Acne ALEXANDER K. C. LEUNG M.B.B.S., F.R.S.H., F.R.C.P.C., F.R.C.P.(Edin.), F.R.C.P.(Glasg.), F.R.C.P.I., F.A.A.P., M.R.C.P.(U.K.), D.C.H.(Lond.), D.C.H.(I.) Clinical Associate Professor, Department of Paediatrics, University of Calgary. WM. LANE M. ROBSON, M.D., F.R.C.P.C. Clinical Associate Professor, Department of Paediatrics, University of Calgary.
a common and distressing problem for adolescents. The term is denved from the Greek word ’acme’, which means ’prime of life’. Although generally considered to be a benign, selflimited condition, acne may cause severe psychological problems or disfiguring scars that may persist for a
CNE is
many
lifetime.
Currently available therapeutic agents are suppressing inflammatory acne and preventing scarring in many patients. All clinicians caring
effective in
for children
adolescents should be familiar with the clinical manifestations, differential diagclinical evaluation, and treatment of acne. or
pathogenesis,
nosis,
EPIDEMIOLOGY than 80% of the population during the second and third decades of life (Editorial, 1979). Rademaker et al reported that the prevalence of acne 10 boys increased from 40% at age 12 years to 95% at age 16 years (Rademaker, et al, 1989). In girls the incidence increased from 61% to 83% (Rademaker, et similarly al, 1989). Clinically significant acne affects approximately 20 to 25% of the population between the ages of 12 and 25 years (Editonal, 1979). The peak incidence of acne occurs during the middle-to-late teenage years and, thereafter, the incidence decreases. The condition is seen in 10 to 15% of adults aged 30 to 40 years, and may progress into later life (Rich, 1980). Acne tends to be more severe among males than females. There is a genetic basis to acne, with a high concordance rate in identical twins (Rich, 1980). The condition is found worldwide. There is no evidence that ethnic or racial differences influence the susceptibility ACNE AFFECTS more
to acne.
PATHOGENESIS ACNE is a disease of the pilosebaceous follicle which consists of large, multiacinar sebaceous glands, a rudimentary hair, and a follicular canal composed of an acro-infundibulum in its upper portion and an infrainfundibulum in its dennal portion. Acne is uniquely human, since sebaceous follicles do not occur in lower animals. Acne usually occurs with the onset of puberty. Under androgenic stimulation, sebaceous glands enlarge and increase their sebum production. Serum androgens are derived from the testes in the male and from the ovaries and adrenal glands in the female. Numerous studies have demonstrated that testosterone is converted to the more potent metabolite dihydrotestosterone by 5Address for correspondence: Dr Alexander K. C. Leung, Alberta 1820 Richmond Road SW, Calgary, Alberta, Children’s Canada T2T5C7.
Hospital,
alpha-reductase, an enzyme present in human skin (Hurwitz, 1979). Current research suggests that dihydrotestosterone is the tissue androgen that causes the hypertrophy of the sebaceous gland and increased production of sebum (Hurwitz, 1979). This explains why elevated androgen levels are seldom found m the blood or urine from patients with acne. When initially produced, sebum is composed of a mixture of triglycerides (60%), wax esters (20%), squalene (a cholesterol precursor) (10%), and miscellaneous minor components (10%) (Rasmussen, 1978). In the pilosebaceous gland, about half of the triglycerides are enzymatically hydrolyzed into free fatty acids and glycerol by lipase from the anaerobic bacterium acnes (P. Acnes), an organism that Propionibacterium increases dramatically at the time of puberty. The free fatty acids, once released into the skm through follicular are cytotoxic and contribute to the inflammatory reaction. Obstruction of the pilosebaceous canal precedes the development of the acne lesion. The obstruction is produced by the accumulation of adherent keratinized
breakdown,
cells within the canal that form an impaction obstructing the flow of sebum. The cause of this abnormality of keratinization is unknown, but the process may be under the influence of androgens. When the normal flow of sebum onto the skin surface is obstructed by follicular hyperkeratosis, a microcomedo is initiating the process of acne.
formed,
CLINICAL MANIFESTATIONS the face, and to a lesser back, chest, and shoulders. These areas correspond to the distribution of the largest and most numerous pilosebaceous units in the body. The distal extremities are always spared. The pathognomonic lesion of acne is the comedo, which may be either open or closed. An open comedo, also called a blackhead, is a flat or slightly raised, black lesion, measuring 1 to 3mm in diameter. The black surface of the open comedo is melanin (Rasmussen, 1978), not dirt or oxidized fat. The pigmentation is limited to the tip of the comedo because melanocytes are present only in the upper portion of the sebaceous follicle. A closed comedo, commonly known as a ACNE LESIONS tend to occur on extent, on the upper
whitehead, appears
as a
pale, slightly elevated papule
without a readily visible central pore. It is flask-shaped with the most narrow portion connected to the skin surface. Blackheads do not generally become inflamed unless the pilosebaceous canal is disrupted by external forces, such as may occur by squeezing the lesions. Whiteheads may either open up their pores resulting in blackheads 57
they may evolve into pustules. For this reason, closed comedones have been called ’the time bombs of acne’. With rupture of the obstructed follicle and release of free fatty acids into the surrounding tissue, an inflammatory reaction ensues, resulting in erythematous papules, pustules, nodules, or cysts depending on the amount and location of the tissue involved, and the magnitude of the inflammatory response. Acne cysts are not true cysts, but rather nodules that have become fluctuant as a result of suppuration. Acne conglobata, found predominately in males, is a severe, destructive and highly inflammatory form of acne marked by the presence of multiporous comedones, nodules, cysts, abscesses and draining sinus tracts on the upper trunk and posterior back. Acne fulminans is a rare form of acne characterized by the sudden eruption of large, necrotic, ulcerating nodulocystic lesions on the back and chest in association with systemic manifestations such as fever, chills, malaise, weight loss, musculoskeletal pain, polyarthralgia, leucocytosis, anaemia, elevated erythrocyte sedimentation rate, and osteolytic bone lesions (Pauli et al, or
1988). DIFFERENTIAL DIAGNOSIS is a common skin manifestation of tuberous sclerosis. Clinically, these lesions appear as
ADENOMA SEBACEUM
small, reddish, brown, or even flesh-coloured, smooth, 1 to 3 mm papules present over the sides of the nose and the medial aspects of the cheeks. They are not
shiny,
associated with comedones respond to anti-acne therapy. Flat warts (verruca plana)
or
pustules
and do not
are small, usually 2 to 4 slightly elevated flat-topped papules with a finely roughened surface. They may be differentiated from closed comedones which have a dome shape and a
mm,
smooth surface. Flat warts vary in size whereas closed comedones are uniformly small. Acne rosacea is an acneiform eruption affecting the face in middle-aged and older persons. It can be distinguished from acne by the presence of telangiectasia and the absence of comedones.
CLINICAL EVALUATION THE HISTORY should include the time of onset, duration, severity, as well as the types and distribution of acne lesions. The use of previous acne medications, including over-the-counter preparations, and their effect, should also be noted. A knowledge of the use of cosmetics, moisturizers, body lotions, shampoos, and hair pomades may be helpful in defining exacerbating factors. The history of past health and present medical illness including menstrual disorders should be obtained. The physical examination should include an assessment of the growth parameters and sexual development. Special attention should be paid to signs of androgen excess such as hirsutism, polycystic ovaries, and obesity. Routine laboratory testing is not necessary. If there is evidence of hyperandrogenism, an evaluation of adrenal and gonadal function is indicated. COMPLICATIONS
erythema and pigmentation may result and may last for several months. Scarring may also result, especially with the severe variants such as POST INFLAMMATORY
58
acne conglobata and acne fulminans. In general, the deeper the inflammatory process, the more likely it will result in permanent scarring. Scarring can vary from small, deep punched-out pits (’ice-pick’ scars) to deep furrows and keloid or hypertrophic scars. Acne can be a psychologically traumatic disease.
Acne occurs at a time of life when personal appearance is very important and self-consciousness is at its peak. In some individuals the psychological scars can be greater than the physical scars. PREVENTION UNDER NORMAL circumstances, dietary factors are probably of no importance in the pathogenesis of acne. It is a common misconception that certain foods, particularly chocolate, pizza, fried foods, fatty foods,
and nuts make
acne worse. Studies have failed to show with these dietary factors (Rasmussen, relationship 1978). Notwithstanding this evidence, if an individual relates an exacerbation of acne to certain foods, a trial of avoidance is appropriate. Since acne is not caused by uncleanliness, frequent of the face will not prevent or clear acne. washing Obsessive scrubbing with soap may actually worsen the condition (Mills and Kligman, 1976). Nevertheless, face should be washed whenever it is oily and mately twice a day otherwise. Mild soaps are preferred a
approx the
(Esterly and Furey, 1978). Many cosmetics are capable of inciting acneiform changes. Make-up should be avoided. If cosmetics are used, water-based products instead of occlusive, oilbased products are preferred and they should be used sparingly. Pinching or popping acne lesions may rupture the pilosebaceous canal and produce larger and more persistent lesions. These practices should be discouraged.
TREATMENT of acne should be individualized. Adolescents should be counselled that treatment is available, appropriate and usually successful. A positive attitude is important. The concept that acne is normal or untreatable should be discouraged. The goals of treatment are to provide the patient with the best appearance possible and to mimimize scarring. The aims of therapy are to prevent follicular atosis, reduce P. acnes, inhibit sebum secretion THE TREATMENT
hyperke~ an
fatty acid production, and eliminate comedones. TOPICAL THERAPY
agents in the
treatment of mild to those containing benzoyl peroxide. Benzoyl peroxide is converted to benzoic acid and oxygen in the skin. The antibacterial effect on P. acnes is due to the oxidation of bacterial proteins (Auld, 1986). Benzoyl peroxide inhibits the lipolysis of sebum triglycerides and decreases the inflammation of acne lesions (Auld, 1986). In addition it has a comedolytic effect (Esterly and Furey, 1978; Hurwitz, 1979). Benzoyl peroxide is formulated in a 2.5, 5 and 10% concentration and as a gel, lotion or wash. Therapy is usually started with the application of a 5% gel once each day in the morning or on alternate days. If the gel is tolerated the frequency may be increased to twice each day or the 10% gel may be used. If the patient has THE MOST common
moderate
acne are
sensitive skin the 2.5% gel should be used. The major reported side effects are localized dryness, erythema, and peeling which, in most patients, will disappear with continued use. An allergic contact dermatitis develops in approximately 2.5% of individuals (Auld, 1986), in which case further use is contraindicated. Another topical agent is retinoic acid (Tretinoin), a naturally occurring derivative of vitamin A. Retinoic acid works by increasing cell turnover within the pilosebaceous duct and decreasing the cohesiveness of epidermal cells (Hurwitz, 1979). These effects, in turn, reverse the follicular retention hyperkeratosis and allow the keratin plugs of microcomedones to be expelled. Retinoic acid also acts as a exfoliant and results in an increased blood flow to the skin. This aids in the resolution of existing papulopustules and nodules. Retinoic acid may be administered as a gel (0.01 % or 0.025% ), cream (0.05% or 0.1 % ) or solution The creams are the least irritating. Therapy is usually started with a 0.1 % cream applied once each day in the evening. Tretinoin may be used in combination with benzoyl peroxide in the morning. Tretinoin should be applied at least 30 minutes after washing and on thoroughly dry skin. The sensitive periorbital and areas should be avoided (Matsuoka, 1983). atients should be advised that improvement may be delayed for 2 or 3 months after starting therapy. The major side effects of retinoic acid are dryness and erythema and are most pronounced with use of the liquid preparation. Retinoic acid also causes thinning of the stratum corneum which may predispose to sunburn and accelerate the carcinogemc effect of sunlight (Auld, 1986). Sunscreens are necessary in patients who are unable to avoid exposure to sun. Salicylic acid has been shown to be comedolytic in concentrations of 5 to 10% (Auld, 1986). The comedolytic effect is due to a weakening of the attachment of corneocytes by a direct action on the intercellular cement substance (Mills and Kligman, 1983). Although somewhat less effective than benzoyl peroxide or retinoic acid, salicylic acid formulations may be used for patients with mild acne, or in those who are sensitive to benzoyl peroxide or retinoic acid. The only significant adverse effect is skin irritation which is usually mild. Topical antibiotics that have been used successfully of acne include erythromycin, clindain the treatment and tetracycline. Topical antibiotics offer the of decreased total absorption and, therefore, a corresponding decrease in systemic side effects compared with systemic antibiotics. Like systemic antibiotics, topical antibiotics act by decreasing colonization with P. acnes and by inhibiting neutrophil chemotaxis. The only significant side effect is dryness and local irritation from the vehicle in which the antibiotics are contained. Topical antibiotics should be applied once or twice a day. Patients should be advised that improvement may take several months to develop. The risk of pseudomembranous colitis from the absorption of topical clindamycin is low. Topical tetracycline has been reported to stain the skin yellow in 20% of patients. In addition, a bizarre fluorescence under light has also been reported with topical
(0.05%).
Operioral
’nycin, advantages
fluorescent
tetracycline (Tunnessen, 1984). A short course of topical steroid may be helpful in severe acute inflammatory lesions (Rich, 1980). As soon as the acne is improved, other topical treatments should be instituted. Fluorinated steroids should not be
used since they may individuals.
cause
steroid
acne
in
susceptible
SYSTEMIC THERAPY
important therapy for the more of acne lesions, including papules, pustules, cysts, and abscesses. Tetracycline and erythromycin, administered systemically, produce a significant reduction in P. acnes (Editorial, 1986). In addition, both antibiotics have been shown to depress the chemotaxis of granulocytes, thereby reducing the pustular inflammatory response to follicular injury (Esterly et al, 1987). Tetracycline or erythromycin, is usually given initially in dosages of 500 to 1000mg per day. The dose is decreased according to the therapeutic response with maintenance doses of as little as 250mg per day. To maximise absorption, tetracycline should taken on an empty stomach. Tetracycline is contraindicated in pregnancy and it may cause staining of teeth in children under the age of twelve years. The most common side effects of tetracycline are mild gastrointestinal upsets and monilial vaginitis. Other side effects include. drug eruptions, photosensitivity, hepatotoxicity, onycholysis, and gram-negative folliculitis (Rich, 1980). Erythromycin is usually well tolerated. The most common side effects are gastrointestinal upsets such as nausea, vomiting, abdominal cramps, and diarrhoea, as well as moniliasis. Oral isotretinoin, 13-cis-retinoic acid (Accutane) has shown promising results in the treatment of severe inflammatory acne. Isotretinoin decreases sebum production, follicular keratinization, and the intrafollicular concentration of P. acnes (Quan and Strick, 1988). In addition, it has a direct anti-inflammatory effect. The recommended daily dosage is 0.5 to lmg per kg. Side effects develop in almost all individuals, are dose related, and include cheilitis, xerosis, conjunctivitis, pruritus, epistaxis, drying of the nasal mucosa, and dry mouth. Other adverse reactions include alopecia, photosensitivity, nausea, vomiting, palmoplantar desmusculoskeletal symptoms, headache, and quamation, increased intracranial pressure. Laboratory abnormalities associated with the use of isotretinoin include hypertriglyceridaemia (up to 25% of patients), hypercholesterolaemia (up to 7% of patients), abnormal liver function tests (up to 10% of patients), elevated erythrocyte sedimentation rate, thrombocytosis, anaemia and leucopenia. The drug has potential teratogenic effects. Women of childbearing age should not be given Accutane until pregnancy is excluded and an effective form of contraception is being used during treatment and for one month after stopping the medication. The use of oestrogens in the form of oral contraceptives in the treatment of acne is based on the ability of oestrogen to suppress the stimulatory effects of androgens on sebum production. They should only be used in women over 16 years of age with severe, recalcitrant, pustulocystic acne who do not respond to conventional therapy. Side effects of oestrogen therapy include nausea, weight gain, chloasma, monilial vaginitis, hypertension, and thromboembolic phenomenon (Hurwitz, 1979). Synthetic progestogens which are also in oral contraceptives can exacerbate acne and should not be administered alone. Patients with acne fulminans or severe acne which is unresponsive to conventional therapy may require systemic steroids. The side effects of systemic steroids include Cushing’s syndrome, diabetes mellitus, hyperORAL ANTIBIOTICS are an
inflammatory types
be
59
tension, opportunistic infection, growth suppression and osteoporosis. When systemic steroids are used, the
PROGNOSIS
PHYSICAL THERAPY
their early twenties.
should be the lowest necessary to control the acne and the medication should not be continued longer than necessary.
dosage
OCCASIONALLY, COME DONE extraction is used to
provide
immediate cosmetic effect. Comedone extraction, if may result in rupture of the improperly performed, pilosebaceous duct leading to the production of inflammatory papules and an actual worsening of appearance. Intralesional injection of 0.05 to 0.25ml of glucocorticosteroid in the form of triamcinolone acetonide or hexacetonide, 2 to 5mg per ml, usually results in rapid involution of nodular or cystic lesions. Systemic side effects are minimal since the amount injected is small. Several physical modalities are helpful in the manresulting from acne. Dermabrasion or agement laserbrasion can help in treating superficial scars if carried out carefully. Complications of dermabrasion include infection, erythema, hypertrophic scars, and alterations (Quan and Strick, 1988). scars can be smoothed by collagen implanDeeper tation. Zyderm, a highly purified, non-antigenic bovine collagen homogenate, can be injected intradermally to restore even surface contours 1980). Adverse reactions are occasionally encountered and include itching and pain at the injection site, erythema, induration, arthralgia, and local granuloma formation. an
of scars
pigmentary
(Cahn,
treatment, the prognosis is very good. Most cases of acne respond to treatment within two months of starting therapy. The usual course of acne is one of several years’ duration with most patients showing clearing of acne by WITH PROPER
REFERENCES
AULD, J. Topical therapy of acne. Aust. J. Dermatol., (1986). 27: 118-124. CAHN, R. L. Current status of acne treatment. Postgrad. Med., (1980).
67 :117-130. Editorial. III Acne. J. Invest. ESTERLY, , N. B., FUREY, N. L.
73: 434-442. (1979). ., Dermatol Acne: Current concepts. Paediatrics,
(1978). 1044-1053. 62: ESTERLY, N. B., FUREY, N. L., antimicrobial agents on leukocyte
70: (1987). 51-55. HURWITZ, S. Acne
FLANAGAN, L. E. The effect of chemotaxis. J. Invest. Dermatol.,
vulgaris: Current concepts
treatment. Am. J. Dis.
of
., (1979). 133: 536-544. Child
pathogenesis
and
MATSUOKA, L. Y. Acne. J. Pediatr ., (1983). 103: 849-854. MILLS, O. H. Jr, KLIGMAN, A.M.. Acne detergicans. Arch. Dermatol.,
111: (1976). 65-68.
MILLS, O. H. Jr., KLIGMAN, A. M. Assay of comedolytic activity in acne Acta. Derm. Venereol., (1983). 63: 68-71. PAULI, S. L., KOKKO, M. L., SUHONEN, R., et al. Acne fulminans with bone lesions. Acta. Derm. Venereol., (1988). 68: 351-355. QUAN, M., STRICK, R. A. Management of acne vulgaris. Am. Fam.
patients.
Physician, (1988). 38: 207-218.
RADEMAKER M., GARIOCH, J. J., SIMPSON, N. B. Acne in schoolchildren: longer a concern for dermatologists. Br. Med. J., (1989). 298:
No
1217-1219. RASMUSSEN, J. E. A
new
look at old
acne.
., Am
Padiatr. Clin. North
(1978). 25: 285-303. RICH, M. Acne: Emphasis on adolescent acne and the role of antibiotics. Aust. Fam. Physician 768-774. , (1980). 9:
TUNNESSEN, W. W. Jr. Acne: An approach to therapy for the pediatrician. Adv. Pediatr.,
31: 325-358. (1984).
Report on Royal Society of Health Study Day 22.11.90 ’Stress and the Professional’ There was a tightly packed programme. The topics were: 1 Stress and Illness: Occupational Hazards 2 Operational Stress in Ambulance Personnel 3 Secondhand Stress: Police Officers at Lockerbie 4 Disaster Psychiatry: Caring for the Carers 5 Preparing to Respond to Stress and Suicidal Behaviour 6 Techniques and Devices to Cope with Stress ’Stress and Illness’: Professor Tom Cox gave a brief but fascinating overview of Stress in general, and defined it as ’the experience of unmanageable pressure and challenge’, an experience made worse if the person has little or no control over the situation and no support. He made a distinction between Chronic Stress: the ongoing pressures of daily life, including job, money, relationships, etc.; and Traumatic Stress, suffered as a result of sudden pressures, such as accident or emergency. He felt there were two main tactics for stress relief: a) making the client feel better, and b) tackling the stressful situation. He felt that most organizations favoured (a) and the dan er was that this could absolve them from the need to tackle He was against organizations buying in counselling or stress management programmes without careful consideration and evaluation, as they could result in the ’elastoplast’ solution with the emphasis on the ’walking wounded’ rather than tackling the larger issues within the organization. After this thought-provoking start most speakers then concentrated on traumatic stress. There was some competition along the lines of ’my disasterwas bigger than yours’ and a danger that stress might be identified as only related to a huge, visible, trauma rather than the enormous, not-so-public traumas we can all suffer. This is happening in the child abuse field where ritual abuse is somehow seen, in the media at least, as worse than ’ordinary abuse’ patently untrue for
~).
-
60
the victim and family, and undermining for workers. There was discussion of special teams being set up for dealing with disasters, and a general avoidance of how this might create a hierarchy within the workers and some resentment in those ’left behind’ to cope with the pile up of more general work. The Naval Psychiatrist (speaker 4) addressed some of these issues when talking of his work with military personnel, especially relevant now as he prepares the force in the Gulf. As Servicemen are used more often now in civilian crises it was especially interesting to hear how the Forces prepared for stress. It seems that the military prepare their workforce well, and support and finance their services better than most disciplines. They expect that a percentage will be unable cope with the stress of Service life. Without strong backing from the organization, belief in the value of support and the money to build an all-round service, there was no point in bothering to pay lip-service to the idea of being a caring
other( to
employer. This point was reiterated by the two speakers offering techniques to cope with stress, who also mentioned that support must be for all.
Every speaker mentioned ’counselling’
counsellors
but
only
two
present. Several police forces mentioned their counselling services; some had force personnel as were
counsellors, others had
contracts
with outside
agencies
to
provide a counselling service. Everyone stressed the need for a confidential service, but Some thought counsellors would be useless as they would have no experience of the ...
work - as if work was the only stress factor! It seems to me there is real scope for the R.S.H. to run a seminar on Stress and the Professional which deals with the stresses inherent in being a care or crisis worker and the
dangers when these combme with distress in everyday life.
ADRIENNE HIRSCHFELD
a common and distressing problem for adolescents. The term is denved from the Greek word ’acme’, which means ’prime of life’. Although generally considered to be a benign, selflimited condition, acne may cause severe psychological problems or disfiguring scars that may persist for a
CNE is
many
lifetime.
Currently available therapeutic agents are suppressing inflammatory acne and preventing scarring in many patients. All clinicians caring
effective in
for children
adolescents should be familiar with the clinical manifestations, differential diagclinical evaluation, and treatment of acne. or
pathogenesis,
nosis,
EPIDEMIOLOGY than 80% of the population during the second and third decades of life (Editorial, 1979). Rademaker et al reported that the prevalence of acne 10 boys increased from 40% at age 12 years to 95% at age 16 years (Rademaker, et al, 1989). In girls the incidence increased from 61% to 83% (Rademaker, et similarly al, 1989). Clinically significant acne affects approximately 20 to 25% of the population between the ages of 12 and 25 years (Editonal, 1979). The peak incidence of acne occurs during the middle-to-late teenage years and, thereafter, the incidence decreases. The condition is seen in 10 to 15% of adults aged 30 to 40 years, and may progress into later life (Rich, 1980). Acne tends to be more severe among males than females. There is a genetic basis to acne, with a high concordance rate in identical twins (Rich, 1980). The condition is found worldwide. There is no evidence that ethnic or racial differences influence the susceptibility ACNE AFFECTS more
to acne.
PATHOGENESIS ACNE is a disease of the pilosebaceous follicle which consists of large, multiacinar sebaceous glands, a rudimentary hair, and a follicular canal composed of an acro-infundibulum in its upper portion and an infrainfundibulum in its dennal portion. Acne is uniquely human, since sebaceous follicles do not occur in lower animals. Acne usually occurs with the onset of puberty. Under androgenic stimulation, sebaceous glands enlarge and increase their sebum production. Serum androgens are derived from the testes in the male and from the ovaries and adrenal glands in the female. Numerous studies have demonstrated that testosterone is converted to the more potent metabolite dihydrotestosterone by 5Address for correspondence: Dr Alexander K. C. Leung, Alberta 1820 Richmond Road SW, Calgary, Alberta, Children’s Canada T2T5C7.
Hospital,
alpha-reductase, an enzyme present in human skin (Hurwitz, 1979). Current research suggests that dihydrotestosterone is the tissue androgen that causes the hypertrophy of the sebaceous gland and increased production of sebum (Hurwitz, 1979). This explains why elevated androgen levels are seldom found m the blood or urine from patients with acne. When initially produced, sebum is composed of a mixture of triglycerides (60%), wax esters (20%), squalene (a cholesterol precursor) (10%), and miscellaneous minor components (10%) (Rasmussen, 1978). In the pilosebaceous gland, about half of the triglycerides are enzymatically hydrolyzed into free fatty acids and glycerol by lipase from the anaerobic bacterium acnes (P. Acnes), an organism that Propionibacterium increases dramatically at the time of puberty. The free fatty acids, once released into the skm through follicular are cytotoxic and contribute to the inflammatory reaction. Obstruction of the pilosebaceous canal precedes the development of the acne lesion. The obstruction is produced by the accumulation of adherent keratinized
breakdown,
cells within the canal that form an impaction obstructing the flow of sebum. The cause of this abnormality of keratinization is unknown, but the process may be under the influence of androgens. When the normal flow of sebum onto the skin surface is obstructed by follicular hyperkeratosis, a microcomedo is initiating the process of acne.
formed,
CLINICAL MANIFESTATIONS the face, and to a lesser back, chest, and shoulders. These areas correspond to the distribution of the largest and most numerous pilosebaceous units in the body. The distal extremities are always spared. The pathognomonic lesion of acne is the comedo, which may be either open or closed. An open comedo, also called a blackhead, is a flat or slightly raised, black lesion, measuring 1 to 3mm in diameter. The black surface of the open comedo is melanin (Rasmussen, 1978), not dirt or oxidized fat. The pigmentation is limited to the tip of the comedo because melanocytes are present only in the upper portion of the sebaceous follicle. A closed comedo, commonly known as a ACNE LESIONS tend to occur on extent, on the upper
whitehead, appears
as a
pale, slightly elevated papule
without a readily visible central pore. It is flask-shaped with the most narrow portion connected to the skin surface. Blackheads do not generally become inflamed unless the pilosebaceous canal is disrupted by external forces, such as may occur by squeezing the lesions. Whiteheads may either open up their pores resulting in blackheads 57
they may evolve into pustules. For this reason, closed comedones have been called ’the time bombs of acne’. With rupture of the obstructed follicle and release of free fatty acids into the surrounding tissue, an inflammatory reaction ensues, resulting in erythematous papules, pustules, nodules, or cysts depending on the amount and location of the tissue involved, and the magnitude of the inflammatory response. Acne cysts are not true cysts, but rather nodules that have become fluctuant as a result of suppuration. Acne conglobata, found predominately in males, is a severe, destructive and highly inflammatory form of acne marked by the presence of multiporous comedones, nodules, cysts, abscesses and draining sinus tracts on the upper trunk and posterior back. Acne fulminans is a rare form of acne characterized by the sudden eruption of large, necrotic, ulcerating nodulocystic lesions on the back and chest in association with systemic manifestations such as fever, chills, malaise, weight loss, musculoskeletal pain, polyarthralgia, leucocytosis, anaemia, elevated erythrocyte sedimentation rate, and osteolytic bone lesions (Pauli et al, or
1988). DIFFERENTIAL DIAGNOSIS is a common skin manifestation of tuberous sclerosis. Clinically, these lesions appear as
ADENOMA SEBACEUM
small, reddish, brown, or even flesh-coloured, smooth, 1 to 3 mm papules present over the sides of the nose and the medial aspects of the cheeks. They are not
shiny,
associated with comedones respond to anti-acne therapy. Flat warts (verruca plana)
or
pustules
and do not
are small, usually 2 to 4 slightly elevated flat-topped papules with a finely roughened surface. They may be differentiated from closed comedones which have a dome shape and a
mm,
smooth surface. Flat warts vary in size whereas closed comedones are uniformly small. Acne rosacea is an acneiform eruption affecting the face in middle-aged and older persons. It can be distinguished from acne by the presence of telangiectasia and the absence of comedones.
CLINICAL EVALUATION THE HISTORY should include the time of onset, duration, severity, as well as the types and distribution of acne lesions. The use of previous acne medications, including over-the-counter preparations, and their effect, should also be noted. A knowledge of the use of cosmetics, moisturizers, body lotions, shampoos, and hair pomades may be helpful in defining exacerbating factors. The history of past health and present medical illness including menstrual disorders should be obtained. The physical examination should include an assessment of the growth parameters and sexual development. Special attention should be paid to signs of androgen excess such as hirsutism, polycystic ovaries, and obesity. Routine laboratory testing is not necessary. If there is evidence of hyperandrogenism, an evaluation of adrenal and gonadal function is indicated. COMPLICATIONS
erythema and pigmentation may result and may last for several months. Scarring may also result, especially with the severe variants such as POST INFLAMMATORY
58
acne conglobata and acne fulminans. In general, the deeper the inflammatory process, the more likely it will result in permanent scarring. Scarring can vary from small, deep punched-out pits (’ice-pick’ scars) to deep furrows and keloid or hypertrophic scars. Acne can be a psychologically traumatic disease.
Acne occurs at a time of life when personal appearance is very important and self-consciousness is at its peak. In some individuals the psychological scars can be greater than the physical scars. PREVENTION UNDER NORMAL circumstances, dietary factors are probably of no importance in the pathogenesis of acne. It is a common misconception that certain foods, particularly chocolate, pizza, fried foods, fatty foods,
and nuts make
acne worse. Studies have failed to show with these dietary factors (Rasmussen, relationship 1978). Notwithstanding this evidence, if an individual relates an exacerbation of acne to certain foods, a trial of avoidance is appropriate. Since acne is not caused by uncleanliness, frequent of the face will not prevent or clear acne. washing Obsessive scrubbing with soap may actually worsen the condition (Mills and Kligman, 1976). Nevertheless, face should be washed whenever it is oily and mately twice a day otherwise. Mild soaps are preferred a
approx the
(Esterly and Furey, 1978). Many cosmetics are capable of inciting acneiform changes. Make-up should be avoided. If cosmetics are used, water-based products instead of occlusive, oilbased products are preferred and they should be used sparingly. Pinching or popping acne lesions may rupture the pilosebaceous canal and produce larger and more persistent lesions. These practices should be discouraged.
TREATMENT of acne should be individualized. Adolescents should be counselled that treatment is available, appropriate and usually successful. A positive attitude is important. The concept that acne is normal or untreatable should be discouraged. The goals of treatment are to provide the patient with the best appearance possible and to mimimize scarring. The aims of therapy are to prevent follicular atosis, reduce P. acnes, inhibit sebum secretion THE TREATMENT
hyperke~ an
fatty acid production, and eliminate comedones. TOPICAL THERAPY
agents in the
treatment of mild to those containing benzoyl peroxide. Benzoyl peroxide is converted to benzoic acid and oxygen in the skin. The antibacterial effect on P. acnes is due to the oxidation of bacterial proteins (Auld, 1986). Benzoyl peroxide inhibits the lipolysis of sebum triglycerides and decreases the inflammation of acne lesions (Auld, 1986). In addition it has a comedolytic effect (Esterly and Furey, 1978; Hurwitz, 1979). Benzoyl peroxide is formulated in a 2.5, 5 and 10% concentration and as a gel, lotion or wash. Therapy is usually started with the application of a 5% gel once each day in the morning or on alternate days. If the gel is tolerated the frequency may be increased to twice each day or the 10% gel may be used. If the patient has THE MOST common
moderate
acne are
sensitive skin the 2.5% gel should be used. The major reported side effects are localized dryness, erythema, and peeling which, in most patients, will disappear with continued use. An allergic contact dermatitis develops in approximately 2.5% of individuals (Auld, 1986), in which case further use is contraindicated. Another topical agent is retinoic acid (Tretinoin), a naturally occurring derivative of vitamin A. Retinoic acid works by increasing cell turnover within the pilosebaceous duct and decreasing the cohesiveness of epidermal cells (Hurwitz, 1979). These effects, in turn, reverse the follicular retention hyperkeratosis and allow the keratin plugs of microcomedones to be expelled. Retinoic acid also acts as a exfoliant and results in an increased blood flow to the skin. This aids in the resolution of existing papulopustules and nodules. Retinoic acid may be administered as a gel (0.01 % or 0.025% ), cream (0.05% or 0.1 % ) or solution The creams are the least irritating. Therapy is usually started with a 0.1 % cream applied once each day in the evening. Tretinoin may be used in combination with benzoyl peroxide in the morning. Tretinoin should be applied at least 30 minutes after washing and on thoroughly dry skin. The sensitive periorbital and areas should be avoided (Matsuoka, 1983). atients should be advised that improvement may be delayed for 2 or 3 months after starting therapy. The major side effects of retinoic acid are dryness and erythema and are most pronounced with use of the liquid preparation. Retinoic acid also causes thinning of the stratum corneum which may predispose to sunburn and accelerate the carcinogemc effect of sunlight (Auld, 1986). Sunscreens are necessary in patients who are unable to avoid exposure to sun. Salicylic acid has been shown to be comedolytic in concentrations of 5 to 10% (Auld, 1986). The comedolytic effect is due to a weakening of the attachment of corneocytes by a direct action on the intercellular cement substance (Mills and Kligman, 1983). Although somewhat less effective than benzoyl peroxide or retinoic acid, salicylic acid formulations may be used for patients with mild acne, or in those who are sensitive to benzoyl peroxide or retinoic acid. The only significant adverse effect is skin irritation which is usually mild. Topical antibiotics that have been used successfully of acne include erythromycin, clindain the treatment and tetracycline. Topical antibiotics offer the of decreased total absorption and, therefore, a corresponding decrease in systemic side effects compared with systemic antibiotics. Like systemic antibiotics, topical antibiotics act by decreasing colonization with P. acnes and by inhibiting neutrophil chemotaxis. The only significant side effect is dryness and local irritation from the vehicle in which the antibiotics are contained. Topical antibiotics should be applied once or twice a day. Patients should be advised that improvement may take several months to develop. The risk of pseudomembranous colitis from the absorption of topical clindamycin is low. Topical tetracycline has been reported to stain the skin yellow in 20% of patients. In addition, a bizarre fluorescence under light has also been reported with topical
(0.05%).
Operioral
’nycin, advantages
fluorescent
tetracycline (Tunnessen, 1984). A short course of topical steroid may be helpful in severe acute inflammatory lesions (Rich, 1980). As soon as the acne is improved, other topical treatments should be instituted. Fluorinated steroids should not be
used since they may individuals.
cause
steroid
acne
in
susceptible
SYSTEMIC THERAPY
important therapy for the more of acne lesions, including papules, pustules, cysts, and abscesses. Tetracycline and erythromycin, administered systemically, produce a significant reduction in P. acnes (Editorial, 1986). In addition, both antibiotics have been shown to depress the chemotaxis of granulocytes, thereby reducing the pustular inflammatory response to follicular injury (Esterly et al, 1987). Tetracycline or erythromycin, is usually given initially in dosages of 500 to 1000mg per day. The dose is decreased according to the therapeutic response with maintenance doses of as little as 250mg per day. To maximise absorption, tetracycline should taken on an empty stomach. Tetracycline is contraindicated in pregnancy and it may cause staining of teeth in children under the age of twelve years. The most common side effects of tetracycline are mild gastrointestinal upsets and monilial vaginitis. Other side effects include. drug eruptions, photosensitivity, hepatotoxicity, onycholysis, and gram-negative folliculitis (Rich, 1980). Erythromycin is usually well tolerated. The most common side effects are gastrointestinal upsets such as nausea, vomiting, abdominal cramps, and diarrhoea, as well as moniliasis. Oral isotretinoin, 13-cis-retinoic acid (Accutane) has shown promising results in the treatment of severe inflammatory acne. Isotretinoin decreases sebum production, follicular keratinization, and the intrafollicular concentration of P. acnes (Quan and Strick, 1988). In addition, it has a direct anti-inflammatory effect. The recommended daily dosage is 0.5 to lmg per kg. Side effects develop in almost all individuals, are dose related, and include cheilitis, xerosis, conjunctivitis, pruritus, epistaxis, drying of the nasal mucosa, and dry mouth. Other adverse reactions include alopecia, photosensitivity, nausea, vomiting, palmoplantar desmusculoskeletal symptoms, headache, and quamation, increased intracranial pressure. Laboratory abnormalities associated with the use of isotretinoin include hypertriglyceridaemia (up to 25% of patients), hypercholesterolaemia (up to 7% of patients), abnormal liver function tests (up to 10% of patients), elevated erythrocyte sedimentation rate, thrombocytosis, anaemia and leucopenia. The drug has potential teratogenic effects. Women of childbearing age should not be given Accutane until pregnancy is excluded and an effective form of contraception is being used during treatment and for one month after stopping the medication. The use of oestrogens in the form of oral contraceptives in the treatment of acne is based on the ability of oestrogen to suppress the stimulatory effects of androgens on sebum production. They should only be used in women over 16 years of age with severe, recalcitrant, pustulocystic acne who do not respond to conventional therapy. Side effects of oestrogen therapy include nausea, weight gain, chloasma, monilial vaginitis, hypertension, and thromboembolic phenomenon (Hurwitz, 1979). Synthetic progestogens which are also in oral contraceptives can exacerbate acne and should not be administered alone. Patients with acne fulminans or severe acne which is unresponsive to conventional therapy may require systemic steroids. The side effects of systemic steroids include Cushing’s syndrome, diabetes mellitus, hyperORAL ANTIBIOTICS are an
inflammatory types
be
59
tension, opportunistic infection, growth suppression and osteoporosis. When systemic steroids are used, the
PROGNOSIS
PHYSICAL THERAPY
their early twenties.
should be the lowest necessary to control the acne and the medication should not be continued longer than necessary.
dosage
OCCASIONALLY, COME DONE extraction is used to
provide
immediate cosmetic effect. Comedone extraction, if may result in rupture of the improperly performed, pilosebaceous duct leading to the production of inflammatory papules and an actual worsening of appearance. Intralesional injection of 0.05 to 0.25ml of glucocorticosteroid in the form of triamcinolone acetonide or hexacetonide, 2 to 5mg per ml, usually results in rapid involution of nodular or cystic lesions. Systemic side effects are minimal since the amount injected is small. Several physical modalities are helpful in the manresulting from acne. Dermabrasion or agement laserbrasion can help in treating superficial scars if carried out carefully. Complications of dermabrasion include infection, erythema, hypertrophic scars, and alterations (Quan and Strick, 1988). scars can be smoothed by collagen implanDeeper tation. Zyderm, a highly purified, non-antigenic bovine collagen homogenate, can be injected intradermally to restore even surface contours 1980). Adverse reactions are occasionally encountered and include itching and pain at the injection site, erythema, induration, arthralgia, and local granuloma formation. an
of scars
pigmentary
(Cahn,
treatment, the prognosis is very good. Most cases of acne respond to treatment within two months of starting therapy. The usual course of acne is one of several years’ duration with most patients showing clearing of acne by WITH PROPER
REFERENCES
AULD, J. Topical therapy of acne. Aust. J. Dermatol., (1986). 27: 118-124. CAHN, R. L. Current status of acne treatment. Postgrad. Med., (1980).
67 :117-130. Editorial. III Acne. J. Invest. ESTERLY, , N. B., FUREY, N. L.
73: 434-442. (1979). ., Dermatol Acne: Current concepts. Paediatrics,
(1978). 1044-1053. 62: ESTERLY, N. B., FUREY, N. L., antimicrobial agents on leukocyte
70: (1987). 51-55. HURWITZ, S. Acne
FLANAGAN, L. E. The effect of chemotaxis. J. Invest. Dermatol.,
vulgaris: Current concepts
treatment. Am. J. Dis.
of
., (1979). 133: 536-544. Child
pathogenesis
and
MATSUOKA, L. Y. Acne. J. Pediatr ., (1983). 103: 849-854. MILLS, O. H. Jr, KLIGMAN, A.M.. Acne detergicans. Arch. Dermatol.,
111: (1976). 65-68.
MILLS, O. H. Jr., KLIGMAN, A. M. Assay of comedolytic activity in acne Acta. Derm. Venereol., (1983). 63: 68-71. PAULI, S. L., KOKKO, M. L., SUHONEN, R., et al. Acne fulminans with bone lesions. Acta. Derm. Venereol., (1988). 68: 351-355. QUAN, M., STRICK, R. A. Management of acne vulgaris. Am. Fam.
patients.
Physician, (1988). 38: 207-218.
RADEMAKER M., GARIOCH, J. J., SIMPSON, N. B. Acne in schoolchildren: longer a concern for dermatologists. Br. Med. J., (1989). 298:
No
1217-1219. RASMUSSEN, J. E. A
new
look at old
acne.
., Am
Padiatr. Clin. North
(1978). 25: 285-303. RICH, M. Acne: Emphasis on adolescent acne and the role of antibiotics. Aust. Fam. Physician 768-774. , (1980). 9:
TUNNESSEN, W. W. Jr. Acne: An approach to therapy for the pediatrician. Adv. Pediatr.,
31: 325-358. (1984).
Report on Royal Society of Health Study Day 22.11.90 ’Stress and the Professional’ There was a tightly packed programme. The topics were: 1 Stress and Illness: Occupational Hazards 2 Operational Stress in Ambulance Personnel 3 Secondhand Stress: Police Officers at Lockerbie 4 Disaster Psychiatry: Caring for the Carers 5 Preparing to Respond to Stress and Suicidal Behaviour 6 Techniques and Devices to Cope with Stress ’Stress and Illness’: Professor Tom Cox gave a brief but fascinating overview of Stress in general, and defined it as ’the experience of unmanageable pressure and challenge’, an experience made worse if the person has little or no control over the situation and no support. He made a distinction between Chronic Stress: the ongoing pressures of daily life, including job, money, relationships, etc.; and Traumatic Stress, suffered as a result of sudden pressures, such as accident or emergency. He felt there were two main tactics for stress relief: a) making the client feel better, and b) tackling the stressful situation. He felt that most organizations favoured (a) and the dan er was that this could absolve them from the need to tackle He was against organizations buying in counselling or stress management programmes without careful consideration and evaluation, as they could result in the ’elastoplast’ solution with the emphasis on the ’walking wounded’ rather than tackling the larger issues within the organization. After this thought-provoking start most speakers then concentrated on traumatic stress. There was some competition along the lines of ’my disasterwas bigger than yours’ and a danger that stress might be identified as only related to a huge, visible, trauma rather than the enormous, not-so-public traumas we can all suffer. This is happening in the child abuse field where ritual abuse is somehow seen, in the media at least, as worse than ’ordinary abuse’ patently untrue for
~).
-
60
the victim and family, and undermining for workers. There was discussion of special teams being set up for dealing with disasters, and a general avoidance of how this might create a hierarchy within the workers and some resentment in those ’left behind’ to cope with the pile up of more general work. The Naval Psychiatrist (speaker 4) addressed some of these issues when talking of his work with military personnel, especially relevant now as he prepares the force in the Gulf. As Servicemen are used more often now in civilian crises it was especially interesting to hear how the Forces prepared for stress. It seems that the military prepare their workforce well, and support and finance their services better than most disciplines. They expect that a percentage will be unable cope with the stress of Service life. Without strong backing from the organization, belief in the value of support and the money to build an all-round service, there was no point in bothering to pay lip-service to the idea of being a caring
other( to
employer. This point was reiterated by the two speakers offering techniques to cope with stress, who also mentioned that support must be for all.
Every speaker mentioned ’counselling’
counsellors
but
only
two
present. Several police forces mentioned their counselling services; some had force personnel as were
counsellors, others had
contracts
with outside
agencies
to
provide a counselling service. Everyone stressed the need for a confidential service, but Some thought counsellors would be useless as they would have no experience of the ...
work - as if work was the only stress factor! It seems to me there is real scope for the R.S.H. to run a seminar on Stress and the Professional which deals with the stresses inherent in being a care or crisis worker and the
dangers when these combme with distress in everyday life.
ADRIENNE HIRSCHFELD
