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ACNE

Definisi
Acne adalah penyakit kronik, rekuren unit
pilosebasea
Terutama mengenai remaja
Dapat mempengaruhi kualitas hidup
Dapat menyebabkan jaringan parut/scar
Gambaran lesi :
1. Non Inflamasi
2. Inflamasi
Definisi
KELENJAR SEBASEA
Terdapat pd seluruh tubuh, kec. telapak tangan &
kaki
ukuran terbesar : di muka, punggung atas
Kepadatan di muka 400-900/cm2 ,bag lain
<100/cm2
What Causes Acne?
There isnt a simple answer to this question
because there are many factors to contribute
to acne. To make sense of the causes of acne it
helps to break down the discussion into
general topic areas.
What Causes Acne?
Genetics
Genetics Play a Central Role in the Development of Acne
Genetic makeup is the dominant factor determining an individuals likelihood of developing acne.
Genetics impact the structure of the hair follicle, sebaceous gland activity, hormone levels and the immune
response to bacteria. For example, many people who suffer from inflammatory acne have immune cells
that are less effective at killing the acne bacteria or produce more inflammatory molecules than the
general population as a result, their body responds more vigorously, but less effectively, to acne causing
bacteria, resulting in increased inflammation.
What Causes Acne?
Bacteria
Propionibacterium acnes are the Bacteria Most Often Associated with Acne Vulgaris
Acne (especially inflammatory acne) is usually the result of bacterial growth deep within the hair follicle.
These bacteria produce molecules which incite an immune response, leading to inflammation and acne
symptoms. The more bacterial growth there is, the more likely an individual will develop acne symptoms.
The bacteria primarily responsible for acne is Propionibacterium acnes (P. acnes), but other bacteria such
as Staphylococcus aureus can also live on the skin and in hair follicles. Antibiotics are commonly used to
control the growth of bacteria and can greatly improve symptoms for many acne sufferers.
There are many different strains of P. acnes bacteria, and many of these strains have developed resistance
to one or many different antibiotics. As a result, some antibiotics, including erythromycin and tetracycline,
are becoming less effective, because many people who suffer from acne carry strains of bacteria that are
resistant. Fortunately, there are still many antibiotics available that do not have this shortcoming.
What Causes Acne?
Environment
Sunlight may help improve acne symptoms for some patients
Environmental conditions, like temperature, sun exposure, humidity and allergens can play a big role in
acne outbreaks. Many people find that their acne symptoms improve during the summer, which may be a
result of increased temperatures or exposure to sunlight.
Low temperatures may decrease the fluidity of the sebum passing through the follicle and increase the risk
of developing a plug. Or low humidity levels can dry the skin, causing the body to upregulate sebum
production in a bid to protect the skin. Sunlight can affect both the bacteria and the skin, causing
physiological changes or damage to various structures.
Allergic reactions may exacerbate skin problems, or cause new ones. Many people notice that their acne
tends to improve or worsen depending on the weather, and this is because the environmental conditions
can directly affect the way the body functions.
What Causes Acne?
Stress
Stress can both cause and aggravate acne symptoms. Stress is well known to disrupt normal hormonal
balance and depress the immune system, but the direct relationship is not well understood. Part of the
difficulty in defining the relationship between stress and acne is that there are many types of stress.
Many people experience acne break-outs after a long night of studying or partying. Alcohol consumption
is also a form of stress. Inadequate sleep is another very common form of stress. Psychological and
emotional stress comes in many forms, all of which can affect the function of your immune system.
What Causes Acne?
Diet
Excessive Consumption of High Glycemic Index Foods (e.g. French Fries) is Associated With Increased
Incidence of Acne
While there isnt much data linking specific foods to worsening acne symptoms (milk excluded), research
has shown a strong connection between high glycemic index diets and increased incidence of acne.
High glycemic diets are those that are high in sugar and simple carbohydrates. Excessive consumption of
sugar and starch is the primary cause of high blood sugar levels, and blood sugar levels are the primary
regulator of metabolic function.
Consistently elevated blood sugar levels are a type of stress, and they appear to negatively affect the body
in ways that are similar to other forms of stress. Besides increased acne symptoms, high blood sugar levels
can lead to other problems, like type 2 diabetes.
Etiopatogenesis
1. Produksi sebum kel. sebasea
2. Hiperproliferasi folikel epidermal
3. Propionibacterium acnes
4. Proses Inflamasi.
Gambaran Klinis
Wajah (99%), punggung (60%), dada (15%)
Keparahan bervariasi, ringan s/d fulminan
Asimtomatik, kadang nyeri. Tidak gatal
Lesi tak-meradang (komedo)
Blackhead
Whitehead
Lesi meradang
Papul eritematosa
Pustul
Nodus, kista
Eritema pascainflamasi
Hiperpigmentasi pasca-inflamasi
Jaringan parut
Hipotrofik
Hipertrofik (dada, punggung)
1. ACNE CONGLOBATA -
Inflamed nodules that are connected to other
nodules under the skin.
2. ACNE VULGARIS
The most common type of acne, which includes blackheads, whiteheads,
cysts, nodules, etc. When people say they have acne, this is likely the type
they are referring to. The term acne vulgaris covers all the types on this
definition list except Acne Conglobata .
3. BLACKHEADS
A type of non-inflammatory acne in which the hair follicle is filled with
dead skin, bacteria, and sebum. The mixture of sebum and air give it the
black color. Usually found on the upper cheeks and nose.
4. COMEDONE
A type of acne that is non-inflammatory, usually distinguished by skin that
looks and feels slightly rough or bumpy. Usually Comedone spots are less
than 1mm.
5. CYST
A pustule that is larger in diameter and more
inflamed. It is like a nodule that is filled with
pus.
6. MACULE
The flat, reddish mark left after an acne lesion
has cleared.
7. MILIA
Small, hard, white non-inflammatory bumps
caused by genetics or the use of oil-heavy
products. They are very similar to whiteheads
in appearance and are difficult to clear
without the help of a dermatologist.
8. NODULE
A papule type of acne that grows to over 1 cm
in diameter. They begin deep in the skin layer
and may feel firm and painful.
9. PAPULE
Red inflamed pimple usually on the face that forms when a
hair follicle wall breaks and fills up with debris and bacteria.
The breakdown of the hair follicle wall is usually caused by
irritation.
10. PUSTULE
A papule pimple that is filled with pus. This is the type of acne that we are
usually referring to when we talk about acne. It is an inflamed area of the
skin with a white center, which is filled with pus. (An easy way to
remember the name is pustule has the word pus in it.)
11. WHITEHEAD
Small, white/clear colored non-inflammatory bumps caused by the
buildup of dead skin and bacteria. They are very similar to milia in
appearance and can be cleared through the process of exfoliation.
Type 1 Acne
There are several different manifestations of acne
with varying degrees of severity. Acne can range
from small patches of red skin with tiny bumps to
large, painful and scarring cysts. Different types of
acne can have profoundly different underlying causes
and understanding precisely what type of acne you
have can help you identify what solutions are going
to have the best chance of being effective.
Type 1 Acne
Minimal inflammation.
Minimal affected area.
Not painful.
Irregular outbreaks.
Type 1 acne is the most mild form of
acne and generally is the least
damaging and easiest to treat form of
the disease. It is characterized by a lack
of inflammation and is usually not
particularly painful. The area of the
body affected by the acne is usually
limited. This type of acne is often
transient and often resolves on its own
after about a week.
Type 2 Acne
Mild inflammation.
Some painful pimples.
Regular outbreaks.
A common manifestation of the disease, Type 2 acne is similar
to Type 1 acne, but is characterized by increased levels of
inflammation and redness. Pimples can range from small red
bumps to medium sized whiteheads.
Unlike Type 1 acne blemishes, the increased inflammation
causes pimples that are often painful to the touch. Over the
counter topical treatments are often partially effective at
decreasing the severity and duration of outbreaks, but are
frequently inadequate. Topical antibiotics and
topical retinoids (e.g. Retin-A) can be quite effective. In some
instances it may be necessary to explore oral antibiotics or oral
retinoids, if the acne is not responsive to treatment. In
general, Type 2 acne is minimally scarring if allowed to resolve
on its own. However, it is important to practice good hygiene
and avoid exacerbating the situation by popping pimples
without cleaning and sterilizing the area before and after.
Type 3 Acne
Large, painful pimples.
Nodular pimples.
Frequent outbreaks.
Type 3 acne is characterized by the presence of mid sized to large
nodules and pustules that are frequently painful. In Type 3 acne,
pimples are often associated with significant amounts of
inflammation.
Large whiteheads and large, painful red bumps are common in
patients with Type 3 acne. Individual pimples can often take a long
time to resolve, sometimes up to 10-14 days. In type 3 acne, much of
the inflammation and infection originates deeper in the tissue than in
Types 1 and 2, often localizing in the dermis and sub-cutaneous fatty
tissue. Because of this, type 3 acne is usually unresponsive to over the
counter topical medications. Likewise, the efficacy of topical
antibiotics and topical retinoids is often limited. In many cases,
oral antibiotics and oral retinoids are the only effective treamtents for
Type 3 acne.
The increased inflammation associated with Type 3 acne poses a
significant risk of permanent scarring. Deep seated nodules and
postules can cause damage to the structural matrix that underlies the
skin, causing pitting, discoloration and the accumulation of scar tissue
Type 4 Acne
Large and painful nodules.
Pustules and Cysts.
Persistent Outbreak.
The most severe form of the disease, Type 4 acne almost
invariably causes permanent skin damage and scarring. Like
Type 3 acne, Type 4 acne is characterized by a deep seated
infection and extensive inflammation. Large cysts, which are
essentially large, irregular nodules are a common feature in
Type 4 acne.
Type 4 acne is is usually completely non-responsive to over
the counter medications. Topical antibiotics and retinoids are
minimally effective, in most cases. Type 4 acne often requires
aggressive oral antibiotic and/or oral retinoid treatments.
Type 4 acne is a serious medical condition that should be
evaluated immediately by a dermatologist, if at all possible.
Type 4 acne can cause extensive damage to the skin and
underlying structure, causing heavy scarring. Type 4 acne is
often extremely painful, both physically and emotionally, and
should be treated as aggressively as possible.
The Different Types of Acne Scars
Types of Acne Scars
Acne scars come in many different shapes, sizes and even colors. Each type of scar
has its own unique characteristics and features. Because of these differences, the
available treatments are not one size fits all, and it is important to carefully choose
the treatment that best matches your needs, in order to achieve optimal results.
In this section we first break down acne scars into three main groups: Depressed
(pitted scars), raised (keloid scars) and discoloration scars. Within those groups we
discuss the most commonly observed sub-types and what the current research
indicates to be the best treatment options for each.
Depressed (Pitted) Acne Scars

Diagram of Depressed (Pitted) Acne Scars

Depressed scars are the most common type of scar that results from inflammatory acne. Within this class
of scars there are three main types that are common in acne sufferers:
Rolling scars relatively broad depressions in the skin that have rounded, sloping edges. The combination
of several of these types of scars in a region of skin gives it a rolling appearance, hence the name.
Boxcar scars also relatively broad depressions, but have steep, defined edges.
Icepick scars as the name implies, are deep and narrow scars. In many cases, they resemble a large,
empty pore in the skin. In general, all the depression scars rest on top of a patch of fibrous, collagen rich
scar tissue. This fibrous tissue anchors the base (bottom) of the scar to the sub-cutaneous tissue,
maintaining the depression and preventing the regrowth of healthy tissue.
Effective treatments for depressed acne scars usually involve disrupting or removing this scar tissue to
allow its replacement with functional, healthy tissue
Rolling Acne Scars

Rolling Acne Scars on the Face (Woo, et al)

Rolling scars are common for in individuals who have had patches of skin that have been
afflicted by long term inflammatory acne. They tend to become more pronounced as the skin
ages and loses its original elasticity and fullness.
Because rolling scars have rounded, sloping borders, many of the available scar treatment
techniques are capable of producing positive results. Laser resurfacing (ablative and non-
ablative), intense pulsed light (IPL), chemical peels, micro-dermabrasion and even red light
therapy can produce improvements in the appearance of rolling scars. Cosmetic fillers are also
occasionally used, but many times the large size of the affected area makes fillers an
unappealing option. Mild surgical procedures, such as needling are also used.
Box Scar Acne Scars

Boxcar Acne Scars on the Temple (Fabbrochini, et al)

Because box car scars have more clearly defined and steeper edges than rolling
scars, it is more difficult to smooth them out and blend them into the surrounding
skin. Laser resurfacing, particularly ablative resurfacing with an Er:YAG or CO2 laser
, often produces good results, although many treatments may be necessary to
achieve maximum improvement.
Box car scars often cover smaller areas than rolling scars and are better candidates
for cosmetic fillers. Shallow box car scars can be treated with chemical peels
and/or micro-dermabrasion, but these treatments are not very effective for deep
scars. Surgical options include punch- out excisions, needling and surgical
subcisions.
Ice Pick Acne Scars

Ice Pick and Boxcar Acne Scars on the Cheek (Fabbrochini, et al)

Ice pick scars are often the most difficult type of acne scar to treat without surgical
intervention. Ice pick scars are often quite deep, making them very difficult to treat
with standard resurfacing techniques. Chemical peels, micro-dermabrasion and
many types of laser resurfacing are unlikely to have a significant impact on ice pick
scars because those techniques do not remove enough tissue to be effective.
Some forms of laser therapy may be effective at disrupting the underlying scar
tissue. Because ice pick scars are quite narrow, punch-out excisions are a
popular,mildly invasive and effective treatment technique.
Raised Acne Scars
Hypertrophic and Keloid Scars

Severe Hypertrophic Acne Scarring along the Jawline (Goodman, et al)

Commonly called hypertrophic or keloid scars, raised scars present a different problem than
depressed scars. Hypertrophic scars are those in which excess scar tissue forms at the site of
the injury, which presents as a raised region of fibrous and firm scar tissue.
When the scar tissue forms in great excess, it can become a large nodule of dense, rubbery scar
tissue that is known as a keloid. The development of hypertrophic and keloid scars is less
common in acne patients than the development of depressed scars. A number of factorscan
potentially be involved in the process, including acne severity and duration, genetics and
secondary infections.
Because hypertrophic and keloid scars are raised, they are more susceptible to treatments like
laser ablation and micro-dermabrasion. They can also be surgically removed. Hypertrophic scars
are generally less responsive to treatments like chemical peels, because the scar tissue is much
more resistant to the ingredients in a chemical peel than healthy tissue.
Discoloration and Pigmentation
Scarring
Hyper-pigmentation

Hyper-pigmentation Acne Scarring on the Face (Goodman, et al)


The trauma associated with acne damage can cause many other abnormal conditions in the skin,
besides the formation of fibrous scar tissue. Perhaps the most common long-term form of acne
scarring is the abnormal discoloration of the skin.
Hyper-pigmentation is a condition where elevated levels of the pigment melanin accumulate in the
skin. This creates the appearance of freckle-like spots or blotches. Hyper-pigmentation occurs
when melanocytes (the cells that produce the melanin pigment) begin to proliferate at the site of
injury, or when an existing population of melanocytes begins to produce excess amounts of
melanin. Both of these events can result from the trauma caused by an inflammatory acne lesion.
Hyper-pigmentation is often treated with laser treatments that specifically target melanin, such as
KTP and pulsed dye lasers, as well as intense pulsed light (IPL) therapy. Hyperpigmentation is also
addressed with the prescription medications like hydroquinolone, which inhibits the production of
melanin, and topical retinoids, which increase the rate of cellular turnover in the skin.
Discoloration and Pigmentation
Scarring
Hypo-Pigmentation

Hypopigmented Macular Acne Scarring (Goodman, et al)

Contrasting with hyper-pigmentation, hypo-pigmentation occurs when


melanocytes are depleted from the injury site or lose their ability to produce
melanin. This is often the case in areas of skin that have been replaced with scar
tissue, which tends to have a light, pinkish appearance. It can also occur in
otherwise healthy looking regions of skin.
Generally this condition is more noticeable in those individuals with darker base
skin tones. Vitiligo is a condition in which melanocytes lose the ability to produce
melanin. There are not many effective treatments available for hypo-pigmentation.
Discoloration and Pigmentation
Scarring
Erythema (Permanent Redness)

Erythematous Scarring (Permanent Redness) from Acne (Goodman, et al)


Erythema is a condition in which small capillaries near the surface of the skin
become damaged or permanently dilated. This condition presents as a region of
redness in the skin. Occasionally, individual capillaries are visible. It is somewhat
common in acne patients and is most visible in patients with lighter skin tones.
Erythema may be treated with topical prescription medications to decrease
vasodilation, but the results are usually temporary. Erythema generally responds
well to laser and light based treatments that selectively target hemoglobin, such as
argon and pulsed dye lasers.
Acne komedonal
Acne komedonal- papulopustul
Acne Papulopustul
Acne nodulokistik
Jaringan parut (hipotrofic scar)
Acne excorie acne mekanika
Erupsi acneformis ( acne steroid )
Pentalaksanaan
Tujuan
Mengurangi gejala
Menghilangkan lesi yang sudah ada
Membatasi aktivitas penyakit
Menghindari dampak negatif pada kualitas hidup
Berkaitan dengan etiopatogenesis, tipe & keparahan lesi,
jenis kulit
Penentuan keparahan (grading)
Penilaian global
Lesi predominan (meradang, tak-meradang)
Penatalaksanaan
Terapi Topikal
Terapi Oral
Modalitas Fisik
Terapi jaringan parut
penatalaksanaan
Penatalaksanaan
Menormalkan keratinisasi
Gol retinoid : tretinoin,adapalen,tazaroten,retinol,retinyl
linoleat,retinylpalmitat
Bahan pengelupas : sulfur, resorsinol, as.salisilat
Mengurangi populasi P.acne
Gol antibiotik topikal, benzoil peroksida, as.azeleik
Menghilangkan massa yang menyumbat pori
Gol. Komedolitik: as.salisilat,retinoids,as.alfa hidroksi,as.azeleik
Mengurangi produksi sebum
Golongan retinoid
Menghilangkan respon inflamasi
Gol.anti inflamasi: as.salisilat, kortikosteroid
Retinoid Topikal
Retinoid
Setiap molekul, baik secara langsung maupun setelah konversi metabolik,
berikatan dan
mengaktifkan reseptor asam retinoat.
Retinoid + RAR/RXR transkripsi gen respons biologik spesifik
turnover epitel folikel mengurangi hiperkornifikasi komedolitik
Efek anti-inflamasi
Sediaan
acne cream 1
.Efek samping
Iritasi kulit (eritema, kulit kering dan terkelupas, kulit terasa kencang, rasa panas)
Peka-matahari
Edukasi
Asam salisilat
Beta- hydroxy acids
Larut dalam lemak (lipofilik), krim / lotion 2 3 % ,
Peeling kimiawi : 20 30% etanol
Efek pada akne :
- deskuamasi epitel folikel
- komedogenesis
- anti inflamasi & antimikroba
Efektif akne komedonal, 1-2 kali sehari.
Kombinasi + asam glikolat > BPO / asam salisilat tunggal.
Efek samping - iritasi / kulit kering
Sediaan : acne clear lotion, acne lotion, acne cr 3
Antibiotik Topikal
Nadifloxacin (terbaru)
- Antibakteri, antiinflamasi
- Alternatif untuk yang sudah resisten terhadap klindamisin dan eritromisin
Eritromisin (1,5 2%)
- Antibakteri, anti-inflamasi
- Sebagian P. acnes sudah resisten
- Dapat dikombinasikan dgn BP atau klindamisin
Sediaan : acne cream 3, acne lotion
Klindamisin
- Bekerja mirip eritromisin
- Gel, solusio, losio
- Dapat dikombinasikan dgn BP atau eritromisin
Sediaan : acne cr 1, acne cr b, acne lotion
Tetrasiklin
- Sudah jarang digunakan (noda kuning, berbau)
Resorsinol (Resorsin)
Larut dalam air, alkohol, eter, dan gliserin
Efek keratolitiknya < asam salisilat
Tersedia dalam bentuk bedak kocok
Umumnya digunakan dalam campuran dengan
sulfur dan asam salisilat
Efek samping : reaksi alergi dan iritasi
Sediaan : acne lotion, acne clear lotion, acne
cr 3
Sulfur
Efek :
- Keratolitik
- Antiinflamasi ringan
- Melonggarkan ikatan antar sel, mencegah retensi keratin
mencegah pembentukan mikrokomedo
Tersedia dalam bentuk bedak kocok dgn konsentrasi 420%
Dlm produk OTC tersedia dengan konsentrasi 3-8%
Sering ditemukan dlm bentuk kombinasi dgn resorsinol
Efek samping : kulit kering, kemerahan, bersisik
Bau yg tidak enak & kesan kotor penggunaannya terbatas
Sediaan : acne cream b, acne clear lotion, acne cr 3
Nikotinamid
Anti inflamasi
Th/ akne dengan inflamasi
Efektifitas gel nikotinamid 4 % ~ gel
klindamisin1 %
Sediaan : oil free cream
Produk Acne Violetta
Acne cream 1 / A : tretinoin, clindamisin, berfungsi untuk cream malam semua jenis acne
Acne cream B : sulfur, clindamisin, bersungsi sebagai tambahan cream acne problem jerawat
pustul (dipake pagi hari ditumpuk sunscreen)
Acne cream 3 : resorsinol, clindamisin, benzoil peroksida, untuk acne konglobata, !! Hati-hati
krn cukup keras, bs membuat kulit menjadi sensitif
Acne clear lotion : resorsin, sulfur, berfungsi untuk mengeringkan pustul yg membandel, &
sebagai P3k pasien yg sudah bebas acne
Oil free cream : nicotinamid, teatree, berfungsi untuk mengurangi sebum & komedo pada kulit
yg berminyak serta mengobati acne type 1-2, dan mencegah acne, sangat aman penggunaan
jangka lama
Anti komedolitik : asam salisilat, berfungsi untuk melunakkan komedo sehingga mudah
dibersihkan. Untuk kulit normal-kering yang mudah white & black head
Anti scar cream : asian cantella
Anti scar malam : asian cantella, tretinoin, berfungsi untuk scar baru maupun lama
Cream malam whitening scar : hq, tretinoin, asian cantella, berfungsi untuk hiperpigmen &
scar post acne
Penatalaksanaan Facial di Violetta
Lesi tidak meradang
White head :
Facial oxygen reguler/ intensif (serum anti acne)
facial acne
Skin care : oil free cream,anti komedolitik, sebum regulating,
acne clear lotion, cream malam
Black head :
Facial oxygen reguler/ intensif (serum anti acne)
facial acne
Skin care : oil free cream/anti komedolitik/sebum regulating,
cream malam
Penatalaksanaan Facial di Violetta
Lesi meradang
Papul eritematosa
facial clarifying
Facial acne+mdt acne
Laser acare 300-500 joule
acne cream 1, oil free cream
Pustul
peeling acne, mdt acne, terapi sinar, IPL, laser acare
acne cream 1, acne cream b, acne clear lotion
Nodul, kista
mdt acne, injeksi acne, terapi sinar, IPL, laser acare
acne cream 1, acne cream 3,
Penatalaksanaan di violetta
Eritema pascainflamasi :
mdt acne, peeling TCA , laser a care
Skin care : anti scar crem,
Hiperpigmentasi pasca-inflamasi :
microdermabrasi, ultimate, peeling tca
Skin care : cream malam, anti scar cream, post inflamasi cream,
Jaringan parut :
microdermabrasi, meso-roller, peeling TCA
Skin care : cram malam, anti scar malam,
Hipotrofik
Hipertrofik (dada, punggung)
Kesimpulan
Akne adalah penyakit umum unit pilosebasea
Empat elemen kunci dalam patogenesis
Hiperproliferasi epidermis folikel
Seborea
Keberadaan & aktivitas P. acnes
Peradangan
Terapi umumnya berupa kombinasi obat topikal dan
sistemik, dgn retinoid sebagai obat utama
Terapi lain (ekstraksi komedo, pengelupasan kimiawi,
terapi sinar, dsbnya) dpt dilakukan sesuai indikasi