Acne

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Fromfinish :

  • Acne is an inflammatory skin disease follicles sebaceous
  • Giving follicular lesions that occur in adolescence and that are linked to both :

➢ seborrhea

➢ Disorders of keratinization of the follicle epithelium of the pilosebaceous canal inducing the formation of the comedo

 

Épidémiologie :

  • common condition +++, affects about 90% teens
  • Button both girls (14-16 years) than boys (16-17 years)

Follicle PilosebaceousPhysiopathologie :

4 mechanisms :

  • Anomaly from operation from the gland sebaceous :

Source and structure of the androgens :

In the man : Testosterone is secreted by testicular Leydig cells and a small part by the adrenal gland

In the women :

50% : by the peripheral conversion of delta 4 androstenedione, This conversion requires the presence of & rsquo; enzyme :  17-β-hydroxy steroid dehydrogenase, it occurs in liver cells and skin cells

acne a125% : is produced by ovarian stroma

25% : by the zona fasciculata of the adrenal

Di-Hydro Testosterone   (DHT) :   a biologically active metabolite of testosterone. It is estimated that DHT is about 30 times more potent than testosterone due to its greater affinity for the d & rsquo receivers; androgens. Stimulates sebum synthesis at the sebaceous gland

  • acne a2Trouble from the keratinization :

Formation   comedone :   keratinocyte proliferation, differentiation,  membership -> follicular obstruction -> sebaceous retention

  • Proliferation from the flora bacterial :

Colonization bacterial : Gram +, anaerobic, responsales follicle inflammation (Propionibacterium acnes, P.Granulosum, P.Avidum)

➢ Peptides p.acnes diffusing through the wall -> chemotaxis poly-morphonucléaires (IL1, 4, 6, 8 et IFN g) -> inflammation

  • Acné a3Terrain genetic : molecular biology studies have recently shown that the cytoplasmic androgen receptor of the sebaceous gland, where DHT binds, included several functional sites resulting in the activation and transcription of these genes. This receiver gene is on chromosome X q1-q12 position. The expression of this gene would vary according to the development and age of the subject, and could intervene in the genetic transmission of acne

CLinique :

Acne vulgar (polymorphic juvenile acne) : c & rsquo; is the most common form

  • Aspect :

Hyper-seborrhea : c & rsquo; is & rsquo; skin shiny predominant on face (midface region), sometimes the front of the chest and the back-vertebral gutter

acné a4lesions retentional :

blackheads open (black dots) : horny plugs of 1-3 mm, made of keratin and sebum that clogs the & rsquo; infundibular hole that will be oxidized by contact with the & rsquo; d & rsquo air, where the black color

blackheads closed (white dots) : are whitish papules 2-3 mm in diameter due to the & rsquo; accumulation of sebum and keratin in & rsquo; infundibulum closed

lesions inflammatory :

lesions superficial :

Papules  :  small red elevations,  farms,

sometimes painful

Pustules : small red elevations with their tops containing a purulent, which can appear immediately or be secondary to papules

lesions deep :

Nodules  :  painful and fluctuating inflammatory swelling by palpation that can lead to fistula,   inflammatory cysts or abscesses. They leave scars after healing

scarring : may be planar, depressed or keloid (en relieves),  they can be hypo- or hyper-chromic

  • Seat : face (midface region), sides of the neck, neckline, shoulders, back screen or the neck

Acné a5shapes clinics :

  • Acne grave :

Conglobata : comedones large and multiple nodules and large. L & rsquo; progresses to indurated scars,   depressed and sometimes flanges, d & rsquo; when its gravity

acné a6Fulminans : male teenager, is characterized by necrotizing ulcerative lesion progression with fever, alteration of the & rsquo; condition, arthralgies, hyperleucocytose

  • Acne newborn : d & rsquo; stimulation of the sebaceous glands of the new- born by maternal androgens. Most of the time, it s & rsquo; is closed comedones, l & rsquo; evolution is favorable after 2-3 month
  • Acne iatrogène  :  some medications can cause breakouts d & rsquo; acne : topical corticosteroids or general, antiepileptic, TB, antidepressants, vitamin B12, oral contraceptives containing an androgenic progestin
  • Acne exogenously : mineral oil, cosmetics (presence of comedogenic products), l & rsquo; occlusion repeated friction (ex : backpack)
  • Acne and pregnancy : evolution is unpredictable, we note the emergence or worsening of acne lesions +++, inflammatory acne affecting mainly the face.
  • Acne from the women :  in women over 25 years,  one should look for signs of hyperandrogenism (hirsutisme, alopecia, weight gain, amenorrhea…). In the absence of signs of hyperandrogenism hormonal balance is not indicated.

➢ predominant lesions in the lower face.

➢ The number is moderate, but deep nodules in small numbers +++

➢ The mechanism of acne in adult women is still unknown

➢ The role of cosmetics is suspected but not proven

➢ If clinical signs of even minimal hirsutism are associated -> examinations to clarify the aetiology (ovarian ultrasound, hormonal balance in the first cycle portion comprising : determination of free testosterone and bound, delta-4 androstenedione, 17-hydroxy-progesterone in case of anomalies of previous assays)

Acné a7Diagnostic positive :

It's clinic +++, is based on the & rsquo; lesions appearance, seat, l & rsquo; age of onset

Diagnostic differential :

  • rosacé : condition that begins at the quarantine, c & rsquo; is a disease of the skin microcirculation, evolves 4 stages :

Flush : sensation of redness and heat on the face.

erythema telangiectatic (permanent)

Phase papulo-pustuleuse

Phase   infiltration   cutaneous (thickened skin) :   most in the & rsquo; men than in women (rhinophyma)

  • Dermatitis Perioral :  the only inflammatory lesions are localized around the mouth.

In  the women : are mostly related to abuse of cosmetics or repeated use of topical corticosteroids.

  • Acne a8Folliculite at seeds at Gram negative : is a follicular pyoderma, complication of too prolonged antibiotic treatment, especially by cyclins
  • Kératose pilaris :

➢ Due to thickening of the superficial part of the skin,

l & rsquo; epidermis, women, appears from preadolescence

➢ Due to the & rsquo; clogging of skin pores, she reached the most often arm, but sometimes thighs, buttocks and rarely face

Complications :

  • L & rsquo; acne evolves in spurts, then stabilize and then disappear to the & rsquo; age 25 years
  • These flares may be influenced by factors :

hormone : we notice an improvement in women at mid-cycle and worsening its end.

food : chocolat, sucrerie, that are most incriminated

Stress : promotes the onset of outbreaks & rsquo; acne acne

solar : the sun aggravates lesions of the face

Tabac +++

  • scarring indelible : are the main complication of acne. It can s & rsquo; act : depressed scars, hypertrophic, flanges, sequelae of cysts, of keloid scars requiring surgical repair
  • Edema facial : this is a rare complication of facial acne, it is a firm swelling, indolent, orbitofrontal regions of the nasal, up extend the forehead and cheeks, its mechanism remains unknown
  • osteoma : they correspond to calcification of acne scarring, they occur on the face and see themselves primarily in severe forms of acne.

Treatment :  is extirpation with a lancet or a lancet tip

Traitement :

  • Goals from treatment :

➢ Reduce the number of lesions

➢ Decrease the formation of new lesions

➢ Avoid inflammation

➢ Prevention of sequelae

➢ Decrease sebum production

➢ Decrease follicular hyperkeratosis

➢ Avoid proliferation P. acnes

➢ Avoid inflammation

  • Means therapeutic :

treatments local :

antibiotics local : erythromycin topical

Form galenic : Eryacné® 4% in gel form.

Action : antimicrobial and anti-inflammatory.

Application  :  the average duration of treatment should be <  2  month, l & rsquo; topical antibiotic therapy should not be associated with a general antibiotic treatment (promotes resistance).

Peroxide from benzoyl :

Form galenic : gel, cream dosed 2.5-10%

Action : anti-inflammatory and slightly keratolytic : Soluger, Ec / aran®, Cutecnyt®

Effects secondary :

Effects irritants : early treatment, This involves the use of low-dose or & rsquo; space applications

phototoxicity : This justifies an application at night, to & rsquo; away from light

Eczema from contact : sometimes, this implies proscribing treatment permanently, treat & rsquo; then eczema pass d & rsquo; other molecules

retinoids topical :

Form galenic : are in the form of cream, gel and lotion : Isotrex®, Locacid®, nities A®, Rétisol A® (0.025-0.05-0.1%).

Action : they have a keratolytic effect predominant, they are sometimes associated with the & rsquo; topical erythromycin (Stievamycine®)

Effects secondary :

Irritation : early treatment

phototoxicity or photosensitivity : apply at night and use a sunscreen cream during periods of strong sunshine

Effect drying : use emollients

treatments systemic :

antibiotics :

✓ What are the cyclins :

1time generation : tetracyclines 500 mg

2e generation : Doxycycline : Vibramycine®, Dotur

Action : antibacterial and anti-inflammatory

Form galenic : tablets 100 mg

Dosage : prescribed because of 100 mg / day for 15 days and then passes 50 mg / j, the minimum duration of treatment is 3 month.

Effects secondary : photosensitivity, digestive disorders

Cons-indications : Telephone exchange, enceinte, child < 8 years

isotretinoin : Roaccutene®, Cureacnë®

Action : only curative treatment of & rsquo; acne, acts causing atrophy of the sebaceous glands, by sebaceous secretion reduction, keratolytic effect, anti-inflammatory action

Form galenic : hard capsules 5-10-20 mg

Dosage : 0.5-1 mg / kg / day up & rsquo; to achieve a total cumulative dose of 120-150 mg/kg (duration : 6-8 month)

Effects secondary :

Chéilite : dry mucous membranes, sign & rsquo; impregnation

xerosis cutaneous

Effect  teratogenic :  explains contraception 1 month before, during the treatment and 2-3 months after the & rsquo; stop

Contraindication absolute : pregnancy.

Hormone : c & rsquo; is the use of & rsquo; cyproterone acetate which has an anti-androgenic effect (DIANE®35)

Action : blocks peripheral receptors DHT sebaceous glands

✓ L & rsquo; hormone therapy may be associated with a local treatment

treatments Additional :

Toilette morning and evening with a Savo surgras or gel cleanser : Dermagor® + cleaning gel, Hyseac® + cleaning gel, Saforelle® dermatological bath

proscribe the Savo suffer and the makeup (or remove make-up)

Cleaning dermatological from the skin : consists in extracting the closed comedones, open

Treatment of the scars : who can be :

Surgical : brides, keloid and depressed lesions.

Peeling chemical : application to the skin of & rsquo; fruit acids that cause an etching of the surface layer of the skin, acts on wrinkles and pigmentations (is done in several sessions with a good photoprotection)

Photoprotection correct : during periods of bright sunshine

use emollient / moisturizing creams

  • Indications :

Acne light or moderate : local treatment only

▪ If predominance of inflammatory lesions :  local antibiotics,  benzoyl peroxide

▪ If predominance of lesions retentional : topical retinoids

Acne plus grave or scope : systemic antibiotics, associated with a topical retinoid or benzoyl peroxide

Acne  nodulo fibrosis  or  failure  a  treatment  general  or  local  well  conduit  : Isotrétinoïnë®

Acne moderate with request from contraception : Diane® 35 associated with local treatment (benzoyl peroxide, local antibiotic, retinoid)acné A9