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Solar elastosis with comedones studding the central face is often referred to as Favre-Racouchot disease. These open and cystically dilated comedones tend to appear in the periorbital region of the face. The clinical manifestations, pathogenesis and current treatment of this disorder are reviewed.
Acne occurs primarily in the first year of life and at puberty. Neonatal and infantile acne may reflect the relatively high androgens from the adrenal in girls and the adrenal and testes in boys characteristic of this age. Early in puberty, acne in boys and girls is primarily comedonal and midfacial. The best predictors of severe acne are early onset of comedones and serum levels of dehydroepiandrosterone sulfate. Early recognition and therapy of acne may prevent scarring and psychological stress.
Acneiform dermatoses are follicular eruptions. The initial lesion is inflammatory, usually a papule or pustule. Comedones are later secondary lesions, a sequel to encapsulation and healing of the primary abscess. The earliest histological event is spongiosis, followed by a break in the follicular epithelium. The spilled follicular contents provokes a nonspecific lymphocytic and neutrophilic infiltrate. Acneiform eruptions are almost always drug induced. Important clues are sudden onset within days, widespread involvement, unusual locations (forearm, buttocks), occurrence beyond acne age, monomorphous lesions, sometimes signs of systemic drug toxicity with fever and malaise, clearing of inflammatory lesions after the drug is stopped, sometimes leaving secondary comedones. Other cutaneous eruptions that may superficially resemble acne vulgaris but that are not thought to be related to it etiologically are due to infection (e.g. gram-negative folliculitis) or unknown causes (e.g. acne necrotica or acne aestivalis).
The nevus comedonicus (NC) is an uncommon variant of adnexal hamartoma which appears clinically as linear groups of open comedones. Its name may be a misnomer since, according to some, true comedones are not present. NC usually occurs by itself but may be linked with a variety of systemic findings such as skeletal or ocular anomalies. Although the nevus comedonicus is viewed by many as a hamartoma arising from a defective mesoderm, others consider this lesion to be an epidermal nevus involving the hair follicle or an appendageal nevus of sweat ducts.
Altogether 30 patients (19 females and 11 males), mean age 19 years, were divided randomly into two groups. All patients had chronic papulopustular acne of the face. A total of 15 patients were treated topically with Silicol gel for 20 min twice daily for 6 weeks and the remaining 15 patients were treated with a placebo gel in a similar fashion. A clinical evaluation was carried out at baseline, and after 2, 4 and 6 weeks of treatment. The clinical variables evaluated were as follows: number of comedones, papules, pustules and cysts on a standard area of the left cheek (area 5 x 5 cm) and measurement of sebum production on the same area by the use of Sebumeter SM 810 PC (Courage and Khazaka, Ltd, Germany). No concomitant treatment was allowed during the study period. One patient using Silicol gel withdrew after 2 weeks of treatment because of severe irritation of the facial skin, leaving 29 patients who could be evaluated. In the active group, the number of comedones decreased from a mean of 48.5 to 15.1 after 6 weeks of treatment. The corresponding figures for papules were 10.7 and 1.0, for pustules 6.8 and 0, and for cysts 0.6 and 0. In the placebo group no improvement could be observed. There was a highly significant difference in efficacy between the two groups (P < 0.001) in favour of the actively treated group. The mean sebum index was 193 at baseline and 88 after 6 weeks. Correspondingly in the placebo group the mean sebum index at baseline was 187 and after 6 weeks 179. This difference between the two groups was also statistically significant (P < 0.001). After a short follow-up period (3 months) no deterioration was observed in the 14 'active' patients, showing either complete cure or improvement.
Acne vulgaris is a disease of the pilosebaceous unit of the skin. It may have profound psychological sequelae. The lesions are due to abnormally adherent keratinocytes causing plugging of the follicular duct followed by accumulation of sebum and keratinous debris. This results in the formation of the primary lesion of acne, the comedo. Inflammation of comedones produces papules, pustules and nodules, which often prompt patients to seek treatment. Various effective treatments include topical anti-inflammatory, antibiotic and peeling agents, oral antibiotics, topical and oral retinoids, and hormonal agonists and antagonists. Useful combination regimens are discussed, and treatment approaches suggested. Mild cases of comedonal acne may respond to a topical retinoid or benzoyl peroxide, while inflammatory lesions benefit from topical antibiotics. More severe inflammatory acne is treated with systemic antibiotics. Recalcitrant cases often require oral isotretinoin or hormonal manipulation.
BACKGROUND: Glycolic acid chemical peels have been widely accepted as a useful modality in many cutaneous conditions characterized by abnormalities of keratinization. OBJECTIVE: The aim of this study is to evaluate the use of glycolic peels in the main clinical forms of acne. METHODS: Between January 1995 and December 1996, 80 women, aged 13-40 years, were visited for acne and selected for the study at the Cagliari University Dermatology Department (Italy). The type and severity of acne in each patient was assessed following the Leeds technique. The chemical peels were performed with a 70% glycolic acid solution, for times that varied in a range between 2 and 8 minutes. The number and frequency of the applications depended on the intensity of the clinical response. RESULTS: The main clinical forms were comedonic acne in 32 cases, papulo-pustular acne in 40 cases and nodule-cystic acne in the remaining eight cases. The most rapid improvement was observed in comedonic acne. In the papulo-pustular forms an average of six applications was necessary. Although nodular-cystic forms required eight to ten applications, a significant improvement of the coexisting post-acne superficial scarring was noted. The procedure was well tolerated and patient compliance was excellent. CONCLUSION: Glycolic acid chemical peels are an effective treatment for all types of acne, inducing rapid improvement and restoration to normal looking skin.
BACKGROUND: Cyproterone acetate is a potent antiandrogen with strong progestational activity. In combination with ethinyloestradiol, it has been shown to be of clinical benefit to women displaying signs of androgenization, such as acne, seborrhoea and hirsutism. In addition, this combined oestrogen/progestogen preparation provides effective contraceptive protection. OBJECTIVE: The aim of this open-label, multicentre study was to determine the efficacy and tolerability of a preparation containing cyproterone acetate and ethinyloestradiol in women with various grades of facial acne. PATIENTS: A total of 890 women aged from 15 to 50 years with grade I-IV facial acne according to the classification of Plewig and Kligman, participated in the study. METHODS: Patients received six cycles of a preparation containing 2 mg cyproterone acetate and 0.035 mg ethinyloestradiol (EE/CPA). Changes from baseline counts of individual acne lesions (open and closed comedones, papules, pustules, nodes and cysts) were monitored together with the simultaneous presence of seborrhoea and hirsutic signs. Reductions in the number of all and individual lesions were classified as: 75-100%, "very good"; 50-75%, "good"; 25-50%, "moderate"; < or = 25%, "absence of therapeutic effect". Body weight and blood pressure were recorded throughout the study. Adverse events and reasons for premature withdrawal from treatment were documented. RESULTS: A "good" or "very good" therapeutic response (i.e. reduction in the total lesion count of > 50%) was seen in 82.8% (95% CI 80.1-85.5) of patients after six cycles of EE/CPA. A similar response was achieved in the different grades of acne with a significant decrease in the number of all lesions throughout the study (p < 0.05). A greater than 50% reduction in open and closed comedones, papules, pustules, nodes and cysts was observed in 75.6%, 80.0%, 88.4% and 85.1% of patients, respectively. By the end of the study, 64.3% of women displayed a lower grade of acne and only 4.9% experienced exacerbation of the condition. EE/CPA was well tolerated, with only 3.4% of patients discontinuing treatment because of adverse events. The majority of events were described as mild, and their incidence declined as the study progressed. No clinically significant changes in blood pressure and body weight were recorded. CONCLUSION: EE/CPA is an effective treatment for acne of all grades and all types of lesion. The preparation is well tolerated and would appear to be an appropriate treatment for women with these symptoms of androgenization.
OBJECTIVE: To investigate the effect of a combiphasic oral contraceptive containing ethinylestradiol and desogestrel (combiphasic EE/DSG) on acne, compared with a preparation containing ethinylestradiol and cyproterone acetate (EE35/CPA). METHODS: An open, randomized, group-comparative, multicenter study was carried out, with 172 women randomized to treatment with either combiphasic EE/DSG (25 microg desogestrel and 40 microg ethinylestradiol for 7 days followed by 125 microg desogestrel and 30 microg ethinylestradiol for 15 days) or EE35/CPA (2.0 mg cyproterone acetate and 35 microg ethinylestradiol for 21 days). Assessments were performed at pretreatment and after cycles 3 and 6. RESULTS: The number of comedones, papules, pustules and nodules significantly decreased in both groups over the 6-month study. Compared with pretreatment (= 100%), the relative numbers of comedones, papules, pustules and nodules at cycle 6 significantly decreased to 37%, 38%, 19% and 12.5% in the combiphasic EE/DSG group and to 24%, 36%, 17% and 1% in the EE35/CPA group, respectively. All reductions were statistically significant (p < or = 0.003) at both cycles 3 and 6, except for nodules at cycle 6 with combiphasic EE/DSG, which probably resulted from differences between the treatment groups at baseline. There were no statistically significant differences between the two treatments. In both groups, the majority of women with severe acne shifted to a less severe acne category. CONCLUSIONS: Combiphasic EE/DSG progressively reduced the number and severity of acne lesions during the six cycles of treatment. The reduction in acne with the combiphasic oral contraceptive was comparable to a preparation containing the antiandrogen cyproterone acetate.
BACKGROUND/AIMS: The primary aim of the study was to establish the clinical efficacy and safety of a combined treatment consisting of topical 20% azelaic acid (AA) cream and the oral antibiotic minocycline in the therapy of severe inflammatory acne (nodular papulopustular acne and acne conglobata) in a comparison with oral isotretinoin therapy. The secondary aim was to establish the value of AA cream as maintenance therapy in the prevention of recurrent acne. METHODS: This open-label but randomised study involved 85 patients with nodular papulopustular acne or acne conglobata (Leeds grading scale > 4) who were treated for 6 months. In an immediately subsequent 3-month second phase, eligible patients from the initial combination group used the AA cream as maintenance therapy, while the eligible patients from the isotretinoin group served as untreated control. RESULTS: A 6-month course of treatment with topical 20% AA cream plus oral minocycline in 50 patients proved to be effective in nodular forms of acne (median reduction of facial comedones: 70%; of papules and pustules: 88%; of deep inflammatory acne lesions: 100%). Overall, the combined treatment was not quite as effective as treatment with oral isotretinoin (35 patients; reduction of comedones: 83%; of papules and pustules: 97%; of deep inflammatory acne lesions: 100%). In the 3-month maintenance therapy phase, about half of the patients who received AA monotherapy maintained the very good facial result achieved by the end of phase I. A similar rate was found in the patients of the isotretinoin group, who received no further active acne treatment. In the other 50% of patients, differences existed between the groups as regards the degree of deterioration: Marked deterioration occurred more frequently under AA treatment, while only slight deterioration was more frequent in the isotretinoin group. The combination was tolerated much better than isotretinoin. The incidence of local side effects observed under the combination of AA and minocycline (36.5%, mainly transient burning and itching of mild or moderate intensity) was considerably lower than that seen with isotretinoin (65.7%). The rate of local side effects of marked intensity observed under the combination, i.e. 6%, was well within the range of 5-10% previously reported for AA. The incidence of systemic side effects was lower (8%, mainly gastrointestinal symptoms) under the combined therapy than under isotretinoin (14.3%). CONCLUSION: The combination of topical 20% AA cream and oral minocycline is an highly effective treatment in severe forms of acne. It is better tolerated and associated with fewer risks than oral isotretinoin - in particular, there is no risk of teratogenicity. The combination can be regarded as a valuable alternative in patients for whom isotretinoin is not indicated, who do not wish to use or can not tolerate isotretinoin therapy and particularly in female acne patients of child-bearing potential. Topical 20% AA cream can be used successfully as maintenance therapy to prolong the recurrence-free interval.
A definition and classification of acneiform dermatoses is presented to distinguish these diseases from true acne. True acne is a follicular eruption which begins with a comedo, sometimes evolving into various inflammatory lesions. Members of true acne are acne vulgaris with its varieties, acne venenata, and comedonal acne due to physical agencies. Acneiform reactions begin with an inflammatory lesion, usually a papule or pustule. Comedones are uncommon and may follow pustules. Acneiform eruptions are almost always drug-induced, the commonest agents being corticosteroids and ACTH, iodides, bromides, anti-convulsive drugs, and INH. Topical treatment with VAA is indicated in every variety of true acne; VAA is helpful in acneiform dermatoses with secondary comedo formation, as for instance in steroid acne. Very satisfying results can be achieve with this regimen.
The effects of topically applied vitamin A acid and benzoyl peroxide were investigated. Short-term (a few days) and long-term (up to 800 days) treatment was analyzed histologically and autoradiographically. Labelled and unlabelled biopsies at various time intervals were taken from face, back, and acne lesions. Kinetics were followed with 3H-TdR and 3H-histidine. All keratinizing epithelia of epidermis and adnexa are stimulated by vitamin A acid. Labelling is high (up to 20-70% L.I) and occurs within a few days. Follicles and comedones can also be stimulated, but respond less and much later than epidermis. Transit time is shortened to 3-4 days. Lose, incoherent horny cells are produced, explaining the therapeutic benefits of vitamin A acid in acne. Benzoyl peroxide is less effective in stimulating epidermopoieses in epidermis, follicles, and comedones. This autoradiographic analysis parallels therapeutic results with these two exfoliants.
The authors present a case of Favre-Racouchot syndrome (elastoidosis nodularis cystica et comedonica) in a male mason aged 65, associated with nodular-ulcerative type of basocellular skin neoplasm and seboroic keratosis of the irritative type. A special reference is given to nodular cystic elastoidosis (NCE) with concurrent numerous skin changes characteristic for chronic actinic skin lesions which were clinically evidenced. An objective examination of the patient revealed the presence of multiple follicular comedones, black in colour, the size of a pinhead, and of yellowish follicular papulas, 2-5 mm in size, of solid consistency, on the top of which is a formation similar to comedone. These eflorescences are densely disseminated in periorbital, zygomatic and temporal regions of the face, sparsely on the nose, forehead and preauricularly. In other regions of the face and neck other manifestations of chronic actinic skin lesions with characteristics of "citrine skin", cutis rhomboidalis nuchae and elastoma Dubreuilh are present as wall. In the right nasolabial furrow a clearly edged tumefaction, 1.2 x 0.8 cm, which belongs to the nodular-ulcerative type of basocellular skin neoplasm is seen. Seboroic keratosis of the irritative type was observed on the skin in the middle of the upper lip was histologically verified.
Eighty-three patients with moderately severe acne were entered into a double-blind study utilizing clindamycin and placebo. Counts of comedones and pustules were made at intervals during a 13-week period. Clindamycin resulted in noticeable improvement of acne in 85% of subjects while in the placebo group improvement was present in 38%. There was also an unexplained reduction of total comedone count in the clindamycin-treated group. Severe side effects occurred in two of 44 patients receiving clindamycin (diarrhea, 1 and rash, 1); although an additional eight patients receiving clindamycin experienced mild diarrhea, discontinuation of therapy was not required. Clindamycin appears to be a valuable additional drug in the treatment of acne.
Nevus comedonicus is uncommon abnormality of pilosebaceous unit, clinically characterized as confluent clusters of dilated follicular orifices plugged with pigmented keratinous material that resembles open comedones. It is suggested that nevus comedonicus is an uncommon variant of adnexal hamartoma, which clinically appears as linear group of open comedones. Since Kofmann's description of nevus comedonicus in 1895, there have been reports of this rare cutaneous disorder associated with developmental anomalies. We present a case of a 19-year-old woman with numerous 1-3 mm size darkly pigmented, keratic plugs clustered in linear unilateral patches on left abdominal part. Our treatment consisted of the avoidance of the formulations containing nickel sulfate and carba mixture, daily local application of tretinoin 0.1% gel and corticosteroid ointment (momethasone furoate). After 4 weeks of local therapy cosmetic result was evident. The slight resolution of keratin plugs could also be seen. Two months after the treatment, there were no visible skin exacerbations.
A 12-week double-blind randomized study was performed to compare benzoyl peroxide 5% (BP) gel and chloroxylenol 0.5% plus salicylic acid 2% (PCMX + SA) cream (Nisal cream) for efficacy and adverse reactions. Thirty-seven volunteers participated in the study, 19 in the BP group and 18 in the PCMX + SA group. The patients applied the medication twice daily to the entire face. Clinical evaluation and lesion counts were obtained at 0, 3, 6, 9 and 12 weeks. At week 12 both groups showed a marked improvement in both inflammatory and noninflammatory lesions (60% and 54% for the BP group and 62% and 56% for and 56% for the PCMX + SA group, respectively). Although PCMX + SA showed a slightly stronger keratolytic effect throughout the study period, there was no statistically significant difference in the reduction of the papulopustules or comedones between the two groups. Adverse effects such as erythema and photosensitivity were significantly fewer in the PCMX + SA group at week 12 (p = 0.0002 and p = 0.05, respectively). These results suggest that PCMX + SA cream is as effective as BP gel in the treatment of papulopustular and comedonal acne and that it is better tolerated.
In a double-blind controlled comparison that lasted eight weeks, tablets of zinc sulfate monohydrate, 411 mg total daily dosage, and a lactose placebo were administered orally to 22 male subjects with moderate acne. At the same time, levels of zinc were determined in serum and urine. There were no statistically significant differences in the lesion counts (papules, pustules, open comedones, and closed comedones) in the zinc-treated and lactose-treated cases, despite evidence in serum and urine of absorption of zinc. The data from this study indicate that oral zinc therapy has no early clinical effect on male patients with moderate acne.
The effects of orally administered zinc sulfate in 52 patients with mild to moderate acne vulgaris were compared to those of a placebo capsule. The numbers of comedones, papules, pustules, infiltrates, and cysts were counted at each visit over a 12-week period. Forty patients completed the study. Zinc appeared to have a somewhat beneficial effect on pustules but not on comedones, papules, infiltrates, or cysts. Fourteen patients (50%) in the zinc group had side effects of nausea, vomiting, or diarrhea. Six patients (21%) in the zinc group could not tolerate the nausea and withdrew from the study.