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SOURCE

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Source: Sibbald D. Acne vulgaris. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=132516259. Accessed March 9, 2017.

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CONDITION/DISORDER SYNONYMS

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  • Acne.

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DEFINITION

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  • A common, usually self-limiting disease involving inflammation of sebaceous follicles of face and upper trunk.

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ETIOLOGY

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  • Genetic, racial, hormonal, dietary, and environmental factors.

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PATHOPHYSIOLOGY

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  • Increased sebum production, hyperproliferation of ductal epidermis, bacterial colonization of ducts, and inflammation.

  • Androgens cause sebaceous glands to increase size and activity.

  • Increased keratinization of epidermal cells and development of obstructed sebaceous follicles (microcomedones)

  • The anaerobic bacterium Propionibacterium acnes causes T-cell-mediated inflammation.

  • Acne characterized by open and closed comedones is termed noninflammatory acne.

  • Inflammatory lesions—including pustules, nodules, and cysts—may form that lead to scarring.

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EPIDEMIOLOGY

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  • Lifetime prevalence is approximately 90%.

  • Affects 79–95% of the adolescent population in Western countries.

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RISK FACTORS

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  • Family history of acne.

  • Adolescence—30 years of age.

  • Elevated testosterone levels.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Lesions occur on face, back, upper chest, and shoulders.

  • Categorized as mild, moderate, or severe, depending on type and severity of lesions.

  • Lesions may take months to heal completely; fibrosis may lead to permanent scarring.

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DIAGNOSIS

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  • Established by patient assessment, including observation of lesions and excluding other potential causes (eg, drug-induced acne)

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DESIRED OUTCOMES

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  • Reduce number and severity of lesions.

  • Slow disease progression.

  • Limit disease duration.

  • Prevent formation of new lesions.

  • Prevent scarring and hyperpigmentation.

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TREATMENT: GENERAL APPROACH

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  • Select treatments appropriate for severity of clinical presentation.

  • Taper effective treatment over time, adjusting to response.

  • Use smallest number of agents at lowest effective doses.

  • After control is achieved, simplify regimen but continue with some suppressive therapy.

  • First line for mild–moderate acne: Exfoliative agents (benzoyl peroxide, topical retinoids, salicylic acid)

  • For moderate–severe acne with inflammatory lesions and scars: Reduce P. acnes with benzoyl peroxide, topical antibiotics (alone or with benzoyl peroxide), oral antibiotics (eg, minocycline), retinoids (tretinoin, adapalene, tazarotene), azelaic acid.

  • For severe acne with extensive nodules, cysts, and scars, or resistant acne: Add antiandrogens, isotretinoin, or topical and oral antibiotics.

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TREATMENT: NONPHARMACOLOGIC THERAPY

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  • Encourage patients to avoid aggravating factors, maintain balanced diet, and control stress.

  • Patients should wash no more than twice daily with mild soap or soapless cleanser. Minimize scrubbing to prevent follicular rupture.

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TREATMENT: PHARMACOLOGIC THERAPY

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  • Topical pharmacotherapy.

    • Exfoliants.

      • Salicylic acid products (up to 2% nonprescription, 5–10% prescription) for mild acne. Start with low concentration and increase as tolerated.

      • Resorcinol 2% and ...

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