18 acne vulgaris & melasma

8/13/2019 18 Acne Vulgaris & Melasma

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Acne vulgarisa chronic

inflammatory disease of

the pilo-sebaceous follicles

characterized by:comedones (opencomedo or blackhead,closed comedone orwhitehead),papules, pustules,nodules, and often scars


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Pathogenesis

Acne is follicular disease with comedo formation

Comedones reveal:

thinned epithelium,dilated follicularcanal filled withlamelar lipid-

impregnatedkeratinous material.


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Four key element of pathogenesis :

1. Follicular epidermal hyperproliferation

2. Excess sebum production3. Inflamation

4. The presence and activity of

Propionibacterium acnes


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primarily affect:face, neck, uppertrunk and upper

arms

begins atpuberty

disease of theadolescent(85% of allteenagers)

Neonatal acnedevelops few days

after birth

Infantile acne :cases that

persist after thefirst 4 weeks of

life

the first sign ofincreased sex

hormone

production

ACNE


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Predisposing factors

- comedogenic greasy or occlusive products

acne cosmetica

- mechanical or frictional forces

- overexuberant washing

- chin straps, violins, hats,

surgical tape

- acne venenata

- drug-induced acne

- endocrinologic disorder


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- woman and children

- irregular menses and hirsutism- acne resistant to conventional

therapy

- relapse quickly after a course

of isotretinoin- sudden onset of severe acne

Hyperandrogenic state


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- serum dehydro

epiandrosterone

sulfate (DHEAS)

-testosterone

Screening test for virilizing tumor(adrenal tumors, congenital adrenalhyperplasia, ovarian tumor)


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Polycystic ovarian syndrome (PCOS)

- serum testosteron

- LH/ FSH ratio (>2-3)

- ovulation < 9 periods per year

or period >40 days apart

- sign of hyperandrogenism


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Gradation of acne

Comedonal acne

Papulopustular acne

Conglobate acne


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ACNE CLASIFICATION

KOMEDO PAPUL/PUSTUL NODUL

MILD < 20 50 >5


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Acne

neonatorum


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Differential diagnosis

1.1. Acneiform eruption- Characterized by papules and pustules- No comedone- Associated to certain drugs glucocorticoid,

isoniazid, high dose of vit B complex,phenobarbital, tetracycline, iodides,bromides

- Sudden onset

- Different distribution to acne vulgaris(Appear on wide distribution)


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2. 2.Rosacea- Chronic eruption of the

central face

- Burning or stingingsensation

- Characterized by :

persistenterytheme, flushing,telangiectasis,papule,pustule, cyste,progressive hyperplasiaof sebaceous glands

- No comedones

- Thickened skin of nose(rhynophyma)


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3. Perioral dermatitis

- Confined inflammation of perioral &perinasal regions

- Predominant in child-bearing woman

- No exact etiology (sensitivity of sun

exposure, acne, rosacea, infection ofcandida or demodex folliculorum,misuse of potent topical steroid )

-Clinnical findings : persistenterytheme, scale with small papule andpustules in the perioral and nasolabial

regions

-There is five millimeter clear zone atthe vermilion edge


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TRE TMENT

- Avoidance of

specific foods is not

necessary

- Scrubbing of theface worsen acne


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Medical therapy

2.Systemic & topical retinoids

1.Systemic & topical antimicrobials

3.hormonal therapy

4.intralesional corticosteroids

5.physical modalities

- comedo extractor- photodynamic therapy- Laser- Dermabrasi

- Bedah Skalpel


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pitted

scars

keloids

wide-moutheddepressions

Complications

Scarring


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MELASMA

(CHLOASMA FACIEI)

dr. IGA SUMEDHA PINDHA, Sp.KK(K)dr. IGAA ELIS INDIRA, SpKK

dr. NLP.RATIH V KARNA, SPKK

Lab/SMF Ilmu Kesehatan Kulit dan Kelamin

FK UNUD/RS Sanglah Denpasar


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amount of melanin

type of melamin (eumelanin =

brown, pheomelanin = yellow orred)

degree of vascularity

presence of carotene

thickness of the stratum corneum

Visible pigmentation of the skin or hair is acombination of


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Melanin is formed from

tyrosine, via the actionof tyrosinase, in the

melanosomes ofmelanocyte Pigmentation require

the adequate manufacture

of melanin appropriate transport of

melanosomes within themelanocyte

The melanosomes aretransferred from a

melanocyte to a group

of 36 keratinocytescalled the epidermalmelanin unit


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MELASMA

Affect darker-complexioned individuals

(Fitzpatrick skin types IV and V)

Most frequently in young women, men 10%

Melasma is

characterized

by

brownpatchestypically on

the malar

prominences

and foreheadquite sharply

demarcated

Clinical

patterns:

centrofacialmalar

mandibular


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PREDISPOSING

FACTORS

Use of dilantin

Pregnancy

Endocrinologic

disorders

hormonal : ingestionof estrogen (oralcontraceptives or

hormonereplacementtherapy [HRT] at

menopause)


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Epidermalbased :

Dermalbased :

Mixed :

woods light lesion

woods light lesion

epidermal anddermal

Melasma classified as


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Pathology

1. Epidermal type

Increasing of melanin disposition on basal, suprabasaland epidermal layers. Vacuolar degeneration in basalcells.

2. Dermal typePerivascular melanin contained macrophag onsuperfisial dermis and middermis layers

3. Mixed type

Both of histologic findingsElectron mic. : scattered melanosomes in keratinosit.

Dopa staining : increasing of melanocytes count.


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Differential diagnosis

Drug induced hyperpigmentation

Hyperpigmentation post inflamation

Ochronosis exogen Mercury deposition on the skin


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Treatment

Avoid exposure to sunlight

Use sunblock with broad-spectrum UV

Treatment

Gold standard bleaching cream withhydroquinone 2% - 4%

Tretinoin cream increase efficacy

Treatment

Kligmansformula : combination of

hydroquinone, tretinoin and topical steroid Glycolic acid added to hydroquinone to

enhance efficacy


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Complication from use high concentration of

hydroquinone

satellite pigmentation local ochronosis

Other topical therapy

azelaic acid, kojic acid

N-acetyl-4-cysteaminyphenol, licorice extract,arbutil

Surgical procedures

peels laser treatment

pretreatment with hydroquinone result


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18 acne vulgaris & melasma

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