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Any discussion of the practice of cosmetic dermatology must include a discussion of acne Although acne is not typically considered to be a cosmetic problem, its highly visible nature makes it a very common complaint among cosmetic patients who are by definition concerned about their appearance Acne can often have a profound psychological impact on patients Recently, an evaluation of the psychosocial implications of acne on selfimage and quality of life found that it may be equivalent to disorders such as asthma or epilepsy1 Acne can be especially troublesome to adults who perceive themselves as too old to have this condition most often associated with adolescence Acne vulgaris is a common, multifactorial process involving the pilosebaceous unit More than 17 million people2 and 75% to 95% of all teens3 are affected by some form of acne each year in the United States alone The majority of patients outside this age range are adult women who typically exhibit a hormonal component to their acne Approximately 12% of women will have acne until the age of 44, whereas only 3% of men will have acne until the same age4 In many cases, adults are more surprised and upset by acne onset than are teenagers In all cases, though, early and individually tailored treatment is necessary to achieve a satisfactory cosmetic appearance for the patient This chapter will include a brief survey of the salient aspects of acne pathophysiology as well as suggestions for treatment and prevention The psychosocial aspects of acne, or the significant psychological distress that this condition provokes, is beyond the scope of this chapter It is worth noting, however, that many patients seeking treatment only for acne report substantial anxiety associated with this disease Regardless of acne severity, acne is also one of the chief concerns of patients with body dysmorphic disorder5 (see 40) ally associated with one another, with the latter often succeeding the former Inflammation of the follicular epithelium, which loosens hyperkeratotic material within the follicle creating pustules and papules, characterizes acnegenesis (Fig 15-1) Comedogenesis is best described as a noninflammatory follicular reaction manifested by a dense compact hyperkeratosis of the follicle, and usually precedes acnegenesis Because the etiology of such lesions varies from person to person and within individuals also, it is difficult to categorically identify or isolate a basic cause of acne; however, three principal factors have been identified The primary causal factors in acne work interdependently and are mediated by such important influences as heredity and hormonal activity increase in androgens, particularly testosterone, which spurs sebum production This imbalance between sebum production and the secretion capacity leads to a blockage of sebum in the hair follicle followed by inflammation Hormones continue to affect sebaceous gland activity into adulthood In males, lipid secretion is regulated by the action of testosterone In females, the immediate increase in luteinizing hormone following ovulation incites acceleration in sebaceous gland activity The higher sebum secretion then stimulates or exacerbates acne breakouts usually 2 to 7 days prior to menstruation Women experiencing excessive androgen states, such as those seen in polycystic ovarian disease, frequently suffer from acne as well The notion that sebum plays a key role in acnegenesis is buttressed by several facts including its comedogenicity, data showing that it causes inflammation when injected into the skin, and the reportedly higher level of sebum production in people with severe acne6 Researchers have also reported that acne patients possess larger sebaceous glands than the general population7 Furthermore, drugs that inhibit sebaceous gland activity, such as antiandrogens, estrogens, and oral retinoids, are integral treatment modalities in the successful control of acne.

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