Acne

Acne is a chronic recurring skin disease, predominantly affecting young people, which is the result of hyperproduction of sebum and blockage of hyperplastic sebaceous glands with subsequent inflammation.

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

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Causes acne

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

Acne can also occur as a result of taking various medications. Drug-induced acne occurs in patients who have been taking glucocorticosteroid hormones (so-called steroid acne) orally for a long time, anabolic steroid hormones, anti-tuberculosis or anti-epileptic drugs (isoniazid, rifampicin, ethambutol, phenobarbital), azathioprine, cyclosporine A, chloral hydrate, lithium salts, iodine, bromine, chlorine preparations, some vitamins, especially D3, B1, B2, B6, B12.

Exogenous acne is distinguished, which develops when various substances with a comedogenic effect come into contact with the skin. The comedogenic effect is associated with increased hyperkeratosis at the mouth of the hair follicles and blockage of the sebaceous glands. Various machine oils and lubricants, tar preparations, as well as cosmetics containing fats (fatty cream powder, blush, eyeshadow, etc.) have this effect. Soaps with detergents also have a comedogenic effect.

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Pathogenesis

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

1. Hyperproduction of sebum by hyperplastic sebaceous glands. This is the main, long-lasting link in the pathogenesis of acne. The high rate of excretion of sebum is the result of the combined effect of the individually formed 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 area of the funnel of the hair follicle. Thus, microcomedones are formed, which are clinically invisible. Later, comedones (open and closed) are formed from microcomedones.
3. Reproduction of microorganisms. The most important role in the development of inflammation is played by Propyonibactertum acnes, which are gram-positive non-motile lipophilic rods and facultative anerobes. The blockage 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 microcomedones, colonization of P. acnes in the follicle is noted, the scale of which increases in closed and open comedones. In addition, saprophytic microorganisms such as fungi of the genus Pityrosporum, Staphylococcus epidermidis are found on the skin and in the area of the hair follicles, also participating in the development of inflammation in acne.
4. Inflammatory processes inside and around the sebaceous glands. The proliferation of P. acnes leads to increased activity of metabolic processes, which results in the release of various types of chemical substances - inflammation mediators. Constant damage to the epithelium of the hair follicle funnel by P. acnes enzymes, free fatty acids, lytic enzymes of neutrophils and macrophages, free oxygen radicals, hydroxyl groups, and hydrogen peroxide superoxides leads to the maintenance of the inflammatory process. In addition, the contents of the sebaceous hair follicle, due to impaired permeability of the epithelium, penetrate into the dermis and also cause an inflammatory reaction. It should be emphasized that inflammation can develop at any stage of acne, and 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 of adolescence. It can also appear in adults. This usually happens against the background of endocrine dysfunctions, which cause seborrhea. In women, polycystic ovary syndrome is detected in combination with anovulatory menstrual cycles and hirsutism, adrenal hyperplasia, and pituitary adenoma. In some cases in adult women resistant to therapy, tumors of the adrenal gland or ovary should also be excluded. In men, adrenal hyperplasia and androgen-producing tumors can be detected.

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Symptoms acne

Acne in childhood (acne neonatorum et acne infantum) is quite rare. In the neonatal period, the appearance of these rashes is believed to be associated with hormonal crisis or, less commonly, excessive secretion of testosterone in the prenatal period. 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 transfer of estrogenic hormones from the ovaries, placenta, and pituitary gland of the mother to the fetus, newborns between the third and eighth day of life may experience a number of physiological conditions resembling the period of puberty. Such conditions include engorgement of the mammary glands, desquamative vulvovaginitis, hydrocele, transient edema, and acne. The rashes are mainly represented by closed comedones on the cheeks, less often on the forehead and chin. Some authors call closed comedones sebaceous cysts. These elements appear after birth in 50% of newborns and have the appearance of pinpoint papules of a pearly white or yellowish color.

The rashes may be single or multiple, they are often grouped, disappear within a few days or after 1.5-2 weeks. In some cases, papular and pustular elements may appear. They resolve spontaneously, in most cases without scarring, after a few weeks or months and therefore rarely require treatment.

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

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Acne in teenagers

Acne vulgaris is a very common pathology: one third of teenagers aged 12-16 suffer from acne requiring treatment. Acne appears earlier in girls than in boys: at the age of 12, acne is observed in 37.1% of girls and 15.4% of boys, and at the age of 16 - in 38.8 and 53.3%, respectively. In 75% of teenagers, acne is observed only on the face, and in 16% - on both the face and back. In most cases, the rash resolves spontaneously by the age of 20, but sometimes the disease can last 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, acne vulgaris manifests itself as comedones, papulopustular acne, and, less commonly, indurative and phlegmonous elements.

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Acne in adults

Adult acne is acne that exists before adulthood or first appears in adults. Sometimes there is a "light" period between the acne of adolescence and the later recurrence of breakouts. The main features of the course of acne in adults are as follows:

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

Clinically, adult acne is characterized by so-called late (acne tarda), inverse and conglobate acne. Late acne is more often observed in women. About 20% of adult women note the regular appearance of acne in the lower third of the face 2-7 days before the onset of menstruation and the gradual disappearance of the rash at the beginning of the next menstrual cycle. In some cases, acne is constant. Basically, such patients have papular and papulopustular elements, but there may also be nodular-cystic acne. Combined clinical manifestations are often detected: melasma, acne, rosacea, seborrhea, hirsutism (MARSH syndrome). Androgenetic alopecia is also diagnosed in patients with late acne. Patients suffering from acne tarda should be carefully examined.

In the classification of Plewig and Kligman, among the clinical varieties of acne in adults, there is such a clinical variety as pyodermа faciale. It is quite possible that it is not entirely correct to classify this form as a variety 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 (rosacea conglobata). This hypothesis is confirmed by the fact that patients do not have comedones, and the onset of the disease is preceded by persistent erythema. Women aged 20 to 40 years are more often affected. Clinically, this form is characterized by an acute, sometimes almost lightning-fast onset. In this case, superficial and deep papulopustular elements on an erythematous background first appear in the central part of the face, then nodes and large conglomerates consisting of nodes and fluctuating cystic formations. The rash is clearly demarcated from the surrounding unaffected skin. There are no comedones. There are no rashes on the chest and back. There are no general symptoms. The rashes resolve slowly, within 1-2 years.

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

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Forms

Acne is localized mainly in seborrheic areas. It can be combined with increased oily shine of the skin. The following types of acne are distinguished:

• comedones {comedo), or acne comedonica;
• papular and papulopustular acne (acne papulosa et pustulosa);
• acne indurative;
• acne conglobates;
• Acne fulminans;
• acne inversum, or hidradenitis suppurative;
• other.

Comedo (blackheads or whiteheads) are non-inflammatory elements that arise as a result of blockage of the mouths of hair follicles. The initial histological manifestation of acne is microcomedones, which subsequently lead to the development of so-called "closed" comedones, the contents of which cannot be freely released onto the skin surface due to a significantly narrowed mouth of the hair follicle. They are non-inflammatory nodules of a dense consistency with a diameter of up to 2 mm. A gradual increase in the volume of these nodules due to the constant production of sebum leads to increased pressure on the walls of the gland and creates conditions for the transformation of most of the elements into papular and papulopustular, and a smaller part - into "open" comedones ("blackhead").

Papular and pustular acne is a consequence of the development of inflammation of varying severity around "closed" and, less often, "open" comedones. It manifests itself in the formation of small inflammatory papules and pustules. In mild forms of the disease, papulopustular acne resolves without scarring. In some cases, when the superficial perifollicular part of the dermis is damaged as a result of the inflammatory reaction, superficial point atrophic scars may appear.

Indurative acne is characterized by the formation of deep spherical infiltrates in the area of cystically altered sebaceous glands, the outcome of their purulent inflammation is always the formation of scars or skin atrophy. In the places of infiltrates, cystic cavities filled with pus and merging with each other (phlegmonous acne) can form.

Conglobate (or piled-up) acne is a manifestation of severe acne. It is characterized by the gradual development of multiple piled-up, deeply located and interconnected inflammatory nodes with large grouped comedones. The lesions can be located not only on seborrheic areas, but also affect the skin of the back, abdomen, limbs, with the exception of the palms and soles. The outcome of the resolution of most of these elements is 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 the age of 40, and sometimes throughout life.

Acne fulminans is a rare and severe form of acne. The disease is characterized by a sudden onset, the appearance of ulcerative-necrotic elements mainly on the trunk, and general symptoms. Pustular rashes, as well as numerous, rapidly ulcerating, papular and nodular acne, appear on the skin of the back, chest, lateral surfaces of the neck and shoulders against an erythematous background. There are typically no rashes on the face. The etiology is not entirely clear. It is assumed that infectious-allergic or toxic-allergic mechanisms play a role in the pathogenesis of the disease. It is known that acne fulminans occurs more often in patients with severe chronic diseases (Crohn's disease, ulcerative colitis, etc.). At the same time, some patients took tetracycline antibiotics, synthetic retinoids, and androgens before acne fulminans appeared. The disease develops quickly. In the clinical picture of the disease, intoxication phenomena predominate: an increase in body temperature above 38° C is almost always observed, the general condition of the patient is disturbed, arthralgia, severe muscle pain, abdominal pain (these phenomena subside against the background of taking salicylates), weight loss, anorexia occur. Some patients may develop erythema nodosum and hepatosplenomegaly, osteolytic processes in the bones develop; a clinical blood test reveals leukocytosis, sometimes up to a leukemoid reaction, an increase in ESR and a decrease in hemoglobin, blood cultures usually give a negative result. Healing of lesions is often accompanied by the formation of many, including keloid ones.

Acne inversum, or hidradenitis suppurativa, is associated with secondary damage to the apocrine sweat glands, which, like the sebaceous glands, are associated with hair follicles. Initially, there is occlusion and rupture of the hair follicle wall, an inflammatory cellular infiltrate around the remains of the follicle, and the apocrine sweat glands are involved in the process secondarily. Various bacteria can be isolated from the lesion, but they are considered a secondary infection. This disease develops after puberty and is usually combined with severe forms of acne in overweight individuals. Contributing factors may include friction from clothing or itching in the appropriate locations (armpits, perineum, navel, areola of the nipples of the mammary glands). The disease usually begins with painful, lumpy subcutaneous infiltrates that open on the skin surface to form fistulous openings. Purulent or bloody-purulent discharge is typical. As a result of inflammation, fistulas form with the formation of retracted scars. The disease is chronic, progresses slowly, and is essentially a type of chronic abscessing pyoderma.

Describing various manifestations of acne, one cannot help but mention a special variety or, rather, complication - exported acne. These acne occur mainly in patients who tend to excoriate even minimal rashes. In this case, scratches of varying depth can be against the background of previously existing acne and even without them. This clinical form can be associated with obsessive-compulsive disorder or indicate a more severe psychiatric pathology. Therefore, it is advisable to consult a psychotherapist or neurologist for patients with excoriated acne.

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Complications and consequences

In cosmetology, the term "post-acne" is used to refer to a symptom complex of secondary rashes that develop as a result of the evolution or therapy of various forms of this disease. The most common manifestations of post-acne include secondary pigmentation and scars.

Hyperpigmentation may occur as a consequence of inflammatory papulopustular acne and is often quite persistent. Its appearance is facilitated by active insolation, squeezing, excoriation of individual acne. Hyperpigmentation is typical for people with dark skin and so-called late acne (acne tarda), which develops in adult women against the background of endocrine dysfunctions. Pigmented spots after acne should be differentiated from other secondary pigmentations after acute and chronic inflammatory dermatoses, from solar lentigines, freckles, border nevi.

Acne Scars

In mild cases of the disease, papulopustular acne usually resolves without scarring. In some cases, when the superficial perifollicular part of the dermis is damaged by an inflammatory reaction, small atrophic point scars (ice-pick scars) may appear. Such manifestations should be differentiated from large-pored skin, which may be a consequence of its dehydration. In this case, the skin - usually in the cheek area, less often the forehead, chin - is grayish in color, thickened, has a "porous" appearance (resembles an orange peel). After the resolution of indurative, phlegmonous and conglobate acne, various scars are formed - atrophic, keloid, "vicious" (papillary, uneven with scar 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 indurative acne, atheromas. The key points of differential diagnosis are the smoothness of the skin pattern, typical for a scar.

In a broader sense of the term "post-acne" we can also consider various other skin changes. In particular, atheromas and milia can persist even after the disappearance of inflammatory acne.

Milia are horny cysts of the epidermis. They are divided into primary and secondary. Primary milia are developmental defects and exist from birth or appear during puberty. They are localized on the skin of the eyelids and around the eyes, sometimes on the trunk and genitals. Secondary milia develop with acne, chronic simple dermatitis, some bullous dermatoses, as complications of laser dermabrasion, deep peeling. Clinically, milia are multiple, white, spherical, dense nodules the size of a pinhead. Milia against the background and after acne are localized mainly on the face (cheeks, temples, chin, in the area of the lower jaw, etc.). Secondary milia should be differentiated from true horny cysts, which are a developmental defect, as well as closed comedones. If comedones are detected, further external acne therapy using comedolytic drugs, as well as cleansing procedures, is indicated.

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Atheroma

Atheroma (atheroma, epidermoid cyst, sebaceous cyst, follicular cyst, trichilemmal cyst) is a retention cyst of the sebaceous gland. It most often develops on the face, clinically manifested by a painless non-inflammatory nodule or nodule of dense consistency. Often in the center of the cyst you can see comedo. When comedo is removed, an opening is formed, from which, when the cyst is squeezed, a pasty whitish mass with an unpleasant odor is released. When infected, the formations turn red, become painful, their capsule fuses with the surrounding tissues. Differential diagnosis is carried out between atheroma and dermoid cyst, trichoepithelioma, syringoma, lipoma, basalioma, cylindroma. Suppurating atheroma must be distinguished from indurative acne and abscessing furuncle.

Thus, the symptom complex "post-acne" is a broad concept. Patient management tactics include various interventions. When choosing acne therapy, one should always consider the possibility of preventing a number of secondary skin changes.

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Diagnostics acne

The scope of examination of patients prescribed by a dermatologist depends on a combination of many factors. When diagnosing acne in adolescents, one should first of all focus on the severity of the disease. Boys with mild to moderate acne can be prescribed standard acne treatment without prior examination. In severe cases, it is important to promptly consult and examine patients with an endocrinologist and gastroenterologist. The scope of examinations should be determined by a specialist in the appropriate field. However, a dermatologist or dermatocosmetologist can direct colleagues to examine and correct a certain pathology. For example, when examining boys with severe acne, an endocrinologist should pay attention to thyroid pathology and carbohydrate metabolism disorders, and a gastroenterologist should pay special attention to pathology of the gallbladder and bile ducts, giardiasis, and helminthic invasion. As for girls, in case of a mild course of the disease, standard external therapy can be prescribed. In case of moderate and severe cases, consultation and examination by a gynecologist-endocrinologist (pelvic ultrasound, sex hormones, etc.) and endocrinologist (thyroid hormones, carbohydrate metabolism) are recommended.

In cases of mild acne in adults, external therapy may be prescribed without examination. In cases of moderate and severe acne, an examination by an endocrinologist or gynecologist-endocrinologist (for women) should be performed. This recommendation is due to the fact that hormonal regulation of sebum secretion can be carried out at four levels: the hypothalamus, pituitary gland, adrenal cortex, and sex glands. Therefore, any change in hormonal levels that leads to changes in androgen levels will indirectly affect sebum secretion. In women, polycystic disease is detected in combination with anovulatory menstrual cycles and hirsutism, adrenal hyperplasia, and pituitary adenoma. In some cases in adult women resistant to therapy, tumors of the adrenal gland or ovary should also be excluded. In men, thyroid pathology, carbohydrate metabolism disorders, adrenal hyperplasia, and androgen-producing tumors may be detected. Emphasis on the examination of the gastrointestinal tract should be placed in the case of a combination of acne and rosacea, especially in men.

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Differential diagnosis

Acne should be differentiated from acne rosacea, papulopustular syphilid, tuberculous lupus of the face, drug-induced acne, perioral dermatitis, small-nodular sarcoidosis and some other dermatoses.

Treatment acne

Acne treatment involves anamnesis data analysis and adequate clinical assessment of manifestations: localization, quantity and type of rashes. When collecting anamnesis, it is necessary to determine the duration of the disease, paying attention to such factors as the influence of stress, premenstrual and seasonal exacerbations, in addition, it is very important to find out the hereditary predisposition. In women, it is necessary to get acquainted with the gynecological anamnesis: menstrual cycle, pregnancy, childbirth, oral contraception. Patients should also find out about previous treatment and its effectiveness.

It should be emphasized that in case of persistent course, resistance to the therapy, regardless of the severity of acne, it is important to examine the patient to assess the pathogenetic background. Clinical blood test, general urine analysis, study of biochemical parameters should be prescribed in cases where systemic therapy with antibiotics or isotretinoin is planned. As for oral contraceptives with an antiandrogenic effect and antiandrogens, they should be prescribed and selected by a gynecologist after an appropriate examination. A dermatologist can only recommend that a gynecologist consider the advisability of prescribing these drugs.

The clinician must necessarily analyze the causes of the severity and sluggishness of acne in each patient. In many situations, it is possible to establish the fact of extremely irrational skin care (frequent washing, excessive use of scrubs, application of alcohol solutions, etc.), use of comedogenic cosmetics, self-harm (with excoriated acne), non-compliance with the treatment regimen (unreasonable interruption of the course, active rubbing of drugs, etc.), passion for unconventional methods (urine therapy, etc.). In such situations, what is needed is not additional research, but normalization of skin care and balanced pathogenetic therapy and, of course, a psychotherapeutic approach to the patient.

According to the results of the latest studies, there is no proven significant influence of food products on the occurrence of acne. However, many patients associate the worsening of acne with the consumption of chocolate, pork, cheese, red wine, citrus fruits, coffee, etc. This may be associated with a number of changes, in particular with the reactive expansion of the superficial network of skin vessels after taking the above-mentioned food products, which leads to increased secretion of sebum and an inflammatory reaction. Therefore, the issue of diet should be decided individually with each patient. General recommendations include a low-calorie diet, leading to weight loss, as well as limiting foods and drinks that increase sebum secretion.

Many patients suffering from acne note an improvement in the summer after insolation. Ultraviolet radiation suppresses the function of the sebaceous glands, enhances superficial peeling, and can also stimulate the immune response in the skin in small doses. Patients note the "masking" of existing defects by pigmentation. At the same time, the literature has accumulated data that ultraviolet radiation enhances the comedogenic properties of squalene, which is part of sebum. Ultraviolet rays in high erythemal doses cause a sharp decrease in local immune protection and, therefore, can worsen the course of acne. The carcinogenic effect of ultraviolet rays A and B, as well as the development of a special type of skin aging - photoaging, are well known. The potential risk of photoaging increases in people who frequently visit solariums, since 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. The combination of ultraviolet irradiation and systemic isotretinoin increases sensitivity to rays due to the keratolytic effect of isotretinoin. Thus, the question of prescribing UFO to a patient with seborrhea and acne should be decided strictly individually. In the presence of a large number of inflammatory acne, against the background of external and systemic therapy, exposure to the open sun and solarium should be avoided, and photoprotective agents should be used. Tanning is also undesirable for those patients who note an exacerbation of the disease in the summer. It should be emphasized that photoprotective agents should be maximally adapted to skin with seborrhea and acne. These products include photoprotectors offered in pharmacies (for example, Antgelios - fluid, gel; Aqua La, La Roche-Posay; Photoderm-AKN - spray, Bioderma, Exfoliac - light sunscreen cream, Merck; Capital Soleil - spray, Vichy; Cleanance - sunscreen emulsion, Avene, etc.). It should be emphasized that photoprotectors should be applied in the morning, before going outside. During insolation, they should be reapplied after swimming, as well as every 2 hours.

Skin care for acne

Complex treatment of acne should include adequate skin care and pathogenetic therapy. Skin care, which implies gentle cleansing, adequate moisturizing, and impact on the pathogenesis links, should be carried out using medicinal cosmetics available in pharmacies. Thus, for gentle cleansing and moisturizing of the skin, patients with acne are recommended the following brands of medicinal cosmetics: BioDerma, Ducray, La Roche-Posay, Avene, Vichy, Uriage, Merck, etc.

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

In recent years, preparations have appeared that have matting, sebum-regulating properties and affect the qualitative composition of sebum. Thus, in order to achieve a matting effect, starch derivatives and silicone are used, and for the purpose of sebum-regulating action - zinc derivatives and other agents. A detailed study of the metabolism of squalene in sebum showed that it can oxidize with the formation of comedogenic squalene monohydroxyperoxide under the influence of protoporphyrins and ultraviolet radiation. Based on the data obtained, scientists managed to create a patented complex of antioxidants (Fduidaktiv), capable of preventing the oxidation of squalene, which is part of human sebum (gamma Sebium, "Bioderma").

Pathogenetic treatment of acne

The choice of pathogenetic treatment methods for acne is based on determining the severity of the course. In everyday clinical work, a specialist can use the following division of acne by severity. Mild acne 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 skin of the face does not exceed 10. With moderate acne, the number of papulopustular elements on the face is more than 10, but less than 40. Single indurative and phlegmonous elements may be detected. Severe acne is characterized by the presence of more than 40 papulopustular elements, as well as abscessing, phlegmonous (nodular-cystic) or conglobate acne. With mild acne, external therapy is usually prescribed. Patients suffering from moderate or severe acne should receive both external and systemic treatment.

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

Treatment of mild acne

In mild cases, modern topical retinoids or azelaic acid are used for at least 4-6 months.

Adapalene is a substance that is not only a new biochemical class of retinoids, but also a drug with proven anti-inflammatory properties. Due to selective binding to special nuclear RA-y receptors of cells of the superficial 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 scales and, therefore, affect hyperkeratosis in the area of the mouth of the hair follicle. The consequence of this is the removal of areas of follicular hyperkeratosis (keratolytic effect) and the prevention of the formation of new microcomedones (comedolytic effect). Good tolerability, low irritant effect and effective delivery of differin to the skin are ensured by the original basis of the drug in the form of a hydrogel and a unique uniform dispersion of adapalene microcrystals in this hydrogel. The drug is available 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 the gel form, which does not change the pH of the skin surface and is well adapted in form for 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: 3 months after the start of using the drug (2 times a day), P. acnes is practically not detected in the mouths of the follicles. Against the background of treatment with this drug, microflora resistance does not develop. The antibacterial effect is due to the active transport of the drug into the bacteria. Azelaic acid is known to effectively affect fungi of the genus Pityrosporum, as well as staphylococcal microflora. This drug also has anti-inflammatory action and inhibits 5a-reductase.

Benzoyl peroxide is a product well known to specialists and used in dermatology for over half a century. Due to its powerful disinfectant effect, it was used to treat trophic ulcers. The keratolytic effect of this drug was widely used in the external therapy of ichthyosis, and its bleaching properties - for various skin pigmentations. Benzoyl peroxide has a pronounced antibacterial effect on P. acnes and Slaphilococcus epidermidis due to its powerful oxidizing effect. This may explain the pronounced positive effect on inflammatory acne, especially pustular acne, revealed in a modern study. It has been proven that this product 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 resistant strains. Many researchers have demonstrated the comedolytic and keratolytic action of benzoyl peroxide. The new benzoyl peroxide preparation, Baziron AC, produced in the form of a 5% gel, is well tolerated compared to previously existing products due to its hydrogel base and the special uniform dispersion of benzoyl peroxide microcrystals in this gel.

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

In the presence of papulopustular elements, drugs with antibacterial and disinfectant effects are also added to the therapy. Monotherapy with topical antibiotics is not indicated due to the lack of adequate pathogenetic effect on follicular hyperkeratosis and the formation of microcomedones, as well as the risk of rapid emergence of insensitive strains of P. acnes.

Treatment of moderate acne

For moderate acne, similar topical therapy is used. It is usually combined with a general prescription of a tetracycline antibiotic (lymecycline, doxycycline, tetracycline, etc.). It should be emphasized that the effectiveness of antibacterial agents for acne is due not only to their direct bacteriostatic effect on P. acnes. It is known that antibiotics such as tetracycline also have a direct anti-inflammatory effect. A more lasting positive effect from antibiotic therapy for moderate acne is possible only with long-term treatment (about 3 months). Therapy with systemic antibiotics in combination with topical antibiotics (without topical retinoids) is not recommended due to 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 antibacterial therapy is insignificant or there are isolated indurative and phlegmonous elements, a tendency to scarring, then it is advisable to prescribe synthetic retinoids (isotretinoin).

Acne Treatment for Women

In addition to external therapy, women can be prescribed contraceptives with an antiandrogenic effect (Diane-35, Yarina, Janine, Trimersi, Bedara, etc.). This method of treatment is possible only after consultation with a gynecologist-endocrinologist and a thorough study of the patient's hormonal background, i.e. it should be prescribed strictly according to indications. Antiandrogens (Androcur) and other drugs can be added to the therapy, depending on the pathology identified.

In 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 provides a lasting clinical effect. Isotretinoin is the most effective drug. The question of its prescription 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 for moderate acne, when long-term repeated courses of antibacterial therapy have not brought the desired result. This drug is indicated for patients whose acne is accompanied by severe psychosocial disorders, as well as one of the additional drugs in the treatment of the most severe form - fulminant acne.

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

It is extremely important to achieve a total cumulative dose of at least 120 mg/kg body weight.

Isotretinoin is contraindicated in women who may become pregnant during treatment, so it is prescribed to female patients with effective contraception. Isotretinoin is also contraindicated in pregnant and lactating mothers due to 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). Roaccutane should not be combined with contraceptives containing low doses of progesterone, since isotretinoin can reduce the effectiveness of progesterone drugs. Isotretinoin is not recommended for patients with liver and kidney failure, hyperlipidemia and diabetes mellitus. Isotretinoin is also contraindicated in cases of hypervitaminosis A and hypersensitivity to the active substance of the drug. The drug must be taken under the supervision of a specialist.

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

• The patient suffers from a severe form of acne that is resistant to conventional treatment methods.
• You can rely on the patient to understand and follow instructions.
• The patient is able to use the prescribed contraceptives.
• The patient was informed by her physician of the risk of pregnancy during treatment with Roaccutane and for one month after its completion. In addition, she was warned about the possibility of discontinuing contraception.
• The patient confirmed that she understood the essence of the precautionary measures.
• A pregnancy test performed within two weeks before the start of treatment was negative.
• She takes effective contraceptive measures without interruption for one month before starting treatment with Roaccutane, during treatment, and for one month after stopping treatment.
• Treatment with the drug begins only on the second or third day of the next normal menstrual cycle.
• In case of relapse of the disease, the patient uses the same effective contraceptives without interruption for one month before the start of treatment with Roaccutane, during treatment and for one month after stopping treatment.

Compliance with the above precautions during treatment should be recommended even to women who do not usually use contraception due to infertility (from the manufacturer's recommendations).

During treatment with isotretinoin, it is necessary to monitor ALT, AST, alkaline phosphatase, triglycerides, and total cholesterol in patients. One month after the start of therapy. Subsequently, if no laboratory changes are detected, the above parameters can be monitored once every three months. If hyperlipidemia is detected, it is recommended to repeat the laboratory tests in two weeks. After completion of treatment, it is recommended to test ALT, AST, alkaline phosphatase, triglycerides, and total cholesterol in all patients. Women who took the drug should undergo a pregnancy test four weeks after the end of therapy. Pregnancy is possible only after two months from the end of isotretinoin therapy.

During isotretinoin therapy, non-systemic and systemic side effects, as well as changes in laboratory parameters, are possible.

Non-systemic:

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

System:

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

Changes in laboratory parameters:

• dyslipidemia (7-25%);
• increased levels of liver transaminases (6-13%).

If systemic side effects occur, the issue of reducing the dose or discontinuing the drug is decided. Such non-systemic effects as dry skin and mucous membranes (drug cheilitis) are expected side effects of systemic isotretinoin therapy. To prevent and eliminate these changes, proper skin care is prescribed, including gentle cleansing (alcohol-free micellar solutions, emulsions, synthetic detergents) and active moisturizing. In a beauty salon, masks can be prescribed to achieve a moisturizing effect or replenish highly specialized skin lipids. To care for the red border of the lips during isotretinoin therapy, lip balms and lipsticks produced by cosmetic companies specifically for skin care of dermatological patients can currently be offered. These products include lip balm with cold cream (laboratory "AveneB "Pierre Fabre"), lip cream "Kelian" (laboratory "Ducray", "Pierre Fabre"), lip cream "Ceralip", stick "Lipolevre" (pharmaceutical laboratory "La Roche-Posay"), protective and restorative stick of long action (laboratory "Linage"), lip balm "Amiiab" (laboratory "Merck"), lip sticks "Lipidiose", lip cream "Nutrilogie" (laboratory "Vichy"), lip balm protective and restorative (laboratory "Klorane", "Pierre Fabre"), lip balm "Neutrogena" (laboratory "Neutrogena"), lipo-balm "DardiSh" ("Intendis") and others. For the eyes, artificial tears, gel are recommended. "Vidi-sik".

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

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

When treating patients, the doctor should take into account the above reasons. In severe cases of acne, topical retinoids are also prescribed in combination with antibacterial treatment (tetracyclines for at least 3 months). A combination of topical retinoids, benzoyl peroxide and systemic antibiotics is possible. In women with severe acne, after examination and recommendation of a gynecologist-endocrinologist, combined oral contraceptives with antiandrogens are prescribed. After completion of the main course of treatment, maintenance topical therapy is indicated using topical retinoids, benzoin peroxide, azelaic acid, salicylic acid for up to 12 months.

Additional Acne Treatments

In case of acne, additional procedures such as skin cleansing, drying and anti-inflammatory masks, darsonvalization (cauterizing effect - large doses), therapeutic laser, superficial peeling, desincrustation, cosmechanics procedure, oxygen therapy, photochromotherapy, photodynamic therapy can be prescribed. It is important that the absence or inadequacy of proper pathogenetic therapy by the time the procedures begin can cause an exacerbation of acne. In case of indurative acne with stagnant phenomena, Jacquet massage and oxygen therapy can be recommended. Any massage in patients with acne should be performed 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 in the management of patients with acne. Given modern understanding of the disruption of the skin barrier properties in patients with acne, cleansing should be as gentle as possible. The cleansing procedure is significantly facilitated by previous external therapy with retinoids (Differin) or azelaic acid (Skinoren) for at least 2-3 weeks.

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

Superficial cryotherapy is also prescribed, which can accelerate the resolution of indurative elements. Peelings (superficial, median) are also used in complex acne therapy. Surgical manipulations for acne have very limited application. Surgical opening of cystic cavities is contraindicated, since it leads to the formation of persistent scars. Sometimes, for abscessing acne, injections of foci with a crystalline suspension of corticosteroid are used. However, this procedure has not become widespread due to the risk of developing atrophy and abscess formation at the injection site.

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Post-acne treatment

The most common manifestations of post-acne include secondary pigmentation and scars. The consequences of acne can also include milia and atheromas.

If there is a tendency to form scars against the background of acne, it is recommended to prescribe the most effective drugs earlier. In case of mild acne, the drugs of choice for external use should be topical retinoids (adapalene - Differin). In case of moderate acne, topical retinoids are recommended in combination with tetracycline antibiotics (lymecycline, doxycycline are the most preferable) for at least 3 months. This recommendation is due not only to the direct effect 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 at the site of inflammation in the dermis. In case of no effect from systemic antibacterial therapy and a tendency to form scars in case of moderate acne, isotretinoin is recommended. In case of severe acne, isotretinoin is the drug of choice. At any severity of the disease, agents that normalize the formation and metabolism of collagen (Curiosin, Regecin, Kontratubex, Mederma, Madecassol, etc.) can be added to the therapy.

The appearance of scars can be facilitated by various medical manipulations, squeezing acne, cleaning. As stated above, surgical opening of cystic cavities is contraindicated, since it leads to the formation of persistent scars. To correct cicatricial changes, some external agents, chemical peels of various depths, physiotherapeutic methods, cryomassage and cryodestruction, filling, mesotherapy, microdermabrasion, laser "polishing" of the skin, dermabrasion, surgical removal of individual scars, excision with a laser, electrocoagulation are used. The choice of treatment method depends on the nature of the cicatricial changes. The desired cosmetic effect can be achieved through the combined use of the listed methods.

In case of multiple point scars, it is recommended to combine different methods of treatment, which, complementing each other, allow for a smoothing effect at different depths (for example, chemical peels + microdermabrasion, laser “grinding” or dermabrasion).

There is an opinion that the best effect on hypertrophic scars can be achieved with laser "polishing" and dermabrasion. For hypertrophic scars, external preparations that affect connective tissue metabolism (Curiosin, Regetsin, Contractubex, Mederma, Madecassol, etc.) and topical glucocorticosteroids can also be used. These agents can be applied to the skin or administered using ultrasound or electrophoresis. Among physical methods, popular techniques affect connective tissue metabolism (laser therapy, microcurrent therapy, magnetic therapy, etc.) are also used. Cryodestruction, laser destruction, surgical treatment of individual scars with subsequent chemical peeling procedures.

For atrophic scars, filling techniques, mesotherapy, mimic peeling, which helps smooth the skin, and less often, external preparations and physiotherapy procedures that affect the metabolism of connective tissue are used. Topical glucocorticosteroids are not indicated for atrophic scars due to the potential risk of additional skin atrophy. It is believed that the filling procedure is most effective for atrophic scars with gentle, rounded shapes on the cut without sharp angles, V-shaped, or trapezoidal. For deeper defects, dermabrasion may be recommended. In some cases, excision of individual atrophic scars is performed with subsequent peeling or dermabrasion.

Treatment of keloid scars after acne (acne-keloid) is particularly difficult. Keloid scars are uncontrolled benign proliferation of connective tissue at the site of skin damage (Greek kele - tumor + eidos - type). According to the histological classification of WHO (1980), they are considered among tumor processes of soft tissues. The literature describes many methods of their treatment using radiotherapy, glucocorticoids, retinoids, long courses of cytostatics, gamma- and alpha-interferon drugs. However, the effectiveness of many of them is quite low, and complications can be more severe than the underlying disease, so they are currently not recommended for the treatment of patients with acne keloids. Destructive methods of treating keloids (surgical excision, laser and cryodestruction, electrothermocoagulation, laser "polishing", dermabrasion) are contraindicated, as they cause even more severe relapses. The results of treating acne keloids depend on their duration of existence and the area of the lesion. It has been shown that at the early stages of their formation (up to 1 year) and with small areas of the lesion, the method of introducing a crystalline suspension of glucocorticosteroids with 1% lidocaine into the keloid tissue is quite effective. Strong topical glucocorticosteroids can also be used. Less often, special pressure bandages and plates are prescribed. Dermatix gel is prescribed externally for keloid and hypertrophic scars, which has a moisturizing effect and simultaneously acts as an occlusive dressing. For long-standing keloids, in addition to the glucocorticosteroid suspension, a collagenase or interferon solution is introduced into the lesions.

If you have a tendency to develop milia, it is important to focus on modern drugs with keratolytic and comedolytic effects (adapalene - Differin, azeaic acid - Skinoren) from the very beginning of therapy. The appearance of milia can be partly facilitated by dehydration of the stratum corneum in patients with acne. Moisturizing agents and procedures are indicated for such patients.

Mechanical removal of milia with a needle is recommended, less often they are removed with a laser. 1-2 weeks before removal, skin preparation can be carried out (using products containing azelaic, salicylic acids, hydroxy acids), facilitating the procedure of enucleating milia.

If you have a tendency to develop atheromas, it is important to focus on modern drugs that have a powerful keratolytic and comedolytic effect. Depending on the severity of acne, long-term therapy with topical retinoids (adapalene, differin) or systemic retinoids (isotretinoin - Roaccutane) is recommended.

Atheromas are removed surgically, less often using a laser. The most preferable is surgical removal of the atheroma together with the capsule.

The so-called MARSH syndrome can also be considered a consequence of a special form of acne. To prevent the severity of melasma, active photoprotection is indicated using sunscreens with maximum protection from ultraviolet rays A and B. It should also be remembered that the manifestations of melasma become more pronounced against the background of taking oral contraceptives, which are prescribed to such patients 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. Good cosmetic results can be achieved by laser skin resurfacing, photorejuvenation, and, less commonly, dermabrasion. Ascorbic acid (vitamin C) and tocopherol (vitamin E) are prescribed internally to inhibit the formation of melanin.

In order to prevent exacerbation of rosacea against the background of active external therapy of acne, gentle care is indicated, both for sensitive skin, in combination with agents that affect the links in the pathogenesis of both acne and rosacea (for example, gel with azelaic acid - Skinoren gel). In addition to rosacea therapy, azole compounds (metronidazole), zinc preparations (Curiosin, Regecin, etc.), sulfur (Delex acne, etc.) are used externally. As basic skin care, various products with an effect on the vascular component of the disease can be offered {(Rozaliak - pharmaceutical laboratory "La Roche-Posay"; Rozelyan - laboratory "Una age"; Sensibio series - laboratory "Bioderma"; Diroseal and Antirouger laboratories "Avene", "Pierre Fabre"; etc.).

Hirsutism is treated with various methods of epilation and depilation. It is important to emphasize that long-term therapy with antiandrogen drugs (at least 1-1.5 years) is indicated for effective treatment of hirsutism.

In conclusion, we would like to warn doctors of various specialties against the widespread use of previously popular acne treatment methods based on outdated ideas about the pathogenesis of this disease. Currently, the questionable effectiveness of a strict diet, enterosorbents and autohemotherapy in patients with acne has been shown. It is also not recommended to prescribe active ultraviolet irradiation for moderate and severe forms due to the proven comedogenic effect and a decrease in local immune protection against the background of acute and chronic exposure to UFO. Penicillin, cephalosporin and other antibiotics that are inactive against P. acnes are not indicated. Wide surgical opening of cystic cavities is contraindicated, since it leads to the formation of persistent scars. Finally, external glucocorticosteroids are contraindicated in the treatment of acne. Currently, the earliest possible prescription of modern external and (or) systemic drugs is the most optimal.

Prevention

In order to prevent the development of secondary hyperpigmentation, effective photoprotection is recommended, especially for people with a tendency to post-inflammatory pigmentation. Such patients are not recommended to undergo ultraviolet irradiation (including in a solarium) during acne treatment. When choosing acne therapy, it is recommended to immediately focus on external preparations that, in addition to affecting the main pathogenetic links, have 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 products that reduce pigment formation. Cosmetic procedures include chemical peeling, cryotherapy, microdermabrasion, and laser dermabrasion. Various products that directly affect the pigment formation process also reduce pigmentation. Benzoyl peroxide, azelaic acid, and topical retinoids have a whitening effect. Ascorbic acid, hydroxy acids, hydroquinone, and other agents are used in external acne therapy. However, as some researchers point out, hydroquinone can cause even more persistent pigmentation in some cases, both in the affected area and around it, so its use is very limited. Currently, the old, previously very popular method of skin whitening with products containing white precipitated mercury is practically not used due to the high risk of developing allergic dermatitis. The need for effective photoprotection during treatment of secondary hyperpigmentation should be emphasized.

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