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ACNE

PATOGENESIS ACNE
Sumbatan ductus pilosebaseus
Perubahan lipid bilayer/ biokimiawi lemak
Meningkatnya produksi sebum
Kolonisasi P. acne didalam folikel
Proliferasi folikuler (karena keratinosit
menempel kuat dan tidak bisa lepas)
Inflamasi
Terapi acne
Anti inflamasi (untuk yg ada inflamasi)
Black head dan white head blm inflamasi
Dapat diberikan:
Aloe vera
Licorice

Chamomile

Coenzym Q10

Cucumber extract

Green tea

Pycnogenol

Niacinamide
Sumbatan dilepas dengan eksfoliate
Exfoliate ada yg bersifat
Coagulasi : TCA
Akantolitik : AHA
Keratolitik, contohnya :
BHA (salisilic acid) (salisilic acid 1% keratoplasty, 2-

4%keratolitik)
BHA more efective reducing number of comedo than AHA
Retinoic acid ( tretinoin, adaphalen, tazarotene, retinol,

retynil linoleate, retinyl palmitate)


Urea (urea juga dapat berfungsi sebagai pelembab.

Konsentrasi 3-8%pelembab, 10-30%keratolitik)


BPO

Azeleic acid

Sulfur

Resorcinol
Bila ada P. acne kolonisasi harus direduced/
dieliminasi dgn:
Antibiotik
BPO (blm ada P.acni resisten BPO)
Eritrosolution
Clinda combination with eritro or with BPO
Azeleic acid
Sodium sulfacetamide
Sulfur
Oral antibiotik
Light terapi (terutama blue)
Perubahan biokimiawi
Untuk memperbaiki acid mantle dapat
diberikan:
Omega 3
Lactic acid

Niacinamid (B6) memperbaiki acid mantle,


moisturizer dan pencerah
Menurunkan produksi sebum
Komedolitik (gol vit A, baik oral maupun topikal,
baik kosmetik ataupun kosmedik)
BHA
AHA
Azeleic acid
Clay
Catatan:
Pasien dgn acne dapat kita berikan
antioksidan karna dianggap pasien dengan
acne banyak terdapat oksidan
Bahan kosmetik harus kita commit untuk
dipakai minimum 3 bulan (karna perbaikan
dicapai kurang lebih dlm 12 minggu)
Karena kita didaerah tropis, kita dapat
memakai antiinflamasi karena banyak
vaskular damage
Acne
Peradangan pada unit kelenjar
polisebaseus disertai penyumbatan
dan penimbunan bahan keratin
Letak: muka, leher, dada, lengan atas
dan punggung.
Gambaran klinis ditandai adanya
erupsi komedo, papel, pustul,
nodulus dan kiste serta jaringan
parut hipotrofik maupun hipertrofik.
A normal follicle looks like this:
Mitos akne
Penyakit remaja hilang sendiri
Masalah kosmetika saja its no big deal
Makanan
Stress
Higiene yang kurang baik,
Make up
Acne dapat sembuh
Medications that can cause acne
ACTH
Azathioprine
Barbiturates
Isoniazid
Lithium Disulfiram
phenytoin Halogens
Iodides
Steroids
Cyclosporine
Vitamins B2,6,12
Pembagian Acne
Ringan
non inflamasi, komedo, milia.
Sedang
inflamasi +
Berat
Nodulocystic
Major Oral Antibiotics Used for Treatment of Acne
Vulgaris by Dermatologists in The United State
Drug Usual dosage Comments Refs
range

Minocycline 50-100 mg once or Vestibular reactions may be 11,19-


(Immediate twice daily dose related and may be more 22,26
release) common with immediate-
release formulations
(especially generic
formulations with rapid
release properties.

Minocycline 1 mg/kg/day (45- Efficacy comparable to 2 17,18


(extended 135 mg once daily) mg/kg/day and 3 mg/kg/day:
release) potential for vestibular
reactiones appear to be lower
than with immediate-release
formulations

Doxycycline 75-100 mg once or Photosensitivity reported to 19-22, 26


twice daily 150 mg be dose related (higher
once daily. potential at 100 mg/day)
Recommended Laboratory Evaluations For Patients With Acne and
Possible Hormonal Abnormalities
Labs to be considered when evaluating a patient with androgen
excess
Dehydroepiandrosterone Sulfate (DHEAS)
Follicle-stimulating Hormon (FSH)
Luteinzing Hormone (LH)
Prolactin
17-Hydroxyprogesterone
Androstenedione
Free and total testosterone
Sex Hormone-binding globulin
In a patient where polycystic ovarian syndrome (PCOS) is
A consideration, add:
Fasting insulin
Fasting lipids
In a patient where cushings syndrome is considered, add Midnight
salivary cortisol level (new test approved by FDA)
FDA Drug Risk Classification System for acne
Medications
Drug Definition Medication
classific
ation
A Controled studies show no fetal Zinc salts
risk.
B No evidence of risk to human Azelaic acid,
fetus erythromycin,
clindamycin,
metronidazole
C Risk to human fetus cannot be Adapalene, benzoyl
ruled out. peroxide, salicylic
acid,
tretinoin.sulfur.sodiu
m sulfacetamide
D Positive evidence of risk to human Tetracycline
fetus : however, potential benefits
may outweigh the potential risk.
X Contraindicated in pregnant Isotretinoin,
tazarotene
Microcomedones become non-inflamed skin
blemishes called comedones--either a
whitehead or a blackhead:
For reasons no one completely understands, follicles, often
called pores, sometimes get blocked. Sebum (oil) which
normally drains to the surface gets blocked and bacteria
begins to grow. Both whiteheads and blackheads start out
as a microcomedone. The picture below is a
microcomedone:
A blackhead occurs when the pore opens to the
surface, and the sebum, which contains the skin
pigment melanin, oxidizes and turns a brown/black
color. It is not dirt and can not be washed away.
Blackheads can last for a long time because the
contents very slowly drain to the surface.
A papule occurs when there is a break in the follicular
wall. White blood cells rush in and the pore becomes
inflamed.
A pustule forms several days later when white blood
cells make their way to the surface of the skin. This is
what people usually refer to as a "zit" or a "pimple".
An inflamed lesion can sometimes completely collapse or explode, severely
inflaming the surrounding skin, and sometimes engulfing neighboring
follicles. These lesions are called nodules or cysts:

Nodule
When a follicle breaks along the bottom, total collapse
can occur, causing a large, inflamed bump that can be
sore to the touch
Development: A nodule occurs when the follicle wall
ruptures deep within the dermis. Contaminated debris
from the follicle empties into the dermis and infects
adjoining follicles. A nodule is a severe form of an acne
lesion.
Cyst
Sometimes a severe inflammatory reaction can result in
very large pus filled lesions.
Development: Like nodules, cysts begin as a deep
break in the follicle wall. A membrane develops around
the infection in the dermis. As a cyst works its way to the
surface, it damages healthy skin tissue, destroying the
follicle. The likelihood of scarring is very high.
Ringan
Sedang
Berat
Tata laksana acne
Perawatan kulit (Skin care) sesuai
patogenesis
Nasehat makanan
Medikamentosa
Pembersihan
Cleansing
Facial Wash
Toner

Yang mengandung bahan antiseptik atau


obat obatan
Tea tree, klorofil, BPO, Antibiotik, Sulfur
Gentle cleansing 2-3 x sehari
Medicated cleaser (BPO/SA)
No overcleasing
No picking
Put an ice and aloe twice daily
Acne Lotion
Asam salisilat
Resorsinol
LCD
Sulfur praecipitatum
Tea tree
Antibiotika
Minyak terpen
Sediaan Krim
Tretinoin
BPO
Antibiotika
Kortikostreroid
Sulfur
Asam salisilat
Azeleac acid ( krim , gel ) 15 % , 20 %-
memperbaiki keratinisasi & mencegah
kumulasi p acne...anti inflamasinya masih
diragukan
B PO ( cuci muka, gel,sol) 2,5-5 %
mencegah kumulatif p acne
Hanya retinoid dan antibiotika yang bersifat
anti inflamasi dan me<< koloni P.Acne
Komedo (open/closed) topikal keratolitik ,
topical retinoid
Inflamasi ( papul, pustule) : topikal
BPO,topikal AB, topikal retinoid
Nodulocystic : all topical inflamation + oral
tretinoid
Sediaan Oral
Antibiotika
Kortikostreroid
Isotretinoin
Zn Gluconas
Vitamin A
Patient Selection and Pre therapy
management Retinoid
Acne nodulocistic mild/ severe
recalcitrant ( min 3months oral AB+
tret/other topical, woman : 4 cycles anti
androgen-estrogen)
KONTRA INDICATION
absolut :pregnancy, breast feed woman,
under 12 years, hepatic and kidney
disorder, chronic sistemic disease (KI
relatif)
Pre therapy management of
retinoid
Patient selection
Lab exam (renal, hepar,lipid blood profile,
pregnancy test)
Photo before therapy
Inform concent
Contraseptif for productive aged woman
begin 1 months before therapy
Pengobatan
Retinoid
oral : isotretinoin 0.5-1 mg/kgBB/hr
dosis kumulatif 120 mg.kbBB
mini dose < 0,5 mg/kgBB/hr ( eg 10
mg/hr)
Topikal tretinoin ( krim, gel, sol) 0.025%, 0.05
%, 0.1 %
adapalene ( gel ) 0.1 %, o.3 %
Therapy management of Retinoid
Starting dose : 0.25-0.5 mg /kgBW/day for 2
weeks
Effect + dose 0.25mg/kgBW/day for 2
weeks total dose 120-150 mg/kgBW
Effect - dose 0.5-1 mg/kgBW/day for 2
weeks
STOP !!! After 4-6 weeks, continous topical
tretinoin
Maximal 3 cycles after 4-6 weeks free
Monitoring lab exam : renal, hepar,lipid blood
profile, pregnancy test
Post therapy management of
retinoid
Lab exam 1 month post tx
Skin care instruction : emolien, lipid
containing make up
Cosmetic use instruction : SPF 15-30
SPO before,during after therapy
Side Effek
Retinoid
oral : teratogenik,kekeringan kulit, gangguan
pertumbuhan tulang, peningkatan kadar
kolesterol darah, hepatotoksisitas, dll
topikal : iritasi, fotosensitivitas
Antibiotik : fotosensitivitas, pigmentasi biru
kehitaman, ggg GIT, resistensi
AZA dan BPO ; iritas
Tretinoin
Iritan
Meningkatkan pulih asal (turnover) sel di
dalam duktus polisebaseus,
Mengurangi perlekatan sel di epidermis
(decreased cohesiveness),
Mengeluarkan isi komedo,
Mengurangi proses radang,
Mempertinggi penetrasi transepidermal
untuk antibiotika dan benzoil peroksida.
Benzoil Peroksida
Iritan
Deskuamasi intraepidermal,
Menekan asam lemak bebas,
Bakteriostatik terhadap
Propionibacterium acnes,
Mencegah hidrolisis trigliserida.
APA TUJUAN TERAPI ORAL ?

1. Menurunkan populasi mikroorganisme di folikel


pilosebasea dan permukaan kulit.
2. Menurunkan kadar asam lemak bebas.
3. Menekan peradangan.
4. Menginhibisi langsung ensim lipolitik lipase.
KAPAN TERAPI ORAL DIBUTUHKAN ?

Bila terapi topikal tidak berhasil


Pada acne inflamasi
Pada acne gradasi sedang atau berat
Antibiotika
Tetrasiklin
Doksisiklin
Demeklosiklin
Minosiklin
Klindamisin
Lincomisin
Erythromisin
Cotrimoxasol
Ciprofloxacin
Antibiotik Oral
a. Tetrasiklin hidroklorida
dosis tinggi 4x250 mg/hr 1jam ac 3-6 mgg,
diturunkan 250mg/hr 6-8 mgg
dosis rendah 250 mg/hr 1jam ac/2jam pc 4-8
mgg
b. Eritromisin
dosis tinggi 4x250mg/hr 1 jam ac 2-6 mgg,
dosis disesuaikan 4-6 mgg
Kindamisin
Derivat Lincomisin
Mekanisme kerja : mengikat ribosom,
sehingga menghalangi pemindahan RNA
(Ribo Nucleic Acid) untuk pembentukan
kompleks ribosomal / messenger-RNA dari
kuman akibatnya mikroorganisme tidak
dapat membentuk protein essential.
Bahan aktif Herbal Anti Acne
Antibakteri
Antiinflamasi
Mengurangi kelenjar keringat
Mempercepat penyembuhan luka
Contoh : witch hazel, centella asiatica, tea tree,
curcuma( temulawak, kunyit)
Sediaan Parenteral
Zn Gluconas
Kortikostreroid (KIL)
Triamcinolon
Untuk acne nodulokistik
Sediaan 10 mg/ml
1 sesi butuh 1 mg (max 0,1 cc)jadi masukkan 0,1 cc
ditambah 0,9 cc NaCl
Bila ingin peeling, tunggu 3 hari post injeksi agar tidak
dekok
Maximal 4x/tahun (4x0,1cc) boleh diulang paling cepat
4 minggu
Bukan disuntikkan ke dalam lesi melainkan ke pinggir
lesi
Bila acne terlalu banyak, cari yg paling parah, 1 lesi 1
strip 0,01