Acne Vulgaris - Secretory Disorders

ACNE VULGARIS

Acne vulgaris is a common follicular disorder affecting suscepti-ble hair follicles, most commonly found on the face, neck, and upper trunk. It is characterized by comedones (ie, primary acne lesions), both closed and open, and by papules, pustules, nodules, and cysts.

Acne is the most commonly encountered skin condition in adolescents and young adults between ages 12 and 35. Both genders are affected equally, although onset is slightly earlier for girls. This may be because girls reach puberty at a younger age than boys. Acne becomes more marked at puberty and during adolescence because the endocrine glands that influence the se-cretions of the sebaceous glands are functioning at peak activity. Acne appears to stem from an interplay of genetic, hormonal, and bacterial factors. In most cases, there is a family history of acne.

Pathophysiology

During childhood, the sebaceous glands are small and virtually nonfunctioning. These glands are under endocrine control, es-pecially by the androgens. During puberty, androgens stimulate the sebaceous glands, causing them to enlarge and secrete a nat-ural oil, sebum, which rises to the top of the hair follicle and flows out onto the skin surface. In adolescents who develop acne, an-drogenic stimulation produces a heightened response in the se-baceous glands so that acne occurs when accumulated sebum plugs the pilosebaceous ducts. This accumulated material forms comedones.

Clinical Manifestations

The primary lesions of acne are comedones. Closed comedones (ie, whiteheads) are obstructive lesions formed from impacted lipids or oils and keratin that plug the dilated follicle. They are small, whitish papules with minute follicular openings that gen-erally cannot be seen. These closed comedones may evolve into open comedones, in which the contents of the ducts are in open communication with the external environment. The color of open comedones (ie, blackheads) results not from dirt, but from an accumulation of lipid, bacterial, and epithelial debris.

Although the exact cause is unknown, some closed comedones may rupture, resulting in an inflammatory reaction caused by leakage of follicular contents (eg, sebum, keratin, bacteria) into the dermis. This inflammatory response may result from the action of certain skin bacteria, such as Propionibacterium acnes, that live in the hair follicles and break down the triglycerides of the sebum into free fatty acids and glycerin. The resultant inflam-mation is seen clinically as erythematous papules, inflammatory pustules, and inflammatory cysts. Mild papules and cysts drain and heal on their own without treatment. Deeper papules and cysts may result in scarring of the skin. Acne is usually graded as mild, moderate, or severe based on the number and type of lesions (eg, comedones, papules, pustules, cysts).

Assessment and Diagnostic Findings

The diagnosis of acne is based on the history and physical exam-ination, evidence of lesions characteristic of acne, and age. Acne does not occur until puberty. The presence of the typical come-dones (ie, whiteheads and blackheads) along with excessively oily skin is characteristic. Oiliness is more prominent in the midfacial area; other parts of the face may appear dry. When there are nu-merous lesions, some of which are open, the person may exude a distinct sebaceous odor. Women may report a history of flare-ups a few days before menses. Biopsy of lesions is seldom necessary for a definitive diagnosis.

Medical Management

The goals of management are to reduce bacterial colonies, de-crease sebaceous gland activity, prevent the follicles from becom-ing plugged, reduce inflammation, combat secondary infection, minimize scarring, and eliminate factors that predispose the person to acne. The therapeutic regimen depends on the type of lesion (eg, comedonal, papular, pustular, cystic).

There is no predictable cure for the disease, but combinations of therapies are available that can effectively control its activity. Topical treatment may be all that is needed to treat mild to mod-erate lesions and superficial inflammatory lesions (ie, papular or pustular).

NUTRITION AND HYGIENE THERAPY

Although food restrictions have been recommended from time to time in treating acne, diet is not believed to play a major role in therapy. However, the elimination of a specific food or food prod-uct associated with a flare-up of acne, such as chocolate, cola, fried foods, or milk products, should be promoted. Maintenance of good nutrition equips the immune system for effective action against bacteria and infection.

For mild cases of acne, washing twice each day with a cleansing soap may be all that is required. These soaps can remove the exces-sive skin oil and the comedo in most cases. Providing positive re-assurance, listening attentively, and being sensitive to the feelings of the patient with acne are essential contributors to the patient’s psychological well-being and understanding of the disease and treatment plan. Over-the-counter acne medications contain sali-cylic acid and benzoyl peroxide, both of which are very effective at removing the sebaceous follicular plugs. However, the skin of some people is sensitive to these products, which can cause irritation or excessive dryness, especially when used with some prescribed topi-cal medications. The patient should be instructed to discontinue their use if severe irritation occurs. Oil-free cosmetics and creams should be chosen. These products are usually designated as useful for acne-prone skin. The duration of treatment depends on the ex-tent and severity of the acne. In severe cases, treatment may extend over years.

TOPICAL PHARMACOLOGIC THERAPY

Benzoyl Peroxide.

Benzoyl peroxide preparations are widelyused because they produce a rapid and sustained reduction of inflammatory lesions. They depress sebum production and pro-mote breakdown of comedo plugs. They also produce an anti-bacterial effect by suppressing P. acnes. Initially, benzoyl peroxide causes redness and scaling, but the skin usually adjusts quickly to its use. Typically, the patient applies a gel of benzoyl peroxide once daily. In many instances, this is the only treatment needed. Benzoyl peroxide, benzoyl erythromycin, and benzoyl sulfur combinations are available over the counter and by prescription. Vitamin A acid (tretinoin) applied topically is used to clear the keratin plugs from the pilosebaceous ducts. Vitamin A acid speeds the cellular turnover, forces out the comedones, and prevents new comedones.

The patient should be informed that symptoms may worsen during early weeks of therapy because inflammation may occur during the process. Erythema and peeling also frequently result. Improvement may take 8 to 12 weeks. Some patients cannot tol-erate this therapy. The patient is cautioned against sun exposure while using this topical medication because it may cause an ex-aggerated sunburn. Package insert directions should be followed carefully.

Topical Antibiotics.

Topical antibiotic treatment for acne is com-mon. Topical antibiotics suppress the growth of P. acnes; reduce superficial free fatty acid levels; decrease comedones, papules, and pustules; and produce no systemic side effects. Common topical preparations include tetracycline, clindamycin, and erythromycin.

SYSTEMIC PHARMACOLOGIC THERAPY

Antibiotics.

Oral antibiotics, such as tetracycline, doxycycline, and minocycline, administered in small doses over a long period are very effective in treating moderate and severe acne, especially when the acne is inflammatory and results in pustules, abscesses, and scarring. Therapy may continue for months to years. The tetracycline family of antibiotics is contraindicated in children younger than age 12 and in pregnant women. Although these medications are considered safe for long-term use in most cases, administration during pregnancy can affect the development of teeth, causing enamel hypoplasia and permanent discoloration of teeth in infants. Side effects of tetracyclines include photosensi-tivity, nausea, diarrhea, cutaneous infection in either gender, and vaginitis in women. In some women, broad-spectrum antibiotics may suppress normal vaginal bacteria and predispose the patient to candidiasis, a fungal infection.

Oral Retinoids.

Synthetic vitamin A compounds (ie, retinoids) are used with dramatic results in patients with nodular cystic acne un-responsive to conventional therapy. One compound is isotretinoin (Accutane). Isotretinoin is also used for active inflammatory papu-lar pustular acne that has a tendency to scar. Isotretinoin reduces sebaceous gland size and inhibits sebum production. It also causes the epidermis to shed (ie, epidermal desquamation), thereby un-seating and expelling existing comedones.

The most common side effect, experienced by almost all pa-tients, is cheilitis (ie, inflammation of the lips). Dry and chafed skin and mucous membranes are frequent side effects. Thesechanges are reversible with the withdrawal of the medication. Most important, isotretinoin, like other vitamin A metabolites, is teratogenic in humans, meaning that it can have an adverse ef-fect on a fetus, causing central nervous system and cardiovascular defects and structural abnormalities of the face. Contraceptive measures for women of childbearing age are mandatory during treatment and for about 4 to 8 weeks thereafter. To avoid addi-tive toxic effects, patients are cautioned not to take vitamin A supplements while taking isotretinoin (Odom et al., 2000).

Hormone Therapy.

Estrogen therapy (including progesterone– estrogen preparations) suppresses sebum production and reduces skin oiliness. It is usually reserved for young women when the acne begins somewhat later than usual and tends to flare up at certain times in the menstrual cycle. Estrogen in the form of estrogen-dominant oral contraceptive compounds may be admin-istered on a prescribed cyclic regimen. Estrogen is not adminis-tered to male patients because of undesirable side effects such as enlargement of the breasts and decrease in body hair.

SURGICAL MANAGEMENT

Surgical treatment of acne consists of comedo extraction, injections of corticosteroids into the inflamed lesions, and incision and drainage of large, fluctuant (ie, moving in palpable waves), nodu-lar cystic lesions. Cryosurgery (ie, freezing with liquid nitrogen) may be used for nodular and cystic forms of acne. Patients with deep scars may be treated with deep abrasive therapy (ie, der-mabrasion), in which the epidermis and some superficial dermis are removed down to the level of the scars.

Comedones may be removed with a comedo extractor. The site is first cleaned with alcohol. The opening of the extractor is then placed over the lesion, and direct pressure is applied to cause extrusion of the plug through the extractor. Removal of come-dones leaves erythema, which may take several weeks to subside. Recurrence of comedones after extraction is common because of the continuing activity of the pilosebaceous glands.

Table 56-5 summarizes the treatment modalities for acne vulgaris.

Nursing Management

Nursing care of patients with acne consists largely of monitoring and managing potential complications of skin treatments. Major nursing activities include patient education, particularly in proper skin care techniques, and managing potential problems related to the skin disorder or therapy.

PREVENTING SCARRING

Prevention of scarring is the ultimate goal of therapy. The chance of scarring increases as the grade of acne increases. Grades III and IV (25 to more than 50 comedones, papules, or pustules) usually require longer-term therapy with systemic antibiotics or isotretinoin. Patients should be warned that discontinuing these medications can exacerbate acne, lead to more flare-ups, and in-crease the chance of deep scarring. Moreover, manipulation of the comedones, papules, and pustules increases the potential for scarring.

When acne surgery is prescribed to extract deep-seated come-dones or inflamed lesions or to incise and drain cystic lesions, the intervention itself may result in further scarring. Dermabrasion, which levels existing scar tissue, can also increase scar formation. Hyperpigmentation or hypopigmentation also may affect the tissue involved. The patient should be informed of these potential outcomes before choosing surgical intervention for acne.

PREVENTING INFECTION

Female patients receiving long-term antibiotic therapy with tetra-cycline should be advised to watch for and report signs and symp-toms of oral or vaginal candidiasis, a yeastlike fungal infection.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care.

In addition to receiving instruc-tions for taking prescribed medications, patients are instructed to wash the face and other affected areas with mild soap and water twice each day to remove surface oils and prevent obstruction of the oil glands. They are cautioned to avoid scrubbing the face; acne is not caused by dirt and cannot be washed away.

Mild abrasive soaps and drying agents are prescribed to elim-inate the oily feeling that troubles many patients. At the same time, patients are cautioned to avoid excessive abrasion because it makes acne worse. Excessive abrasion causes minute scratches on the skin surface and increases possible bacterial contamina-tion. Soap itself can irritate the skin.

All forms of friction and trauma are avoided, including prop-ping the hands against the face, rubbing the face, and wearingtight collars and helmets. Patients are instructed to avoid manip-ulation of pimples or blackheads. Squeezing merely worsens the problem, because a portion of the blackhead is pushed down into the skin, which may cause the follicle to rupture. Because cos-metics, shaving creams, and lotions can aggravate acne, these sub-stances are best avoided unless the patient is advised otherwise. There is no evidence that a particular food can cause or aggravate acne. In general, eating a nutritious diet helps the body maintain a strong immune system.