How to treat Acne Vulgaris

Therapy of acne vulgaris consists of systemic therapy, topical, physical, surgical, and diet.

1. Systemic therapy

a.    oral antibiotics
        Oral antibiotics are indicated for patients with acne who still inflamed. Tetracycline antibiotics are given (tetracycline, doxycycline, minocycline) erythromycin, cotrimoxazole, and Clindamycin. These antibiotics reduce the inflammation of acne by inhibiting the growth of P. Acnes.
      The first-generation tetracycline (tetracycline, oxytetracycline, tetracycline chloride) is a drug often used for acne. These drugs are used as first-line therapy because of the benefits and the price is cheap, although the incidence of resistance is quite high. Within 6 weeks of treatment 50% decrease inflammatory reactions and usually given in doses of 1 gram / day (500 mg given in 2 times), after a few months can be derived 500 mg / day. Because absorbtion inhibited by food, then the drug is administered 1 hour before meals with water for optimal absorption.
        Alternatively, the second-generation tetracycline (doxycycline) 100mg-200mg administered / day and 50 mg / day as a maintainance dose, (minocycline) are usually given 100mg/day. This class of drugs are more expensive but the fat-soluble and better absorbed in the digestive tract. 1g/day Erythromycin can be given as an alternative regimen. This drug is as effective as tetracycline, but cause high resistance to P acnes and are often associated with treatment failure. Clindamycin is highly effective drugs, but not good for long-term use because it can cause colitis perimembranous. Cotrimoxazole (sulfometoksasol / trimethoprim, 160/800mg, twice daily) is recommended for patients with inadequate respond to other antibiotics and for patients with gram-negative folliculitis.

b.    Isotretionoin oral
         Oral isotretinoin is the most effective drug sebosupressive and provided for severe acne. As with other retinoids, isotretinoin mngurangi Comedonegenesis, shrink the size of the gland sabaseus up to 90% with a decrease of basal sebocyte proliferation, suppresses the production of sebum in vivo and inhibit the termina sebocyte differentiation. Although not a direct effect to the P. Anes, this inhibiting effect of sebum production and reduce the number of P. Anes resulting in inflammation.
       Still a debate for doses (1gram/weight/day or 50mg/weight/day), although the results shown for both doses of long-term treatment is the same, but the incidence of relapse and require re-treatment is often found in low doses given for acne heavy. 1gram/weight/day initial therapy given for first 3 months, and lowered 0.5mg/weight/day, if possible, be given an additional 0.2 for 3-9 months to optimize therapeutic outcomes.
     The results of isotretinoin therapy shows more rapid improvement of inflammatory lesions compared with comedone. Pustules disappearing faster than papules or nodules, and lesions located on the face, upper arms, and legs rather than on your back and body.

c.    hormonal
     Hormonal therapy is indicated in women who have not responded to conventional therapy. Mechanism of action of these hormonal drugs systemically and dehidroepiandrosterone reduce testosterone levels, which in turn can reduce sebum production and reduce comedone formation. There are three types of hormonal therapies are available, namely: with prednisolone estrogen, estrogen with cyproterone acetate (Diane, Dianette) and spironolactone. Hormonal therapy should be administered for 6-12 months and the patient should continue topical therapy. As with antibiotics, the response rate of hormonal drugs also slow, in the first month of therapy do not get change and change is sometimes new can be seen in the sixth month of usage. Therapy after that will look real change.      
         The resulting change in the use of diane similar to tetracycline 1 g / day. Diane is a combination of 50 mcg ethinylestradiol and 2 mg cyproterone acetate. In women older age (> 30 years) with relative contraindications to oral contraceptives containing estrogen, one treatment option is the use of spironolactone. The effective dose is given between 100-200 mg.
       Anti-androgen hormone can be given to female patients with the target and inhibit production unit pilosabaseus 12 565% serum. If a decision has been made to hormonal therapy, there are various options surrounding the sharing of androgen receptor blockers and inhibitors of androgen synthesis in the ovaries and adrenal glands.

2. Topical
        The use of drugs as a topical therapy is one way that has been chosen to overcome the disease acne vulgaris. Given the purpose of therapy is to reduce the number of existing acne, prevent the formation of a new spot and prevent formation of scars (acne scars). Topical therapy is given for several months or years, depending on the severity of acne. Topical drugs are not only applied to areas affected by acne, but also in the surrounding area.

There are various kinds of drugs are used topically, namely:

a. Topical retinoids.
Mechanism of action of topical retinoids:
- Removing the comedone which have been mature.
- Pursue the establishment and the number of microcomedone.
- Inhibits inflammatory reactions.
- Pressing microcomedone-new developments, which are essential for maintenance therapy.

b. tretinoin
        Tretinoin is a retinoid first introduced by Stuttgen and Beer. Significantly reduces comedone and inflammatory acne lesions. This is shown in the experiment for 12 weeks lowered 32-81% for non-inflamnatory lesions and 17-71% for inflammatory lesions. Tretinoin tersedian in galanic formulation: 0.025% cream, 0.1%, gel 0.01%, 0.025%) and the solution (0.05%). Topical gel formula contains polyoprepolymer-2, tretinoin penetration.

c. isotretinoin
      Isotretinoin is available in gel preparations, has similar efficacy to tretinoin, between 48-78% reduction of comedone and inflammatory lesions between 24 and 55% after 12 weeks of treatment.

d. adapalene
       Adapalene is a third generation of retinoid available in gel, cream, or solution in a concentration of 0.1%. In a survey involving 1000 patients demonstrated that adapalen 0.1% gel has an efficacy similar to tretinoin 0.025%

e. Tazarotene
        In addition to psoriasis, tazarotene is also used as a treatment for acne, in the U.S. 0.5 and 0.1% gel or cream.

f. Topical Antibiotics
       The most important and fundamental usefulness of topical antibiotics is low irritant, but the disadvantage is to add drugs that are resistant to P. acnes and S. Aureus. For overcome this problem, Clindamycin and Erythromycin increased the concentration of 1 to 4% and a new formulation with zinc or a combination product with BPOs or retinoids.
      Topical antibiotics are widely used as an acne treatment. Mechanism of action of topical antibiotics is the main as an antimicrobial. This has proven to Clindamycin 1% effect in reducing the number of P. Anes either the surface or in the lymph channels sebasea. More effectively given on the pustules and papulopustular lesions are small. Erythromycin 3% with the combination of benzoyl peroxide 5% is available in gel form. Thomas et al conducted a study comparing Clindamycin Erythromycin 1.5% to 1% get results that are equally effective, 2/3 of patients have an excellent response within 12 weeks, but the use of a single Erythromycin is not recommended because it can lead to resistance. Use of Erythromycin in combination with benzoyl peroxide is more recommended.
       The effectiveness of topical antibiotics in acne is limited due to the mechanism of action in eliminating the bacteria require a long period of time. Bacteria can occur everywhere and does not directly cause acne. On the circumstances in which the sebaceous glands produce excess sebum, the skin pores will also be easier to open so many bacteria that will come in and develop. The presence of dead skin cells can also aggravate the situation. When the sebaceous glands do not produce excessive sebum, the bacteria do not easily fit into the skin. In other words, the amount of sebum production in acne becomes a major problem. Topical antibiotics work is limited, because it does not solve the problem in the production of sebum.

g. Salicylates acid
        The main effect of salicylic acid is a keratolytic, increasing the concentration of other substances, but it also has a bacteriostatic effect and bacteriosidal.

h. Anti-androgen
      Since acne is known that one of the diseases associated with the activity of androgens, several dermatological and pharmacological industry to develop a topical anti-androgen therapy as one of the acne that does not have a systemic effect. The study was developed on the use of topical 17apropylmesterolone, but preparations are not yet commercially available.

3. Physical Therapy
       In addition to topical therapy and oral therapy, there are some additional therapy with the use of tools or physical agents, such as:

a. Comedone extraction
       Appointment comedone by pressing the area around the lesion by using an extractor tool can be useful in dealing with acne. In theory, removal of closed comedos can prevent the formation of inflammatory lesions. It takes skill and patience to get better results.

b. Intralesional corticosteroids
       Acne cysts can be treated with intralesional triamcinolone or cryotherapy. Nodules are inflamed showed good change Within 48 hours after being injected with steroids. The dose used is 2.5 mg / ml triamcinolone acetonide and using 1ml syringe. The total amount of drug that is injected at the lesion ranged from 0.025 to 0.1 ml and the injection should be the middle of the lesion. Injecting too deep or too superficial will lead to atrophy.
Injection of glucocorticoids can reduce drastically the size of the lesion nodular. Injection 0:05 to 0:25 ml per lesion of triamcinolone acetate with suspense (2.5-10mg/ml) is recommended as an anti-inflammatory. This type of therapy is beneficial compared to other therapies for acne nodular type. It should be repeated in 2-3 weeks. Its main benefit is eliminating the nodular lesions without an incision, thereby reducing scar formation.
   
c. Liquid Nitrogen
     Another way to treat acne cysts is to apply the liquid nitrogen for 20 seconds, the second application is given the next 2 minutes. This therapy works by cooling the fibrotic wall of acne cysts and causes damage to the wall.

d. Ultraviolet radiation
        UV radiation has the effect to inhibit inflammation by inhibiting the action of cytokines. UVA and UVB radiation should be given jointly to improve the results to be achieved. Phototherapy can be administered two times a week. Natural ultraviolet radiation (UVR) is obtained from sun exposure, 60% can be used as adjunctive therapy in acne, but now the therapy is not recommended anymore.

4. Diet
        Some articles suggest a low-fat diet for sufferers of acne vulgaris. Implications of research on diet chocolate, milk, and fatty foods and its relationship to acne are still being studied. Until now there is no evidence base to support the elimination of food will have an impact on acne, but some patients will have the appearance of acne after consuming these foods.

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