Clinical Patterns

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Acne is a polymorphic disease that occurs on the face (99%), back (60%) and chest (15%).

Acne vulgaris is the most common type of acne. The individual lesions of acne vulgaris are divisible into three types: non-inflamed lesions, inflamed lesions and scars (Table 11.2).

Table 11.2 Acne lesions


Non-inflamed lesions


Closed comedones (whiteheads)

Open comedones (blackheads)


Inflamed lesions







Atrophic scars (icepick, rolling, boxcar)

Hypertrophic scars (keloids)


Hyperpigmented macules

Non-inflamed lesions are called comedones. Comedones may be microscopic (microcome-dones) or evident to the eye as blackheads or whiteheads (Figs. 11.1, 11.2). The microcomedo is an early distention of the follicle by corneoc-ytes, detectable only in histological sections. The closed comedo, whitehead, is the first visible lesion, a firm whitish nodule resembling a milium, 1-2 mm in diameter. Open comedones (blackheads), 5 mm in diameter or even more, are secondary to the dilatation of the orifice by a protruding mass of darkly pigmented horny material. The pigment is mostly oxidated melanin. Closed comedones are more likely to become inflamed.

Most patients have a mixture of non-inflamed and inflamed lesions. Inflamed lesions can be superficial or deep, and arise from non-inflamed lesions. The superficial lesions are usually papules and pustules (5 mm or less in diameter), and the deep lesions are large pustules and nodules. Papules are small, raised, red spots, while pustules are predominantly yellow (Figs. 11.3,11.4). Pustules frequently start as solid lesions, like papules, which soon liquefy. Usually, the roof of the pustule bursts, allowing the pus to escape. The pustule represents a par-

Fig. 11.1. Microcomedonic acne

Fig. 11.1. Microcomedonic acne

Fig. 11.2. White-head comedones

Fig. 11.3. Inflammatory acne: papules and pustules total disintegration of a comedo with far-reaching consequences. The dissolution of the adjacent pilosebaceous units propagate the inflammatory reaction and the abscess can reach the subcutaneous tissue (Fig. 11.5); sinus formation between nodules may also occur, with devastating cosmetic effects. The cysts are large, skin-colored, rubbery nodules, 5-20 mm in diameter, occurring mainly on the back and less frequently on the cheeks, especially in the case of acne conglobata (Figs. 11.6,11.7 and 11.8). Histo-logically they are not true cysts as they are not lined by an epithelium. In fact, the cysts in acne are a result of repeated ruptures and re-encapsulations, and may be best defined as secondary comedones. Pressure releases a cheesy, crumbly material (corneocytes, hairs, bacteria and sebum).

Nodules are associated with scarring in any case, but even papular or pustular acne lesions can lead to scars. Scars have to be considered a hallmark of acne. Facial scarring affects both sexes equally and occurs to some degree in 95% of cases. Scars that result in a loss of tissue are

Fig. 11.3. Inflammatory acne: papules and pustules

Fig. 11.4. Papulo-pustular acne localized on the chin

tial breakdown of the comedo. Nodules can be classified as small nodules if 5-10 mm and large nodules if greater than 1 cm. Nodules are initially firm, tender and very red. Then, they soften and the overlying skin breaks, producing a hemorrhagic crust. The nodule represents the

Fig. 11.5. Nodular acne
Hidradenitis Suppurativa Cure

Fig. 11.8. Acne conglobata the most common type. Atrophic acne scars can be divided into three basic types: icepick, rolling and boxcar.

■ Icepick scars are narrow (<2 mm), deep, sharply marginated epithelial tracts that extend vertically to the deep dermis or subcutaneous tissue (Fig. 11.9).

■ Boxcar scars are round to oval depressions with sharply demarcated vertical edges, similar to varicella scars (Fig. 11.10).They can be divided into shallow (0.1-0.5 mm) or deep (>0.5 mm).

■ Rolling scars, usually wider than 4 to 5 mm,are the result of the abnormal fibrous anchoring of the dermis to the subcutis and give a rolling or undulating appearance to the overlying skin

Fig. 11.9. Icepick scars

Fig. 11.10. Boxcar scars

Fig. 11.10. Boxcar scars

Much less commonly, acne scarring may become thickened (hypertrophic or keloidal) rather than atrophic. Hypertrophic scars represent the presence of excessive fibrous tissue with marked vascularization. While hyper-trophic scars tend to maintain the same size as the initial inflammatory lesion, keloids extend beyond the dimension of the original acne lesion.

In some patients, hyperpigmented macules may persist following resolution of inflammatory acne lesions. These dark areas have to be considered as healing lesions and not active acne. Post-inflammatory hyperpigmentation generally resolves, even if the resolution time may be very long.

Fig. 11.9. Icepick scars

Fig. 11.11. Rolling scars

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