Patient with neonatal acne will present as → a 4-week old baby boy brought in by mother with c/o of a red rash on the sides of his face. She states that the rash has been present for a week now. It does not appear to itch at this time. On PE, you note comedones, papules on the lateral aspect of his face.
Patient will present as → a 14-year-old boy with dozens of erythematous papules, pustules, and cysts. On closer exam, he also has atrophic scars on the lateral forehead, consistent with permanent scarring from previous acne lesions. He is started on topical retinoids and topical benzoyl peroxide. You suggest that he also consider a systemic retinoid if this topical therapy does not work.
Acne is a chronic inflammatory skin disorder that is most commonly seen in areas with the highest concentration of sebaceous glands.
- It is most commonly seen on the face, upper chest & back. It is the MC skin problem of adolescence.
- It affects both sexes equally; more severe in males than in females. Onset can be as early as 8 years of age and can proceed into adulthood. The pilosebaceous unit (comprising of the hair follicle along with its associated sebaceous gland) is chronically inflamed leading to the formation of micro-comedo.
- Nodules & cysts are more likely to cause scarring.
- Papules & pustules are ruptured comedones that have become infected by Propionibacterium acnes.
The hallmark of acne pathogenesis involves 3 components:
- Increased production of sebum
- Increased keratin production
- Bacterial overgrowth by P. acnes.
Androgens can stimulate sebum production and can become a risk factor for acne formation as seen in hyperandrogenism caused by polycystic ovarian syndrome (PCOS) or by androgen-producing tumors.
Neonatal acne is seen in newborn up to first 8 weeks of life. It is typically limited to the face and responds well to ketoconazole 2% cream.
Diagnosis is typically clinical. Lab studies are typically not necessary. In a woman with resistant acne, hyperandrogenism should be suspected.
Acne severity is graded into: mild, moderate or severe based on the number & type of lesions. The stages of acne are:
- I - Comedonal: comedones (+/- small amounts of papules and pustules)
- II - Papular: moderate number of lesions, little scarring
- III - Pustular: lesions > 25, moderate scarring
- IV - Nodulocystic: severe scarring
Differential diagnosis includes
- rosacea (in which no comedones are seen)
- corticosteroid-induced acne (which lacks comedones and in which pustules are usually in the same stage of development)
- perioral dermatitis (usually with a more perioral and periorbital distribution)
- acneiform drug eruptions.
Patients should be educated on the use of medications and cosmetics. It typically takes about 4-6 weeks to see improvements on the face and another 3-4 months for the upper back. Oils and greases should be avoided. Anxiety and depression can result especially in adolescents. A diet low in carbs can also improve the symptoms of acne. Pharmacologic treatment depends on the severity.
- Comedonal acne: topical retinoids are very effective for treatment of comedonal acne. Tretinoin 0.025% cream can be used effectively. A major side effect is skin irritation caused by tretinoin. For this reason, patients who have skin irritation with the use of tretinoin can use adapalene gel 0.1%. Another treatment for comedonal acne is the use of benzoyl peroxide 2.5%.
- Mild inflammatory acne (grade 2): Benzoyl peroxide + or _ topical antibiotic + keratinolytic agent (alpa-hydroxy acids, salicylic acid, azelaic acid).
- Moderate inflammatory acne (grade 3): add systemic antibiotic (doxycycline, minocycline, Bactrim) to grade 2 regimen.
- Severe inflammatory acne (grade 4): as in grade 3 or isotretinoin. Isotretinoin is a vitamin A analog that reduces production of sebum, reduces keratin overgrowth and reduces the formation of 5 alpha-dihydrotestosterone and androgen receptor binding capacity. For this reason, isotretinoin is the only medication that can permanently treat acne. ABSOULTELY CONTRAINDICATED IN PREGNANCY. Two serum pregnancy tests should be performed before the initiation of treatment. Serum pregnancy test should be obtained every month afterward. Two forms of birth control should be started. Other treatment options for severe acne include intra-lesional injection with triamcinolone and laser therapy.
During adolescence, acne vulgaris is more common in females than in males
During adulthood, acne vulgaris is more common in men than in women
African Americans have a higher prevalence of pomade acne
Neonatal acne most often requires treatment with topical retinoids
Down-regulation of vascular cell adhesion molecule-1 (VCAM-1)
Presence of Propionibacterium granulosum
Stunted sebum production
Keratinocyte proliferation and decreased desquamation
Open and closed comedones without inflammatory papules and nodules
Comedones, inflammatory papules, and pustules
Comedones and a few papulopustules
Comedones, inflammatory lesions, and large nodules (> 5 mm in diameter)
Topic retinoid monotherapy
Antimicrobial therapy monotherapy
Topic retinoid and hormonal cotherapy
Topic retinoid and antimicrobial cotherapy
A combination of trimethoprim and azithromycin