The Pathogenesis of Acne Part 2

People are praying to the God of acne to make sure they don't break out before the next big date or business presentation that they have, but the real clue is in your heredity. You can be predisposed to several of the types of acne, and you may need to work with your dermatologist to develop a game plan that will stand you in good stead at the various ages and stages of life.

Four Pathogenic Factors in Acne
o Excessive secretion of sebum is a necessary prerequisite for the onset of acne.
o Epithelial cells in the sebaceous follicles undergo abnormal desquamation. The combination of abnormally desquamated cells and excessive sebum form a microcomedo the precursor lesion of both no inflammatory comedones and inflammatory lesions.
o The anaerobic bacterium Propionibacterium acnes proliferates in the lipid-rich environment of the microcomedo.
o Acne produces proinflammatory mediators and chemotactic factors that can cause microcomedones to inflame and evolve into papules, pustules, and nodules.
Hormones in Acne
o Most acne patients probably have sebaceous glands that are hypersensitive to the effects of androgens.
o The most important hormones in the pathogenesis of acne are testosterone and dihydrotestosterone (DHT).
o Women with signs of virilization may have excess androgen production and need to undergo a hormonal work-up.
Topical Retinoids Render Follicles Inhospitable to P acnes
o Topical retinoids such as adapalene (Differin®), or tretinoin (Retin-A®, Retin-A Micro™, or Avita®) are the treatment of choice for normalizing follicular epithelial desquamation and making the environment less favorable for P acnes proliferation.
o The application of adapalene or tretinoin results in a "less plugged" follicle.
o To achieve optimal results, topical retinoids should be used for several months.
o Combination therapy with antibiotics, either topically or systemically, makes sense for most patients.
Treating Acne
o For mild inflammatory acne: daily applications of a topical retinoid along with a combination of benzoyl peroxide with erythromycin.
o For mild to moderate inflammatory acne, either adapalene or tretinoin with benzoyl peroxide, or topical retinoids with a combination of benzoyl peroxide/erythromycin.
o Depending on severity, some patients may need to use both an oral and a topical version of a single antibiotic.
o Patients with large lesions can be treated with a local injection of a corticosteroid.
o Patients with nodular, cystic lesions may respond to oral antibiotic therapy alone. Some may require the systemic retinoid isotretinoin. In women, hormonal therapy with or without spironolactone is another option.
o For women with excessive ovarian androgen production, oral contraceptives containing estrogens or progestins are a good choice.
o Acne fulminans usually responds to oral corticosteroids.
o Acne surgery can be used if there are a large number of comedones, and the patient has applied topical retinoids for 1 to 2 months.

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