Comprehensive Health Guide

Infantile and juvenile acne mainly affects male babies of 3 to 24 months of age and may continue up to age of 5 years. The lesion are more localized and commonly affects cheeks. The lesions contain comedones, papules and pustules, and sometime it may include nodules and scarring also. Another disease which is almost same as acne is seen among infants in first 3 weeks of life called neonatal cephalic pustulosis. Here also papules and pustules are seen in cheeks. These are commonly due to Malassezia sympodiales. This is self limiting disease and need no treatment. But topical antifungal creams can be of help.

In one of the study on infantile and juvenile acne, it was found that about ¼ of patients had mild acne, approximately 60% had moderate acne and remaining had ‘severe acne’ and mean age of onset was 9 months of age. This type of acne are mainly of inflammatory type. The infantile and juvenile acne may be due to transplacental stimulation of adrenal glands because most of the patients have increased adrenal androgens in plasma.

Sebaceous glands in skin have enzymes which can convert adrenal androgens to testosterone and androstenidione. Infantile acne rarely involved with other adrenal disorders like hirsutism. It is not clear why infantile acne sometime last for several years. If the child is well and no other abnormal features, than endocrinological investigantions are not required. But endocrine investigations may be required if patient develop acne at the age of 5 to 8 years.

Treatment: Treatment of infantile and juvenile acne consists of same principle for adults. But tetracycline group of antibiotics has to be avoided because it can cause permanent discoloration of dentition (teeth). If disease is mild than topical benzoyl peroxide, retinoid or erythromycin or clindamycin can be used successfully. But retinoid with one antibiotic like erythromycin or clindamycin are preferred. For moderate acne topical retinoid and an antibiotic like erythromycin ethyl succinate 125mg 3 times per day for 6 months can be used successfully. In severe form of infantile acne the treatment is same as moderate but the duration of antibiotic theory has to be much longer. Isotretionin is reserved for patients not responding to standard treatment . Another alternatives is trimethoprime 100mg two times per day.

Patient with infantile acne can develop severe acne during adolescence.

They are miscellaneous groups of diseases which coexist with acne .

(1) Acne excoriee: This usually occurs in females. Two types are there, first without any inflammatory lesion and the other with mild primary inflammatory acne lesions. This is usually seen in a female who ‘fiddle’ with the skin and exacerbate the small lesion. Contact dermatitis should be excluded. Patient commonly suffer from personality or psychological problem.

Treatment is with oral antibiotics like oxytetracycline 0.5gm twice daily or with lymecycline once daily for several months. Topical ointments are of no use, they only irritate the skin and aggravate the situation. Advice should be given not to pick the spots, which is very useful. After treatment with oral antibiotics patient get fewer spots to “play” with.

(2) Apert’s Syndrome: It is a disease where epiphyseal closer occurs early due to androgen mediated events like acne. The characteristic facial abnormalities are flattened occiput, hypertelorism (abnormally increased distance between two organs or parts) proptosis (bulging of eyeball) due to shallow orbit, prognathism (abnormal protrusion of one or both jaws mainly lower jaw), parrot beaked nose and fused shortened digits. Two genetic mutations on fibroblastic growth factor has been blamed for the causation of the disease. Because of all the above the patient has a characteristic appearance with extensive acne. Acne usually occurs at uncommon sites like arms. Treatment of this type of acne do not respond well to antibiotics and need isotretinoin.

(3) Darie’s Disease: It is associated with acne, usually nodular type and very difficult to treat with conventional therapy. Patients with Darie’s disease are sometimes missed as nodular acne .

(4) Body Dysmorphic Disorder and Acne : A small number of patients with body dismorphic disorder have acne as their main symptom. Acne is usually mild and patients complain is out of proportion physical sign. Patients are depressed and have risk of suicide. They do not tolerate psycho therapy well. Dermatologists should treat acne vigorously with isotretinoin and minocycline.

(5) Drug Induced Acne: Many drugs have been implicated to cause acne. Evidence is through isolated case reports. The following drugs causes acne as side effect:-

(1) Halogens: Bromide, iodide, halothane .

(2) Antitubercular drugs:Isoniazid, rifampicin.

(3) Antiepileptic dregs: Phenytoin, phenobarbitone

(4) Miscellaneous: Disulfirum, chloral hydrate, lithium, cyanecobalamine, psoralens, quinine, sulphur, thiouracil and thiourea.

Steroids induce cornification of the upper part of pilocebaceous duct. Androgens including anabolic steroids taken by athletes to enhance performance, can aggravate acne. Oral conntraceptive pills can also cause deterioration of preexisting acne as they reduce SHBG levels.

(6) Endocrine acne :This type of acne is seen in patients with endocrine disease like Cushing’s disease and polycystic ovarian syndrome(commonest cause of endocrine acne).

Here is a ready for checking (BMI) list. In the first left column your height in centimeters and to the right of that column your body weight. The nos. 17,18.5, 20, 22, 25, 30, 35 and 40 denotes BMI. The BMI of 18.5 to 30 is the normal range. BMI above 30 is obesity and not good for health. BMI below 18.5 is underweight, it is also not good for health.

If your weight and height do not match in the list you can calculate your own BMI by the following formula:

Body Mass Index or BMI (Quetelet’s index)

Weight (in kg)

=————————-

Height ²(in meters)

Here remaining four severe forms of acne are discussed:

(3) Gram-Negetive Folliculitis: This is a complication of long term antibiotic therapy for treatment of acne. Usually oral antibiotic are responsible and less commonly topical antibiotics. Common presentation is sudden eruption of multiple, follicular pustules (with pus ) or nodules. Examination of samplings reveals gram-negative organisms like klebsiella, proteas, Escherchia coli (e.coli) or pseudomonas. Treatment is stopping of antibiotics and replace them with ampicillin (250mg four times/day) or trimethoprime (600mg/day). But relapses are common and response is slow. So nowadays isotretinoin is the treatment of choice, with this relapses are less common.

(4) Pyoderma Faciale: Also known as rosacea fulminans. Though it is a variant of acne it is more related to rosasea. This is severe form of facial dermatosis. It is uncommon and occurs by suddenly producing eruptions of pustules and nodules, mainly in face. Common age group is 20-40 years of females, usually followed by stress; comedones are rare and there is no systemic involvement. Pyoderma faciale is reported to be associated with daily high dose of vitamin B complex and with Chron’s disease, but the cause of association is not known.

Treatment is with minocycline (100-200mg/day) and intra-lesional steroids. But the treatment of choice is oral isotretinoin 0.5mg/kg/day for 4-6 months. To reduce exacerbation oral prednisolone (0.5 to 1mg/kg/day) is used and tapered to zero over 4 weeks should be given. The prednisolone should be started 2-3 weeks before starting isotretinoin. Other alternative is metronidazole and dapsone.

(5) SAPHO syndrome: SAPHO is sinuvitis, acne, pustulosis, hyperostosis and osteitis. It is associated with recurrent chronic multifocal osteomyelitis which have skin disorders. Severe acne is one of the less frequently associated disorder. This may due to immunological reaction to a particular bacterial antigen.

(6) Vasculitis/pyoderma Gangresisum acne: This occurs in otherwise mild acne patients. There is sudden onset of severe vasculitic and pyoderma gangrenosum like lesions. There is severe scarring as a consequence. The cause of this devastating acne may be due to immunological reaction to P.acnes. These patients do not respond to isotretinoin but can be controlled to some extent by oral steroids and azathioprine (200mg/day) it given for 2-3 moths.