Macrocomedones can be regarded as a variant of acne if found in isolation, or part of a more classical acne vulgaris if found with other

signs of acne.

Clinical findings
Macrocomedones are effectively large whiteheads They are more frequent on the face than the chest

Management
Macrocomedones are best treated by gentle cautery given by someone familiar with the technique Patients with associated moderate-severe acne, needing isotretinoin, should get the macrocomedones treated before commencing isotretinoin otherwise a severe inflammatory response can develop

Infantile and juvenile acne is very uncommon.

Aetiology
There are usually no significant underlying endocrinopathies and, in the absence of precocious puberty or other developmental abnormalities, investigations are not needed

History
It is more common in boys and presents between the ages of three and 18 months, and may last up to the age of three years

Clinical findings
The severity is usually mild-moderate but occasionally can be severe

The face is the most frequently affected site, often with a mixture of comedones, papules and pustules Nodules and scarring occasionally occur

Management
Topical retinoids and/or benzoyl peroxide and, if necessary, oral erythromycin Tetracyclines must be avoided because of the risk of permanent tooth discoloration On occasions acne can be severe with nodules or scarring, such patients should be referred urgently to a dermatologist for consideration of treatment with isotretinoin

Neonatal acne

Infantile acne Sandpaper acne is defined by the presence of many small, undeveloped lesions (microcomedones) on the skin that are nearly invisible but feel rough to the touch.

Clinical findings
Multiple small whiteheads (closed comedones), associated with superficial inflammation The skin is rough to feel - like fine sandpaper

Sandpaper acne

Sandpaper acne Acne conglobata is an ill-defined form of severe acne.

History
Mainly found in males Usually appears in the early teens but becomes increasingly active in the second to third decades of life

Clinical findings
Distribution o o o o Characterised by severe disease on the trunk and face Typically blackheads are grouped in clusters of several lesions, which frequently become inflamed producing sinus tracts Multiple inflamed papules and tender nodules Scarring can be extensive

Morphology

Management

Treatment is difficult The patient should be considered and treated as having severe disease but, unfortunately, oral retinoids are not always successful. Consequently, severe scarring is the rule and associated hidradenatis suppuritiva is common

Aetiology
Acne excoriee is uncommon and occurs particularly in young females There are two reasons for this presentation:

Very occasionally patients with very mild acne just pick acne spots in the belief that simply by so doing that will help the acne. A simple explanation from the doctor of the harm that they are doing can help considerably In the other subgroup, the majority, there may be underlying psychological problems, which are often difficult to unravel. There may even be no pathological acne lesions, the patient just scratches the skin - such patients may be considered to have dermatitis artifacta and /or dysmorphophobia

Management
Management requires a multidisciplinary approach

The general practitioner may be in the best place to offer relevant management as they would know the patient and their family better than a consultant dermatologist Is the patient getting any acne? One way this can be determined is to ask the patient to come to see you as soon as a spot appears - if you never see a spot the patient may not have any acne, and so is suffering from dermatitis artefacta. The most severely affected patients may need to be referred to a psychiatrist If acne is present it needs to be managed effectively with the least irritant topical treatment, and also systemic antibiotics, where appropriate. If patients are not responding well, are scarring or have very marked psycological upset they should be referred promptly to see a dermatologist for consideration of isotretinoin

Acne excoriee This patient had small amounts of acne, but her picking resulted in scars

Dermatitis artefacta No evidence of acne but the patient had been picking at her skin, which resulted in many scars