atlas-cover-3

Chapter 2. Acne Vulgaris

Definition

A disease of infundibulosebaceous units, especially infundibula, that may manifest itself solely as noninflammatory lesions, i.e., comedones and intact cysts, or as inflammatory lesions, i.e., papules, nodules, and pustules. The process may resolve without residua or with scars of different types, e.g., keloidal or atrophic, including cribriform. The condition usually affects adolescents, but may at times be seen in neonates and young adults.

Virtually every adolescent is affected by acne vulgaris, if only in a mild form. In adolescents and young adults it may persist for years, whereas in neonates it usually lasts for weeks or a few months. The most severe expressions of acne occur in males.

Course

Beginning with the flow of androgens at puberty, typical lesions of mild to moderately severe acne vulgaris in adolescents come and go for several years, usually disappearing completely and without residua, except at times for patulous infundibula on the nose and malar region. Episodically, the process is more fulminant and prolonged, conglobate lesions being long lasting and healing with unsightly atrophic scars. New lesions of acne keloidalis on a nape may continue to appear as the inflammatory process smoulders well into adulthood. Severe acne that occurs especially on the back in males often resolves with a type of anetoderma that presents itself as atrophic papules, and that is incorrectly designated “macular atrophy.”

A comedo may become progressively larger and eventually be gigantic. In time, the ever-expanding plug of cornified cells causes the wall of an infundibulum to become so thin that eventually it is breached, spewing into the dermis cornified cells, sebaceous secretion, and microorganisms. This event sets in motion an inflammatory reaction marked initially by suppuration, then by granulomatous inflammation, and, in time, by fibrosis. A pustule situated within an infundibulum, in a fashion comparable to a comedo, may become so large that its contents are disgorged into the dermis where they inevitably induce granulomatous inflammation and, sometimes, fibrosis.

If the focus of suppuration in the reticular dermis (and, at times, the subcutaneous fat) becomes very large, a huge abscess forms and the destructive effects of products of the neutrophils that compose it lead invariably to extensive fibrosis. When the epithelium of infundibula and eccrine ducts then proliferates in pseudocarcinomatous fashion in an attempt to “wall off” the abscess, sinus tracts may come into being. If several contiguous abscesses have formed, each being positioned at the site of an infundibulum, the result may be sinus tracts that are interconnected. That phenomenon resolves with extensive fibroplasia.

Acne vulgaris may consist only of comedones, but in most patients, comedones are joined by reddish papules and pustules. That very common expression of acne vulgaris does not, as a rule, resolve with scars. If, however, abscesses form and especially if the process eventuates in draining sinuses, severe scarring is a certainty. Whereas pustules of acne vulgaris may begin to wane in days, abscesses that are followed by granulomatous inflammation and fibrosis may not resolve completely for many months.

Integration: Unifying Concept

Every textbook of dermatology and dermatopathology asserts that acne vulgaris is a disease of the hair follicle. That contention is dead wrong; the follicle (bulb, stem, and isthmus) is unaffected. It is infundibular epidermis. i.e., the infundibulum, that is essential to the process.

The infundibulum-centered acne vulgaris and variants of it seem to be a single pathologic process. The spectrum of its severity ranges from comedones and inflamed papules that resolve without residua to fluctuant and draining sinuses that heal with ugly scars. But whether the condition is called acne vulgaris, acne conglobata, acne keloidalis, hidradenitis suppurativa, or dissecting cellulitis of the scalp (perifolliculitis capitis abscedens et suffodiens), the process is fundamentally the same.

Inflammatory cells, neutrophils chief among them, appear first around and then within infundibula. If the collection of neutrophils is confined to an infundibulum, the lesion is a pustule. If the process is more florid and the collection of neutrophils is so great that much of an infundibulofollicular unit is obscured by it, pseudocarcinomatous proliferation of infundibular keratocytes develops in an attempt to contain it. The result is one or more of a constellation of acne conglobata, acne keloidalis, dissecting cellulitis of the scalp, and hidradenitis suppurativa. The legitimacy of the concept that acne is basically a single pathologic process seems to be verified by the fact that all of its manifestations?among them, vulgaris, conglobata, keloidalis, dissecting cellulitis, and hidradenitis suppurativa?may be present in one person. For acne, in any of its expressions, to come into being requires the play of androgens on the infundibulosebaceous unit.

Therapy

Click here for an up-to-date discussion of therapeutic management presented in Therapeutic Strategies in Dermatology.

Distribution

at002g01.jpg

Fig. 2-1

The face is the favored site.


Individual Lesions

at002g02.jpg

Fig. 2-2

Comedones may be “open” (black) and “closed” (white).


at002g03.jpg

Fig. 2-3

Comedones, “open” and “closed,” the latter being synonymous with milia.


at002g04.jpg

Fig. 2-4

“Open” comedones are present mostly, but milia are, too.


at002g05.jpg

Fig. 2-5

A cluster of comedones situated on an uncommon site.


at002g06.jpg

Fig. 2-6

Comedones, inflamed papules, and tiny atrophic scars.


at002g07.jpg

Fig. 2-7

Comedones, inflamed papules, and tiny pitted scars.


at002g08.jpg

Fig. 2-8

Comedones, patulous infundibula, and small atrophic scars.


at002g09.jpg

Fig. 2-9

Comedones, patulous infundibula, and tiny atrophic scars.


at002g10.jpg

Fig. 2-10

Inflamed papules and nodules, as well as scars. The nodules represent the effects of rupture of infundibular cysts.


at002g11a.jpg

Fig. 2-11 A

The upper part of the chest is a common site, as is the upper part of the back.


at002g11b.jpg

Fig. 2-11 B

The upper part of the chest is a common site, as is the upper part of the back.


at002g12a.jpg

Fig. 2-12 A

Comedones, patulous infundibula, inflamed papules, pustules, hemorrhagic crusts, and scars; (b) closeup view of (a).


at002g12b.jpg

Fig. 2-12 B

Comedones, patulous infundibula, inflamed papules, pustules, hemorrhagic crusts, and scars; (b) closeup view of (a).


at002g13.jpg

Fig. 2-13

Comedones, patulous ostia of infundibula, inflamed papules, inflamed nodules (ruptured infundibular cysts), and scars.


at002g14.jpg

Fig. 2-14

Inflamed papules, some of them excoriated (“acneexcoriée des jeunes filles” because it occurs mostlyin young girls).


at002g15.jpg

Fig. 2-15

Comedones, inflamed papules (some of them excoriated), and scars.


at002g16.jpg

Fig. 2-16

Comedones, inflamed papules, and a few pustules.


at002g17.jpg

Fig. 2-17

Inflamed papules and papulopustules.


at002g18.jpg

Fig. 2-18

Patulous ostia of infundibula, inflamed papules, pustules, and scars.


at002g19.jpg

Fig. 2-19

Inflamed papules and nodules, as well as papulopustules, patulous ostia, and scars.


at002g20.jpg

Fig. 2-20

Patulous ostia of infundibula, inflamed papules, pustules, and scars.


at002g21.jpg

Fig. 2-21

Inflamed papules and papulopustules, and residual hyperpigmented atrophic scars.


at002g22.jpg

Fig. 2-22

Inflamed papules, papulopustules, pustules, and crusts.


at002g23.jpg

Fig. 2-23

Inflamed papules, papulopustules, and pustules.


at002g24.jpg

Fig. 2-24

Inflamed papules, inflamed nodules, and papulopustules.


at002g25.jpg

Fig. 2-25

Inflamed papules, pustules, and crusts.


at002g26.jpg

Fig. 2-26

Inflamed papules, papulopustules, erosions, and hemorrhagic crusts. The erosions are secondary to excoriation.


at002g27.jpg

Fig. 2-27

Excoriated papules.


at002g28.jpg

Fig. 2-28

Inflamed papules and plaques, erosions, hemorrhagic crusts, and scars.


at002g29.jpg

Fig. 2-29

Inflamed plaque, erosions, hemorrhagic crusts, and pustules.


at002g30.jpg

Fig. 2-30

Inflamed papules and plaques, hemorrhagic crusts, and scars.


at002g31a.jpg

Fig. 2-31 A

Inflamed papules, erosions, large vegetative hemorrhagic crusts, and scars.


at002g31b.jpg

Fig. 2-31 B

Inflamed papules, erosions, large vegetative hemorrhagic crusts, and scars.


at002g32.jpg

Fig. 2-32

Papules, nodules, scars, and crusts.


at002g33.jpg

Fig. 2-33

Pitted scars.


at002g34.jpg

Fig. 2-34

Atrophic scars.


at002g35.jpg

Fig. 2-35

Atrophic and hypertrophic scars.


at002g36.jpg

Fig. 2-36

Many small keloids.


at002g37.jpg

Fig. 2-37

Large keloids on the chest, and inflamed papules and scars on the face.


at002g38.jpg

Fig. 2-38

Keloids.


Neonatal Acne

at002g39.jpg

Fig. 2-39

Papulopustules and pustules.


at002g40.jpg

Fig. 2-40

Inflamed papules (some of them purpuric) and papulopustules.


at002g41.jpg

Fig. 2-41

Inflamed papules and milia.


Acne Keloidalis

at002g42.jpg

Fig. 2-42

Infundibulocentric pustules and keloidal papules.


at002g43.jpg

Fig. 2-43

Comedones, infundibular cysts, pustules, and keloids.


at002g44.jpg

Fig. 2-44

Keloids with tufted hairs.


Hidradenitis Suppurativa

at002g45.jpg

Fig. 2-45

Patulous ostia of infundibula, pus at ostia of sinus tracts, noninflamed and inflamed nodules, an ulcer, and linear scars.


at002g46.jpg

Fig. 2-46

Markedly patulous ostia of infundibula, some representing the opening of sinuses, papules, nodules, and scars.


at002g47.jpg

Fig. 2-47

Patulous ostia of sinuses, some having discharged pus, nodules, and hypertrophic scars.


at002g48.jpg

Fig. 2-48

Scars at sites of sinuses.


at002g49.jpg

Fig. 2-49

Patulous ostia of sinuses and depressed hyperpigmented scars.


Steroid Acne

at002g50.jpg

Fig. 2-50

Monomorphous infundibular papules.


at002g51.jpg

Fig. 2-51

Monomorphous infundibular papules in a patient in intensive care.


at002g52a.jpg

Fig. 2-52 A

Monomorphous infundibular papules and papulopustules.


at002g52b.jpg

Fig. 2-52 B

Monomorphous infundibular papules and papulopustules.


at002g52c.jpg

Fig. 2-52 C

Widespread discrete papules and papulopustules are all infundibulocentric.


Favre-Racouchot

at002g53.jpg

Fig. 2-53

Cluster of comedones and infundibular cysts on sun-damaged skin.


at002g54a.jpg

Fig. 2-54 A

Numerous comedones and infundibular cysts of different sizes in clusters on skin injured badly by sunlight.


at002g54b.jpg

Fig. 2-54 B

Numerous comedones and infundibular cysts of different sizes in clusters on skin injured badly by sunlight.


New! Additional Images

at002eg001.jpg

Fig. 2-55

Acne vulgaris: Papules, papulopustules, pustules, nodules, and atrophic scars, as well as patulous ostia of infundibula that previously housed a comedo.


at002eg002.jpg

Fig. 2-56

Acne: Comedones, papules, papulopustules, pustules, and hypopigmented atrophic scars.


at002eg003.jpg

Fig. 2-57

Acne: Comedones, papules, and atrophic scars.


at002eg004.jpg

Fig. 2-58

Acne keloidalis. Papules, some scaly, others crusted of acne keloidalis.


at002eg005.jpg

Fig. 2-59

Acne conglobata. Comedones, papules, papulopustules, and honey-colored and hemorrhagic crusts, some of which have peculiar geometric outlines by virtue of lesions having become confluent, of acne conglobata.


at002eg006.jpg

Fig. 2-60

Acne. Comedones, papules, papulopustules, and pustules.


at002eg007.jpg

Fig. 2-61

Acne. Numerous milia, i.e., tiny infundibular cysts.


at002eg008.jpg

Fig. 2-62

Acne. Tiny atrophic scars.


at002eg009.jpg

Fig. 2-63

Acne keloidalis.Comedones, milia, keloids, and atrophic scars of acne keloidalis.


at002eg010.jpg

Fig. 2-64

Steroid acne. Papules, situated mostly in the center of the face, are a result of topical application for months of high-potency corticosteroids, of steroid acne.


at002eg011.jpg

Fig. 2-65

Steroid acne. Papules and papulopustules, each situated at the ostium of an infundibulum, a result of systemic administration of corticosteroid (steroid acne).


at002eg012.jpg

Fig. 2-66

A plum-colored nodule, the result of rupture of an infundibular cyst, situated above a linear scar within which are dilated ostia of infundibula, each of which represents an opening of a pilonidal sinus.


at002eg013a.jpg

Fig. 2-67 A

Acne vulgaris. Papules, papulopustules, and hemorrhagic crusts.


at002eg013b.jpg

Fig. 2-67 B

Acne vulgaris. Papules, papulopustules, and hemorrhagic crusts.


at002eg014.jpg

Fig. 2-68

Favre-Racouchot syndrome. Comedones and milia (small infundibular cysts) of Favre-Racouchot syndrome consequent to injury of skin by rays of the sun received for many decades. There also are seborrheic keratoses.


at002eg015.jpg

Fig. 2-69

Neonatal acne. Milia, i.e., tiny infundibular cysts, range from pinpoint to papular and cover most of the face of a neonate (neonatal acne).