Acne (acne)

Acne is a chronic, relapsing skin disease predominantly in young people, resulting from overproduction of sebum and blockage of hyperplastic sebaceous glands with subsequent inflammation.

Acne develops in seborrheic areas against the background of seborrhea (hyperproduction of sebum with hyperplastic sebaceous glands), which can occur against the background of functional or organic endocrine disorders.

[1], [2], [3], [4], [5]

Causes of the eels

It is known that testosterone is the main hormone, which increases the secretion of sebum. It is to this sex hormone that there are receptors on the membrane of sebocytes. Interacting with the receptor on the surface of the cell producing sebum, testosterone under the action of the enzyme 5-alpha-reductase is converted into its active metabolite - dehydrotestosterone, which directly increases secretion production. The amount of biologically active androgen, as well as the sensitivity of the sebocyte receptors to it, and the activity of 5-alpha-reductase, which determine the secretion rate of the sebaceous glands, are genetically determined. In general, hormonal regulation of sebum secretion can occur at four levels: the hypothalamus, pituitary gland, adrenal cortex and sex glands. Therefore, any change in the hormonal background, leading to changes in the content of androgens, will indirectly affect the secretion of sebum. During puberty, when the individual hormonal status of a person is formed, there is an increased fat content of the skin. With seborrhea, the amount of unsaturated fatty acids decreases and the secret of the sebaceous glands ceases to act as a biological brake.

Acne can also occur when taking various medications. Medicinal acne occurs in patients who for a long time take glkzhokortikosteroidnye hormones (the so-called steroid acne), anabolic steroid hormones, antituberculous or antiepileptic drugs (isoniazid, rifampicin, ethambutol, phenobarbital), azathioprine, cyclosporin A, chloral hydrate, lithium salts, iodine preparations , bromine, chlorine, some vitamins, especially - D3, B1, B2, B6, B12.

Isolate exogenous acne, which develops when the skin is exposed to various substances that have a comedogenic effect. Comedogenic effect is associated with increased hyperkeratosis at the mouth of the hair follicles and occlusion of sebaceous glands. This action has different engine oils and lubricants, tar preparations, as well as cosmetics containing fats (fatty cream powder, blush, shadows, etc.). Soap with detergents also have a comedogenic effect.

[6], [7], [8], [9], [10]

Pathogenesis

In the pathogenesis of acne formation, the main mechanisms can be distinguished:

1. Hyperproduction of sebum with hyperplastic sebaceous glands. This is the main, long-lasting link in the pathogenesis of acne. A high rate of excretion of sebum is the result of the combined effect of an individual hormonal status on the sebaceous glands.
2. Follicular hyperkeratosis. Significant changes in the barrier properties of the skin lead to compensatory proliferation and keratinization of the epithelium in the funnel area of the hair follicle. Thus, micro-medones are formed, which are not clinically visible. In the future, from the micro-comedones are formed comedones (open and closed)
3. Reproduction of microorganisms. The most important role in the development of inflammation is played by Propyonibactertum acnes, which are Gram-positive fixed lipophilic rods and facultative anerobes. The occlusion of the mouth of the hair follicle and the accumulation of sebum inside it create the prerequisites for the reproduction of these microorganisms inside the hair follicle. Already at the stage of micro-medones colonization of P. Acnes in the follicle is noted, the scales of which increase in closed and open comedones. In addition, saprophytic microorganisms such as the fungi of the genus Pityrosporum, Staphylococcus epidermidis, also taking part in the development of inflammation in acne, are found on the skin and in the area of the hair follicles.
4. Inflammatory processes inside and around the sebaceous glands. Reproduction of P. Acnes leads to an increase in the activity of metabolic processes, the consequence of this is the isolation of various kinds of chemical substances - mediators of inflammation. Constant damage to the epithelium of the funnel of the hair follicle by P. Acnes enzymes, free fatty acids, lytic enzymes of neutrophils and macrophages, free radicals of oxygen, hydroxyl groups, superoxide of hydrogen peroxide leads to the maintenance of the inflammatory process. In addition, the contents of the sebaceous hair follicle, due to impaired permeability of the epithelium, penetrates the dermis and also causes an inflammatory response. It should be emphasized that inflammation can develop at any stage of acne, while it can occur in the superficial and deep layers of the dermis and even in the hypodermis, which causes a variety of clinical manifestations.

Acne is a manifestation, characteristic not only for adolescence. They can appear in adults. This happens, as a rule, against the background of endocrine dysfunctions, in which seborrhea occurs. In women, polycystic ovaries are identified in conjunction with anovulatory menstrual cycles and hirsutism, adrenal hyperplasia, pituitary adenoma. In some cases, adrenal or ovarian tumors should also be excluded in adult women who are resistant to therapy. In men, hyperplasia of the adrenal gland and androgen-producing tumors can be detected.

[11], [12], [13], [14], [15], [16], [17], [18], [19]

Symptoms of the eels

Acne in childhood (acne neonatorum et acne infantum) are rare. In the newborn period, the appearance of these rashes is believed to be associated with hormonal crisis phenomena or, more rarely, excessive secretion of testosterone in the intrauterine period. The hormonal crisis is caused by a sharp decrease in estrol in the blood of newborns during the first week of life. As a result of the intrauterine transition of estrogen hormones from the ovaries, placenta and pituitary gland to the fetus, newborns between the third and eighth day of life, a number of physiological conditions resembling the period of sexual maturation can be observed. Such conditions include breast engorgement, desquamative vulvovaginitis, hydrocele, transient edema and acne. Eruptions are mainly closed comedones on the cheeks, less often on the forehead and chin. Closed comedones, some authors call greasy cysts. These elements appear after birth in 50% of newborns and have the form of papules of pearlescent white or yellowish color.

Eruptions can be single or multiple, they are often grouped, run for several days or after 1.5-2 weeks. In some cases, papular and pustular elements may appear. They are resolved spontaneously, in most cases without scarring, in a few weeks or months and therefore rarely require treatment.

Sometimes acne occurs later, at the 3rd-6th month of the child's life, may progress, causing sometimes quite severe lesions that last for a long time (up to 5 years). Eruptions can be associated with congenital adrenal hyperplasia or an androgen-producing tumor, so a child with acne should be examined in detail. The statement that this process foreshadows the severe form of acne in the future is controversial.

[20], [21], [22]

Acne in adolescents

Youthful or vulgar acne is a very common pathology: one-third of adolescents aged 12-16 years suffer from acne requiring treatment. In girls, blackheads appear earlier than in boys: at 12 years of age, blackheads are observed in 37.1% of girls and 15.4% of boys, and at 16 years - in 38.8 and 53.3%, respectively. In 75% of adolescents, acne is observed only on the face, and 16% - on the face and on the back. In most cases, rashes are spontaneously resolved by age 20, but sometimes the disease can continue for a long time: approximately 5% of women and 3% of men aged 40-49 have clinical manifestations of acne, and sometimes so-called "physiological acne" is observed up to 60 years. In this case, this type of acne is referred to as acne adultorum. Clinically youthful acne is manifested by comedones, papulopustular acne, less often inducible and phlegmonous elements.

[23], [24], [25], [26], [27], [28], [29], [30]

Acne in adults

Acne of adults is an acne that exists before adulthood or first appears in adults. Sometimes between the eels of adolescence and the later resumption of rashes there is a "light" gap. The main features of acne in adults are as follows:

• high frequency of seasonal exacerbations and exacerbations after insolation, low frequency of exacerbations on the background of dietary errors;
• the presence of concomitant diseases, which determine the pathogenetic background for the development of acne;
• taking medications that cause drug acne;
• exacerbations against the background of the menstrual cycle in women with acne tarda;
• a significant effect of acne on quality of life.

Clinically, adult acne is characterized by so-called late (acne tarda), inverse and conglobata acne. Late acne is more common in women. Approximately 20% of adult women report regular appearance of acne in the lower third of the face 2-7 days before the onset of menstruation and the gradual disappearance of rashes at the beginning of the next menstrual cycle. In some cases, acne is permanent. In general, these patients have papular and papulopustular elements, but there may be nodular-cystic acne. Combination clinical manifestations are frequently identified: melasma, acne, rosacea, seborrhea, hirsutism (MARSH syndrome). Patients with late acne are also diagnosed with androgenetic alopecia. Patients suffering from asne tarda should be carefully examined.

In the classification of Plewig and Kligman, among clinical varieties of acne in adults, a clinical variant such as pyoderma faciale is distinguished. It is possible that it is not entirely correct to refer this form to varieties of acne. Its etiology is not fully understood. In most cases, pyogenic microflora, endocrine and immune disorders are not the cause of the disease. Some researchers rightly believe that pyoderma faciale is one of the most severe forms of rosacea conglobata. This hypothesis is confirmed by the fact that patients do not have comedones, moreover, the onset of the disease is preceded by persistent erythema. Women are more often sick in the age of from 20 till 40 years. Clinically, this form is characterized by a sharp, sometimes almost lightning, onset. In the central part of the face first surface and deep papulopustular elements appear on the erythematous background, then knots and large conglomerates consisting of nodes and fluctuating cystic formations. The rashes are clearly delineated from the surrounding uninfected skin. Comedones are absent. There are no rashes on the chest and back. There are no general symptoms. Rashes are resolved slowly, within 1-2 years.

The general characteristics of acne in adults include the combination of acne with signs of dehydration of the skin due to irrational basic care, as well as signs of skin aging. With prolonged course, scars and post-inflammatory hyperpigmentation, high frequency of excoriated acne are characteristic. In addition, in adults, exogenous acne (mechanical, medicamental, etc.) is registered more often than in children and adolescents.

[31], [32], [33], [34], [35]

Forms

Acne rash is localized mainly in seborrheic areas. It can be combined with increased sebaceous shine of the skin. There are the following varieties of acne:

• comedo (comedo), or acne comedonica;
• papular and papulopustular acne (acne papulosa et pustulosa);
• acne indurative;
• conglobata acne (acne conglobates);
• fulminant acne (acne fulminans);
• inverse acne (acne inversum), or suppurative hydradenitis (hidradenitis suppurative);
• others.

Comedo (black or white acne) are non-inflammatory elements that result from blockage of the mouths of the hair follicles. The initial histological manifestation of acne is microcosmodes, which subsequently lead to the development of so-called "closed" comedones, the contents of which can not be freely allocated to the surface of the skin due to the greatly narrowed mouth of the hair follicle. They are non-inflammatory nodules with a dense consistency of up to 2 mm in diameter. The gradual increase in these nodules due to the constant production of sebum leads to an increase in pressure on the walls of the gland and creates the conditions for turning most of the elements into papular and papulopustular, and to a lesser extent into "open" comedones ("blackhead").

Papular and pustular acne is a consequence of the development of inflammation of varying degrees of expression around "closed", less often "open" comedones. They are manifested by the formation of small inflammatory papules and pustules. With a mild form of the disease, papulopustular acne is resolved without scar formation. In a number of cases, when the surface perifollicular part of the dermis is damaged as a result of an inflammatory reaction, superficial point atrophic scars may appear.

Indurative eels are characterized by the formation of deep globular infiltrates in the region of cystically altered sebaceous glands, the outcome of their purulent inflammation is always the formation of scars or skin atrophy. In places of infiltrates, cystic cavities filled with pus and fused together (phlegmonous acne) can form.

Conglobata (or heaped-up) acne is a manifestation of severe acne. They are characterized by the gradual development of multiple heaped, deeply located and communicating inflammatory nodes with large grouped comedones. The lesions can be located not only on seborrheic sites, but also to capture the skin of the back, abdomen, limbs, with the exception of the palms and soles. The outcome for the resolution of most of these elements are atrophic or hypertrophic and keloid scars. The manifestations of this form of the disease do not always decrease after the completion of puberty, they can recur up to 40 years of age, and sometimes throughout life.

Lightning acne (acne fulminans) is a rare and severe form of acne. The disease is characterized by a sudden onset, the appearance of ulcerative-necrotic elements predominantly on the trunk and common symptoms. On the skin of the back, chest, side surfaces of the neck and shoulders appear on the erythematous background pustular eruptions, as well as numerous, rapidly ulcerating, papular and nodular acne. Characteristic of the absence of rashes on the face. The etiology is not completely clear. It is suggested that in the pathogenesis of the disease, the role is played by infectious-allergic or toxic-allergic mechanisms. It is known that acne fuhninans occur more often in patients with severe chronic diseases (Crohn's disease, ulcerative colitis, etc.). However, some patients before the appearance of acne fulminans took antibiotics of the tetracycline series, synthetic retinoids, androgens. The disease develops rapidly. The clinical picture of the disease is dominated by intoxication: almost always there is an increase in body temperature above 38 ° C, the general condition of the patient is disturbed, arthralgia, severe muscle pains, abdominal pain (these phenomena subscribe to salicylates), weight loss, anorexia. In some patients, erythema nodosum and hepatosplenomegaly may occur, osteolytic processes in the bones develop; in the clinical analysis of blood, leukocytosis is found, sometimes up to the leukemoid reaction, an increase in ESR and a decrease in hemoglobin, blood cultures usually give a negative result. Healing lesions is often accompanied by the formation of many including keloids.

Inverse acne (acne inversum), or suppurative hydradenitis (hidradenitis suppurativa), are associated with a secondary lesion of the apocrine sweat glands, which, like the sebaceous glands, are associated with the hair follicles. Initially, occlusion and rupture of the wall of the hair follicle, an inflammatory cell infiltrate around the follicle remains, and apocrine sweat glands are involved in the process again. Various bacteria can be sown from the lesion focus, but they are referred to secondary infection. This disease develops after a period of puberty and is usually combined with severe forms of acne with increased body weight. Contributing factors can be friction clothing or itching in the appropriate locations (axillary cavities, perineal areas, navel, areola mammary glands). The disease usually begins with painful, tuberculous subcutaneous infiltrates, which are opened on the surface of the skin with the formation of a fistulous opening. Characteristic purulent or bloody-purulent discharge. As a result of inflammation, fistulas form with the formation of retracted scars. The disease proceeds chronically, slowly progresses and is, in essence, a form of chronic abscessed pyoderma.

Describing different manifestations of acne, one can not help mentioning their particular variety or, rather, the complication - the exported window. These acne occurs mainly in patients prone to excoriate even minimal rashes. In this case, combing of different depths can be against the background of pre-existing acne and even without them. This clinical form can be associated with obsessive-compulsive disorder or point to a more severe psychiatric pathology. Therefore, patients with ekskoriirovannymi eels it is advisable to consult a psychotherapist or psychoneurologist.

[36], [37], [38], [39]

Complications and consequences

In cosmetology, the term "post-acne" has been adopted, which refers to the symptomatic complex of secondary rashes that develop as a result of the evolution or therapy of various forms of the disease. The most frequent manifestations of post-acne include secondary pigmentation and scars.

Hyperpigmentation can occur as a consequence of inflammatory papulopustular acne and is often quite persistent. Its appearance is promoted by active insolation, extrusion, excoriation of individual acne. Hyperpigmentation is characteristic for people with swarthy skin and so-called late acne (acne tarda), which develop in adult women on the background of endocrine dysfunctions. Pigmented spots after acne should be differentiated from other secondary pigmentation after acute and chronic inflammatory dermatoses, from solar lentigines, freckles, border nevuses.

Scars after acne

With a mild form of the disease, papulopustular acne is usually resolved without scar formation. In some cases, when the surface perifollicular part of the dermis is damaged as a result of an inflammatory reaction, small point atrophic scars (ice-pick scars) may appear. Such manifestations should be differentiated from large-porous skin, which may be a consequence of its dehydration. In this case, the skin - as a rule, in the cheek area, less often the forehead, chin - grayish color, thickened, has a "porous" appearance (resembles an orange peel). After the resolution of inducible, phlegmonous and conglobate acne, various scars are formed - atrophic, keloid, "perverse" (papillary, irregular with scarring bridges), with "comedones" sealed in them. Atrophic scars are often depigmented. They should be differentiated from depigmented secondary spots, perifollicular elastoses, vitiligo. Hypertrophic and keloid scars should be differentiated from inducible acne, athere. The key points of differential diagnosis are the smoothness of the skin pattern, typical for the scar.

In the broader sense of the term "post-act", various other skin changes can be considered. In particular, atheroma and milium can also be protected after the disappearance of inflammatory acne.

Milium is a horny cyst of the epidermis. They are divided into primary and secondary Primary milium are developmental defects and exist from birth or appear in the period of puberty. They are localized on the skin of the eyelids and around the eyes, sometimes on the trunk and genitals. Secondary miliums develop with acne, chronic simple dermatitis, some bullous dermatoses, as complications of laser dermabrasion, deep peeling. Clinically, miliums are plural, white, spherical, dense nodules with the size of a pinhead. Milium on the background and after acne are localized mainly on the face (cheeks, whiskey, chin, in the lower jaw, etc.). Differentiate secondary miliums from true horny cysts, which are a developmental defect, as well as closed comedones. In the case of detection of comedones, further external therapy for acne with the use of kadonololytic drugs and cleaning procedures are indicated.

[40], [41], [42], [43], [44]

Atheroma

Atheroma (atheroma, epidermoid cyst, sebaceous cyst, follicular cyst, tricholemal cyst) is a retinal cyst of the sebaceous gland. It often develops on the face, it is clinically manifested by a painless non-inflammatory nodule or a knot of dense consistency. Often in the center of the cyst can be seen comedo. When removing comedo, a hole is formed, from which, when squeezing the cyst, a pasty whitish mass with an unpleasant odor is released. When infected, the formation turns red, becomes painful, their capsule is soldered to surrounding tissues. Differential diagnosis is carried out between atheroma and dermoid cyst, trichoepithelioma, syringoma, lipoma, basal cell, cylinder. Suppurating atheroma should be distinguished from an inductive eel and an abscessed boil.

Thus, the symptom complex "post-act" is a broad concept. The management of patients includes a variety of effects. When choosing acne therapy, you should always consider the possibility of preventing a number of secondary skin changes.

[45], [46], [47], [48], [49]

Diagnostics of the eels

The scope of the examination of patients, appointed by a dermatologist, depends on a variety of factors. In the diagnosis of acne in adolescents should, in the first place, be guided by the severity of the course of the disease. Boys with mild to moderate acne can be treated with standard acne treatment without prior examination. In severe cases it is important to promptly consult and examine patients from an endocrinologist and gastroenterologist. The scope of research should be determined by a specialist of the appropriate profile. However, a dermatologist or dermatocosmetologist can direct colleagues to examine and correct a specific pathology. For example, when examining boys with severe acne in an endocrinologist, one should pay attention to the pathology of the thyroid gland and the violation of carbohydrate metabolism, and the gastroenterologist should pay special attention to the pathology of the gallbladder and biliary tract, giardiasis, and helminthic invasion. As for girls, in case of mild disease, standard external therapy can be prescribed. With an average and severe course, consultation and examination is shown in a gynecologist-endocrinologist (ultrasound of the pelvis, sex hormones, etc.), an endocrinologist (thyroid hormones, carbohydrate metabolism).

When acne in adults in cases of mild course, external therapy can be prescribed without examination. In case of a moderate and severe course, an endocrinologist, gynecologist-endocrinologist (for women) should be examined. This recommendation is due to the fact that hormonal regulation of sebum secretion can occur at four levels: the hypothalamus, the pituitary gland, the adrenal cortex and the sex glands. Therefore, any change in the hormonal background, leading to changes in the content of androgens, will indirectly affect the secretion of sebum. Women are diagnosed with polycystic disease in combination with anovulatory menstrual cycles and hirsutism, adrenal hyperplasia, pituitary adenoma. In some cases, adrenal or ovarian tumors should also be excluded in adult women who are resistant to therapy. In men, thyroid gland disorders, carbohydrate metabolism disorders, adrenal hyperplasia and androgen-producing tumors can be detected. An emphasis on the study of the gastrointestinal tract should be done in the case of a combination of acne and rosacea, especially in men.

[50], [51], [52], [53], [54], [55]

Differential diagnosis

Acne should be differentiated from acne in rosacea, papulopustular syphilis, tuberculosis of the face, medication acne, perioral dermatitis, small-node sarcoidosis and some other dermatoses.

Treatment of the eels

Treatment of acne involves analysis of the history and adequate clinical evaluation of manifestations: localization, quantity and type of rashes. When collecting an anamnesis, you should determine the duration of the disease, paying attention to such factors as the impact of stress, premenstrual and seasonal exacerbations, in addition, it is very important to determine the hereditary predisposition. Women should familiarize themselves with the gynecological anamnesis: menstrual cycle, pregnancy, childbirth, oral contraception. Patients should also find out the previous treatment and its effectiveness.

It should be emphasized that with persistent current, resistance to ongoing therapy, regardless of the severity of acne, it is important to examine the patient to assess the condition of the pathogenetic background. A clinical blood test, an overall urine test, a biochemical test should be administered in cases where systemic therapy with antibiotics or isotretinoin is planned. As for oral contraceptives with anti-androgenic effect and antiandrogens, they should be prescribed and selected by a gynecologist after an appropriate examination. The dermatologist can only recommend to the gynecologist to consider the expediency of prescribing these drugs.

The clinician must necessarily analyze the causes of the severity and torpidity of acne in each patient. In many situations, it is possible to establish the fact of extremely inappropriate skin care (frequent washing, excessive use of scrubs, the use of alcohol solutions, etc.), the use of comedogenic cosmetics, self-harm (caused by excoriated acne), failure to adhere to the treatment regimen (unsound interruption, active rubbing drugs, etc.), hobbies non-traditional methods (urinotherapy, etc.). In such situations, not additional studies are needed, but the normalization of skin care and balanced pathogenetic therapy and, of course, the psychotherapeutic approach to the patient.

According to the results of recent studies, the significant effect of food on the appearance of acne has not been proven. However, many patients associate with the deterioration of the acne disease with the use of chocolate, pork, cheeses, red wine, citrus, coffee, etc. This may be due to a number of changes, in particular with the reactive expansion of the surface network of the skin vessels after taking these foods , which leads to increased secretion of sebum and an inflammatory reaction. Therefore, the question of diet should be addressed individually with each patient. To general recommendations, low-calorie meals, leading to a decrease in body weight, as well as the restriction of foods and beverages that enhance sebum secretion, will be discouraged.

Many patients suffering from acne, note improvement in the summer after insolation. Ultraviolet irradiation suppresses the function of the sebaceous glands, enhances superficial exfoliation, and can also stimulate in small doses an immune response in the skin. Patients mark the "masking" of the existing defects with pigmentation. At the same time, the literature accumulates evidence that ultraviolet irradiation intensifies the comedogenic properties of squalene, which is part of sebum. Ultraviolet rays in high erythemic doses cause a sharp decrease in local immune defense and, therefore, can worsen the course of the acne. The carcinogenic effect of ultraviolet rays A and B is well known, as well as the development of a special kind of skin aging - photoaging. The potential risk of photoaging increases in people who often visit the solarium, as the solarium lamps are mainly represented by the long-wave range (UVA), which is attributed to the effect of photoaging (destruction of elastic fibers of the dermis, etc.), phototoxic and photoallergic reactions. In a combination of ultraviolet irradiation and systemic isotretinoin enhances sensitivity to the rays due to keratolytic action of isotretinoin. Thus, the issue of the appointment of a UFO to a patient with seborrhoea and acne should be decided individually. In the presence of a large number of inflammatory acne, against the background of external and systemic therapy, one should avoid staying in the open sun and in a solarium, and also use photoprotective agents. Tan is also undesirable for those patients who note the exacerbation of the disease in the summer. It should be emphasized that photoprotective agents should be maximally adapted for the skin with the phenomena of seborrhea and acne. Such agents include photoprotectors offered in pharmacies (for example, Antgeilios-fluid, gel, Aqua Le, La Roche-Posay, Photoderm-AKN-spray, Bioderma, Exfoliak-sunscreen light cream, Merck, Capital soleyl- spray, "Vichy", Klinans - sunscreen emulsion, "Aven", etc.) It should be emphasized that photoprotectors should be applied in the morning, before going out on the street. During insolation, they should be applied again after bathing, and also every 2 hours.

Skin care for acne

Complex treatment of acne should include adequate skin care and pathogenetic therapy. Skin care, implying gentle cleansing, adequate moisturizing, impact on the links of pathogenesis, should be performed with the use of therapeutic cosmetics, presented in pharmacies. So, for the careful cleansing and moistening of the skin, patients with acne are recommended by the following brands of medical cosmetics: BioDerma, Ducre, La Roche-Posay, Aven, Vichy, Urjage, Merck, etc.

Skin care for patients with acne can also include a mild effect on the links of pathogenesis. Specialists traditionally focus on such qualities of modern care products as follicular hyperkeratosis, proliferation of P. Acnes and inflammation (for example, Narmermerm, Sebium AKN and Sebium A1, Keraknil, Efakpar K, Efaklar AN, Klinans K, Diakneal, Iseak cream with AHA, Akno-mega 100 and Akno-mega 200, etc.). To this end, they include keratolytics, as well as disinfectants and anti-inflammatory agents (salicylic acid, hydroxy acids, retinaldehyde, zinc, copper, etc.). With minor manifestations of the disease (for example, the so-called "physiological" acne), these drugs can be used as monotherapy, or they are prescribed simultaneously with external and systemic drugs.

In recent years, drugs have appeared that have matting, seborrhagating properties and affect the qualitative composition of sebum. Thus, for the purpose of achieving a matting effect, starch derivatives, silicone, are used, and for the purpose of seborrhagating action, zinc derivatives and other agents. A detailed study of the metabolism of squalene sebum showed that it is able to oxidize with the formation of comedogenic monohydroxyperoxide squalene under the influence of protoporphyrins and ultraviolet radiation. On the basis of the obtained data, scientists managed to create a patented complex of antioxidants (Fdyuyaktiv), capable of inhibiting the oxidation of squalene, which is a part of the human skin sulphate (gamma Sebium, Bioderma).

Pathogenetic treatment of acne

The choice of methods of pathogenetic treatment of acne is based on the definition of the severity of the flow. In everyday clinical work, a specialist can use the following division of acne according to the severity of the flow. An easy course is diagnosed in the presence of closed and open comedones with significant signs of inflammation. In this case, the number of papulopustular elements on the face skin does not exceed 10. With an average expression of acne, the number of papulopustular elements on the face is more than 10, but less than 40. Single indifferent and phlegmonous elements can be detected. The severe course of acne is characterized by the presence of more than 40 papulopustular elements, as well as abscessing, phlegmonous (nodular-cystic) or conglobular acne. With a mild acne, external therapy is usually prescribed. Patients suffering from moderate or severe forms of acne should receive both external and general treatment.

The most widely used for external therapy are synthetic retinoids (adapalene-Differin, isotretinoin-Retinoic ointment), benzoyl peroxide (Basironum AC), azelaic acid (Skinoren), and topical antibiotics (erythromycin-zinc complex-Zinerite, clindamycin-Dalacin, etc.) or disinfectants drugs (fusidic acid - fucidin, preparations containing zinc and hyaluronic acid - Kuriosin, Regecin, preparations containing sulfur - Delex acne, etc.).

Treatment of blackheads with easy flow

With a light current apply modern topical retinoids or azelaic acid for a period of at least 4-6 months.

Adapalene is a substance that is not only a new biochemical class of retinoids, but also a drug that has proven anti-inflammatory properties. Due to the selective binding to the special nuclear RA-y receptors in the cells of the surface layers of the epithelium, adapalene is able to most effectively regulate the processes of terminal differentiation of keratinocytes, normalize the processes of exfoliation of horny flakes and, consequently, affect hyperkeratosis at the mouth of the hair follicle. The consequence is the removal of follicular hyperkeratosis (keratolytic effect) and the prevention of the formation of new micro-medones (comedolytic effect). Good tolerance, low irritant effect and efficient delivery to the skin of thiererin is provided due to the original basis of the preparation in the form of a hydrogel and a unique uniform dispersion of adapalene microcrystals in this hydrogel. The drug is released in the form of 0.1% gel and cream.

Azelaic acid is a natural organic acid, the molecule of which contains 9 carbon atoms and two carboxyl groups, it does not have mutagenic and teratogenic properties. The drug is available in the form of 15% gel and 20% cream (Skinoren). For the treatment of acne it is advisable to use a gel form that does not change the pH of the skin surface and is well adapted in shape to patients with seborrhea. Azelaic acid has a pronounced effect on the final stages of keratinization, preventing the formation of comedones. Another important effect is antibacterial: after 3 months after starting the drug (2 times per day), P. Acnes is practically not found in the follicle estuaries. Against the background of the treatment, this drug does not develop microflora resistance. The antibacterial effect is due to the active transport of the drug inside the bugheries. The effective effect of azelaic acid on fungi of the genus Pityrosporum is known, as well as on the staphylococcal microflora. This drug also has an anti-inflammatory effect and inhibits 5a-reductase.

Benzoyl peroxide - a tool well known to specialists and used in dermatology for more than half a century. Thanks to a powerful disinfecting action, it was used to treat trophic ulcers. The keratolytic effect of this drug was widely used in external therapy of ichthyosis, whilst whitening properties - with various skin pigmentations. Benzoyl peroxide has a pronounced antibacterial effect on P. Acnes and Slaphilococcus epidermidis due to the powerful oxidative effect. This can explain the pronounced positive effect with respect to inflammatory acne, in particular pustular ones, revealed in a modern study. It has been proven that this agent actively affects strains resistant to antibiotics, in particular to erythromycin. This drug does not cause the emergence of antibiotic-resistant strains of microorganisms. It is also known that the combined use of benzoyl peroxide and antibacterial drugs significantly reduces the risk of the emergence of resistant strains. Many researchers have demonstrated the comedolytic and keratolytic action of benzoyl peroxide. A new preparation of benzoyl peroxide - Baziron AS, produced in the form of 5% gel, in comparison with the previously existing products, has good tolerance due to the hydrogel base and a special uniform dispersion of the microcrystals of benzoyl peroxide in this gel.

Multiple clinical studies have shown the efficacy and safety of Regecin gel in patients with vulgar acne (as a monotherapy for mild disease, combined with dermatotropic antibiotics and other systemic medications for moderate to severe forms, and for the prevention of relapses). It should be noted that the zinc-hyaluronic associate contributes to the formation of a cosmetic scar at the site of resolving the deep elements of acne, which can be used in the prevention of post-eruptive skin changes.

In the presence of papulopustular elements, drugs with antibacterial and disinfecting effects are also added to therapy. Monotherapy with topical antibiotics is not indicated because of the lack of adequate pathogenetic effects on follicular hyperkeratosis and the formation of microcosmodes, and also because of the risk of rapid appearance of insensitive P. Acnes strains.

Treatment of acne vulgaris

For acne vulgaris, a similar external therapy is used. It is usually combined with the general administration of the antibiotic tetracycline (limecycline, doxycycline, tetracycline, etc.). It should be emphasized that the effectiveness of antibacterial agents for acne is not only due to their direct bacteriostatic effect on P. Acnes. It is known that such antibiotics as tetracycline also have a direct anti-inflammatory effect. A more stable positive effect of antibiotic therapy for moderate acne is possible only with prolonged treatment (about 3 months). Therapy with systemic antibiotics in combination with antibiotics externally (without topical retinoids) is not recommended because of the high risk of developing insensitive strains of microorganisms. Tetracyclines are contraindicated in pregnant women and children under 12 years of age. If the effect of antibiotic therapy is insignificant or if there are isolated indifferent and phlegmonous elements, a tendency to scarring, then it is expedient to prescribe synthetic retinoids (isotretinoin).

Acne Treatment in Women

In addition to external therapy, women can be prescribed contraceptive drugs with anti-androgenic effect (Diane-35, Yarina, Janine, Trimerci, Bedara, etc.). This method of treatment is possible only after consultation of the gynecologist-endocrinologist and careful examination of the patient's hormonal background, that is, it should be prescribed strictly according to the indications. To therapy, depending on the revealed pathology, antiandrogen (Androkur) and other drugs can be added.

With the general treatment of severe forms of acne, the drug of choice is isotretinoin - Roaccutane (synthetic retinoid), the duration of therapy is 4-12 months. Roaccutane effectively affects all links in the pathogenesis of acne and produces a persistent clinical effect. Isotretinoin is the most effective remedy. The question of its appointment should be considered only in patients with severe forms of the disease, especially in the presence of abscessing, phlegmonous and conglobate acne with the formation of disfiguring scars. Isotretinoin can sometimes be prescribed and with an average severity of acne, when prolonged repeated courses of antibiotic therapy did not bring the desired result. These drugs are indicated in patients with acne accompanied by severe psychosocial disorders, and also as one of the additional drugs in the treatment of the most severe form - fulminant acne.

The optimal dose is 0.5 mg / kg of body weight per day for 3-4 weeks. The subsequent dosage depends on the clinical effect and tolerability.

It is extremely important to collect a total cumulative dose of not less than 120 mg / kg of body weight.

Isotretinoin is contraindicated in women who may become pregnant during the course of treatment, so it is prescribed to female patients on a background of effective contraception. Isotretinoin is also contraindicated in pregnant and lactating mothers because of the potential teratogenicity of retinoids. The drug should not be combined with vitamin A (due to the risk of hypervitaminosis A) and tetracyclines (due to the risk of increased intracranial pressure). Roacutane should not be combined with contraceptives containing small doses of progesterone, since isotretinoin can weaken the effectiveness of the drugs with progesterone. Isotretinoin is not recommended for patients with hepatic and renal insufficiency, with hyperlipidemias and diabetes mellitus. Isotretinoin is also contraindicated in cases of hypervitaminosis A and with increased sensitivity to the active substance of the drug. The drug should be taken necessarily under the supervision of a specialist.

During the therapy, clinical and laboratory monitoring of the patient is carried out. Before the start of treatment, patients are examined ACT, ALT, triglycerides, cholesterol, creatinine. Patients prescribed the drug only after a negative test result for pregnancy, and it is advisable to start treatment on the second or third day of the next menstrual cycle. Patients who are fertile, Roaccutane should not be prescribed until each of the following conditions is met:

• The patient suffers from a severe form of acne resistant to conventional methods of treatment.
• You can rely on the fact that the patient understands and complies with the instructions.
• The patient is able to use the prescribed contraceptive means.
• The patient was informed by her doctor about the dangers that pregnancy entails during treatment with Roaccutane and within one month after the end of it. In addition, she was warned about the possibility of refusing contraceptives.
• The patient confirmed that she understands the essence of precautions.
• The pregnancy test, conducted within two weeks before the start of treatment, gave a negative result.
• Within a month before the start of treatment with Roaccutane, during the treatment and within a month after discontinuation of treatment, it takes effective contraceptive measures without interruption.
• Treatment with the drug begins only on the second or third day of the next normal menstrual cycle.
• In the case of a relapse of the disease, the patient without breaks applies the same effective contraceptive within one month prior to initiation of treatment with Roaccutane, during treatment and for one month after discontinuation of treatment.

Compliance with these precautions during treatment should be recommended even to women who usually do not use contraceptives due to infertility (from the recommendations of the manufacturer).

In the process of treatment with isotretinoin it is necessary to control in patients with ALT, ACT, alkaline phosphatase, triglycerides, total cholesterol. 1 month after the start of therapy. In the future, in the absence of identified laboratory changes, it is possible to monitor these indicators every three months. In case of detection of hyperlipidemia, a repeat of laboratory tests is recommended in two weeks. After the end of treatment, a study is recommended in all patients of ALT, ACT, alkaline phosphatase, triglycerides and total cholesterol. Women who took the drug should have a pregnancy test four weeks after the end of therapy. The onset of pregnancy is possible only on the application of two months after the end of isotretinoin therapy.

Against the background of isotretinoin therapy, non-systemic and systemic side effects are possible, as well as changes in laboratory parameters.

Non-systematic:

• dry skin and mucous membranes (96%);
• nosebleeds, hoarseness (51%);
• conjunctivitis (19%).

System:

• headache (5-16%);
• arthralgia, myalgia (15-35%).

Changes in laboratory indicators:

• dyslipidemia (7-25%);
• an increase in the level of hepatic transaminases (6-13%).

When there are systemic side effects, decide whether to reduce the dose or to cancel the drug. Such non-systemic effects as dryness of the skin and mucous membranes of medicinal cheilitis are the expected side effects of systemic therapy with isotretinoin. To prevent and eliminate these changes, the right skin care is prescribed, including gentle cleansing (micelle solutions without alcohol, emulsions, synthetic detergents) and active moisturizing. In a cosmetic salon, masks can be prescribed to achieve a moisturizing effect or to replenish highly specialized skin lipids. To care for the red lip rim on the background of isotretinoin therapy, lip balms and lipsticks, produced by cosmetic companies especially for skin care of dermatological patients, can now be offered. These include lip balm with a wax cream (AveneB "Pierre Fabre" laboratory), lip cream "Kelian" (laboratory "Ducray", "Pierre Fabre", lip cream "Ceralip", stick "Lipolevre" ( pharmaceutical laboratory "La Roche-Posay"), protective and restorative stick for long-term action (laboratory "Linage"), lip balm "Amiiab" (laboratory "Merck"), lipsticks "Lipidiose", lip cream "Nutrilogie" ( laboratory "Vichy"), Lip balm for the lips, protective and restorative (laboratory "Klorane", "Pierre Fabre"), lip balm "Neutrogena" (Neutrogena), lipo-balm "DardiSh (" Intendis "), etc. For eye p Komenda artificial tears, gel "Vidy-sik."

It should be emphasized that the main causes of relapse after isotretinoin therapy are:

• lack of proper influence on the predisposing pathogenetic background;
• insufficient cumulative dose;
• refusal of maintenance therapy after the termination of treatment.

In the management of patients, the doctor should take into account these reasons. In severe acne is also prescribed topical retinoids in combination with antibacterial treatment (tetracyclines for at least 3 months). A combination of external retinoids, benzoyl peroxide and systemic antibiotics is possible. In women with severe manifestations of acne after the examination and the recommendations of a gynecologist-endocrinologist prescribe combined oral contraceptives with antiandrogens. After the end of the main course of treatment, supportive external therapy with external retinoids, benzoin peroxide of azelaic acid, salicylic acid for up to 12 months is shown.

[56]

Additional methods of treating acne

Acne can be prescribed such additional procedures as skin cleansing, drying and anti-inflammatory masks, darsonvalization (cauterizing action - large doses), therapeutic laser, surface peeling, disinfestation, cosmechanics procedure, oxygen therapy, photochromotherapy, photodynamic therapy. Important is the fact that the absence or inferiority of proper pathogenetic therapy at the time of the commencement of procedures can cause an aggravation of the course of acne. With indurative acne with stagnant phenomena, Jacquet massage, oxygen therapy can be recommended. Any massage in patients with acne should be done without the use of oils in order to avoid the comedogenic effect of the latter.

Skin cleansing, or so-called "comedoextraction," is an important additional procedure for managing patients with acne. Given the current understanding of the violation of barrier skin properties in patients with acne, cleansing should be as gentle as possible. The previous external therapy with retinoids (Differin) or azelaic acid (Skinoren) significantly improves the cleaning procedure for at least 2-3 weeks.

In recent years, ultrasound has become more attractive - providing a good cosmetic effect after the course of procedures. I would also like to emphasize that cleaning should not substitute for pathogenetic therapy for acne, but only supplement it. Cleaning is not indicated with the predominance of inflammatory elements, especially pustular. If the cosmetologist sees the need to prescribe this procedure in the presence of pustular acne, then the skin should be prepared with benzoyl peroxide (Basiron AC) for 10-14 days, and then - to produce the procedure.

Assign also surface cryotherapy, which can speed up the resolution of the inductive elements. In complex therapy, acne is also used peeling (surface, median). Surgical manipulations with acne have very limited application. Surgical opening of cystic cavities is contraindicated, as it leads to the formation of persistent scars. Sometimes, with abscessed acne, focalization of the foci with a crystalline suspension of the corticosteroid is used. However, this procedure was not widely used because of the risk of developing at-the-site injection of atrophy and abscessing.

[57], [58], [59], [60], [61]

Postoperative treatment

The most frequent manifestations of post-acne include secondary pigmentation and scars. The consequences of acne can also include milium, atheroma.

With a tendency to form scars against the background of acne, you can earlier assign the most effective drugs. With an easy flow of acne from external drugs, the drugs of choice should be topical retinoids (adapalen - Differin). In case of moderate disease, topical retinoids are recommended in combination with tetracycline antibiotics (most preferred are limycycline, doxycycline) for a period of at least 3 months. This recommendation is due not only to the direct effects of the drug on P. Acnes and other microorganisms. It is known that tetracyclines affect the maturation of collagen and have an anti-inflammatory effect directly in the center of inflammation in the dermis. In the absence of the effect of systemic therapy with antibacterial agents and the tendency to form scars with an average acne flow, isotretinoin is recommended. In cases of severe drug flow, isotretinoin is the choice. With any severity of the course of the disease, drugs that can normalize the formation and metabolism of collagen (Kuriosin, Regecin, Kontratubeks, Mederma, Madecassol, etc.) can be added to therapy.

The appearance of scars can contribute to various medical manipulations, squeezing out acne, cleaning. As mentioned above, surgical opening of cystic cavities is contraindicated, as it leads to the formation of persistent scars. For correction of cicatricial changes, some external means, chemical peelings of various depths, physiotherapy methods, cryomassage and cryodestruction, philling, mesotherapy, microdermabrasion, laser skin resurfacing, dermabrasion, surgical removal of individual scars, excision with laser, electrocoagulation are used. The choice of method of treatment depends on the nature of cicatricial changes. The desired cosmetic effect can be achieved through the combined use of these methods.

With multiple spot scars, it is recommended to combine different impact techniques, which, complementing each other, allow for equalizing effect at different depths (for example, chemical peelings + microdermabrasion, laser "grinding" or dermabrasion).

It is believed that the best effect for hypertrophic scars can be achieved by laser "grinding" and dermabrasion. In hypertrophic scars, external preparations that affect the metabolism of connective tissue (Kuriosin, Regecin, Kontraktubeks, Mederma, Madecassol, etc.) can also be used, as well as topical glucocorticosteroids. These agents can be applied to the skin or injected with ultrasound, electrophoresis. From the physical methods of exposure, techniques that affect the metabolism of connective tissue (laser therapy, microcurrent therapy, magnetotherapy, etc.) are popular. Cryodestruction, laser destruction, surgical treatment of individual scars with subsequent chemical peeling procedures are also used.

Atrophic scars use methods of philling, mesotherapy, mimic peeling, which helps to smooth the skin, less often - external drugs and physiotherapy that affect the metabolism of connective tissue. Topical glucocorticosteroids are not indicated in atrophic scars due to the potential risk of additional skin atrophy. It is believed that the procedure of filling is most effective at atrophic scars with flat, rounded forms on a cut without sharp angles, V-shaped, or trapezoidal. With deeper defects, dermabrasion can be recommended. In a number of cases, excision of individual atrophic scars with subsequent peelings or dermabrasion is undertaken.

Particular difficulty is the treatment of keloid scars after acne (acne-keloid). Cystic scars are uncontrolled benign proliferation of connective tissue at the site of skin damage (Greek kele - tumor + eidos - species). According to the histological classification of WHO (1980), they are considered among tumorous processes of soft tissues. In the literature, many methods of their treatment with the use of X-ray therapy, glucocorticoids, retinoids, long courses of cytostatics, preparations of gamma and alpha-interferon have been described. However, the efficacy of many of them is low enough, and complications can be heavier than the underlying disease, so they are not currently recommended for the treatment of patients with acne-keloids. Destructive methods of treatment of keloids (surgical excision, laser and cryodestruction, electrothermocoagulation, laser "grinding", dermabrasion) are contraindicated, since they cause even more severe relapses. The results of the treatment of keloids in acne depend on the period of their existence and the area of the lesion. It is shown that at the early stages of their formation (up to 1 year) and with small areas of damage, the method of introducing a crystalline suspension of glucocorticosteroids with 1% lidocaine into the keloid tissue is effective. Strong topical glucocorticosteroids can also be used. Less often appoint special pressure bandages, plates. Outer in keloid and hypertrophic scars, gel Dermatix is prescribed, which has a moisturizing effect and simultaneously acts as an occlusive dressing. With long-existing keloids, in addition to the suspension of glucocorticosteroids, the introduction of collagenase or interferon into the foci of the solution is used.

With a tendency to form miloons, it is important from the very first stages of therapy to focus on modern drugs that have keratolytic and comedolytic action (adapalene-Differin, azeic acid-Skinoren). The appearance of miloons can be partly facilitated by dehydration of the stratum corneum in patients with acne. Such patients are shown moisturizers and procedures.

It is recommended to remove the milium mechanically with a needle, less often they are removed with a laser. For 1-2 weeks before the removal can be carried out skin preparation (using azelaic, salicylic acid, hydroxy acid), facilitating the procedure of vyluschivaniya milium.

With a tendency to the formation of athere, it is important to focus on modern drugs that have a powerful keratolytic and comedological effect. Depending on the severity of the course of acne, prolonged therapy with topical retinoids (adapalene, diferin) or systemic retioids (isotretinoin - Roaccutane) is recommended.

Atheromas are removed surgically, more rarely using a laser. Most preferably, surgical removal of atheroma with the capsule.

The so-called MARSH-syndrome can also be considered the consequence of a particular form of acne. To prevent the expression of melasma, active photoprotection using sunscreens with maximum protection against ultraviolet rays A and B is also indicated. It should also be remembered that the manifestations of melasma become more vivid when oral contraceptives are taken, which are prescribed by such a patient as pathogenetic therapy for acne.

Melasma therapy includes long courses of azelaic acid, topical retinoids, benzoyl peroxide, ascorbic acid, chemical peels with hydroxy acids (alpha, beta and polyhydroxy acids or trichloroacetic acid, hydroquinone and other drugs.) A good cosmetic result can be given by laser skin resurfacing, photorejuvenation, less often - dermabrasion Inside with the goal of inhibiting the formation of melanin is prescribed ascorbic acid (vitamin C) and tocopherol (vitamin E).

In order to prevent exacerbation of rosacea against a background of active external therapy of acne, careful care is shown, both over sensitive skin, in combination with agents that affect the links of the pathogenesis of both acne and rosacea (for example, gel with azelaic acid - Skinoren gel). In addition to the therapy of rosacea, external azole compounds (metronidazole), zinc preparations (Kuriozn, Regecin, etc.), sulfur (Delex acne, etc.) are used. As a basic skin care, various agents can be proposed with the effect on the vascular component of the disease {(Rosaliac - pharmaceutical laboratory "La Roche-Posay", Roselyan - laboratory "Una age", Sensibio series - laboratory "Bioderma", Dirosale and Antitiger laboratory "Avene", "Pierre Fabre", and others).

With hirsutism, various methods of depilation and depilation are used. It is important to emphasize that for effective effects on hirsutism, prolonged therapy with antiandrogenic drugs (not less than 1-1.5 years) is indicated.

In conclusion, I would like to warn doctors of various specialties of the widespread use of the previously popular methods of treating acne, based on outdated ideas about the pathogenesis of this disease. At present, the questionable effectiveness of a strict diet, enterosorbents and autohemotherapy in patients with acne is shown. It is also not recommended for patients with moderate and severe forms to prescribe active ultraviolet irradiation because of the proven comedogenic effect and reduction of local immune defense against the background of acute and chronic UV exposure. Antibiotics of the penicillin, cephalosporin series and others are not shown, which are inactive with P. Acnes. Contraindicated extensive surgical opening of cystic cavities, as it leads to the formation of persistent scars. Finally, external glucocorticosteroids are contraindicated in the treatment of acne. Currently, the most optimal as early as possible the appointment of modern external and (or) systemic drugs.

Prevention

In order to prevent the development of secondary hyperpigmentation, effective photoprotection is recommended, especially in individuals with a tendency to post-inflammatory pigmentation. Such patients are not shown ultraviolet irradiation (including in the solarium) on the background of acne treatment. When choosing the therapy of acne, it is recommended immediately to focus on external drugs that, in addition to affecting the main pathogenetic links, bleaching properties (azelaic acid, benzoyl peroxide, topical retinoids).

To reduce or remove secondary pigment spots after acne, various cosmetic procedures are used, as well as agents that reduce pigmentation. From cosmetic procedures apply chemical peeling, cryotherapy, microdermabrasion, laser dermabrasion. Reduces pigmentation and various drugs that affect directly the process of pigmentation. Bleaching effect is benzoyl peroxide, azelaic acid, topical retinoids. Used for external therapy of acne, as well as ascorbic acid, hydroxy acids, hydroquinone and other agents. However, as some researchers have pointed out, hydroquinone can in some cases cause even more persistent pigmentation both in the lesion and around it, so its use is very limited. At present, the old, previously very popular method of bleaching the skin with the help of preparations containing white precipitate mercury, is practically not used, because of the high risk of developing allergic dermatitis. It should be emphasized the need for effective photoprotection against the background of treatment of secondary hyperpigmentation.

[62], [63], [64]