Current approaches to the treatment of acne

Acne or acne (UB) is one of the most urgent problems of modern dermatology. The increased interest in the pathology of the skin is due, according to Cunlife, famous scientist, for many years successfully working on the problem of UB, "what in the world of patients with acne is not just become more intractable and increased the number of forms."

In his view, this may be due to environmental degradation on Earth, leading to an increase in genetic disorders in the population, as well as the increase of drug resistance, especially to antibiotics (3).

Acne - caused by long flowing genetically polymorphic multifactorial disease of the skin, sebaceous glands and hair follicles. Acne is one of the most common skin diseases in young adults, occurs in 85% of boys and girls aged 12 to 24 years, and 10% retained until age period 25 - 45 years. The majority of women to 25 years in kickback development of acne. Only 11% of acne lesions occur at the age of 25 - 35 years old and 5% - 40 years of age or older. In recent years there has been a tendency to increase the number of women who have acne debut at the age of 25 years and older.

The complex influence of genetic factors remains a subject of study, but important, if not primary, role played by genetically determined type of secretion of the sebaceous glands during puberty.

According to KN Suvorova et al. (1) different allelic variations and expressivity of genes that determine the development of sebaceous glands, their functional ability and activity of enzymes may play an important role in the development of BE and to a large extent determine the severity of clinical manifestations. There are reports of the presence of nuclear R-factor, which determines the genetic predisposition. These facts can probably explain the development of some people have light, while others - severe UB. A history of acne in both parents creates a 50% chance of developing severe forms of the disease in adolescent (1).

It is known that human skin, especially its appendages (hair follicles, sebaceous and sweat glands) have steroidochuvstvitelnye receptors that perceive gormonoreguliruyuschie influence on the development and secretory activity of these structures. During puberty, these interactions are beginning to manifest itself actively. The main targets for skin sex steroids are the epidermis, hair follicles, sebaceous glands, melanocytes and fibroblasts.

A German scientist named C. Schmitz skin of the largest endocrine gland in the body. The skin has been actively involved in the metabolism of steroid hormones, in particular in the formation of androgens ekstraglandulyarnom of steroid precursor, being both the main target-tissue for androgens.

Leather is a peripheral element of the metabolism of male sex hormones, their effects through specific androgen receptors that are found in various androgen-dependent structures of the skin. Stimulation of androgen receptors increases the mitotic activity and differentiation of cells of the epidermis, increases the synthesis of intercellular lipids, stimulates hair growth and the secretion of sebum (3).

An important aspect is the participation in the development of inflammation Propion i bacterium acnes: they synthesize a variety of chemoattractants that draw white blood cells in the inflammatory focus, lipase, and a number of enzymes that cause damage to the wall of the follicle, produce vasoactive amines such as histamine that increase inflammation.

Conventional classification UB has not yet been developed. There are a number of classifications that are based either on clinical manifestations of disease or to assess its severity.

The most convenient and commonly used in dermatological practice classification proposed by the American Academy of Dermatology. According to this classification distinguishes the following severity UB:

- 1st degree - is characterized by comedones (open and closed) and up to 10 papules;

- 2nd degree - comedones, papules, pustules and 10;

- Third degree - comedones, papules-pustular rash, up to 3 knots;

- 4th stage - severe inflammatory reaction in the deeper layers of the dermis with the formation of multiple painful knots and cysts.

Among the clinical manifestations of the UX is the most common form of pustular papules, - 70-80% of cases. Komedonalnaya form and the most severe manifestations of acne - acne conglobata - is found in 10-15% of patients.

There are several approaches to the treatment of UB. The tactics of treatment depends on the severity and prevalence of clinical symptoms. In addition, it is necessary to take into account age, sex, presence of comorbidity. The treatment plan is based on the assessment of severity of illness.

In milder forms of UB is sufficient external therapy. UB moderate to severe systemic and require a combination of external therapy (2,5).

Outdoor therapy is the appointment stirs up sediment, including sulfur, resorcinol, salicylic acid, benzoyl peroxide gel. In today's outdoor therapy uses drugs as tretinoin, azeloinovoy acid, topical antibacterials, including the most popular tetracycline, erythromycin and clindamycin. They reduce the colonization of P. ═ acnes on the skin surface and in the follicles. In addition, antibiotics have anti-inflammatory effect, inhibiting leukocyte chemotaxis, and regulate the content of free fatty acids in the surface fat.

Modern systemic therapy includes antibiotics, UB, retinoids and glucocorticosteroid therapy антиандрогенозаместительную drugs. Sufficiently prolonged courses of these drugs have anti-inflammatory effect, normalizes keratinization of follicles, affect the composition of sebum.

In some regimens fulminant acne introduced salicylates, corticosteroids, dapsone.

Systemic drugs for patients with acne, as stated above, shall be appointed by moderate and severe disease. From the long list of antibiotics only some can be recommended for the treatment of acne. Given the fact that antibiotics are prescribed UB quite a long time, they must have low toxicity.

Penicillin was ineffective at UB, and sulfonamides hard tolerated. Antibacterial drugs with anti-inflammatory properties, such as tetracycline (and its derivatives - doxycycline, minocycline) and macrolides (erythromycin and azithromycin) are the drugs of choice for pustular acne-papullo.

The use of tetracycline in the treatment of acne due to its ability to update the content of free fatty acids in surface lipids. ═ The dose of tetracycline was established by clinical experience, for other drugs the dose was adjusted in terms of tetracycline.

No specific studies, some dermatologists are considering antibiotic therapy for acne only as an antibacterial effect on the disease process. In this regard, we should consider the variety of legitimate motivation of both system and topical antibacterial agents at UB. It should be noted that acne is not contagious, but antibiotics are included in the scheme of treatment of this disease as a significant element. First, P. acnes were sensitive to all antibiotics active against gram-positive pathogens. Second, all performance-enhancing drugs by 90% or more decrease the amount of P. acnes, reducing by 50% the proportion of free fatty acids in surface lipids. The levels of fatty acids can be reduced without visible influence on P. acnes. One of the proven mechanisms of inhibition of bacterial growth is to reduce the concentration of fat-lipase. Tetracyclines inhibit bacterial lipase is more effective than erythromycin, which leads to the expected therapeutic effect. Antibiotics, especially tetracycline, and sulfones provide a pharmacological effect, which is not directly related to the bacterial inhibition. They have a mild anti-inflammatory effects by acting on neutrophil chemotaxis and macrophage function. These drugs are also effective for rosacea, perioral dermatitis, lichenoid pityriasis, which are not caused by bacteria.

Currently used in the treatment of acne only two groups of antibiotics: tetracyclines and macrolides. Comparative characteristics is often based on the measurement of drug concentration in blood, but this is not enough. The level of antibiotic in the blood does not provide information about its concentration in target tissues. Lipophilic tetracyclines such as minocycline, better penetrate the lipid-rich follicles and sebatsitnye mikrokomedony. Doxycycline Monohydrate has the same efficiency as minocycline, but has no side effects on the central nervous system.

Macrolides are a weighty alternative to tetracycline (4). A significant advantage is the possibility of appointing during pregnancy and lactation. Of the modern macrolides as treatment for UB azithromycin is of interest - a broad spectrum antibiotic macrolide azalides subgroups. Without creating a high concentration in the blood, azithromycin, due to its high lipophilicity, is widely distributed in the body, permeating many of the organs, tissues, and the environment. With the additional transport it accumulates neutrophils in inflammation in very high concentrations (tens to hundreds of times higher than serum levels) and held for a long time, providing postantibiotichesky effect. Azithromycin is resistant to degradation in the gastric juice.

Given that at UB justified the use of antibiotics only two groups (tetracyclines and macrolides), it can be argued that the appointment of tetracycline in the main aims change the chemistry of sebum, macrolides also implement a bactericidal effect against P. acnes, anti-inflammatory and immunomodulatory effects.

In severe forms of BE, such as fulminant and conglobata, against the background of immunosuppression is usually associated coccal flora, which justifies the use of azithromycin. It is for severe acne should be included in the regimen given an antibiotic. Substantial persuasive argument in favor of azithromycin is the fact that the literature contains no reports on the stability of P. acnes to the drug.

In dermatological practice widely used drug azithromycin "Azikar." In the treatment of UB Azikar take a dose of 500 mg once a day for 3 days, then - 500 mg 1 time per week for 9 weeks.

For treatment we used UB Azikar in 45 patients with various forms of pathological process. Treatment of patients held by the scheme proposed above. The clinical effect was achieved in all (100%) patients. Treatment was well tolerated by all patients. Adverse events during therapy were observed. Thus, we recommend Azikar in the treatment of UB as the drug of choice.

Of course, during the treatment with antibiotics is necessary to consider UB possible adverse reactions. Sometimes the use of antibiotics may experience nausea, vomiting, gastro-intestinal disorders. The most common such manifestations develop in the appointment of macrolides erythromycin and dzhozamitsina, but these drugs are not used for mild acne. Tetracyclines can cause such reactions as phototoxicity, localized on the face, legs and feet, as well as phototoxic onycholysis. In some cases, individuals with fair skin may be a severe reaction in the form of bubbles. Sometimes allergic reactions and record fixed erythema. Occasionally, Gram-positive bacteria inhibition leads to changes in the microflora in the direction of gram-negative microorganisms and gram-negative folliculitis can be formed. We can not exclude the possibility of developing candidiasis lesions, mainly in the form of candidal vaginitis. In the application of tetracycline and minocycline pigmentation can develop. In addition to skin pigmentation include noted in the thyroid gland, bone marrow, in some visceral organs.

Antibacterials for acne can sometimes be combined with tretinoin rates because their combination is more effective than either drug alone (3). Tretinoin affects vascularization, which increases the concentration of antibiotic in the tissues.

Systemic retinoids inhibit the secretion of sebum and promote the differentiation of epidermal cells. One of the representatives of the retinoid is isotretinoin (Roaccutane). The drug reduces the activity of the sebaceous glands, reducing their size, the formation of sebum, slows down the process of keratinization, and this eliminates hyperkeratosis mouth ductless sebaceous gland, preventing the formation of comedones, positive effect on the bacterial flora of sebum and reduces the colonization of P. acnes. The most serious side effects of Roaccutane - embryotoxic and teratogenic.

Hormone replacement therapy sometimes has a positive effect for women who have a traditional acne treatment proved ineffective. Extremely rare for severe acne prescribe anti-androgens (tsiprosteron acetate), spironolactone (potassium-sparing diuretic).

Early treatment of acne or other fulminant severe inflammatory acne for about 1 month prescribed steroids: 6-8 tablets per day in terms of prednisolone followed by successive reduction of the dose.

Thus, the diagnosis of severe forms of the UX involves the compulsory inclusion in the plan of treatment of systemic medications, especially antibiotics. The skillful combination of drugs pathogenic action for indoor and systemic application allows you to achieve a good clinical response, improve the quality of life in most patients with different forms of acne.

Literature

1. Cuvorova KN, Kotova, NV. Severe forms of acne. IU. honey. J.. 2000; with. 732 - 26.

2. Collier A., ​​Freemann S., Dellavalle R. Acne vulgaris. In: Evidence-based dermatology, Blackwelle Publishing, 2008; 83 - 104.

3. Cunliffe WJ, Collnick HM. Acne. Diagnosis and management. - London, 2001. - 166 p.

4. Kus S., Yucelten D., Aytug AC / / Clin Exp Dermatol 2005; 30: 215 - 20.).

5. Noble W. / / Semin. Dermatol. 1990. -Vol. 9; p. 586 - 90.