Acne vulgaris (AV) is a commonly diagnosed inflammatory skin condition that affects pediatric and adult patients. Although tradi- tionally viewed as an. PDF | Acne vulgaris is a very common dermatosis affecting the general population. For a long time diets were dismissed from the etiologi-. Keywords: acne vulgaris; Propionibacterium acnes; linoleic acid. RESU MO. A acne .. For a long time diets were dismissed from the etiologi- cal point of view.
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Acne vulgaris is the most common skin condition affecting late adolescents across the globe. Although prior studies have evaluated epidemiologic patterns of acne vulgaris in various ethnicities and regions, adequate understanding of the worldwide burden of the disease associated with patients in their late adolescence 15—year olds remains lacking.
To assess the global burden of the disease associated with acne vulgaris for late adolescents 15—year olds and provide an overview of the epidemiology, pathophysiology, and treatment options for acne in this population.
Global Burden of Disease regions comprised countries with prevalence of acne vulgaris between the ages of 15 and 19 years. Geographic region-level disability-adjusted life year rates perpersons associated with acne vulgaris in years through Median percentage change in disability-adjusted life year rates was estimated for each region across the specified study period. Acne vulgaris-associated disease burden exhibits global distribution and has continued to grow in prevalence over time within this population.
This continued growth suggests an unmet dermatologic need worldwide for this disorder and potential opportunities for improved access and delivery of dermatologic care. Our analysis of the literature reveals numerous opportunities for enhanced patient care.
The epidemiology of acne vulgaris in late adolescence
To that end, we highlight some of the effective and promising treatments currently available and address important factors, such as sex, nationality, genetics, pathophysiology, and diet, as they relate to acne vulgaris in late adolescence. As of now, the rising incidence of acne vulgaris in late adolescence is a global issue; however, it is unknown whether this increase is a result akkne higher prevalence of the Western diet, earlier onset of puberty, genetic drift, or a byproduct of unknown environmental factors.
Despite its prevalence, misconceptions of the initiating and exacerbating factors that influence the development of acne vulgaris continue to exist. By providing data that accurately describe the epidemiology, risk factors, pathogenesis, genetics, comorbidities, and treatment associated with acne vulgaris in late adolescence, we hope to improve the awareness of the demographics affected by this condition and lead to important changes in patient education and treatment.
Additionally, it is useful for physicians to be aware of these important issues associated with acne vulgaris to fully and successfully treat patients. All review articles published within the last decade that included the previously mentioned terms were examined in addition to the articles which they cited that contained one or more of the previous key search terms in their title. Articles that focused on a population outside of the adolescent to young adult period were excluded in this study.
Analysis of burden of the disease of acne vulgaris was done using the data from the GBD Compare search dtiologi. Globally, epidemiological studies have demonstrated a higher incidence of acne vulgaris in different ethnicities of color in samples collected from the population aged 10—70 years. To address this, we analyzed the collection of data gathered from the GBD Compare study over specific regions, controlling for specific age ranges in etioloyi case, 15—year olds to see the trend in disability-adjusted life year DALY rates perpeople.
Calculation of YLDs is defined as the prevalence of the disease multiplied by the relevant disability weight. By dividing the rate of DALYs of 15—year olds by the rate of DALYs of all ages within the given population, we are left with a surrogate measure of the comparative rate of incidences of acne vulgaris in people aged 15—19 years perpeople in any region listed between and The results are shown in Figure 1A and Skne.
B This figure demonstrates a similar finding when comparing developing and developed countries. Figure 1A exhibits a general upward trajectory for all regions except Sub-Saharan Africa, with a clear separation in both prevalence and rate of incline between traditionally more wealthy regions Western Europe, high-income Asia Pacific, US, and Canada and traditionally poorer regions Sub-Saharan Africa, Oceania, Latin America, and Caribbean.
Similar patterns are seen for incidence and rate of incline in the comparison of developing versus developed nations, as shown in Figure 1B. While it is possible culgaris infer that the variances observed in these ethnically distinct regions are due to racial differences, this theory is confounded by the fact that many of these regions etoologi racially diverse and heterogeneous in population.
These data are limited by etioloogi consistency of physicians vulgsris clinically significant acne. The data provided by the GBD database do not specify the body location associated with the reported acne vulgaris. In addition, the data in Figure 1A or B should not be confused with the prevalence of acne vulgaris within a given population. The raw prevalence of acne vulgaris for patients aged 15—19 years for each region listed in can be found through the University of Washington tool http: Interestingly, Taiwan of East AsiaWestern Europe, and South Asia have the highest prevalence in the 15—19 age group among their respective unadjusted age population despite their difference in the rate of incidence.
Taken together, these data demonstrate that the causes and treatment of acne vulgaris in late adolescence are likely complex and multifactorial in nature, reflecting the interplay of many factors such as increased access to proper health care, socioeconomic status of individuals and families, and shifting cultural perceptions of skin care and beauty.
At least in the US, as the Affordable Care Act continues to enhance the health care access in our society and as the projected US population continues to shift, these reported incidences within different ethnic groups will undoubtedly continue to increase. As noted, cultural perceptions or attitudes toward acne is also reflected in our analysis.
For example, it has been noted that the South Asian population, in general, tend to believe that diet and poor hygiene play a significant role in the pathogenesis of acne and tend to self-treat by excessive scrubbing or face washing.
Cultural vulgars regarding skin and hair care practices have also been cited as possible factors contributing to the variable incidence of acne vulgaris among different ethnic populations. Within the black population, for example, a common practice is frequent use aknf lotions containing cocoa butter, a highly comedogenic substance, with the intent to get even skin tone and improve hyperpigmented scars. Acne vulgaris is a disease affecting the pilosebaceous unit PSU of the skin and is typically described as either noninflammatory open and closed comedones or inflammatory papules and pustules.
The basement membrane is lined with basal stem cells that, given the correct hormones from the body, develop into sebaceous cells and keratinocytes that produce oil and hair, respectively. Lining the central canal of the follicular part of the PSU are squamous epithelial cells, also known as ductal lining cells. When stimulated etlologi hormones, namely androgens, these cells the sebaceous cells, keratinocytes, and ductal lining cells are activated and begin to proliferate.
When the proliferating ductal lining cells cannot escape the infundibulum of the PSU, they form a plug, backing up the sebum production and hair growth that continue beneath it. The pressure within the unit compromises the availability of diffusible oxygen to cells below, constraining their metabolism and providing an ideal, anoxic environment for flora Proprionibacterium acnes to grow.
Moreover, the overproduction of sebum provides a resource of nutrients in the form of fatty acids to bacteria rapidly multiplying within the PSU. Malassezia furfur is a yeast that is also naturally found on the skin surface and can contribute to the pathogenesis of acne. White blood cells immediately recognize the lipoproteins of this foreign pathogen through receptors, specifically the Toll-like receptor-2 and Toll-like receptor-4, stimulating keratinocytes to secrete interleukin-6 and interleukin-8 and giving rise to erythematous inflammation.
Over time, the inflammatory response repairs the damage within the PSU and the skin returns to normal. Dihydrotestosterone DHTan endogenous androgen, is one of the potent acnenogens derived from a number of readily available precursors found in both men and women.
Its formation is brought about by the direct action of enzymes found within the PSU Figure 2. While the occurrence of vu,garis vulgaris in males and females is initiated by the onset of puberty, it is most likely prolonged into late adolescence by transient increases in insulin and IGF-1 levels.
This trend is readily seen when using the rate of DALYs for acne vulgaris provided by GBD Compare, where a quantitative difference between the onsets of male versus female puberty can be seen on a global level inwith females reporting a higher incidence of the disease at younger ages Figure 3.
For reasons explained previously, we see a separation in the rate of incidences between developed versus developing countries.
Interestingly, the rate of acne vulgaris among females remains higher than their male counterparts. As the incidence of acne vulgaris peaks at the age 15 for both sexes, we begin to see a decline in late adolescence consistent with average age of puberty completion 15—17 years for females and 16—17 years for males.
Change in the rates of incidence across all age categories compared between,and were negligible and, therefore, not included in the data set.
The factors attributing to the incidence difference seen between males and females are, once again, likely complex and multifactorial.
Indeed, whether the variance of incidence among men versus women in this age group is due to greater attention to skin care, the use of certain cosmetics, or exogenous hormone sources, including diet, requires further research. As a result, acne vulgaris is absent in these populations. Insulin activates the Akt signaling pathway directly through its receptor and indirectly through the production of IGF-1 and its receptor.
Some evidence to support this concept comes from a randomized, controlled trial in which recruited male participants, aged 15—25 years, with mild-to-moderate facial acne were separated and instructed to eat a diet of high protein low glycemic index foods or the conventional high glycemic load diet. Other randomized controlled trials have since been released, similarly demonstrating the definitive effect of high glycemic index foods on acne in young adults across different ethnicities.
Unlike high glycemic index foods, there have been no randomized controlled trials to date that have investigated a relationship between dairy consumption and acne. At a cellular level, high amounts of dairy are thought to promote acne pathogenesis by providing exogenous hormones and by stimulating pathways that converge with the effects of insulin on the PSU. Amino acids, primarily leucine, found in dairy milk and whey directly stimulate the L-type amino acid transporter LAT found in sebaceous cells and keratinocytes, signaling a cascade of downstream signaling events that lead to activation of mTORC1, independent of the Akt signaling pathway Figure 2.
Apart from amino acids, cow milk is also known to contain exogenous steroid hormones that are true anabolic androgen precursors of DHT, including 5a-pregnanedoine, 5a-pregnan-3B-olone, 5a-androstene-3B, 17B-diol, 5a-androstanedoin, and 5a-androstan-3B-olone.
Meat, a staple food of the Western diet, is one of the most popular menu items consumed by patients in late adolescence or young adulthood in Western countries. It is this latter mechanism that has been hypothesized to be at work in the pathogenesis of acne; however, the evidence to support this as a significant contribution to acnegenesis is limited. Globally, the ingestion of nicotine from tobacco products is highest among young adults 18—year oldsalthough the rate of usage has been declining in developed regions, developing regions have seen an incline, particularly in young adult men.
Acne vulgaris in late adolescence is associated with numerous psychological comorbidities, with female patients being more prone to emotional and behavioral difficulties than their male counterparts.
Similarly, boys with significant acne reported suicidal ideation three times more frequently than those with mild acne While the large majority of acne comorbidities revolve around mental health, acne in late adolescence is also associated with other diseases.
The genetic component of acne vulgaris has been described in twin studies, with some studies citing late adolescent acne patients having at least one first-degree relative with this condition. The multifactorial nature behind the driving force of acne makes mutations conferring over- or underactivation in any one of the enzymes and receptors described in this review or illustrated in Figure 2 as possible genetic influences to acne pathogenesis.
For example, Laron syndrome, a rare recessive disease in which there is inadequate production of IGF-1, is one of the few known phenotypes in which patients documented that they have never suffered from any degree of acne vulgaris.
Moreover, it has been documented that transient rises of insulin secretion arising from insulin resistance occur during both normal puberty and adolescence — further adding to the molecular complexities that drive acne pathogenesis. The treatment of acne vulgaris in late adolescence is approached in much the same way as in the rest of the population.
Treatment options for acne vulgaris have been well described in the literature, and as a result, this list is not meant to be exhaustive. We aim to provide the reader with generalized treatment options currently being used and those in development for acne vulgaris in late adolescence.
Benzoyl peroxide is a mainstay in over-the-counter treatment of acne vulgaris. It is safe and works by reducing P.
The epidemiology of acne vulgaris in late adolescence
Topical retinoids remain a fundamental treatment option for clinical acne and continue to be a first-line option for mild-to-moderate acne vulgaris. Topically, the macrolides, clindamycin, and erythromycin are used for their bacteriostatic effect on P. Erythromycin may be used in patients alne to tetracyclines, but little evidence exists to support the use of other oral antibiotics ie, clindamycin, cotrimoxazole, quinolones.
The concomitant use of systemic and topical antibiotics should be avoided when possible. One of the biggest concerns surrounding the treatment of acne vulgaris with antibiotics either topical or systemic etiokogi increasing P. Oral isotretinoin therapy is one vjlgaris the most efficacious therapies for the treatment of severe acne since its introduction in Use of oral isotretinoin is only available through specialist care in many countries, being tightly regulated as a result of its teratogenic effects.
Oral contraception, used properly, can be akje effective method in treating acne vulgaris among female patients in their late adolescence. Most birth control, regardless of the route of administration, consists of a combination of estrogen and progestins, which increases the production of a protein called sex hormone-binding globulin in the blood, which binds the free testosterone in the blood capable of activating the androgen receptors in the PSU.
This can lead to life-threatening conditions, such as the formation of pulmonary embolisms, and the administration of an oral contraceptive as a treatment for acne vulgaris rtiologi be approached with caution. Androgen blockers that can theoretically be used by vuulgaris sexes, including spironolactone, cyproterone acetate Dianefinasteride, dutasteride, and flutamide, have not been well studied in patients who are in their late adolescence.
Acne vulgaris, according to the GBD, is the tenth highest cause of DALYs in the late adolescent period 15—year olds across developed countries. It is particularly prevalent during the late adolescent period, which many sources regard as being between the ages of 15 and 18 years, most likely initiated by the onset of puberty.
The cellular mechanisms at play during this time frame mostly involve an increase in androgens capable of stimulating an intranuclear receptor and activating the proliferation of cells within the PSU. The Western diet, including meats, dairy, and high glycemic index foods, can also influence this same pathway by inactivating the regulator of the androgen receptor, FoxO1. Another environmental factor seen to play a role in acnegenesis is smoking, although evidence is lacking. The cellular physiology underlying the pathogenesis of acne vulgaris is complex, and any number of dysfunctional or overactivated proteins can affect the genetic component of the disease.
The consideration of the effects of acne on patients in their late adolescence should not be confined to the dermatological realm due to the pervasive psychosocial comorbidities among patients plagued with the disease.
While girls are often more susceptible than boys, both sexes frequently suffer from anxiety, depression, and suicidality along with their acne vulgaris.