Acne vulgaris is usually a self-limited disorder of teenagers and young adults, although 10 to 20 percent of adults may experience some form of the disorder. The permissive factor for the expression of the disease is the increase in sebum release by sebaceous glands after puberty. Small cysts, called comedones form in hair follicles due to blockage of the follicular orifice by retention of sebum and keratinous material.

The action of lipophilic yeast and bacteria within the comedones releases free fatty acids from sebum, causes inflammation within the cyst, and results in rupture of the cyst wall. An inflammatory reaction develops as a result of extrusion of oily and keratinous debris from the cyst.

The clinical hallmark of acne vulgaris is the comedo, which may be closed (white head) or open (black head). Closed comedones appear as 1 to 2 mm of pebbly white papules that are accentuated when the skin is stretched. They are the precursors of inflammatory lesions, and the contents are not easily expressed.

Open comedones, which rarely result in inflammatory acne lesions, have a large dilated follicular orifice and are filled with easily expressible oxidized, darkened oily debris.

Closed comedones are usually accompanied by inflammatory lesions: papules, pustules or nodules.

The earliest lesions in adolescence are generally mildly inflamed or non-inflammatory comedones on the forehead, followed by more typical inflammatory lesions on the cheeks, nose and chin. The most common location for the acne is the face, but the chest and back may be involved. Most diseases remain mild and do not lead to scarring; a subset of patients develops large inflammatory cysts and nodules, which may drain and result in significant scarring.

Exogenous and endogenous factors can alter the expression of acne vulgaris. Friction and trauma may rupture pre existing micro comedones and elicit inflammatory acne.

Treatment

This is commonly seen with headbands or chin strips of athletic helmets. Agents that predispose to comedone formation include topical agents in cosmetic or hair preparations such as lanolin, petrolatum, butylstereate, lauryl alcohol and oleic acid and chronic topical exposure to certain industrial compounds that contain insoluble cutting oils (impure paraffin oil mixtures), halogenated hydrocarbons and coal tar and its derivatives. Glucocorticoids, applied topically or administered systemically, may also elicit acne.

Other systemic medications such as isoniazid, halogens, Dilantin and Phenobarbital may produce acneiform eruptions or aggravate pre existing acne.

Treatment is directed towards elimination of comedones, decreasing the population of lipophilic bacteria and yeast, and decreasing inflammation. Although areas affected with acne should be kept clean, removal of surface oils does not play an important role in therapy. Indeed, overly vigorous scrubbing may aggravate acne due to mechanical rupture of comedones. Oral tetracycline or erythromycin in doses of 250 to 1000mg daily will decrease follicular colonization with some lipophilic organisms and may have an anti-inflammatory effect independent on anti-bacterial effects.

Topical agents such as retinoic acid, benzyl peroxide or salicylic acid may alter the pattern of epidermal desquamation; prevent the formation of comedones, and aid in the resolution of pre existing cysts. Topical anti-bacterial agents such as benzyl peroxide, topical erythromycin, clindamycin or tetracycline are also adjuncts to therapy. Severe nodulocystic acne not responsive to oral antibiotics and topical therapy may be treated with the synthetic retinoid isotretinoin at doses of 0.5 to 1.0 mg/kg body weight per day for 15 to 20 weeks. The use of this drug is limited by its teratogenicity, and women must be screened for pregnancy prior to initiating therapy, maintain a fail-safe method of birth control during treatment, and be screened for pregnancy during treatment.

Patients receiving this medication develop extremely dry skin and cheilitis and must be followed for development of hypertriglyceridemia. Patients treated with isotretinoin, particularly for long term therapy for disorders other than acne, are also at risk to develop calcifications of tendons and bony overgrowths of vertebrae.

Herbal Pack for Acne

• Kaishore guggulu – 2 tablets twice daily

• Gandhak Rasayan – 2 tablets twice daily

• Neem Capsules – 2 capsules twice daily