Acne Cure Diet

Acne No More Ebook

Acne is not only a patch to the beauty of a person but a painful and ever growing disease which has been common problem. Lots of chemical products are available in the market which not makes a big hole in pocket but hardly gives promising results. Acne no more is indeed a book that will permanently solve your all acne problems in the most holistic way without using any drugs or ointments. No matter whatever the age or sex of the person, it works on all. In addition to acne treatment it includes all the remedies for blackhead removal, scar marks and excessive oiliness. It includes all the step by step holistic process to get the best glowing and healthy without using any chemicals. Indeed the best in the market and written by Mike Warden who is certified Nutrition Specialist, Health Consultant, Medical Researcher and Author. The fastest and permanent results are guaranteed by the author and have been used and trusted by thousands of readers of this book. Within 2 months get prepared to get the glowing and clean skin that you have ever wished for. Read more...

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Acne And Pseudofolliculitis Treatment

Salicylic acid is listed among active products to treat acne (26,27). However, clearcut evidence for a significant benefit at low concentration in well-controlled experimental and clinical trials is scanty. Similarly, medium concentrations of AHAs, such as glycolic acid, lactic acid, and mandelic acid, are employed twice daily to improve mild acne (12). Such a treatment awaits validation by independent controlled studies. In our experience, the lower AHA concentrations present in some cosmetic products have no effect whatsoever on acne and comedones. Another modality of acne treatment has been proposed using high concentrations of glycolic acid in an office setting (12). The procedure has to be repeated weekly or so. Improvement has been reported to be precipitous while patients were also taking tetracyclines (12). Discomfort, mild diffuse erythema, and fine scaling are often experienced by patients. In addition, there is a risk for stronger irritation leading to a papular and...

Acne A Introduction

Acne is one of the most common and distressing of skin diseases commonly present during adolescence and usually (but not always) resolves in early adult life. Seventy percent of the population develop acne, but only a relatively small proportion seek medical attention. Several variants of acne are recognized, including infantile acne, which occurs on the face during the first few months and usually settles spontaneously, and occupational acne, resulting from exposure to oil, coal tar, chlorinated hydrocarbons, or insecticides. Acne may be precipitated or exacerbated by certain combined oral contraceptive pills or by androgenic hormones. Acne vulgaris commonly affects the face, chest, and upper back, and usually presents during puberty. The clinical features include an increased rate of sebum secretion, comedones, papules, and pustules (Fig. 3). Severe acne may be complicated by atrophic or nodular keloid-type scars or by the formation of chronic nodules and cysts (Fig. 4). Patients...

Conditions That May Simulate Acne Vulgaris

Papulopustular rosacea may resemble acne, but usually occurs on a backdrop of flushing and telangectasia. Comedones and cysts are absent except in rare cases when both diseases occur simultaneously. Most rosacea lesions are on the face. This localized eruption is almost exclusively limited to female patients. It presents with a localized papular and eczematous eruption with tiny pinpoint pustules in the perioral, perinasal, or periocular areas of the face. It superficially resembles acne, but lacks comedones, nodules, and cysts. Topical acne medications will exacerbate the condition. Acne-Like Drug Eruptions A long list of medications can cause an acne-like eruption. Hormones (especially systemic steroids), halogen-containing medications, tuberculostatic agents, and anti-epileptic drugs are the major classes of drugs. These eruptions consist of sheets of fragile pustules, which are not limited to sebaceous locations. Comedones, nodules, and cysts are absent. This is a complication of...

Treatment of Acne

The aims of treatment are to reduce the bacterial population of the hair follicles to encourage the shedding of comedones to reduce the rate of sebum production and to reduce the degree of inflammation. Topical therapy is appropriate for mild-to-moderate acne, but more severe forms of acne, in which there is a risk of scarring, will require systemic therapy. Skin cleansers such as Phisomed or Hibiscrub are of some value. Benzoyl peroxide reduces comedone formation, as well as reducing the population of P. acnes, and may also have an anti-inflammatory effect. Benzoyl peroxide cream may be applied twice daily at an initial concentration of 2.5 and increased to 5 or 10 as tolerated. Benzoyl peroxide can have an irritant effect and may also bleach both hair and clothing.

Acne Vulgaris

Seborrheic Dermatitis Differin

Etiology Abnormal follicular keratinization, increased sebum 2 to androgens, Propionibacterium acnes (bacteria), inflammation. Treatment Options Based on Acne Type Selected Topical Medications for the Treatment of Acne Selected Systemic Medications Acne Treatment Patients should be forewarned of acne exacerbations in the first month of systemic therapy as deep-seated acne comes to the surface. Also, systemic therapy can require 6 wk before benefits are noted.

Printed In The United States Of America

There is little commonality in the scientific methods, processes, and formulations required for the wide variety of cosmetics and toiletries in the market. Products range from preparations for hair, oral, and skin care to lipsticks, nail polishes and extenders, deodorants, body powders and aerosols, to quasi-pharmaceutical over-the-counter products such as antiperspirants, dandruff shampoos, antimicrobial soaps, and acne and sun screen products.

Thirdgeneration progestins

The newer OCs are more effective in reducing acne and hirsutism in hyperandrogenic women. They are therefore an option for women who have difficulty tolerating older OCs. There is an increased risk of deep venous thrombosis with the use of these agents, and they should not be routinely used.

Step 2 Assess the history

Galactorrhea is suggestive of hyperprolactinemia. Hirsutism, acne, and a history of irregular menses are suggestive of hyperandrogenism. C. Step 3 Physical examination. Measurements of height and weight, signs of other illnesses, and evidence of cachexia should be assessed. The skin, breasts, and genital tissues should be evaluated for estrogen deficiency. The breasts should be palpated, including an attempt to express galactorrhea. The skin should be examined for hirsutism, acne, striae, acanthosis nigricans, vitiligo, thickness or thinness, and easy bruisability. D. Step 4 Basic laboratory testing. In addition to measurement of serum hCG to rule out pregnancy, minimal laboratory testing should include measurements of serum prolactin, thyrotropin, and FSH to rule out hyperprolactinemia, thyroid disease, and ovarian failure (high serum FSH). If there is hirsutism, acne or irregular menses, serum dehydroepiandrosterone sulfate (DHEA-S) and testosterone should be measured.

Postpeeling Care and Complications

Bland cleansers and moisturizers are continued for 48 h or until all post-peel irritation subsides. Patients are then able to resume the use of their topical skin care regimen including topical bleaching agents, acne medications, and or retinoids. Post-peel adverse reactions such as excessive desquamation and irritation are treated with low to high potency topical steroids. Topical steroids are extremely effective in resolving post-peel inflammation and mitigating the complication of post-inflammatory hy-perpigmentation. In the author's experience, any residual post-inflammatory hyperpigmen-tation resolves with use of topical hydro qui-none formulations following salicylic acid peeling. An excellent peeling agent in patients with acne vulgaris

Clinical manifestation

Skin changes facial plethora striae ecchymoses and purpura telangiectasias skin atrophy hirsutism and male pattern balding in women increased lanugo facial hair steroid acne acanthosis nigricans Central obesity increased adipose tissue in the face (moon facies), upper back at the base of neck (buffalo hump), and above the clavicles

Comparison With Other Surface Modalities

Level III methods include CO2 resurfacing, phenol peels, and dermabrasion. Because of deeper penetration to or beyond the papillary-reticular junction, these manifest longer recovery and post-inflammatory erythema, as well as increased risk of scarring or pigmentary changes. They also produce the most significant improvement with regard to superficial rhytids, acne scars, and solar elastosis. I believe that CO2 resurfacing has effectively replaced the other two modalities in this level, but whether or not you agree, this algorithm may be useful in your consultation room. This simple approach permits every practitioner the ability to adapt it to his or her own preferences and needs.

Dissecting cellulitis of scalp

Associated with acne conglobata, hidraden-itis suppurativa, and pilonidal cysts, all of which have follicular blockage as the common mechanism retained material dilates and causes follicular rupture keratin and organisms from the damaged hair follicles initiate neutrophilic and granulomatous response bacterial infection secondary event

History and Classification

Acne is a common disease affecting almost 100 of youngsters 1, 2 . Acne settles in the vast majority by 20-25 years of age but 1 of males and 5 of females exhibit acne lesions at 40 years of age 3 . Scarring occurs early in the course of acne and may affect, to some degree, 95 of patients from both sexes 4 . Differences in the cell-mediated immune response are involved in the personal tendency to develop post-acne scarring 5 . Acne scars are debilitating and socially disabling for the individual. Treatment of acne scars presents a challenge for a treating physician. Usually they cannot be effectively corrected by a single treatment modality because of their widely varied depth, width and structure. A few morphologic acne scar classifications have been proposed to assess the efficacy of different therapeutic options based on the scar According to other classification acne scars are divided to elevated, dystrophic or depressed 7 . Elevated scars are subdivided to hyper-trophic,...

Prepeeling Preparation

Treatment of acne scars must be individually tailored to address the specific findings. The patient has to understand that the scar revision process may require more that one surgical session. Punch excisions or elevations have to be performed 4-6 weeks before the peel, while subcision can be performed at the same session with the peel. Before the peel prophylactic acyclovir, vala-cyclovir or famvir is given to patients with history of recurrent herpes simplex. Systemic antibiotics (minocycline) are important for patients with active acne.

Peeling Technique

A white precipitate which represents crystallization of the salicylic acid begins to form at 30 s to 1 min following peel application. This should not be confused with frosting or whitening of the skin, which represents protein agglutination. After 3-5 min the face is thoroughly rinsed with tap water to remove salicylic acid crystals. The face is gently blotted to remove excess water. When treating hyperpigmentation, TCA 10 or 15 is then applied to the areas of hyperpigmentation with a cotton-tipped swab for 2-3 min, producing minimal (Level 1) or no (Level 0) frosting. The face is again rinsed with tap water. If treating photodamage, acne, or tex-turally rough skin, TCA is applied to the entire face. This protocol usually involves a regimen of two or three combination peels performed at 2- to 4-week intervals.

Patients Informed Consent

My_(site) treated with CHEMICAL PEELING USING A COMBINATION SALICYLIC ACID 20 AND 30 AND TRICHLORO-ACELIC ACID 10 OR 15 . The peeling procedure can improve dark spots (hyperpigmentation), photodamage (sun damage), textural roughness, acne, tone, and the overall appearance of the treated area. This combination peeling agent will cause shedding of the outermost layers of the skin.There may or may not be visible peeling.The procedure involves first having the peel site prepped with alcohol,ace-tone or other pre-peel cleansing agents. The salicylic acid peeling agent is applied first, followed by application of the trichloroacetic ac-id.The area is rinsed and blotted dry.

Differential Diagnosis

Occasionally, however, there is ambiguity. The term acnei- form eruption denotes conditions resembling acne, which are almost always drug induced. Like acne, acneiform eruptions originate in sebaceous follicles, the initial lesions are inflammatory, typically papules and pustules, while comedones are always secondary lesions. These eruptions are independent of age, sudden in onset, monomorphous in their appearance and have typical localizations. Systemic signs of drug toxicity may occur. Acneiform eruptions clear with drug discontinuation. Corticoster-oids, both systemic and topical, are potent ac-negens, but also aminopterine, phenytoin, lithium, PUVA, phenobarbitone, thiourea, thioura-cil, iodides, bromides, and disulfiram can induce acneiform eruptions. In most cases, the pathogenesis is unknown. In general, drugs that cause acneiform eruptions can also exacerbate pre-existing acne. Rosacea is a chronic disorder affecting the central parts of the face,...

Australian tea tree Melaleuca alternifolia Myrtaceae

In Australia, Europe, and North America, tea tree oil (Melaleuca aetheroleum) from a tree native to subtropical coastal regions of New South Wales has become very popular in the last decades. Today it is obtained almost exclusively from cultivated material. The use of this species in biomedicine is based on the medical traditions of the Australian Aborigines and includes the treatment of infectious skin conditions (acne). It is also used in cosmetics.

Morphologic and Physiologic Skin Differences in Dark Skin

Dark skin demonstrates significantly greater intrinsic photoprotection because of the increased content of epidermal melanin. Clinical photodamage, actinic keratoses, rhytides, and skin malignancies are less common problems in deeply pigmented skin. However, darker skin types are frequently plagued with dyschromias because of the labile responses of cutaneous melanocytes 7 . In a survey of 2000 black patients seeking dermatologic care in a private practice in Washington, DC, the third most commonly cited skin disorders following acne and eczema was pigmentary problems other than vitiligo 8 . Of these patients, the majority had a diagnosis of post-inflammatory hyper-pigmentation, followed in frequency by melas-ma. In a survey of 100 women of color assessing issues of cosmetic concerns for darker skin types, the most commonly cited problems were dark spots or blotchy skin, texturally rough skin, and increased sensitivity to topical products 9 . Patients surveyed also complained of oily...

Medium and Deep Peels

Medium-depth peels also utilize glycolic acid 70 or Jessner's solution in combination with 35 TCA. Combination medium-depth peels are often used to treat moderate to severe photodamage. Fifteen Middle Eastern patients with atrophic or pitted acne scars were treated with a combination of Jessner's solution and 35 TCA peeling 11 . All patients were of light brown to dark brown complexion. Six percent had excellent improvement, 53 had moderate improvement and mild improvement was noted in 27 . Nine patients (73.4 ) developed transient post-inflammatory hyperpigmenta-tion which resolved after 3 months. Patients with light brown complexions did not develop hyperpigmentation. In the author's experience, aggressive peels of this nature have a substantially greater likelihood of inducing persistent hyperpigmentation and hypopigmentation in darker skin types.

Micronutrients vitamin A

Vitamin A is required in small amounts in crucial biological processes such as controlling the differentiation and proliferation of epithelial cells, maintaining general growth and visual and reproductive functions. Therapeutically, vitamin A is used in dermatology for curing various skin diseases, and one of the metabolites of retinol, all-trans retinoic acid, is used topically to treat acne. Vitamin A, as retinyl esters, is also taken in various amounts as a food supplement.

Parakeratosis and Hyperkeratosis of the Ectocervix

The proliferative effect of estrogens, furthermore, promotes ascending repair of columnar epithelium or epithelial defects, which are overgrown by regenerative epithelium of ectocervical origin (see p. 19. Similar hyperkeratinization follows the stimulatory effects induced by chronic trauma, as in uterine prolapse.

TABLE 302 Glogau Classification

Mild pigmentary changes No keratoses Minimal wrinkles Patient age 20s or 30s Minimal or no makeup Minimal acne scarring Early to moderate photoaging Early senile lentigines visible Keratoses palpable but not visible Parallel smile lines beginning to appear Patient age late 30s or 40s Some foundation usually worn Mild acne scarring Acne scarring present makeup does not cover Makeup cannot be worn it cakes and cracks Severe acne scarring

Gender Ethnicracial And Life Span Considerations

You may note that the skin has a waxy appearance fewer than normal wrinkles for the patient's age and a decreased amount of body, pubic, and axillary hair. Assess the patient's skin for hyperpigmentation, oiliness, acne, and diaphoresis. Assessment of visual function is important because pituitary tumors may press on the optic chiasm. Assess the patient's visual fields, visual acuity, extraocular movements, and pupillary reactions. A classic finding is bitemporal hemianopsia (blindness in the temporal field of vision). Perform an assessment of the cranial nerves. The tumor may involve cranial nerves III (oculomotor, which regulates pupil reaction), IV (trochlear, which along with the abducens regulates conjugate and lateral eye movements), and VI (abducens). Examine the patient's musculoskeletal structure, determining whether foot and hand size are appropriate for body size whether facial features are altered, such as thick ears and nose and whether the skeletal...

Indications and Dosage

The efficacy of systemic retinoid therapy in a variety of dermatologic diseases, such as acne, psoriasis (pustular and erythrodermic types), and disorders of keratiniza-tion (ichthyoses, symmetric progressive erythrokeratoderma, Darier disease, pityriasis rubra pilaris, and palmoplantar hyperkeratosis), is well known. There are also reports of successful treatment of other dermatologic conditions, including disorders of epidermal differentiation (epidermodysplasia verruciformis, confluent and reticulated papillomatosis, and axillar granular parakeratosis) and inflammatory and immunodermatoses (atrophoderma vermiculatum, lichen planus, sarcoidosis, and granuloma annulare). Various synthetic retinoids have also been tried in the treatment of patients with different forms of cutaneous LE (CLE), and there are numerous reports of good responses to etretinate, acitretin, and isotretinoin (Duna and Cash 1995, Furner 1990b). Etretinate has been shown to be effective in the treatment of DLE,...

Dehydroepiandrosterone DHEA

DHEA has multiple possible adverse effects. It may cause liver injury. Other side effects include acne, hair loss, voice deepening, fatigue, altered menstruation, abdominal pain, hypertension, and increased risk of some hormone-sensitive cancers, including breast, endometrial, and prostate cancer. The safety of long-term DHEA use has not been established.

See Risk For Impaired Skin Integrity

Defining Characteristics (Specify radiation effects erythema, dryness, itching, increased pigmentation, dry desquamation, necrotic tissue chemotherapy and antibiotic induced side effects local phlebitis, stomatitis, mucositis, maculopapular rash, hyperpigmentation, nail changes, pruritus, dermatitis, alopecia, photosensitivity, acne, erythema, poor wound healing.)

Clinical Application Questions

A shy 14-year-old girl accompanied by her mother presents for treatment of acne of 1 year's duration. 4. The patient has fairly dense acne of the face and mid-upper back. Her chest, shoulders, neck, and lower back are spared. Her lesions are predominantly noninflammatory papules, open comedones, and a few inflammatory papules and pustules. Her mother has read about isotretinoin therapy. How would you grade her acne, and what would be an appropriate treatment regimen 5. What would you change in your management if her acne also involved her chest, shoulders, and lower back

Dermatologic Physical Exam

The first two primary lesions listed above predominate in grade I acne. The middle two primary lesions predominate in grade II acne. The last two primary lesions predominate in grade III acne. A spectrum of lesions in different stages of evolution is present in grades II and III. Microdistribution Acne is a disease of the terminal or sebaceous hair follicle, which occurs in the anatomic locations listed below.

What should you look for on physical exam Answer

The patient has fairly dense acne of the face and mid-upper back. Her chest, shoulders, neck, and lower back are spared. Her lesions are predominantly noninflammatory papules, open comedones, and a few inflammatory papules and pustules. Her mother has read about isotretinoin therapy. How would you grade her acne, and what would be an appropriate treatment regimen a. Grade I acne. c. Regularly scheduled follow-up visits for acne surgery, medication adjustment, and to assess progress. 5. What would you change in your management if her acne also involved her chest, shoulders, and lower back

Tetracycline hydrochloride

Superficial ophthalmic infections due to Staphylococcus aureus, Streptococcus, Streptococcus pneumoniae, Escherichia coli, Neisseria, and Bacteroides. Prophylaxis of Neisseria gonorrhoeae in newborns. With oral therapy for treatment of Chlamydia trachomatis. Topical Acne vulgaris, prophylaxis or treatment of infection

Old burntout Lesions of Discoid Lupus Erythematosus

Cutaneous Lupus Hyperpigmented

Atrophic scars may be indistinguishable from burnt-out DLE, lacking any signs of inflammation, particularly depigmented scars after superficial third-degree burns. Atrophic acne scars differ by their multiplicity and characteristic distribution. They are not accompanied by pigmentary changes in white skin. The characteristically depressed scars after cutaneous leishmaniosis, in contrast, are hyperpigmented. In all instances, the borders of the scars must be carefully inspected to detect residual rims of scaling erythemas, which would be a clue for DLE.

Infection Of The Skin

The yeast Candida albicans may cause vulvovaginitis in women, especially during pregnancy, in those taking oral contraceptives, or those who are receiving systemic antibiotics for acne. It may also cause stomatitis in infants, and may exacerbate intertrigo in the body folds of obese individuals and the napkin area during infancy. The nail plate may also be infected, and the organism may cause chronic paronychia in those involved with wet-work such as bar workers or housewives. Topical treatments with imidazole creams is often effective, although more serious infections may require systemic therapy.

Structure Based Drug Design for Nuclear Receptors

Structure Based Drug Discovery

Retinoids are used in the treatment of various skin diseases, including psoriasis and acne, and in the treatment or chemoprevention of cancer, such as acute promyelocytic leukemia and skin, cervical, and breast cancer.31 RARb gene is frequently deleted or its expression is epigenetically silenced during cancer progression and RARb re-expression can restore retinoic acid-mediated growth control, suggesting that the anticancer action of retinoids is mediated by RARb. RARb has been viewed as a tumor suppressor.

Contraindications

It is important to obtain details regarding isotretinoin (Accutane, Roacutane) treatment and history of keloid or hypertrophic scar formation. Isotretinoin use necessitates a delay period of 6-12 months (depending on the skin thickness and oiliness) until chemical peel is performed. Active acne is not a contraindication for chemical peel. In these cases the peel is combined with systemic antibiotics for 2-3 weeks. It is always advisable to consider isotret-inoin treatment after the peel to avoid acne flare and scar reappearance.

Pregnancy Category B vaginal

Uses Should not be used for trivial infections. Systemic. Serious respiratory tract infections (e.g., empyema, lung abscess, pneumonia) caused by staphylococci, streptococci, and pneumococci. Serious skin and soft tissue infections, septicemia, intraabdominal infections, pelvic inflammatory disease, female genital tract infections. May be the drug of choice for Bacteroides fragilis. In combination with aminoglycosides for mixed aerobic and anaerobic bacterial infections. Staphylococci-induced acute hematogenous osteomyelitis. Adjunct to surgery for chronic bone joint infections. Bacterial endocarditis prophylaxis. Non-FDA Approved Uses Alternative to sulfona-mides in combination with pyri-methamine in the acute treatment of CNS toxoplasmosis in AIDS clients. In combination with primaquine to treat Pneumocystis carinii pneumonia. Chlamydial infections in women. Bacterial vaginosis due to Gardnerella vaginalis. Topical Use. Used topically for inflammatory acne vulgar-is. Vaginally to...

Therapy

Comedonal acne tretinoin 0.025 cream or adapalene 0.1 gel or tazarotene 0.1 gel alpha hydroxy acid preparation Inflammaroty acne tetracycline or doxycy-cline or minocycline benzoyl peroxide 5 gel azelaic acid 20 cream clindamycin 1 lotion or cream erythromycin 2 gel or cream Recalcitrant acne in women oral contraceptive containing norgestimate 0.25 mg and ethinyl estradiol 0.035 mg spironolactone prednisone Acne where sweating is an aggravating factor aluminium chloride solution Severe nodulocystic acne unresponsive to other therapies isotretinoin* Acne surgery comedone expression incision and drainage of fluctuant cysts and abscesses chemical peel microdermabra-sion intralesional triamcinolone 2-4 mg ml

Indications

Glycolic acid has been recognized as an important adjunctive therapy in a variety of conditions including photodamage, acne, rosacea, striae albae pseudofolliculitis barbae, hyper-pigmentation disorders, actinic keratoses, fine wrinkles, lentigines, melasma and seborrheic keratoses 5 . Moreover, it can reduce UV-in-duced skin tumor development and it has been proposed as a therapeutic modality against skin exfoliative conditions such as ichthyosis, xeroderma and psoriasis. In post-menopausal women a cream containing 0.01 estradiol and 15 glycolic acid, applied to one side of the face for 6 months, induces a significant improvement in reversing markers (rete peg pattern, epidermal thickness) of skin aging 6 . Glycolic acid chemical peels are an effective treatment for all types of acne, inducing rapid improvement and restoration of normal-looking skin. In these patients glycolic acid is more widely used than Jessner's solution, considering the equal treatment effect but a reduced...

Skin Preparation

To peeling thins the stratum corneum and enhances epidermal turnover 6 . Such agents also reduce the content of epidermal melanin and expedite epidermal healing. Retinoids also enhance the penetration of the peeling agent. They should be discontinued several days prior to the peeling procedure. Retinoids can be resumed post-operatively after all evidence of peeling and irritation subsides. When treating conditions such as melasma, acne, and postinflammatory hyperpigmentation, as well as darker skin types, retinoids should be discontinued 1 or 2 weeks before peeling or even eliminated from the prep to avoid post-peel complications such as excessive erythema, desquamation, and post-inflammatory hyperpigmentation. Topical alpha hydroxy acid or polyhydroxy acid formulations can also be used to prep the skin. In general, they are less aggressive agents in impacting peel outcomes. The skin is usually prepped for 2-4 weeks with a formulation of hydroquinone 4 or higher compounded...

Benzoyl peroxide

Free-radical, oxygen-mediated bacteriocidal effects on P. acnes in sebaceous follicles Basak PY, Gultekin F, Kilinc I, Delibas N (2002) The effect of benzoyl peroxide and benzoyl per-oxide erythromycin combination on the antioxidative defence system in papulopustular acne. European Journal of Dermatology i2(i) 53-57

Clinical Findings

Common name Vitamin A (deficiency xerophthalmia). Chemical name Retinol. Source Liver and vegetable carotenoids. Recommended Daily Intake (RDI) Females, 2550 years old, 2700 IU males slightly higher. Toxic dose 25,000 IU kg bolus, 25,000 IU per day every 30 days such doses have been used to treat cystic acne. Antidote None.

Topical Antibiotics

Topical erythromycin, clindamycin, and tetracycline are all effective in acne (1417). These antibiotics reduce the population of P. acnes and Staph. epidermidis, and may have a separate anti-inflammatory action. The advantage of topical antibiotics is the reduction in the risk of potential systemic side effects, and this is particularly true with topical clindamycin. Topical tetracyclines may cause some yellow staining of clothing and fluoresce under ultraviolet radiation. It is also possible that they may exacerbate the problem of bacterial antibiotic resistance.

Topical Retinoids

Topical retinoids, including tretinoin and isotretinoin, act by decreasing epidermal proliferation and reducing the abnormal keratinization process in the hair follicle. This prevents new comedones forming and softens and removes existing comedones. There is also a reduction in the level of P. acnes within the hair follicle. Although topical retinoids are of particular value in severe acne, when there are numerous comedones present, they are also effective in other forms of mild to moderate acne. Initially, there may be some increased irritation and pain, but this usually settles with use. Tretinoin cream is preferable to tretinoin gel for those with dry or fair skin.

Medical treatment

Danazol (Danocrine) has been highly effective in relieving the symptoms of endometriosis, but adverse effects may preclude its use. Adverse effects include headache, flushing, sweating and atrophic vaginitis. Androgenic side effects include acne, edema, hirsutism, deepening of the voice and weight gain. The initial dosage should be 800 mg per day, given in two divided oral doses. The overall response rate is 84 to 92 percent.

Patient Preparation

Peel preparation varies with the condition being treated. Regimens differ for photodamage, hy-perpigmentation (melasma and postinflammatory hyperpigmentation) and acne vulgaris 10 . In addition there are special issues to be considered when treating darker racial-ethnic groups (see darker skin section). A detailed history and cutaneous examination is performed in all patients prior to chemical peeling. Standardized photographs are taken of the areas to be peeled including full-face frontal and lateral views. Use of topical retinoids (tretinoin, tazaro-tene, retinol formulations) for 2-6 weeks prior to peeling thin the stratum corneum and enhance epidermal turnover. Such agents also reduce the content of epidermal melanin and expedite epidermal healing. Retinoids also enhance the penetration of the peeling agent. They should be discontinued several days prior to the peeling procedure. Retinoids can be resumed post-operatively after all evidence of peeling and irritation subsides. In...

Cosmeceuticals

The major forms of retinoids that may be of significant interest to the cosmeceuti-cal industry are retinol, retinal, and possibly, retinoic acid. The main role of retinoids in cosmeceuticals are in extrinsic aging (photoaging). Currently, topical retinoic acid is FDA-approved for the treatment of acne, and in the adjunct treatment of fine skin wrinkling, skin roughness, and hyperpigmentation due to pho-toaging, as well as reducing the number of senile lentigines (liver spots) (9-11). At present, retinol is becoming an increasingly utilized ingredient in cosmetic preparations, such as moisturizers and hair products. One reason for this is that retinol is a nonprescription preparation. It has also been demonstrated to be less irritating topically than retinoic acid (12), which makes retinol a more favorable cosmetic ingredient than retinoic acid. It is therefore necessary to review the scientific basis for use of retinoids and their purported efficacy.

Complications

It is of paramount importance that the dermat-ologic surgeon be familiar with the complications of TCA peels. These include infections (bacterial, viral, fungal), pigmentary changes, prolonged erythema, milia, acne, textural changes, and scarring. Bacterial infections include Pseudomonas, Staphylococcus or Streptococcus. In general, prophylaxis with antibiotics is not indicated and strict adherence to wound care instructions will prevent this untoward complication. In patients with a history of herpes labialis, even if remote, prophylaxis with antiviral agent is necessary. Scarring is a rare, yet feared complication of medium-depth chemical peels. Although the etiology of scarring is unknown, factors which are contributory include poor wound care, infections, uneven peeling depth, mechanical injury and previous history of ablative procedures. Localized areas of prolonged erythema, particularly on the angle of the jaw can be indicative of incipient scarring. Proper attention to risk...

Scarring

Scarring is still the most dreadful complication of chemical peels. The contributing factors are 8 not well defined yet. Incidence of scarring with traditional Baker' formula is less than 1 22 , while with less aggressive phenol peels, the incidence is lower. The most common location of the scars is in the lower part of the face, probably due to more aggressive treatment in this area or due to the greater tissue movement, because of eating and speaking, during the healing process. Previous surgical lift elevates the neck skin to the higher position, imitating normal facial skin appearance. Thus, special precautions should be taken while peeling lower lateral portions of the face in post-surgical face-lift patients, even years later. We do not recommend combining deep chemical peels with any other surgical facial procedure, since skin undermining severely compromises the post-peel healing process and increases the risk of scarring. Isotretinoin therapy interferes with normal tissue...

Erythromycin base

Mophilus influenzae, and Bacte-roides infections. Also prophylaxis of ocular infections due to Neisseria gonorrhoeae and Chlamydia trachomatis. Topical solution Acne vulgaris. Topical ointment Prophylaxis of infection in minor skin abrasions treatment of superficial infections of the skin. Acne vulgaris. Contraindications Use of topical preparations in the eye or near the nose, mouth, or any mucous membrane. Ophthalmic use in dendritic keratitis, vaccinia, varicella, myobac-terial infections of the eye, fungal diseases of the eye. Use with steroid combinations following uncomplicated removal of a corneal foreign body. Special Concerns Use of other drugs for acne may result in a cumulative irritant effect. Additional Side Effects When used topically Erythema, desquamation, burning sensation, eye irritation, tenderness, dryness, pruritus, oily skin, generalized urticaria. Drug Interactions Antagonism has been observed when topical eryth-romycin is used with clindamycin. How Supplied...

Peeling Preparations

When treating conditions such as melasma, post-inflammatory hyperpigmentation, and acne, as well as darker skin types, retinoids should be discontinued one or two weeks before peeling to avoid post-peel complications, such as excessive erythema, desquamation, and post inflammatory hyperpigmentation. The skin is usually prepped for two to four weeks with a formulation of hydroquinone 4 or higher compounded formulations (5-10 ) to reduce epidermal melanin. Other topical bleaching agents include azelaic acid,kojic acid, arbutin, and licorice (see photoaging section). Patients can also resume use of topical bleaching agents post operatively after peeling and irritation subsides 7,8 .

Definition

Acne is one of the most common skin diseases that physicians see in everyday clinical practice. It is a follicular eruption which begins with a horny impaction within the sebaceous follicle, the comedo. The rupture of the comedo leads to a foreign body inflammatory reaction which clinically presents as papules, pustules and nodules. The morphological expressions of acne are variable. Acne can affect persons of all ages, including neonates, infants and mature adults, being most prevalent and most severe during adolescence. Significant psychosocial disabilities can arise as a consequence of the disease. Patients may frequently experience poor self-image, anxiety, depression and social isolation employment opportunities also seem to be influenced by the presence of acne. As a consequence, an effective management of acne can have a relevant impact on the acne patient's life.

Epidemiology

Acne vulgaris typically begins around puberty and early adolescence it tends to present earlier in females, usually at about 12 or 13 years, than in males, 14 or 15 years, due to later onset of puberty in males. Acne has been estimated to affect 95-100 of 16- to 17-year-old boys and 83-85 of 16- to 17-year-old girls. Acne settles in the vast majority by 23-25 years of age, persisting for longer in some 7 of individuals 1 of males and 5 of females exhibit acne lesions at 40 years of age. There is a small group of individuals who develop late-onset acne, beyond the age of 25 years. Acne can present in the neonate, with an incidence that may be around 20 , considering the presence of only a few comedones. Infantile or juvenile acne (acne infantum) typically appears between the age of 3 and 18 months. Males are affected far more than females in a ratio of 4 1. The lesions usually occur on the face and in about 1 in 20 patients on the trunk. Acne infant-um seems to be predictive of severer...

Pathophysiology

The pilosebaceous follicles are the target sites for acne. The pathophysiology of acne centers on interplay of follicular hyperkeratinization, increased sebum production, action of Propionibacterium acnes (P. acnes) within the follicle, and production of inflammation (Table 11.1). Table 11.1 Pathophysiology of acne 3. Increased number of P. acnes The earliest morphological change in the sebaceous follicle is an abnormal follicular epithelial differentiation, which results in ductal hypercornification. Cornified cells in the upper section of the follicular canal become abnormally adherent. Comedones represent the retention of hyperproliferating ductal keratinoc-ytes in the duct. Several factors have been implicated in the induction of hyperproliferation sebaceous lipid composition, androgens, local cytokine production (IL-1, EGF) and bacteria (P. acnes). Sebum has a central role in the pathogenesis of acne it provides a medium for the proliferation of P. acnes. Patients with acne also...

Clinical Patterns

Acne is a polymorphic disease that occurs on the face (99 ), back (60 ) and chest (15 ). Acne vulgaris is the most common type of acne. The individual lesions of acne vulgaris are divisible into three types non-inflamed lesions, inflamed lesions and scars (Table 11.2). Table 11.2 Acne lesions Table 11.2 Acne lesions Fig. 11.1. Microcomedonic acne Fig. 11.1. Microcomedonic acne Fig. 11.3. Inflammatory acne papules and pustules total disintegration of a comedo with far-reaching consequences. The dissolution of the adjacent pilosebaceous units propagate the inflammatory reaction and the abscess can reach the subcutaneous tissue (Fig. 11.5) sinus formation between nodules may also occur, with devastating cosmetic effects. The cysts are large, skin-colored, rubbery nodules, 5-20 mm in diameter, occurring mainly on the back and less frequently on the cheeks, especially in the case of acne conglobata (Figs. 11.6,11.7 and 11.8). Histo-logically they are not true cysts as they are not lined by...

Clinical Types

Even though acne vulgaris is the most common type of acne, other forms also exist (Table 11.3). 1) Acne conglobata is a chronic, severe form of inflammatory acne, characterized by grouped comedones, cysts, abscesses, draining sinus tracts and scars. 2) Acne fulminans is characterized by multiple intensely inflamed nodules, cysts and plaques (Fig. 11.12). Systemic signs and symptoms such as fever, arthralgias, osteo- Table 11.3 Clinical variants of acne Acne vulgaris Acne conglobata Acne fulminans Acne excoriee Acne mechanica Occupational acne (chloracne) Drug-induced acne Acne neonatorum Acne infantum Acne in adults Fig. 11.12. Acne fulminans Fig. 11.12. Acne fulminans lytic lesions of the clavicles or ribs can be present. Sudden onset, usual truncal involvement and failure to respond to antibacterial therapy represent other typical features of this form of acne. 3) Acne excori e, also called acne excori e des jeunes filles, is predominantly a disease of young, adult women and almost...

Epidermoid Cyst

Pilar Epidermoid Cyst

CLINICAL PRESENTATION On the eyelid epidermoid cysts present as a slow-growing round, firm flesh-colored to yellow or white lesion within the dermis or subcutaneous tissue. On the face they may be associated and causally related to the obstructing effects of acne vulgaris and seborrhea. Epidermoid cysts are usually solitary, fluctuant, and freely movable, and are generally less than 1 to 2 cm in diameter. Sometimes a central pore or depression is seen, but this is an inconsistent finding. The cyst can be pigmented in darker skinned individuals. A foul-smelling cheese-like material may discharge from the lesion. Rupture of the cyst wall may cause an inflammatory foreign body reaction, with associated tenderness or pain. Less frequently the cyst can become infected. Rarely carcinomas, such as basal cell carcinoma, may arise within an epidermoid cyst.

Autoradiography

Autoradiographic techniques have been used extensively to visualize and quantify penetration through, and distribution within, animal (182-187) and human (405) skin. The general procedure is as follows (a) a radiolabeled permeant is applied to the skin surface (b) after a suitable time, a skin sample is excised and microtomed perpendicular or parallel to the surface to produce a section of the skin (c) the section is placed in contact with a photographic emulsion (d) exposure to radiation produces a latent image showing the pattern of distribution of the radiolabel within the sample (e) photographic development reveals the image (f) evaluation of the intensity of the image allows qualitative and quantitative evaluations of routes and degrees of permeation. The technique is particularly useful in the assessment of attempts to target drugs to specific regions of the skin. For example, compounds that act against acne are targeted at the pilosebaceous unit (186).

Isopropanol

Toxicity Gastrointestinal > dermal > CNS Gastrointestinal Caustic hemorrhagic gastroenteritis, necrotic mucosal ulcerations, late esophageal stricture. Dermal Caustic burns, contact dermatitis (iodophor), ioderma acne (iodide). CNS Metabolic acidosis, delirium, vasomotor collapse. Treatment No emesis careful aspiration lavage with starch, milk, or sodium thiosulfate to reduce most toxic elemental iodine (I2) to the least toxic iodide (I-) activated charcoal (AC) and early endoscopy. Dermal Ioderma acne. Airway Painful swelling of salivary glands with sialorrhea acute parotitis iodine mumps, upper airway obstruction. Gastrointestinal Metallic taste, nausea, vomiting, gingivitis, sialorrhea, no gastrointestinal mucosal burns. Treatment Corticosteroids for parotitis.

Laser Resurfacing

CO2 laser resurfacing may be used for many types of clinical problems however, we find it most useful in patients seeking treatment for dermatologic conditions affecting the reticular dermis. We have found that patients with acne scarring benefit more from CO2 laser resurfacing than from any type of chemical peeling. In our practice, it has supplanted dermabrasion as the procedure of choice for the treatment of acne scarring. For patients with deep ice-pick type scars, the best treatment is punch excision and grafting, followed by laser resurfacing. This has produced improved results.

Jessners Solution

Salicylic acid has been formulated in a hydro-ethanolic vehicle at concentrations of 20 and 30 for use as a superficial peeling agent 18 . It is a lipophilic agent that produces desquamation of the upper lipophilic layers of the stratum corneum. Grimes 19 treated 25 patients with skin types V and VI with salicylic acid peels. Conditions treated included acne vulgar-is, post-inflammatory hyperpigmentation, oily skin, with textural changes, and melasma. Patients were pretreated for 2 weeks with hydro-quinone 4 , followed by a series of two 20 and three 30 salicylic acid peels. Peels were performed biweekly. Moderate to significant improvement was observed in 88 of the patients treated. Minimal to mild side effects occurred in 16 . Three patients experienced hy-perpigmentation that resolved in 7-14 days. Thirty-five Korean patients with facial acne were treated biweekly for 12 weeks with 30 salicylic acid peels 20 . Both inflammatory and non-inflammatory lesions were significantly...

Disadvantages

Pictures Deep Chemical Peels

A 52-year-old patient with boxcar acne scars before (a) and 1 month after (b) deep chemical peel and skin abrasion Fig. 9.9. A 52-year-old patient with boxcar acne scars before (a) and 1 month after (b) deep chemical peel and skin abrasion Fig. 9.11. A 44-year-old patient with rolling acne scars before (a) and 3 months after (b) deep chemical peel combined with subcision and dermabrasion Fig. 9.11. A 44-year-old patient with rolling acne scars before (a) and 3 months after (b) deep chemical peel combined with subcision and dermabrasion

S160202

(NCI-H460, A549, NCI-H69, SCLC6, and NIH OVCAR-3) in terms of growth delay when given on a weekly schedule.119 It was superior to doxorubicin and cyclophosphamide against chemoresistant A549 nonsmall cell lung carcinomas in nude mice, A549 tumor cells metastases in severe combined immunodeficiency (SCID) mice, and intravenously implanted Lewis lung carcinomas.120 Preliminary conference reports of Phase I trials suggest a maximum tolerated dose of about 150 mgm _ 2, with the major toxicity being acne-like lesions.

Glycolic Acid

Glycolic acid, an alpha-hydroxy acid (AHA), has become the most widely used organic car-boxylic acid for skin peeling. Glycolic acid formulations include buffered, partially neutralized, and esterified products. Concentrations for peeling range from 20 to 70 . Several published studies have assessed the efficacy of gly-colic acid peels in darker-skinned racial-ethnic groups. A series of ten Asian women with me-lasma and fine wrinkles were treated with 2 hydroquinone and 10 glycolic acid applied to both sides of the face 13 . A series of 20-70 glycolic peels were performed on one side for comparison. Greater improvement with minimal side effects was noted on the side treated with the series of glycolic acid peels. Forty Asian patients with moderate to moderately severe acne were treated with a series of 35-70 glycolic acid peels 14 . The investigators noted significant improvement in skin texture and acne. Side effects were reported in 5.6 of patients.

Retinoids

Late 30s-40s Early senile lentigines Dyschromia Early actinic keratoses Parallel smile lines Early wrinkling Some foundation worn Mild acne scarring Usually aged 50-65 Dyschromia, telangiectasias Visible keratoses Wrinkling at rest Always wears makeup Moderate acne scarring Patient age 60-75 Actinic keratoses Prior skin cancers Wrinkling throughout Makeup cakes & cracks Severe acne scarring

Chemistry

Retinoids are naturally occurring compounds and synthetic derivatives of retinol (vitamin-A alcohol) that show vitamin A activity. There are three generations of synthetic retinoids today. Manipulation of the polar group and the polyene side chain of vitamin A forms the first generation of retinoids, which includes tretinoin (all-trans-retinoic acid), isotretinoin (13-cis-retinoic acid), and alitretinoin (9-cis-retinoic acid). The aromatic retinoids, etretinate and acitretin, are produced by replacing the cyclic end group of vitamin A with different substituted and nonsubstituted ring systems and are synthetic retinoids of the second generation. The third-generation retinoids, tazarotene and adapalene, known as polyaromatic compounds, are topical agents for the treatment of psoriasis and acne (Fig. 27.3). Bexarotene is also a third-generation retinoid and is approved for the systemic treatment of cutaneous T-cell lymphoma (Brecher and Orlow 2003, Orfanos et al. 1987).

Follicular Delivery

Lieb et al. (175,176) proposed that liposomes may be useful for targeting drugs to skin follicles for the treatment of diseases, such as acne and alopecia. Their initial experiments, using the hamster ear pilosebaceous unit, demonstrated that carboxy-fluorescein, incorporated into phospholipid liposomes, was more efficiently targeted to follicles than when formulated as a simple aqueous solution, a propylene glycol (5 ) solution, or a sodium dodecyl sulfate (0.05 ) solution (175). However, most of the carboxyfluorescein was located in the epidermis. In later experiments, application of cimetidine, incorporated in phospholipid and nonionic liposomes, was compared with its application in a 50 alcohol solution (176), and generated data that was similarly equivocal. In this case, although small amounts of drug were located within the pilosebaceous unit, most was located on the surface or within the stratum corneum (determined by tape-stripping). Nonetheless, the data showed that the...

Topical Agents

Ized, double-blind, vehicle-controlled study using tretinoin 0.1 cream for 40 weeks to treat facial PIH in black patients demonstrated significant lightening with tretinoin 0.1 cream compared with vehicle 11 . The overall improvement was initially noted after 4 weeks of therapy. Fifty percent (12 of 24) of the tretinoin-treated patients experienced erythema and desquamation however, none had any further hyperpigmentation or depigmentation as a side effect. In another double-blind, randomized, vehicle controlled study, Grimes and Callender 12 reported the efficacy of once-daily tazaro-tene 0.1 cream in the treatment of PIH from acne in patients with Fitzpatrick skin types IV-VI. Significant advantage over vehicle was noted at 10 weeks of therapy and only trace lev els of erythema, burning, and peeling were reported throughout the study. An open label study of darker-skinned patients with acne showed the utility of adapalene 0.1 gel to reduce in PIH 13 . Fig. 16.2. a Post-inflammatory...

Tazarotene

Mild to moderate facial acne vulgaris. Contraindications Pregnancy. Use on eczematous skin. Use of cosmetics or skin medications that have strong drying effect. Special Concerns Use with caution during lactation. Safety and efficacy have not been determined in children less than 12 years of age. Psoriasis may worsen from month 4 to 12 compared with first 3 months of therapy. Use with caution with drugs that cause photosensitivity. Side Effects Dermatologic Pruritus, photosensitivity, burning stinging,

Specific History

Acne most often begins in an insidious fashion with the accumulation of noninflammatory papules and blackheads. This phase is often ignored, especially by male patients, and may progress for months or years before the lesions become clinically inflammatory and are no longer easily ignored. Changes may be evident as early as ages 8 to 9 years however, the peak incidence occurs during the teens, ages 14 to 19 years. Adult onset is almost entirely limited to female patients who often remark that they never had acne as teenagers. In most patients, noninflammatory lesions accumulate over varying periods of time. This early phase may remain as such, and when it occurs without a significant number of inflamed lesions, is referred to as comedonal or grade I acne. Even this mildest type is usually associated with heavy oil secretion or seborrhea. Some patients will transition gradually to inflammatory acne, or this change may occur suddenly in an explosive fashion. If the inflammatory lesions...

Azelaic Acid

Azelaic acid is a naturally occurring dicarboxyl-ic acid (1,7-heptanedicarboxylic acid) that has demonstrated beneficial therapeutic effects in the treatment of acne and several disorders of hyperpigmentation 48 . There are minimal effects on normally pigmented human skin, freckles, senile lentigines, and nevi. The cytotoxic and antiproliferative effects of azelaic acid may be mediated via inhibition of mitochondrial ox-idoreductase activity and DNA synthesis. Disturbance of tyrosinase synthesis by azelaic acid may also influence its therapeutic effects. Azela-ic acid can be used as a hypopigmenting agent in patients sensitive to hydroquinone.

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