Acne, commonly known as “acne” or “pimples”, is a chronic inflammatory skin disease that occurs mostly in adolescents. -If left untreated or improperly prevented, it can leave a lifelong scar that affects the appearance of young patients.
Causes of Acne]
The causes of acne are complex and related to a variety of factors, such as unreasonable diet, mental stress, internal organ dysfunction, poor living or working environment, lack of certain trace elements, genetic factors, and constipation. But the main cause is the maturity of puberty, the body androgen levels rise, and stimulate sebum and hair follicles shed epithelial cells, gathered into yellow-white material embolism in the hair, that is, the formation of powder now when acne. If it is difficult to discharge sebum from the small follicle mouth and form small grayish white papules, that is, whitehead acne. The pimples that are exposed outside the follicle opening become black when they are contaminated with air, dust, and gas, which is called blackhead pimples. In addition, there is a large number of Propionibacterium acnes in the lumen of the hair follicle. This causes inflammation of varying degrees in and around the hair follicles, resulting in pus, nodules, cysts, or pimples. Repeated inflammation over a long period of time can leave unhealed scars on the face, making the skin uneven and rough.
Grading of Acne]
Acne classification is an important basis for acne treatment and efficacy evaluation. According to the nature and severity of acne lesions, acne can be divided into three or four grades.
Grade 1 (mild): Only acne is present.
Grade 2 (moderate): Inflammatory papules in addition to acne.
Grade 3 (moderate): Pustules in addition to pimples and inflammatory papules.
Grade 4 (severe): nodules, cysts or scarring in addition to acne, inflammatory papules and pustules.
Treatment of acne
I. Local treatment local cleaning: Attention should be paid to washing the face with water to remove the mixture of oil and dander and bacteria from the skin surface. However, excessive washing should not be done. Do not squeeze or scratch the acne with your hands. In addition, avoid using oil and grease, powder skin care cosmetics and ointments and creams containing hormonal ingredients.
Topical medication
1. Vitamin A acid drugs
(1) 0.025%~0.1% retinoic acid (all-trans retinoic acid) cream or gel: This agent can regulate the differentiation of epidermal keratin-forming cells and dissolve and discharge acne. The skin is mildly irritated at the beginning of 5~12 days, such as local flushing, flaking and tightness or burning sensation, but it can gradually disappear. Therefore, it should be applied once a day at night starting from low concentration to avoid increasing drug irritation after light exposure, and topical application once a week after symptoms improve.
(2) 13-cis-retinoic acid gel: regulates the differentiation of epidermal keratin-forming cells and reduces sebum secretion, once or twice daily.
(3) Third-generation retinoids: 0.1% adapalene gel, once a night, has good efficacy in the treatment of mild to moderate acne. 0.1% tazarotene cream or gel, used once every other night to reduce local irritation.
2. Benzoyl peroxide: This drug is a peroxide that slowly releases neo-oxygen and benzoic acid after topical application, which can kill Propionibacterium acnes, dissolve acne and have an astringent effect. It can be formulated into 2.5%, 5% and 10% lotions, emulsions or gels of different concentrations, and should be used from low concentrations. The gel containing 5% peroxymethylphenidate and 3% erythromycin can improve the efficacy.
3. antibiotics: erythromycin, chloramphenicol or clindamycin, formulated with alcohol or propylene glycol at 1% to 2%, are more effective. 1% chloramphenicol phosphate solution is a water-soluble lotion free of oil and alcohol for acne patients with dry and sensitive skin. 1% chloramphenicol hydrochloride solution is equally effective.
4. Azelaic acid: It can reduce the flora on the skin surface, in the hair follicles and sebaceous glands, especially has an inhibitory effect on Propionibacterium acnes and acne lysis effect, and is effective for different types of acne. It can be formulated as 15%-20% cream for external use, with the side effects of local erythema and stinging pain.
5. Selenium disulfide: 2.5% selenium disulfide lotion has the effect of inhibiting fungi, parasites and bacteria, and can reduce the free fatty acid content of the skin. Use for clean skin, slightly diluted with the solution, evenly coated in the seborrhea obvious parts, about 20min and then wash with water.
6. 5-10% sulfur lotion: It has the function of regulating the differentiation of keratin-forming cells and reducing free fatty acids in the skin, and it also has a certain inhibitory effect on Propionibacterium acnes.
Second, acne antibiotic treatment oral antibiotics is one of the effective ways to treat acne, especially moderate to severe acne. Among the many colonizing microorganisms (including Staphylococcus epidermidis, Propionibacterium acnes, Malassezia furfur and other gram-negative bacilli), only live Propionibacterium acnes is clearly associated with the aggravation of the inflammatory response to acne. In addition to infection-induced inflammation, immune and nonspecific inflammatory responses are also involved in the formation of inflammatory damage in acne, so antibiotics that can both inhibit Propionibacterium acnes reproduction and take into account nonspecific anti-inflammatory effects should be given priority. Combining the above factors with the pharmacokinetics of antibiotics, especially selective distribution at the seborrheic site, tetracyclines should be preferred, followed by macrolides, and others such as cotrimoxazole and and metronidazole can be used as appropriate, but β-lactam antibiotics should not be chosen. Among the tetracyclines, first-generation tetracyclines such as tetracycline are poorly absorbed orally and have low sensitivity to Propionibacterium acnes. Second-generation tetracyclines such as minocycline, doxycycline and lymetetracycline should be preferred, and the two should not be substituted for each other. For systemic infections currently the main or commonly used antibiotics such as clarithromycin, roxithromycin and levofloxacin are avoided. Since the important basis for effective antibiotic treatment of acne is the inhibition of Propionibacterium acnes reproduction, rather than the predominantly nonspecific anti-inflammatory effect, it is important to prevent or slow down the development of resistance in Propionibacterium acnes, which requires the standardization of drug dosage and regimen. Usually, the daily dose of minocycline and doxycycline is 100-200 mg, which can be taken orally once or in 2 doses; tetracycline is 1.0 g daily, taken orally in 2 doses on an empty stomach; erythromycin is 1.0 g, taken orally in 2 doses. The course of treatment should be no less than 6 weeks, but should not exceed 12 weeks. Antibiotics for acne mainly inhibit the reproduction of Propionibacterium acnes, rather than non-specific anti-inflammatory effects, so it is important to prevent or slow down the development of drug resistance in Propionibacterium acnes. Usually, the dose of minomycin and doxorubicin is 100-200mg/d, which can be taken orally once or in 2 doses, tetracycline 1.0g/d, taken orally in 2 doses on an empty stomach, and erythromycin 1.0g/d, taken orally in 2 doses. The treatment course is 6-12 weeks.
Antibiotic treatment of acne should pay attention to how to avoid or reduce the development of drug resistance. This includes.
① Avoiding individual use for acne treatment, especially long-term topical application.
② Treatment should be started in adequate doses and should not be reduced for maintenance once effective.
③ Discontinue or switch to other antibiotics when there is no efficacy 2-3 weeks after treatment, and pay attention to patient compliance and differentiate between gram-negative bacterial folliculitis.
(iv) Adequate course of treatment should be ensured and intermittent use should be avoided.
⑤Propionibacterium acnes is a parasitic bacterium of normal skin, and treatment is aimed at effectively inhibiting its reproduction rather than achieving complete elimination; therefore, the dose should not be unprincipledly increased or the course of treatment extended, much less as a maintenance treatment or even as a relapse prevention measure.
(6) Drug resistance of Propionibacterium acnes can be monitored when available to guide the rational clinical use of drugs. The treatment should pay attention to the adverse drug reactions, including the more common gastrointestinal reactions, drug rash, liver damage, photosensitivity reactions, vestibular involvement (such as dizziness and vertigo) and benign intracranial pressure elevation syndrome (such as headache), etc. Rare adverse reactions include lupus-like syndrome, especially the application of minomycin. It should be used with caution or disabled for patients with long-term alcohol consumption, hepatitis B, photosensitive dermatitis, etc. Tetracyclines should not be used in pregnant women and children under 16 years of age.
Dividing the daily dose of minomycin into oral doses or using the extended-release dosage form once a night may partially reduce adverse reactions. Discontinue the drug promptly in case of serious adverse reactions or if the patient cannot tolerate it and treat the symptoms. Both macrolides and tetracyclines are prone to drug interactions, and care should be taken when combining other systemic drug treatments.
3. Systemic retinoic acid treatment for acne Oral isotretinoin is the standard treatment for severe acne and is currently the most effective treatment for acne. Isotretinoin acts on all pathophysiological factors in the development of acne. Although the therapeutic effect is remarkable, considering its side effects, isotretinoin is not used as the preferred treatment for mild acne as much as possible.
Fourth, hormone therapy for acne is currently believed to play a role in the development of acne. Due to its heavy side effects, estrogen or anti-androgen therapy can be used for female acne with high androgenicity or late onset adult acne and premenstrual acne that is significantly aggravated. 1 Estrogens: Estrogens include two major categories: estrogen and progestin. The FDA approves contraceptive pills for the treatment of acne in women over the age of 15. The current drug of choice is often: Daing-35 (Diane35) (each tablet contains 2mg of cyproterone acetate + 35ug of ethinyl estradiol). 2 Anti-androgen therapy Androstadienone: It is an aldosterone compound.
Mechanism of action.
①Competitive inhibition of dihydrotestosterone binding to receptors on skin target organs, thus affecting its action and inhibiting the growth of sebaceous glands and sebum secretion.
②Inhibits 5a reductase and reduces the conversion of testosterone to dihydrotestosterone. Not recommended for male patients. Metacycline (cimetidine): It has a weak anti-androgenic effect and can competitively block the binding of dihydrotestosterone to its receptor, but does not affect the serum androgen level, thus inhibiting sebum secretion.
3. Application of glucocorticoids Glucocorticoids have the function of inhibiting androgen secretion caused by hyperadrenocorticism, anti-inflammatory and immunosuppressive effects. Oral glucocorticosteroids are mainly used for violent acne or coalescent acne.
V. Chinese medicine treatment of acne
1. Chinese herbal medicine should be used to treat acne by type and add or subtract with the symptoms, which is one of the effective methods of acne treatment. The treatment for acne with papules is to clear the lungs and stomach; for acne with pustules, to detoxify and disperse the nodes; for acne before menstruation, to regulate the flushing method; for acne with aggregates, pigmentation or scarring after healing, to activate blood circulation and disperse stasis.
2.Acupuncture therapy: The acupuncture points of Dazhi, Spleen Yu, Foot Sanli, Hegu and Sanyinjiao are often selected. Ear acupuncture uses the lung points on both sides of the patient’s ear as the main acupuncture points, together with Shen Men, sympathetic and endocrine points.
VI. Physical therapy for acne Physical therapy is the best choice for acne patients who are intolerant to medication or unwilling to receive medication.
1. Photodynamic therapy (PDT): By using specific wavelengths of light to activate the porphyrins metabolized by Propionibacterium acnes, acne is treated through phototoxic reactions, induction of cell death and stimulation of macrophages to release cytokines and promote self-healing of lesions. At present, we mainly use blue light (415nm), blue light and red light (630nm) combined therapy and red light + 5-ALA therapy to treat various types of common acne.
2. Laser therapy: 1450nm laser, intense pulsed light (IPL), pulsed dye laser and fractional laser are currently one of the effective methods for treating acne and acne scars, and can also be combined with medication.
Graded treatment of acne]
The grading of acne reflects the severity of acne and the nature of the lesions. Therefore, acne treatment should be based on its grading by selecting the appropriate treatment drugs and means, reflecting the individualization of acne treatment.
Grade 1: Topical treatment is generally used. If only acne is present, topical retinoid preparations are the best choice. Patients with inflammatory papules and pustules may be treated with peroxymethylphenidate or other topical antibacterial agents to improve efficacy, if necessary. Patients with high psychological burden are treated with psychological counseling as necessary.
Grade 2: Treatment for grade 1 acne is usually used, but oral antibiotics may be used for those with more inflammatory papules and pustules and where topical treatment is not effective. This type of acne can also be treated with combination therapy, such as oral antibiotics plus topical retinoid preparations, or with physical therapy methods such as blue light and photodynamic therapy, and Chinese medicine.
Grade 3: This type of patient often requires a combination treatment approach in which the systematic use of antibiotics is one of its basic treatments and the course of treatment should be adequate. The use of hormonal therapy is also effective in female patients who require contraception or have other gynecological indications, and Chinese medicine can improve the efficacy of each treatment.
Grade 4: Oral isotretinoin is the most effective treatment for this group of patients and can be used as first-line therapy. For those with more inflammatory papules and pustules, a combination of systemic antibiotics and topical peroxynivalenol can also be used first. After these lesions improve significantly, the treatment can be switched to oral isotretinoin for the remaining lesions such as cysts and nodules. The methods used for grade 3 acne and the combination therapy described above can also be tried.
Combination therapy for acne] Combination therapy is currently the standard treatment for mild to moderate acne.
Advantages of combination therapy.
1. The clinical efficacy of antibiotics combined with topical retinoids is significantly better than that of antibiotics alone.
2. Faster on inflammatory damage and acne.
3. combination can target different pathophysiologic factors.
4. topical application of retinoic acid can increase the penetration of antibiotics and accelerate the action of antibiotics
5. Benzoyl peroxide is added to topical retinoic acid and oral antibiotics to reduce the incidence of drug resistance. A combination of treatments that take advantage of each can achieve better results.
Maintenance treatment for acne] All current treatments for acne only inhibit its pathogenesis. The process of microcomedema formation remains permanent and continuous after acne is cleared, and avoiding the formation of microcomedema has a preventive effect. Therefore, it is necessary to follow all treatments with maintenance therapy. Maintenance treatment regimen: Topical topical retinoic acid is the main choice for maintenance treatment for 6-12 months; azelaic acid and salicylic acid can be chosen for the second line.
[Acne Precautions] 1. Cleanse the face, wash the face with warm water 2 – 3 times a day, use neutral or alkaline soap, or facial cleanser, to remove excess oil from the skin surface and clear the blocked aggregates in the pores, use neutral or alkaline soap or facial cleanser to remove excess oil from the skin surface and clear the blocked aggregates in the pores, so that sebum Normal discharge. 2. Do not squeeze or pinch acne pimples to avoid infection and inflammation and scarring. 3. Eat less spicy and oily food, eat more vegetables and fruits, and drink more water. Keep your bowels clear. 4, patient treatment under the guidance of a doctor, do not use corticosteroids indiscriminately, keep optimistic emotions. 5, choose suitable cosmetics, should not use oily and modifying cosmetics.