Acne Vulgaris

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Acne vulgaris is a common chronic skin disease involving blockage and/or inflammation of pilosebaceous units (hair follicles and their accompanying sebaceous gland). Acne can present as noninflammatory lesions, inflammatory lesions, or a mixture of both, affecting mostly the face but also the back and chest.

Diagnosis

Examination in patients with acne vulgaris includes the following features:

  • Comedonal acne: Presence of open and closed comedones but usually no inflammatory papules or nodules
  • Mild acne: Presence of comedones and a few papulopustules
  • Moderate acne: Presence of comedones, inflammatory papules, and pustules; a greater number of lesions are present than in milder inflammatory acne
  • Nodulocystic acne: Presence of comedones, inflammatory lesions, and large nodules greater than 5 mm in diameter; scarring is often evident

Laboratory tests

Acne vulgaris is a clinical diagnosis. However, laboratory testing may be indicated in the following situations:

  • Female patients with dysmenorrhea or hirsutism: Consider a hormonal evaluation with levels of total and/or free testosterone, dehydroepiandrosterone sulfate, luteinizing hormone, and follicle-stimulating hormone
  • Cases refractory to treatment or when improvement is not maintained: Culture skin lesions to rule out gram-negative folliculitis
  • Management

    Treatment of acne vulgaris should be directed toward the known pathogenic factors, including follicular hyperproliferation, excess sebum, P acnes, and inflammation. The most appropriate treatment is based on the grade and severity of the acne.

    Pharmacotherapy

    The following medications are used in the treatment of Propionibacterium acne vulgaris:

    • Retinoid-like agents (eg, topical tretinoin, adapalene, tazarotene, isotretinoin)
    • Antibiotics (eg, tetracycline, minocycline, doxycycline, trimethoprim/sulfamethoxazole, clindamycin, topical clindamycin, topical erythromycin, daptomycin)
    • Selective aldosterone antagonists (eg, spironolactone)
    • Estrogen/progestin combination oral contraceptive pills (eg, ethinyl estradiol, drospirenone, and levomefolate; ethinyl estradiol and norethindrone; ethinyl estradiol and norgestimate; ethinyl estradiol and drospirenone)
    • Acne products (eg, erythromycin and benzoyl peroxide, clindamycin and tretinoin, clindamycin and benzoyl peroxide, azelaic acid, benzoyl peroxide)

    When a topical or systemic antibiotic is used, it should be used in conjunction with benzoyl peroxide or topical retinoid to reduce the emergence of resistance.

    Nonpharmacotherapy

    Diet therapy, such as a low-glycemic diet and avoidance of “junk foods,” has been suggested as a nonpharmacologic measure to manage acne vulgaris.

    Procedures

    Procedural treatments for acne vulgaris include the following:

    • Manual extraction of comedones
    • Intralesional steroid injections
    • Superficial peels that use glycolic or salicylic acid

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