lipase converts triglycerides in the sebum into free fatty acid. Free fatty acid will cause inflammation. Many times the inflammation becomes red, inflamed. 

Clinical Features

Clinically various types of acne are seen called polymorphic. Poly means multiple and morphic means morphologic. So multiple types of morphological lesions can be seen. These lesions can be comedones (most characteristic) or there can be other lesions in the form of papules, pustules, nodules/cyst. 

Comedones

Comedones are the most characteristic lesions of the acne and they are of 2 types : Open/ black comedones and Closed/ white comedones. If there is disruption of the epithelial lining, the keratin gets exposed and due to exposed keratin, it gets oxidized and appears black. Sometimes there is intact epithelial lining on keratin, due to which they appear white

Grading of Acne

Grade 1- if the lesions are mainly comedones

Grade II- if the lesions are mainly papules

Grade III- if the lesions are mainly pustules

Grade IV- if the lesions are mainly nodules, cyst called nodulocystic acne. It is the severe type of acne

Grade I Acne Vulgaris.Since the majority of the lesions are comedones

Grade II- Papules,pustules with solid raised lesions

Grade IV- Severe acne, large lesion with cystic swelling, nodules and abscess, along with other various lesions

Variants of Acne

• Most common is acne vulgaris. 
• Neonatal acne- occur due to the maternal androgens which are passed to the neonate. Generally resolve within few weeks

• Infantile acne- due to increased DHEA. Immature adrenal gland of the infant start secreting more of DHEA
• Senile acne- commonly seen in old individuals.Due to excessive photo damage

• Acne fulminans- is associated with systemic features like fever

• Acne conglobata- is considered the most severe type of acne. Grouping of the lesions not only on the face but other body sites are also involved like trunk, back, extremities

• Acne excoriee- commonly seen in females suffering from obsessive compulsive disorders (continuous obsessive behaviour seen). No acne lesion present only excoriations marks are seen

• Drug induced acne- induced from drugs also known as monomorphic acne. Only papules are present on the back, front and face. Drugs like steroids (most common in the world), oral contraceptive pills (most common cause in western), Isoniazid (most common cause in India), lithium, Iodine, phenytoin. Patients taking anti tubercular therapy might experience monomorphic acne also known as acneiform eruptions.

Management

Varies, depending on the different grades.

Grade I- topical treatment like Retinoids (adapalene, Tretinoin

Grade II- along with topical retinoids add topical antibiotics (clindamycin) with or without benzoyl peroxide

Grade III- along with topical retinoid topical antibiotic +with or without benzoyl peroxide, add oral antibiotic like doxycycline, minocycline or azithromycin

Grade IV- drug of choice is oral retinoids (Isotretnoin)

Side effects of drugs

• Doxycycline- is a group of tetracycline drugs. Due to excessive sun exposure can cause photo onycholysis
• Minocycline- can lead to hyperpigmentation of skin and nails (melanonychia)
• Isotretinoin- dose 0.5-1 mg/kg body weight. Duration - can continue till the cumulative dose of 120-150 mg/kg body weight is reached. Most common side effect is dryness of lips.It can cause hypertriglyceridemia. It is hepatotoxic drug , so before initiating therapy check liver function test. It is a teratogenic drug,and is contraindicated in pregnant women. It can cause pseudotumor cerebri (benign raised intracranial tension). If taking isotretinoin, avoid other drugs like hypervitaminosis A, tetracycline because they also cause intracranial tension. Most common severe side effect is DISH (Diffuse Interstitial Skeletal Hyperostosis)

Systemic Retinoids

 Systemic retinoids are teratogenic. Should not be used in pregnancy. There are 2 types :

1. Isotretinoin- drug of choice for nodular cystic acne
2. Acitretin- drug of choice for pustular psoriasis

Systemic retinoids once they are consumed, they start accumulating in the fat and after stopping, they keep on releasing slowly .The drug can still be teratogenic for a period of time even after stopping. For Isotretinoin-  patients should not conceive during the therapy as well as I month after stopping the therapy. The wash out period for isotretinoin is 1 month. For Acitretin- it requires 3 years to completely wash out. 

Question:

Patient is taking isotretinoin, for how much duration patient should not conceive after taking the therapy?

• The duration is 1 month. 

And that is everything you need to know about acne vulgaris for your Dermatology preparation for NEET PG. For more interesting and informative articles like this, download the PrepLadder app now.

Also Read: BLISTERING DISORDERS of the Skin - NEET PG Dermatology