ACNE & ADNEXAL DISORDERS Diany Nurdin

DISORDER OF ADNEXAL ADOLESCENS SKIN SEBACEOUS GLANDS APOCRINE GLANDS ECCRINE GLANDS

PHYSIOLOGY OF REGULATORY MECHANISM

INSURANCE ? Acne vulgaris Is it important or just Trivial ? Is it a disease ? INSURANCE ?

Embarrasing Devastating

Why it is important – serious disease The morbidity - the prevalence 85% – 95% (100% teenager) adult acne- women > 21th -the most common dermatologic disorder in US, RSS the II nd The embarrasing disease The cost - skin care - treatment of complication - scar

MOST FREQUENT QUESTIONS DIET –CHOCOLATE -SPICY -FRIED FOODS -MILK STRESS SEXUAL ACTIVITY

What is ACNE ? Not an infectious but Inflammatory skin condition Common, chronic, recurring disease Self limited disease Influences Quality of Life Constitute a socioeconomic problem

ACNE VULGARIS DEFINITION: CHRONICALLY INFLAMMATION OF SEBACEOUS FOLLICLE 2. LESSION COMEDONE-PAPULE-PUSTULE- NODULE-CYST-SCAR (PLEOMORPHIC) 3. PREDILECTION SEBORRHOIC AREA 4. AGE -PUBERTY

Prevalence ( 85 %) mild ( 15 %) need medical treatment

PREVALENCE THE MOST COMMON VISIT DERMATOLOGIST AGE 15-45 MAN > WOMAN ------- VISIT OF WOMEN 80% > FREQUENT > AGE 19 YRS US DATA PRESCRIPTION ANTIBIOTICS $ 5 MILLION ISOTRETINOIN $ 1.4 MILLION

PATHOGENESIS: ANDROGEN DHT 5ar type 1 MICROCOMEDONE Linoleic acid IL-1 alpha ABNORMAL KERATINIZATION Acroinfundibulum INFLAMMATION RUPTURE FOLLICLE WALL TNF -ALPHA LIPASE P.ACNE SEBUM SECRETION

Gollnick H et al J.Am.Acad.Dermatol 2003:;49(1 Suppl) S1-S37

MICROBIOLOGY OF PILOSEBACEOUS UNIT STAPHYLOCOCCI, MICROCOCCI GRAM (+), COAGULASE (-) SUPERFICIAL AEROBIC PORTION OF SEBACEOUS UNIT PITYROSPOSPORUM OVALE, PITYROSPORUM ORBICULARE. LIPOFILIC YEAST PROPIONEBACTERIUM ACNES, ANEROBIC PLEOMORHIC DIPHTEROID. MOST PREVALENT ORGANISM IN FOLLICULAR INFRAINFUNDIBULUM ANAEROBIC CONDITION OF SEBACEOUS UNIT INFLAMATORY REACTION OCCURS IN ACNE MICROBIOLOGY OF PILOSEBACEOUS UNIT

PATHOGENESIS: THE DEVELOPMENT OF ACNE LESSION MIKROCOMEDO COMEDO INFLAMMATION LESSION

CLINICAL SIGN: PRIMARY LESSION COMEDO 1.OPEN 2.CLOSED

DIAGNOSE OF ACNE VULGARIS: 1. PREDILECTION 2. LESSION 3. SEBORRHOE 4. TEENAGE

CLINICAL VARIATION: NEONATAL ACNE

ADULT ACNE

ACNE IN COLORED SKIN

SUBTYPES OF ACNE: CYSTIC ACNE

SUBTYPE ACNE : ACNE FULMINAN

SUBTYPES ACNE: MECHANICAL ACNE ACNE COSMETICA – POMADE ACNE

ACNE EXCORIEE

ROSACEA DIFFERENTIAL DIAGNOSIS: ERYTHEMATOTELANGIETATIC PAPULOPUSTULAR

DIFFERENTIAL DIAGNOSIS: PHYMATOUS OCULAR

DIFFERENTIAL DIAGNOSIS: ACNEIFORM ERUPTION * CORTICOSTEROID * INH * BROMIDE. IODIDE * PHENYTOIN

DIFFERENTIAL DIAGNOSIS PERIORAL DERMATITIS

Perioral Dermatitis, Corticoid Damage

GRAM NEGATIVE FOLLICULITIS DIFFERENTIAL DIAGNOSIS: GRAM NEGATIVE FOLLICULITIS

TREATMENT: ANTI -ANDROGEN RETINOIC ACID ANTIBIOTIK ANTI INFLAMMATION ABNORMAL KERATINIZATION RETINOIC ACID ANTI INFLAMMATION INFLAMMATION P.ACNE ANTIBIOTIK SEBUM SECRETION

Actions of Anti-Acne Therapies Topical retinoids: Normalize follicular hyperproliferation and cohesiveness Reduce inflammatory response Oral Isotretinoin: Reduces sebum Normalizes hyperkeratinization Inhibits P. acnes growth (indirect) Reduces inflammatory response Antibiotics: Reduce microorganisms Reduce inflammatory response Hormones: Reduce sebum production Reduce proliferation of follicular keratinocytes Benzoyl peroxide: Reduces microorganisms

CURRENT ACNE TREATMENT TOPICAL -RETINOIDS -ANTIBIOTICS : CLINDAMYCIN, ERYTHROMYCIN, NADIFLOXACIN, NA SULFACETAMIDE, DAPSONE -BENZOYL PEROXIDE -AZELAIC ACID -SALICYLIC ACID, SULFUR -NICOTINAMIDE, ASCORBIC ACID SYSTEMIC -ANTIBIOTICS -HORMONAL -ISOTRETINOIN ADJUVANT -CHEMICAL PEELING -LASER & LIGHT -CRYO THERAPY -DIET

Actions of Anti-Acne Therapies Sebum production Hyper- keratinization Inflammation Reduction in P.acnes Topical therapies Retinoids - ++ + Benzyl peroxide +++ Antibiotics Azelaic acid +/- Nicotinamide Systemic therapies Hormonal therapy Indirect Layton AM. A review on the treatment of acne vulgaris. Int. J. Clin. Pract. 60(1), 64–72 (2006).

TREATMENT: NON INFLAMMATION TOPICAL KERATOLYTIC COMEDOLYTIC BACTERICIDAL

TREATMENT: INFLAMMATION TOPICAL = ACNE NONINFLAMMATION BENZOIL PEROKSIDE ANTIBIOTIC SYSTEMIC ANTIBIOTIC ANTI INFLAMMATION HORMON

BROMHIDROSIS APOCRINE ECCRINE

BROMHIDROSIS APOCRINE : BROMIDROSIS OSMIDROSIS ECCRINE : KERATINOGENIC-- BACTERIAL DEGRADATION OF MACERATED STRATUM CORNEUM--ODOROGENIC FATTY ACID

BROMHIDROSIS EXCESSIVE –ABNORMAL BODY ODOR FOUL SMELLING SWEAT-MALODOR ARISE FROM THE APOCRINE GLAND

BROMHIDROSIS YOUNG ADULTS BLACK SUMMER FAMILY HISTORY CULTURAL SUBJECTIVE -RACES

BROMHIDROSIS PATHOGENESIS Increase number & size apocrine glands, increase ratio apocrine/eccrine -----increase production Axillary bacteria ------- e-3-methyl 2 hexenoic acid Short chain fatty acids & ammonia. Trimethylaminuria- FISH ODOR

PREDISPOSING FACTOR HYPERHYDROSIS OBESITY INTERTRIGO DIABETES MELLITUS FOODS - GARLIC - ALCOHOL HERITABLE AMINOACIDURIA

BROMHIDROSIS TREATMENT HYGIENE –SOAP & WATER DEODORANT REDUCING BACTERIA REDUCING APOCRINE /ECRINE SWEAT -ANTIPERSPIRANT -ABSORBENT POWDERS -SURGERY- CURRETAGE SUBCUTANEOUS - EXCISION - SYMPATHECTOMY -BOTULINUM TOXIN INJECTION -IONTOPHORESIS

ANTIPERSPIRANT Aluminum chloride hexahydrate Aluminum chlorhydrate Aluminum sesquichlorohydrate Aluminum chlorohydrex Aluminum zirconium tetrachlorohydrate Formaldehyde 10% Glutaraldehyde 10% Methenamine 8% Glycopyrrolate Metal ions form precipitating complexes with mucopolysaccharides --damage to luminal epithelial cell -- obstructive conglomerate -- completely plugs the acrosyringium..

DEODORANT Triclosan Benzalkonium chloride, Chlorhexidine. Propylene glycol Fragrances

Iontophoresis with tap water by producing a physical blockage of the sweat ducts at the level of the stratum

Botulinum toxin injection Botulinum toxin, a neurotoxin, acts by blocking the release of acetylcholine from the presynaptic terminal of the neuromuscular junction. It enters the cytosol and very specifically cleaves protein components of the neuroexocytosis apparatus; consequently, acetylcholine cannot be released. The use of Botulinum toxin to block sympathetic innervation of eccrine sweat glands