INTRODUCTION

Acne is a universal disease among adolescents and young adults, reaching an incidence of 80% to 90%, however, it can be seen in neonates, infants and children. The term is derived from the Greek word acne, which means spring of life. The importance of acne in adolescence lies in the involvement of the most visible part of the body, the epidermis, sometimes leaving irreparable scars.

A certain ethnicity does not prevail, but it tends to be more severe in males than in females during adolescence, and its appearance depends on several triggering factors: genetics, stress, excessive sweating and mechanical trauma.

ETIOLOGY / PHYSIOPATHOGENY

The etiology of acne is still unclear. The inflammatory process begins in the pilosebaceous units, which consist of sebaceous glands, ducts and rudimentary hair follicles, found on the face, upper chest and upper back. The follicles of the epidermis, in patients with acne, are stretched due to anomalous keratinization, under the influence of androgens. This makes the follicle more susceptible to forming a plug. Under androgenic stimulation, sebaceous glands excrete a large amount of sebum in the follicle, which becomes colonized by bacteria from the normal flora of the skin, including Propionibacterium acnes , which is a gram-positive anaerobic.

These bacteria contain lipases that degrade the triglycerides in sebum, releasing fatty acids and glycerol, which triggers an intense inflammatory response, associated with that produced by the local bacterial toxins themselves.

Some factors can contribute to the onset or worsening of acne. Among them we mention: progestogenic phase of the menstrual cycle, use of androgenic contraceptives, polycystic ovary disease, excess of testosterone, derivatives of gonadal or adrenal origin and pro-pathologies present in them.

Dehydroepiandrosterone sulfate is the main adrenal androgenic hormone responsible for the appearance of pubic and axillary hair, seborrhea, axillary odors, acne and adenarch or pubarche phenomena in adolescents.

CLINICAL MANIFESTATIONS

Acne tends to occur on the face and, to a lesser extent, on the upper back, chest and shoulders. This area corresponds to the largest body distribution of pilosebaceous units. The distal ends are always spared. According to the classification of acne, which is done even for treatment purposes, the injury is divided into:

1. non-inflammatory (comedonal and papular);

2. inflammatory (papulopustular, pustular and nodule-cystic).

Pathognomonic injury is comedao, which can be opened or closed. The first is also called the black head, is flat or slightly elevated, measuring about 1 to 3mm in diameter. The black part, contrary to what many lay people think, is not dirt or oxidized fat, but melanin, coming from melanocytes, which are concentrated only at the end of the sebaceous follicle. A closed comedao, commonly known as a white head, appears as a pale, slightly raised papule with a visible central pore.

The black heads generally do not become inflamed, unless the pilosebaceous canal is traumatized by external forces, such as the act of squeezing the lesions. White head injuries can open your pores, resulting in melanization and formation of black heads, as well as becoming pustular. The danger lies in the rupture of pustular lesions, which release free fatty acids to the surrounding tissues, resulting in an intense inflammatory reaction. This is caused by the action of polymorphonuclear leukocytes and complement cells.

Erythematous papules, pustules, nodules and cysts (which are actually floating and suppurative nodules) can occur depending on the magnitude of the inflammation.

Conglobated acne, seen predominantly in boys, is a form of severe, destructive and highly inflammatory acne, which can involve all types of associated lesions, in the upper and posterior trunk.

Fulminant acne is another rare and sudden form of large ulcerated, necrotic and nodule-cystic lesions, located on the chest and back, associated with systemic symptoms of toxemia.

DIAGNOSIS

It is basically clinical.

a) Clinical history:

 initial age of onset of lesions;

 use of medications;

 occupational activities and / or exposure;

 previous dermatological diseases;

 in women: menstrual cycle;

 signs of androgenization.

b) Physical examination:

 type of injury;

 extent of involvement and severity;

 hirsutism;

 acanthosis nigricans .

c) Laboratory tests: blood measurements are not routine, unless there is suspicion of metabolic or neoplastic disease, such as polycystic ovary syndrome, late-onset congenital adrenal hyperplasia and adrenal and ovarian tumors.

DIFFERENTIAL DIAGNOSIS

a) Folliculitis: inflammatory / infectious process, usually caused by staphylococcus;

b) gram-negative folliculitis;

c) rosacea;

d) flat wart: non-inflammatory and which can affect the entire face;

e) sebaceous adenoma (tuberous sclerosis);

f) red miliaria;

g) perioral dermatitis: caused by the use of topical fluorinated corticosteroids for prolonged use;

h) suppurative hidradenitis;

i) Favre-Racouchout disease;

j) secondary syphilis, with presence of pustules on the face, in adolescents, arranged in a numeral aspect, with satellite adenopathy. TOPIC

TREATMENT Isotretinoin It is a retinoic acid that acts by increasing the mitotic activity of cells within the follicles. The cells become less cohesive, decreasing the formation processes of the microcomedoes. Isotretinoin has no antimicrobial or anti-inflammatory activity. However, due to the reduction in the number of comedoes, the number of inflammatory lesions also decreases. a) Dose – creams: 0.025%, 0.05% and 0.1%; gel: 0.01%, 0.025% and 0.05%; b) application: before bedtime at night, 20 minutes after washing your face.

c) side effects: erythema; dry and scaly skin, which resolves after approximately three weeks; sensitivity to the sun may occur, requiring protection with sunscreen.

Benzoyl peroxide

It has an effective antimicrobial effect against gram-positive microorganisms, significantly reducing the number, on the skin surface, of Propionibacteria acnes and Staphylococcus epidermidis , and should be a first line of therapy for medium inflammatory acne. It often induces dry, flaky skin because it reduces the free fat on the skin’s surface.

a) Dose: 2%, 5% and 10% gel;

b) application: once or twice a day;

c) side effects: erythema, stain on clothes and contact allergy.

Topical

antibiotics Topical antibiotics decrease the number of Propionibacteria acnes and also have intrinsic anti-inflammatory activity. They are very effective for mild inflammatory acne, particularly in combination with a comedogenic agent. Three groups of broad-spectrum antibiotics are used: tetracyclines, erythromycin and clindamycin. They are indicated for all types of inflammatory acne, particularly those of medium grade.

Azelaic acid

Has an antimicrobial effect and normalizes the keratinization of the follicle. 20% cream.

Other agents

Agents that cause skin peeling, such as salicylic acid, in the form of a cream or solution of 2% to 5%. Alpha-hydroxy acids and ultraviolet light are also local anti-acne treatment methods.

SYSTEMIC TREATMENT

It is instituted in severe cases, in nodular acne and in skins with many scars and with a tendency to develop keloids. The duration of treatment is six to eight weeks.

Antibiotics

a) Tetracycline:

 frequent use because it is a less expensive treatment;

 dose: 500mg orally twice a day;

 side effects: gastrointestinal, photosensitivity, vulvovaginitis and cerebral pseudotumor;

 do not use on individuals under 12 years of age because of the pigmentation age of the teeth.

b) Erythromycin:

 frequent use because it is a less expensive treatment, but induces bacterial resistance;

 dose: 500mg orally twice a day;

 side effects: gastrointestinal.

c) Doxycycline (derived from tetracycline):

 little used due to the high cost.

 dose: 100mg orally twice daily.

 for 14 days, then continue with one tablet a day for up to 90 days.

d) Minocycline:

 little used due to the high cost;

 dose: 100mg orally once daily;

 side effects: hives, blue pigmentation of the skin and mucous membranes, permanent discoloration of the teeth, autoimmune hepatitis and lupus syndrome. Use for 15 days.

e) Clindamycin:

 dose: 150mg orally once daily;

 side effect: pseudomembranous colitis.

f) Sulfamethoxazole-trimethoprim:

 limited use due to the induction of liver necrosis and erythema multiforme.

g) Azithromycin:

 well accepted because of the few side effects and the ease of dosing;

 dose: 500mg orally once daily for three days; three to four cycles with an interval of ten days.

Isotretinoin

It is 13-cisretinoic acid, derived from vitamin A. It is used in severe acne that is refractory to other treatments and in patients psychologically affected due to acne. Its action is anti-keratinizing, atrophying the sebaceous glands and the inflammatory effect of acne.

a) Side effects: hypervitaminosis A syndrome (dry lips, cheilitis, erythema, arthralgias, epistaxis, etc.) and teratogeny (therefore, it should be used with extreme care in women of childbearing age in adolescence; contraceptive control should be emphasized , as they will only be able to conceive three menstrual cycles after the end of the treatment);

b) laboratory control: blood count, transaminases, cholesterol and triglycerides;

c) dose: from 0.5 to 1mg / kg / day in two to three doses a day;

d) duration of treatment: four to five months.

Hormonal treatment

Aims to antagonize androgen effects, as the sebaceous glands are androgen dependent. Oral contraceptives are usually used with a greater antiandrogenic effect (ethinyl estradiol + cyproterone).

FREQUENTLY ASKED QUESTIONS FROM ADOLESCENTS

1. What is acne?

It is a manifestation of the skin that ranges from the appearance of small whitish or black spots to a deep and diffuse inflammation of the skin, especially on the face, shoulders, chest and back. In these places there are small glands that produce a certain type of fat called sebum. Acne appears when the pilosebaceous unit is clogged.

2. Why do teenagers have acne?

During adolescence, hormonal changes during puberty occur. Some of these hormones increase the production of sebum (fat) at the level of the pilosebaceous units, a phenomenon that contributes to the formation of a local cork, which triggers the inflammatory process of acne.

3. What foods can influence the onset of acne?

No oily food causes acne, but the greater oiliness of the skin itself. That is why it is important to use the most frequent anti-acne soaps.

4. Can acne be cured?

There are several treatments for acne, for the maintenance of skin without acne and to avoid more serious consequences, such as permanent sequelae of extreme cases, those that can leave the skin all pitted. Acne tends to disappear in late adolescence (around 20-21 years old), and can appear in women between 20 and 40 years old, during the period of menstrual cycles (hormonal changes).

5. How to prevent acne?

The important thing is to consult the teenager’s doctor or dermatologist, to follow the most appropriate treatment, and to have persistence, as the constant maintenance of it contributes to the adolescent to have the skin as healthy as possible. Do not buy medicine at the pharmacy without knowing what you are buying. Avoid staying in a polluted environment with fats, like fast food. Always use neutral soap and avoid cosmetics and sunscreens that can be very oily. Prefer those with the label of non-comedogenic. Never squeeze the wounds: contrary to what many think, they can inflame and cause further complications.

6. Sun improves and makes pimples disappear?

Does exposure to dust and dirty environments cause pimples? Excessive sun is contraindicated, especially between 10am and 4pm. Skin hygiene is very important and should always be emphasized.