(1) definition and pathophysiology
Acne, commonly known as "acne", is a chronic inflammatory skin disease with hair follicle and sebaceous glands, which occurs in adolescence, and some can occur in adulthood or continue into adulthood.
Acne mostly occurs in the head and face, which is easy to cause obvious appearance damage, and its psychological and social impact on teenagers even exceeds asthma and epilepsy.
Acne is a chronic inflammatory disease of sebaceous unit of hair follicle, and its pathogenesis has not been fully clarified.
Heredity, androgen-induced sebum secretion, keratosis of sebaceous ducts in hair follicles, reproduction, verification and immune response of Propionibacterium acne may all be related to it.
(2) Epidemiology
It is reported that the incidence of acne is very high, with an incidence rate of 70-87% among teenagers. /kloc-the prevalence rate of women before 0/3 years old is higher than that of men, and most of them are closed (papular type); After 13 years old, the prevalence rate of men is higher than that of women, and the skin lesions are diversified.
At present, the age of onset is multipolar, which is no longer the patent of teenagers. On the whole, there are more women than men.
Pathogenesis Hair follicle sebaceous gland is an independent endocrine tissue of skin, which is regulated by sex hormones. After puberty, the increase of androgen level or the imbalance between androgen and estrogen can increase the secretion of sebaceous glands and sebum. Sebum provides oil and anaerobic environment for the growth of microorganisms such as propionibacterium acnes in hair follicles. Propionibacterium acne can be hydrolyzed into cell proliferation and hyperkeratosis, which hinders the secretion of sebaceous glands. Acne is formed when sebum and keratin plugs accumulate in hair follicles.
Inducing/inducing factors
1. Glucocorticoids, androgens and other drugs can induce acne or make it worse.
2. Eating habits: high-sugar diet, dairy products, etc. Can induce acne or aggravate acne, so eat less sweets and whole milk and drink more yogurt. Although the current research proves that greasy diet will not make acne worse, it is recommended to eat less high-fat food for the health of teenagers.
3. High temperature environment, such as summer, in the kitchen, if you often apply oily emulsion or foundation cream, it will induce acne. In addition, wearing a helmet often can also cause the skin to be in a high temperature environment and induce acne.
4. Psychological stress and staying up late lead to increased sebum secretion and aggravated acne.
(4) Clinical manifestations and classification
Acne mostly occurs in fatty parts such as face, chest and back, and occasionally occurs in other parts.
The course of acne is usually chronic, with mild and severe symptoms.
characteristic symptoms
1. Whitehead acne: sebum and keratinocytes accumulate, blocking the mouth of hair follicles and forming white papules without openings on the skin surface.
2. Blackhead acne: Sebum and keratinocytes are embolized in pores and have openings on the skin surface. When sebum is exposed to air, it oxidizes and turns black, forming blackheads.
3. Papules and pustules: After the pores are blocked, bacterial infection is easy to occur, and red raised papules will appear, usually accompanied by increased skin temperature and pain. If the inflammation is serious, there will be a "white hat" (pustule) at the top of the papule, which may be accompanied by severe pain.
4. Skin nodule: a hard and painful lump on the skin surface.
5. Cyst: the skin surface is painful and there is a liquid lump when touched.
Disease development
1, the initial acne has just begun to appear, such as white-headed acne and blackhead acne. White-headed acne can pick out yellow bean curd residue-like substances, and double-headed acne can be seen as black on the top and yellow on the bottom.
2, aggravated when the blocked pores are inflamed or infected by bacteria, inflammatory papules can be formed.
3, sustainable development can form unequal dark red nodules or cysts, which have a sense of fluctuation when squeezed, and even fester to form abscesses, and often form sinuses and scars after rupture.
(4) Clinical manifestations and classification
Classification according to the nature of skin lesions
1. papular acne
2. Pustular acne
3. Acne induration
4. Cystic acne
5. Atrophic acne
6. Aggregative acne
(5) Strength and classification
According to the nature of lesions, no matter how many lesions, acne can be divided into 3 degrees and 4 grades:
Mild 1 grade: only acne.
Moderate grade II: Besides acne, there are inflammatory papules.
Moderate grade III: Besides acne and inflammatory papules, there are pustules.
Severe grade IV: Besides acne, inflammatory papules and pustules, there are nodules, cysts or scars.
Second, the principle of treatment
drug therapy
First-class acne: local treatment is generally enough, and tretinoin preparation is the first choice for external use.
Type ⅱ acne: combined with tretinoin and benzoyl peroxide or antibiotics for external use, and combined with oral antibiotics if necessary.
Tertiary acne: oral antibiotics combined with benzoyl peroxide and/or retinoic acid drugs are needed. Female patients with indications can also consider antiandrogen therapy.
Grade Ⅳ acne: Oral isotretinoin is the most effective treatment and can be used as first-line treatment. For those with more inflammatory papules and pustules, antibiotics combined with benzoyl peroxide can be systematically applied first, and then isotretinoin is taken orally for sequential treatment after the skin lesions are obviously improved.
(2) Physical therapy
For patients who are intolerant or unwilling to receive medication, physical therapy and chemotherapy can also be considered.
Photodynamic therapy: Porphyrin metabolized by Propionibacterium acne is activated by light with a specific wavelength, and cell death is induced by phototoxic reaction. Stimulate macrophages to release cytokines, promote self-healing of skin lesions and achieve the purpose of treating acne. There was slight itching during the treatment, and some patients showed slight desquamation after treatment, and no obvious side effects were found. Experiments show that photodynamic therapy can inhibit sebaceous gland secretion, reduce the number of acne and inflammatory lesions, and promote tissue repair.
Laser treatment: 1450 nm laser intense pulse light pulse dye laser and dot matrix laser are one of the effective methods to treat acne and acne scars at present, and can also be used in combination with drugs. 1450 nm laser is approved by the Food and Drug Administration to treat acne. Intense pulsed light can help inflammatory acne, and the red mark disappears in the later stage. Dot matrix laser can improve acne and scar to some extent.
Acne removal: this is one of the effective methods to treat acne at present, but it must be treated with drugs at the same time to fundamentally inhibit the emergence and development of acne.
Intracapsular injection: it is helpful to quickly eliminate inflammation and is a treatment for larger nodules. Cyst is a very effective method.
Fruit acid therapy: Fruit acid widely exists in fruits and sugarcane in nature, with simple molecular structure, small molecular weight, non-toxic, tasteless, strong permeability, safe action and no damage to epidermal barrier function. The mechanism of fruit acid is to reduce cutin and form cells by interfering with the binding rate of cell surface, accelerate the shedding and renewal of epidermal cells by adhesion, stimulate the synthesis of dermal collagen and enhance the moisturizing function. The higher the concentration of fruit acid, the longer the action time, the better the effect, but the greater the relative adverse reaction.
(3) drug therapy
Retinoic acid drugs:
Objective: To improve the keratinization of sebaceous glands in hair follicles, dissolve acne and resist inflammation, and also improve and prevent scars and pigmentation after acne.
Commonly used drugs: adapalene, tazarotene, tretinoin ointment, etc.
External antibacterial drugs
Objective: To kill Propionibacterium acnes and resist inflammation.
Commonly used drugs, benzoyl peroxide, clindamycin, fusidic acid, azelaic acid, selenium disulfide salicylic acid, etc.
Oral drug therapy
antibiotic
Objective: To kill Propionibacterium acne, doxycycline and minocycline are commonly used as anti-inflammatory drugs.
Vitamin a acid
Objective: To improve the keratosis of sebaceous ducts in hair follicles, dissolve acne and resist inflammation. Mainly used for nodular cyst acne.
Common drugs, isotretinoin and viaminate.
Antiandrogen therapy.
Objective: To inhibit androgen and reduce sebum secretion.
Commonly used drugs such as spironolactone, ethinylestradiol and cyproterone tablets.
B vitamins
Objective: To control oil secretion.
Commonly used drugs, vitamin B, vitamin B6.
glucocorticoid
Objective: Anti-inflammation is mainly aimed at severe acne with severe inflammatory reaction in fulminant acne, and it is used in a small dose for a short time.
Commonly used drugs such as prednisone and dexamethasone.
External medicine
Retinoic acid cream for external use
It has the functions of regulating epidermal cutin, forming cell differentiation, improving keratinization of sebaceous duct in hair follicle, and dissolving micro-acne and acne. In addition, it also has the function of controlling pigmentation after acne inflammation and improving acne and scar formation.
It is a single first-line drug for mild acne, a combination drug for severe acne and the first choice drug for acne maintenance treatment.
Existing products include.
The first generation of retinoids,
The second generation isotretinoin gel or all-trans retinoin cream,
The tolerance and safety of the third generation adapalene gel are better than isotretinoin gel or all-trans retinoin cream, and the curative effect on non-inflammatory skin lesions is better than all-trans retinoin.
Retinoic acid cream
Indications: acne vulgaris, verruca plana, leukoplakia mucosa, pityriasis rubra, keratofolliculitis and dandruff. Adjuvant treatment of diseases.
Usage and dosage For external use, apply the medicine to acne vulgaris once every night before going to bed. For psoriasis, ichthyosis and other rashes, it is suspicious to appear in the covered area for one to three times, or wash your hands after use as directed by the doctor.
Adverse reactions for external use may cause skin irritation symptoms, such as erythema and desquamation, which may make skin lesions more obvious, but at the same time, it shows that drugs are working, not aggravating the condition. Most skin can adapt and tolerate, and the irritation can gradually disappear. If the irritation persists or worsens, the drug can be used intermittently or suspended under the guidance of a doctor.
Matters needing attention
1. Avoid direct sunlight at the drug application site.
2. It cannot be used in a large area.
3. Do not use for skin ulcers.
4. During the subsidy period, women should stop the subsidy and prohibit women of childbearing age from getting pregnant while taking medicine.
5. Avoid contact with eyes and other mucous membranes.
6. If there is burning sensation, itching, redness, etc. Stop taking the medicine, wash the local medicine and consult a doctor if necessary.
7. Used for treating acne. In the first few weeks, you can continue to treat for more than six weeks because of furniture to achieve the maximum effect.
8. This product may cause serious irritation or desquamation, so it is not suitable for skin wrinkles.
Isotretinoin gel
Indications for treating local acne vulgaris and acne.
Usage and Dosage For external use, apply a small amount to the affected area once or twice a day for six to eight weeks as a course of treatment. Clean the affected skin before taking the medicine, and then take the medicine after the skin is dry.
Matters needing attention
1. Avoid using it on lips, mouth, eyes or other mucous membranes if it is thick.
2. Sensitive skin parts such as neck should be used with caution.
3. The exposed part of the gel should be protected from sunlight. If sunlight is unavoidable, sunscreen drugs or shielding measures should be used, and fluorescent lamps should also be avoided during gel use.
4. Avoid using damaged skin, eczema-like lesions and sunburn.
Adapalene gel
Indications This product is suitable for the skin treatment of acne vulgaris with acne, papules and pustules as the main manifestations, and can also be used for the treatment of acne on face, chest and back.
Usage and dosage: After each use, clean the affected area before going to bed, and apply a thin layer on the affected area of skin after drying. For patients who have to reduce the frequency of drug use or suspend drug use, the frequency of drug use can be restored when the patient recovers the tolerance to adapalene during administration. Don't use cosmetics that cause acne and atrophy.
Adverse reactions in the first two to four weeks of treatment, the most common adverse reactions are erythema, dryness, desquamation, itching, burning or tingling. Most adverse reactions are mild to moderate, and rare adverse reactions are sunburn, skin irritation, skin disdain and tingling. Rare adverse reactions include acne, redness, dermatitis and contact dermatitis, facial edema, conjunctivitis, erythema, itching, skin discoloration, rash and eczema. If the adverse reactions are serious, we should reduce the frequency of drug use or stop taking drugs.
Precautions in case of allergy or severe irritation. After determining the degree of local stimulus response, patients can reduce the frequency of medication under the guidance of doctors. Stop the drug temporarily or completely. This product should not be used for skin with cuts, abrasions, eczema or sunburn, nor for patients with very serious acne or eczema skin wounds. When using other vitamin A acid drugs or depilatory wax alone, you should avoid using this product for treatment.
Avoid contact with eyes, lips, oral mucosa, internal hemorrhoids and other mucosal tissues. In the process of using this product, if it is delivered in the sun, the dose of solar lamp that emits ultraviolet light should be reduced to the lowest dose. For patients who are often exposed to strong sunlight and allergic to sunlight, special attention should be paid to outdoor sports. When sunlight is unavoidable, sunscreen products should be used in the treatment area. When the climate is extremely abnormal, such as strong wind or cold, it may also happen to patients treated with this product.
Benzoyl peroxide water-based gel
As a peroxide, benzoyl peroxide is backward, slowly releasing new ecological oxygen and benzoic acid, and has the functions of killing Propionibacterium acne, dissolving acne and converging.
L benzoyl peroxide can reduce the occurrence of drug resistance of propionibacterium acne. If patients can tolerate it, it can be used as the first choice for external antibacterial drugs for inflammatory acne.
This medicine can be used alone, or combined with tretinoin drugs or antibiotics for external use.
L a few sensitive skin will have mild irritation. It is suggested that patients with sensitive skin should try it from a very small range of low concentration and apply it to the affected area once or twice a day according to the severity of symptoms.
benzoyl peroxide water base gel
The indication is acne vulgaris.
Usage and Dosage: Wash the affected area, gently dry it, apply proper amount of this product to the affected area, once a day 1-2 times.
Adverse reactions can cause contact dermatitis, burning sensation, itching, redness, dry skin, desquamation and so on.
Caution: Avoid contact with eyes and other mucous membranes. If there is burning sensation, redness and swelling at the application site, stop using the medicine and wash the local medicine to avoid contact with hair and fabric to avoid discoloration. External antibiotics
L Commonly used antibiotics for external use include erythromycin, lincomycin and its derivatives, clindamycin, chloramphenicol or clindamycin.
In recent years, it has been found that fusidic acid cream for external use has good killing effect and anti-inflammatory activity against Propionibacterium acnes, and has no cross-resistance with other antibiotics, so it can also be used as one of the choices of external antibiotics for acne treatment. Because topical antibiotics are easy to induce drug resistance of Propionibacterium acnes, it is not recommended to use them alone. It is recommended to use it in combination with benzoyl peroxide or topical retinoids.
Fusidic acid cream
Indications are suitable for all kinds of skin bacterial infections. Mainly used for skin infections caused by Gram-positive cocci, such as pustulosis, furuncle, folliculitis, paronychia, beard sore, hyperhidrosis, tinea versicolor, acne vulgaris, wound infection, eczema infection, ulcer infection, etc.
Usage and dosage: This product should be applied locally to the affected area and gently rubbed. If necessary, the affected area can be bandaged with porous bandage, 2 ~ 3 times a day, and 7 days is a course of treatment. A course of treatment can be repeated if necessary.
Adverse reactions Local application of this product generally has no place to reflect, and occasionally there will be a slight irritation. The treatment of deep leg ulcer will be accompanied by pain, but it is usually not necessary to stop taking medicine. Rare allergic reaction. Caution: This product is irritating to conjunctiva, so it should be avoided around the eyes. When treating severe skin infections or intractable skin diseases. Increase the systemic drug use rate to prevent serious irritation or allergic reaction. We should stop taking drugs and switch to other drugs.
Selenium disulfide lotion
Selenium disulfide lotion can inhibit fungi, parasites and bacteria and reduce the content of free fatty acids in skin.
Usage: After cleaning the skin, slightly dilute the liquid medicine and evenly apply it to the obvious parts. After three to five minutes, wash with clear water.
Systemic medication
Retinoic acid drugs, oral isotretinoin
indicate
1. Nodular cystic acne
2. Other treatments have poor effect on moderate and severe acne.
3. Acne with scar or tendency to form
4. Acne often recurs.
5. Acne with severe sebum overflow.
6. Mild to moderate acne, but patients should quickly tell their needs.
7. The so-called patients have severe psychological stress.
8. Variants of acne, such as fulminant acne and aggregated acne, can be used after using antibiotics and glucocorticoids to control the inflammatory reaction.
Antibiotic doxycycline/minocycline
[indications]
1. The first choice for patients with moderate and severe acne.
2. Patients with severe acne, especially patients with severe inflammation, can use antibiotics in the early stage. When isotretinoin or isotretinoin is ineffective in sequence, antibiotics can be used instead.
3. Acne variability, such as fulminant acne and aggregated acne.
The dosage and course of treatment are 100 to 200mg per day, which can be taken orally once or twice after meals for six to eight weeks.
Doxycycline hydrochloride enteric-coated capsules
counteraction
Oral administration of this product to digestive system can cause gastrointestinal reactions such as nausea, vomiting, abdominal pain and diarrhea. Occasionally, esophagitis and esophageal ulcer are reported, mostly in patients who stay in bed immediately after taking the medicine.
L hepatotoxic fatty liver, degenerative patients and pregnant women are prone to occur, and patients who do not have the above conditions can also occur, and occasionally pancreatitis. Pancreatitis caused by this product may also be accompanied by hepatotoxicity, and the patient is not accompanied by primary liver disease.
Most allergic reactions are maculopapules and erythema, and a few patients may have urticaria, angioneurotic edema, allergic purpura, pericarditis and systemic lupus erythematosus. Skin lesions are aggravated, exfoliative dermatitis is uncommon, and allergic shock and asthma are occasionally seen. Some patients who use this product may appear bright in the sun, so it is suggested that patients should not directly contact the sun or ultraviolet rays during taking this product, and should stop taking the drug immediately once the skin appears erythema. The blood system occasionally causes hemolytic anemia, thrombocytopenia, neutropenia and eosinophilia. The central nervous system can increase benign intracranial pressure, which can be manifested as headache, vomiting, optic nerve, nipple and edema. The infection can be reduced after drug withdrawal. Long-term use of this product can cause digestive tract, respiratory tract and urinary tract infections caused by drug-resistant Staphylococcus aureus, gram-negative bacteria and fungi, and even lead to sepsis. The application of tetracycline drugs can reduce the normal flora in human body, make vitamin deficiency fungi multiply in large numbers, and lead to dry mouth, pharyngitis, angular stomatitis, glossitis and so on.
Caution: Overpropagation of drug-resistant bacteria may occur when using this product. In case of double infection, stop using this product and treat it accordingly. In the treatment of sexually transmitted diseases, if it is suspected that Treponema pallidum infection is complicated at the same time, dark field microscope examination and serological examination should be carried out before medication, the latter once a month, at least four times. Long-term medication should be followed up regularly to check blood routine and liver function. Patients with renal insufficiency can use drugs such as drugs without adjusting the dose. When using this product, blood urea nitrogen usually rises synchronously. This product can be taken with food, milk or carbonated drinks.
Minocycline hydrochloride capsules
counteraction
L flora imbalance, this product causes flora imbalance is more common, light cause vitamin deficiency, but you can often see double infection caused by drug-resistant bacteria such as Candida albicans. Clostridium difficile pseudomembranous enteritis can also occur.
L digestive tract reaction, loss of appetite, nausea, vomiting, abdominal pain, diarrhea, stomatitis, glossitis, perianal inflammation, etc. There should be no esophageal ulcer.
L liver damage, occasional nausea, vomiting, jaundice, fatty liver, elevated serum transaminase, hematemesis and hematochezia. In severe cases, coma and death may occur.
Renal damage can aggravate renal damage caused by renal insufficiency, leading to the increase of blood urea nitrogen and creatinine.
L affects the development of teeth. This product can be deposited in teeth and bones, causing yellow staining of teeth and affecting the normal development of bones of fetus, newborn and baby.
The main manifestations of allergic reactions are rash, urticaria, drug fever, photosensitive dermatitis and asthma. Rare systemic lupus erythematosus, if it appears, should be stopped immediately and treated properly.
L dizziness, tinnitus, ataxia, nausea and vomiting can be seen. Vestibular dysfunction often occurs in the first few doses and can be recovered after 24 to 48 hours of drug withdrawal.
There are hemolytic anemia, thrombocytopenia and neutropenia in the blood system, which makes the acid granulocyte increase.
Vitamin deficiency, occasionally vitamin K deficiency, vitamin B deficiency, normal intracranial pressure increase, occasionally vomiting, headache, diplopia, papilla edema, degeneration, swelling and other symptoms of intracranial pressure increase, should immediately stop taking drugs.
L shock, occasional shock, need to pay attention to observation. If you have discomfort, abnormal oral sensation, asthma variation, tinnitus and other symptoms. You should stop taking medicine immediately and do proper treatment.
L maculopapules, erythema, etc. Exfoliative dermatitis, mixed drug eruption, erythema multiforme and Shiloh syndrome can be seen occasionally. Long-term use of this product may occasionally cause pigmentation of nails and skin mucosa.
Matters needing attention
L Use with caution in patients with liver and renal insufficiency (until they pass through obstacles), elderly people with oral malabsorption or unable to eat, and patients with deteriorating general condition.
Because of its vestibular toxicity, this product can not be used as a therapeutic drug for Neisseria meningitidis carriers and Neisseria meningitidis infections.
L because it can cure dizziness, fatigue and so on. Drivers engaged in dangerous machine operation and aerial work should avoid taking this product.
L this product will cause esophageal ulcer when it disintegrates in the esophagus, so drink plenty of water, especially when taking it before going to bed.
L liver and kidney function should be checked regularly during medication.
Patients with acute gonococcal urethritis or secondary syphilis should usually undergo dark field examination. When other types of syphilis are suspected, serological examination should be carried out every month for at least four months.
The dose of patients with severe renal insufficiency should be lower than the usual dose. If long-term treatment is needed, the blood drug concentration should be monitored.
L this product is easy to cause photosensitive dermatitis, so you should avoid sun exposure after taking it.
L This product can be taken together with food, milk or carbonated drinks.
Antiandrogen drugs and oral contraceptives
indicate
1. Acne problems with hyperandrogenism usually occur in the middle and lower parts of the face, especially in the mandible, with or without irregular menstruation and hirsutism.
2. Female post-adolescent acne
3. Acne that was significantly aggravated in the early stage.
4. Conventional treatment, such as systematic use of antibiotics, or even systematic use of tretinoin to treat patients with poor response or rapid recurrence after withdrawal.
Commonly used contraceptive doses and courses include ethinylestradiol, cyproterone and estradiol. Drospirenone was stopped for seven days after 2 1 day from the first day of menstrual cycle, and repeated for 2 1 day after menstruation again. It takes two to three months to take effect, usually for more than six months. It is generally recommended to consolidate for one to two months after the skin lesions are completely controlled, and stop taking drugs. Withdrawing drugs prematurely will increase the frequency of recurrence.
Glucocorticoid prednisone
Indications explosive acne, aggregated acne and premenstrual acne
Dosage and course of treatment
1. Pox explosion: prednisone, 20-30mg daily, divided into two or three times. After four to six weeks of oral administration, the dose gradually decreased, and it was used or replaced with isotretinoin.
2. Polymeric acne, prednisone 20 to 30 mg per day for two to three weeks, and gradually reduced to stop taking medicine within six weeks.
3. For premenstrual acne, the physiological dose is 5 mg of prednisone or 0.75 mg of dexamethasone, taken every night. Take it seven to ten days before menstruation every time until menstruation comes.
Adverse reactions A large dose of this product is easy to cause diabetes, peptic ulcer and NecCushing's syndrome, and has a strong inhibitory effect on hypothalamus, pituitary gland and adrenal axis, with infection as the main adverse reaction.
Matters needing attention
1. After long-term medication, the dosage should be gradually reduced before stopping medication.
2. Use with caution in patients with diabetes, osteoporosis, liver cirrhosis, renal insufficiency and hypothyroidism.
3. For patients infected by bacteria, fungi and viruses, adequate and sensitive antibiotics should be used with caution.
4. Long-term high-dose use of glucocorticoid should be avoided to avoid adverse reactions such as hormonal acne or folliculitis.