Rashes on the skin of the face are one of the most common reasons why patients turn to dermatologists and cosmetologists. This material will discuss the pathogenesis of acne, the clinical manifestations of inflammatory and non-inflammatory acne.

Ekaterina Bardova, Ph.D., Department of Dermatovenerology, NMAPE named after. P. L. Shupika (Ukraine)

Acne is one of the most common chronic skin diseases in young people, but can also affect older people. Thus, in adolescents, acne occurs in 80% of cases or more, in 12% of cases the disease manifests itself after 25 years and can last until the age of 30, and often, in the presence of severe neuroendocrine disorders, acne can persist even after 30–40 years.

Acneiform dermatoses include a group of diseases that have a similar clinical picture to acne vulgaris. At the same time, the formation of comedones is not the initial factor; without their occurrence, the inflammatory reaction of the pilosebaceous complex occurs. This group of diseases includes rosacea, rosacea lupoides, perioral dermatitis, small nodular sarcoidosis of the face, and skin tuberculosis.

Also, acne-like rashes can develop after taking certain medications , such as immunomodulators, gold salts, photosensitizers, antiepileptic drugs, barbiturates, anti-tuberculosis drugs (isoniazid, rifampicin, ethambutol), halogen preparations, lithium salts, B vitamins.

Separately, excoriated acne is distinguished - occurring mainly in young women who are susceptible to neurotic reactions and are prone to excoriation of even minimal manifestations of the rash. It is known that excoriations can occur against the background of acne and even without them. This pathology is most often associated with obsessive-compulsive disorder and requires consultation with a neuropsychiatrist.

Very often, dermatovenereologists, when examining skin scales and the contents of the excretory ducts of the sebaceous glands, discover subcutaneous mites Demodex folliculorum and Demodex brevis , which makes it possible to establish a diagnosis of “demodex.” But, despite the fairly high prevalence of these types of mites in nature, the incidence of demodicosis does not exceed 2.1% in the structure of all skin diseases. According to some authors and our observations, demodicid mites play a certain role in the etiopathogenesis of acne and some acneiform dermatoses, in particular rosacea and perioral dermatitis, and can complicate their course. The largest number of mites is found in patients with rosacea - up to 77–90%, with perioral dermatitis - up to 60%, with acne - up to 29%.

Currently, there is a tendency to increase the proportion of treatment-resistant forms of acne and acneiform dermatoses, which lead to complications, which, in turn, causes the development of mental disorders and social maladaptation of patients.

ACNE

Acne belongs to a genetically determined heterogeneous group of inflammatory lesions of the pilosebaceous apparatus, caused, firstly, by neuroendocrine imbalance, causing a number of sebomotor, immunological and microbiological disorders. The exact etiology of the disease remains controversial. The leading role in the pathogenesis of acne belongs to hormonal imbalance and disruption of the normal microbiocenosis of the skin surface, in which the activation of conditionally pathogenic and transient microflora occurs - in particular, anaerobic gram-positive diphtheroids Propionobacterium acne , which have been in the follicle since puberty.

Modern ideas about the pathogenesis of acne are as follows:

• hyperproduction of sebum by the sebaceous glands under the influence of androgens;
• follicular hyperkeratosis;
• proliferation of Propionobacterium acne ;
• the occurrence of an inflammatory reaction.

An increase in sebum production leads to a decrease in the concentration of linoleic fatty acid, which is the trigger for the occurrence of pathological follicular hyperkeratosis and creates favorable anaerobic conditions for the proliferation of P. acne , and hydrolysis of sebum occurs by bacterial lipases to free fatty acids, which leads to the development of perifollicular inflammation and formation of comedones. Inflammation is also enhanced by the activity of Propionobacterium acne , which produces neutrophil chemotaxis factors.

The first manifestations of acne are caused by pathological hyperkeratinization of the follicular epithelium, the cells of which normally exfoliate freely and are carried with the secretion of the sebaceous glands to the surface of the skin. With acne, larger follicular epithelial cells stick together and form a dense stratum corneum, which closes the follicle's excretory canal.

This leads to blocking of the follicular duct, filling it with secretion and the formation of a microcomedone, which subsequently enlarges, develops to a closed comedone and can be detected clinically.

Clinical manifestations of acne

Clinical manifestations of acne are varied and include inflammatory and non-inflammatory phenomena.

The non-inflammatory type of lesion is closed (white) and open (black dots) comedones.

Inflammatory superficial lesions are characterized by the presence of papules and pustules, nodes and deep pustules are characteristic of deep inflammation. Most patients simultaneously exhibit signs of two types of lesions.

Mild acne is characterized by the presence of closed and open comedones or papules with single pustules, which can resolve without therapeutic intervention within 1–2 weeks. The course of acne of moderate severity is characterized by numerous papules and pustules, deep pustules. Nodules and cysts characterize severe dermatosis (photo 1).

Acne vulgaris (source: Fitzpatrick T. et al. Dermatology. Atlas-reference book (3rd ed.). – M.: Praktika. – 1999, 1,043 p.)

Acne can be combined with demodicosis - with this combination there will be a tendency towards lateralization of the rashes: the rash is localized mainly on the skin of the lateral surfaces of the face, on the cheeks, in 89% - unilateral asymmetric localization. Minor flaking and itching may also occur. Moreover, it should be noted that with late acne in women, demodex can be a marker of hormonal disorders.

ROSACEA

Rosacea is a chronic dermatosis that is characterized by the formation of erythema and telangiectasia in the central part of the face, as well as the appearance of papulopustular rashes and foci of hyperplasia of the sebaceous glands and connective tissue (photos 2–4). It is known that the disease occurs after 30 years of age, reaches a peak at 40–60 years of age, more often affects women, but has a more severe course in men.

Rosacea. Moderate form of the disease (source: Fitzpatrick T. et al. Dermatology. Atlas-reference book (3rd ed.). – M.: Praktika. – 1999, 1,043 pp.)

The leading role in the pathogenesis of rosacea is given to pathology of the gastrointestinal tract , dysfunction of the endocrine system, psychosomatic and immune disorders.

Some products, in particular alcohol, hot drinks, spices, through a reflex action cause dilation of facial skin vessels. Physical factors such as sun exposure, heat, and cold worsen the course of rosacea. There is an opinion that the secretion of the sebaceous glands of the facial skin contains an increased content of porphyrins, which causes photodynamic damage to the structural elements of the skin.

By the way, sometimes antimalarial drugs with photoprotective properties improve the course of the disease.

The contents of pustules in rosacea are predominantly sterile, and gram-negative microorganisms are found only in severe forms

.

Rosacea. Mild damage to the face (left). The same patient many years later (right).
Swelling and proliferation of the soft tissues of the nose (rhinophyma), cheeks and forehead (source: Fitzpatrick T. et al. Dermatology. Atlas-reference book (3rd ed.). – M.: Praktika. – 1999, 1,043 pp.)

The role of Demodex folliculorum mites is unclear . Demodex folliculorum is a physiological representative of the skin microflora, and its colonization of follicles increases with age. Mites can be found histologically in rosacea infiltrates and may support the idea that Demodex folliculorum is a causative agent of rosacea. Demodex folliculorum is found in granulomas - apparently, mites provoke the development of granulomatous rosacea.

If the primary factor in the development of the disease is infection with mites of the genus demodex , it is characterized by the appearance of individual erythematous-squamous lesions in the central part of the face: in the T-zone, on the wings of the nose, in the area of the nasolabial triangle. In this case, the condition is accompanied by itching and a “crawling” sensation. Against the background of erythematous spots, individual small follicular conical papules with a micropustule at the apex are observed. If the process (demodex) is secondary, then the rash is represented mainly by papulopustular elements against the background of hyperemia, located symmetrically, affecting a larger surface of the skin. If, when ticks are detected, their number is less than 5 per square meter. cm, then it can be argued that rosacea is the primary process, and demodicosis complicates the course. If the number of mites is greater, rosacea is considered the primary predisposing factor.

It is known that exacerbation of rosacea in women occurs during pregnancy, menopause, and before menstruation . Most often, the disease is observed among patients with early menopause, physiological or surgical menopause. In the pathogenesis of rosacea, there is no doubt the role of changes in the metabolism of sex steroid hormones such as estradiol, progesterone, testosterone and androstenediol.

Clinical and experimental studies show that dysregulation of the brain's influence on the blood vessels of the facial skin plays a special role in the pathogenesis of rosacea: a slowdown in the redistribution of blood flow develops, venous stasis in the area of the outflow of the facial vein, which corresponds to the most common localization of rosacea. The conjunctiva also enters the outflow zone of the facial vein, which explains the frequent presence of conjunctivitis in rosacea. It is assumed that the blood and lymphatic vessels of the skin are not primarily involved in the pathological inflammatory process.

In the majority of patients with rosacea, significant disorders of the humoral and cellular components of immunity have been established.

Clinical manifestations of rosacea

It is customary to distinguish four stages of the disease:

• erythematous;
• papular;
• pustular;
• infiltrative-productive.

Frequent episodes of hot flashes (first stage) are followed by persistent erythema (erythrosis) and telangiectasia (second stage). Only in half of the cases do these patients develop papules and pustules (acne, rosacea). Rhinophyma is the fourth and final stage, develops only in some men, begins with erythrosis, and is represented by a limited area of the nose. Eye lesions develop simultaneously with the course of rosacea. Histologically, dilated blood and lymphatic vessels are visible.

The next stage is characterized by the appearance of isolated and grouped purple papules covered with delicate scales against a background of diffuse thickening of the skin. Papules exist for a long time, for weeks. In some large papules the base is infiltrated. The nodules then turn into papulopustules and pustules. The lesion also affects the skin of the face, behind-the-ear areas, the anterior surface of the neck, and not just the periorbital area. Rhinophyma occurs almost exclusively in men and can only be a manifestation of rosacea.

With rosacea, the pathological process, as already mentioned, may involve the eyes. In 57% of cases, skin manifestations precede eye damage, in 27%, the eyes are affected simultaneously with the skin, and in 20% of cases, before the skin. Subjectively, eye lesions with rosacea are characterized by a burning sensation, soreness, photophobia and foreign body sensation. With rosacea keratitis, vision can be significantly reduced due to clouding of the cornea.

There is a granulomatous, or lupoid, type of rosacea, when brownish-red papules and small nodules appear against the background of erythema. With a clinical picture resembling acne conglobata , the so-called rosacea conglobata may be observed, when large abscessed acne forms.

A more severe variant of rosacea conglobata is rosacea fulminans (or pyoderma faciale ). Pyoderma faciale manifests itself as inflammatory acneiform lesions of the central part of the face, occurring exclusively in young women 20–30 years old who have once experienced episodic hot flashes and facial redness. The rash goes away after 1–2 years, leaving pinpoint and linear scars.

In addition, there is a gram-negative form of rosacea, which is characterized by multiple folliculitis, in the contents of the pustules of which gram-negative bacteria are isolated. Most often it is a complication of irrational antibiotic therapy, mainly of the tetracycline series.

OTHER CHRONIC DERMATOSES

Perioral dermatitis (PO) is a chronic dermatosis affecting the skin around the mouth and predominantly affects young women. It is more common in patients with a history of allergic reactions. The development of the disease can also be caused by the following factors: the use of fluoride-containing toothpastes and other cosmetics and personal hygiene products containing halogens, long-term use of topical corticosteroids, prolonged insolation, taking hormonal contraceptives, infection with Demodex mites and Candida fungi, diseases of the gastrointestinal tract . Some researchers attribute PO to a special variant of rosacea or seborrheic dermatitis, but the more widespread opinion is that it is an independent disease of the pilosebaceous follicles. The clinical picture is represented by multiple small red or red-brown papules around the mouth. Over time, against the background of erythema, the papules merge into larger elements, which are partially transformed into pustules. Basically, the rash develops in a reverse manner without scar formation, sometimes spreading to the periorbital zone, the area of the nasolabial triangle, and the scalp. In rare cases, a lupoid form of PO develops, which, as a rule, is severe (photo 5).

Perioral dermatitis. Small papules and pustules coalesced into plaques around the mouth. Similar rashes can be around the eyes, and sometimes only around the eyes (source: Fitzpatrick T. et al. Dermatology. Atlas-reference book (3rd ed.). - M.: Praktika. - 1999, 1043 pp.)

In combination with demodicosis (up to 13% of cases), the rash can acquire an asymmetrical arrangement and be accompanied by itching, which complicates the course.

In the differential diagnosis of acneiform diseases, it is necessary to exclude red granularity of the nose - a disease with a presumably hereditary nature, the development of which is facilitated by neuroendocrine disorders and vasomotor disorders. It is characterized by the appearance in childhood of telangiectasia, cyanosis on the skin of the nose, then small papules of a dark pink color, prone to grouping. Dew-like drops of sweat can be found on the surface, which is associated with hyperhidrosis.

Mallorca acne ( Mallorca-acne, acne aestivalis , the disease was first recorded in young people from Scandinavia who were vacationing on the island of Mallorca) refers to acneiform dermatoses, characterized by uniform flat follicular papules that suddenly appear in the summer and spontaneously regress in the winter. The disease also develops due to excessive use of sun protection products that have a fatty base (ointments, oils), due to exposure to sunlight and sometimes after tanning beds.

The disease largely corresponds to polymorphic photodermatosis . Comedogenic irritation, especially when using sun protection, results in papules and pustules. At the same time, there may be papulovesicles that are not acne. There are no comedones in this picture of the disease. The process may involve the cheeks, neck, shoulders and upper limbs. Rashes identical to this type of acne are often observed in patients treated for chronic dermatoses with 8-methoxypsoralen and PUVA.

Multiple steatocystoma (Steatocystoma multiplex, multiple fatty cyst, pilosebocystomatosis) is an autosomal dominantly inherited acne-like dermatosis that predominantly affects men. Cysts may be present at birth or develop shortly after birth. Clinically, the disease is characterized by soft or dense multiple cystic nodes with a diameter of several millimeters to 1.5 cm. The rashes are localized mainly on the chest, in the sternal area, less often on the scrotum, back, and less on the upper extremities. The disease is asymptomatic, and sometimes secondary infection is possible.

Miliary disseminated lupus of individuals (Lupus miliaris disseminatus faciei - acne agminata) - this rare disease was previously called cutaneous tuberculosis. It is characterized by small, brownish-red, rough lesions that resemble acne papules. Rashes typically occur in the infraorbital zone and on the eyelids, as well as in areas uncharacteristic of endogenous acne. When pressed with a glass spatula, a yellow tint may appear as a manifestation of granulomatous inflammation with a curdled mass in the center, although there is no M. tuberculosis infection.

Pityrosporon follikulitis , an infection of P. ovale, is expressed by various types of rashes such as erythematosquamous dermatitis or pityrosporon folliculitis, which is very similar to papulopustular acne. Among the differences are moderate peeling, the absence of pustular rashes and comedones, most often limited inflammation that occurs along with itching.

It should be noted that inflammatory lesions in chronic facial dermatoses leave behind post-inflammatory spots, hypo- or hyperpigmentation, which can persist for 6–12 months, residual erythema, which can be observed for a month after the disappearance of the rash. Deep lesions, in particular cysts, can lead to the formation of atrophic, hypertrophic and even keloid scars. Currently, the term “post-acne” has been adopted in dermatocosmetology, combining a whole symptom complex of secondary rashes that develop as a result of the evolution of various forms of acne and acneiform dermatoses. And since the requirements for appearance in modern society are constantly increasing, the search for new alternative schemes for the treatment and rehabilitation of the skin does not stop.

Literature

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First published in Les Nouvelles Esthetiques 2015/№4

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