Topical treatments for acne

Acne vulgaris, folliculitis and acne rosacea are common disorders of the pilosebaceous units, which consist of sebaceous glands and their associated hair follicles. The most common anatomic sites of involvement are those that have the largest and greatest density of sebaceous glands: the face, neck, upper chest and back, and upper arms. Acne vulgaris is a common disorder that peaks in incidence around the time of puberty. The pathogenesis of acne vulgaris is multifactorial. Abnormal keratinization in the upper canal of the hair follicle causes formation of hyperkeratotic, adherent plugs that are derived from desquamated epithelial cells, resulting in comedones (appearing clinically as whiteheads and blackheads), the noninflammatory lesions of acne vulgaris. Androgens stimulate the secretion of lipid-rich sebum from the sebaceous glands; sebum, in turn, provides a growth substrate for the commensal Propionibacterium acnes, an anaerobic diphtheroid. Proliferation of P. acnes is particularly facilitated by the anaerobic environment of the follicles that are plugged by comedones. This results in the production of proinflammatory mediators that are largely responsible for the appearance of the inflammatory lesions of acne vulgaris: papules, pustules, and nodules. Folliculitis Folliculitis is a somewhat nonspecific term that refers to inflammation of the hair follicle (in clinical practice, this term does not include acne vulgaris). The most common etiology of folliculitis is bacterial infection, often due to Staphylococcus aureus. The usual clinical presentation is superficial pustules and/or papules in the distribution of the hair follicles. The face, chest, back, thighs, and buttocks are often involved. Folliculitis is frequently initiated by mild physical injury to the follicles, such as friction caused by tight-fitting garments, or by ingrown hairs in the beard area in men. Less commonly, folliculitis is caused by infection by fungi, such as dermatophytes or Pityrosporum. Folliculitis due to Pseudomonas aeruginosa ("hot tub folliculitis") may occur in patients exposed to water sources that are contaminated by that organism. Treatment of folliculitis is aimed at eliminating the offending agent(s), and includes topical and/or systemic antibacterial or antifungal preparations. Acne Rosacea Rosacea is an inflammatory disorder of uncertain etiology that most commonly affects adults of northern European ancestry, between 30 and 50 years of age. The earliest manifestation of this disease can be recurrent episodes of flushing and blushing, often triggered by stimuli such as ingestion of hot beverages, spicy foods, and ethanol or exposure to ultraviolet radiation. Clinical findings in the fully developed eruption include papules, pustules, erythema, and telangiectasias. The central face, including the nose, forehead, chin and cheeks, is involved predominantly. Chronic inflammation may lead to permanent enlargement (phyma) of the affected areas due to sebaceous gland and soft tissue hypertrophy; rhinophyma("W. C. Fields nose") refers to enlargement of the nose. Involvement of the eye may lead to conjunctivitis and/or blepharitis. Rosacea may clinically resemble acne vulgaris; however, in contrast to acne, comedones are absent. Treatments of mild rosacea include topical metronidazole gel, lotion or cream, or a combination of sodium sulfacetamide and sulfur. In moderate to severe cases, oral antibiotics, of which the tetracyclines are the most widely used, may be added. Isotretinoin may be used in severe, recalcitrant cases.

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