Fundamental differences between late acne

Late acne

The problem of acne appears approximately 2-3 weeks before it appears on the surface of the skin. Although patients may think that the rash appears overnight, the process is actually much longer and more complex.

In the pathogenesis of acne, there are several main factors: disruption of the circulation of certain hormones, lipid imbalance, follicular hyperkeratosis, hyperplasia and hypersecretion of the sebaceous glands, activation of flora on the surface of the skin, development of inflammation of the sebaceous glands and around them. Our skin is the border between the inner and outer world, and it is the skin that reacts strongly to seasonal changes. Many patients note an improvement in their condition in the summer. Due to tanning, acne becomes less noticeable, but its number does not decrease. Moreover, ultraviolet radiation promotes the appearance of comedones, and its high erythemal doses sharply reduce local immune defense and cause aggravation of acne. It has also been established that acne is not associated with poor hygiene or poor diet.
Of course, self-medication is always insufficient or ineffective, and often dangerous, since it can lead to the progression of acne, severe complications and scarring. The sooner you start treatment, the faster and more effective the result will be.

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 latter 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, and 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.

Features of treatment
Acne therapy should be based on anamnestic data, taking into account the duration of previous treatment, its effectiveness, the patient’s age, the development and course of relapses, the presence of concomitant diseases of internal organs and foci of chronic infection. The complexity of the pathogenesis and the variety of clinical forms of acne are the reason for the variety of methods for its treatment. They can be divided into three groups, depending on their focus:

• decreased sebum secretion;
• normalization of keratinization processes of the pilosebaceous follicle canal;
• microbial factor.

A wide range of modern drugs are used to treat acne. According to the method of application, they are divided into external and systemic.

Use of antibiotics
Systemic antibiotics for acne are prescribed for mild severity that does not respond to other types of treatment, as well as moderate severity. The drugs of choice are tetracyclines - they accumulate in the sebaceous glands and selectively penetrate into areas of inflammation, suppressing the activity of P. acnes, inhibiting bacterial lipases.

However, the use of antibiotics is limited by the development of side effects (dysbacteriosis, candidiasis, immunosuppression, etc.) and complications (toxicoderma, erythema multiforme, Lyell's syndrome). In addition, there are a number of disadvantages of this therapy:

• firstly, the high resistance of microflora to this antibiotic, increasing every year;
• secondly, the duration of the course: the first signs of improvement occur only weeks or months after the start of treatment;
• thirdly, frequent relapses, dictating the need for repeated multiple courses.

Treatment with retinoids

In order to treat acne, regardless of the severity, retinoids are also used: externally in the form of ointments and creams, and in severe forms - systemically. To date, these are the only drugs whose use leads to a sharp decrease in the secretion of the sebaceous glands and the onset of stable remission. Under the influence of retinoids, there is a significant reduction in sebaceous cysts, in which, in fact, inflammation occurs. This explains not only the rapid, but also the persistent clinical effect after its administration, because the main conditions for the excessive proliferation of bacteria are eliminated.
However, the side effects of retinoids are also well known. This is dryness of the skin of the face and lips, less often - the mucous membrane of the nose and eyes, possible redness and flaking of the skin, the development of photosensitivity, pain in muscles and joints, increased liver transaminases.
In addition, it must be remembered that Roaccutane is a terratogenic drug. The main contraindication to its use in women of childbearing age is pregnancy or planning pregnancy. During treatment with Roaccutane, it is necessary to monitor liver function: laboratory tests a month after the start of therapy, and then every three months. If the level of liver transaminases exceeds the norm, it is necessary to reduce the dose of the drug or discontinue it.

Hormone therapy

Another well-known treatment regimen is hormone therapy. It is prescribed to women with late hyperandrogenic, persistent acne, menstrual irregularities and other signs of hyperandrogenism. Progestogen and combined estrogen-progestogen contraceptive drugs are currently used as antiandrogenic drugs, the antiandrogenic effect of which is based on the principle of competitive binding of receptors in target organs, including the sebaceous glands, as well as a direct effect on comedonation.
Complications when taking hormonal drugs: secondary amenorrhea (caused by ovarian hyperinhibition syndrome) may occur; risk of thrombosis, tendency to hypertension, impaired glucose tolerance. These disorders have a pronounced dose-dependent effect. Treatment of men with hormonal drugs is accompanied by a decrease in libido, as well as the development of gynecomastia and azoospermia. It has also been proven that when taking tetracyclines and hormonal contraceptives simultaneously, the effectiveness of the latter decreases by 6-7 times.

Cosmetology opportunities
In recent years, various methods of skin resurfacing have become popular in acne therapy. These are microdermabrasion (mechanical skin resurfacing), chemical peels, and laser skin resurfacing. All of them are a procedure for removing the thin top layer of skin in various ways and in some cases they can achieve quick and impressive results, which certainly improves the quality of life of patients with acne. Thus, α-hydroxy acids and salicylic acid have good keratolytic and anti-inflammatory effects. To treat inflammatory forms of acne with a large number of papules and pustules, this acid is used in combination with triethyl citrate. It is triethyl citrate, which is part of the peeling, that is able to control bacterial colonization and the process of inflammation.

However, the use of all methods of resurfacing is indicated only for mild and moderate forms of acne without pronounced inflammatory manifestations, as well as to prevent further transformation of comedones into inflammatory elements.

Literature:

• Maria Shirshakova, dermatologist, cosmetologist, assistant at the Department of General Medicine of the State Educational Institution of Further Professional Education of the Russian Medical Academy of Postgraduate Education of the Russian Health Service, certified trainer for injection drugs at Merz Pharma LLC, scientific consultant at the Expert Research Center (Russia, Moscow)
• Tatyana Al Sabunchi, Candidate of Medical Sciences, dermatovenerologist, cosmetologist, scientific consultant of the Expert Research Center and the Society of Mesotherapists (Russia, Moscow)
• KOSMETIK international journal, No. 2/2011
• Alina Mantula, Ph.D., head of the department of the universal dermatological clinic “Euroderm” (Ukraine)
• Bogdan Litvinenko, Director of the Institute of Psoriasis and Chronic Dermatoses LLC (Ukraine)
• Les Nouvelles Esthetiques Ukraine3 (103)/2017