Features of pubertal and post-pubertal acne

Yana Yutskovskaya, MD, professor, doctor of the highest category, owner of the network of clinics LLC "Professor's Clinic Yutskovskikh" (Vladivostok) and LLC "Professor Yutskovskaya's Clinic" (Moscow), owner of the "School of Professor Yutskovskaya", member of the board of directors of NADK , freelance expert of Roszdravnadzor of the Ministry of Health of the Russian Federation, President of the Association of Gender Medicine

Alexandra Sukhanova , intern doctor of the Department of Skin Diseases and Cosmetology of the Federal Postgraduate Educational Institution of the Russian National Research Medical University named after. N. I. Pirogov Ministry of Health of Russia (Moscow)

Tatyana Sintsova, dermatologist, cosmetologist, clinical mycologist LLC "Clinic of Professor Yutskovskaya" (Moscow)

According to 2012 data, in the United States, acne occurs in women between the ages of 21 and 30 in 45% of cases, in 31–40 years – in 26%, in 41–50 years – in 12% [13]. Also, according to US data, the number of acne patients increased from 5.6 million in 1996 to 6.7 million in 1998, the average age of patients increased from 26.5 to 40.5. In France, every fifth patient is consulted about acne, and up to 142 million euros are spent on anti-acne drugs per year [1]. In Germany, this disease affects up to 26.8% of residents, and it occurs more often in men. In Russia, such statistics are not kept, but this does not mean that the problem does not exist. According to W. Cunliffe and H. Colinick, all over the world there are not only more patients with acne, but also an increase in the number of intractable forms. This may be due to the deterioration of the environmental situation, leading to an increase in genetic disorders in the population, as well as an increase in resistance to drugs, primarily antibiotics.

According to our observations, over three years (2013–2015), among the patients who applied to LLC “Clinic of Professor Yutskovskaya”, the majority were teenagers aged 13–17 years.

Acne is considered a multifactorial chronic disease of the pilosebaceous apparatus, which results in increased secretion of sebum, the formation of closed and open comedones and, as a consequence, inflammatory elements. The connection between high levels of sebum and acne is confirmed by the following factors: acne does not occur in children aged 2–6 years (during this period sebum production is minimal); the severity of sebum secretion in persons with acne is higher than without it; Treatment aimed at reducing sebum production leads to an improvement in the course of the disease [11]. In pathogenesis, the main role is played by hypersecretion of sebum due to relative or absolute hyperandrogenism (irregular menstrual cycle, clitoral hypertrophy, changes in secondary sexual characteristics, etc.) [2].

Hypersecretion of sebum and hyperplasia of the sebaceous glands are caused by the influence of free testosterone, dehydroepiandrosterone and androstenedione, as well as progesterone, which has androgenic and antiestrogenic activity. It has also been proven that sebaceous glands of different locations have different numbers of testosterone receptors. This explains the fact that in some patients certain areas are often affected, for example, only the skin in the chin area or only the skin of the back. In women, the pathogenesis of dermatosis involves peripheral hormonal dysfunctions in keratinocytes and sebocytes associated with hyperactivity of enzymes involved in the metabolism of androgens and progestins, as well as hypersensitivity of androgen receptors [4].

CLINICAL SIGNS OF ACNE IN ADOLESCENTS AND ADULTS

The main clinical signs of acne are increased sebum production, closed and open comedones, papulopustular and nodular elements. However, there are clear morphological differences between adolescent acne and adult acne. Adult acne is acne that persists until adulthood and persists or first appears after age 18.

Late acne is most common in women. So, Ch. Collier et al. studied 1,013 acne patients who developed the disease after age 20. The average age of the patients was 48 years. Among the patients there were 540 women and 473 men [10]. The authors showed that in adolescence, boys and girls suffer from acne in almost equal proportions, while in late acne, sick women predominate significantly. Most often in adult patients, rashes are represented by nodular elements localized on the lower third of the face - the chin, branches of the lower jaw, neck and perioral region, while other inflammatory elements (pustules, nodes) may be absent [3].

The pathological process is persistent, with long periods of relapses, often leading to the formation of post-inflammatory elements [5]. The ratio of inflammatory and non-inflammatory elements in adult women is higher than in adolescents.

In adolescents, the disease begins during puberty, accompanied by the appearance of multiple closed and open comedones in the T-zone of the face (forehead, nose, cheeks, chin), inflammatory elements, and increased sebum production. The pathological process can resolve on its own with normalization of hormonal levels without the formation of post-inflammatory elements.

Despite the fact that scientific data do not provide clear differences in the pathogenesis of acne in adolescents and adults, clinical data indicate a number of pathogenetic factors characteristic of women: stress, ultraviolet exposure, hereditary factors, obesity, an increase in atherogenic lipoproteins in the blood, food, which can have adverse effect on the course of the disease [6–9].

The choice of one or another treatment method should be determined taking into account the patient’s age, since the disease in the postpubertal period can be difficult to treat, mature skin is more susceptible to irritation when using local drugs. It is also necessary to take into account the fact that the response in this group of patients can take a very long time to develop, about which the patient should be warned before starting treatment.

CLINICAL CASE OF JUVENILE ACNE

Patient L., 15 years old, first contacted the Professor Yutskovskaya Clinic LLC (Moscow) in September 2014 with complaints of small rashes on the skin of the face, predominantly affecting the forehead (photos 1–3).

An amnes morbi: the first rash appeared at the age of 14, for no apparent reason, localized on the skin of the forehead, after which within 1 month it spread in small quantities to the skin of the chin and the periphery of the cheek area. The patient visited an esthetician in a beauty salon for a year, where she underwent superficial chemical peeling and cosmetic facial cleansing procedures; a short-term improvement in skin condition was observed for 7 days, after which small rashes on the face reappeared. I did not use external medical products such as creams, gels or solutions. She did not seek medical help from a dermatologist. At the time of contacting Professor Yutskovskaya Clinic LLC, she was not taking any medications orally.

Anamnes vitae: it is known that the patient’s mother suffered from moderate acne with the formation of post-acne scars as a teenager. During the year, the patient experiences ARVI 2–3 times; According to her, there was interstitial pyelonephritis in early childhood; no other features of organs and systems were identified. The menstrual cycle began at the age of 14, until now it has been irregular (28–35 days, 3–5 days at a time), painless. She is not sexually active; there have been no pregnancies or childbirths. There is no allergic history.

Status localis: the skin has a physiological color, the ducts of the sebaceous glands are moderately dilated. The skin process is chronic inflammatory, localized mainly on the skin of the forehead, cheekbone, nose and chin and is represented by many open and closed comedones, papules and pustules. The rashes are located isolated from each other and are not prone to grouping. There are a small number of post-inflammatory pink spots on the skin of the cheekbones - up to 5 on both sides. The skin of the back, shoulders and décolleté is free from rashes.

Preliminary diagnosis: juvenile acne, papulopustular form, moderate severity.

Concomitant diagnosis: interstitial pyelonephritis.

Diagnostics: clinical blood test (CBC), biochemical blood test, skin scraping for Demodex folliculorum, skin culture for microbiota with determination of sensitivity to antibiotics, diagnosis of facial skin, antibodies to Giardia, exclusion of Helicobacter pylori infection (IgA, IgE, IgM), consultation with a gynecologist-endocrinologist to exclude absolute/relative hyperandrogenism, with an ultrasound of the pelvic organs and mammary glands, and a study of the hormonal profile.

Examination results: Demodex folliculorum was not found in facial skin scrapings; in culture - epidermal staphylococcus from the enrichment medium; clinical blood test, biochemical blood test - without pathological abnormalities; Giardia and Helicobacter hylori were not detected; Diagnosis of facial skin: insufficient hydration, increased skin oiliness in the T-zone, average level of keratinization in the T-zone. Based on the results of an examination by a gynecologist, absolute/relative hyperandrogenism was not detected.

Main diagnosis: juvenile acne, papulopustular form, moderate severity.

Concomitant diagnosis: interstitial pyelonephritis.

Treatment: in accordance with the established diagnosis, it is advisable to treat such patients with a combination of two external drugs: adapalene and azelaic acid - in order to normalize disrupted keratinization processes in the follicles of the sebaceous glands, reduce the content of free fatty acids in skin lipids and, as a result, to reduce its oiliness . The main drug in the treatment of this form of acne is adapalene, a retinoid metabolite with pronounced comedolytic and anti-inflammatory activity, which has shown its effect in vivo and in vitro, affecting inflammatory factors by inhibiting the migration of leukocytes in the site of inflammation and the metabolism of arachidonic acid. The patient was prescribed adapalene 0.1% in gel form daily, in the evening for 12 weeks, from the 13th week of use - 2 times a week in the evening for 2 months, and azelaic acid in gel form in the morning for 3 months. from the 4th month - in the morning and evening for 6 months (in the evenings, alternating with 0.1% adapalene gel 2 times a week for 2 months).

During the first weeks of treatment, the patient experienced an exacerbation of the pathological process (photos 4–5) due to the beginning of the death of opportunistic flora, which releases toxins that irritate the skin, as well as increased keratinization, leading to the release of deeply located elements.

In addition, for 3 months the patient took a zinc preparation and a vitamin complex as prescribed by a gynecologist-endocrinologist. In addition to external and oral treatment, the patient was prescribed comprehensive cosmetic facial cleansing once every 1.5 months and a series of retinoic peels.

Already after 1 month of therapy only with external agents and taking a zinc-containing drug and dietary supplement, a significant improvement was observed in the form of a decrease in the number of open comedones and partial regression of papular and pustular rashes (photos 6–7).

On the 3rd month of treatment, the oiliness of the skin in the T-zone returned to normal, fresh papules, pustules and comedones did not appear, the number of closed and open comedones was significantly reduced, post-inflammatory spots on the skin of the cheekbones were not visualized.

Starting from the 4th month of observation, the patient was switched to the following therapeutic regimen: 0.1% adapalene gel 2 times a week in the evening, 15% azelaic acid gel in the morning and evening (alternating with 0.1% adapalene gel 2 times a week in the evening) due to positive dynamics - the absence of fresh papules and pustules, a decrease in the number of closed comedones and cleansing of the skin from open comedones, normalization of oil content.

At the 6th month of treatment, a lasting aesthetic result was achieved in the form of complete regression of papular rashes, the absence of post-inflammatory spots and closed comedones, the presence of a smooth relief of the skin of the forehead, a significant reduction in the number of open comedones in the T-zone, normalization of skin oiliness and hydration (photo 8– 10).

The patient is observed with recommendations: non-comedogenic home care, facial skin diagnostics once every 3 months, facial cleansing once every 1.5–2 months, azelaic acid gel at night for 9–12 months.

CLINICAL CASE OF POST-BURERTATE ACNE

Patient G., 29 years old, in September 2014 contacted the Professor Yutskovskaya Clinic LLC (Moscow) with complaints of rashes localized mainly in the lower third of the face and neck, on the back, shoulders and chest.

Anamnes morbi : the rash first appeared at the age of 14, simultaneously with the onset of the menstrual cycle. The process was localized mainly in the face, in the form of single inflammatory elements, and within several months began to spread to other parts of the body (neck, back, chest). Increased rashes occur during the premenstrual period. I did not see a dermatologist, I treated myself, 3 weeks before the appointment I used 15% azelaic acid gel 2 times a day and erythromycin solution 1 time a day at night; According to the patient, no improvement was noted. Among somatic pathologies, he notes frequent colds (up to 4–5 times a year), has no history of allergies, denies bad habits, denies hereditary diseases, and does not take medications. The menstrual cycle - from the age of 13, was established immediately, until now regular (28-30 days, 3-5 days), painless. Pregnancy – 1, childbirth – 1, currently not planning pregnancy.

Status localis : the pathological process is widespread, symmetrical, acutely inflammatory in nature, localized on the skin of the lower third of the face (chin, angles of the lower jaw), neck, décolleté, shoulders and back, represented by single open comedones, multiple papules and pustules of pink-red color, with clear borders ranging in size from 0.2 to 0.4 cm in diameter, tending to group, and are painful on palpation. The skin also has multiple post-inflammatory atrophic scars and pink-red pigmentation (photos 11–14).

Preliminary diagnosis: postpubertal acne, papulopustular form, severe severity, period of exacerbation.

Diagnostics: scraping from facial skin for Demodex Folliculorum, culture of skin for microbiota with determination of sensitivity to antibiotics, diagnostics of facial skin, clinical blood test (CBC), biochemical blood test, as well as determination of antibodies to Giardia and H. pylori (IgA, IgE, IgM), consultation with an immunologist-allergist, gynecologist-endocrinologist with a study of the patient’s hormonal status, SASS and an ultrasound scan of the pelvic organs and mammary glands in order to identify relative/absolute hyperandrogenism and prescribe appropriate therapy.

Diagnostic data: skin scraping is negative for Demodex Folliculorum, culture shows Staphylococcus epidermidis from the enrichment medium; clinical blood test, biochemical blood test - without pathological abnormalities; Giardia and Helicobacter pylori were not detected; Diagnosis of facial skin: insufficient hydration, normal oil content, increased pH level to 6.9; indicators of CAC, biochemical blood test and ACC are within the reference values. The gynecologist confirmed the syndrome of relative hyperandrogenism, according to which antiandrogen therapy was prescribed with monophasic oral contraceptives (drospirenone 3 mg + ethinyl estradiol 20 mg) 1 tablet per day for 6 months. An examination by an immunologist revealed chronic tonsillitis, chronic pharyngitis, and persistent EBV infection, and appropriate therapy was prescribed.

Main diagnosis : postpubertal acne, papulopustular form, severe severity, acute stage.

Concomitant diagnosis: chronic tonsillitis, chronic pharyngitis, persistent EBV infection.

Treatment: The main drug for the treatment of severe and very severe acne is isotretinoin. Its main effect is the inhibition of the function of the sebaceous gland, as well as the normalization of terminal cell differentiation, inhibition of proliferation of the epithelium of the sebaceous gland ducts, the formation of detritus and facilitating its evacuation. The patient was prescribed isotretinoin at a dose of 40 mg/day. per os (after meals, washed down with milk) for 4 months. Auxiliary therapy: dexpanthenol cream to eliminate dryness, hygienic lipstick, for the eyes - an artificial tear preparation.

During the treatment, the patient noted a significant improvement in the skin, a decrease in inflammatory elements, and the absence of new inflammatory papules and pustules (photos 15–17). Side effects include dry skin, retinoid cheilitis and dermatitis.

On the 3rd month of treatment, the patient began to notice the appearance of new elements, and therefore the dose of isotretinoin was increased to 60 mg/day. for 14 days, and then again reduced to 40 mg/day. In January 2015, during a second appointment, the patient complained of dry lips and hands, which worsened upon contact with water. No new inflammatory elements were identified, and no rashes appeared before menstruation.

Recommendations: in January continue taking isotretinoin at a dose of 40 mg/day, in February – reduce to 20 mg/day, then completely stop. At the end of therapy, inflammatory elements were completely absent (photos 18–20).

Status localis : the skin is light pink in color, with moderately enlarged pores, there are single open comedones in the area of the nose, cheeks and chin. In the area of the cheeks and corners of the lower jaw there are atrophic scars and post-inflammatory pigmentation.

Recommendations: non-comedogenic home care (washing, toning and moisturizing), skin diagnostics once every 3 months, cleansing once every 1.5–2 months, azelaic acid gel once at night - for a long time. In the future, treatment of post-inflammatory elements is planned.

CONCLUSION

The problem of acne does not only affect teenagers, but also affects a huge number of adult women, having an extremely negative impact on their overall health. Postpubertal acne has a number of distinctive features and also requires a different approach to therapy. It is necessary to take into account the age-related aspects of acne, since only a comprehensive understanding of the problem will help in finding its best treatment.

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