What is Medicine – Acne Vulgaris
Pilosebaceous unit dysfunction and chronic inflammatory dermatosis in acne vulgaris is characterised by open/closed comedones, papules, pustules, and nodules. Aspects of Geriatrics Favre-Racouchot syndrome: sun-induced comedones on the face or head pregnant women's issues Acne may flare up or go away; typically gets better in the first trimester; may get worse in the third; can be treated with topical benzoyl peroxide, azelaic acid, erythromycin, or clindamycin; orally with erythromycin, azithromycin, or cephalexin; avoid topical tretinoin and adapalene as they may cause retinoid embryopathy; class C; contraindicated with t Child Safety Considerations Neonatal acne (neonatal cephalic pustulosis) affects newborns up to 8 weeks old; lesions are confined to the face and are typically self-limited. Infantile acne: lesions on the face, neck, back, and chest; topical/systemic prescription; infant to one year Early to middle childhood acne (rare; 1 to 7 years old); take hyperandrogenism into account. Preadolescent acne affects 7 to 12 year olds; it is prevalent, affecting 47% of kids, and is typically caused by comedonal lesions. Tetracyclines shouldn't be used in children under 8; instead, employ therapy more suited to adolescents. EPIDEMIOLOGY Male > Female (teen), Female > Male (adult) Predominant age: early to late puberty, may remain in 20- 40% of affected persons beyond 4th decade Prevalence 80–95% of teenagers are affected, 8% of adults are 25–34 years old, 3% are 35–44 years old, and 37% of African Americans and 24% of Caucasians are affected. PATHOPHYSIOLOGY AND AETIOLOGY Androgens (testosterone and dehydroepiandrosterone sulphate [DHEA-S]) increase keratinocyte proliferation, sebum production, and qualitative alterations in sebum in follicles. Keratin plug blocks follicle growth, resulting in sebum buildup and follicular distention. An anaerobe called Cutibacterium acnes phylotype Ia colonises and multiplies within a biofilm in the blocked follicle. C. acnes encourages proinflammatory mediators, which inflames the dermis and hair follicles. Genetics 50% of cases include family ties Increased endogenous androgenic impact, oily cosmetics, cocoa butter, polyvinyl chloride, chlorinated hydrocarbons, cutting oil, and polyvinyl chloride are risk factors. Cell phones, hands against the skin, pandemic masks ("maskne"—a subset of acne mechanica), occluding skin surface (e.g., sports equipment such as helmets and shoulder pads), androgenic steroids (e.g., steroid abuse, some birth control pills), lithium, and phenytoin; and endocrine disorders such as PCOS, Cushing syndrome, congenital adrenal hyperplasia, androgen-secreting tumours Stress Diets high in dairy products (skim milk), high glycemic loads, and whey protein supplements may aggravate acne. With smoking, severe acne could get worse. DURATIONAL PREVENTION avoiding risk elements COMMONLY ASSOCIATED CONDITIONS Pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA), as well as seborrhea, acne, hirsutism, and alopecia (SAHA), include acne conglobata, hidradenitis suppurativa, pomade acne, and SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and o Patients with dark skin had 50% keloidal scarring and 50% hyperpigmented acne macules. DIAGNOSIS HISTORY Obtain information on the duration, relationship to menstruation, medications, cleaning agents, stress, smoking, exposures, food, and family history. PHYSICAL EXAM: Nodules or papules, pustules, cysts, closed comedones (whiteheads), open comedones (blackheads), Scars include sinus tracts, ice pick, rolling, boxcar, hypertrophic, depressed, and atrophic macules. Although guidelines don't specify a particular global grading system, consistent grading is helpful. The American Academy of Dermatology's 1990 grading scale - Mild: a few pustules/papules but no nodules - Moderate: a few nodules and a few papules/pustules - Serious: many papules, pustules, and nodules incredibly severe acne: acne conglobata, acne fulminans, and acne inversa The most frequently affected body parts are the face, chest, back, and upper arms (where sebaceous glands are most concentrated). Adult females have face lesions that are similar to those in teenagers and do not just occur in the mandibular and perioral regions. DIFFERENTIAL DIAGNOSIS Folliculitis: gram-negative and gram-positive, perioral dermatitis, pseudofolliculitis barbae, drug eruption, keratosis pilaris, sarcoidosis, seborrheic dermatitis, lupus erythematosus, and acne (rosacea, cosmetica, steroid-induced). DETECTION & INTERPRETATION OF DIAGNOSIS Initial examinations (lab, imaging) Only recommended if there are further indicators of androgen overproduction; in that case, test for free and total testosterone, DHEA-S, and take into account LH and FSH (PCOS). TREATMENT Mild inflammatory acne (grade 2): benzoyl peroxide +/- topical retinoid or benzoyl peroxide +/- topical antibiotic +/- topical retinoid. Comedonal (grade 1): keratinolytic agent Moderate inflammatory acne (grade 3): Upgrade the grade 2 treatment to include a time-limited systemic antibiotic. The first-line treatment for more severe cases of the condition is topical retinoid combined with a topical antibacterial agent, such as Severe inflammatory acne (grade 4): as in grade 3 or isotretinoin. For mild to moderate, topical retinoid plus antibiotic (topical or oral) is preferable to either one alone. The first-line treatment for maintenance therapy is topical retinoids. Don't use prolonged antibiotics for maintenance. Steer clear of using oral or topical antibiotics alone. Use with topical retinoids or BP. Recommended automobile class - Creams, lotions, or ointments for dry or sensitive skin - Gel, solution, wash for oily skin and humid conditions - Areas that bear hair: foam, hydrogel, or lotion Use topical medications to treat the entire affected area, not just any apparent lesions. Use gentle soap everyday to manage oiliness; stay away from abrasives. To reduce MEDICATION ALERT, stay away from drying chemicals and use gentle cleansers and noncomedogenic moisturisers. The majority of topical prescription drugs carry high prices. Keratinolytic drugs (-hydroxy acids, salicylic acid, topical retinoids, azelaic acid) (Side effects include dryness, erythema, and scaling; start with lower strength or alternate day prescription; increase as tolerated.) Tretinoin comes in a variety of strengths and formulations (Retin-A, Retin-A Micro, Avita, and Atralin): To lessen irritation, wash the skin and let it air dry for 30 minutes before applying. At bedtime, use a pea-sized amount. - The BP-stable Retin-A Micro, Atralin, and Avita are less irritating. Apply every other day for the first 2 to 4 weeks to relieve the first flare-up of lesions; avoid using on pregnant or nursing women. - Prices vary depending on formulation; generic tubes cost $50 to $150 each. Adapalene (Differin): 0.1%, topically applied HS - May be used with benzoyl peroxide (Epiduo) 0.1 or 0.3%/2.5%—very effective for skin of colour - Effective; less irritant than tretinoin or tazarotene - Available over-the-counter (OTC); significantly less expensive ($10–$15) than other prescription retinoids Apply tazarotene (Tazorac) before going to bed. Most irritating and ineffective; teratogenic, $400 per tube 20% topical BID azelaic acid (Azelex, Finevin) Reduces postinflammatory hyperpigmentation in people with dark skin due to keratinolytic, antimicrobial, and anti-inflammatory compounds. - Erythema, dryness, scaling, and hypopigmentation are side effects. - Safe during pregnancy-risk Category B - Effective in treating post-adolescent acne - 20% Rx >$400 per tube; OTC 10% and 15% versions cost $10 to $40 each tube. Salicylic acid (2%), while less irritating and less efficacious than tretinoin. -Hydroxy acids: over-the-counter Topical benzoyl peroxide has no resistance in C. acnes; 2.5% formulations are just as efficient as stronger ones, and gel penetrates the follicles more thoroughly. – Apply benzoyl peroxide in the morning and tretinoin at night when using with tretinoin. - Negative effects irritation that varies with dosage; garments that may fade; and photosensitivity Different types of topical antibiotics from benzoyl peroxide Due to antibiotic resistance, avoid using as a monotherapy (2)[A]. - Once daily use of metronidazole gel or cream, erythromycin 2%, and clindamycin 1%. - Benzamycin (benzoyl peroxide-erythromycin), which works best when combined with azelaic acid. - Clindamycin with benzoyl peroxide (BenzaClin, DUAC, Clindoxyl) - Benzoyl peroxide-salicylic acid (Cleanse & Treat, Inova): comparable to benzoyl peroxide in terms of efficacy–clindamycin - Sodium sulfacetamide (Sulfacet-R, Novacet, Klaron) is effective for treating rosacea or acne with seborrheic dermatitis. - Dapsone (Aczone) 5% gel: effective for treating adult females with inflammatory acne; when combined with BP, it may induce yellow or orange skin pigmentation; also highly expensive ($350 per bottle). Oral antibiotics: Use for the shortest time possible, often 6 to 12 weeks of therapy, with a maximum of 6 months if necessary (2); use when acne is more severe, involves the trunk, is resistant to topical medications, or is more likely to leave scars. Do not use as a monotherapy. - Tetracycline: 500 to 1,000 mg/day divided BID; initially high dose, taper in 6 months; less effective than doxycycline or minocycline (2); use while fasting or without dairy; photosensitivity and esophagitis are side effects. - Minocycline: adverse effects include photosensitivity, urticaria, gray-blue skin, vertigo, autoimmune hepatitis, and lupus; prolonged release preparation is better tolerated. - Sarecycline (Seysara): 60 to 150 mg (1.5 mg/kg) taken once daily, narrow spectrum, $1,000/month - Doxycycline: 20 to 200 mg/day, divided daily—BID; photosensitivity - Erythromycin's effectiveness is diminishing due to C. acnes resistance; 500 to 1,000 mg/day, divided BID-QID. Trimethoprim-sulfamethoxazole: QD or BID (Bactrim DS, Septra DS) - Azithromycin (Zithromax): 500 mg three times per week for the first month, then 250 mg every other day for the next two months. Oral retinoids - Isotretinoin: 0.5 to 1.0 mg/kg/day divided BID to maximum 2 mg/kg/day divided BID for very severe disease; usually given for 12 to 20 weeks; maximum cumulative dose = 120 to 150 mg/kg; 20% of patients relapse and require retreatment (1), 0.25 to 0.40 mg/kg/day in moderately severe acne Night blindness, erythema multiforme, Stevens-Johnson syndrome, pancreatitis, excessive skin dryness, hypertriglyceridemia, hepatitis, blood dyscrasias, hyperostosis, premature epiphyseal closure, night blindness, psychosis, and teratogenic consequences are only a few of the side effects. Avoid taking vitamin A or tetracyclines while taking isotretinoin. At baseline and once a month, check for pregnancy, psychiatric/mood changes, CBC, lipids, glucose, and LFTs. The iPLEDGE programme (www.ipledgeprogram.com) requires that both the patient and the physician sign up, and two types of reliable contraception are needed. FDA-approved oral contraceptives (listed in order of potential effectiveness) for women exclusively[B] Drospirenone/ethinyl estradiol (Yaz) or drospirenone/ethinyl estradiol/levomefolate (Beyaz) are superior than norethindrone acetate/ethinyl estradiol (Estrostep) and norgestimate/ethinyl estradiol (Ortho Tri-Cyclen). The majority of combination contraceptives work well and can last for three to six months. Spironolactone (Aldactone); 25 to 200 mg/day; antiandrogen; lowers production of sebum; not FDA-approved for acne Rx ISSUES FOR REFERRAL Acne scar management ADDITIONAL THERAPIES Topical hydroquinone (1.5-10%), topically applied azelaic acid (20%), topical retinoids, low-dose corticosteroids, topical dapsone 5% gel (Aczone): anti-inflammatory; usage in patients over 12 years old, sunscreen The best evidence is for photodynamic therapy using 5-aminolevulinic acid. Other light-based treatments include pulse dye, infrared laser, and ultraviolet A/ultraviolet B (UVA/UVB), blue or blue/red light. SURGICAL AND OTHER PROCEDURE Comedo extraction is performed after the epithelial layer covering a closed comedone is cut. Large cystic lesions are then injected with 0.05 to 0.30 mL triamcinolone (Kenalog 2 to 5 mg/mL) using a 30-gauge needle to slightly enlarge the cyst. Retinoids, steroid injections, cryosurgery, electrodesiccation, micro-/dermabrasion, chemical peels, laser resurfacing, pulsed dye laser, microneedling, fillers, punch elevation are all methods for treating acne scars. ALTERNATIVE & COMPLEMENTARY MEDICINE Tea tree oil, seaweed extract, Kampo formulations, Ayurvedic formulations, rose extract, basil extract, epigallocatechin gallate, barberry extract, gluconolactone solution, and green tea extract may all be helpful, according to the evidence (2). Limited data for dermocosmetics' acne treatment SUCCESSIVE RECOMMENDATIONS Utilise oral antibiotics for no more than three months; take off topical antibiotics as lesions heal. DIET Skim milk and foods with a high glycemic index may make acne worse. EDUCATION OF PATIENTS In the first two weeks of treatment, lesions may get worse; after at least four weeks of treatment, lesions usually get better. PROGNOSIS gradual progress over time (often 8 to 12 weeks after starting therapy) Acne conglobata, a severe form of confluent inflammatory acne with systemic signs, is a complication. psychological suffering, such as anxiety, sadness, and suicide thoughts, together with facial scarsScars, keloids, and post-inflammatory hyperpigmentation are more prevalent in those with darker skin.
0 Comments
Leave a Reply. |
Kembara's Health SolutionsDiscovering the world of health and medicine. Archives
June 2023
Categories
All
|