Complex therapy of late acne in women

Relevance of the topic

For decades, acne has been viewed as a disease predominantly of young people, with the term “juvenile acne” widely used, with a clear definition of complete recovery between the ages of 20 and 24 years. However, in recent years there has been a steady increase in the number of patients with late forms of acne [1⎼2].

Thus, according to a study conducted in the USA between 1990 and 1999, it was found that the average age of acne patients increased from 26.5 to 40.5 years. However, when studying publications 30–40 years ago devoted to this issue, information about the problem of late-onset acne is sparse.

In the doctoral dissertation of Professor Yu. Korolev “Clinicology, etiology, pathogenesis and treatment of seborrhea and its complications,” it is noted that in some women, activation of acneiform rashes develops at the age of 18–26 years. The author noted that, as a rule, this was preceded by disorders of the hormonal activity of the ovaries after pregnancy, abortion, inflammatory diseases of the uterus and appendages, general severe diseases, and mental trauma [3].

Decades later, the dermatological community again turned to this problem, but only in the last ten years have serious studies appeared on the study of late forms of acne in women.

Decades of experience on this issue led to the creation of a consensus in 2013 called “Female Acne: A New Paradigm” with the participation of such recognized experts in the field as Dreno B., Layton A., Zouboulis CC. This document has been revised and updated with new data in June 2016 [4⎼5].

One of the main issues discussed in the literature devoted to the problem of late forms of acne is the age of patients, when we can speak with confidence about this particular disease. Summarizing the study, the authors believe that this dermatosis occurs in a large number of women over the age of 25 years.

It is important to note that today there are three known subtypes of late acne in women, depending on the time of onset:

• persistent acne (continuous or recurrent since adolescence) – 80%;
• acne with late onset, or late acne that first appeared in adulthood – 20–40% of cases;
• recurrent acne, or acne with light spaces, is the third subtype of acne in women, distinguished by S. Preneau and B. Dreno. They develop in women who have a history of acne in adolescence and resolve within several years, are characterized by a long period of remission and reappear in adulthood (but, unfortunately, this subtype of acne is the least studied).

All types are characterized by inflammation, pigmentation disorders and scarring.

Fundamental differences between late acne

In our opinion, an important issue is the fundamental differences in the morphological and topographical signs of late acne in women. In this age group, lesions are localized predominantly in the lower part of the face: in the cheek area, around the mouth and lower part of the chin, much less often the middle and upper part of the face are involved. Involvement of the back, chest, and shoulder girdle in the pathological process is observed much less frequently, as a rule, after mechanical impact, the use of massage oils, comedogenic body care products, intense exercise in the gym, due to the abuse of protein shakes and dietary supplements, vitamin complexes .

It should be noted that late acne in women is characterized by a predominance of papular elements of an inflammatory and non-inflammatory nature; nodules, comedones and especially pustules are much less common.

Taking into account the constant presence of patients in this group in a state of chronic stress, often accompanied by psycho-vegetative disorders and maladjustment, the nature of the complaints prevails over the objectification of the clinical picture. Patients often note severe pain, a feeling of fullness, pressure, pulsation in the lesions, severe itching and burning, which, in turn, leads to a significant decrease in the quality of life.

Currently, two main clinical forms of late acne in women have been identified:

• inflammatory form: according to the literature, occurs in 58% of women. This form is characterized by the appearance of papular-pustular elements, and in extremely rare cases - nodes. Increased work of the sebaceous gland in the form of seborrhea is slightly expressed;
• non-inflammatory (retention) form, which is much less common. In this form, as a rule, open and closed comedones are observed; against the background of increased sebum secretion, inflammatory elements are less common [6].

When assessing the clinical manifestations of late acne, a significant aspect, in our opinion, is the presence of signs of skin hypersensitivity, such as areas of redness and peeling, and the presence of a vascular component in the form of telangiectasia. The phenomena of photodamage and chronoaging of the skin should also be taken into account. Signs of skin dehydration, characteristic of this age group, may be aggravated by previous drug treatment, as well as irrational basic skin care.

All of the above aspects have not yet allowed us to stop studying this issue and force us to look for more and more new methods for correcting this problem.

Treatment of patients with acne at any age is carried out taking into account the clinical picture, severity, and should also be aimed at basic correction of the dominant links in the development of the disease. At the same time, we must remember that topical therapy and medicinal cosmetics are a very important component of accompanying therapy, and in the future they can play the role of active prevention of disease relapses. In recent years, a wide range of care products for acne-prone skin has appeared in the arsenal of dermatologists and cosmetologists.

All drugs can be divided into two large groups: pharmaceutical and cosmetic (or parapharmaceutical). From the first group of drugs, the doctor “designs” a treatment regimen in each specific case. It is necessary to remember that each drug affects its own pathogenesis link and has its own “zest”. The purpose of the second is auxiliary care, maintaining the skin in good condition both during treatment procedures and after the therapeutic effect is achieved.

In an acute process, the doctor’s primary task is to relieve inflammation. For this purpose, external antibacterial drugs are used: “Zinerit” (zinc with erythromycin), “Baziron” (it contains benzoyl peroxide, as well as softening, moisturizing additives), “Dalacin-T”, “Delex-acne”. The latter drug is interesting because it contains sulfur, traditionally used in the treatment of acne, which inhibits the development of demodex mites, quickly relieves inflammation and has a resolving effect.

When the acute inflammatory process is stopped, the problem of eliminating deep plugs remains. At this point, it is worth prescribing drugs with anti-inflammatory and keratolytic effects. This could be Differin (at the initial stage - in gel form, later - in the form of a cream). “Differin” (“Adapalene”) is interesting for its ability to “pull out” deep blockages of the sebaceous gland; it also provides better removal of closed comedones during cleaning. Skinoren is used for more superficial blockage of the sebaceous gland, open comedones, and mild acne.

Finally, at the next stage, when the skin has generally cleared up, the task of rehabilitation arises. In this case, we also use Skinoren, but for a long time - for 2-3 months. It removes the last inflammatory elements and helps give the skin a smooth and healthy appearance, evens out the surface of the skin, and regulates its acidity. In addition, this drug has a slight whitening effect, which allows you to get rid of often occurring post-traumatic pigmentation.

Systemic therapy

Indications for oral therapy among patients with acne include both patients with moderate and severe forms of the disease, and patients with mild forms of the disease. Oral therapy includes antibiotics, antiandrogens and retinoids (Roaccutane). The choice of treatment is based, firstly, on the severity of the disease and, secondly, on taking into account the patient's response to previous therapy. Thus, in severe nodular cystic form, treatment should begin with isoretinoin (Roaccutane) as early as possible, since the effect of antibiotic therapy, even in large doses, is insignificant.

Many years of experience have shown that the most severe forms of acne can be perfectly cured with a non-hormonal drug containing retinoids - Roaccutane. Perhaps, now this drug is one of the most famous in the world for the treatment of acne, which is associated with its lasting effect. Treatment with this drug requires a lot of experience from the doctor, since an individual dose is selected for each patient depending on the severity, form of the disease and weight at each stage of treatment. During the treatment process, the doctor adjusts the dose taking into account the patient’s individual sensitivity to Roaccutane.

Mesotherapy

The inclusion of homeopathic and antihomotoxic drugs in mesotherapy treatment regimens for acne increases the efficiency of the cosmetologist. It is very important that these injections can be carried out not only in the problem area, but also at acupuncture points on the body and limbs, which affect the condition of facial tissues. All this enhances the results of mesotherapy. It is undesirable to carry out mesotherapy in an acute condition against the background of hyperemia, swelling, pustulization, but only after the removal of acute inflammatory phenomena. Mesotherapy is more often used to restore skin with post-acne.

Materials and methods

Rice. 1

We observed 30 patients aged from 25 to 37 years (Fig. 1):

• 13 (43%) patients had recurrent acne;
• 10 (33%) patients had acne with late onset;
• 7 (24%) had persistent acne.

All patients underwent a comprehensive examination: general clinical tests, hormonal profile examination on days 3–5 and 21 of the menstrual cycle, urine steroid profile was determined in the 2nd phase of the menstrual cycle, ultrasound of the pelvic organs on days 5–10 menstrual cycle, a consultation with a gynecologist-endocrinologist was also carried out.

Studies of the functional properties of the skin (sebometry, corneometry, pH-metry) were carried out before and after therapy using the Soft Plus device (Italy). For visual assessment and photo documentation, a Fotofinder digital dermatoscopy device (Germany) was used.

Statistical data processing was carried out using the Statistica 6 program.

Study design

According to the examination results, endocrine pathology was identified in 19 patients (63%):

• hyperandrogenism of ovarian origin was determined in 6 patients (32%);
• hyperandrogenism of adrenal origin occurred in 4 women (21%);
• in 1 patient (5%) hyperandrogenism of neuroendocrine origin was detected;
• 8 women (42%) were diagnosed with hyperandrogenism of mixed origin.

Therapy for this group of patients was carried out jointly with a gynecologist-endocrinologist; correction included hormonal replacement therapy, selected by a specialist depending on the type of hyperandrogenism.

The second group – 11 women (37%) – included patients without changes in hormonal-endocrine status.

Daily care for patients in both groups included gentle cleansing with a cleansing gel, then toning with lotion for oily and problematic skin. The anti-inflammatory and drying “Purity Concentrate” was applied locally only to the inflammatory elements 1–2 times a day.

The final stage of daily care was the application of a sebum-regulating and moisturizing cream for oily and problematic skin.

As decorative cosmetics, all patients used exclusively sebum-regulating foundation, the peculiarity of which is its therapeutic effect and the simultaneous absence of a comedogenic effect.

Professional care for patients was carried out once every 7–10 days in a clinical setting and included the additional use of a bacteriostatic absorbent mask for oily and problematic skin, Anti-Acne ampoules, and an alginate modeling cryogenic mask for oily and problematic skin.

Results and research

During the therapy, both groups showed positive dynamics of the pathological process on the skin (photo 1):

• the number of newly appeared inflammatory and comedogenic elements of the rash decreased, especially in the group of patients receiving basic therapy prescribed by a gynecologist-endocrinologist;
• skin color has improved, the number of enlarged pores has decreased;
• a decrease in sebum secretion was confirmed objectively according to sebumetry data;
• in both groups an increase in skin hydration was noted;
• The patients also noted an improvement in skin turgor and elasticity, and the absence of redness and skin irritation;
• Normalization of the pH level (slightly acidic environment) was objectively noted.

conclusions

The problem of late acne in women remains one of the most significant in modern dermatology. Late acne has clear clinical and morphological differences and a special nature of the course of the disease in comparison with acne in adolescents. The therapeutic approach in this group of patients should be comprehensive, combining the use of systemic therapy and adapted medicinal cosmetics.

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