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Overview |
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Definition |
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Acne vulgaris is a disease of the skin manifested by comedones and
inflammatory lesions. Essentially all adolescents are affected, while only about
3% of the population aged 35 to 44 years suffer from some degree of acne.
Severity of disease is greater in males, but more persistent in females. Acne
affects areas of the skin containing the largest sebaceous glands, including the
nose, central forehead, medial cheeks, middle chin, back, and trunk.
A less common disorder, acne rosacea, is now classified as an acneiform as it
bypasses the comedo stage. It involves dilation of small blood vessels that
leave a prolonged facial redness. It is more prevalent in fair-skinned men and
women, occurs later in life, and predominately afflicts those of Celtic and
Northern European backgrounds.
Neonatal acne begins in the first six weeks of life, resolves within three
months with no scarring, and is not predictive of later acne. Infantile acne
begins at three to six months of age, may result in scarring, and is associated
with increased risk of acne vulgaris. |
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Etiology |
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Acne vulgaris is caused by increased production in the sebaceous gland in
response to elevated androgen activity with subsequent pathophysiologic
responses. The precise etiology of acne rosacea is unproven but thyroid
dysfunction and other triggers seem to provoke the skin condition.
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Risk Factors |
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Acne vulgaris:
- Greasy/oily cosmetic or hair products containing vegetable or animal
fats
- Genetic predisposition
- Acne at age 10 is predictive of severe acne at age 15
- Humid climates
- Sun exposure
- Occlusion of skin pores
- Oral contraceptive use
- Constipation
Acne rosacea:
- Genetic predisposition
- Personal triggers—diet (cheese, meat, spicy
foods, caffeine, alcohol, hot soup or drink), cold, sun, wind, exercise, stress,
menopause
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Signs and Symptoms |
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Acne vulgaris:
- Open comedo ("blackheads")
- Closed comedo ("whiteheads")
- Inflamed papule
- Cysts and nodules
- Nodulocystic lesions
- Scarring
Acne rosacea:
- Prolonged facial redness
- Pustules, papules
- Ocular rosacea, conjunctivitis, stye formation
- Rhinophyma (enlargement of the nose resulting from tissue
overgrowth)
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Differential
Diagnosis |
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- Flat warts
- Folliculitis
- Dermatitis
- Lupus erythematous—for rosacea
- Fungal infection—for
rosacea
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Diagnosis |
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Physical Examination |
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Comedones, papules, pustules, and scarring may all be visible. Emotional
upset of patient may also be evident and should be addressed.
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Pathology/Pathophysiology |
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Acne vulgaris:
- Overactive sebaceous glands drain into follicular canal, becoming
plugged with keratinous debris that contains Propionibacterium acnes
(comedo)
- Sebaceous gland increases production in response to increased androgen
activity during puberty; girls with severe acne have significantly higher serum
dehydroepiandrosterone sulfate (DHEA-S)
- P. acnes (or possibly Staphylococcus epidermidis or
Pityrosporon ovale) organisms mix with sebum and produce lipolytic
enzymes that convert the sebum to free fatty acids
- Patulous pilosebaceous orifice—open
comedo
- Follicular wall ruptures high in the dermis, contents extruded into
subadjacent dermis, induces a neutrophillic inflammatory
response—pustules form if inflammation stays near
surface; nodules form if inflammation develops deeper
- Liquefied masses of inflammatory debris may develop from suppuration
and reaction to giant cells
- Pathogenesis unknown for acne flares one week prior to
menstruation
Acne rosacea:
- Erythema
- Vasodilation
- Telangiectasia (permanent dilation of preexisting blood
vessels)
- Sebaceous hyperplasia and tissue overgrowth results in
rhinophyma
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Treatment Options |
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Treatment Strategy |
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Acne cannot be cured but often can be well controlled. Treatment focuses on
curtailing lesions and avoiding scarring. Acne vulgaris is usually
self-limiting. |
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Drug Therapies |
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Acne vulgaris:
- Tretinoin (Retin-A)—for comedones; a retinoid
that normalizes follicular keratinization; side effects include
photosensitivity, erythema, and peeling; pustule flares possible at beginning of
treatment; response in three to six months; typically 0.025% cream; at least one
study shows addition of polyolprepolymer-2 reduces cutaneous irritation with
comparable efficacy
- Isotretinoin—for nodulocystic acne, reduces
sebum excretion, decreases inflammation, antibacterial properties for P.
acnes; only drug that alters the course, effect lasts beyond administration;
0.5 to 1.0 mg/kg/day for 16 to 20 weeks; side effects include dry or inflamed
skin, eyes, and mucous membranes, muscle and joint aches; rule out preexisting
liver disease; potent teratogen
- Benzoyl peroxide—a topical keratolytic that
dissolves keratin plugs and follicular debris, allowing sebaceous secretion
outflow, antibacterial properties for P. acnes; prescription (10%) and
OTC preparations (2.5% and 5%) may be used in the morning (begin every other
day) with a retinoid in the evening
- Oral antibiotics—inhibit bacterial lipases,
reduce free fatty acids; enhanced by benzoyl peroxide and tretinoin; commonly,
tetracycline (500 mg/bid)—must not be taken with food;
side effects include phototoxicity, gastrointestinal problems, Candida
vaginitis, teratogenic, decreases contraceptive effectiveness
- Topical antibiotics—less effective than oral;
enhanced by benzoyl peroxide and tretinoin
- Oral contraceptives—inhibit sebum production;
must be estrogen-containing
Acne rosacea:
- Antibiotics—tetracycline (500 to 1000
mg/bid)
- Isotretinoin—0.5 to 1 mg/kg/day
- Topical metronidazole 0.75% gel
- Cosmetic and sunscreen
protection
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Surgical Procedures |
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- Glucocorticoid intralesional injections—for
painful nodulocystic lesions; 3 mg/ml
- Dermabrasion—decreases depth of
scars
- Scar excision
- Focal chemical peeling, carbon dioxide laser, scar excision, punch
grafting, and dermabrasion—effective combined treatment
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Complementary and Alternative
Therapies |
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Herbal remedies may be effective at balancing hormones and improving
digestion in order to stimulate androgen metabolism. Proper nutrition supports
skin health. |
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Nutrition |
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- Eliminate allergenic foods (especially dairy), caffeine, sugars,
alcohol, and refined foods. Iodine may exacerbate outbreaks. Decrease
pro-inflammatory fats (i.e., animal products) and increase anti-inflammatory
oils (i.e., cold-water fish, nuts, and seeds). Include carotene-rich orange,
yellow, and leafy green vegetables. High consumption of water.
- Vitamin A (10,000 IU/day) or beta carotene (25,000 IU/day), vitamin E
(400 IU/day), and zinc (15 to 30 mg/day) for skin health.
- Vitamin B6 (pyridoxine). Take 50 to 100 mg/day for
PMS-associated acne.
- Acidophilus (one capsule with meals) to restore normal bowel
flora.
- HCl and pancreatic enzymes may be beneficial especially with acne
rosacea or with concurrent
constipation.
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Herbs |
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Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or
tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp.
herb/cup water steeped for 10 minutes (roots need 20 minutes). For the following
herbs, take 20 to 30 drops tincture bid to tid, or drink two to three cups tea
daily.
- For both acne vulgaris and rosacea, include the following herbs in
equal parts: cleavers (Galium aparine), red clover (Trifolium
pratense), calendula (Calendula officinalis), and coneflower
(Echinacea purpurea).
- For acne vulgaris, add yellowdock (Rumex crispus) and burdock
root (Arctium lappa). For severe cases, substitute Oregon grape
(Berberis aquafolium) for burdock.
- For acne rosacea add: blue flag (Iris versicolor) and yarrow
(Achillea millefolium). For vasomotor instability, substitute oatstraw
(Avena sativa) for yarrow.
- An bitters [e.g., dandelion (Taraxacum officinale), greater
celandine (Chelidonium majus)] plus milk thistle (Silybum
marianum) to stimulate digestive tract.
For increased testosterone levels, add saw palmetto (Serenoa repens)
200 mg bid to tid. |
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Homeopathy |
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An experienced homeopath would consider the individual's constitution. Some
of the most common acute remedies are listed below. Acute dose is three to five
pellets of 12X to 30C every one to four hours until symptoms
resolve.
- Belladonna for flushes of heat to the face or inflamed pustular
acne that is better with cold applications
- Calcarea carbonica for severe acne in those with a tendency
toward constipation and dairy allergies, as well as those who are easily
chilled
- Rhus tox for acne rosacea that is generally aggravated by cold,
wet weather
- Sulphur for ruddy complexion with enlarged veins on the cheeks
or nose, or for those who are easily overheated
- Kali bromatum for deep acne in chilled patients and for those
who are suffering from insomnia
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Physical Medicine |
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External wash bid:
- Calendula soap or tea (1 tsp. herb per cup water) for gentle
cleansing
- Tea tree oil (15 to 20 ml per cup water) for severe
acne
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Acupuncture |
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May be useful in resolving hormonal or constitutional imbalances and
facilitating detoxification. |
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Massage |
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Stimulates circulation and helps to eliminate
toxins. |
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Patient Monitoring |
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Ensure drug treatment compliance. |
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Other
Considerations |
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Prevention |
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- Isotretinoin—only preventive drug for acne
vulgaris
- Avoid triggers to prevent
rosacea
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Complications/Sequelae |
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- The potentially serious psychological and social impact of severe
acne, especially during adolescence, warrants prompt and continuing treatment.
- Squeezing of lesions causes local inflammation and ruptures intact
lesions.
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Prognosis |
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- Vulgaris—symptoms generally diminish after
adolescence
- Rosacea—requires ongoing management
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Pregnancy |
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- Tetracycline and isotretinoin—contraindicated
during pregnancy as they are teratogenic
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References |
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Behrman RE, ed. Nelson Textbook of Pediatrics. 15th ed.
Philadelphia, PA: W.B. Saunders; 1996.
Dambro MR. Griffith's 5-Minute Clinical Consult. 1999 ed. Baltimore,
MD: Lippincott Williams & Wilkins, Inc.; 1999.
Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles
of Internal Medicine. 14th ed. New York, NY: McGraw-Hill;
1998.
Habif TP. Clinical Dermatology. 3rd ed. St. Louis, MO:
Mosby-Year Book; 1996.
Hoffman D. The New Holistic Herbal. New York, NY: Barnes & Noble
Books; 1995: 77, 79.
Lucky AW, Cullen SI, Jarratt MT. Comparative efficacy and safety of two
0.025% tretinoin gel: results from a multicenter double-blind, parallel study.
J Am Acad Dermatol. 1998; 38(4): S17–23.
Lucky AW, Biro FM, Simbartl LA. Predictors of severity of acne vulgaris in
young adolescent girls: results from a five-year longitudinal study. J Am
Acad Dermatol. 1998; 38(4): S17–23.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993.
Rakel RE, ed. Conn's Current Therapy. 50th ed.
Philadelphia, PA: W.B. Saunders; 1998.
Scalzo R. Naturopathic Handbook of Herbal Formulas. 2nd ed.
Durango, Colo: Kivaki Press; 1994: 66-67.
Werbach M. Nutritional Influences on Illness. New Canaan, Conn: Keats
Publishing; 1988: 3-4.
Whang KK, Lee M. The principle of a three-staged operation in the surgery of
acne scars. J Am Acad Dermatol. 1999; 40(1):
95–97.
White GM. The evolving role of retinoids in the management of cutaneous
conditions. J Am Acad Dermatol. 1998;
39(2). |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |