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Thứ Ba, 31 tháng 12, 2013



Objectives—The purpose of this study was to assess the sonographic morphology of the clinical and subclinical pathology of facial acne vulgaris.

Methods—We studied patients with facial acne vulgaris diagnosed by certified dermatologists, and using a standardized protocol for sonographic examinations, we sequentially described the sonographic pathomorphologic characteristics. Lesions of particular interest to the referring clinician were also analyzed separately. Additionally, acne involvement was staged clinically and sonographically (SOS-Acne) using morphologic definitions of the relevant lesions and predefined scoring systems for gradation of the severity of acne lesions.

Results—A total of 245 acne lesions in 20 consecutive patients were studied. Sonographic abnormalities consisted of pseudocysts, folliculitis, fistulas, and calcinosis. Most conditions were subclinical and mostly due to lesion extensions deep into the dermis and hypodermis (52% of pseudocysts and 68% of fistulas). The statistical concordance between acne severity scores assigned by two separate clinicians was strong (κ=0.8020), but the corresponding sonographic scores generally showed more severe and clinically occult involvement.

Conclusions—Facial acne vulgaris often involves deeper tissues, beyond the reach of the spatially restricted clinical examination; these subclinical conditions can be detected and defined with sonography. Additionally, acne vulgaris is amenable to sonographic scoring.


The ultrasound machines used in the study were HDI 5000 (Philips Healthcare, Bothell, WA) and LOGIQ E9 (GE Healthcare, Milwaukee, WI), with settings at the lowest pulse repetition frequencies and wall filters and color gain below the noise threshold. The compact linear ultrasound probes had upper frequencies of 15 to 18 MHz; sonograms were recorded in 2-dimensional grayscale, color Doppler, and power Doppler modes as well as 3-dimensional views (5- to 8-second sweeps).

Sonographically, acne lesions (Figure 1) were defined and grouped as follows:

1. Folliculitis—oblique hypoechoic bands traversing the dermis, corresponding to hair follicle swelling;

2. Inflammatory focal—poorly defined but localized hypoechoic dermal lesions;

3. Pseudocysts—round or oval anechoic or hypoechoic structures without well-defined walls, frequently with a posterior acoustic reinforcement artifact;

4. Fistulas—bandlike well-defined anechoic or hypoechoic structures; and

5. Calcinosis—dense highly localized hyperechoic spots.

Special attention was paid to lesions of particular interest to the referring clinician (ie, lesions for which the clinician wanted to know the exact sonographic images underlying the clinical appearances), which were marked on the skin with a letter (A–C) immediately before the sonographic examination and specifically addressed in the sonographic report.

A scoring system divided into 3 categories (stages 1–3), based on the Cunliffe classification but merging the severe and very severe categories into one (severe), was used for the clinical assessment of acne severity. The sonographic scoring system that we call SOS-Acne was based on the predominant lesions that may imply the activity and severity of the disease (pseudocysts and fistulas) and classifies patients into 3 categories (Table 3): mild (stage 1), moderate (stage 2), and severe (stage 3). Calcinosis, keloids, and scars were not included in the sonographic scoring system, that was called SOS-Acne, as they do not imply disease activity. Comedones and folliculitis were also excluded from this staging system because of their small size and large number that could affect the reproducibility of the scoring. Moreover, in contrast to pseudocysts and fistulas, comedones and folliculitis usually imply a low degree of severity by themselves. However, all types of lesions were morphologically described on sonography.

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