الفهرس 
Sebaceous gland activity
1.10. Pathogenesis of AcneOnly 14 pages are availabe for public view
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Abstract
The psychological burden associated with acne was described years ago by Sulzberger and Zaidens (1948) in the following quote: ”There is probably no single disease which causes more psychic trauma, more maladjustment between parents and children, more general insecurity and feeling of inferiority and greater sums of psychic suffering than does acne vulgaris”.
Acne is a common skin disorder affecting more than 85% of adolescents and can persist or develop over time to affect up to 50% of adults older than 20 years of age. Although the prevalence of acne and severity generally improves with time, worsening was reported by 4% of men and 13% of women.
Acne is usually recognized as a disorder of adolescence. However, the referral of patients over the age of 25 years with acne has significantly increased. Patients with post-adolescent acne appear to represent an increasingly important population of acne sufferers. External factors do not seem to have a significant aetiological role. Two main clinical groups are identified: those with persistent acne and those with late-onset acne.
Chiefly affecting the face, upper back, and chest, it manifests as two types of lesions: comedones and inflammatory lesions, both are follicular based. Comedones may be closed (whiteheads) or open (blackheads). Inflammatory lesions evolve from ruptured comedones or microcomedones, which are not clinically apparent, and originate more frequently from closed than open comedones. Once developed, inflammatory papules may become pustules or nodules, which may subsequently develop into cysts. Cystic Acne can result in severe scarring.
As a sequele of acne, collagen and other tissue damage from the inflammation of acne leads to permanent skin texture changes and fibrosis. Scars normally proceed through the specific phases of the wound-healing cascade: inflammation, granulation, and remodeling. However, even normal scars never reach the same level of strength as original skin, only about 80% at best. Dermal damage is more long lasting and results in an increase or decrease of tissue and often worsens in appearance with age as a result of normal skin changes. In contrast, damage limited to the epidermis or papillary dermis can heal without scar formation. Acne scarring can be divided into 3 basic types: icepick scars, rolling scars, and boxcar scars. Boxcar scars can be further subdivided into shallow or deep.
Acne vulgaris has the potential to cause significant psychiatric and psychological complications, while negatively affecting quality of life. Many factors influence the non-dermatological aspects of acne including personality, perceptions, age, and social and cultural factors, as well as disease characteristics (duration, severity, scarring). It is important to note that not all patients who develop acne experience psychiatric or psychological complications or any alteration in quality of life.
Acne has been related to psychiatric morbidity for many years. Emotional stress can exacerbate acne, and patients with acne develop psychiatric problems as a consequence of their condition. Psychiatric issues associated with acne include problems with self-esteem/self-confidence, body image, embarrassment/social withdrawal, depression, anxiety, anger, preoccupation with acne, frustration/confusion, limitations in lifestyle, and problems in family relationships.
Stress has been shown to cause heightened levels of glucocorticoids and androgens, which may initiate or exacerbate acne flares. A variety of neuroendocrine mediators may be involved in the precipitation or aggravation of acne by stress, including adrenal steroids, corticotropin-releasing hormone, melanocortins, beta-endorphin, vasoactive intestinal polypeptide, neuropeptide Y, insulin-like growth factor, and calcitonin gene-related peptide.
In terms of intervention, long term utilization of stress management techniques may lead to improved acne control, better adherence to medication regimens, and improvements in overall health.
The aim of this study is to establish the relationship of acne with degree of psychological and psychiatric morbidity and effect on quality of life in pre-adolescent and post-adolescent populations and comparing them to one another using different validated questionnaires.
This study was carried on 400 patients with acne vulgaris (200 patients with pre-adolescent and 200 with post-adolescent acne), excluding patients with juvenile acne vulgaris (< 14 years of age) or those with other skin or systemic disease. One hundred age and sociodemographically cross-matched healthy volunteers are included as controls.
All patients were examined and divided into groups according to severity grading of their acne using Leeds revised acne grading system. All subjects in this study answered the following questionnaires; Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS), Beck Depression Inventory-II (BDI-II), Hamilton Anxiety Rating Scale (HAMA), PCASEE quality of life scale, and Cardiff Acne Disability Index (CADI). Controls answered all of them except CADI.
Compared to controls, pre-adolescent and post-adolescent acne patients showed no statistically significant difference regarding depression and PCASEE quality of life scale (P>0.05), while they showed a significantly higher score of Body Dysmorphic Disorder measure and anxiety scale (P<0.05). In different grades of acne severity, in both pre-adolescent and post-adolescent patients, there was a positive correlation between clinical severity and CADI and dysmorhophobia (P<0.05); and while no correlation was found between clinical severity grading and each of depression, anxiety and general QOL scale (P>0.05).
In different socioeconomic classes, pre-adolescent acne cases of low socioeconomic classes showed significantly increased CADI score (P<0.001) i.e. more impaired acne specific quality of life than those of moderate and high socioeconomic classes. On the other hand, low socioeconomic class showed significantly increased dymorphophobia and depression scores than those with moderate and high socioeconomic class (P<0.001). There was no statistically significant difference between low, moderate and high classes regarding anxiety and PCASEE quality of life scores (P>0.05). Post-adolescent acne cases of low socioeconomic class, showed significantly increased CADI scores; and significantly decreased dysmorphophobia, depression and anxiety than those of moderate and high socioeconomic classes (P< 0.05). There was no difference between different socioeconomic classes and PCASEE quality of life score (P>0.05).
On comparing pre-adolescent and post-adolescent acne patients, pre-adolescents showed significantly scores of dysmorphophobia; and pre-adolescent female acne patients showed significantly higher score of body dysmorphophobia, depression, and anxiety compared to post-adolescent female acne patients (P<0.05).
Pre-adolescent and post-adolescent acne patients had a higher incidence of experiencing great discrepancy between what the person sees and what the public sees, due to society’s modern preoccupation with blemish-free skin. Both groups face higher incidence of having associated anxiety feelings with the diseased face, leading to feelings of apprehension and fear accompanied by physical symptoms. The absence of significant difference between acne cases and controls regarding depression and quality of life is rationalized by decreased quality of life in the country as a whole, and depression now represents the second cause of health burden worldwide. Pre-adolescents, especially females, are more vulnerable to more dysmorphophobia, depression and anxiety compared to post-adolescents, as adolescence is a highly volatile period in a patient’s life, with issues relating to self, beauty, dating, social and academic competences being confronted on a regular basis.
In conclusion, relationship of acne with psychological and psychiatric morbidity and effect on quality of life is quite complex and controversial. In this study, we found that acne vulagaris does not affect the general quality of life, with a positive correlation between clinical severity grading and acne-specific QOL (CADI) scores. In psychiatric assessment, acne vulagaris significantly caused higher body dysmorphophobia and anxiety compared to unaffected persons. Pre-adolescents are at higher risk, especially pre-adolescent girls.