KONSEP DASAR PENYAKIT CLAVUS

 A. Pengertian
Pengertian
Clavus (klavus) adalah istilah kedokteran, di masyarakat awam biasanya disebut mata
ikan. Clavus bukanlah tumor, bukan pula tanda awal kanker, melainkan penebalan dari
kulit. Mata ikan adalah kelainan pada kaki berupa kulit yang menebal, tidak merata ,
tampak seperti kerucut terbalik dengan alasnya ada pada permukaan kulit. Kalau
dipegang akan terasa keras, namun kalu dibawa berjalan akan terasa nyeri. Sumber 
lain mengatakan bahwa clavus ini adalah semacam tumor jinak yang biasanya tumbuh
pada kulit permukaan kaki. Bentuk mata ikan itu sendiri biasanya bulat dan berwarna
putih persisi seperti mata ikan beneran. Ada juga yang berpendapat clavus merupakan
pertumbuhan semacam “kapalan” dimana hanya terlokasi hanya pa da satu sisi dan
menimbulkan rasa sakit tertekan yaitu pertumbuhan sel-sel tanduk yang tidak normal.
Biasanya ditelapak kaki dan pertumbuhannya yang pesat menekan sel-sel sekitarnya
termasuk jaringan dibawahnya ataupun sel-sel syaraf.
Penyakit seperti ini tidak bisa dibiarkan, disamping mengganggu aktivitas kita, juga
akan terus membesar dan melebar. Sehingga menjadi benjolan semacam tumor,
bahayakan lambung secara langsung. Bersamaan saat nyeri terjadi akan meningkatkan
keasaman dari lambung
Berbagai profesi akrab dengan clavus misalnya pemain gitar di jari-jari yang menekan
senar pada keher (neck) gitar, sepatu pada jari kaki, penjahit pada jari telunjul, dsb.
Lokasi akan menentukan apakah ia akan basah atau kering. Ia akan kering bila terjadi
di permukaan kulit dan basah bila terjadi disela jari. Bila terjadi demikian jangan
menutup clavus dengan kapas karena tidak menyerap air. Mata ikan biasa berubah
menjadi borok terinfeksi.

B. Penyebab
 Ada beberapa
beberapa pendapat
pendapat yang
yang menyebutkan
menyebutkan penyebab
penyebab timbulnya
timbulnya mata ikan. Pendapat
Pendapat
pertama yaitu mata ikan timbul disebabkan oleh virus yang kemudian masuk diantara
kulit dan daging kemudian merusak jaringan bawah kulit, sehingga makin lama, makin
mengeras, dan membesar. Pendapat kedua adalah Mata ikan tidak disebabkan oleh
kuman, tapi disebabkan oleh gesekan atau tekanan dalam waktu yang lama, sehingga
terjadi penebalan kulit. Penyebab terjadinya penebalan dari kulit ini adalah tekanan dan
gesekan terus-menerus pada bagian kaki yang terkena. Misalnya, karena pemakaian
sepatu yang terlalu sempit atau lama. Oleh karena tekanan terbesar pada telapak kaki,
maka biasanya clavus timbul pada telapak kaki.

C. Tanda dan Gejala

Walaupun merupakan penyakit yang banyak terjadi,munculnya clavus kadang-kadang
 juga dapat
dapat berhubungan
berhubungan dengan
dengan penyakit
penyakit lain.
lain. Clavus dapat merupakan
merupakan adanya
adanya
gangguan saraf tepi akibat kencing manis, atau pada penderita arthritis rematoid (salah
satu jenis rematik) menjadi tanda sudah ada perubahan sendi tulang-tulang kaki.
Jika clavus terjadi pada orang diabetes yang sudah mengalami gangguan saraf tepi
kaki, biasanya tidak terasa nyeri. Tetapi hal ini malah dapat berbahaya, karena dapat
mmeluputkan perhatian akan adanya luka/ borok yang dapat berakibat serius pada
penderita diabetes mellitus.

D. Pengobatan dan Perawatan

Bila tidak mengganggu biarkan saja, bila mengganggu pengobatannya adalah operasi.
Hanya clavus akan tumbuh kembali bila faktor tekanannya tidak dihilangkan.
Sebenarnya pengangkatan clavus dengan operasi kecil merupakan cara cepat untuk
 menghilangkan nyeri yaitu dengan mengeluarkan inti mata ikan atau eksisi total.Tapi
 jika ingin mencoba cara tanpa operasi, mungkin dapat dicoba dengan mengoleskan
salep keratolik pada mata ikan, memberikan obat-obat oles yang dapat menipiskan
lapisan kulit yeng menebal yaitu yang mengandung urea, asam
glikolat/malat/salisilat.Untuk mengurangi nyeri, sementara dapat ditempelkan plester 
tebal pada clavus.
Harus memperhatikan sepatu atau sandal yang dipakai selama ini. Apakah sudah
nyaman atau terlalu sempit. Jika perlu , gantilah alas kaki selama ini. Yang penting,
hindari hak tinggi.
Jika clavus berulang kembali dan anda juga menderita rematik, mungkin perlu dirontgen
untuk melihat kondisi tulang-tulang kaki dan sendi-sendinya, karena dikhawatirkan
sudah terjadi perubahan pada tulang dan sendi. Bila hal ini terjadi ada baiknya
konsultasi juga dengan dokter spesialis penyakit dalam, konsultan rematologi.
(Djoerban. Z,2008)
Selain dioperasi clavus dapat diobati dengan cara berikut :
1. Saat ini ada alat yang dapat menghilangkan kutil dengan cepat, yaitu dengan
menggunakan electric cauter. Electric cauter adalah sejenis alat yang cara kerjanya
membakar kulit secara electir dan dengan menggunakan metode tertentu sehingga kutil
akan terbakar dan lepas dengan sendirinya sampai keakar-akarnya. Dengan
pengobatan ini kutil dapat langsung dihilangkan tanpa mengeluarkan darah.
Pengobatan ini bisa di dapatkan dari dokter spesialis kulit dan kelamin (Sp.KK). Disana
anda dapat bebas berkonsultasi tentang permasahannya dan tentu saja dokter spesialis
itu akan memberikan pengobatan yang terbaik buat kamu. Jadi jangan ragu, untuk pergi
ke dokter, semakin awal dalam mengobati penyakit itu semakin baik.
2. Obat kutil dan mata ikan, yaitu dengan menggunakan salep herbal. Salep dioleskan
pada pagi dan malam hari , ditutup kapas, diplester dan dibiarkan meresap.
3. Pengobatan tradisional
Pengobatan tradisional kutil daun dewa juga dipercaya dapat menyembuhkan kutil.
Daun dewa (Gynura divaricata, gynura segetum (lour) Meer, atau gynura pseudochina)
cukup lama dikenal sebagai tanaman anti kanker. Dibeberapa daerah daun dewa
dikenal dengan nama beluntas cina, atau samsit. Menurut penelitian dari Fakultas
Farmasi UGM dan Badan Tenaga Nuklir Nasional ( BATAN), secara laboratoris ekstak
etanol daun dewa mampu menghambat pertumbuhan tumor paru pada mencit (tikus
putih kecil). Ekstark ini juga mampu menghambat pertumbuhan sel kanker.
Pada beberapa tulisannya menngenai tumbuhan berkhasiat obat Indonesia Prof HM
Hembing Wijayakusuma menyampaikan bahwa daun dewa memiliki banyak khasiat.
Manfaat itu banyak berasal dari daun dan umbinya. Daunnya berkhasiat untuk
mengobati luka terpukul, melancarkan sirkulasi darah, menghentikan perdarahan,
pembengkakan payudara, melancarkan haid, dan lain-lain. Sementara umbinya
berkhasiat untuk mengatasi bekuan darah, pembengkakan, perdarahan, tulang patah,
dan lain-lain.
Daun dewa tergolong tumbuhan semak yang subur pada ketinnggian 0-100 meter 
diatas permukaan laut. Tinggi tumbuhan ini bisa mencapai 50 cm. Daunnya tunggal
bertangkai pendek berbentuk bundar telur berujung lancip. Kedua permukaan daunnya
berambut dengan warna putih. Warna permukaan daun dibagian atas hijau tua,
sedangkan dibawahnya berwarna hijau muda. Bunganya terletak dibagian ujung
batang, berwarna kuning berbentuk bonggol.
Efek farmakologis daun dewa adalah anti kuagolan (koagulan=zat yang mempermudah
dan mempercepat pembekuan darah), mencairkan bekuan darah, stimulasi sirkulasi,
menghentikan perdarahan, menghilangkan panas, dan membersihkan racun. Daun
dewa mengandung zat saponin, minyak atsiri, flavonoid, dan tenin. Efek farmakologis
didapatkan dari seluruh tanaman.

E. Pencegahan
Pencegahan dapat dilakukan dengan sebisa mungkin menghindari kaki dari tekanan
yang terus-menerus. Sebaiknya pilih alas kaki yang baik, waktu yang tepat untuk
memilih alas kaki adalah siang hari, karena saat itu kaki berada pada bentuk aslinya.
Memakai alas kaki (sepatu) yang cukup (tidak terlalu sempit) pastikan kaki nyaman
memakainya, selal ganti secara rutin kaos kaki, selalu jaga kebersihan kaki kalau perlu
secara rutin dilakukan perawatan yang lebih intensif lagi. Jangan dibiasakan berjalan
tanpa alas kaki meskipun itu didalam rumah, karena bisa beresiko kemasukan benda
asing.

 A clavus is a thickening of the skin due to intermittent pressure and frictional forces.
These forces result in hyperkeratosis, clinically and histologically. The extensive
thickening of the skin in a clavus may result in chronic pain, particularly in the forefoot;
in certain situations, this thickening may result in ulcer formation. The word clavus has
many synonyms and innumerable vernacular terms, some of which are listed in the
Table below; these terms describe the related activities that have induced clavus
formation.

Synonyms for clavus include callosity, a hyperkeratotic response to trauma; corn,

heloma, or a circumscribed hyperkeratotic lesion that may be hard (ie, heloma durum)
or soft (ie, heloma molle); and callous, callus, or a diffusely hyperkeratotic lesion.
Localized callosities of the soles, which do not resolve, are termed plantar callus,
heloma, tyloma, keratoma, or plantar corn .[1] When callosities occur over 1 or more
lateral metatarsals, they are termed intractable plantar keratoses .[2]

Clinically, all these lesions look like hyperkeratotic or thickened skin. Maceration and
secondary fungal or bacterial infections are a common overlying feature in heloma molle
and diabetes. Plantar helomas tend to have a central keratin plug, which, when pared,
reveal a clear, firm, central core. The most common sites for clavus formation are the
feet, specifically the dorsolateral aspect of the fifth toe for heloma durum, in the fourth
interdigital web of the foot for heloma molle, and under the metatarsal heads for 
calluses.[3]

Table. Clavus Formation Named for Specific Etiology or Location (Open Table in a new
window)

Vernacular Term Location Association

Jeweler's callus, cherry pitter's Thumb Digital changes, including callosities related to
[4]
thumb, cameo engraver's repetitive use of fine jeweler's instruments, which also
corn[5] may be seen with the use of cherry-pitting tools

Weight lifter's callus[6] Callosities over the palmar Caused by the friction of weight-lifting apparatus (This
metacarpophalangeal joints also may be seen in athletes who participate in crew.)

Prayer callus[7, 8] Callosity on the forehead From kneeling prayer with the hands on the forehead

Cigarette lighter's thumb[9] Hyperkeratosis of the radial aspect of the Caused by excessive cigarette lighter flicking
thumb

Knuckle pads[10] Hyperkeratosis over the knuckles Caused by boxing training

Russell sign[11] Callosities of the dorsum of the hand over Caused by the friction involved with self-induced
the metacarpophalangeal and emesis in bulimia nervosa
interphalangeal joints

Screwdriver operator's Palmar surface of the hand Occurs at the site of contact with a screwdriver handle
[12]
clavus

Spine bumps Hyperkeratosis over the spinal column Caused by dancing with spinning on one's back

Hairdresser's hand First finger on dominant hand Callus formation at the site of friction caused by
scissors around the first finger on the dominant hand

Sucking calluses[13] Lip, hand, or foot of a newborn Callus formation at the site of an area of suction on
the lip, hand, or foot of a newborn

Vamp disease[14] Feet Clavus formation due to wearing tight high-heeled

shoes

 A clinical image of a screwdriver operator's clavus is below.

Screwdriver operator's callus (ie, clavus).

Pathophysiology
The shape of the hands and feet are important in clavus formation. Specifically, the
bony prominences of the metacarpophalangeal and metatarsophalangeal joints often
are shaped in such a way as to induce overlying skin friction. As clavus formation
ensues, friction against the footwear is likely to perpetuate hyperkeratosis.

Toe deformity, including contractures and claw, hammer, and mallet-shaped toes, may
contribute to pathogenesis. Bunionettes, ie, callosities over the lateral fifth metatarsal
head, may be associated neuritic symptoms due to compression of the underlying
lateral digital nerves. Furthermore, Morton toe, in which the second toe is longer than
the first toe, occurs in 25% of the population; this may be one of the most important
pathogenic factors in a callus of the common second metatarsal head, ie, an intractable
plantar keratosis.

Chronic or repetitive motion may also induce clavus formation, as is seen in computer 
users and text messengers (ie, "mousing" callus) .[15] Callosities can also form from
excessive leg crossing.[16]

Epidemiology
Frequency
United States 

Clavus is a common disorder because of the frequency of usage of occlusive footwear 

and participation in repetitive activities, such as running.

Mortality/Morbidity
Extensive thickening of the skin may result in chronic pain, particularly in the forefoot; in
certain situations, ulcer formation may result. Clavus may be a sign of underlying
neuropathy due to diabetes or neuroborreliosis, or due to the deformities of rheumatoid
arthritis. In the case of neuropathy, a clavus may hide ulceration or denote abnormal
 neurovasculature of the feet. In the case of rheumatoid arthritis, clavus may enhance
the pain of deformed joints.

Race
Persons of any race may be affected by clavus.

Sex
Clavus is more common in women than in men because of their use of occlusive and
poorly fitted footwear.

Age
 Anyone can have a clavus, but most individuals acquire the risk factors for clavus
formation after puberty because of the onset of traumatic footwear use, repetitive
motion injuries, and progressive foot deformities.

 A clavus forms because of inappropriate distribution of pressure onto a specific site,

usually of the foot. A localized callosity of the soles, which do not resolve, are termed
plantar callus, heloma, tyloma, keratoma, or plantar corn. When callosities occur over 
one or more lateral metatarsals, they are termed intractable plantar keratoses.

Physical
Clinically, all variants of clavus lesions look like hyperkeratotic or thick skin; maceration
and secondary fungal or bacterial infections are a common overlying feature in heloma
molle and diabetes. Plantar helomas tend to have a central keratin plug, which, when
pared, reveal a clear, firm, central core. The most common sites for clavus formation
are the feet, specifically the dorsolateral aspect of the fifth toe for heloma durum, in the
fourth interdigital web of the foot for heloma molle, and under the metatarsal heads for 
calluses.

 Examination of patients should include assessment of the types of footwear worn, activities
performed, gait, and current home therapy or previously prescribed therapy.
 Lesions should be palpated and pared to look for underlying blood vessels (black dots or 
pinpoint bleeding), which are seen in warts, and to look for underlying ulcerations, as seen in
neurovascular ulcerations (especially in patients with diabetes).
 Paring of callosities or corns, as opposed to plantar warts, should reveal normal
dermatoglyphics .[17]
 Callosities are generally more painful with direct pressure, whereas warts are more painful
with lateral pressure.[18]
 Pedobarographic studies are pressure assessments that may be used to detect an altered
distribution of foot pressure. MRI may delineate diabetic foot problems more clearly.
 Biopsy of lesions reveals hyperkeratosis and, occasionally, mucin deposition.
Causes
Conditions associated with clavus formation

  Advanced patient age

  Amputation (ie, stump callosities)
 Use of a brace or orthopedic stabilizing product
 Bulimia nervosa[11]
 Costa acrokeratoelastoidosis [19]
 Doxorubicin toxicity[20]
 Keratoderma palmaris et plantaris
 Obesity
 Pachyonychia congenita [21]
 Sensory neuropathies, including neuroborreliosis
 Tethered spinal cord syndrom e[22]
 Vascular occlusion syndromes[23]
 Warts (ie, verruca vulgaris)[1]
Faulty mechanics: Irregular distribution of pressure and repetitive motion injury
(especially in athletes) are believed to be the main inciting causes; however,
inappropriately shaped or constrictive footwear in the presence of bony prominences
(eg, talar bone prominences [24] ) may exacerbate clavus formation. Furthermore, some
 disorders may alter the shape or sensation of the soles of the feet. Bony prominences
and faulty foot mechanics then allow clavus formation to continue .[25, 26, 27, 28, 29]

 Rheumatoid arthritis [30] : About 17% of patients with rheumatoid arthritis present with
intractable foot pain. Chronic arthritis leads to foot deformities and consequent callus
formation. Bleeding into callosities in patients with rheumatoid arthritis may be a sign of 
rheumatoid angiitis.
 Diabetes mellitus with associated peripheral neuropathy [31] : In patients with diabetes, chronic
callosities in the presence of neurovascular deterioration may lead to ulcerations and
superinfections.
 Obsessive-compulsive disorder (pseudo-knuckle pads)
 Ectopic nail
  Acanthosis Nigricans
  Acrokeratoelastoidosis
  Arsenical Keratosis
  Atypical Fibroxanthoma
  Atypical Mole (Dysplastic Nevus)
 Nevi, Melanocytic
 Warts, Nongenital
 Warty Dyskeratoma
Medical Care
Treatment of a clavus should be aimed at reducing symptoms such as pain and
discomfort with walking. Paring of the lesions immediately reduces pain. Once the
etiology of the foot pressure irregularity is determined, attempts at pressure
redistribution should be made. The use of orthotics and conservative footwear with extra
toe space are often beneficial. When all else fails, surgery may be performed.

If abnormal dermatoglyphics or pinpoint bleeding is seen, wart therapy is initiated. If 

normal dermatoglyphics are noted, salicylic acid compounds and orthotics may be
beneficial.

Relief of symptoms may be achieved by thinning and cushioning of the involved lesions.

 Paring of the lesions immediately relieves pain, especially with helomas. Lesions may be
maintained in this state if the patient uses short soaks and pumice stone debridement at
home. Debridement may be enhanced with the use of keratolytic agents, such as ureas,
alpha-hydroxy acid (eg, glycolic, malic, or lactic acid), or beta-hydroxy acid (eg, salicylic
acid).[33] Garlic extracts have also been described as being helpful .[34]
 Self-adhesive pads are most effective for reducing thick lesions, whereas lotions, creams, and
medicaments in petrolatum are best for maintenance. Most salicylic acid compounds are 10-
17%. High concentrations of salicylic acid (eg, 40%) may lead to severe maceration, and in
patients with diabetes, it may lead to frank foot ulcerations .[35] Intralesional triamcinolone and
topical vitamin A acid compounds also may reduce localized hyperkeratosis. Triamcinolone
can lead to localized hypopigmentation .[36]
  A carbon dioxide laser can be used to pare deep lesions .[37]
  A combination product to be applied by physicians consisting of 1% cantharidin, a vesicant,
mixed with 30% salicylic acid and 5% podophyllin has been described as effective for most
people after just one session. In a study looking at 72 patients, 90.3% with callosities on the
feet demonstrated that application of this agent after paring with a 15 blade effected clearance
in 79.2%, 12.5%, 6.9%, and 1.4% after 1, 2, 3, and 4 sessions, respectively, with only one
recurrence at 1 year follow-up.[38]
Reduced friction may be accomplished with the use of silicone-lined sleeves on the
toes, padding, and, in select cases, silicone [39] or collagen injections [3] over the bony
prominence in question.

 Lamb's wool may be beneficial in interdigital corns. Pads or permanent insoles, which place
pressure proximal to the metatarsal head, relieve stress on the region. Insoles may be made
of silicone or soft plastics.
 Shoes with extra length are required for toe deformity, and shoes with extra width are required
for lateral toe callosities. Shoes should be soft inside without seams that rub or press.
Orthotics can be placed in the shoe for patients with abnormalities of the foot, such as
cavovarus. Orthotics can be created by using insoles made to correct deformities noted on
dynamic pressure molds. Reduction of heel height may be helpful for patients with metacarpal
head callosities.[40]
  Vacuum orthoses have been described to aid in lesional clearance for diabetic patients with
plantar callosities.[41]
Surgical Care
Surgical options for clavus should be used when only conservative measures fail.

 Chronic foot pain despite conservative therapy is the number one indication for surgery.
 Hallux valgus correction may aid in reduction of painful callosities over the long term .[41]
 Surgical corrections for claw, hammer, and mallet toes are simple procedures.
 Shaving of prominent condyles of bony prominences may be beneficial particularly on the fifth
digit.
  Arthroplasty of the fifth toe interphalangeal joint also may be performed.
 Metatarsal condylectomy or chevron osteotomy may be performed to relieve metatarsal head
pressure.[42]
 Mann and DuVries described the use of a combination of arthroplasty and condylectomy. This
combination results in 95% clearance, with only a 13% occurrence of transfer lesions .[45]
 When thinning of the plantar fat pads is contributory to the formations of callosities, injectable
silicone can be used on the soles underneath the callosities and corns to reduce pressure
related callous formation.
 Description of excision followed by either grafting, use of flaps, or grafting using split-thickness
graft with or without a collagen/elastin matrix graft has been described as effective in a single
resistant case.[45]
Consultations
  An orthopedist and a podiatrist can be helpful in adjusting abnormalities of gait or pressure
distribution.
 Dermatologists are best consulted to assess for the possibility of other disorders in the
differential diagnosis, especially warts and keratoderma.
Diet
No special diet is required; however, weight loss relieves some of the foot pressures
involved.

Activity
 Adjustment of the footwear and the use of special insoles aid in the maintenance of full
mobility and eliminate the need for activity limitation.

Medication Summary
Debridement may be enhanced with the use of keratolytic agents, such as ureas, alpha-
hydroxy acid (eg, glycolic, malic, or lactic acid), or beta-hydroxy acid (eg, salicylic acid).
The use of these agents is not recommended in pregnant women and young children.
Most salicylic acid compounds are 10-17%. High concentrations of salicylic acid (eg,
40%) may lead to severe maceration and frank foot ulcerations in patients with
diabetes. Self-adhesive pads are most effective for reducing thick lesions, whereas
lotions, creams, and medicaments in petrolatum are best for maintenance. Intralesional
Kenalog and topical vitamin A acid compounds also may reduce localized
hyperkeratosis. Kenalog may be injected during pregnancy because of its limited
absorption; however, it can lead to localized hypopigmentation. Topical vitamin A
derivatives are not intended for use in women who are pregnant or intending to become
pregnant because their safety ranges from category C to category X.

 A combination product to be applied by physicians consisting of 1% cantharidin, a

vesicant, mixed with 30% salicylic acid and 5% podophyllin has been described as
effective for most people after just one session .[38]

Keratolytics
Class Summary
These agents cause cornified epithelium to swell, soften, macerate, and then
desquamate. Commonly used agents include urea, alpha-hydroxy acids (eg, lactic acid,
glycolic acid), and beta-hydroxy acids (eg, salicylic acid).

View full drug information

Ammonium lactate (Lac-Hydrin)

May loosen the adhesion of the keratinocytes in the stratum corneum, thereby thinning
the skin.

View full drug information

Salicylic acid topical (Compound W, Panscol, Sal-Plant)

May be compounded in petrolatum at any percentage, usually is used at 5-20%,

beginning with lower percentage. Can be purchased over the counter as a liquid or pad
preparation, ranging from 17-40% (multiple companies make these). Can be irritating or 
cause blistering.

View full drug information

Urea (Ureacin-40, Aquacare)

Promotes the hydration and removal of excess keratin in conditions of hyperkeratosis.

Intralesional corticosteroids
Class Summary
These drugs have anti-inflammatory properties and cause profound and varied
metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

View full drug information

Triamcinolone (Kenalog, Amcort)

Injectable version of triamcinolone is available in concentrations of 3-40 mg/mL.

Generally, this compound is diluted to 1-4% for injection into lesions, such as a clavus.

Corticosteroids cause the skin to thin, and this beneficial side effect can be used to
reduce the thickness of a clavus. However, overusage also can lighten the skin and
cause atrophy.

Retinoids
Class Summary
Retinoids decrease the cohesiveness of abnormal hyperproliferative keratinocytes, and
they may reduce the potential for malignant degeneration. Retinoids modulate
keratinocyte differentiation.

These agents are not specifically approved for use in clavus therapy. Only tretinoin has
been shown to be useful for clavus therapy in the topically applied form. These agents
cause the skin to peel by loosening of keratinocyte adhesion. Irritation and discomfort
are limiting adverse effects.

View full drug information

Tretinoin topical (Retin-A, Avita)

Inhibits microcomedo formation and eliminates lesions present. Makes keratinocytes in

sebaceous follicles less adherent and easier to remove. Available as 0.025%, 0.05%,
and 0.1% creams. Also available as 0.01% and 0.025% gels.