- Acne is a highly prevalent disorder affecting many adolescents and adults.
- It is an extremely complex disease with an etiology originating from multiple causative and contributory factors.
- Elements of pathogenesis involve defects in epidermal keratinization, androgen secretion, sebaceous function, bacterial growth, inflammation, and immunity.
- Acne vulgaris cannot be “cured.” Goals of treatment of this chronic disorder include control and alleviation of symptoms by reducing the number and severity of lesions, slowing progression, and limiting disease duration and recurrence. Key elements for patient adherence to therapy include prevention of long-term disfigurement associated with scarring and hyperpigmentation and avoidance of psychologic suffering.
- The most critical target for treatment is the microcomedone, as the entire pathogenic cascade of acne is arrested if follicular occlusion is minimized or reversed. This involves a combination of treatment measures, integrating pharmacologic protocols targeting all four mechanisms involved in acne pathogenesis: increased follicular keratinization, increased sebum production, bacterial lipolysis of sebum triglycerides to free fatty acids, and inflammation.
- Nondrug measures are aimed at both long-term prevention and treatment. Patients should eliminate aggravating factors, maintain a balanced, low-glycemic load diet, and control stress. They should wash twice daily with a mild soap or soapless cleanser, and restrict cosmetic use to oil-free products. Comedone extraction results in immediate cosmetic improvement in approximately 10% of patients. Shaving should be done as lightly and infrequently as possible, using a sharp blade or electric razor.
- First-, second-, and third-line therapies should be selected and altered as appropriate for the severity and staging of the clinical presentation.
- Treatment is directed at controlling the disorder, not curing it. Regimens should be tapered over time, adjusting to response. The smallest number of agents should be used at the lowest possible dosages to ensure efficacy, safety, avoidance of resistance, and patient adherence.
- Once control is achieved, simplify the regimen but continue with some suppressive therapy. It takes 8 weeks for a microcomedone to mature; thus, any therapy must be continued beyond this duration to assess efficacy in terms of comedonal and inflammatory lesion count, control or progression of severity, and management of associated anxiety or depression. Safety end points include monitoring for adverse effects of treatment.
- Through empathic and informative counseling, the health professional can motivate the patient to continue long-term therapy.
On completion of the chapter, the reader will be able to:
Describe the epidemiology of acne vulgaris.
Discuss the etiology of acne vulgaris and other types of acne variants.
Explain the pathophysiologic mechanisms underlying acne vulgaris and its variant forms.
Describe the clinical presentation of acne vulgaris and other types of acne, and differentiate between subjective symptoms and objective signs.
Identify diagnostic considerations in the assessment and differential diagnosis of acne vulgaris.
Describe general approaches to treatment for acne, and summarize how various drug and nondrug measures are applied in a general perspective.
Discuss desirable outcomes and priorities for managing acne.
Identify appropriate nondrug measures for managing acne.
State drug treatments of first choice according to ...