Abstract

Acne vulgaris (AV) is characterized by non-inflammatory lesions with open and closed comedones; inflammatory lesions or inflammatory nodules, pustules or papules. It is common among adolescents and can be persistent in some. 

This is a case of a 26-year-old woman who presented with persistent nodular skin papulesof the facial skin.In addition, multiple comedones could be detected. The patient was diagnosed with AV.

The lady was successfully treated by 1% tretinoin gel. She was also prescribed a sunscreen,which was to be used in the daytime.This led to a mean percent reduction in the inflammatory and noninflammatory lesion counts. It also improved the severity of lesions without causing any adverse effects. 

Introduction

Acne vulgaris (AV) – a disease of the pilosebaceous unit, causes non-inflammatory lesions with open and closed comedones; and inflammatory lesions – papules, pustules and nodules; and varying degrees of scarring. AV is a common condition with a lifetime prevalence of approximately 85% and occurs mostly during adolescence. AV can persist into adulthood, with a 50.9% prevalence rate of acne in women aged 20-29 years, and 26.3% in women aged 40-49 years. Nearly one-third of all dermatology office visits for acne are by women older than 25 years.

Acne vulgaris usually cause residual scarring and thus, significant morbidity due to psychological impacts such as poor self-image, depression and anxiety. Especially in women, scarring due to AV may result in depression and reduced quality of life. 

Factors contributing to acne occurrence include – genetics; family history; diet; and environmental factors – like occupational exposure, smoking and occlusive cosmetics. The pathogenesis underlying the formation of acne lesions involve – alteration of follicular keratinization that leads tocomedones; increased and altered sebum production under the influence of androgen; follicular colonization by Propionibacterium acnes; and complex inflammatory mechanisms that involve both innate and acquired immunity. In adult females, androgens play a major role of the pathogenesis of acne, for instance in cases with hyperandrogenism disorders –such as polycystic ovary syndrome (PCOS). Androgens stimulate sebum production via androgen receptors on the sebaceous glands and changes in these hormonal levels during premenarche or in PCOS may trigger acne.¹

Case report

A 26-year-old lady complained of persistent nodular skin papules on her face. 

On examination, multiple comedones were observed. Lesions resembles that of AV.

The patient was prescribed 1% tretinoin gel for use after sunset. She was also advised to use a sunscreen, during the day, to prevent photodamage. 

This therapy aided in achieving mean percent reduction in inflammatory and noninflammatory lesion counts. It also improved the severity of the lesions and quality of life of the patient. 

No adverse effect was reported apart from mild skin dryness at the site of application. Overall, the treatment was well-tolerated and rendered satisfactory results, as well as prevented acne recurrence. 

Discussion

Topical treatments should be preferred in cases with mild-to-moderate acne – of both, inflammatory and noninflammatory forms. According to American Academy of Dermatology guidelines, retinoids is deemed as an effective topical treatment. Topical antibiotics are also widely used; however, they may predispose to antimicrobial resistance. Other, less-effective topical modalities include – salicylic acid, azelaic acid, sulfur, resorcinol, sodium sulfacetamide, aluminum chloride and zinc. 

Topical retinoids, for example, tretinoin, reverse abnormal desquamation and interfere with microcomedone formation. Topical retinoids are indicated for noninflammatory acne because of their anti-inflammatory properties. 

Topical agents are considered safer than oral medications for use in women who are pregnant or lactating because systemic availability of the drug is lower. Some topical medications do not even have a pregnancy category for short-term use.¹

Systemic antibiotics may be prescribed for moderate-to-severe cases and treatment-resistant forms of inflammatory acne. The most commonly prescribed antibiotics for acne are tetracycline, erythromycin, clindamycin, doxycycline and minocycline. Oral erythromycin should be used only when tetracyclines cannot be used, such as in pregnancy or in patients with known allergies. When other antibiotics cannot be used, trimethoprim-sulfamethoxazole can be an effective alternative.

Long-term use of antibiotics is not recommended owing to the risk of gastrointestinal irritation, antimicrobial resistance and other side-effects like vaginal candidiasis in women. Doxycycline mayinduce photosensitivity reactions while long-term use of minocycline may cause cosmetically displeasing skin hyperpigmentation.

Isotretinoin is indicated for severe recalcitrant nodular acne and in some patients with treatment-resistant acne resulting in physical scarring. This systemic agent has anti-inflammatory action, inhibits sebum production and impacts follicular desquamation. This drug is a teratogen and should not be prescribed in women of reproductive age.^2,3

Conclusion

Topical therapy is recommended for treating mild, moderate and severe acne in women of reproductive potential. Systemic agents may lead to side-effects and are used as a last resort, in recalcitrant AV. Topical retinoids have been widely used for the treatment of AV and has shown good results with respect to attenuating symptoms and improving the scar and severity of acne.

This case study relates a successful treatment of persistent acne vulgaris in a 26-year-old woman with 1% tretinoin gel. The report demonstrates that the use oftretinoin gel at nighttime, along with daytime sunscreen application for 12-weeks can ameliorate symptoms of AV and improve the severity of the lesions, and may also prevent recurrence.

References:

1. Tan AU, Schlosser BJ, Paller AS. A review of diagnosis and treatment of acne in adult female patients. Int J Womens Dermatol. 2017;4(2):56-71. Published 2017 Dec 23. doi:10.1016/j.ijwd.2017.10.006
2. Massa AF, Burmeister L, Bass D, Zouboulis CC. Acne Fulminans: Treatment Experience from 26 Patients. Dermatology. 2017;233(2-3):136-140. doi:10.1159/000473860
3. Harper JC, Baldwin H, Stein Gold L, Guenin E. Efficacy and Tolerability of a Novel Tretinoin 0.05% Lotion for the Once-Daily Treatment of Moderate or Severe Acne Vulgaris in Adult Females. J Drugs Dermatol. 2019;18(11):1147-1154.