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Acne vulgaris (an inflammatory skin disease)

Acne vulgaris is a common facial rash occurring in adolescence and rarely in early and mid-adult life. The cause is multifactorial but the blockage of pilosebaceous units with surrounding inflammation is the main pathological process and this can occur because of a number of different factors.

Clinical features and cause of Acne vulgaris

Acne presents in areas rich in sebaceous glands such as the face, back and sternal area. The three cardinal features are:
open comedones (blackheads) or closed comedones (whiteheads)
inflammatory papules
pustules

The skin may be very greasy (seborrhoea). Rupture of the inflamed lesions may lead to deep-seated dermal inflammation and nodulocystic lesions, which are more likely to cause facial scarring. A premenstrual exacerbation of acne is sometimes noticed. There is a tendency for spontaneous improvement over a number of years but acne can persist unabated into adult life.

A number of clinical variants of Acne vulgaris exist:

Infantile acne

Facial acne is occasionally seen in infants and is sometimes cystic. It is thought to be due to the influence of maternal androgens and resolves spontaneously.

Steroid acne

Acne may occur secondary to corticosteroid therapy or Cushing's syndrome. Comedones and cysts are rare in this variant but involvement of the back and shoulders (rather than the face) is common. Clinically the rash often appears as a pustular folliculitis.

Oil acne

This is an industrial disease seen in workers who have prolonged contact with oils or other hydrocarbons and is common on the legs and other exposure sites.

Acne fulminans

This is a rare variant seen most commonly in young male adolescents. Severe necrotic and crusted acne lesions appear, associated with malaise, pyrexia, arthralgia and bone pain (due to sterile bone cysts). It requires urgent treatment with oral prednisolone (30-40 mg daily) and analgesics followed by a course of oral isotretinoin.

Follicular occlusion triad

This is a rare disorder most commonly seen in black Africans. It is characterized by the presence of severe nodulocystic acne, dissecting cellulitis of the scalp and hidradenitis suppurativa. It has been suggested that this is caused by a problem of follicular occlusion rather than having an infective aetiology.

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