1. Omar Abdulaziz Al-Sheikh, M.D.
Acne and Acne related disorders Disorders of sebaceous glands and Rosacea
Omar Abdulaziz Al-Sheikh, M.D.
College of Medicine
King Saud University

2. Objectives
Acquiring knowledge of the etiology and pathogenesis of acne and acne related disorders.
Understanding the disease spectrum and various types of clinical presentations.
Knowing the differential diagnosis of acne and related disorders.
Acquiring knowledge of the therapeutic options and their indications.
to be familiar with the etiology, clinical types and treatment of rosacea.

3. Definition:
Is a chronic inflammatory disorder of the pilosebaceous apparatus of certain body area (Face> Torso > rarely the Buttocks), resulting in greasiness and polymorphic skin eruption.

4. Incidence:
Acne affects all skin types, the male and female ratio is virtually the same but tends to be more severe in males.
85% affects the age group 12 – 24 years
8% affects the age group 25 – 34 years
3% affects the age group 35 – 44 years

5. Etiology:
Genetic Aspect, (Acne runs in family) other example: the case of severe acne that is associated with XXY syndrome.
Occupation (Environmental, Mechanical) e.g. exposure to acnegenic mineral oil (Pomade acne), dioxin
Drugs Oral and topical Hydrocortison (Steroid acne), Lithium, Hydantoin, contraceptives
Endocrine Factors (Recalcitrant Acne, POD/s, MARSH Syndrome) .

6. Pathogenesis: ( three main steps recognized and hypothesized)
1. Follicular Hyperkeratosis (the cause not fully understood) theory suggest:
deficiency in Linoleic acid,
the effect of 5-a reductase enzyme on converting Androgen (Testosterone) hormone to the active acnegenic and potent (Dihydrotestosterone) DHT,
the direct effect of Interleukin-1 on follicular hyperkeratosis

7. Fig 1
Fig 2
Fig 3
Perifollicular Hyperkeratosis histology

8. Seborrhoea is a common feature between patients with acne.
2. Abnormal production of abnormal sebum increasing the ratio of wax ester to cholesterol and cholesterol ester and is believed to be the response of sebaceous glands to DHEA

9. 3. Colonization of the affected unit with bacteria Propionibacterium acne and yeast named Malassezia furfur
Fig 4
Fig 5
Malassezia furfur
Propionibacterium acne

10. P acne is a potent activator of complement via classical pathway
Fig 6
Fig 7

11. Propionobacterium acne lipases act on sebaceous fatty acid (Triglycrides) to release irritant free fatty acid and low-molecular- weight peptide an extra cellular factor that penetrate the follicular wall and stimulate Polymorphs and Lymphocytes initiating inflammation
Fig 8

12. Hydrolytic enzymes released from the activated complement antibodies complex together with exoenzymes produced from P acne cause rupture of follicular wall
Fig 9

13. Once the wall is damaged Various agents (prostaglandin-like substance, amino acid, short chain fatty acids) that are produced by the inflammatory cells and P acne extrude to the dermis causing more inflammation

14. Clinical features: (Acne and acne related Disorders)
Acne Vulgaris:
Papules: (Less than 0.5 cm)
Comedones (Open “Blackheads” or closed “Whiteheads”)

15. Open Comedones (Blackheads)
Fig 10
Fig 11
Open Comedones

16. Closed Comedones (Whitehead)
Fig 12
Fig 13
Closed Comedones

17. Inflammatory papules
Fig 14
Fig 15
Inflammatory papules

18. Pustules :
Fig 16
Fig 17
Pustules

19. Nodule (more than 0.5 cm)
Fig 18
Fig 19
Nodule

20. Cystic acne: the cysts are usually large 1-4cm
Fig 20
Fig 21

21. 2. The nodules and cysts could be associated with sinuses as in Acne inversa
Acne inversea (Hidradenitis suppurativa “a misleading name”) because it is considered by some to be a disorder of apocrine gland (Sweat gland) but In my opinion Acne inversa affects primarily the Pilo Seb. Unit and affect secondarily the sweat gland, hence the correct name Acne inversa rather than Hidradenitis suppurativa is preferred.

22. Fig 22

23. 3. Neonatal Acne and Infantile Acne
Neonatal acne: cause unknown but some believed is due to passing of Transplacental androgen other suggest the role of Mlalassezia furfur and sympodalis . affect 1 in 5 mainly inflammatory comedones on nose and cheeks affect new born between the 1st and 6th week of age

24. Fig 23

25. Infantile Acne: affect males more than females, usually between 3 and 6 months of age, and tend to be severer than the neonatal one and believed to be due to Endogenic androgen from the infant’s gonads.

26. Fig 24

27. 4. Recalcitrant Acne
Affect Women and associated with (Adrenal hyperplasia "11-B- or 21-B hydroxlase deficiencies) acne is usually nodulocystic

28. 5. Acne Fulminans
Affect youngsters 13 – 17 years of age, very severe with ulceration and puss discharge, associated symptoms include (fever, malaise, myalgia, arthritis and bone pain) laboratory investigation shows ESR
Can be induced by starting the patient on high dose of isotretinion (Roaccutane).

29. Fig 25

30. 6. Acne Conglobata
Very severe Acne, Nodulocystic form with abscess formation, affect Torso more than the face, usually associated with XYY Syndrome.

31. Fig 26
Fig 27

32. 7. Acne Agminata (Lupus Milliaris Disseminatus Faciei)
Some believe it is form of Rosacea (Granulomatous type), diagnosis is made at Histological base, Caseating Granulomata at the dermal level.

33. Fig 28

34. 8. Acne as part of other syndromes
MARSH Syndrome (Melsma, Acne, Rosacea, ,Seborrhoeic eczema, and Hirsutism)
Acne Conglobata
Favre Racouchot syndrome elderly with elastosis as part of Helioderma, sun exposure is a predisposing factor.
Polycystic ovarian syndrome
Atrophoderma vermiculatum as part of so called Ulerythema ophryogenes, in Noonan Syndrome, de Lange Syndrome, and Rubinstein-Taybi Syndrome  Not considered acne

35. 9. Occupational I Environmental
Chloracne rare forms of acne affect patients exposed to Halogenated Hydrocarbons or who ingested Chlorinated Phenols (Dioxin)
Pomade acne or known as Oil Folliculitis
Acne Aestivalis or so called Mallorca Acne

36. Occupational II mechanical acne
Folicullitis Nuchae or so called Acne Keloidalis
Pseudofollicultis barbae
Acne excoriee as part of Psychodermatosis

37. TREATMENT Note: All medications used for the treatment of acne act as:
Anti comedonal
Anti inflammatory
Anti microbial

38. Topical Keratolytic
Retinoid ( Retinoic acid 0.025, 0.05, 0.1%)
Adapalene (Differin 0.1%)
Salicylic acid
Benzoyl peroxide (peeling agent and antimicrobial)
Azelaic Acid (10, 15, 20 %)

39. Topical Antibiotic
Topical clindamycin (Dalacin T)
Erythromycin
Mupirocin (Bactroban)
Sodium Fusidic acid (less significant in the treatment)

40. Systemic therapy
Antibiotic (Macrolides and Tetracylines)
Tetracycline
Doxycycline
Minocycline (blue grey discoloration and drug induced LE)
Azithromycin

41. Systemic Retinoids : Isotretinoin caps (Roaccutane): 0.5 – 1 mg/kg
The most effective drug for acne.
Indicated for severe forms (nodulocystic and fulminant) but also for milder forms associated with scarring or with significant psychological impact.
Relapse is minimal with cumulative dose of 120 – 150 mg/kg.
Side effects include: cheilitis, dryness, alopecia (less frequent than with acitretin), photosensitivity, xerophthalmia, decreased night vision, keratitis, benign intracranial hypertension (incresed risk with concomitant use of tetracyclines), photosensitivity, hypertriglyceridemia, hypercholesterolemia, elevated liver enzymes, depression (controversial), skeletal hyperostosis, myalgias.
Teratogenicity : Retinoid - induced embryopathy. Pregnancy category X.
Pregnancy must be prevented during treatment and for at least 1 month after discontinuing the drug.

42. Other forms of therapy
Systemic steroid (Prednisolone): for acne fulminans and intralesional steriods for cystic acne.
Photodynamic therapy i.e. Laser therapy and phototherapy (Less significant)
SMT D002 is a new promising and potentially safe medication (Oxybutynin chloride), it has successfully completed two Phase I trials in healthy volunteers and believed to treat seborrhoea, a symptom of Parkinson's disease and the primary cause of acne. Topical formulation of the drug is currently being developed by Summit company.
Hormonal therapy (Anti-androgen)
Spironolacton (Potassium sparing agent) and Metformin as (Hypogylcemic agent) in treatment of PCOS (Polycystic Ovary Syndrome) have good results on acne

43. Rosacea
A controversial topic in dermatology largely because of its uncertain pathophysiology and clinical variation.
Erythema of the central face that has persisted for months or more.
Primary features: flushing, papules pustules and telangiectases.
Secondary features: burning, stinging, edema, plaques, dry appearance, phyma, peripheral flushing and ocular manifestations.

44. Epidemiology Common in caucasian population Fair skinned individuals
women>men
Onset typically begins after age 30

45. Etiology and pathogenesis
1) Vascular reactivity:
Rosacea is induced by chronic repeated triggers of flushing exposure, they include:
1) Hot or cold temperature ) Sunlight
2) Hot drinks
3) Spicy foods
4) Alcohol ) Emotional disteress
5) Certain cosmetics ) Topical irritants
6) Medications

46. Etiology and pathogenesis
2) Dermal matrix degeneration and endothelial damage
Inherent problems with vessels permeability
Delayed clearance of inflammatory mediators and waste products
Photodamaged connective tissue (solar elastosis is a common background on which rosacea histologic features are superimposed

47. Etiology and pathogenesis
The role of microbe – induced follicle based inflammation
Commensal organisms which reside in hair follicles and sebaceous glands may trigger folliculocentric inflammatory papules.
Demodex folliculorum (mite) or associated bacteria (bacillus oleronius).

48. Sub-type classification
Sub types were defined by the National Rosacea Society (NRS) expert committee in 2002.
1) Erythematotelangiectatic : persistent erythema and telangiectasias on the central face.
2) Papulopustular: papules and pustules predominate on convex areas on a background of persistent erythema
3) Phymatous: patulous follicular orifices, thickened skin and nodularity
Most often affect the nose (rhinophyma)
Almost exclusively in men
4) Ocular: Blepharitis is the most common feature (mebomian gland dysfunction)
Conjuctivitis, iritis, scleritis, keratitis

49. Fig 29 Erythematotelangiectatic Rosacea

50. Fig 30 Papulopustular Rosacea

51. Fig Rhinophyma

52. Rosacea variants
Granulomatous rosacea: Rosacea variant characterised by monomorphic yellow brown or red papules/ nodules located on the cheeks and periorificial skin.
Granulomas on histology
The background facial skin is otherwise normal

53. Differential Diagnosis
Full and detailed history (including medications)is required,
Medications that induce flushing include : all vasodilators, calcium channel blockers, nicotinic acid, morphine, amyl and butyl nitrite, cholinergic drugs, bromocriptine, tamoxifen, cyproterone acetate, systemic steroids and cyclosporine.
Diagnosis is made clinically
Differential diagnosis include:
Seborrheic dermatitis
Steroid folliculitis/Perioral Dermatitis
Acne vulgaris
Erythromelanosis faciei and keratosis pilaris rubra
Lupus erythematosus
Lupus miliaris disseminatus faciei

54. Treatment Sunscreens Avoidance of aggravating factors.
Topical medications include:
Metronidazole
Sodium sulfacetamide and sulfur
Azelaic acid
Benzoyl peroxide
Tretinoin
Erythromycin and Clindamycin

55. Oral medications include:
Tetracyclines:
Tetracyclines are the most commonly prescribed oral medications for the treatment of rosacea.
They act by their anti-inflammatory effects
Erythromycin (for children with granulomatous perioral dermatitis)
Isotretinoin

56. Laser and light therapy
Laser and Intense Pulsed light IPL is useful in treating persistent erythema and telangiectasias
Pulsed dye laser (585 or 595 nm)
Potassium-titanyl phosphate laser KTP 532nm, for superficial small telangiectasias.
Deep facial vessels require longer wavelengths :
Diode laser (810)
The long pulsed alexandrite laser (755nm)
Long pulse ND:YAG (1064nm)

57. Treatment of Phymatous Rosacea
Early to moderate Phymatous changes could be treated with Isotretinoin.
Advanced phyma is treated with surgery or surgery followed by isotretinoin.
Scalpel tangential excision
Electrosurgery
Laser CO2 ablation.

58. Fig 1, 2 www. scf-online. com/. /keratinization38_e
Fig 1, 2 keratinization of the duct of the hair follicle.
open (Blackheads) comedones, Medical Encyclopedia
Fig.3
Fig 4. Malassezia furfur Closed comedones Skin and allergy centre.
Fig 5
Fig 6 Mayo Foundation for Medical and research.
Fig 7
Fig 8 bacterial colonization
Fig 9 Breakage of follicular wall papule
Fig 10 open comedones
Fig 11
Fig 12 closed comedones
open and closed comedones schematic pictures
proriobionacterium acne in pilosabaceous unit
follicular hyperkeratosis in acne
Fig 13
Fig 14
Fig 15
Fig 16 pustule
Fig 17. Courtesy of Skin and allergy centre
Fig 18 nodule
Fig 19 nodule
Fig 20
Fig 21 Courtesy of Skin and allergy centre
Fig 22 Courtesy of Skin and allergy centre
Fig 23 at neonatal dermatology benign lesions Auckland district health board.
Fig 24 Courtesy of Polonia, second edition
Fig 25
Fig 26 Courtesy of Skin and allergy centre
Fig 27 Acne conglobata
Fig 28 acne Agminata Granulomatous rosacea in infants. Report of three cases and discussion of the differential diagnosis João Borges da Costa, Sousa Coutinho V, L Soares de Almeida, M Marques Gomes PhDDermatology Online Journal 14 (2): 22

59. Fig 29, courtesy of Rook 2010
Fig 30, courtesy of Fitzpatrick 2008
Fig 31, courtesy of Polonia 2008

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