Acne, a pleomorphic disorder of the skin, is characterized by
both less severe non-inflammatory lesions as well as the severe
inflammatory type. Acne is mostly prevalent during adolescence – the
most difficult period of physical and psychosocial development
in the life of an individual.
Although not life threatening, acne vulgaris in its severest
form has tremendous clinical, as well as psychological impact
due to the severe inflammation and permanent residual scarring
that can occur on the face, chest and back of the sufferer. This
leads to feelings of low self esteem, social withdrawal, depression,
anxiety and stress. Severity of this disorder thus causes both
mental as well as physical discomfort.
Severe acne classified into four different subtypes
Four main subtypes of severe acne can be diagnosed. They are
called; acne conglobata, acne fulminans, gram-negative folliculitis
and nodulocystic acne.
Acne vulgaris is the most common presentation of acne and the
type of acne that most people experience. Acne vulgaris involves
the initial development of comedones which are blackheads and/or
white heads. Blackheads are plugs of sebum that build up in affected
hair follicles where the plug is open to the skin surface. Whiteheads
are also plugs of sebum in hair follicle canals but here the hair
canal is closed over by dead skin. These comedones are non-inflammatory.
However, when the comedones get bigger they may rupture the follicular
walls. The immune system responds to the sebum and inflammatory
papules, pustules and nodules are produced. These inflamed spots
are the classic presentation of acne vulgaris.
Acne conglobata is a chronic and severe form of acne vulgaris,
characterized by deep abscesses, inflammation and widespread damage
to the skin. Scarring blackheads or open comedones are found conspicuously
and distributed thickly on the face, neck, trunk, upper arms and
back. This form is unique in the formation of inflammatory nodules
around multiple comedones that become bigger until they rupture
and release pus. Ulcers and abscesses found beneath the nodules
result in deep uneven scars and crust formation on the surface
of the nodules. There may be the manifestation of acne cysts,
papules or pustules preceding acne conglobata, which deteriorate
instead of healing.
Acne fulminans is characterized by a sudden occurrence of highly
debilitating inflammation. Symptoms include severe and ulcerating
acne, fever, inflammation and pain in the joints of hips and knees.
Acne conglobata, when unsuccessfully treated, can give rise to
this form of acne.
This form of severe acne is characterized by cysts occurring
in isolation or in thick clusters, on the face, neck, scalp,
back, chest and shoulders. These measure several centimeters
in diameter and are usually painful. These nodular cysts are
nodules of inflammation arising from popular or nodular acne
lesions or from cysts in outer epidermal layer. The inflamed
and infected cysts contain yellow fluid and can occur close
together often coalescing and resulting in cell destruction
and acne conglobata.
Gram-negative folliculitis is an inflammation of follicles caused
by a bacterial infection often resulting from prolonged antibiotic
treatment. So patients who are being treated with antibiotics
for severe acne may subsequently develop gram-negative folliculitis.
Acne in females
Acne is also more common amongst women with the onset of menarche.
Many women experience this skin disorder due to ovarian or adrenal
hyperandrogenism accompanied by severe sebum secretion starting
in adulthood and occurring mostly before menstruation. In these
cases, hormone therapy is considered to be effective.
Infantum or Pre-pubertal acne
Acne is sometimes found to occur in infants immediately after
birth and present till they are 6 months of age. The cause of
the acne is due to high levels of DHEA that has crossed the placenta
from the mother into the baby shortly before birth. This type
of acne is generally not treated as it clears up of its own accord
as the mother’s DHEA is gradually metabolized.
Treatment of acne types
Isotretinoin and antibiotics are the usual treatment of choice
for acne conglobata, nodulocystic acne and gram-negative folliculitis.
Several courses of treatment may be necessary over a period of
years. Corticosteroids or non-steroidal anti-inflammatory medications
may be given to reduce inflammation in acne fulminans. Some very
large follicular cysts that do not respond to medications may
require drainage and surgical excision.