Acne , also known as acne vulgaris , is a long-term skin disease that occurs when hair follicles are blocked by dead skin cells and skin oils. It is characterized by blackheads or whiteheads, acne, oily skin, and possibly scarring. It mainly affects the skin area with relatively high amounts of oil glands, including the face, upper chest, and back. The resulting appearance can cause anxiety, reduce self-esteem and, in extreme cases, depression or suicidal thoughts.
Genetics is considered a major cause of acne in 80% of cases. The role of diet and smoking is unclear, and no cleanliness or exposure to sunlight plays a role. During puberty, in both sexes, acne is often caused by increased hormones such as testosterone. A common factor is the overgrowth of the bacteria Propionibacterium acnes, which is usually present in the skin.
Many treatment options for acne are available, including lifestyle changes, medications, and medical procedures. Eating fewer simple carbohydrates like sugar can help. Treatment is applied directly to the affected skin, such as azelaic acid, benzoyl peroxide, and salicylic acid, usually used. Antibiotics and retinoids are available in formulations applied to the skin and taken by mouth for acne treatment. However, resistance to antibiotics may develop as a result of antibiotic therapy. Some types of birth control pills help fight acne in women. Isotretinoin pills are usually reserved for severe acne because of the potential for larger side effects. Early and aggressive acne treatment is recommended by some medical communities to reduce overall long-term impact on individuals.
By 2015, acne is thought to affect 633 million people worldwide, making it the 8th most common disease worldwide. Acne usually occurs in adolescence and affects about 80-90% of teenagers in the Western world. Lower rates are reported in some rural communities. Children and adults can also be affected before and after puberty. Although acne is becoming less common in adulthood, but still there are almost half of people affected until their twenties and thirties and smaller groups continue to have difficulty entering their forties.
Video Acne
Classification
The severity of acne vulgaris (Gr "," "point" L. vulgaris, "common") may be classified as mild, moderate, or severe as it helps to determine the appropriate treatment regimen. Light acne is classically defined by the presence of clogged skin follicles (known as comedones) that are confined to the face with occasional inflammatory lesions. The severity of moderate acne is said to occur when the higher number of papules and pustus inflammation occurs on the face compared with mild cases of acne and is found in the trunk. Severe acne is said to occur when nodules ('painful' bulges under the skin) are typical facial lesions and extensive body involvement.
Large nodules were previously referred to as cysts, and the term nodulocystic has been used in medical literature to illustrate cases of severe acne inflammation. True cysts are actually rare in those with acne and the term severe nodular acne is now the preferred terminology.
Acne inversa (L. invert ?, "upside down") and rosacea acne (rosa, "colored roses" - "ceus," forming ") are not true acne forms and each refers to the condition of the skin of hidradenitis suppurativa (HS) and rosacea. Although HS has certain common features with acne vulgaris, such as the tendency to clog the skin follicles with skin cell debris, the opposite condition does not have the distinct features of acne and is therefore considered a different skin disorder.
Maps Acne
Signs and symptoms
Characteristics of acne include increased secretion of oily sebum by the skin, microcomedones, blackheads, papules, nodules (papules), pustules, and often lead to scarring. The appearance of acne varies with skin tone. This can lead to psychological and social problems.
Scars
Acne scars are caused by inflammation in the skin layer and are thought to affect 95% of people with acne vulgaris. This scar is created by abnormal healing after this skin inflammation. The scars are most likely to occur with severe acne, but can occur with various forms of acne vulgaris. Acne scars are classified according to whether the abnormal healing response after skin inflammation causes excessive collagen deposition or loss in the location of acne lesions.
Acne atrophic scars lose collagen due to a healing response and are the most common type of acne scar (accounting for about 75% of all acne scars). They may be further classified as ice-pick scars, boxcar scars, and scrolling scars. A narrow ice-pick scar (less than 2 mm), a deep scar that extends into the dermis. Boxcar scars are round or oval with sharp edges and sizes vary from 1.5-4 mm. The scar is wider than the icepick and boxcar (4-5 mm) and has a depth-like wave pattern on the skin.
Hypertrophy scars are rare, and are characterized by elevated levels of collagen after an abnormal healing response. They are described as hard and raised from the skin. Hypertrophic scars remain within the initial limit of the wound, whereas the keloid scar can form scar tissue beyond this limit. Keloid marks from acne are more common in men and people with darker skin, and usually occur on the trunk of the body.
Pigmentation
Postinflammatory hyperpigmentation (PIH) is usually the result of nodular acne lesions. These lesions often leave an inflamed dark marker after the original acne lesions have been resolved. This inflammation stimulates special pigment-producing skin cells (known as melanocytes) to produce more melanin pigment which leads to the appearance of dark skin. People with darker skin tone are more often affected by this condition. Pigmented scar is a general term used for PIH, but it is misleading because it indicates a permanent color change. Often, PIH can be prevented by avoiding the aggravation of nodules, and may fade over time. However, untreated PIHs may persist for months, years, or even permanent if deeper skin layers are affected. Even minimal skin exposure to sun's ultraviolet rays can maintain hyperpigmentation. Daily use of SPFÃ, 15 or higher sunscreen can minimize such risks.
Cause
Risk factors for the development of acne, in addition to genetics, have not been identified with certainty. Secondary contributions may include hormones, infections, diets and stress. Studies that investigated the effects of smoking on the incidence and severity of acne have been convincing. Sunlight and cleanliness are not associated with acne.
Gen
The tendency for acne for certain individuals is probably explained by the genetic component, a theory supported by studies that examine acne rates among twin brothers and first-degree relatives. Severe acne can be associated with XYY syndrome. Acne vulnerability is likely due to the influence of some genes, as the disease does not follow the classical inheritance pattern (Mendel)). Several candidate genes have been proposed including certain variations in tumor necrosis factor-alpha (TNF-alpha), IL-1 alpha, and CYP1A1 genes, among others. Increased risk was associated with a single 308 G/A nucleotide polymorphism variation in genes for TNF.
Hormones
Hormonal activity, such as occurs during the menstrual cycle and puberty, may contribute to the formation of acne. During puberty, an increase in sex hormones called androgens causes the follicle's skin glands to grow larger and make sebum more oily. Some hormones have been linked to acne, including testosterone androgens, dihydrotestosterone (DHT), and dehydroepiandrosterone (DHEA); high levels of growth hormone (GH) and growth factors such as insulin 1 (IGF-1) have also been linked to worsening acne. Both androgens and IGF-1 appear to be important for acne, since acne does not develop in individuals with complete androgen insensitivity syndrome (CAIS) or Laron syndrome (insensitivity to GH, resulting in very low levels of IGF-1).
Medical conditions that usually cause high androgen states, such as polycystic ovary syndrome, congenital adrenal hyperplasia, and androgen-secreting tumors, can cause acne in affected individuals. Conversely, people with androgenic hormone deficiency or are not sensitive to androgen effects rarely have acne. Increased androgen synthesis and oily sebum can be seen during pregnancy. Acne can be a side effect of testosterone replacement therapy or the use of anabolic steroids. Bodybuilding and supplements of freely sold foods are usually found to contain illegally added anabolic steroids.
Infection
It is widely suspected that anaerobic bacterial species Propionibacterium acnes (P. Acnes) contribute to the development of acne, but its exact role is not well understood. There are certain sub-types of P. acne associated with normal skin, and moderate or severe inflammatory acne. It is not clear whether these unwanted strains evolved on-site or acquired, or may both depend on the person. This strain has the ability to alter, perpetuate, or adapt to the abnormal cycle of inflammation, oil production, and inadequate decay of dead skin cells from acne pores. Infection with the parasitic mite Demodex is associated with the development of acne. It is not clear whether eradication of mites increases acne.
Diet
The relationship between diet and acne is unclear, as there is no high-quality evidence that forms the definitive relationship between them. The high-glycemic-load diet has been found to have different degrees of effect on the severity of acne. Several randomized controlled trials and nonrandomized studies have found a low-glycemic-load diet to be effective in reducing acne. There is evidence of a weak observation that suggests that dairy consumption is positively associated with higher frequencies and acne severity. Milk contains whey proteins and hormones such as IGF-1 bovine and dihydrotestosterone precursors. These components are hypothesized to promote the effects of insulin and IGF-1 and thereby increase the production of androgen hormones, sebum, and promote the formation of comedones. The effects of other potentially contributing food factors, such as consumption of chocolate or salt, are not supported by evidence. Chocolate does contain a variable amount of sugar, which can cause a high glycemic load, and can be made with or without milk. Several studies have examined the relationship between obesity and acne. Vitamin B 12 can trigger a skin outbreak similar to acne (acne eruption), or aggravate existing acne, when taken in doses exceeding the recommended daily intake. Eating oily foods does not increase acne or make it worse.
Stress
Several high-quality studies have been conducted that show that stress causes or aggravates acne. While the relationship between acne and stress has been debated, several studies have shown that increased severity is associated with high levels of stress in certain contexts such as hormonal changes seen in premenstrual syndrome.
Environmental factors
Mechanical obstruction of the skin follicles by helm or chinstraps may aggravate existing pimples.
Drugs
Some medications may aggravate existing acne, with examples of lithium, hidantoin, isoniazid, glucocorticoid, iodide, bromide, and testosterone.
Pathophysiology
Acne vulgaris is a chronic skin disease of the pilosebaceous unit and develops due to a blockage in the hair follicles of the skin. This blockage is thought to occur as a result of the following four abnormal processes: the higher production of oily sebum than normal (influenced by androgens), excessive keratin protein deposition leading to comedo formation, follicular colonization by Propionibacterium acnes P. Acne ) bacteria, and the local release of pro-inflammatory chemicals in the skin.
The earliest pathological change is the formation of plugs (microcomedone), which is mainly driven by excessive growth, reproduction, and accumulation of skin cells in hair follicles. In normal skin, dead skin cells appear on the surface and out of the pores of the hair follicles. However, an increase in the production of oily sebum in those with acne causes dead skin cells to remain united. The accumulation of dead skin cell debris and oil sebum block the pores of hair follicles, thus forming microcomedone. This is further exacerbated by the biofilms made by P. acne within the hair follicle. If microcomedone is superficial within the hair follicle, melanin skin pigment is exposed to air, resulting in oxidation and dark appearance (known as blackheads or open comedones). Conversely, if microcomedone occurs deep within the hair follicles, this leads to the formation of whitehead (known as closed comedo).
The main hormone driver producing oily sebum in the skin is dihydrotestosterone. Another androgenic hormone responsible for increased activity of the sebaceous glands is DHEA-S. The higher amount of DHEA-S is secreted during adrenarche (puberty stage), and this leads to an increase in sebum production. In a skin-rich environment of sebum, natural skin bacteria and most commensal P. acne is easy to grow and can cause inflammation in and around the follicle due to activation of the innate immune system. P. acnes triggers skin inflammation in acne by increasing the production of some pro-inflammatory chemical signals (such as IL-1 ?, IL-8, TNF-?, and LTB4); IL-1? is known to be very important for the formation of blackheads.
The main mechanisms of acne-related skin inflammation are mediated by P. acnes the ability to bind and activate the immune system receptor classes known as toll-like receptors (TLRs), especially TLR2 and TLR4. Activation of TLR2 and TLR4 by P. acnes leads to increased secretion of IL-1, IL-8, and TNF-. The release of these inflammatory signals attracts various immune cells to the hair follicles including neutrophils, macrophages, and Th1 cells. IL-1? stimulates increased activity and reproduction of skin cells, which in turn fosters comedo development. Furthermore, sebaceous gland cells produce more antimicrobial peptides, such as HBD1 and HBD2, in response to TLR2 and TLR4 binding.
P. acnes also provokes skin inflammation by altering the fatty composition of oily sebum. Lipid squalene oxidation by P. acnes is very important. Squalene Oxidation activates NF-? B (protein complex) and consequently increase IL-1? level. In addition, squalene oxidation leads to an increase in the activity of the 5-lipoxygenase enzyme responsible for the conversion of arachidonic acid into leukotriene B4 (LTB4). LTB4 promotes skin inflammation by acting on the peroxisome-activated receptor alpha (PPAR?) Protein. PPAR? increase activator activity protein 1 (AP-1) and NF-? B, thus leading to the recruitment of inflammatory T cells. The inflammatory properties of P. acne can be further explained by the ability of bacteria to convert sebum triglycerides into pro-inflammatory free fatty acids through the secretion of lipase enzymes. This free fatty acid stimulates the production of cathelicidin, HBD1, and HBD2, leading to further inflammation.
This inflammatory cascade usually leads to the formation of inflammatory acne lesions, including papules, infected pustules, or nodules. If the inflammatory reaction is severe, the follicle may penetrate the deeper layers of the dermis and subcutaneous tissue and lead to the formation of deep nodules. The involvement of AP-1 in the above mentioned inflammatory cascade causes the activation of metalloproteinase matrices, which contribute to local tissue damage and scar formation.
Diagnosis
Blackheads (blackheads and whiteheads) should be present to diagnose acne. In their absence, a similar appearance to acne will show different skin disorders. Microcomedones (precursors for blackheads and whiteheads) are invisible to the naked eye when examining the skin and can only be seen with a microscope. There are many features that may indicate a person's vulgaris acne is sensitive to hormonal influences. Historical and physical clues that may show hormone-sensitive acne include the onset between the ages of 20 and 30; worsens the week before the woman's menstrual cycle; acne lesions mainly above the jaw line and chin; and inflammatory/nodular acne lesions.
Several scales exist to assess the severity of acne vulgaris, but no single technique is universally accepted as a diagnostic standard. The grading scale of Cook uses photos to assess the severity of 0 to 8 (0 being the most severe and the 8th most severe). This scale is the first to use standard photography protocols to assess the severity of acne; since its founding in 1979, the scale has undergone several revisions. The technique of acne grading Leeds counts acne lesions on the face, back, and chest and categorizes them as inflammatory or non-inflammatory. Leeds scores range from 0 (at least weight) to 10 (at most weight) although the modified scale has a maximum score of 12. Pillsbury's acne scoring scales only classify acne severity from 1 (at least severe) to 4 (at most severe).
Differential diagnosis
Many skin conditions can mimic acne vulgaris and are collectively known as acne eruptions. Such conditions include angiofibroma, epidermal cysts, flat warts, folliculitis, keratosis pilaris, milia, perioral dermatitis, and rosacea, among others. Age is one factor that can help distinguish between these disorders. Skin disorders such as perioral dermatitis and keratosis pilaris may appear similar to acne but tend to occur more frequently in childhood, whereas rosacea tends to occur more frequently in older adults. A reddish face that is triggered by heat or consumption of alcohol or spicy food is suggestive of rosacea. The presence of blackheads helps health professionals distinguish acne from similar skin disorders in appearance. Chloracne, due to exposure to certain chemicals, may look very similar to acne vulgaris.
Management
Many different treatments for acne. These include alpha hydroxy acids, anti-androgen drugs, antibiotics, antiseborrheic drugs, azelaic acid, benzoyl peroxide, hormonal treatments, keratolytic soaps, nicotinamides, retinoids, and salicylates. They are believed to work in at least four different ways, including the following: reducing inflammation, hormonal manipulation, killing P. acne, and normalizing the shedding of skin cells and the production of sebum in the pores to prevent clogging. Common treatments include topical therapies such as antibiotics, benzoyl peroxide, and retinoids, and systemic therapy including antibiotics, hormonal agents, and oral retinoids.
Recommended therapies for first-line use in the treatment of acne vulgaris include topical retinoids, benzoyl peroxide, and topical or oral antibiotics. Procedures such as light therapy and laser therapy are not considered first-line treatments and usually have an adjuvant role because of their high costs and limited evidence of efficacy. Drugs for acne work by targeting the early stages of comedo formation and are generally ineffective for visible skin lesions; improvements in acne appearance are usually expected between six and eight weeks after starting therapy.
Diet
A simple low-sugar diet is recommended as a method to correct acne. By 2014, there is insufficient evidence to recommend milk restrictions for this purpose.
Drugs
Benzoyl peroxide
Benzoyl peroxide (BPO) is the first-line treatment for mild and moderate acne because of its effectiveness and mild side effects (especially skin irritation). In the skin follicles, benzoyl peroxide kills P. acnes by oxidizing its proteins through the formation of oxygen-free and benzoic acid free radicals. These free radicals are considered to interfere with the metabolism and the ability of bacteria to make proteins. In addition, benzoyl peroxide is slightly effective in breaking blackheads and inhibiting inflammation. Benzoyl peroxide can be paired with topical antibiotics or retinoids such as benzoyl peroxide/clindamycin and benzoyl peroxide/adapalene, respectively.
Side effects include increased skin photosensitivity, dryness, redness and occasional peeling. The use of sunscreen is often recommended during the treatment, to prevent skin burning. Lower benzoyl peroxide concentrations are as effective as higher concentrations in treating acne but are associated with fewer side effects. Unlike antibiotics, benzoyl peroxide does not appear to produce bacterial antibiotic resistance.
Retinoid
Retinoids are drugs that reduce inflammation, normalize the life cycle of follicle cells, and reduce sebum production. They are structurally associated with vitamin A. Retinoids appear to affect the life cycle of cells in the follicle layer. This helps prevent the accumulation of skin cells within the hair follicles that can make the blockage. They are first-line acne treatments, especially for people with dark skin, and are known to cause faster improvement of postinflammatory hyperpigmentation.
The commonly used topical retinoids are adapalene, isotretinoin, retinol, tazarotene, and tretinoin. They often cause early flare-ups of acne and redness of the face, and can cause significant skin irritation. In general, retinoids increase skin sensitivity to sunlight and are therefore recommended for use at night. Tretinoin is the least expensive of topical retinoids and is the most irritating to the skin, whereas adapalene is the least irritating to the skin but the price is much more expensive. Tazarotene is the most effective and costly topical retinoid, but it can not be well tolerated. Retinol is a form of vitamin A that has the same but lighter effect, and is used in many free-sell moisturizers and other topical products.
Isotretinoin is an oral retinoid that is very effective for severe nodular acne, and stubborn moderate acne in other treatments. One or two months' use is usually enough to see improvement. Acne is often lost completely or much lighter after 4-6 months of oral isotretinoin. After one course, about 80% of people report an increase, with more than 50% reporting complete forgiveness. Approximately 20% of patients require a second course. Concern has arisen that the use of isotretinoin is associated with an increased risk of side-effects, such as depression, suicide, anemia, although there is no clear evidence to support some of these claims. Isotretinoin is superior to antibiotics or placebo in reducing acne lesions. The frequency of adverse events is about twice as high as isotretinoin, although this is mostly associated with drought. There is no increased risk of suicide or depression found convincingly. The use of isotretinoin in women of childbearing age is regulated because of the harmful effects known in pregnancy. For women who are considered candidates for isotretinoin, she should undergo a confirmed negative pregnancy test and use an effective form of birth control. In 2008, the United States started the iPLEDGE program to prevent the use of isotretinoin during pregnancy. iPledge requires that women undergoing isotretinoin therapy have two negative pregnancy tests and mandate the use of two types of birth control at least one month before therapy begins and one month after treatment is completed. The effectiveness of the iPledge program has been questioned because of the continuous example of contraceptive nonadherence.
Antibiotics
Antibiotics are often applied to the skin or taken orally to treat acne and are considered to be working due to their antimicrobial activity against P. acnes and their ability to reduce inflammation. With the widespread use of antibiotics for acne and the increasing frequency of antibiotic-resistant P. acne worldwide, antibiotics become less effective, especially macrolide antibiotics such as topical erythromycin. Commonly used antibiotics, either applied to the skin or taken orally, include clindamycin, erythromycin, metronidazole, sulfacetamide, and tetracyclines such as doxycycline and minocycline. When antibiotics are applied to the skin, they are usually used for mild to moderate acne. Orally taken antibiotics are generally considered to be more effective than topical antibiotics, and result in faster resolution of inflammatory acne lesions than with topical applications. Topical and oral antibiotics are not recommended for joint use.
Oral antibiotics are recommended for no more than three months because antibiotic programs that exceed this duration are associated with the development of antibiotic resistance and do not show clear benefits over shorter programs. In addition, if long-term oral antibiotics beyond three months are considered necessary, it is recommended that benzoyl peroxide and/or retinoids be used at the same time to limit the risk of developing P. acnes antibiotic resistance. Dapsone is not a topical first-line antibiotic because of higher costs and a lack of obvious advantages over other antibiotics. Topical dapsone is not recommended for use with benzoyl peroxide because of the yellow-orange coloration of this combination.
Hormonal agents
In women, acne can be enhanced by the use of a combination of birth control pills. It lowers the production of androgen hormones by the ovaries, resulting in lower sebum skin production, and consequently reduces the severity of acne. Combinations containing third or fourth generation progestin such as desogestrel, drospirenone, or norgestimate are preferred for women with acne because of their stronger antiandrogenic effects. A review of 2014 found that oral antibiotics seemed to be more effective than birth control pills to reduce the number of inflammatory acne lesions at three months. However, both treatments are more or less the same in success at six months to reduce the number of inflammatory, non-inflammatory, and acne lesions. The authors suggest that birth control pills can be the preferred first-line acne treatment, more than oral antibiotics, in certain women because of equal efficacy at six months and a lack of associated antibiotic resistance.
Antiandrogens such as cyproterone acetate and spironolactone have been successfully used to treat acne, especially in women with signs of excessive androgen production such as increased hairiness or sebum skin production, or baldness. Spironolactone is an effective treatment for acne in adult women, but unlike combined oral contraceptives, is not approved by the US Food and Drug Administration for this purpose. The drug is mainly used as an aldosterone antagonist and is considered a useful acne treatment because of its ability to block androgen receptors at higher doses. It can be used with or without oral contraceptives. Hormonal therapy should not be used to treat acne during pregnancy or breast-feeding because they have been associated with birth disorders such as hypospadias, and feminization of a male or infant fetus. Finasteride is probably an effective treatment for acne.
Azelaic acid
Azelaic acid has been shown to be effective for mild to moderate acne when applied topically at a concentration of 20%. Treatment twice daily for six months is necessary, and as effective as topical benzoyl peroxide 5%, isotretinoin 0.05%, and erythromycin 2%. Azelaic acid is considered an effective acne treatment because of its ability to reduce the accumulation of skin cells in the follicle, and its antibacterial and anti-inflammatory properties. It has little skin lightening effect because of its ability to inhibit melanin synthesis, and is therefore useful in treating individuals with acne that are also affected by postinflammatory hyperpigmentation. Azelaic acid can cause skin irritation but is otherwise very safe. This is less effective and more expensive than retinoids.
Salicylic acid
Salicylic acid is a beta-hydroxy acid used to stop reproduction and has keratolytic properties. This opens the clogged skin pores and increases the shedding of epithelial skin cells. Salicylic acid is known to be less effective than retinoid therapy. Dry skin is the most commonly seen side effect with topical applications, although skin darkening has been observed in individuals with darker skin types.
Other drugs
Topical and oral preparations of nicotinamide (an amide form of vitamin B 3 ) have been suggested as alternative medical treatments. It is thought to increase acne due to its anti-inflammatory properties, its ability to suppress sebum production, and by promoting wound healing. Topical and oral preparations of zinc have also been proposed as an effective treatment for acne; evidence to support its use for this purpose is limited. The claimed efficacy of zinc is associated with its capacity to reduce inflammation and sebum production, and inhibit P. acnes . Antihistamines can improve the symptoms among those who are already taking isotretinoin because of their anti-inflammatory properties and their ability to suppress sebum production.
Hydroquinone brightens skin when applied topically by inhibiting tyrosinase, an enzyme responsible for converting amino acid tyrosine to melanin skin pigment, and is used to treat post-acne-related hyperpigmentation associated with acne. By interfering with the production of new melanin in the epidermis, hydroquinones cause less hyperpigmentation because dark skin cells naturally disappear over time. Repair of skin hyperpigmentation is usually seen in six months when used twice a day. Hydroquinone is not effective for hyperpigmentation that affects deeper skin layers such as the dermis. Use of sunscreen with SPFÃ,15 or higher in the morning with reapplication every two hours is recommended when using hydroquinone. Its application only to the affected areas reduces the risk of brightening the normal skin color but can cause a temporary circle of bright skin around the hyperpigmentation area. Hydroquinone is generally well tolerated; side effects are usually mild (eg, skin irritation) and occur with a higher use of the recommended 4% concentration. Most preparations contain sodium metabisulphite preservatives, which have been associated with rare cases of allergic reactions including anaphylaxis and severe asthma exacerbations in susceptible people. In very rare cases, repeated topical applications of high-dose hydroquinones have been associated with the accumulation of homogentisic acid in connective tissue, a condition known as exogenous ochronosis.
Combination therapy
Combination therapy - using drugs of different classes together, each with different mechanisms of action - has proven to be a more effective approach to acne treatment than monotherapy. The use of topical benzoyl peroxide and antibiotics together has proven to be more effective than antibiotics alone. Similarly, using topical retinoids with antibiotics clears acne lesions faster than antibiotics alone. Commonly used combinations are as follows: antibiotics and benzoyl peroxide, topical antibiotics and retinoids, or topical retinoids and benzoyl peroxide. The benzoyl peroxide pair with retinoids is preferred over a combination of topical antibiotics with retinoids because both regimens are effective but benzoyl peroxide does not cause antibiotic resistance.
Pregnancy
Although late pregnancy is associated with increased sebaceous gland activity in the skin, unreliable pregnancy is associated with worsening acne severity. In general, topically applied drugs are considered the first-line approach for acne treatment during pregnancy, since they have little systemic absorption and therefore are unlikely to endanger the developing fetus. Highly recommended therapies include topical benzoyl peroxide (category C) and azelaic acid (category B). Salicylic acid carries category C safety ratings due to higher systemic uptake (9-25%), and the relationship between use of anti-inflammatory drugs in the third trimester and adverse effects on developing fetuses including too little amnionic fluid in the uterus. and premature closure of the infant ductal artery blood vessels. Long-term use of salicylic acid in areas of significance on the skin or under occlusive dressings is not recommended as it enhances systemic uptake and potential fetal harm. Tretinoin (category C) and adapalene (category C) are absorbed very badly, but certain studies have suggested teratogenic effects in the first trimester. Due to persistent safety issues, topical retinoids are not recommended for use during pregnancy. In a study examining the effects of topical retinoids during pregnancy, fetal damage has not been seen in the second and third trimesters. Retinoids contraindicated for use during pregnancy include topical tazarotene retinoids, and oral retinoids isotretinoin and acitretin (all X categories). Spironolactone is relatively contraindicated for use during pregnancy because of its antiandrogen effect. Finasteride is not recommended because it is very teratogenic.
Topical antibiotics considered safe during pregnancy include clindamycin, erythromycin, and metronidazole (all categories B), due to the negligible systemic absorption. Nadifloxacin and dapsone (category C) are other topical antibiotics that can be used to treat acne in pregnant women, but receive fewer studies. No fetal adverse effects were reported from topical use of dapsone. If retinoids are used there is a high risk of abnormalities that occur in the developing fetus; women of childbearing age are therefore required to use effective birth control if retinoids are used to treat acne. Oral antibiotics considered safe for pregnancy (all B categories) include azithromycin, cephalosporins, and penicillin. Tetracyclines (category D) are contraindicated during pregnancy because they are known to deposit in developing fetal teeth, resulting in yellow discoloration and dental enamel thinning. Its use during pregnancy has been associated with the development of acute fatty liver pregnancy and is further avoided for this reason.
Procedures
Extraction of blackheads is supported by limited evidence but recommended for comedones that do not improve with standard care. Another procedure for immediate relief is the injection of corticosteroids into the inflamed pimple of acne. Electrocautery and electrofulguration have also been reported as an effective treatment for blackheads.
Light therapy is a treatment method that involves sending certain wavelengths of light to the affected area of ​​the acne. Both ordinary light and laser light have been used. When light is used immediately after the application of skin-sensitive substances such as aminolevulinic acid or methyl aminolevulinate, this treatment is referred to as photodynamic therapy (PDT). PDT has the most supportive evidence of all light therapy. Many different types of nonablative lasers (ie, lasers that do not vaporize the upper layers of the skin but cause a physiological response to the skin from light) have been used to treat acne, including those using infrared wavelengths of light. Ablative lasers (such as CO 2 and fractional types) have also been used to treat active acne and scars. When ablative lasers are used, treatments are often referred to as laser coatings because, as previously mentioned, the entire top layer of skin evaporates. The ablative laser is associated with a higher adverse effect rate than the nonlative laser, with examples of postinflammatory hyperpigmentation, persistent facial flushing, and persistent pain. Physiologically, certain light wavelengths, used with or without major chemicals, are thought to kill bacteria and reduce the size and activity of the glands that produce sebum. In 2012, evidence for a variety of light therapy is not enough to recommend them for routine use. The disadvantages of light therapy may include cost, the need for multiple visits, the time required to complete the procedure, and the pain associated with some treatment modalities. Various light therapies seem to provide short-term benefits, but data for long-term outcomes, and for results in those with severe acne, are rare; it may have a role for individuals whose acne has been resistant to topical medications. Typical side effects include exfoliation, temporary redness of the skin, swelling, and postinflammatory hyperpigmentation.
Dermabrasion is an effective therapeutic procedure to reduce the appearance of superficial atrophy scars from boxcar and rolling varieties. Burns do not respond well to treatment with dermabrasion because of the depth. This procedure is painful and has many potential side effects such as skin sensitivity to sunlight, redness, and decreased skin pigmentation. Dermabrasion is not preferred by the introduction of laser coatings. Unlike dermabrasion, there is no evidence that microdermabrasion is an effective treatment for acne.
Microneedling is a procedure in which instruments with multiple rows of small needles are rolled over the skin to obtain a wound healing response and stimulate collagen production to reduce the appearance of acne atrophy in people with darker skin tones. The most important adverse effects of microneedling include postinflammatory hyperpigmentation and tram traces (described as slightly discrete discrete injuries in linear distributions similar to tram lines). The latter is thought to be primarily due to improper technique by practitioners, including the use of excessive pressure or an improper large needle.
Subcision is useful for treating superficial acne atrophy and involves the use of a small needle to loosen the fibrotic adhesion that results in the appearance of a depressed scar.
Chemical peels can be used to reduce the appearance of acne scars. Light skins include those using glycolic acid, lactic acid, salicylic acid, Jessner's solution, or lower concentrations (20%) of trichloroacetic acid. This skin affects only the epidermal skin layer and can be useful in the treatment of superficial acne scars as well as changes in skin pigmentation from acne inflammation. Higher trichloroacetic acid concentrations (30-40%) are considered skin with moderate strength and affect the skin as deep as the papillary dermis. The concentrated trichloroacetic acid formulation of up to 50% or more is considered to be a deep chemical peeling. Medium-strength and in-strength chemical peels are more effective for deeper atrophic scars, but are more likely to cause side effects such as changes in skin pigmentation, infections, and small shallow white cysts known as milia.
Alternative medicine
Complementary therapy has been studied to treat people with acne. Low quality evidence suggests a topical application of tea tree oil or bee venom can reduce the total number of skin lesions in those with acne. Tea tree oil is considered as effective as benzoyl peroxide or salicylic acid, but has been associated with allergic contact dermatitis. Proposed mechanisms for the anti-acne effect of tea tree oil include antibacterial action against P. acnes, and anti-inflammatory properties. Many other plant-derived treatments have been observed to have a positive effect on acne (eg, basil oil and oligosaccharides from seaweed); However, several studies have been conducted, and most have a lower methodological quality. Lack of high-quality evidence for the use of acupuncture, herbalism, or bruise therapy for acne.
Self-care
Many over-the-counter treatments in various forms are available, often referred to as cosmeceuticals. Certain makeup types may be useful to cover acne. In those with oily skin, water-based products are preferred.
Prognosis
Acne usually improves around the age of 20, but it can continue into adulthood. Permanent physical scars may occur. There is good evidence to support the idea that acne and associated scarring negatively impact a person's psychological condition, exacerbate mood, lower self-esteem, and deal with higher risk of anxiety disorders, depression, and suicidal thoughts. Another psychological complication of acne vulgaris is the acne exclamation, which occurs when a person constantly picks and scratches acne, regardless of the severity of their acne. This can cause significant scarring, skin pigmentation changes in the affected person, and cyclic worsening of the anxiety of the affected person about their appearance. Rare complications of acne or its treatment include the formation of pyogenic granulomas, osteoma cutis, and solid facial edema. Early and aggressive acne treatment is recommended by some medical communities to reduce the likelihood of these poor outcomes.
Epidemiology
Globally, acne affects about 650 million people, or about 9.4% of the population, in 2010. It affects nearly 90% of people in Western societies during their adolescence, but can occur before adolescence and can last into adulthood. While acne that first developed between the ages of 21 and 25 is not common, it affects 54% of women and 40% of men older than 25 years, and has a lifetime prevalence of 85%. About 20% of those affected have moderate or severe cases. This is slightly more common in women than in men (9.8% versus 9.0%). In those over 40 years, 1% of men and 5% of women still have problems.
Prices seem lower in rural communities. While some studies have found it affects people from all ethnic groups, acne may not occur in non-Westernized people Papua New Guinea and Paraguay.
Acne affects 40-50 million people in the United States (16%) and about 3-5 million in Australia (23%). Severe acne tends to be more common in Caucasian or Hispanic people than in African descent.
History
The pharaohs listed already have acne, which may be the earliest known reference to the disease. At least since the reign of Cleopatra (69-30 BC), the application of sulfur on the skin has been recognized as a useful treatment for acne. The sixth-century Greek physician of Amida is credited with the term "ionthos" (??????) or "acnae", which is believed to have been a reference to facial skin lesions occurring during "'acme' life" (puberty).
In the 16th century, the French physician and botanist FranÃÆ'§ois Boissier de Sauvages de Lacroix gave one of the earliest descriptions of acne. He uses the term "psydracia achne" to describe small, red and hard tubes that alter the appearance of a person's face during adolescence, and are neither itchy nor painful.
Acknowledgment and characterization of acne developed in 1776 when Josef Plenck (an Austrian doctor) published a book proposing a new concept of classifying skin diseases with their baseline (early) lesions. In 1808, the English dermatologist Robert Willan perfected Plenck's work by giving the first detailed description of some skin disorders using the morphological terminology still used today. Thomas Bateman continues and extends the work of Robert Willan as his disciple and provides the first description and illustration of acne that is accepted as accurate by modern dermatologists. Erasmus Wilson, in 1842, was the first to make a distinction between acne vulgaris and rosacea. The first professional medical monograph dedicated entirely to acne was published in New York in 1885.
Scientists initially hypothesize that acne represents a disease in skin hair follicles, and occurs due to pore blockage by sebum. During the 1880s, bacteria were observed by microscopy on skin samples exposed to acne and considered to be the causative agent of blackheads, sebum production, and eventually acne. During the mid-twentieth century, dermatologists realized that no single hypothesis factor (sebum, bacteria, or excess keratin) could explain the disease completely. This leads to the current understanding that acne can be explained by the sequence of related events, beginning with the blockage of skin follicles by excessive dead skin cells, followed by bacterial invasion of the hair follicle pores, altered sebum production, and inflammation.
The approach to acne treatment has undergone significant changes during the twentieth century. Retinoids were introduced as medical treatments for acne in 1943. Benzoyl peroxide was first proposed as a treatment in 1958 and has been routinely used for this purpose since the 1960s. Acne treatment was modified in 1950 with the introduction of oral tetracycline antibiotics (such as minocycline). This reinforces the idea among dermatologists that the growth of bacteria on the skin plays an important role in causing acne. Furthermore, in the 1970s tretinoin (the original trade name Retin A) was found to be an effective treatment. The development of oral isotretinoin (sold as Accutane and Roaccutane) was followed in 1980. After being introduced in the United States it was recognized as a remedy that is likely to cause birth defects if taken during pregnancy. In the United States, more than 2,000 women became pregnant while taking isotretinoin between 1982 and 2003, with most pregnancies ending in abortions or miscarriages. About 160 babies are born with birth defects.
Acne treatment with crushed dry ice (called "cryoslush") was first described in 1907, but is no longer done in general. Before 1960, the use of X-rays was also a common treatment.
Society and culture
The cost and social impact of acne is enormous. In the United States, acne vulgaris is responsible for over 5 million doctor visits and costs more than US $ 2.5 billion annually in direct costs. Similarly, acne vulgaris is responsible for 3.5 million doctor visits each year in the UK. Sales for the top ten acne treatment brands in the US by 2015, have been reported for $ 352 million.
Misconceptions about the causes of acne and the aggravating factors are common, and those affected are often blamed for their condition. Such mistakes can worsen the sense of self-worth of the affected person. Until the 20th century, even among dermatologists, the list of causes is believed to include sexual thoughts and excessive masturbation. Dermatologic associations with sexually transmitted infections, especially syphilis, contribute to stigma.
Acne vulgaris and the scars it produces have been linked to significant social and academic difficulties that can persist into adulthood, including the difficulty of getting a job. Until the 1930s, it was mostly seen as a trivial matter among middle-class girls - a trivial matter, because, unlike smallpox and tuberculosis, nobody died of it, and feminine problems, because boys were much smaller the possibility to seek medical help. therefore. During the Great Depression, dermatologists discovered that young men with acne had difficulty finding employment, and during World War II, some soldiers in the tropical climate developed severe tropical acne that extends over their bodies so that it was declared medically unhealthy for duty.
Research
Efforts to better understand the sebum production mechanism are ongoing. The purpose of this study was to develop drugs that target and disrupt hormones known to increase sebum production (eg, IGF-1 and alpha-melanocyte-stimulating hormone). Additional sebum-lowering drugs under study include topical antiandrogens and peroxisome proliferator-activated receptor modulator. Another way of early-stage research has focused on how best to use laser and light therapy to selectively destroy sebum-producing glands in skin hair follicles to reduce sebum production and improve the appearance of acne.
The use of antimicrobial peptides against P. acnes is being investigated as a treatment for acne to overcome antibiotic resistance. In 2007, the first genome sequencing of P. acnes bacteriophage (PA6) was reported. The authors propose applying this research to the development of bacteriophage therapy as a treatment of acne to address the problems associated with long-term antibiotic therapy such as bacterial resistance. Oral and topical probiotics are also evaluated as a treatment for acne. Probiotics have been hypothesized to have a therapeutic effect for those affected by acne because of their ability to reduce skin inflammation and increase skin moisture by increasing the skin's ceramide content. In 2014, studies examining the effects of probiotics on acne in humans are limited.
Decreased levels of retinoic acid in the skin may contribute to comedo formation. To overcome this deficiency, methods to increase the production of retinoid acid skin are being explored. Vaccines against inflammatory acne have shown promising results in mice and humans. Some people have voiced concerns about the manufacture of a vaccine designed to neutralize a stable normal bacterial skin community known to protect the skin from colonization by more harmful microorganisms.
Other animals
Acne can occur in cats, dogs, and horses.
References
Further reading
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Amy S. Paller; Anthony J. Mancini (2015). Hurwitz's Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood And Adolescence . Elsevier. ISBN: 0323244750. -
Cordain, Loren; Lindeberg, Staffan; Hurtado, Magdalena; Hill, Kim; Eaton, S. Boyd; Brand-Miller, Jennie (December 1, 2002). "Acne vulgaris". Dermatology Archive . 138 (12). doi: 10.1001/archderm.138.12.1584. - Del Rosso, JQ (December 2013). "The role of skin care as an integral component in the management of acne vulgaris: part 1: the importance of cleaning and moisturizing agents, design, and product selection". Clinical and aesthetic dermatology journals . 6 (12): 19-27. PMCÃ, 3997205 . PMIDÃ, 24765221.
External links
- Media related to Acne on Wikimedia Commons
- Questions and Answers about Acne - US National Institute of Arthritis and Musculoskeletal and Skin Diseases
Source of the article : Wikipedia
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