The Basic Lesion in .NET

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The Basic Lesion
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The fundamental acne lesion is the microcomedo, or microcomedone, an enlarged hair follicle full of sebum and P acnes Although there is a long list of materials that can cause comedones, the mechanism of spontaneous comedone formation is unknown11 The comedo that remains beneath the skin is a whitehead; a comedo that opens to the surface of the skin is labeled a blackhead because it appears black on the epidermis The diverse array of other acne lesions includes papules (small, inflamed lesions presenting as pink, tender, nonpustular bumps); pustules (small, inflamed, tender, pustular lesions, usually red at the base); nodules (relatively large, spherical, painful lesions located deeper in the dermis); and cysts (even deeper, inflamed, pustular, painful lesions that can cause scarring) (Figs 15-4 and 15-5)
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There are several therapeutic regimens for acne, most of which focus on prevention of future eruptions rather than treatment of present lesions This is the reason that the majority of treatments take 8 weeks to work Only salicylic acid, benzoyl peroxide, and steroids treat lesions already visible on the skin Steroids, BOX 15-1 Conditions That Can Be Confused with Acne Adenoma sebaceum Keratosis pilaris Perioral dermatitis Pityrosporum folliculitis Rosacea Seborrheic dermatitis Steroid abuse/use dermatitis Tinea barbae
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FIGURE 15-2 Open comedones and in ammatory papules on the neck
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Desquamated cells clog follicle
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CHAPTER 15 ACNE (TYPE 1 SENSITIVE SKIN)
Bacteria moves in
Bacteria, inflammation Pus, bacteria and cells Rupture of follicle wall
FIGURE 15-3 A close-up of the hair follicle and sebaceous gland demonstrating the different stages of acne A Desquamation of keratinocytes occurs in the same way that it does on the skin s surface However, instead of sloughing into the environment, the keratinocytes slough into the hair follicle This is a continuous and normal process that represents the culmination of the cell cycle B The rst stage of acne is also known as comedogenesis The sloughed cells stick together inside the hair follicle, resulting in a clogged pore or comedone This is caused by several factors including increased amounts of sebum, in ammation of the sides of the hair follicle preventing the release of the desquamated keratinocytes, and inceased cohesion of keratinocytes C The keratinocyte plug and sebum is an excellent food source for bacteria The bacteria invade the comedone and release in ammatory factors that lead to the next stage of acne D In ammation continues with increased redness and pus This is clinically detectable as a papule or pustule E Continued in ammation may lead to so much in ammation that the hair follicle ruptures and the bacteria and debris are released into the dermis When severe, this can lead to scarring although frequently used, are not advised because they can lead to steroid acne Five basic principles govern the successful treatment of acne: from sticking together (Box 15-2) Retinoids achieve this goal by reducing the positive and negative charges that render the cells sticky and by decreasing the levels of transglutaminase an enzyme responsible for cross-linking cell membrane proteins of the keratinocytes In fact, tretinoin has been said to have superior ability to eradicate existing comedones and prevent the formation of BOX 15-2 Products That Block Step 1 (Retinoids) Tretinoin (Avita , Renova , Retin-A , Retin-A Micro , Atralin ) Adapalene (Differin ) Tazarotene (Tazorac ) Retinol, retinyl linoleate, retinyl palmitate Oral retinoids: isotretinoin (Accutane , Claravis, Sotret, Amnesteen)
The Five Steps
NORMALIZING KERATINIZATION/EXFOLIATION The first step in controlling acne is to prevent the exfoliated keratinocytes
onset of therapy14 All oral retinoids have teratogenic effects and patients should be cautioned to avoid pregnancy while taking these medications ELIMINATING OR REDUCING P ACNES BACTERIA The use of antibiotics or benzoyl peroxide attacks the bacterial population thereby decreasing the level of inflammatory extracellular products induced by P acnes (Box 15-3) The two antibiotics that are most commonly used in the treatment of acne, and have been shown to be equally effective,15 are erythromycin and clindamycin In addition to being antibacterial, these agents exhibit anti-inflammatory activity as they lower the percentage of inflammatory free fatty acids produced by bacterial digestion of surface lipids16 The escalating incidence of antibiotic resistance is also an important consideration when treating the bacterial aspect of acne Recent research suggests that as many as 60% of acne patients exhibit antibiotic-resistant strains of P acnes17 A recent review of 50 controlled trials found that there was a gradual decrease in the efficacy of topical erythromycin, but that the efficacy of topical clindamycin stayed the same17 The preponderance of bacteria remain sensitive to medication in most of these patients, but an increasing number of patients have gradually developed less sensitive or more resistant strains Regardless, the use of two modalities (ie, benzoyl peroxide and a topical antibiotic) in acne therapies has been shown to decrease the resistance Although standard dosing regimens of oral antibiotics remain a mainstay of treatment, newer lower-dose antibiotic formulations represent submicrobial dosing and again are seen as a prudent approach to combating bacterial resistance With such low-dose antibiotics, the drug works as an antiinflammatory agent rather than an antimicrobial Benzoyl peroxide kills bacteria by generating reactive oxygen species in BOX 15-3 Products That Affect Step 2
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