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Acne Vulgaris
• Common pilosebaceous disorder that occurs in ~85% of individuals 12–24 years of age and 15–35% of adults (especially women) in their 30s–40s.
• Clinical presentations range from mild comedones to severe, explosive eruptions of suppurative nodules associated with systemic manifestations.
• May result in scarring and psychosocial repercussions such as anxiety, depression, and social withdrawal.
• A tendency to develop moderate to severe acne can run in families.
• Multiple factors affecting the pilosebaceous unit contribute to acne pathogenesis (Fig. 29.1), a process that typically begins when androgen production increases at adrenarche.
• The relationship between diet and acne is controversial, with some evidence of possible associations with milk intake (especially skim milk) and a high glycemic index diet.
Clinical Features and Variants of Acne
• Favors the face and upper trunk, sites with well-developed sebaceous glands.
– Closed comedones (whiteheads) are small (~1 mm), skin-colored papules without an obvious follicular opening (Fig. 29.2A,B).
Fig. 29.2 Comedonal acne vulgaris. A Closed comedones highlighted by side lighting. B Open and closed comedones as well as post-inflammatory hyperpigmentation on the cheek. C Prominent open comedones in a patient with scarring cystic acne. A, Courtesy, Ronald P. Rapini, MD; B, Courtesy, Andrew Zaenglein, MD, and Diane Thiboutot, MD.
– Open comedones (blackheads) have a dilated follicular opening filled with a keratin plug, which has a black color due to oxidized lipids and melanin (Fig. 29.2B,C).
– Erythematous papules and pustules (Fig. 29.3A).
Fig. 29.3 Inflammatory acne vulgaris. A Papules, obvious pustules, and atrophic scars are present. B Severe nodulocystic acne. This form is best treated with low doses of isotretinoin initially (± a preceding course of oral antibiotics) to avoid precipitating a flare. A, Courtesy, Andrew Zaenglein, MD, and Diane Thiboutot, MD.
– Nodules and cysts filled with pus or serosanguinous fluid; may coalesce and form sinus tracts (Fig. 29.3B).
– Acne conglobata (severe nodulocystic acne) is classified in the follicular occlusion tetrad along with dissecting cellulitis of the scalp, hidradenitis suppurativa, and pilonidal cysts (see Chapter 31); it is also a part of pyogenic arthritis, pyoderma gangrenosum, and acne conglobata (PAPA) and pyoderma gangrenosum, acne, and suppurative hidradenitis (PASH) syndromes.
• Inflammatory acne commonly results in post-inflammatory hyperpigmentation, especially in patients with darker skin, which fades slowly over time (Fig. 29.4A); nodulocystic acne (and less frequently other inflammatory > comedonal forms) often leads to pitted (Fig. 29.4B) or hypertrophic scars (the latter especially on the trunk; see Fig. 81.4).
Fig. 29.4 Sequelae of acne. A Post-inflammatory hyperpigmentation. Such pigmentary changes are most common in patients with darker skin colors. B ‘Ice-pick’ scarring secondary to nodulocystic acne. A, Courtesy, Andrew Zaenglein, MD, and Diane Thiboutot, MD.
Post-Adolescent Acne
• Age >25 years; favors women.
• Tends to flare in the week prior to menstruation; up to one-third of these women have hyperandrogenism.
• Typically features papulonodules on the lower face, jawline, and neck.
Acne Excoriée
• Favors teenage girls and young women.
• Habitual picking at comedones and inflammatory papules, resulting in crusted erosions (often linear/angular) and potential scarring (see Fig. 5.3).
• Some patients have an underlying obsessive–compulsive or anxiety disorder.
Acne Fulminans
• Favors boys 13 to 16 years of age.
• Sudden development of numerous, markedly inflamed nodular lesions on the face, trunk, and upper arms.
• Coalescence into painful, oozing, friable plaques with hemorrhagic crusting, erosion/ulceration, and eventual scarring (Fig. 29.5).
Fig. 29.5 Acne fulminans. Inflamed, friable papulopustules and plaques with erosions, oozing, and formation of granulation tissue. Courtesy, Julie V. Schaffer, MD.
• Systemic manifestations include fever, malaise, myalgias, arthralgias, osteolytic bone lesions (most often of clavicles and sternum), and hepatosplenomegaly.
• Laboratory findings: leukocytosis and increased ESR > anemia, microscopic hematuria, and proteinuria.
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