Case
A 13 year old male comes to your office for a high school entry exam. He is in good health and has no problems. His physical exam is normal except for some pimples on his face. After discussing other teenage issues such as safety, school, drugs, and sexually transmitted diseases, you need to recommend a treatment plan for his acne.

Pathogenesis

1. Obstruction of the pilosebaceous unit by abnormal keratinization and increased production of sebum that usually begins around puberty in association with increased androgen production. 
2. There is proliferation of bacteria, primarily Propionbacterium acnes on the skin
3. Inflammatory reaction secondary to sebum in follicles rupturing into surrounding tissue and production of free fatty acids produced by lipases from the bacteria acting on triglycerides in the sebum.
4. Blackheads are "open comedones" and the darkness is from melanin not dirt. Usually not associated with inflammation.
5. Whiteheads are "closed comedones" with only microscopic opening of pores and are the forerunners of "pimples" The rupture of the pore wall leads to an inflammatory reaction because of expelling of sebum. Near the surface this becomes a pustule, below the surface becomes either a papule or nodule.

1. Decrease follicular hyperkeratosis and obstruction of the pore opening
2. Decrease bacteria which breakdown sebum to free fatty acids which cause inflammation
3. Eliminate comedones
4. Diet has little role in preventing and controlling acne
5. Incessant washing with astringents has little role in acne therapy
6. Touching of face may cause disruption of comedone unit and leads to inflammation
7. Use of cosmetics okay
8. Encouragement and discuss that time is important and not to expect immediate changes
9. The face may look "worse" before there is improvement

1. Benzoyl peroxide- comedolytic by causing follicular desquamation and antibacterial action vs. P.acnes. Can be bought over the counter and has drying effect causing irritation and redness. Begin qod. Adjust concentration as go along.
2. Tretinoin (Retin-A)- Need Rx. Reduces hyperkeratosis. Irritating to skin and suggest starting qod. Follow directions and drying will be less if used about 30 minutes after washing face. Must use sunblock and moisturizer. The creams are milder than the gels. May use with Benzoyl peroxide. Very expensive
3. Systemic antibiotics- Eliminate bacteria from the skin and inhibit lipase causing decrease concentration of FFA and decrease in neutrophile chemotaxis and follicular inflammation. 
1. Tetracylcline
2. Erythromycin
3. Clindamycin
4. Topical Antibiotics
5. Isoretinoin (Accutane) Useful for severe pustulocystic acne. Should be under care of dermatologist if the patient needs Isoretinoin. Teratogenic so must make sure patient isn't and doesn't plan to become pregnant while on the drug. 


Biggest obstacle to successful treatment of acne in teenagers is compliance. Teens want rapid results and are often discouraged by time it takes to see results. Also, side effects of the medications are sometimes deterrents to further use of drugs. Encouragement and frequent visits to monitor progress is important.


Psychosocial impact of Acne

Skin conditions such as acne have often been considered as benign diseases and have sometimes been dismissed as insignificant, even trivial, when compared to other diseases of childhood.  Research however has shown that even clinically mild to moderate facial acne is associated with significant depression and suicidal ideation. In another study, patients with severe acne reported levels of psychosocial and emotional problems that were as great as those reported with chronic disabling asthma, epilepsy, diabetes, back pain and arthritis. Complaints of acne should thus be taken seriously by the pediatrician.

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4. Mancini Anthony Acne Vulgaris: A Treatment Update.  Contemporary Pediatrics December 2000
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6. Krowchuk D. Managing Adolescent Acne Pediatrics in Review July 2005
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8. New Insights into the Management of Acne.  J of American Academy of Dermatology. 2009;60:S1-50
9. Gupta MA & Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. British Journal of Dermatology. 2002. Volume 139 Issue 5, Pages 846 - 850
10.   Mallon E, Newton JN, Klassen A et. Al. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. British Journal of Dermatology. 2001. Volume 140 Issue 4, Pages 672 – 676.