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Thursday, May 27, 2010

ACNE

Acne vulgaris (commonly called acne) is a common human skin disease, characterized by areas of skin with multiple noninflammatory follicular papules or comedones and by inflammatory papules, pustules, and nodules in its more severe forms. Acne vulgaris mostly affects the areas of skin with the densest population of sebaceous follicles; these areas include the face, the upper part of the chest, and the back. Severe acne is inflammatory, but acne can also manifest in noninflammatory forms. Acne lesions are commonly referred to as pimples, blemishes, spots, zits, or simply acne. Acne lesions are caused by changes in pilosebaceous units, skin structures consisting of a hair follicle and its associated sebaceous gland, changes which require androgen stimulation.
Acne occurs most commonly during
adolescence, affecting more than 96% of teenagers, and often continues into adulthood. In adolescence, acne is usually caused by an increase in male sex hormones, which people of both genders accrue during puberty.
SIGNS AND SYMPTOMS
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1)Scars
Acne often leaves small
scars where the skin gets a "volcanic" shape.
Physical acne scars are often referred to as "Icepick" scars. This is because the scars tend to cause an indentation in the skin's surface. Ice pick scars: Deep pits, that are the most common and a classic sign of acne scarring.
Box car scars: Angular scars that usually occur on the temple and cheeks, and can be either superficial or deep, these are similar to
chickenpox scars.
Rolling scars: Scars that give the skin a wave-like appearance.
Hypertrophic scars: Thickened, or
keloid scars.
2)Pigmentation
Pigmented scars is a slightly misleading term as it suggests a change in the skin's pigmentation and that they are true scars; however, neither is true. Pigmented scars are usually the result of nodular or cystic acne (the painful 'bumps' lying under the skin). They often leave behind an inflamed red mark. Often, the pigmentation scars can be avoided simply by avoiding aggravation of the nodule or cyst. When sufferers try to 'pop' cysts or nodules, pigmentation scarring becomes significantly worse and may even bruise the affected area. Pigmentation scars nearly always fade with time taking between three months to two years to do so, although rarely can persist.
On the other hand, some people—particularly those with naturally tanned skin—do develop brown
hyperpigmentation scars due to increased production of the pigment melanin. These too typically fade over time.
CAUSES OF ACNE
Acne develops as a result of blockages in
follicles. Hyperkeratinization and formation of a plug of keratin and sebum (a microcomedo) is the earliest change. Enlargement of sebaceous glands and an increase in sebum production occur with increased androgen (DHEA-S) production at adrenarche. The microcomedo may enlarge to form an open comedone (blackhead) or closed comedone .Comedones are the direct result of sebaceous glands becoming clogged with sebum, a naturally occurring oil, and dead skin cells. In these conditions the naturally occurring largely commensal bacteria Propionibacterium acnes can cause inflammation, leading to inflammatory lesions (papules, infected pustules, or nodules) in the dermis around the microcomedo or comedone, which results in redness and may result in scarring or hyperpigmentation
Hormones
Hormonal activity, such as
menstrual cycles and puberty. During puberty, an increase in male sex hormones called androgens cause the follicular glands to grow larger and make more sebum. Use of anabolic steroids Several hormones have been linked to acne: the androgens testosterone, dihydrotestosterone (DHT) and dehydroepiandrosterone sulfate (DHEAS), as well as insulin-like growth factor 1 (IGF-I).
Development of acne vulgaris in later years is uncommon, although this is the age group for
Rosacea which may have similar appearances. True acne vulgaris in adult women may be a feature of an underlying condition such as pregnancy and disorders such as polycystic ovary syndrome or the rare Cushing's syndrome. Menopause-associated acne occurs as production of the natural anti-acne ovarian hormone estradiol fails at menopause. The lack of estradiol also causes thinning hair, hot flashes, thin skin, wrinkles, vaginal dryness, and predisposes to osteopenia and osteoporosis as well as triggering acne (known as acne climacterica in this situation).
Genetics
The tendency to develop acne runs in families. For example, school-age boys with acne often have other members in their family with acne as well. A family history of acne is associated with an earlier occurrence of acne and an increased number of retentional acne lesions.
Psychological
While the connection between acne and stress has been debated, scientific research indicates that "increased acne severity" is "significantly associated with increased stress levels."The National Institutes of Health (USA) list stress as a factor that "can cause an acne flare." A study of adolescents in Singapore "observed a statistically significant positive correlation between stress levels and severity of acne.
Infections
Bacteria in the
pores. Propionibacterium acnes (P. acnes) is the anaerobic bacterium that causes acne. In-vitro resistance of P. acnes to commonly used antibiotics has been increasing.
Diet
A high
glycemic load diet and cow's milk have been associated with worsening acne. Other associations such as chocolate and salt are not supported by the evidence.
MANAGEMENT

Many different treatments exist for acne including: benzoyl peroxide, antibiotics, retinoids, antiseborrheic medications, salicylic acid, alpha hydroxy acid, azelaic acid, nicotinamide, and kera-tolytic soaps.
Benzoyl peroxide
Benzoyl peroxide a first line treatment for mild and moderate acne vulgarus due to its effectiveness It has been found to be nearly as effective as antibiotics Products containing azelaic acid are also used in the treatment of P. acnes
Antibiotics
Commonly used antibiotics either topically or orally include:
erythromycin, clindamycin and tetracycline.
Hormonal treatments
In females, acne can be improved with
hormonal treatments. The common combined estrogen/progestogen methods of hormonal contraception have some effect, but the antiandrogen, Cyproterone, in combination with an oestrogen (Diane 35) is particularly effective at reducing androgenic hormone levels. Along with this, treatment with low dose spironolactone can have anti-androgenetic properties, especially in patients with polycystic ovarian syndrome.
Intralesional steroid
If a pimple is large and/or does not seem to be affected by other treatments, a dermatologist may administer an injection of
cortisone directly into it, which will usually reduce redness and inflammation almost immediately. This has the effect of flattening the pimple, thereby making it easier to cover up with makeup, and can also aid in the healing process.
Topical retinoids
A group of medications for normalizing the follicle cell lifecycle are
topical retinoids such as tretinoin , adapalene , and tazarotene .Like isotretinoin, they are related to vitamin A, but they are administered as topicals and generally have much milder side effects. . The retinoids appear to influence the cell creation and death lifecycle of cells in the follicle lining. This helps prevent the hyperkeratinization of these cells that can create a blockage. Retinol, a form of vitamin A, has similar but milder effects and is used in many over-the-counter moisturizers and other topical products. . Topical retinoids often cause an initial flare up of acne and facial flushing.
Oral retinoids
A daily oral intake of vitamin A derivative
isotretinoin over a period of 4–6 months can cause long-term resolution or reduction of acne. It is believed that isotretinoin works primarily by reducing the secretion of oils from the glands, however some studies suggest that it affects other acne-related factors as well. Isotretinoin has been shown to be very effective in treating severe acne and can either improve or clear well over 80% of patients. The drug has a much longer effect than anti-bacterial treatments and will often cure acne for good. The treatment requires close medical supervision by a dermatologist because the drug has many known side effects . It is often recommended that one lets a few months pass between the two treatments, because the condition can actually improve somewhat in the time after stopping the treatment and waiting a few months also gives the body a chance to recover. Occasionally a third or even a fourth course is used, but the benefits are often less substantial. The most common side effects are dry skin and occasional nosebleeds (secondary to dry nasal mucosa). Oral retinoids also often cause an initial flare up of acne within a month or so, which can be severe. . . Blood triglycerides also need to be monitored. However, routine testing are part of the official guidelines for the use of the drug in many countries. . The drug also causes birth defects if women become pregnant while taking it or take it while pregnant. For this reason, female patients are required to use two separate forms of birth control or vow abstinence while on the drug
Anti-inflammatories
Nicotinamide, (Vitamin B3) used topically in the form of a gel, has been shown in a 1995 study to be of comparable efficacy to topical clindamycin topical antibiotic used for comparison.Topical nicotinamide is available both on prescription and over-the-counter. The property of topical nicotinamide's benefit in treating acne seems to be its anti-inflammatory nature. It is also purported to result in increased synthesis of collagen, keratin, involucrin and flaggrin and may also according to a cosmetic company be useful for reducing skin hyperpigmentation (acne scars), increased skin moisture and reducing fine wrinkles
Rofecoxib was shown to improve premenstrual acne vulgaris in a placebo controlled study, although this drug has since been withdrawn
Naproxen or ibuprofen are used for some moderate acne for their anti-inflammatory effect.
Calendula used in suspension is used as an anti-inflammatory agent.
Sulfur
Sulfur is probably the oldest acne remedy known to medicine and its origins as an anti-acne treatment date to ancient Greek, Roman, and Chinese texts citing its efficacy in balneotherapy. Sulfur formulations are effective both as a micro-exfoliant and as a mild antiseptic. Sulfur is hydrophilic and can easily penetrate sebaceous pores where its antiseptic properties can assist local immune response in rapidly eliminating infection resulting from acne proliferation. Because the growth of acne bacteria is limited naturally by the skin's slightly acidic pH, alkaline cleansers (including soaps and detergents) can have a detrimental effect on controlling acne proliferation. Sulfur-based cleansers with a balancing or neutral pH can help eliminate acne and prevent future breakouts by maintaining the hydrolipidic layer's acidity and thereby controlling acne populations on the surface of the skin. Sulfur is abundant in keratin and its use is also helpful in promoting collagen synthesis. An active ingredient in prescription and over-the-counter lotions, creams, gels, washes, and shampoos, sulfur is also very effective in controlling seborrheic dermatitis, rosacea, eczema, psoriasis, pityriasis versicolor, scabies, and lice
Micro dermabrasion
. Microdermabrasion is a more natural skin care that is a gentler, less invasive technology for doing an exfoliation on the skin. The goal of the microdermabrasion is to eliminate the superficial layer of the skin called the epidermis. If the surface of the abraded skin is touched, a roughness of the skin will be noticed. The roughness is keratinocytes, which are better hydrated than the surface corneocytes. Keratinocytes appear in the basal layer from the proliferation of keratinocyte stem cells. They are pushed up through the cells of the epidermis, experiencing gradual specialization until they reach the stratum corneum where they form a layer of dead, flattened, strongly keratinized cells called squamous cells. This layer creates an efficient barrier to the entry of foreign matter and infectious elements into the body and reduces moisture loss. Keratinocytes are shed and restored continuously from the stratum corneum.
The time of transit from basal layer to shedding is generally one month. Corneocytes are cells derived from keratinocytes in the late stages of terminal specialization of squamous epithelia. The microdermabrasion is done to eliminate some of the corneocytes. These cells are responsible for the impermeability of the skin. The minimizing or elimination of scars, skin lesions, blotchiness and stretch marks from the skin can be an easy process with the use of skin exfoliation. The result depends on how well the procedure known as "skin remodeling" works. Results are optimal and fewer treatments are needed with more recent and/or superficial scars. Still, microdermabrasion can be used on scars that showed up during puberty or many years later.
Phototherapy
'Blue' and red light
Light exposure has long been used as a short term treatment for acne. Recently, visible light has been successfully employed to treat mild to moderate acne (
phototherapy or deep penetrating light therapy) - in particular intense violet light (405-420 nm) generated by purpose-built fluorescent lighting, dichroic bulbs, LEDs or lasers. Used twice weekly, this has been shown to reduce the number of acne lesions by about 64% and is even more effective when applied daily. The mechanism appears to be that a porphyrin (Coproporphyrin III) produced within P. acnes generates free radicals when irradiated by 420 nm and shorter wavelengths of light. Particularly when applied over several days, these free radicals ultimately kill the bacteria. Since porphyrins are not otherwise present in skin, and no UV light is employed, it appears to be safe, and has been licensed by the U.S. FDA.
The treatment apparently works even better if used with a mixture of the violet light and red visible light (660 nanometer) resulting in a 76% reduction of lesions after three months of daily treatment for 80% of the patients; and overall clearance was similar or better than benzoyl peroxide. Unlike most of the other treatments few if any negative side effects are typically experienced, and the development of bacterial resistance to the treatment seems very unlikely. After treatment, clearance can be longer lived than is typical with topical or oral antibiotic treatments; several months is not uncommon. The equipment or treatment, however, is relatively new and reasonably expensive to buy initially, although the total cost of ownership can be similar to many other treatment methods (such as the total cost of benzoyl peroxide, moisturizer, washes) over a couple of years of use.
Photodynamic therapy
In addition, basic science and clinical work by dermatologists Yoram Harth and Alan Shalita and others has produced evidence that intense blue/violet light (405-425 nanometer) can decrease the number of inflammatory acne lesion by 60-70% in four weeks of therapy, particularly when the P. acnes is pretreated with
delta-aminolevulinic acid (ALA), which increases the production of porphyrins. However this photodynamic therapy is controversial and apparently not published in a peer reviewed journal. A phase II trial, while it showed improvement occurred, failed to show improved response compared to the blue/violet light alone.
Surgery
For patients with cystic acne, boils can be drained through
surgical lancing.
Laser treatment
Laser surgery has been in use for some time to reduce the scars left behind by acne, but research has been done on lasers for prevention of acne formation itself. The laser is used to produce one of the following effects:
to burn away the follicle sac from which the hair grows
to burn away the sebaceous gland which produces the oil
to induce formation of
oxygen in the bacteria, killing them
Since lasers and intense pulsed light sources cause thermal damage to the skin, there are concerns that laser or intense pulsed light treatments for acne will induce hyperpigmented macules (spots) or cause long-term dryness of the skin.
Less widely used treatments
Aloe vera: there are treatments for acne mentioned in Ayurveda using herbs such as Aloe vera, Neem, Haldi (Turmeric) and Papaya. There is limited evidence from medical studies on these products.Products from Rubia cordifolia, Curcuma longa (commonly known as Turmeric), Hemidesmus indicus (known as ananthamoola or anantmula), and Azadirachta indica (Neem) have been shown to have anti-inflammatory effects, but not aloe vera.
Azelaic acid (brand names Azelex, Finevin and Skinoren) is suitable for mild, comedonal acne.
Heat: local heating may be used to kill the bacteria in a developing pimple and so speed healing.
Pantothenic acid, (high dosage vitamin B5)
Tea tree oil (melaleuca oil) dissolved in a carrier (5% strength) has been used with some success, where it is comparable to benzoyl peroxide but without excessive drying, kills P. acnes, and has been shown to be an effective anti-inflammatory in skin infections.The reason it is a good substitution for benzoyl peroxide is because it also has the ability to kill bacteria on the surface of the skin but mostly due to fact that some people are allergic to benzoyl peroxide or have sensitive skin. Tea tree oil is a gentler and more natural solution.
Zinc: Orally administered zinc gluconate has been shown to be effective in the treatment of inflammatory acne, although less so than tetracyclines.
Prognosis
Acne usually improves around the age of 20 but may persist into adulthood.