Page 88 - The Netter Collection of Medical Illustrations - Integumentary System_ Volume 4 ( PDFDrive )

Plate 4-3 Integumentary System

ACNE VARIANTS
Acne conglobata. Severe cystic, scarring,
nodular acne lesions that can be exquisitely
tender. Associated with disfiguring scarring
and psychological distress. Almost always
treated with isotretinoin.

ACNE (Continued)

persistent nodules and cysts coming and going. Acne
aestivalis is one of the rarest forms of acne. It has a
seasonal variation to its course. It begins in spring and
resolves by early fall. It is a disease predominantly of
adult women.
Steroid-induced acne occur secondary to the chronic
use of oral or intravenous steroids. It manifests as a
monomorphic eruption of inflammatory papules. Many
other medications can be associated with acneiform
eruptions, including iodides, lithium, and the epidermal
growth factor inhibitors.
Pathogenesis: Acne is believed to have a multifacto- Adult female acne is characterized
rial basis. Follicular keratinization appears to be faulty, by acneiform papules and pustules
and the keratinocyte adhesions do not separate as along the jaw line.
quickly as they should, leading to a follicular plug and
microcomedone formation. Excessive sebaceous gland
production also plays a role and is probably mediated
by hormonal influences. If the sebaceous gland material
is produced in an amount sufficient to cause rupture of
the comedone, the contents spill into the dermis,
causing an inflammatory response; clinically, this is
manifested by inflammatory papules, nodules, and
cysts. The third player in the pathogenesis is the gram-
negative anaerobic bacteria, Propionibacterium acnes. Sertoli-Leydig cell tumor
This bacteria is believed to cause an activation of the
immune system and results in an inflammatory infil- Male-
trate. Rare causes of acne include adrenal gland disor- patterned
ders that can cause virilization. These tumors are rare hair loss
and often are associated with a sudden onset of acne, Acne
hirsutism, and irregular menstrual cycles. Any state of
hyperandrogenism can cause acne or make preexisting Hirsutism
acne worse. The most common cause is the polycystic
ovarian syndrome in women. Less commonly, a Sertoli- Breast
Leydig cell tumor can lead to a hyperandrogenic state atrophy
and resultant acne.
Histology: Biopsies of acne are not required for diag-
nosis. A biopsy specimen from an inflammatory acne Male
papule shows a folliculocentric lesion with a dense escutcheon
inflammatory infiltrate. The follicular epithelium has
signs of spongiosis. Foreign body giant cells, plasma
cells, neutrophils, and lymphocytes are all seen in
varying degrees. Comedones show compacted corneo-
cytes within the sebaceous gland lumen.
Treatment: Treatment for acne vulgaris is multidi-
mensional. One often uses a combination of a kerato-
lytic and antibacterial agent, such as benzyl peroxide,
with tretinoin (a medication that increases differentia- Excessive androgen production results in Open comedone is a common finding in acne patients.
tion and maturation of keratinocytes) and an antibiotic. loss of female secondary sex characteristics. Compact keratin fills the comedone cavity.
The antibiotics are used for their antiinflammatory and
antibacterial properties. The antibiotic may be given in
a topical or oral form. More severe acne, cystic acne,
acne conglobata, and acne fulminans require the sys-
temic use of isotretinoin to prevent severe scarring. Many other treatment options exist, including topical All the medications used for acne have potential side
Isotretinoin is given for 5 to 6 months. Significant agents such as azelaic acid, adapalene, tazarotene, sali- effects, and treatment must be tailored to the individ-
precautions need to be taken, because this medication cylic acid, and topical antibiotics. Oral medications that ual. Comedone extraction, intralesional triamcinolone,
is a well-known teratogen. Prednisone is often advo- can be used include multiple oral antibiotics, spirono- and photodynamic therapy have shown some success in
cated for these severe cases of cystic acne. It is usually lactone, and birth control pills. The latter two medica- treating acne. Laser resurfacing, chemical peels, and use
used transiently, when first beginning therapy with tions are especially helpful in the treatment of adult of artificial fillers should be reserved for the treatment
isotretinoin, to help decrease some of the severe inflam- female acne. They work on the hormonal influence on of scarring after the inflammatory acne has been
mation. It should not be used for long periods. acne and are highly successful in this type of patient. controlled.

74 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS