Acne Vulgaris = common acne Definition Inflammation of the pilosebaceous units of cetain body areas (face, trunk, rarely

buttocks) that occurs most frequently in adolescence and manifests itself as comedones (comedonal acne), papulopustules (papulopustular acne), or nodules and cysts (nodulocystic acne and acne conglobata). Pitted, depressed, or hypertrophic scars may follow all types especially nodulocystic acne and acne conglobata. Epidemiology y y y y Very common, 85% of young people Onset : puberty > severe in males Multifactorial genetic background

Contributory factors y Drugs : lithium, hydantoin, isoniazid, glucocorticoids, oral contraceptives, iodides, bromides, androgens, danazol Others : emotional stress, occlusion and pressure on the skin

y Etiology

Follicular epidermal hyperproliferation, increased production of sebum, inflammation, Propionoibacterium acnes activity Pathogenesis Key factors : follicular keratinization, androgens, Propionoibacterium acnes. A change in the keratinization pattern in the pilosebaceous unit [keratinous material becoming more dense and blocking secretion of sebum] y Comedonal plugging Complex interaction between androgens and bacteria Inflammation Androgens stimulate sebaceous glands to produce larger amount of sebum Bacteria contain lipase [converts lipid into fatty acids], and produce proinflammatory mediators. Sterile inflammatory response to the pilosebaceous unit Distended follicle walls break Contents enter dermis Provoke inflammatory and foreign-body response (papule, pustule,nodule) Rupture + intense inflammation Scars

Symptoms Pain in lesions (especially nodulocystic type) Gradation Comedonal I II III IV Papulopustular I II III IV Conglobata

<10 comedones on 1 side of the face 10-24 comedones 25-50 comedones >50 comedones <10 papulopustular lesionas on 1 side of the face 10-20 21-30 >30

Physical Examination Skin Lesions y Comedones : open (blackheads) or closed (whiteheads) y papules and papulopustules y nodules or cysts y sinuses y scars (atrophic or hypertrophic) y seborrhea Sites of Predilection Face, neck, trunk, upper arms, buttocks Diagnosis Comedones are required for diagnosis of any type of acne History Taking 1. Keluhan Utama : jerawat/beruntus merah sebagian bernanah yang kadang terasa gatal/nyeri di wajah/punggung/dada 2. Anamnesis khusus : y sejak kapan timbul kelainan kulit y keluhan subjektif : nyeri/gatal y lokasi pertama kali timbul y perubahan kelainan kulit y penyebaran y gejala lain yang menyertai keluhan saat ini 3. faktor pencetus/memperberat a. stress fisik/emosional b. obat-obatan (steroid, gol. Lithium, vitamin) c. mekanik (garukan, tekanan) d. penggunaan kosmetika e. pajanan sinar matahari f. makanan tertentu yang memicu jerawat 4. faktor predisposisi a. riwayat berjerawat pada keluarga

b. wanita : riwayat kehamilan, menstruasi Differential Diagnosis comedones are not a feature of ALL the conditions listed below y Face : o S. aureus folliculitis  shaving hairy regions (beard area, axillae,legs) facilitates follicular infection  papule or pustule confined to the ostium of the hair follicles, at times surrounded by an erythematous halo  pseufofolliculitis barbae : most commonly of shaved beard area o rosacea  symmetric localization on the face o perioral dermatitis  on the perioral and uncommonly, periorbital, glabella and forehead. o acne-like conditions (steroid acne, drug induced acne, acne aestivalis, gram negative folliculitis) y Trunk : o Malassezia folliculitis  More common in subtropical and tropical climates  Pruritic, monomorphic eruption o hot-tub pseudomonas folliculitis  Occurs on the trunk following immersion in spa waters o S. aureus. Folliculitis o acne like conditions Course and Prognosis y Clears spontaneously by the early twenties, can persist to the 4th decade or older. y Flares : winter, onset of menses y Sequelae: scarring (treat with oral isotretinoin early in the course of the disease) Management Umum y Hindari trauma y Menjaga kebersihan wajah dengan sabun bersifat lembut, 2x sehari y Penggunaan kosmetik nonkomedogenik y Perawatan kulit wajah untuk kulit berminyak Khusus Topikal y Benzoil peroksida (siang hari) o Gradually liberates oxygen (in the presence of water) which kills bacteria and additional keratolytic and comedolytic properties y Tretinoin 0.025-0.1% (malam hari) o Potent comedolytic : promotes lysis of keratinocytes, prevents horny cells from binding to each other, hence comedones cannot form. No antibacterial action but stimulates epidermal cell turnover (causes peeling) y Klindamisin 1-2 % atau Eritromisin 2% o Less effective against P. acnes than benzoyl peroxide. Do not irritate the skin but can cause sensitization. y Kombinasi sulfur, resorsinol, dan asam salisilat

Asam azalea 20% o Reduces cutaneous bacterial density, FFA content of skin surface lipids and proliferation of keratinocytes

Sistemik Only indicated in severe cases with cysts and pustules which are likely to form scars y Tetracyclines MOA : Tetracyclines are primarily bacteriostatic ; inhibit protein synthesis by binding to 30s ribosomes in susceptible organisms o Doksisiklin : 2 x 50-100 mg/hari o Minosiklin : 2 x 50-100 mg/hari o Tetrasiklin : 2 x 250-500 mg/hari y Macrolides MOA :Bacteriostatic at low but cidal at high concentrations. Inhibits bacterial protein synthesis by binding to 50s ribosome subunits and interferes with translocation o Eritromisin : 2-4 x 250500 mg/hari o Azitromisin : 250-500 mg, 3x/minggu y Klindamisin : 50-100 mg/hari MOA :inhibits protein synthesis by binding to 50s ribosomes y Isotretinoin o Reduces production of sebum and corrects abnormal keratinization of follicles. Highly teratogenic. Also used in the prevention and treatment of skin cancers. y Wanita : dapat diberikan kontrasepsi oral/antiandrogen o Can be used only in girls over 16 years of age. Tindakan y Ekstraksi komedo y Injeksi kortikosteroid intralesi y Peeling kimiawi y Mikrodermabrasi y Fototerapi UVB, 2 kali per minggu y Laser nonablatif Algoritma Pengobatan Akne Vulgaris Ringan Komedonal Papulopustular Lini Pertama Lini Kedua Retinoid topical Retinoid topical + Antibiotik topical Asam azalea atau asam salisilat

Sedang Papulopustular Antibiotic oral + retinoid topical BPO Antibiotika oral + retinoid topical BPO + Kontrasepsi oral / antiandrogen

Nodular Antibiotika oral + retinoid topical BPO Isotretinoin oral atau antibiotik oral + retinoid topical BPO/asam azalea + Kontrasepsi oral / antiandrogen

Asam azaleat atau asam salisilat

Wanita

Berat Konglobata/ Fulminan Isotretinoin oral + kortikosteroid oral Antibiotika oral dosis tinggi + retinoid topical + BPO + kontrasepsi oral / antiandrogen

Invasive

Ektraksi komedo

Ekstraksi komedo

Pengoba tan tidak berhasil

Periksa kepatuhan

y y y y

Ekstraksi komedo, Injeksi injeksi kortikosteroid kortikosteroid intralesi intralesi Periksa kepatuhan Singkirkan follikulitis gram negative Wanita : singkirkan PCOS, tumor adrenal atau ovarium, congenital adrenal hyperplasia Pria : singkirkan congenital adrenal hyperplasia

Mainten ance

Retinoid topical BPO

References 1. Fitzpatrick s Color Atlas & Synopsis of Clinical Dermatology 2. RSHS Standar Pelayanan Medik : Ilmu Kesihatan Kulit dan Kelamin 3. KD Tripathi s Essentials of Medical Pharmacology 4. Modul Kulit & Kelamin