Chapter 113: Acne Vulgaris

KEY CONCEPTS

• Acne is a highly prevalent disorder affecting adolescents and adults, with a large psychosocial impact.

• The etiology of this complex disease originates from multiple causative and contributory factors, including genetics and environment. The diagnosis is based on the patient’s history and clinical presentation.

• Acne is a disease of the pilosebaceous unit. Elements of pathogenesis involve defects in epidermal keratinization, androgen secretion, sebaceous function, bacterial growth, inflammation, and immunity.

• Acne vulgaris is a chronic disorder which cannot be “cured.” Goals of treatment and prevention include control and alleviation of symptoms by reducing the number and severity of lesions, slowing progression, limiting disease duration and recurrence, prevention of long-term disfigurement associated with scarring and hyperpigmentation and avoidance of psychologic suffering. Targeting goals may increase patient adherence to therapy.

• The most critical target for treatment is the microcomdedone. Minimizing or reversing follicular occlusion will arrest the pathogenic acne cascade and involve combining treatment measures to target all pathogenic elements.

• Nondrug measures are aimed at long-term prevention and treatment. Patients should eliminate aggravating factors, maintain a balanced, low-glycemic load diet, and control stress. Cleanse twice daily with mild soap or soapless cleanser and use only oil-free cosmetics. Comedone extraction in approximately 10% of patients produces immediate cosmetic improvement. Shave infrequently as possible, using a sharp blade or electric razor.

• First-, second-, and third-line therapies should be appropriate for the severity and staging of the clinical presentation and directed toward control and prevention.

• Treatment regimens should be tapered over time, adjusting to response. Combine the smallest number of agents at the lowest possible dosages to ensure efficacy, safety, avoidance of resistance, and patient adherence.

• Once control is achieved, maintenance regimens should be simplified to continue with some suppressive therapy. Therapy must be continued beyond 8 weeks: efficacy is assessed through comedonal and inflammatory lesion count, control or progression of severity, and management of associated anxiety or depression. Safety end points include monitoring for treatment adverse effects.

• Motivate the patient to continue long-term therapy through empathic and informative counseling.

Preclass Engaged Learning Activity

Watch the video entitled “Acne” by Dr Sheilagh Maguiness, pediatric dermatologist, available on the Society for Pediatric Dermatology Website (https://tinyurl.com/saa9t4s). This 5-minute video provides a brief overview regarding information patients need to know about acne vulgaris. The video is useful to enhance student understanding regarding what information to provide to patients regarding causes of acne, triggers, cleansing, over the counter and prescription options, directions for use and precautions. It gives a brief summary of take-home points useful to direct counseling.