Acne and acne-related conditions




9: Acne and acne-related conditions


Abstract:



Acne and acne-related conditions are characterized by the development of comedones, papulopustules, and/or cystic lesions. Although morphologically related, these conditions have diverse etiologies and require distinct management. This chapter reviews acne, rosacea, folliculitis, pityrosporum folliculitis, pseudofolliculitis barbae, acne keloidalis nuchae, hidradenitis suppurativa, dissecting cellulitis of the scalp, and epidermal inclusion cysts.

Key terms:


acne vulgaris


acne conglobata


rosacea


acne rosacea


folliculitis


carbuncle


furuncle


epidermal inclusion cyst


epidermoid cyst


pityrosporum folliculitis


pseudofolliculitis barbae


acne keloidalis nuchae


hidradenitis suppurativa


dissecting cellulitis of the scalp



Acne


Payal Shah and Nikita Lakdawala


Clinical features





Differential diagnosis


The main differential includes perioral dermatitis and rosacea.



Work-up





Initial steps in management


General management comments





Recommended initial regimen


For mild to moderate acne, the recommended initial regimen includes the use of 2.5% to 5% benzoyl peroxide, a daily face wash, and the gradually increased use of topical retinoids to daily at bedtime (tretinoin 0.025%–0.1%, tazarotene 0.05%–0.1% cream or gel, or adapalene gel 0.1%–0.3%).



Topical antibiotics, such as clindamycin 1% lotion or solution, erythromycin 2% gel, dapsone 5% or 7.5% gel, or minocycline 4% foam, can also be used for mild to moderate cases.



Partial but inadequate response


If there is a partial but inadequate response after a 3-month trial of combination topical therapies, oral antibiotics can be tried for 3 to 4 months (doxycycline 100 mg daily or BID; minocycline 100 mg daily or BID; tetracycline 500 mg daily or BID).



Hormonal therapy can also be tried for female patients, particularly if the acne is in a perioral and jawline distribution (spironolactone 50–100 mg daily or BID).


Continued inadequate response


If the response continues to be inadequate and you are confident that the patient has acne that is refractory to a combination of topical therapies and oral antibiotics, then the next step includes isotretinoin therapy.



Warning signs/common pitfalls


Although acne is a benign skin condition, it can lead to permanent scarring or postinflammatory hyperpigmentation and significant psychological distress, making early treatment intervention critical for optimal patient outcomes.


Acne requires consistent treatment adherence for months to achieve the clinical response. Therefore lack of response before 6 to 8 weeks of treatment should not be assessed as refractory acne or a failure of treatment.


Counseling


Your doctor has diagnosed you with acne, a very common chronic inflammatory condition of the pilosebaceous unit that presents because of a combination of factors, including increased sebum production, follicular hyperkeratinization, proliferation of bacteria (Cutibacterium acnes), and inflammation. It often is a self-limited disease that typically begins in adolescence because of androgen-stimulated sebum production and keratinization changes of the follicle.


Acne should be treated because it can cause permanent scarring of your skin. Acne treatment is targeted at preventing new lesions rather than treating existing lesions. The importance of treatment adherence cannot be overstressed because a clinical response is only expected after at least 8 weeks and ideally up to 2 to 3 months of strong adherence. Lack of adherence is the biggest reason for treatment failure. Treat the entire field of potential acne, rather than individual spots, with topical therapies.


The use of harsh cleansers and antibacterial soaps is discouraged because they may exacerbate acne. Additionally, pimples should not be squeezed because it may lead to scarring and infection.


Low glycemic diets that minimize the spike in blood sugar and insulin levels may improve acne, but more studies are needed to establish the relationship. Diets that are considered low glycemic can be found on the Internet.


Rosacea


Payal Shah and Nikita Lakdawala


Clinical features







Differential diagnosis


The main differential includes acne and seborrheic dermatitis.



Work-up




Initial steps in management


General management comments


An assessment of the predominant phenotype and severity guides treatment.



Recommended initial regimen


The recommended initial regimen for rosacea includes 0.75% metronidazole gel BID for oily skin types and cream or lotion BID for normal/dry skin types. For all skin types, avoidance of triggers and the use of sun protection is recommended.


Partial but inadequate response


If there is a partial but inadequate response after a 3-month trial of combination topical therapies, oral antibiotics can be tried for 12 weeks (doxycycline 40mg daily; minocycline 50mg BID).



Continued inadequate response


If the response continues to be inadequate, severe papulopustular rosacea may be treated with systemic isotretinoin therapy, which requires obtaining a baseline and then regular interval levels of CBC, glucose test, liver function test, fasting lipids, and pregnancy tests for female patients (because isotretinoin is known to be teratogenic).



Warning signs/common pitfalls


Although rosacea is a benign skin condition, it can lead to significant psychological distress and possibly irreversible erythema and telangiectasias, making treatment intervention important for patients and their quality of life.


Counseling


Your doctor has diagnosed you with rosacea, which is a common chronic inflammatory condition with a waxing and waning disease course that has no cure. The condition can be adequately controlled, however, with treatment adherence and lifestyle changes.


Your doctor will advise you to avoid hot beverages, spicy foods, alcohol, chocolate, topical steroids on this rash, stress, and extreme temperature changes because these may trigger your rash. Also, the use of broad-spectrum sunscreens and sun avoidance to help control the condition are recommended. Gentle skincare products and cosmetic camouflage may also help.


Your doctor will prescribe some topical therapies and possibly some antibiotics. It will take several weeks to months for your condition to improve. Please know that this eruption can recur in the future but can be treated again if that occurs.


Perioral dermatitis


Nikita Lakdawala


Clinical history





Work-up




Initial steps in management


General management comments



Jul 22, 2021 | Posted by in Dermatology | Comments Off on Acne and acne-related conditions
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