Soft Tissue Augmentation

The popularity of soft tissue augmentation with dermal fillers and autologous fat implantation is increasing because of minimal downtime, immediate results and availability of an array of newer agents. It is mainly indicated for the treatment of soft atrophic acne scars with loss of dermal tissue. Dermal fillers placed under the scars, elevate them and bring the surface of the scars in level with the surface of surrounding skin. They include: collagen based fillers (i.e. Zyplast and Cosmoderm), hyaluronic acid based fillers (i.e. Restylane and Hylaform), and calcium hydroxyl apatite fillers such as Radiesse. Moreover, promising dermal fillers are in development that will offer superior capabilities in the future.
The ideal dermal filler should be easy to administer, provide reproducible cosmetic results, remain in the dermis for a significant period of time, and have a superior safety profile. Injection of fillers usually requires the use of either a topical numbing cream or a local injection of numbing medication. Then, using a small needle, the dermal filler is injected into each wrinkle or scar that requires treatment. Some mild burning and stinging is normal and quickly resolves.
The results can last from three months to five years, depending on the filler being used. Collagen provides the shortest duration with effects lasting anywhere from three to six months. Restylane tends to last a bit longer with effects lasting from six months to one year. Radiesse can provide results that last greater than 3 years. Side effects are uncommon but can include limited allergic reactions (hypersensitivity), ulceration, reactivation of herpes infection, bacterial infection, localized bruising, and granuloma formation.
Hypersensitivity reactions to the older collagen-based dermal fillers were frequent and required skin testing ahead of the treatment, but are becoming less common with the use of human collagen (Cosmoderm, Cosmpolast) instead of cow derived collagen (Zyderm, Zyplast).
Ulceration is rare and occurs when the filler is injected into a blood vessel; cutting off the blood supply to the overlying skin. Bacterial infections are rare and may be treated with antibiotics. Localized bruising is temporary and may be reduced by applying ice before and after injection. Granuloma formation may require steroid injections, or surgical extraction of the granuloma.

Microdermabrasion

Microdermabrasion is a superficial, office-based, minimally invasive technique of mechanical abrasion of the skin using a pressurized stream of abrasive particles such as aluminum oxide crystals. It may also be performed with a disposable or reusable diamond tip. There is superficial wounding of the skin, followed by epithelialization, stimulation of epidermal cell turnover and it may also cause stimulation and remodeling of dermal collagen. It is mainly indicated for the treatment of superficial acne scars and is ineffective for deeper scars. It is contraindicated in the presence of active infection and concurrent dermatoses on the face. The patient must be adequately counseled regarding the limitations of the procedure, the need for multiple sittings and expected outcome and complications. Contact lenses should be removed and eye protection is important to prevent stray particles from entering the eyes. After degreasing and cleansing the skin, the machine parameters are set with pressure levels from 10-30 mm of Hg depending on the thickness of the epidermis, the depth required and number of passes planned. The key to effective microdermabrasion is stretching the skin under tension for effective abrasion and achieving a vacuum to aspirate the epidermal debris and used crystals. The hand piece is then moved over the treatment area in a sweeping, outward motion covering each cosmetic unit. Thicker skin over the forehead, nose and chin can be treated more aggressively, while delicate areas such as eyelids should be avoided. A second pass of treatment can be done in a direction perpendicular to the first pass, except on the neck where treatment should be in a vertical direction. The desired endpoint is erythema while focal acne scars are treated more aggressively. The area is wiped with wet gauze to remove residual crystals and a moisturizer or topical antibiotic is applied. Treatment is repeated weekly until the desired result is obtained. Erythema, edema, infection, purpura, pigmentary changes and scarring can occur. If eye protection is not adequate, eye complications such as conjunctival congestion, crystals adherence to the cornea, and superficial punctate keratopathy can occur. Thus, microdermabrasion is a safe procedure particularly in darker skin and requires no downtime. It has the limitations of requiring multiple sittings with maintenance therapy and the inability to improve deeper scars.

Lasers

The lasers used for ablative resurfacing are the CO 2 laser (10,600 nm, scanned, superpulsed or ultrapulsed modes), Er:YAG laser (2940 nm) and a combination of the two. These high-energy pulsed lasers emit short pulses of light to remove thin layers of the skin precisely in a single pass, with minimal damage to surrounding tissue. The CO 2 laser removes approximately 30-50 microns leading to epidermal ablation, thermal dermal contraction, and stimulation of new collagen along with dermal remodeling. To reduce complications of pigmentary changes, especially in darker skin, single or few passes are done and the eschar is left in place as a natural dressing. Healing occurs in 7-10 days. The Er:YAG laser causes less thermal damage, removes 2-5 microns of tissue per pass and hence, requires two to three passes to ablate the epidermis. It also causes less collagen shrinkage and more bleeding. The advantage is that it causes less erythema and pigmentary changes, with a quicker recovery time as compared to the CO 2 laser. Full-face resurfacing in dark-skinned patients (such as those encountered in south India) is associated with a significant risk of postoperative pigmentation, which may persist for several weeks. Proper counseling of the patient is therefore essential. But now a days ablative fractional lasers are available and results are encouraging with these lasers without significant side effects.The techniques of subcision, punch excision techniques and resurfacing are sequentially combined to give optimal results. More often, resurfacing is done 6-8 weeks after punch excision techniques. However, the procedures may also be combined in a single session to shorten the total duration of treatment.

Punch excision/elevation/grafting

These techniques are utilized for depressed scars such as ice pick and boxcar scars. According to the diameter of the scar, a biopsy punch of appropriate size is used to excise the scar.
Punch excision and closure: If the scar is > 3.5 mm in size, it is excised and sutured after undermining, in a direction parallel to the relaxed skin tension lines.

Punch incision and elevation: If the depressed scar has a normal surface texture, it is incised up to the subcutaneous tissue and elevated to the level of the surrounding skin.

Punch excision and grafting: Depressed pitted ice pick scars up to 4 mm in diameter, are excised and replaced with an autologous, full-thickness punch graft. The donor site is commonly the postauricular region or the buttock. Care should be taken to avoid cobblestoning, which is a common complication.
These punch excision techniques are followed by resurfacing to achieve optimum results

Subcision

The principle of this procedure is to break the fibrotic strands, which tether the scar to the underlying subcutaneous tissue. It is useful mainly for rolling scars. The scars are marked with a marking ink or pen. Local infiltration anesthesia with 2% xylocaine is desirable. A no. 18 or 20 gauge needle is inserted adjacent to the scar with the bevel upwards parallel to the skin surface, into the deep dermis and moved back and forth and in a fan-like motion under the scar, to release fibrous bands. Individual depressed scars are treated using multiple puncture sites. Hemostasis is achieved by applying pressure. Care is taken to avoid the preauricular, temporal and mandibular areas in order to avoid injury to branches of the facial nerve and major vessels. Postoperative hematoma is a common complication after this procedure and may need application of ice and administration of non-steroidal antiinflammatory drugs (NSAIDs).

Scars

Close inspection of acne skin can reveal some scarring in up to 90% of individuals . But significant scarring occurs in 22%. Scars may show increased collagen or be associated with loss of collagen
Types scars
Macular-(Flat): Hyperpigmented tiny flat scars. They are more common in darker skinned patients and in those who pick their lesions (acne excoriee).
Depressed(Ice pick): These are sharp, deep, depressed scars, wider at the surface and narrow at the base. -Rolling: These are distensible, depressed scars with gentle sloping edges. -Boxcar: These are shallow or deep, punched out scars, wide at the surface and the base.
Elevated(Hypertrophic): These are elevated, fibrotic scars, more common in males and frequently seen in the mandibular area of the face and back. -Keloidal: These are keloids developing in acne lesions. They are seen more often in males, on the back and chest. -Papular: These scars are raised, papular and fibrotic, most commonly seen on the chin and nose. -Bridging scars and sinus tracts: These are multiple linear scars, joined together by epithelial tracts containing foul-smelling products of sebum.

Pigmented marks

In some of the individuals, acne heals with black pigmentation known as acne marks. They usually takes time to disappear. Duration of the marks to disappear depends upon the depth of the pigmentation. If the pigmentation is associated with acne, azelaic acid and adapalene are commonly used. Where as for pigmentation alone, skin lightning creams containing hydroquinone and arbutin are used .Chemical peeling like glycolic acid peeling also help to reduce the pigmentation. Glycolic acid 20-35%. is used It is well tolerated and does not produce systemic toxicity. It is an effective peeling agent even when used in lower concentrations and has a long shelf life.

Physical modalities

Facial saunas, heat and massage probably worsen the condition by precipitating the development of inflamed lesions. Removal of comedones can, however, be aided by hot compresses. Comedone removal can be surprisingly uncomfortable and a variety of specially shaped tools, particularly for blackhead removal, are available. After cleansing with spirit, the comedone extractor is centred over the comedone and firm downward pressure is applied along the direction of the hair follicle to express the contents.For closed comedones, the top of the lesion is first pierced with a 21 G needle to make extrusion less traumatic. Undue force, which could increase inflammation and lead to potential scarring, should never be applied.
Light cautery after the application of a local anaesthetic (EMLA) has been shown to help patients with multiple macro-whiteheads and blackheads (up to 1.5mm diameter).The EMLA is applied for 60-90min beneath an occlusive dressing. The cautery is used at a very low setting so as to produce little or no pain. The aim is to produce very low-grade thermal damage so as to stimulate the body's own defence mechanisms to eradicate the comedo. The actual cautery procedure takes 5-10min and is associated with very little scarring or postinflammatory pigmentation. Such therapy is more effective than topical tretinoin.
Superficial freezing with liquid nitrogen will hasten the resolution of chronic fluctuant nodular lesions and is comparatively painless. Two freeze-thaw cycles of 15sec each are recommended. It is uncertain how this treatment works, but it probably invokes an inflammatory reaction, so breaking down the indolent tissue surrounding the lesion. Cryotherapy is superior to intralesional steroid injections in the treatment of older (7 or more days) nodular lesions, whereas intralesional steroid is preferred in lesions less than 7 days old. Triamcinolone, 2.5mg/ml, may be administered from a syringe with a 30-gauge needle. Placement too superficially or too deeply may cause atrophy; 0.025-0.1ml should be injected into the middle of the lesion, causing slight distension. Aspiration before the steroid injection is desirable, but not always possible because of the nature of the fluctuant nodular lesions, which are not true cysts. Chemical peeling also helpful as an adjuvant treatment for actve acne. Salicylic acid 20-30% is the peeling agent of choice in acne as it has keratolytic and anti-inflammatory properties. As it is lipophilic in nature, it can easily penetrate the pilosebaceous unit.

Other oral treatment

Before the advent of the retinoids and antiandrogens, several other therapies were used, and may occasionally be tried in difficult cases of acne if the newer drugs are contraindicated, unobtainable or ineffective. Oral zinc, certain non-steroidal anti-inflammatory drugs, such as ibuprofen and benoxaprofen, have been shown to reduce inflamed lesions.Clofazimine (200mg three times a week) has been shown to improve acne fulminans, but should not be given as a first option. Dapsone (100-300mg/day for 6 months) has also been tried with varied success.

Isotretinoin(Roaccutane)

oral isotretinoin (13cis-retinoic acid; Roaccutane; Accutane ) revolutionized the treatment of acne. It remains the most clinically effective anti-acne therapy, producing long-term remission in 70% of patients.It is the only treatment that has an effect on all the major aetiological factors involved in acne. It significantly reduces elevated sebum production. , comedogenesis, and surface and ductal colonization with P. acnes. It is also has anti-inflammatory effect on acne When isotretinoin was first introduced(in 1983) its prescription was restricted predominantly to patients suffering from severe nodular acne.
With increasing clinical experience, use of the drug has been expanded to include less severely affected patients who have responded unsatisfactorily to what have been called conventional therapies, including long-term antibiotics and/or appropriate topical antimicrobial or retinoid-like therapies. Acne may produce scars in 30% of patients with of conventional treatment must be followed by a course of isotretinoin unless specifically contraindicated. Conventional anti-acne treatment that fails to produce an improvement over 3 months successive treatment courses is taken as an absolute indication for oral isotretinoin by some physicians. There is abundant evidence to show that isotretinoin significantly reduces the psychological problems associated with acne.

Age should not be a barrier to the prescribing of isotretinoin, whatever the acne severity. A very small number of neonates or juveniles with acne that has not responded to all appropriate topical or oral therapy have been treated successfully with isotretinoin, the usual dose being 0.5mg/kg/day. Some pre-adolescent youngsters, even below the age of 10 years, do develop troublesome acne with scarring. Oral isotretinoin should be prescribed for paediatric acne patients if there are sufficient clinical indications. Apert's syndrome is a rare disorder associated with a hyperresponse of the epiphyses and sebaceous glands to androgens, which results in premature epiphyseal fusion, particularly of the long bones and skull, and in acne. These patients, presumably because of the hypersensitivity of the sebaceous glands to androgens, respond poorly to conventional therapy, and ought to be prescribed isotretinoin sooner rather than later.

Most patients receive a dose within the range 0.5-1.0mg/kg/day. There are variations in the way treatment is started. Most physicians usually begin at 0.5mg/kg/day and increase to 1.0mg/kg/day, but in some centres patients are begun at 1.0mg/kg/day. Published data clearly show that an optimal benefit is achieved at the higher dose. The majority of physicians, whether they start on a higher or lower dose, will adjust the dose according to the response and the presence or absence of side-effects. The duration of therapy varies from centre to centre. The range is usually 16-30 weeks, with a mean of about 20 weeks. Post-therapy relapse is minimized by treatment courses that amount to a total of at least 120mg/kg, but there is no added benefit when 150mg/kg is exceeded. Typically, this total dose can be achieved by 4-6 months at 0.5-1.0mg/kg/day. Demographic factors, such as age, sex and duration of acne, may also govern the rate of response and relapse. For example, males with more truncal acne and more severe acne, who have had acne for less than 7 years, fail to respond as well as, and relapse more quickly than, female patients with predominantly facial acne and those with less severe acne. Eighty-five per cent of patients who receive a dose of 1.0mg/kg are virtually clear of their acne by 16 weeks. Thirteen per cent require 5 or 6 months to clear, and 3% require a longer course. A very small number of patients (fewer than 1%) may need up to 12 months of therapy. Low-dose courses of isotretinoin are successful in mature adults with persistent and late-onset acne. Typical treatment consists of 0.5mg/kg/day taken 1 week out of 4 for a period of 6 months. Ninety-one per cent will be clear of acne using this regimen.

What are the reasons for a slow response?. Analysis of slow responders to isotretinoin shows that the cause is due to the presence of macrocomedones in 70%, nodular acne in 15% and unknown in about 5%. It may be necessary to stretch the skin to detect macrocomedones. These must be sought prior to starting isotretinoin, For patients with causes of poor response other than macrocomedones, the course of isotretinoin should be continued, possibly at an increased dose if the side-effects are tolerated. Some female patients with hormonal dysfunction, due, for example, to polycystic ovarian syndrome, may need additional treatment with a hormonal preparation such as Dianette/Diane 35. The duration of therapy should be adjusted to give at least 90% clearing of acne. Further courses of therapy are usually successful if required. There is no contraindication, apart from pregnancy, to represcription and there is no tachyphylaxis. Some patients have needed two or three courses, and fewer than 3% require up to five courses with no signs of cumulative toxicity.

Isotretinoin is teratogenic. Fifty per cent of pregnancies spontaneously abort, and of the remainder about half of the infants are born with cardiovascular or skeletal deformities .Pregnancy test be performed a few days before instituting therapy. Adequate counselling is essential even in a 10-year-old girl. Counselling should best be given by someone who is experienced in family-planning issues. Most side-effects of oral isotretinoin are predictable and do not interfere with the patient's management. They are tolerated by modification of the dose and/or additional symptomatic therapy. An acne flare early in the course of isotretinoin occurs in 6% of subjects and in half of these is clinically important. Risk factors for this flare include the presence of macrocomedones in two-thirds and nodules in almost one-third of patients. When the acne flares, the isotretinoin should, depending on the extent of flare, either be stopped or reduced to a dosage of 0.25mg/kg/day. If stopped, the drug can be slowly reintroduced at a dose of 0.25mg/kg/day, and then increased or decreased as necessary.
The mucocutaneous side-effects can usually be prevented by the use of moisturizers and lip salves, but occasionally a retinoid dermatitis, a severe retinoid cheilitis or conjunctivitis occurs, which is often complicated by secondary infection with Staphylococcus aureus. These patients may need oral antistaphylococcal therapy and/or topical mupirocin 2% ointment may be required.A nasal preparation of mupirocin can be used to eradicate nasal carriage of staphylococci.

Significant systemic effects are uncommon, and mainly consist of headaches, which may be early features of benign intracranial hypertension, and arthralgia. Tetracyclines, including doxycycline and minocycline, must not be taken along with isotretinoin, as both drugs may produce benign intracranial hypertension. Depression, diarrhoea, mood changes, urticaria, vasculitis and diffuse noscarring type of hair loss are the other side effects. There is much debate as to whether liver-function tests and lipids should be monitored while on therapy. Elevations in these tests occur in almost all patients and rapidly return to pretreatment levels after therapy has been stopped. It is, however, essential to carry out these tests pretherapy. Recent published evidence suggests that the laboratory tests need not be repeated except in groups at risk, such as diabetics and patients with known familial hypertriglyceridaemia.

Hormonal treatment

Hormonal regimens are indicated usually where standard antibiotic regimens have failed, where concomitant period control or contraception and acne therapy is required, and where oral isotretinoin is inappropriate or not available. Topical therapy should be prescribed alongside hormonal regimens.Antiandrogens are a logical approach to the treatment of acne, as they suppress sebum production to an extent that depends on the drug and dose prescribed. The antiandrogen cyproterone acetate (CPA) is commonly used antiandrogen. CPA (2mg) combined with 35 micrograms of ethinyl oestradiol (Diane 35/Dianette) is an oral contraceptive that ameliorates acne. It is also of potential benefit in women with acne resistant to other therapies. In women, the side-effects of CPA with oestrogen are no different from those of conventional contraceptive pills, apart from a possible slight risk of weight gain. Diane 35/Dianette can be given for 6-8 years; thereafter, a conventional contraceptive pill, possibly one of the triphasic pills such as Trinordiol (ethinyl oestradiol+levonorgestrel ), which suppresses sebum excretion. The main side-effects are menstrual irregularity, occasional fluid retention and, rarely, melasma. A question mark remains over its long-term use because of possible neoplastic (breast cancer) potentiation. This has been shown in animal but not human studies. All hormonal regimens should be combined with appropriate topical therapies. For the patient with intractable moderate or severe acne, or if appropriate antiandrogens are unavailable, isotretinoin is the treatment of choice. Isotretinoin is more effective than Dianette for acne patients. Spironolactone also has antiandrogen properties and can also be used for females over 30 years of age. Its effects are dose dependent and it is usually prescribed at a dose of 100-200mg for 6 months.Now a days rarely used for acne treatment.

Oral antibiotics

Oral antibiotics are the most widely prescribed oral therapy worldwide. Tetracyclines (tetracycline, oxytetracycline, doxycycline and minocycline) are the antibiotics of choice.but erythromycin is preferable in the female who is or might become pregnant or is breastfeeding. Trimethoprim is also sometimes used. However, reducing the P. acnes bacteria will not, in itself, do anything to reduce the oil secretion. Additionally the antibiotics are becoming less and less useful as resistant P. acnes are becoming more common. Acne will generally reappear quite soon after the end of treatment—days later in the case of topical applications, and weeks later in the case of oral antibiotics. Furthermore side effects of tetracycline antibiotics can include yellowing of the teeth and an imbalance of gut flora, so are only recommended after topical products have been ruled out. Now a days doycycline and minocycline are more often used than tetracycline. Minocycline produces a blue-black pigmentation in a dose-dependent way, and in the skin this presents in three forms: pigmentation in inflamed acne lesions, in scars (acne and non-acne) and, more rarely, generalized dark-grey discoloration. The pigmentation is due to a melanin-drug complex and it lasts for an average of 8-15 months posttherapy.The brown-grey pigmentation due to minocycline may also occur in the nails,oral mucous membranes and sclera.
The serious side-effects are of three types, all of which are rare. Hypersensitivity syndrome reactions (including pulmonary eosinophilia) and serum sickness-like reactions occur within 3 months of treatment and are characterized by fever, malaise, and arthralgia possibly with major organ involvement. The late-reaction pattern occurs much later, usually at about 6-48 months. These patients, predominantly female, present with a symmetrical polyarthritis or polyarthralgia in the small joints. Some of these patients have concomitant liver disease, which may occur in the absence of joint symptoms. A liver biopsy shows chronic active hepatitis, and serology for lupus is usually positive. Thus, minocycline should be avoided in patients with a personal or family.

Tea tree oil

The essential oil of Melaleuca alternifolia , also known as tea tree oil or Melaleuca oil, has been used medicinally in Australia for more than 80 years.The tree itself has been used therapeutically for even longer, being one of the plants used in traditional medicine by the Bundjalung aborigines of northern New South Wales.Tea tree oil (TTO) is well characterized and contains approximately 100 terpenes and their related alcohols.The physical and chemical properties of commercial TTO are regulated by an international standard.
Tea tree oil has broad-spectrum antimicrobial and anti-inflammatory activity in vitro .These properties have formed the basis of its use in the treatment of a range of superficial dermatoses such as cuts, insect bites, boils and dermatophytosis., There are study reports suggesting the use of 5% tea tree oil for the treatment of acne vulgaris and showing the efficacy of tea tree oil gel against Propionibacterium acnes.

Nicotinamide

The marked anti-inflammatory properties of topical nicotinamide, the amide derivative of vitamin B3 (niacin), have been used to treat acne vulgaris.Nicotinamide, (Vitamin B3) used topically in the form of a gel, has been shown in a 1995 study to be more effective than a topical antibiotic used for comparison, as well as having fewer side effects. Topical nicotinamide is available both on prescription and over-the-counter. The property of topical nicotinamide's benefit in treating acne seems to be its anti-inflammatory nature. It is also purported to result in increased synthesis of collagen, keratin, involucrin and flaggrin.It is often combined with topical antibiotics

Azelaic acid

This dicarboxylic acid, derived from Pityrosporum yeasts. Among its many properties is broad-spectrum antibacterial activity. It is useful in mild to moderate acne. Azelaic acid does not affect the rate of sebum excretion.Used as a depigmenting agent in melasma, post inflammatory hyperpigmentation. This is ideal cream if the person has mild acne with many pigmented marks.

Topical retinoids

A group of medications for normalizing the cell lifecycle are topical retinoids such as tretinoin, adapalene and tazarotene . Like isotretinoin, they are related to vitamin A, but they are administered as topicals. They can, however, cause significant irritation of the skin. Tretinoin is the most and adapalene is the least irritant. These helps to prevent the hyperkeratinization of these cells that can create a blockage. Retinoids are the choice for treatment of comedonal acne. In appropriate cases, a topical retinoid can be used in the evening and an anti-inflammatory agent in the morning. Retinol, a form of vitamin A, has similar but milder effects and is used in many over-the-counter moisturizers and other topical products. Effective topical retinoids have been in use over 30 years but are available only on prescription so are not as widely used as the other topical treatments. Topical retinoids often cause an initial flare up of acne and facial flushing. Acne starts improving after 4 weeks. These are contraindicated during pregnancy.

Topical antibiotics(erythromycin ,azithromycin and clindamycin etc..)

Only the lipid-soluble forms, for example the base, propionate or stearate, are effective.
A topical 2% erythromycin gel has been shown to be as effective as 1% clindamycin phosphate in patients with mild to moderate acne. Clindamycin is as effective as oral minocycline 50mg twice a day, and oral tetracyline. Clindamycin was found to be as effective as 5% benzoyl peroxide gel in patients with papular or pustular acne in some persons. Erytromycin is commonly used for infantile acne and during pregnancy. Now a days resistance to erythromycin is the more common, and such organisms share a cross-resistance to clindamycin. Topical antibiotic resistance should be suspected in four circumstances:1if the patient fails to respond;2 if the patient relapses while on therapy;3 if the patient has had multiple courses of oral and topical antibiotics;4 if the patient has a history of poor compliance with therapy. In such cases alternative therapy may be necessary depending upon the circumstances. Among the side effects allrgic contact dermatitis is rare bur irritant dermatitis is quite common.

Benzoyl peroxide.

Widely available over the counter(OTC) bactericidal products containing benzoyl peroxide may be used in mild to moderate acne. Benzoyl peroxide is available in concentrations of 2.5%, 5% and 10%, either alone or with a combination of sulphur, hydroxyquinolone, glycolic acid or zinc lactate. The gel or cream containing benzoyl peroxide is applied , twice daily. Bar soaps or washes may also be used and vary from 2 to 10% in strength. In addition to its therapeutic effect as a antimicrobial benzoyl peroxide also has keratolytic(dissolve the excessive skin cells).This is also safe during pregnancy. Care must be taken when using benzoyl peroxide, as it can very easily bleach any fabric or hair when it comes in contact with. However, it routinely causes dryness, local irritation and redness. A sensible regimen may include the daily use of low-concentration (2.5%) benzoyl peroxide preparations. It can also cause pigmentation of skin, if exposed to the sunlight after rubbing on the skin.

Choice of treatment

Patients with mild acne usually receive topical therapy; patients with moderate acne receive topical and some time with oral therapies; patients with severe acne should immediately receive oral therapies.. The severity assessment should include not just the extent of the inflammatory and comedonal lesions, but also the presence of scarring, the psychological effects of the disease, and the lack of success with previous treatment.

In general treatments are believed to work in at least 4 different ways (with many of the best treatments providing multiple simultaneous effects).

1.Anticomedonal: Adapalene, tretinoin, azaleic acid and isotretinoin

2.Antimicrobial: Erythromycin, clindamycin,azaleic acid benzoyl peroxide.

3.Anti-inflammatory: Adapalene, erythromycin, clindamycin, Nicotinamide.

4.Antiandrogen; Cyproterone acetate.

systemic/internal diseases associated with acne

Acne some time associated with cysts in the overies known polycystic ovary(PCO) syndrome. Other manifestations include menstrual irregularities, obesity and infertility.
Some of the ovarian tumours known as virilizing ovarian tumours causes acne,hirsutism(male pattern distribution of hair over the face),amenorrhoea or oligomenorrhoea , alopecia and deepening of the voice.
Adrenal hyperplasia, adrenal tumours and Cushing's disease can also cause acne.

Acneiform /pimple like rash

If the acne like rash appear due to drugs , known as acneiform eruptions. Corticosteroids, orally, topically and intranasally, and by injection, may provoke an acneiform eruptions. Although the precise mechanism is uncertain. Corticosteroids do not affect the number of surface bacteria, but do induce cornification(increase skin cells) in the upper part of the pilosebaceous duct.
Androgens including anabolic steroids and gonadotrophins, may precipitate acne, especially in females and in athletes who take illegal performance-enhancing drugs.
Some time other drugs like bromides, iodides, phenobarbitone, isoniazid and rifampicin can also cause acneiform eruptions.

Infantile and juvenile acne

Infantile and juvenile acne, which mainly affects males, presents as facial acne at around 3-24 months, and may last up to 5 years of age. Acne are more localized than in adults and particularly affect the cheeks. The individual lesions include not just comedones, papules and pustules, but also both nodules and scarring may be found. It is thought that juvenile acne initially results from transplacental stimulation of the adrenal gland, as most sufferers have elevated plasma adrenal androgens, but it is uncertain why the acne lasts for up to 5 years.

Acne fulminans

The patients are predominantly young males, who quite suddenly develop extensive inflammatory lesions, especially on the trunk Associated features are fever, joint pain , weight loss, anorexia and general malaise. Bone pain also common may show lytic lesions on X ray. It is an uncommon, immunologically induced, systemic disease in which the offending antigen is P. acnes. This is considered as sever form of acne due to systemic features

Acne conglobata

This is a most uncommon but severe form of acne, found particularly in males; the lesions usually occur on most of the trunk, face and limbs. Nodules are characteristic and frequently fuse to form multiple draining sinuses. Grouped, multiple, fused blackheads and extensive scarring are also features. The disease is characterized by persistence well into 40-50 years of age.

senile comedones/pimples

These are common in elderly people, especially in the periorbital areas. Most patients have had high exposure to UV radiation, and the solar damage to the supporting dermis allows the pilosebaceous duct to become more easily distended with impacted corneocytes. The edge of the adjacent skin may be mistaken for the pearly edge of a basal cell carcinoma. The lesions are easily removed with a comedo expressor, but they slowly recur.

Tropical/hydration acne

Certain occupations may aggravate pre-existing acne, for example workers in a hot, humid environment, such as cooks and pressers, are at risk.It is thought that hydration of the pilosebaceous duct pores may accentuate blockage of the duct and so precipitate inflamed lesions. Potentially comedogenic sunscreens may be an additional factor in these patients. These types of acne also common after a holiday in a hot, humid environment.

Detergent acne

This uncommon form of acne. This type of acne develops in patients who wash many times each day with soap, in the mistaken hope of improving their existing acne. Pustular and papular lesions are most noticeable. Several bacteriostatic soaps contain weak acnegenic compounds, such as hexachlorophene are responsible for such acne. These acne start improving once they discontinue using of such soaps.

Mechanical acne

This term covers a mixed group of disorders in which the acne occurs at the site of physical trauma, as indicated by the pattern of the lesions. Examples are so-called fiddler's neck, which occurs on the neck of violin players, and is also characterized by the presence of lichenification and pigmentation. Headbands (as worn by sports-people and hippies) and tight bra straps are other causes. Continuous friction from turtle-neck sweaters may localize acne to the neck. Adolescent patients lying in bed for a long time, for example following a fractured femur in the orthopaedic ward, may develop a flare of acne-the so-called 'immobility acne'. This is probably due to a change in the environment of the skin, which may enhance bacterial colonization of the duct.

Occupational acne

Acne can appear in areas in contact with oils and crude tars in certain workers. Men are more often affected than women. The skin may show conspicuous comedones, and only occasionally do frank inflammatory lesions arise; these are usually superficial. Lesions can occur within 6 weeks of exposure on almost any site, but the thighs and lower arms are especially prone. The commonest oils involved are the impure paraffin mixtures used in the engineering industry. Crude petroleum can affect oilfield and refinery workers; workers exposed to heavy coal-tar distillates.

pomade acne

Pomades are greasy preparations used in hair creams. The rash is similar to cosmetic acne but consists of non-inflamed lesions around the forehead and other areas where greasy pomades may extend onto the hairless skin. It may also coexist with acne vulgaris. The rabbit-ear model has shown that certain pomades are comedogenic. Restriction of the use of pomades is essential.

cosmetic acne/pimples

Use of potentially comedogenic cosmetics causes acne known as cosmetic acne. The lesions characteristically occur in the perioral area of mature females, especially those who had acne as adolescents and have used cosmetics for a long time. some cosmetics, especially those containing lanolin, petrolatum, certain vegetable oils, butylstearate, lauryl alcohol and oleic acid, are comedogenic.

Acne excoriee

This is a variant of acne, occurs predominantly in females. Two subgroups exist: those with some primary inflammatory acne lesions, and those with virtually none. Both groups usually consist of females who 'fiddle' with the skin to exacerbate even the smallest lesions. There is often some personality or psychological problem.

conditions resembling Pimples

Rosacea, which occurs in an older group and lacks comedones, nodules, cysts or scarring.In females, confusion with perioral eczema is possible, but in these patients the lesions itch, the skin is dry and non-inflamed lesions are lacking.Whiteheads may resemble small epidermal cyst known as milia.
Drugs like corticosteroids,anabolic steroids for bodybuilding, androgens (in females), oral contraceptives,isoniszid, iodides and bromides may produce acneiform/pimple like eruptions.

Stress and pimples

It is unlikely that stress induces the formation of acne lesions. However, acne itself induces stress, and 'picking' of the spots will aggravate the appearance.This is particularly obvious in young females who present with acne excoriée.Acne patients experience shame (70%), embarrassment and anxiety (63%), lack of confidence (67%), impaired social contact (57%) and a significant problem with unemployment.Severe acne may be related to increased anger and anxiety.

Diet

Many people think that certain foods, in particular chocolate and pork fat causes acne, but scientific proof is lacking. Chocolate, for example, appears to have no significant influence.Dietary restriction resulting in marked weight loss reduces seborrhoea, but cannot be considered as routine treatment.A personal study of 100 acne patients found no link between acne severity, caloric intake, carbohydrate, lipids, proteins, minerals, amino acids or vitamins.

Mark and scars

Once the pimples heals may leave mark/scar. Close inspection of acne skin can reveal some scarring in up to 90% of individuals . But significant scarring occurs in 22%. Scars may show increased collagen (hypertrophic scars and keloids) or be associated with loss of collagen (i.e. ice-pick scars, depressed fibrotic scars, atrophic macules and perifollicular elastolysis).Ice-pick scars are self-explanatory, and are most evident on the cheeks. Post inflammatory pigmentation is known as pimple marks. A common feature of darkly pigmented skin is the relatively persistent marks, which may be more disabling than the original disease. Many people are worried about these consequences.

blackheads and whiteheads

Non-inflamed pimples are known as comedones They are more frequent in the younger patients.There are two types of comedones. One is blackheads also known as open comedones , in which the black colour is due to melanin but not dirt.And another is whiteheads also known as closed comedones.
Apart from blackheads and whiteheads ,we often see inflammatory pimples like papules, pustules (5mm or less in diameter), and nodules.

common sites

Acne is a polymorphic disease, which occurs predominantly on the face (99%) and, to a lesser extent, occurs on the back and shoulder(60%) and chest (15%).In young men, it affects mainly the face, and in older males the back is also significantly affected. Increase oiliness of the face known as Seborrhoea is a frequent feature.

How pimples are developed ?

1.There is increase multiplication with retention of skin cells at tip of oil secreting glands(sebaceous glands) known as ductal hypercornification ,which presents histologically as micro-comedones, and clinically as blackheads and whiteheads.So,comedones represent the retention of hyperproliferating ductal keratinocytes/skin cells in the duct. Several factors have been implicated in the induction of hyper proliferation, and include sebaceous lipid composition, androgen's, local cytokine production and bacteria. There is also increase in secretion of sebum from the sebaceous glands.
2.Acne is not infectious. The major organisms isolated from the surface of the skin and the duct of patients with acne are Propionibacterium acnes .Pimples/acne are associated with a significant increase in P. acnes, but there is little or no relationship between the number of bacteria on the skin surface or in the ducts and the severity of acne.
3.Inflammation/redness in acne lesions are due to pro-inflammatory mediators present within the skin producing inflammatory acne.

Genetic factors for pimples.

Several studies have shown that genetic factors influence susceptibility to acne. A genetic influence is confirmed by the very high concordance between mono zygotic twins, in which the extent and severity of acne and the sebum excretion rate (SER) are virtually identical. Comedone numbers are also similar in identical twins, suggesting a genetic role in comedone formation.. Furthermore, in three pairs of identical twins, severe nodular acne developed at approximately the same time in each pair.

Age limit for pimples

The condition usually starts in adolescence and frequently resolves by the mid-twenties. But can start as early as 9 years of age and may continue to appear even after 40 years of age.
One type of pimples appear during infancy known as infantile acne and usually subside at the end of second year, but may last up to 5 years of age.

Defination of pimple/acne

Pimple is a chronic inflammatory disease of the pilosebaceous units(oil secreting gland of the skin also known as sebaceous gland,which is present around the hair follicle).The medical term for pimple is known as acne.Common form of acne known as acne vulgaris.
It is characterized by the formation of comedones, red/erythematous papules and pustules, less frequently by nodules or pseudo cysts and, in some cases, is accompanied by scarring.

Introduction

Beautiful is applied to that which gives the highest degree of aesthetic pleasure to the senses or to the mind and suggests that the object of delight approximates one's conception of an ideal. Our skin is god’s gift which covers and protects our internal organs. Maintaining our skin as beautiful as possible is our prime duty. The skin, by virtue of its visual appeal, smell and feel, plays an important role in social and sexual communication in humans, as it does in other animals. Cosmetics and clothes are used to enhance the appearance and sometimes (but not always) sexual attraction
People are becoming more aware about their skin.Adolescence and adults are very concern about their skin especially the skin over the face. In this age group the most important cosmetic problem is pimple. In this blog every point is discussed about pimples with nice photographs.