Acne vulgaris is the most common skin condition encountered by physicians, and it affects an estimated 17 million people in the United States. Within the last few years, several new agents for the treatment of acne have become available. This review provides a brief discussion of the pathophysiology of acne, principles for successful management, and an overview of existing therapies. This is followed by a discussion of the new antiacne agents and how they fit into a successful acne treatment strategy.
ACNE, ITS PATHOGENESIS, AND TREATMENT GOALS
Acne vulgaris is a multifactorial disease affecting the pilosebaceous follicles. It arises from the interplay of 4 pathogenic factors: sebum production, follicular hyperkeratinization, microbial colonization of the pilosebaceous unit by Propionibacterium acnes, and the release of inflammatory mediators into the follicle and surrounding dermis. Acne begins in the prepubertal period, when increased amounts of adrenal androgens cause enlargement of the sebaceous glands and increased production of sebum on the face, chest, and back.
The resulting follicular obstruction by the combination of sebum and desquamated epithelial cells causes the formation of a microcomedone, the precursor lesion of acne. This is also a suitable environment for the proliferation of P acnes, an anaerobic diphtheroid that colonizes sebum-rich follicles and uses lipids found in sebum as a nutrient source. Lipases released from P acnes hydrolyze sebum triglycerides into free fatty acids, which are an irritant to the follicular wall and the surrounding dermis after follicular rupture. P acnes also release chemotactic factors and proinflammatory mediators that contribute to the observed inflammatory response. The clinical results of these pathophysiological events include noninflammmatory open (blackheads) and closed comedones (whiteheads), as well as inflammatory papules, pustules, and nodules. Although acne is not a life-threatening disease, it has significant physical and psychological ramifications such aspermanent scarring, poor self-image, social inhibition, depression, and anxiety.
STRATEGIES FOR SUCCESSFUL ACNE MANAGEMENT
Patient Factors
Successful management of acne requires careful patient evaluation followed by consideration of several "patient factors" and "medication factors" in choosing a particular therapeutic regimen. Most patients have a mixture of noninflammatory and inflammatory lesions. The predominance of one type, along with the number of lesions, plays a role in determining acne severity. In addition, other factors to be considered include age, skin type (dry, oily, or combination), coexisting conditions, patient motivation, lifestyle, menstrual regularity and premenstrual flareups, evidence of hirsutism, effect of acne, and potential therapies on the patient's quality of life. If the patient is taking birth control pills, it is important to determine the brand, as certain formulations contain agents (eg, androgenic progestins) that may provoke acne.
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