The youngster slouching on the couch in your waiting room with his or her head behind a magazine may be one of the 80 percent of adolescents and young adults with acne vulgaris (common acne), an inflammatory disorder of the sebaceous glands. The diagnosis of acne vulgaris with its comedones, papules, pustules, and cysts is usually fairly straightforward when the patient is in the expected age range of 12-20; however, acne can persist into middle age, making the diagnosis more difficult. Common acne begins on the forehead and progresses downward or starts along the nose and spreads laterally. The back and chest also may involved (see “How acne develops,” page 134).
An unhurried private history taking can help relax a self-conscious teenager as well as provide substantive clues to diagnosis. Answers to key questions in the history can also offer important implications for therapy:
* Did either your patients or siblings have acne? Acne tends to be familial. You may want to treat a youngster with moderate-to-severe acne more vigorously if there is a family history of severe scarring acne.
* When did your acne first begin? You will probably treat a 16-year-old who has had acne for several years more aggressively than a 12-year-old whose acne has begun recently.
* how do you look today compared with how you usually look? Since this chronic condition has flares and remissions, your patient is the best guide to whether his acne is better or worse than usual.
* What acne medications or treatments have other doctors given you? Are there any that seemed to help? Where there any to which you were allergic? An allergic reaction to antibiotics or to previously prescribed drugs has important implications for your plan of treatment. Try to find out what instructions were given and how well the youngster followed the prescribed regimen. Consider a more aggressive program for the youngster who seems to be discouraged by prior unsuccessful treatment.
* What medications, soaps, and cosmetics do you use on your face? Try to find out what agents the patient uses and how he applies them. For example, vigorous or frequent washing with strong soaps and the abrasive particles in scrub cleansers and pads can irritate the skin and worsen acne. Water-base or oil-free cosmetics are less comedogenic than lipid-base products.
* Is there anything you’ve noticed that seems to aggravate or relieve your acne? Ask about excessive stress at school or home and flares during menstruation. Although diet is considered to play no role, determine whether the youngster feels that certain types of foods exacerbate his acne. Use the history to help distinguish acne vulgaris from acneiform eruptions, which are caused or aggravated by a number of external and internal factors:
* Endocrine-related acne Endocrine disease may be responsible for severe cystic acne. The most common disorders producing abnormally high androgen levels and, hence, severe cystic acne are polycystic ovary syndrome in women and partial adrenal 21-hydroxylase deficiency in men.
* Acne medicamentosa Rule out drug usage
as a cause of acneiform eruption. Causative drugs include general classes such as iodides, bromides, some oral contraceptives, and specific drugs such as isoniazid (INH, Nydrazid), lithium carbonate (Eskalith, Lithane, lithonate, etc.), phenobarbital, phenytoin sodium (Dilantin), and trimethadione (tridione). These generally produce pustular lesions on the head, neck, and upper trunk. Older children and adults who are chronic users of systemic corticosteroids or adrenocorticotropic hormone can develop pustular eruptions predominantly on the trunk, arms, and neck.
* Acne cosmetica Women over age 20, particularly those who’ve had acne in adolescence may develop small comedonal lesions, especially on their chins, from frequent use of oil-base moisturizers and cosmetics. Many attempt to cover the dark comedona lesions with heavy makeup, thus perpetuating the condition.
* Pomade acne Oily makeup and grooming agents such as greasy pomades can induce concentrations of closed comedones on the forehead.
* Acne mechanica Friction ruptures closed comedones. Tight clothing and sports equipment such as helmets, straps, and shoulder pads can traumatize acne, pushing the inflammation deeper into the tissue. Acne localized to the chin and jaw may indicate that the youngster has a habit of propping his chin on his hands. Other sources of trauma include excessive or abrasive scrubbing of the face or friction from pushing the hair across the forehead.
* Acne excoriee Crusting and scabs are a clue to this self-perpetuating form of acne. Seen most often in adolescent girls, the lesions are caused by repeated squeezing and manipulation.
* Tropical acne Heat and humidity can induce acne in certain individuals. Humidity seems to worsen existing cases of acne.
* Occupationa acne Unrefined petroleum derivatives–solvents, oils, waxes, and greases–can cause eruption at the sites of contact (usually the forearms) in those who work on farms and in factories, garages, and restaurants. The oils used in frying have been implicated in cases of “MacDonald’s acne.”
The patient’s age and the location of the lesion will help you differentiate two other disorders of the sebaceous glands: perioral dermatitis and “acne” rosacea. Suspect perioral dermatitis in adolescent girls and middle-aged women with inflamed itching papules around the mouth, nasolabial fold, and chin. Rosacea tends to occur in middle-aged patients and presents as inflammatory papules and pustules on or near the nose along with general erythema of the center of the face. In both conditions there is generally an absence of comedones.
After diagnosing acne vulgaris, examine the patient carefully under a bright light to determine the scope and severity of his or her condition. Observation alone will help you classify the acne by the predominant lesion:
* The mildest form, grade 1, consists primarily of comedones.
* Moderate acne, grade 2, has comedones and papules.
* A more serious form, grade 3, has comedones, papules, and pustules.
* Grade 4, the most severe form, consists of comedones, papules, pustules, and cysts.
Remember that severity is a function of both the number and type of lesions; there may be gradations within each classification. For example, one patient with several cysts and few other lesions has mild grade 4 acne, while another youngster with numerous blackheads may have severe grade 1 acne. It’s usually unnecessary to count the lesions, but you may find it helpful to record your baseline findings on a skin map to aid in measuring improvement.
Although the lesions your patients is most concerned about are those on his face, check whether acne is also present on the shoulders, back, chest, and buttocks. A young girl, for example, may neglect to mention some papules on her back. Point out to her that these lesions should also be treated. They may not be bothersome in winter, but in summer, when she’ll want to wear a swimsuits, she’ll be all too aware of those pimples or scars on her back.
Scarring also determines the severity of the condition. There may be ice pick or chicken pox-type scars on the jaw and upper back and shoulders. If the patient already has scarring, consider a more aggressive approach to acne control. Also, check for any evidence of excoriation. Make certain that the patient understands that “home acne surgery” will perpetuate the condition, regardless of treatment.
Your findings on physical examination when combined with the information gleaned from the patient’s history determine your treatment plan. While topical therapy is the cornerstone of acne control, oral antibiotics and surgical procedures also are important, particularly for patients with severe scarring acne. The majority of your patients can be successfully treated with topical medications–either with a single drug or with a combination of two or more agents through step therapy.
Depending on your evaluation, therapy might start with any of the following steps:
* Step I–Tretinoin cream, gel, or liquid (Retin-A) or benzoyl peroxide cream, lotion, or gel
* Step II—Tretinoin and benzoyl peroxide
* Step III–Step II plus a topical antibiotic such as clindamycin solution (Cleocin T), tetracycline HCl solution (Topicycline), erythromycin solution (A/T/S, Eryderm, Staticin), or meclocycline sulfosalicylate (Meclan)
* Step IV–Step II or Step III plus an oral antibiotic such as tetracycline HCl, erythromycin, or minocycline HCl (Minocin)
* Step V–Isotretinoin (Accutane)
…. Cont. in Part II