Acne: the search for the ideal classification

Acne is one of the most common diseases among the population. But it does not yet have a single recognized classification convenient for diagnosing the disease and prescribing therapy.

Svetlana YUDINA, dermatovenerologist, Honored Doctor of Ukraine, chief physician of the Doctor Yudina clinic

The term “acne” was first mentioned in the writings of the ancient Greek physician Aetius of Amid, who served at the court of Justinian I. On the island of Crete, there is still a temple to a priestess named Acne, whom this doctor treated for acne, and in her honor, as legend says, he named this disease. Scientists suggest a different source for the origin of this word: the term “acne” originally had the spelling acme or achne (“top”, “cone”, “point”), and the modern name was obtained due to a text transcription error. In the Middle Ages, the Greek word lonthos (“bearded”) was used to denote the term “acne,” which indicated the fact that with the appearance of a beard, acne also appeared on the face of a young man.

However, only from the middle of the 19th century did doctors become interested in this problem, which can be explained by severe epidemics and other serious health problems among people in those distant times. In 1840-1850, the Austrian doctor of medicine Hebra turned his attention to acne, linking the occurrence of acne with insufficient hygiene and subsequent infection of the sebaceous glands, and also pathogenetically substantiated the mechanisms of occurrence of this type of rash.

Subsequently, with a more in-depth study of acne, numerous differences in the course of this disease in patients were established, and the need arose to classify acne.

In 1930, Carmen Thomas of Philadelphia pioneered a new method of classifying acne by using a system of counting acne elements.

Currently, there are several systems for classifying the severity of acne. They do not take into account etiopathogenetic factors, since they are based purely on the study of the quantitative and qualitative characteristics of acne.

In 1956, Pillsbury, Shelley and Kligman published the earliest classification system known to date. It included division into 4 degrees of severity without quantitative indication of the elements of the rash, but with clarification of its localization (on the face and torso). In 1958, James and Tisserand, in their review of acne treatment, proposed an alternative classification scheme, where they clarified the types of rashes and distinguished inflammatory and non-inflammatory forms of acne.

The need to evaluate the effectiveness of treatment prompted Witkowski and Simons in 1966 to use a slightly different item count to assess acne severity. Lesions were counted on one side of the face to save time after it was determined that the number of lesions on the left side was almost equal to those on the right.

In 1977, Michaelson, Juhlin, and Vahlquist counted the number of features on the face, chest, and back and applied an index to each rash type based on the severity of those features. Thanks to this system, it became possible to assess the patient's condition at each new visit to the doctor, but the discrepancy between parametric and non-parametric data exposed this classification to criticism.

In 1979, Cook, Centner and Michaels rated the severity of acne using a 9-point system, adding photographic parameters to the qualitative and quantitative descriptions of the elements.

Subsequent classifications were improved and new research methods were added to them. A thorough study and comparative characteristics of various elements of the rash, their quantitative indicators, consideration of localization and therapeutic monitoring of the effectiveness of treatment contributed to the creation of numerous classification systems for acne. Research methods such as standard photography, fluorescent microscopy with a fluorescent light source, and polarized light photography are of great help in assessing the severity of acne.

Modern classifications of acne evaluate acne by severity and clinical forms.

The most convenient and commonly used classification for determining the severity of acne is the classification proposed by the American Academy of Dermatology in 1990, which evaluates the inflammatory and non-inflammatory elements of the skin rash, the presence of complications and the level of psychosocial impact.

In terms of clinical forms, the classification proposed in 1994 by Plewig and Kligman is recognized as one of the most successful.

1. Acne of newborns.

2. Infantile acne.

3. Juvenile acne with the following forms: comedonal; papulopustular; conglobate (spherical); inverse; fulminant forms of acne; mechanical; solid persistent facial swelling.

4. Adult acne with the following forms:

• in the back area;
• tropical;
• late acne in women;
• premenstrual;
• postmenopausal;
• hyperandrogenic (women);
• acne in pregnant women with adroluteoma;
• doping;
• bodybuilding;
• conglobate (men with the XYY chromosome set);
• testosterone-induced fulminant (tall adolescents).

5. Contact: cosmetic, chloracne, acne due to oils, resins, tar.

6. Comedo, provoked by physical factors: x-ray radiation, sun, solarium, acne Mallorca.

This classification takes into account not only the description of certain types of acne, but also draws the attention of doctors to the causes of acne, the physiology of the occurrence of rashes in certain age periods, and thus suggests individual tactics for managing such patients.

In 1997, the classification was supplemented by K. N. Suvorova and N. V. Kotova.

A. Constitutional acne, idiopathic acne.

1. Seborrheic acne in childhood, adolescence and young adulthood:

• acne of newborns (acne neonatorum);
• baby acne (acne infantum);
• juvenile acne (acne juvenilis).

1. Late acne:

• premenstrual acne;
• postmenopausal acne;
• late hyperandrogenic acne (Stein-Leventhal syndrome and other hyperandrogenism in women);
• conglobate-cystic acne in men with chromosomal polysomy Y (XYY) syndrome and Klinefelter syndrome.

B. Provoked acne.

1. Artificial (mechanical, traumatic).

2. Oil (including professional, resin and tar).

3. Cosmetic (acne toxica, acne venenata, acne de la bril-liantine).

4. Excoriated acne (acne excoriee des jeunes filles, acne neurotica).

B. Special forms of acne.

1. Gram-negative folliculitis.

2. "Facial pyoderma."

3. Resistant acne.

The search for an optimal acne classification system is ongoing and highly anticipated among dermatologists. At this stage, there is no unified acne classification system. An ideal classification system would be:

• accurate and reflecting the complete clinical picture of the disease;
• capable of being documented and reproducible for further verification;
• be easy for clinicians to use;
• do not require a lot of time to use;
• be less expensive and easier to use clinically;
• would involve taking into account subjective criteria such as psychosocial factors.

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First published in Cosmetologist 6/2016