Acne Fulminans
Western University of Health Sciences Silver Falls Dermatology
Lauren Boudreaux, PGY2 Bryce Desmond, PGY3 Stephanie Howerter, PGY2 Ben Perry, PGY3 Karla Snider, PGY4 Scott Thomas, PGY4 40-50 million individuals in the US affected each year
Infants to adults
Peaks in adolescence and affects 85% of people between age 12-24 years old
35% of women and 12% of men
$2.5 billion in annual cost 1. Microcomedo formation Alteration in the keratinization process/epidermal hyperproliferation Secondary to androgens, decreased linoleic acid, increased IL-1 alpha 2. Sebum production Androgens 3. P. acnes follicular colonization Breaks down TGs, stimulates ab production, inflammatory response, binds TLR2 release of IL-1a, IL-8, IL-12, TNFa Coproporphyrin III 4. Release of inflammatory mediators Before or after microcomedo formation . Controversial . High glycemic diets and dairy (especially milk) have been found to be associated with increased prevalance and severity . High glycemic index foods and dairy consumption increase androgen levels and insulin-like growth factor-1 (IGF-1) . IGF-1 controls signaling of the Fox01 nuclear transcription factor . Fox01 in combination with nutrient-sensitive kinase mTOR complex 1 signaling currently hypothesized to be primary mediators of food-induced acne promotion Non-flammatory Comedones (follicular) Open (blackhead) Closed (whitehead) Inflammatory Papules Pustules Cysts Nodules Sinus tracts
Scarring can occur from all forms, including comedones
PIH and persistent erythema can be permanent . Neonatal: 2-3 weeks to 3 months, no comedones, Malassezia
. Infantile: 3-6 months, comedones presents, transient elevation of DHEA • Severe nodulocystic acne WITHOUT systemic symptoms
• Follicular occlusion tetrad • Acne conglobata, dissecting cellulitis of the scalp, hidradenitis suppurativa, pilonidal cyst
• Treatment: Isotretinoin . Most severe form of acne . Abrupt onset in young men . Systemic symptoms . Fever, arthralgias, myalgia, hepatosplenomegaly . Osteolytic bone lesions in the clavicle and sternum . Painful, oozing, friable plaques with hemorrhagic crusts . Labs: elevated ESR, leukocytosis, anemia, proteinuria . Treatment: Isotretinoin + oral corticosteroids . May be associated with SAPHO syndrome . Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis . Treatment: NSAIDS, sulfasalazine, infliximab • Pyogenic Arthritis, Pyoderma gangrenosum, Acne • PSTPIP1 gene encoding CD2 antigen-binding protein 1 (CD2BP1) • Tx: Infliximab, Anakinra . Acne mechanica
. Acne excoriee des jeunes
. Acne with endocrine abnormality . PCOS/Stein-Leventhal syndrome
. Congenital adrenal hyperplasia • Monomorphorous inflammatory papules • Hormones • Anabolic steroids (danazol, testosterone) • Corticosteroids, Corticotropin • Phenytoin • Lithium • Isoniazid • Iodides, bromides • EGFR inhibitors
. Exposure to chlorinated aromatic hydrocarbons . Chloracnegens – fat-soluble, persist in body fat . Insecticides, insulators, fungicides, herbicides, wood preservatives . Malar, retroauricular, mandibular, axillae, scrotum . Scarring, recurrent outbreaks for many years . TREATMENT . Topical/oral retinoids and antibiotics .Topicals
.Systemics
.Light/Laser
.Surgery . Benzoyl peroxide (BPO), salicylic acid, glycolic acid, azelaic acid, lipohydroxy acid, sulfur, tea tree oil . Antibiotics: Clindamycin, Dapsone . Retinoids: . 1st gen – Tretinoin, isotretinoin . 2nd gen – Etretinate, alitretin . 3rd gen – Tazarotene, adapalene, bexarotene . Cornerstone of combination therapy . Bind nuclear retinoic acid receptors – RAR, RXR . Reverse abnormal keratinization; down regulating K6, K16 . Comedolytic effect . Anti-inflammatory effect via inhibition of TLR-2 . Antibiotics: doxycycline, cephalosporins, minocycline . Isotretinoin: . Teratogenic ipledge . Adverse effects: xerostomia/cheilitis, pseudotumor cerebri, hypertriglyceridemia . Hypertriglyceridemia: 150 – 499 lifestyle changes >500 first line = treatment . 1st line treatments: niacin, omega 3 fatty acids . 2nd line: fibrates, statins . OCPs . Spironolactone . Zinc . Probiotics . P. acnes makes coproporphyrin III light (blue) reactive oxygen species . Red light penetrates deeper . PDT
. CO2 . Picosecond PDL . Picosecond Alexandrite . Histology suggest improvement in scarring from laser goes beyond remodeling of collagen . Bolognia J, Jorizzo JL, Rapini RP (eds). Dermatology. 2nd ed. Vol. 2. St. Louis: Mosby/Elsevier; 2008. Chapter 68 Alopecias; p.992-95.
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