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ACNE Disorders of sebaceous gland

ACNE Disorders of sebaceous gland. Omar Abdulaziz Al-Sheikh, M.D. College of Medicine King Saud University. Definition:.

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ACNE Disorders of sebaceous gland

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  1. ACNEDisorders of sebaceous gland Omar Abdulaziz Al-Sheikh, M.D. College of Medicine King Saud University

  2. 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.

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

  4. 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 acnegenic mineral oil (Pomade acne) dioxin • Drugs Oral and topical Hydrocortison (Steroid acne) Lithium, Hydantoin, contraceptives • Endocrine Factors (Recalcitrant Acne, POD/s, MARSH Syndrome) .

  5. Pathogenesis: ( three main steps recognized and hypothesized) 1.Follicular Hyperkeratosis (the cause not fully understood) theory suggest: • deficiency in Linoleic acid, • the effect off 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

  6. Fig 1 Fig 2 Fig 3 Perifollicular Hyperkeratosis histology

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

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

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

  10. 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

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

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

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

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

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

  16. Inflammatory papules Fig 14 Fig 15 Inflammatory papules

  17. Pustules : Fig 16 Fig 17 Pustules

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

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

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

  21. Fig 22

  22. 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

  23. Fig 23

  24. 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.

  25. Fig 24

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

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

  28. Fig 25

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

  30. Fig 26 Fig 27

  31. 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.

  32. Fig 28

  33. 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 triat in Noonan Syndrome, de Lange Syndrome, and Rubinstein-Taybi Syndrome Not considered acne

  34. 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

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

  36. TRAETMENT • Note: All medications used for the treatment of acne act as: • Anti comedonal • Anti inflammatory • Anti microbial

  37. Topical Keratolytic • Retinoid ( Retinoic acid 0.025, 0.05, 0.1%) • Adapelene (Diffrine 0.1%) • Salicylic acid • Benzoic acid • Azelaic Acid (10, 15, 20 %)

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

  39. Systemic therapy • Antibiotic (Macrolides and Tetracyline) • Tetracycline • Doxycycline • Minocycline (Photo sensitivity and LE) • Erythromycines • Clarythromycines • Azithromycine

  40. Systemic Retinoid Isotretinoine caps (Roaccutane) New promising and potentially safe medication SMT D002 Phase I clinical trial Is believed to treat seborrhoea a symptom of Parkinson's disease and the primary cause of acne

  41. Other form of therapy • Systemic steroid (Prednisolone) acne fulminans and intralesional steriods for forms of cystic acne. • Photodynamic therapy i.e. Laser therapy and phototherapy (Less significant) • Hormonal therapy (Antiandrogen) Spironlacton (Potassium sparing agent) and Metformin as (Hypogylcemic agent) in treatment of POS have good results on acne

  42. Fig 1, 2 www.scf-online.com/.../keratinization38_e.htm keratinization of the duct of the hair follicle. www.nlm.nih.gov/.../ency/imagepages/2087.htm open (Blackheads) comedones, Medical Encyclopedia Fig.3 Fig 4. Malassezia furfur www.doctorfungus.org/thefungi/Malassezia.htmClosed comedones Skin and allergy centre. Fig 5 Fig 6 www.ohiohealth.com/bodymayo.cfm?id=6&action=t... Mayo Foundation for Medical and research. Fig 7 Fig 8 bacterial colonization www.healthcaresouth.com/pages/acnewhatis.htm Fig 9 Breakage of follicular wall www.healthyskinbydesign.com/acne.cfm papule Fig 10 open comedones www.healthcaresouth.com/pages/acnewhatis.htm Fig 11 Fig 12 closed comedones www.healthcaresouth.com/pages/acnewhatis.htmfig www.dermalogix.net/acne/acne.html open and closed comedones schematic pictures www.dermalogix.net/acne/acne.html proriobionacterium acne in pilosabaceous unit www.healthyskinbydesign.com/acne.cfm. follicular hyperkeratosis in acne Fig 13 Fig 14 Fig 15 Fig 16 www.healthyskinbydesign.com/acne.cfm pustule Fig 17. Courtesy of Skin and allergy centre Fig 18 www.healthyskinbydesign.com/acne.cfm nodule Fig 19 nodule www.acnekil.com/What's_Acne/photo_gallery2.htm Fig 20 Fig 21 Courtesy of Skin and allergy centre Fig 22 Courtesy of Skin and allergy centre Fig 23 www.adhb.govt.nz/.../BenignLesions.htm at neonatal dermatology benign lesions Auckland district health board. Fig 24 http://www.virtualendocrinecentre.com/diseases.asp?did=860 (infantile) Fig 25 Fig 26 Courtesy of Skin and allergy centre Fig 27 Acne conglobata www.consultantlive.com/showArticle.jhtml?arti... 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

  43. text: Moulin G, Thomas L, Vigneau M, Fiere A.[A case of unilateral Elastosis with cyst and Comedones of Favre-Racuchet syndrome]. Amn. Dermatol Venereol 1994, 121(10), 721-3 Sanchez-Yus E, DejRb E, Simon P, Requenal A, Vazquez H.[ The histopathology of close and open Comedones of Favre-Racuchet disease]. Arch dermatol 1997 Dec. 133 (12) 1592. Zugerman C. [ Chloracne, clinical manifestation and etiology]. Dermatol clin. 1990 jan. 8 (1) 209-13. Birian B. [ Peri orbital Comedones ]. J Am Acad Dermatol 2000. 42. 622-7. Khorsow Mehrany, Josedh M, Kist Roger H, Weenig, Patricia M, Witman. [ Acne Fulminana]. Inter. J. Dermatol 2005. 44 132. Charles N, Ellis, Kent J, Krach. [ Uses and complications of isotretinoin therapy]. J Am Acad. Dermatol. 2001. 45: S1. 150-7. Bedlow A J. Otter M. Marsder R A. [ Axillary acne agminata ( lupus Miliaria Desseminatus Facies)]. Clin. Exp. Dermatolo 1998 May. 22 (3) 125-8 Ogunbiyi A, George A. [ Acne keloidalis in female: Case report and review of literature]. Nati. Med assoc. 2005 Aug. 97 (8) 1178 Alfred L, Knable Jr, C William Hanke, Rene Gonin. [ Prevalence of acne Keloidalis Nuchae in Football players ]. J Am Acad Dermatol1997. 37. 570-4 Shenefelt PD. [ Using hypnosis to facilitate resolution of psychogenic excoriation in Acne Excoriee]. Am. J. Clin. Hypn. 2004 Jan. 46 (3) 239-45 Griffiths WA. [The red face-an overview and delineation of the MARSH syndrome] Clin. Exp. Dermatol. 1999 Jan. 24(1):42-7 Thomas B Fitzpatreick, Richard Allen Johnson, Klaus Wolf, Dick Suurmond, [Disorders of Sebaceous and Apocrine glands]. Color Atlas of Synopsis of Clinical Dermatology by McGraw-Hill. 2001 . Page 2-17

  44. Diane Thiboutot, MD Hershey, Pennsylvania [Acne: 1991-2001] . J Am Acad DermatolJuly 2002 •Volume 47 • Number 1 • p109 to p117 Carolyn I. Jacob, MD,* Jeffrey S. Dover, MD, FRCPC, and Michael S. Kaminer, MD [Acne scarring: A classification system and review of treatment options] J Am Acad Dermatol 2001; 45:109-17 Susan C. Taylor, Fran Cook-Bolden, Zakia Rahman, and Dina Strachan. [Acne vulgaris in skin of color] J Am Acad Dermatol 2002;46:S98-106 Jerry K. L. Tan, Kirsten Vasey, Karen Y. Fung, [Beliefs and perceptions of patients with acne] J Am Acad Dermatol 2001;44:439-45 Clement A. Adebamowo, Donna Spiegelman, William Danby, • Lindsay Frazier, Walter C. Willett, Michelle D. Holmes. [High school dietary dairy intake and teenage acne]. J Am Acad Dermatol 2005; 52:207-14 Brian B. Adams, MD, Viziam B. Chetty, MD, and Diya F. Mutasim, MD Cincinnati. [Periorbital comedones and their relationship to pitch tar: A cross-sectional analysis and a review of the literature]J Am Acad Dermatol 2000;42:624-7 V. Goulden, G. I. Stables,W. J. Cunliffe. [Prevalence of facial acne in adults] J Am Acad Dermatol 1999;41:577-80 Lowell A. Goldsmith, Jean L. Bolognia, Jeffrey P. Callen, Suephy C. Chen, Steven R. Feldman Henry W. Lim, Anne W. Lucky, Barbara R. Reed Elaine C. Siegfried, Diane M. Thiboutot, onald G. Wheeland.[American Academy of Dermatology Consensus Conference* on the Safe and Optimal Use of Isotretinoin: Summary and recommendations ] J Am Acad Dermatol 2004 june. Volume 50 number 6 Marvi Iqbal, Michael S. Kolodney, [Acne fulminans with synovitis-acne-pustulosishyperostosis- osteitis (SAPHO) syndrome treated with infliximab] . J Am Acad Dermatol 2005;52:S118-20. Harold P. Lehmann, MD, PhD, Karen A. Robinson, MSc, John S. Andrews, MD,Victoria Holloway, MD, and Steven N. Goodman, MD, MHS, PhD. [Acne therapy: A methodologic review]. J Am Acad Dermatol 2002;47:231-40 Harald Gollnick, MD, and William Cunliffe, Diane Berson, Brigitte Dreno, Andrew Finlay, James J. Leyden, Alan R. Shalita, Diane Thiboutot. [Management of Acne A Report From a Global Alliance to Improve Outcomes in Acne]. J AM ACAD DERMATOLJULY 2003. VOLUME 49, NUMBER 1 Gary M. White. [Recent findings in the epidemiologic evidence, classification, and subtypes of acne vulgaris]. J Am Acad Dermatol 1998;39:S34-7 John Y. M. Koo, Jennifer H. Do, Chai Sue Lee. [Psychodermatology]. J AM ACAD DERMATOL NOVEMBER 2000. VOLUME 43, NUMBER 5 Sharam S Yashar, Ali Moiin, .[ TREATMENT OF PSYCHODERMATOSES WITH SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS]. J AM ACAD DERMATOL MARCH 2004. P 33

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