Alternative Ways to Treat Acne

Acne No More Ebook

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Acne acne vulgaris OMIM 604324

Acne is an inflammatory dermatosis, the genetics of which have not been well studied. Acne is characterized by the development of inflammatory papules, comedones and pustules, leading on to possible disfiguring scarring. At a minimal level of severity, acne is ubiquitous in adolescence, and only a minority of cases will develop scarring or have a clinical course running into the second quarter of life. No secular trends or geographical differences in incidence for the principal clinical variants of acne are known. Family studies of acne are difficult to interpret because the peak prevalence of the disease is in adolescence, recall of disease imperfect, and the disease course is altered by widely available and effective therapies. Goulden and colleagues in a UK population provided evidence of clustering of acne within families with a fourfold increase in the chance of a relative of a proband case having acne compared with the relative of a control subject (Goulden et al., 1999). Three...

Isotretinoin Therapy in Patients with Acne and Coexistent HS

It is well known that acne and HS can occur in the same person. In addition to the coexistence of acne and HS, there are the so-called acne triad (acne conglobata, HS and perifolliculitis capitis abscedens et suffodiens) and acne tetrad (original acne triad and pilonidal sinus) conditions 16 . This clinical overlap of acne and HS has led to the inclusion of inhomogeneous patients in the treatment groups. It concerns two possible different types of HS firstly the disease that only affects the inguinal folds and the axil Table 17.2. Reported results of isotretinoin treatment of patients with acne and coexisting HS Table 17.2. Reported results of isotretinoin treatment of patients with acne and coexisting HS lae ( Verneuil's disease ), and secondly inguinal and axillary involvement in patients with acne affecting the face and back 2, 13, 17 . The last disease has also been called acne ectopica and acne tetrad. Harms 2 treated eight patients suffering from HS, of whom five had concurrent...

Acne And Other Skin Conditions

Over the past 2-3 decades, tetracyclines and macrolide antibiotics have been widely prescribed for the treatment of acne however, resistance has been reported, especially to erythromycin and clindamycin with cross-resistance being widespread among strains of Propionibacterium acnes. As a result, non-antibiotic treatments such as topical and oral zinc preparations have been investigated as both alternatives and adjuncts to these treatments. Oral supplementation Numerous studies have been conducted investigating the effects of zinc supplementation in acne vulgaris (Dreno et al 1989, 1992, 2001, Goransson etal 1978, Hillstrom etal 1977, Orris et al 1978, Weimar et al 1978, Weismann et al 1977, Verma et al 1980). Doses between 90 mg and 200 mg (30 mg elemental zinc) daily taken over 6-12 weeks have been associated with generally positive results, whereas larger doses tend to be poorly tolerated. More recently, an open study involving 30 subjects with inflammatory acne found that a lower...

Acne Conglobata

Acne conglobata (AC) is a disease attributed to an occlusion of sebaceous glands by a process of keratinization. This occlusion can be responsible for secondary sebaceous inflammation. Clinically, the patient presents with comedones, cysts, abscesses and draining sinus tracts, mainly located on the trunk and buttocks, but the face, neck and extremities may also be involved. In the literature, several cases of so-called AC may very well in fact be HS, such as in Whipp's two familial cases of fatal squamous cell carcinoma, in which a 56-year-old woman had suffered from widespread abscesses predominantly affecting the buttocks, AXILLAE and back 3 . The question of an association between AC and HS arises. In contrast to HS, AC is predominant in men 2 . It is however also highly inflammatory, starting in early adult life with an important tendency to scarring, which in AC is sometimes keloidal. Oral isotretinoin represents a major therapeutic improvement in the treatment of this once...

Acne Vulgaris

An open study of 117 subjects with different forms of acne found that after 6 weeks' treatment with a 0.2 dried extract of Vitex agnus-castus and a topical disinfectant, 70 of cases experienced total resolution with the highest success rates reported for acne vulgaris, foilicularis and excoriated acne (Amann 1975). A group that was not treated with the herb took 30-50 longer to achieve similar results. Although encouraging, it is difficult to determine the contribution of vitex treatment to these results. Until controlled studies using vitex as a stand-alone treatment are conducted, the herb's role in this condition is still uncertain.

Adverse Reactions

A systematic review of the herb's safety, published in 2005, analysed data from six electronic databases, postmarketing surveillance studies, spontaneous reporting schemes (including WHO), herbalist organisations and manufacturers (Daniele et al 2005). The review concluded that vitex is a safe herbal medicine and any adverse effects associated with its use tend to be mild and reversible. The most common adverse effects are nausea, headache, gastrointestinal disturbances, menstrual disorders, acne, pruritis and erythematous rash. Additionally, no drug interactions have been reported.

Immunohistochemistry of Hidradenitis Suppurativa

These changes mirror those found in experimentally induced early acne lesions 16 where a high ratio of T4 to T8 cells was found at 24 h. Further work looking at time-coursed biopsy samples in acne also confirmed these findings 17 . These identical results in early HS and acne lesions suggest there may be a common mechanism with a type-IV delayed hypersensitivity response to an as yet unidentified antigen.

Follicular Occlusion Diseases

Acne vulgaris (AV) Acne conglobata (AC) The term follicular occlusion disease refers to a possible common pathogenic mechanism of occlusion of sebaceous or apocrine glands, and diseases included in this term are listed in Table 6.1. An association of these disorders has been described in several patients, suggesting that a causal relationship may be found rather than mere co-occurrence. It has therefore been suggested that the association of HS, acne conglo-bata (AC) and dissecting folliculitis of the scalp should be named follicular occlusion triad. Acne tetrad includes pilonidal cyst in addition to the three aforementioned components. The actual evidence in favour of such aggregation is however predominantly morphological. Epidemiological studies raise doubt about the general value of these observations (see Chap. 8). They have failed to support it and clinical experience also suggests that these diseases are not generally associated with HS. Acne vul-garis (AV) appears to be...

Dissecting Folliculitis of the Scalp

A synonym for this entity is perifolliculitis capitis abscedens et suffodiens. This disease shows considerable geographical variation and most often appears to affect Afro-Caribbean male patients. It usually starts during early adulthood. It has been described in women and girls 20 as well, and familial occurrence has also been documented 21 . An association with acne is reported in 30 of cases 22 . The disease is however uncommon and only a few cases have been reported in the literature making it difficult to establish reliable arguments for an association 20 . Treatment is generally not rewarding. Antibiotics are commonly prescribed, and combination therapy using rifampicin and clindamycin has been advocated 24 . Tetracyclines in acne doses are usually not effective, whereas some relief may be gained from anti-staphylococcal medicines such as dicloxacillin in long-term therapy (authors' personal experience). Isotreti-noin is occasionally (rarely) helpful at a dosage between 0.67 and...

Causes of Hyperandrogenism

On the other hand, hyperandrogenic skin changes ( idiopathic hirsutism, hypertrichosis in men, most cases of acne, AGA in women but also in men) mostly occur in fact in patients with normal androgen levels. Increased enzyme activities in the peripheral metabolism of steroids, and or increased sensitivity of AR, both presumed to be subjected to genetic polymorphisms, might account for abnormal responses to androgens. The first possibility in patients with androgen-dependent skin manifestations corresponds to increased metabolic pathways that lead to the transformation of weaker an- The second possibility (the two not being mutually exclusive) is directly linked to AR sensitivity. AR is a structurally conserved member of the nuclear receptor superfamily. The amino-terminal domain is required for transcriptional activation and contains a region of polygluta-mine encoded by CAG trinucleotide repeats. In humans the number of CAG repeats is polymorphic. Longer repeat lengths are associated...

The Cosmetic Care Of Elderly Skin

By far the most exciting discovery in cutaneous gerontology during the past decade is the effect of tretinoin (all-trans retinoic acid) on the clinical and histological appearance of photoaged skin. Kligman first realized that topical tretinoin improved the appearance of middle-aged women using the drug to control facial acne. Support for the concept was provided by a double-blind vehicle-controlled trial documenting tretinoin's effectiveness on human photoaging. After 4 months of daily application, 0.1 tretinoin cream produced statistically significant improvement in fine and coarse wrinkling, sallowness, and roughness of sun-damaged facial and arm skin 16 .

Clinical Experience Etretinate and Acitretin for HS

4 months of isotretinoin at a dose of 1.4 and 2.0 mg kg per day, respectively 38 two courses at a dose of 0.8 mg kg per day for 4 and 3 months, respectively 36 two full courses for 5 months at a dose of 2 mg kg per day 35 , and in one patient a 4-month course of isotretinoin (1 mg kg per day), which cleared the patient's acne conglobata but was singularly unhelpful for his HS lesions 37 . Stewart 34 treated his six patients with ongoing doses of etretinate and they were observed over periods of 6-39 months. After 3 months of treatment, three patients showed good clearing of disease (50 -75 ) and after 12 months of treatment all patients eventually had an excellent response. The criteria for clearing in the HS patients were disappearance of sinuses and cessation of discharge. Two patients were taken off etretinate, and it took 4 months for them to begin to show signs of disease recurrence (increasing discharge and formation of the old sinus tracts). Hogan and Light 35 treated a...

Cutaneous Resurfacing Using High Energy Pulsed CO2 Lasers

Although cutaneous resurfacing with CO2 lasers is not a new technique, the older systems were not well suited for the delicate areas around the eyes and mouth. The newest generation of high-energy pulsed (''ultrapulse'') CO2 lasers produces high-energy bursts that allow maximal lesional ablation with minimal heat conduction to uninvolved skin which greatly reduces the risks of scarring. Alster 16 has shown that although both the surgi-pulse and ultrapulse high-energy CO2 lasers are effective in reducing the appearance of periorbital rhytides, computer analysis of skin-surface impressions shows a more substantial improvement after ultrapulse laser treatment. Indeed, the skin-surface texture was found to be comparable to normal. Alster 17 has also used optical profilometry to document that laser resurfacing can also effectively improve or even eliminate atrophic facial acne scars.

Hidradenitis Suppurativa Introduction

This concept held sway over more than a century, during which numerous reports were in concordance. It was not till 1939 that Brunsting identified the apocrine, rather than the eccrine sweat glands as the specific target of the disease, although he did not quarrel with the prevailing idea that the primary event was inflammation of the apocrine glands 2 . In a later paper in 1952 3 he presciently recognized that hidradenitis suppurativa had some similarities to acne vulgaris regarding clinical manifestations. The latter idea was further fleshed out in 1951 by Kierland, also of the famous Mayo Clinic, who perceived that hidrad-enitis suppurativa was not solely restricted to localization of the apocrine glands. He saw a relationship between acne conglobata and dissecting cellulites of the scalp, which sometimes occurred concomitantly 4 . Later workers confirmed Kierland's concept that hidradenitis suppurativa was an umbrella term encompassing a variety of clinical...

Body Proportions At Different Ages

Development Fetus Month Month

Certain nutrients in large amounts, particularly vitamins, act in the body as drugs. The acne medication isotretinoin (Accutane) is a derivative of vitamin A that causes spontaneous abortions and defects of the heart, nervous system, and face. The tragic effects of this drug were noted exactly nine months after dermatologists began prescribing it to young women in the early 1980s. Today, the drug package bears prominent warnings, and it is never prescribed to pregnant women. A vitamin Abased drug used to treat psoriasis, as well as excesses of vitamin A itself, also cause birth defects. This is because some forms of vitamin A are stored in body fat for up to three years after ingestion.

Analytic Epidemiology

Has been repeatedly drawn toward the possible role of hormonal factors 4, 12, 14 . No convincing data are available. In a study of 66 women with HS, 23 had acne and 23 (34.8 ) were significantly obese (body mass index, BMI, 30 kg m2). Plasma androgens were compared with controls matched for BMI and hirsuteness and no difference was documented 12 . The prevalence of HS has been found to be higher among patients attending a sexually transmitted disease (STD) clinic than in an unselected general population 6 . In principle, a selection bias may explain such a difference. However, an association with chlamydial infections has been also suggested. A case-control study based on patients in a STD clinic was unable to confirm the association with chlamydial infection 15 but, quite unexpectedly, it found a higher prevalence of genital human papilloma virus (HPV) infection among HS cases as compared with controls. The significance of such a finding is unclear and a chance effect is quite...

Immunological Contact Urticaria

ACNEGENICITY This refers to the capacity of some agents to cause acne or aggravate existing acne lesions. This term may be subdivided to include comedogenicity and pustulogenicity. Acnegenicity Mills OH Jr, Berger RS. Defining the susceptibility of acne-prone and sensitive skin populations to extrinsic factors. Dermatologie Clinics, 1991 9(1) 93-98.

And Other Corticosteroids

Early studies of adrenocorticotrophic hormone (ACTH) and corticosteroids suggested that general immunosuppression was beneficial to the well-being of HS patients 4 . These studies however do not conform to current requirements for evidence as they are anecdotal rather than randomized and controlled. Relief is however regularly offered to patients with flares of HS by treating with prednisolone, either as monotherapy or in combination with other therapies. In this manner systemic corticoste-roids may be used in a manner analogous to their use in acne fulminans. Usually doses of 0.5-0.7 mg kg are sufficient to achieve control of the inflammation. Initial doses can then be tapered over weeks to control the disease. However, in some cases tapering is not possible due to rapid flares and alternative therapies must therefore be instituted. The patients reported by Rose et al. 5 are examples of such cases. Systemic corticosteroids are therefore often used in conjunction with other therapies...

Hidradenitis Surgery Before And After

Hidradenitis Suppurativa Pictures

Hidradenitis suppurativa (HS, synonym acne inversa) is a cicatrizing and frequently persistent inflammatory disorder of the sebaceous follicles and terminal hair follicles of apocrine-gland-bearing areas in the adult 12, 31 . The condition may remain relatively mild but nevertheless distressing 32 , ranging from a few but recalcitrant suppurating lesions to an advanced widespread and disabling disease lasting for years or decades. Possible consequences of longstanding, recurrent disease are multiple surgery and considerable social burden caused by chronic infection, with purulent discharge, odor, and pain 35 . In addition, there is a risk of developing a squamous cell carcinoma 9, 36, 40, 73 ,

IL1 Receptors in the Skin

Mation, such as inflammatory bowel diseases, alopecia areata, psoriasis, lichen sclerosus or lupus erythematosus, IL1RN*2 homozygosity increases the severity of the inflammation, suggesting that persons with this allele have a more prolonged and more severe proinflammatory immune response than do persons with other IL-1RA genotypes 73 . Interestingly, the frequency of the two-repeat allele of IL-1RN is increased among patients with acne conglobata but not among those with HS. In addition, IL1RN*2 homozygosity was detected only amongst patients with severe acne conglobata, suggesting that allele 2 of the IL-1RN gene may contribute to the development of acne conglo-bata but not HS 38 .

Intralesional Therapy

In contrast to topical therapy the use of intralesional anti-inflammatory therapy has been used more extensively. This therapy represents an intermediate form of treatment between pharmacological therapy and surgery. The intralesional injection of corticosteroids is aimed at reducing inflammation rapidly, and may even be suggested to have an atrophogenic effect on formed sinus tracts, which is desirable from a theoretical point of view. There is a long tradition of using this modality in acne cysts, where the results are often most convincing. Early studies found that low-dose therapy using intralesional triam-cinolone for acne cysts was often as successful as more potent preparations, and carried less risk of atrophy or other complications 38, 39 .

And the Commensal Microbiota of the Skin

The human skin is densely populated with resident microbiota, composed of commensal microorganisms such as S. epidermidis, P. acnes, Micrococcus luteus and or Malassezia furfur. These microorganisms compete for nutrients and space, limiting each other's population size and also competing out pathogens that may attempt to colonize the skin. Despite the density of the microbiota, epidermal keratinocytes do not activate pro-inflammatory signaling cascades in response to commensal microorganisms, suggesting a complex host-microbe relationship in the epidermis. Thus, epidermal keratinocytes may need to discriminate the presence of commensals from the presence of pathogens, by mechanism s that are not yet fully identified One possible explanation for the un-responsiveness of the skin to resident microbiota is the anatomical localization of the TLR-ex-pressing keratinocytes. Since TLRs are expressed by the basal keratinocytes, the layer that is normally not exposed to commensal...

The Last Metamorphosis of Verneuils Disease

In 1956, Pillsbury, Shelley, and Kligman brought together acne conglobata, hidradenitis suppura-tiva, and dissecting cellulitis of the scalp 32 under the name follicular occlusion triad 33 , whose common feature was a tendency to fol-licular hyperkeratinization leading to the retention of keratin products with secondary bacterial infection. In 1975, Plewig and Kligman 34 added pilo-nidal sinus to the triad and proposed the term acne tetrad, pointing out the absence of apo-crine involvement in hidradenitis suppurativa. More recently, Plewig and Steger proposed designating entities previously named acne triad or tetrad as acne inversa 35 . The fundamental change in acne inversa is the hyperkeratosis of the infundibulum as in acne vulgaris 36 . The authors denied that ec-crine or apocrine sweat glands are involved in the pathogenesis of acne inversa. The involvement of sweat glands was regarded as secondary only. More recently, studies have shown that acne inversa is a defect of the...

Antiandrogenic Progestins

Other progestins with antiandrogen properties 11, 14 (antagonists at the AR levels) include chlormadinone acetate (CMA), drospirenone and dienogest. They may be used either in combination with EE 5, 8, 16 as a contraceptive OC (similarly the combination of CPA 2mg + 30 g EE) or as antiandrogenic progestin alone (CMA for instance) according to countries where the drugs have been approved. In fact no evaluation of the effects of these progestins exists in women with hirsutism, severe acne or chronic alopecia.

Lack of Association between HS and Endocrinopathies

Lapse after pregnancy, as well as premenstrual and menstrual exacerbations are usually noted, suggesting that hormones, at least oestrogens, may influence the course of the disease. Oestrogens in fact are known to interfere with inflammatory processes, independently of a direct genomic action of the steroids. This could account for their influence on the natural course of inflammatory diseases, such as acne, but also HS. Other observations in HS in terms of premenstrual and or menstrual exacerbations may be unrelated to the oestrogen or androgen dependency of the disease. Although HS may be associated in some women with classic signs of skin androgeniza-tion such as acne and or hirsutism, no real association of HS with hirsutism (the major symptom of hyperandrogenism) has ever been reported. In a series of 70 women with HS, acne was not more frequent than in controls 10 . The incidence of patients with signs of androgeniza-tion did not differ significantly between the two groups. Only...

End Organ Androgen Sensitivity

All the above data suggest that the main mechanism for the possible role of sex hormones in HS lies in end-organ sensitivity rather than in the plasma levels. Women can develop HS while taking oral contraceptives especially when an-drogenic progestins are used, and this also suggests, as in acne, a possible androgen dependence of the disease 19 . In acne, not only sebocytes but also other epithelial cells are involved in the skin hyperandrogenism that is responsible for the formation of the comedo. Keratinocytes from the acroinfundibulum express the key enzymes involved in the in situ metabolism of androgens (in situ synthesis of the weaker androgens, their transformation into testosterone and its reduction into DHT) 5 . Investigation for the activity of these enzymes in the epithelial cells that are presumed to be involved in the first stage, i.e. follicular occlusion, of HS remains to be conducted.

Molecular Carriers Definition Description

Molecular carriers represent a delivery system in which one compound is used to bind another compound to a substrate, thereby changing the former's characteristics. This allows the bound material to be delivered to a surface and released when conditions are appropriate. One example of this type of technology is cyclodextrin chemistry. Cyclodex-trins are created from starch-derived glucopyranose units and are classified as cyclic oligosaccharides. When formed, they contain a hydrophobic cavity capable of entrapping molecules of different sizes, shapes, and polarities. Molecules entrapped as such are found to be more resistant to environmental stresses and therefore more stable 14 . They can be used to entrap various types of compounds such as fragrances, vitamins, pigments, and dyes. Cyclodextrins have been used in cosmetic products for a variety of reasons, such as to reduce odor in mercaptan-containing systems 15 , improve the stability of hair dyes 16 , and as an active ingredient...

Pustulogenic Potential

Upon first using a new cosmetic, papules and pustules are sometimes observed after a few days. To the consumer this is acne, although this type of papulopustular reaction may be a form of follicular irritation. Certainly, as Mills and Berger pointed out, it occurs more quickly than can be accounted for by the formation of hyperkeratotic plugs and its sequalae 7 . Thus, Mills and Berger suggested that pustulogenic potential the ability to cause inflammatory lesions should be differentiated from comedogenic potential the ability to cause the formation of hyperkeratotic plugs.

Potential Contribution of the VIP Gene to HS

TIZ emerged as one of the genes with real potential as a candidate for HS. TIZ inhibits TRAF6, a tumour-necrosis-factor- (TNF-) associated factor that is a signal transducer in the TNF receptor superfamily pathway, and also mediates nuclear factor kappa B (NF-kB) and JNK activation in the interleukin-1 receptor Toll-like receptor (IL-1R TLR) signalling pathway. NF-kB together with activator protein 1 are activated in acne lesions with consequent elevated expression of their target gene products, inflammatory cytokines and matrix-degrading metalloproteinases 31 . TRAF6 deficiency in mice illustrates its role in immune and inflammatory response. These mice showed a defect in normal B-cell differentiation, lymph node organogenesis, IL-1 signalling and lipopolysac-charide signalling. The mice, generally, showed features of hypohidrotic ectodermal dysplasia (HED) due to sweat gland, hair and dental abnormalities. This phenotype is not associated with HS but TNF and IL-1 signalling pathways...

Clinical Experience

It is well known that acne patients with epithelial sinus tracts with recurrent inflammation respond poorly to isotretinoin and are in fact most of the isotretinoin failures, at a high cumulative dose of isotretinoin as well 6, 13, 14 . These lesions are identical to those found in the axillae and groin in patients with HS 13, 14 .

Bacteria Found in HS Lesions

Staphylococcus aureus, coagulase-negative staphylococci, enterococci, group B hemolytic streptococci, group C hemolytic streptococci, Bacillus cereus, diphtheroides, enterobacteriacae- Peptostreptococcus species, Propionibacterium acnes, microaerophilic streptococci, Lactobacillus species, Bacteroides fragilis, other Bacteroides species, Prevotella species Lapins et al. 33 circumvented problems both of contamination and of missing the active area of infection by using a carbon dioxide (CO2) laser surgical method to evaporate the diseased tissue level by level from the surface downwards. This allows sampling for bacteriological cultures from each level without the risk of contamination with bacteria from the level above. By using this method, bacteria were found even in the deeper and closed parts of HS. Staphylococcus aureus and coagulase-negative staphylococci were also the most commonly found species. After the Staphylococcus species the most commonly cultured bacteria were the...

Measure of Quality of Life Quantitative Approach

A quantitative approach for measuring QoL in HS was performed 2 . Questionnaires widely used in other skin diseases such as the Dermatology Life Quality Index (DLQI) questionnaire, Skindex and VQ-Dermato 1, 4, 5 were chosen. This approach allows a direct comparison of the results with those from previous studies on other skin diseases. We will discuss two studies, one already published and our unpublished data 2 . In both studies, in addition to this questionnaire, basic demographic data and aspects of the history of HS were collected 114 patients participated in the first one 2 and 61 in the second. In the study of der Werth and Jemec 2 the recorded mean DLQI score was 8.9, higher than scores found in several other dermatological conditions such as alopecia, acne, psoriasis, Hailey-Hailey disease, vascular anomalies of face, and atopic dermatitis. In our center (unpublished data) using two other skin-disease-specific QoL questionnaires (Skindex and VQ-Dermato) 1, 5 , the scores...

Mechanism of Action [1

With Acne and Coexistent HS However, in contrast to what happens in acne, the size of sebaceous glands is not increased in HS. Isotretinoin also reduces the ductal population of Propionibacterium acnes, and although this has a very important effect on acne pathogenesis, it does not appear to be useful for the treatment of HS, because Propionibacterium acnes has not been cultured in HS lesions. Isotretinoin does not affect the size of apocrine glands.

Of Hidradenitis Suppurativa

10.1 Clinical Genetics the follicular occlusion triad - acne conglobata, of Hidradenitis Suppurativa 70 dissecting cellulitis of the scalp, and hidradeni- 10.5 Positional Cloning of familial occurrence of HS in association with ofDominantlyInheritedDiseaseGenes 75 acne conglobata was published by Gold and

Ginseng In Cosmetic Preparations

Ginseng saponins are structurally near chemical relatives of the antiinflammatory compounds such as steroids and glycyrrhetinic acid from liquorice (Glycyrrhiza glabra L.). It is thus not surprising that antiinflammatory properties have been reported for ginseng extracts and ginseng has been suggested as an ingredient of cosmetic creams with non-allergenic, cutaneous bioactivity for the treatment of wrinkles and eczema. The many recent patent applications involving cosmetic creams, anti-wrinkle creams, acne applications and hair growth preparations with supporting claims of efficacy suggest probable effectiveness (cf Chapter 9). Curri et al. (1986) had reported that ginseng extract applied topically as a phospholipid liposomal formulation produced a favourable effect on skin ageing, moisturisation of the stratum corneum and improved skin elasticity. Saponins of ginseng, the ginsenosides Rb1, Rb2, Rc, Re and Rg 1, as well as 70 per cent methanolic extract of P. ginseng, increased the...

The Role of Antibiotics in the Treatment of HS

Long-term administration of tetracyclines or erythromycin may be used in regimens similar to acne vulgaris and seems to prevent episodic flares 19, 21 . As is the case with acne vulgaris, it is not known whether the most important factor in the treatment of HS is antibacterial or anti-inflammatory. Lincosamides and tetracyclines have been known for their immunomodulatory effects. Clindamycin suppresses the complement-derived chemotaxis of polymorphonucle-ar leukocytes in vitro, thereby reducing the inflammation potential 43, 52 . Tetracyclines Hindle et al. treated seven patients with a combination therapy of clindamycin (300 mg twice daily) and rifampicin (300 mg twice daily) for a 10-week period 25 . Three patients did not tolerate the combination, two because of diarrhea associated with Clostridium difficile, and three of them responded well and remained clear at 12 months. The combination of rifampi-cin and clindamycin was also successfully used for two other chronic and...

CoExistence of HS and CD

Lead to colonoscopy, as the presence of gastrointestinal endoscopic lesions and granulomas on biopsy establishes the diagnosis of CD. Conversely, there is a need for a systematic search for acne, folliculitis, and HS skin lesions in CD patients, particularly when a steroid treatment is planned.

And Antiandrogen Therapies

Non-hormonal Depilation, epilation Anti-acne (retinoids, antibiotics) CPA is a progestin with several antiandrogenic activities binding to AR, inhibition of androgen metabolism and antigonadotropic activity. CPA has been used extensively in Europe for 30 years in the treatment of hirsutism. It can be given according to various regimens (usually 50 mg daily on days 1-20 of each menstrual cycle, but other regimens are possible with CPA of 50 or 100 mg) together with natural E2 or with an OC pill. Good results may be obtained in hirsutism and also in women with severe and or persistent acne or with androgenic alopecia. Side-effects are uncommon and the anti-androgen is well tolerated 6, 11, 17, 18 . Spironolactone is the most generally used anti-androgen in countries where CPA has not been approved. Spironolactone binds to AR but is devoid of antigonadotropic activity. Doses needed for antiandrogenic efficacy are 75-200 mg daily depending upon the indication (acne, alopecia or...

Isotretinoin in Combination Treatment of HS

One author reported on a patient with Crohn's disease and HS who showed a satisfactory outcome following treatment with azathioprine (150 mg day) and methylprednisolone (16 mg day) combined with isotretinoin (0.7 mg kg per day) and periodic administration of antibiotics 28 . Another report details a patient with multiple pustular and cystic lesions located on swollen and red labia majora. She was successfully treated with prednisolone and erythromycin for months and then long-term isotretinoin (mostly 1.0 mg kg per day) for 15 months, and no significant relapse of the so-called vulval apocrine acne occurred during a follow-up period of 10 months 29 .

HS and Biological Hyperandrogenism

Furthermore, as far as serum levels of andro-gens and SHBG are concerned, there is no clear evidence for biochemical hyperandrogenism. On average, androgen levels (total plasma testosterone and free testosterone index due to a low SHBG) were increased, but were normal in many individual patients, and no significant decrease of SHBG could be detected 13 . In fact, SHBG is known to be regulated by factors that influence body weight and this study was not controlled for body weight, and neither was a second one which found hyperandrogenism in a subgroup of women who did not experience a premenstrual flare in their disease 9 . In a further group of 66 women with HS, among which 23 had acne, 23 were significantly obese and 19

Rheumatological Disorders

Inflammatory dermatoses such as psoriasis have well-known rheumatological associations and often lead to collaboration between dermatologists and rheumatologists for the benefit of the patient. Similarly pustular diseases have well recognized rheumatological aspects, e.g. SAPHO syndrome, where SAPHO stands for the combination of synovitis, acne, pustulosis, hyperostosis and osteitis. The association between HS and rheumatological disorders has been less well studied, although a better understanding of it may add significant information about the pathogenesis of HS.

And Innate Immune Responses of the Epidermis

The pilosebaceous unit is an important site of skin infections such as acne vulgaris, folliculitis, furunculosis, and carbunculosis. A common pathogen associated with infections in the pilosebaceous unit is P. acnes. Although acne vulgaris is not an infectious disease, the role of P. acnes in the pathogenesis of acne is well documented 37, 40 . Recent results describing the expression of TLRs in the pilosebaceous unit together with the increased amount of bacteria in acne vulgaris suggest that inflammation found in acne is at least partially mediated by the TLR signaling pathways (Fig. 13.3) 40, 54 .

Incidence and Prevalence

It is very difficult to find reliable figures about the incidence or prevalence of squamous cell carcinoma in HS patients since there are very few publications describing follow-up of HS patients. Mostly isolated didactic cases are described, which increase clinical vigilance but do not provide predictive data. The risk of squa-mous cell carcinoma in HS has been estimated at between 1.7 and 3.2 52 . Case reports however also allow the reader to form a clinical picture of a given problem when they are sufficiently numerous. In fact, there may be as many as 100 87, 92 cases of squamous cell carcinoma arising from HS reported so far in the literature these include cases arising from so-called acne conglobata of the buttocks perineum or postsacral skin 5, 52-54, 70-93 and cases of malignant degeneration occurring in patients with long-standing pilonidal disease, with a mean duration of 23 years 92 . Both these diagnostic groups may potentially be confused with HS.

Nature Of Interactions Between Products And The Superficial Epidermis

The intended, beneficial interactions of cosmetic products with the epidermis are the traditional ones, namely improvement of scaling, improvement of skin color, improvement of wrinkles (fine and coarse), improvement of elasticity, and a range of beneficial effects on the specialized superficial epidermis, namely the hair and nails. These effects are well known. However, interactions of products with the epidermis may also be innocent or irrelevant or directly harmful, with adverse events such as irritant or allergic contact dermatitis or special events such as development of comedoes and acne. Fragrance allergy is now the number two allergy in industrialized countries, with increasing prevalence. Fragrances are, however, contained not only in cosmetic products, but also in a broad range of household products. Harmful effects on the epidermis may be direct or indirect, acute short term or chronic long term, predictable and dose dependent (AHA products, urea, and others), or...

Definitions And Basic Concepts

The other major data inputs for an economic study are the benefits of a successful medical, public health, or policy intervention, such as money saved, lives saved, quality-of-life improvements, productivity increases, suffering prevented, or adverse events avoided. An economic study should include benefits relevant to the interventions or actions under study. For example, measuring the number of lives saved by an acne cream would not be a useful measure of benefit, whereas improvement in quality of life (or number of dates saved) would.

Hidradenitis Suppurativa as a Side Effect of Immunosuppressive Drugs

HS has also been described as a side-effect of immunosuppression associated with rapamycin (Sirolimus) treatment 13 . This drug has been reported to be associated with acne-like and other follicular inflammation in renal transplant patients. The study was carried out with stringent dermatological evaluation of patients, and an incorrect diagnosis of HS is therefore relatively unlikely. Specific immunosuppressive mechanisms may therefore play a role and not all immunosuppressants may be suitable for use in HS. In addition, bacterial infections may simulate HS to non-dermatologists and cause additional confusion.

Premenstrual Syndrome

Vitamin B6 supplementation is used in doses beyond RDI levels for the treatment of PMS. A 1999 systematic review of nine clinical trials involving 940 patients with PMS support this use, finding that doses up to 100 mg day are likely to be of benefit in treating symptoms and PMS-related depression (Wyatt etal 1999). Comparative study One randomised double-blind study compared the effects of pyridoxine (300 mg day), alprazolam (0.75 mg day), fluoxetine (10 mg day) or propranolol (20 mg day) in four groups of 30 women with severe PMS (Diegoli et al 1998). In this study, fluoxetine produced the best results (a mean reduction of 65.4 in symptoms) followed by propanolol (58.7 ), alprazolam (55.6 ), pyridoxine (45.3 ) and placebo (39.4-46.1 ). Symptoms responding well to pyridoxine were tachycardia, insomnia, acne and nausea (Diegoli et al 1998).

Hydroquinone 14dihydroxybenzene

Arndt and Fitzpatrick 4 , in a non-placebo-controlled study, compared the efficacy of 2 and 5 hydroquinone cream for treatment of various pigmentary disorders in 56 patients. Results showed that hydroquinone was a moderately effective depigmenting agent in 80 of cases and that there was no difference between the two concentrations in therapeutic efficacy. Two percent hydroquinone was less irritating than 5 . Fitzpatrick et al. 5 , in a non-placebo-controlled study, evaluated the efficacy of a 2 cream of stabilized hydroquinone in 93 patients. Sixty-four percent of them showed decreasing hypermelanosis without untoward effects. Sanchez and Vazquez 6 treated 46 patients with melasma using two versions of a 3 hydroalcoholic solution of hydroquinone. In this non-placebo-controlled study, overall improvement was noted in 88 of the patients and moderate-to-marked improvement in 36 . Side effects were minimal. The usage of a sunscreen agent was necessary for therapeutic efficacy. The...

Conglobata Controversial Views

In the twentieth century the French School of Dermatology centered the nosological discussion on the connections between acne conglo-bata (described in 1901 by Spitzer under the name of dermatitis folliculitis et perifolliculitis conglobata) 24 and hidrosadenitis. In 1949, Degos et al. (Paris) presented a case of acne conglobata abnormally localized to the axillaries, perianal area, and inter- and sub-mammary region, sparing the scalp and the back of the neck 27, 28 . For the authors, the observation gave credence to the follicular origin of the so-called hidradenitis. In fact, Degos insisted on the difficulty or impossibility of establishing a definite distinction between acne conglobata and Verneuil disease. In this respect, Moline (Paris) underlined the fact that the close relations between sweat glands and pilosebaceous follicles and the consequences of the infectious process made a rigorous distinction between acne conglobata and hidrosadenitis quite difficult. A common...

Jorgensen Hidradenitis 2018

Boer J, Weltevreden EF (1996) Hidradenitis suppu-rativa or acne inversa. A clinicopathological study of early lesions. Br J Dermatol 135 721-725 11. Burkhart CN, Burkhart CG (2003) Microbiology's principle of biofilms as a major factor in the pathogenesis of acne vulgaris. Int J Dermatol 42 925-927 15. Dreno B (2004) Topical antibacterial therapy for acne vulgaris. Drugs 64 2389-2397 16. Eady EA, Holland KT, Cunliffe WJ (1982) The use of antibiotics in acne therapy oral or topical administration J Antimicrob Chemother 10 89-115 25. Hindle EAO, Kirby B, Griffiths CEM (2002) Hi-dradenitis suppurativa and acne keloidalis nuchae treated with clindamycin and rifampicin a case series. Br J Dermatol 147 22-23 26. Holland KT, Holland DB, Cunliffe WJ, et al (1993) Detection of Propionibacterium acnes polypeptides which have stimulated an immune response in acne patients but not in normal individuals. Exp Dermatol 2 12-16 27. Jansen I, Altmeyer P, Piewig G (2001) Acne inversa (alias...


Aromatherapists use eucalyptus for its mentally uplifting and stimulating effects and to aid concentration. It is also used in massage and vapourisers to relieve respiratory symptoms, treat minor skin infections and acne, and relieve headache and muscular aches and pain. Usually eucalyptus oil is included in a blend of 3-5 essential oils for a massage but may be used alone for an inhalation.


Closed comedones ( white heads ) are never present in areas of HS. Open comedones ( black heads ) are also absent in early disease but may appear in long-lasting HS, usually as double-ended comedones. These may be taken to reflect the distortion and degradation of the dermal architecture caused by the extensive inflammation and scarring of the disease. They are particularly conspicuous in burnt out lesions, presumably when no longer obscured by the active disease (see Fig. 3.10). As in acne conglobata these are tertiary lesions i.e. tombstone comedones . They are present in 50 of patients 8 . Their prevalence does not appear to be affected by either concurrent acne or a previous history of significant acne 1 .


Classification can also be made along purely practical lines, i.e., from the therapy. To classify diseases according to their response to standardized therapies may appear non-academic but is useful in practice and allows more specific speculations to be made about the etiology and pathogenesis when the therapeutic principle of the drug is known. In HS, clindamycin-rifampicin, anti-TNF biologics, sometimes cor-ticosteroids and even immunosuppressive drugs may be helpful, while they are not useful in acne. In contrast, the retinoids, which are the most effective drugs in the treatment of acne, appear generally ineffective in HS (see Chap. 17). Thus the terminology acne inversa may lead to an erroneous management. The lack of efficiency of retinoids is in good agreement with the absence of local seborrhea and supports the classification of HS as a follicular disease different from the acnes.

Clinical Features

The clinical characteristics of HS, i.e., deep-seated lesions and topography, are very specific and the hallmark of the disease however, they are not explained by the histological pictures which form the main evidence for establishing a connection with acne and the so-called follicular obstruction diseases. Exceptional case reports of an association of HS with dissecting folliculitis of the scalp, acne conglobata, large epithelial cysts and pilonidal cysts have focused attention on a possible common mechanism shared by these diseases and their grouping together under the term follicular obstruction diseases. Some case reports of an association with Dowling-Degos pigmentation of the flexure also point to a follicular obstruction. In spite of these anecdotal reports, the prevalence of acne in HS patients is identical to the prevalence in controls. The rarity of these reports and the Table 9.1. Similarities and differences between acne vulgaris, acne conglobata, hidradenitis suppurativa...

Fox Fordyce Disease

The pathogenesis of acne embraces increased sebum production, follicular hyperkeratosis, colonization with propionibacteria and inflammatory changes. The sebaceous duct hyperkera-tinization is mediated by the production of in-terleukin-1 alpha (IL1-a) and tumour necrosis factor alpha (TNF-a) by keratinocytes and T-lymphocytes. The result is hyperproliferation of keratinocytes, reduced apoptosis and consequent hypergranulosis. As a result the sebaceous follicle becomes blocked with densely packed keratin and so evolves the comedo. Early comedones show a dilated hair follicle associated with infundibular hyperkeratosis. Later due to rupture an acute dermal inflammatory response ensues. This can be complicated by a foreign body granulomatous reaction. In severe cases abscesses frequently present and cysts and sinuses form. Dermal scarring frequently results in these cases. In 1956, Pillsbury, Shelley and Kligman coined the term follicular occlusion triad for the common association of...

Azelaic Acid

When using this treatment 0.5-1.0 ml triamcinolone (10 mg ml) is injected into the lesions with a no. 27 or thinner needle. Weaker concentrations of triamcinolone may also be useful, whereas betamethasone has been reported as being less effective in acne lesions 38 . On occasion the injected triamcinolone will leak from the sinus tract, and paralesional injections may therefore also be used. The use of intralesional steroids has been successfully combined with topical and systemic use in the treatment of acne sinus tracts, and may also be combined with systemic therapy in the treatment of HS 39 .

Animal Models

The rabbit ear is the most commonly used animal model. The rabbit's ear follicle has many structural similarities to the human sebaceous follicle. In 1941, Adams et al. 8 showed that the rabbit ear would respond similarly to human skin when exposed to chlorinated hydrocarbons, the most common cause of acne in industrial accidents. Until the rise of the animal rights movement in the late 1980s, cosmetic products were routinely screened using rabbits. Briefly, the method entails that the test product or ingredient is applied daily to the inner surface of one ear. This site is left open. The other ear is used as the negative control. At the end of either 2 or 4 weeks, the animal was sacrificed, and the degree of follicular hyperkeratinization is assessed. Frequently this was done by taking histological sections and giving an overall score based on the number and degrees of compacted follicles. Occasionally the impactions were removed from the ear using cyanoacrylate glue on a glass...


The multifunctional properties of phosphatidylcholines lead to a number of different applications. So, formulations with unsaturated phosphatidylcholine are preferred to support skin regeneration, antiaging, acne preventing, and penetrating other active agents like vitamins and their derivatives into the skin. Formulations with hydrogenated phosphatidyl-choline may be used for skin and sun protection, but it should be emphasized that in this

Cosmetic Forms

Some patches that stand between drug and cosmetic fields, e.g., acne or acneic conditions, are included in this category, and as we will see later, in some countries the actives combining with the claims characterize the classification, although in others products like these are considered to be real cosmetics. We could synopsize some simple rules to draw a bold line between these two classes


Hidradenitis Suppurativa The Head

Hidradenitis suppurativa (HS) was originally classified according to location, and this remains a hallmark of the disease. Shortly after the diagnosis was established, an erroneous association with apocrine glands was made and the name created. A classification according to topography alone obviously does not improve the understanding of pathogenesis and hence is of little help. The erroneous classification according to an incorrect deduction based only on simple co-localization obviously delayed the development of knowledge This mistake comes from a paradox the lesions of HS are predominantly or exclusively situated in the regions of apocrine sweat glands, yet the histological picture is one of follicular obstruction like that seen in acne lesions, and sweat gland involvement is usually absent from early lesions. The apocrine sweat gland's excretory canal opens into the follicular duct immediately above the sebaceous duct (see Fig. 9.1). This distinctive anatomical characteristic may...

Acute ICD

Pustular and Acneiform ICD Pustular and acneiform ICD may result from contact to irritants such as mineral oils, tars, greases, some metals, croton oil, and naphthalenes. Pustules are sterile and transient. The syndrome must be considered in conditions in which acneiform lesions develop outside typical acne age. Patients with seborrhoea, macroporous skin, and prior acne vulgaris are predisposed along with atopics.


The significance of bacterial findings in HS is controversial. While bacteria are likely to be involved in the pathogenesis to some extent, it is probably in a role similar to that in acne in early lesions. In later stages of the disease bacterial infection seems to be a risk factor for the destructive scarring and progression of HS lesions. Coagulase-negative staphylococci are the most common bacteria found in cultures from the deep portions of HS lesions, as seen following carbon dioxide laser surgery 1 . An extensive review of HS bacteriology is found in Chaps. 11 and 15. Although the influence of bacteria is unclear, topical as well as systemic antibiotics are frequently used in treatment of HS.

Vitamin E2

Various oxidative stressors have been shown to deplete vitamin E, among other antioxidants. In the epidermis, a dose of at least four minimal erythemal doses (MED) of solar simulated UV radiation (SSUV) is needed to deplete vitamin E 6 , while doses as low as 0.75 MED are capable of destroying vitamin E in the human SC 4 . Mouse experiments have shown that a dose of 1 ppm X 2h of ozone (O3) depletes SC vitamin E 7 . Since this concentration of O3 is higher than the naturally occuring levels of tropospheric O3 the biological relevance of these findings for the skin of humans is not yet clear. A one time application of benzoyl peroxide BPO (10 w v), a concentration commonly used in the treatment of acne, depleted most of the SC vitamin E in human volunteers 8 .

Topical Clindamycin

Clindamycin is a lincosamide antibiotic that is bacteriostatic and works by inhibiting protein synthesis in sensitive bacteria. Its antibacterial spectrum includes Gram-positive bacteria, in particular the genera Staphylococcus and Streptococcus, and several of the anaerobic bacteria. Clindamycin also suppresses the complement-derived chemotaxis of polymorphonuclear leukocytes (in vitro), thereby reducing the inflammation potential 4 . Topical clindamycin 1 , which is widely used in the treatment of acne, is applied to affected areas once or twice daily. Absorption of topically administered 1 clindamycin is estimated to be 1-5 5 . Adverse effects are mostly local irritation, erythema, peeling, itching, dryness, and burning. As rare events, episodes of diarrhea and even two cases of pseudomembranous colitis have been reported after topical clindamycin treatment 6, 7 . One complication of the use of topical antibiotics is the development of bacterial resistance. The number of patients...


While the etiology and pathogenesis of HS remain largely unknown, the disease has been shown to occur in association with other disorders of follicular occlusion, such as acne conglo-bata and dissecting cellulitis of the scalp. In these disorders, follicular occlusion leads to overgrowth of bacteria and subsequent neutrophilic inflammation. Many observations have been reported regarding the role of androgens hormones, obesity, and genetics, which may in addition influence the clinical picture 3, 4 . It is the reported association with Crohn's disease (CD), however, which has led to speculation and opportunities for novel management. It has been postulated that the two conditions share similar pathological immune mechanisms, such as increased levels of tumor necrosis factor alpha (TNFa) and neutrophilic chemotaxis 5 . This interesting co-occurrence of HS and CD highlights both the inflammatory nature of the disease and the rationale for using biologics known to be effective in CD 6 .


One of the less sex-specific effects of androgens is that on the skin and its appendages, and in particular their action on the pilosebaceous unit. Hirsutism is the major symptom of hyper-androgenism in women. Other dermatological conditions include acne and the chronic hair loss usually termed androgenic alopecia (AGA). Whereas acne, hirsutism and chronic hair loss may coexist in the same patient, it is not unusual to find only one of these androgenic manifestations 16 .


HS is a disease of the hair follicle with histological signs of poral occlusion 9-11 . Although there are only a few publications about the use of keratolytics in HS 12, 13 , the follicular occlusion brought about by hyperkeratosis may be a therapeutic target. Therefore, by analogy to acne, this also appears to be a good target for keratolytics. In acne, another disease of the follicle with abnormal keratinization (microcom-edo), the mainstay in classical therapy of early lesions is topical treatment with peeling agents, especially topical retinoids 8, 14, 15 . Here, the rationale is that all acne lesions arise out of a comedo and so it makes sense to treat acne patients with comedolytic agents 8, 14, 15 . Topical comedolytic agents are also recommended for use in maintenance therapy in acne by some authors 8, 14, 15 . Although topical retinoids such as tretinoin, isotretinoin, adapalene and tazarotene are strongly recommended in the management of most patients with acne vulgaris,...

Two Main Zones

(3-5 cm) epidermal cysts, which can also be observed on the trunk or face of patients with HS (see Fig. 3.13). Clinically, these cysts appear to be associated with primary elements of HS and offer a positive clue to the possible efficacy of retinoids in the treatment. Other lesions such as acne or pilonidal cyst are covered in Chap. 6.

Cyproterone Acetate

The fact that no difference was noted between the two groups does not favour a role for CPA as an antiandrogen in HS. The combination used in the control group was an OC with an androgenic progestin. In hirsutism, which is a major skin hyperandrogenic condition, and in severe acne, this kind of combination with either 50 g or 35 g EE is not effective, while 50 mg CPA daily is. If some improvement in HS could be noted in 12 patients out of the initial 24, whichever combination was used, this cannot be related to the antiandrogenicity of CPA. Rather, it may reflect the indirect antiandrogenicity of EE, decreased ovarian androgen production and increased SHBG synthesis, as evidenced by the variations in plasma testosterone, Also in 1986, Sawers et al. 13 reported the analysis of four women with HS who received CPA in combination with EE according to the then classic reversed sequential regimen of Hammerstein, namely 100 mg CPA per day for 10 days and 50 g EE per day for 21 days. This was...


Other potential applications of ginseng in anticancer treatment, as liver protective agents, in alcohol intoxication therapy, for morphine, cocaine and amphetamine withdrawal problems, in topical preparations for skin affections such as acne and eczema and in cosmetics still require careful clinical trials to demonstrate indisputably that standardised ginseng phytochemicals or formulations are really effective in human subjects.

Medical treatment

Danazol (Danocrine) has been highly effective in relieving the symptoms of endometriosis, but adverse effects may preclude its use. Adverse effects include headache, flushing, sweating and atrophic vaginitis. Androgenic side effects include acne, edema, hirsutism, deepening of the voice and weight gain. The initial dosage should be 800 mg per day, given in two divided oral doses. The overall response rate is 84 to 92 percent.


Dida but also Pneumocistis carini especially for those also on chemotherapy), thinning of skin, increased bruising, peripheral edema, vascular bone necrosis, insomnia, irritability, acne, cushingoid state, hypertension, and proximal myopathy (45). Many ofthese effects are reversible with steroid reduction but they can cause serious quality of life issues. Because DMS has a long half-life, we generally recommend morning loading when possible to lessen some of the night-time side effects such as insomnia (i.e., for bid dosing we would recommend taking medication at breakfast and lunch instead of 8 am and 8 pm). For steroid weaning we generally decrease DMS by 2 mg every 4 d as tolerated. It is important to emphasize to patients that steroid dosing is a mix of an art and science and that good doctor patient communication will allow the best care.


Physical therapies may be directed against either the secondary prevention of early lesions or the destruction of established lesions. For true primary prevention of early lesions the pathogenic process is insufficiently described to allow a causal therapy, although the use of laser depilation may yet prove to be fruitful in proper studies. The possible effect of PDT on the hair follicle is at present unclear. It is not convincingly proven that the penetration of ALA-PDT is sufficiently deep to allow treatment of established lesions of Hurley category II or III. Nor is it established that ALA-PDT has any effect on sinus tracts. The effects may therefore be more in line with the effects of this treatment in acne vulgaris, where a significant clinical effect has been shown in some studies. ALA-PDT is however associated with considerable post-treatment pain and inflammation in acne patients and this may also limit its use in HS.

Scope of chapter

I will take a selective approach dealing with the most common diseases acne, dermatitis, psoriasis and skin cancer account for over half the dermatology cases seen in primary care and around 80 of the workload of a secondary care dermatologist (Harris et al., 1990). What (little) we know of the genetics of acne, atopic dermatitis and psoriasis will be summarized briefly, and the role of genetic factors in skin cancer dealt with in more detail.

For 3 days Dose ped

Acute spinal cord injury 30 mg kg IV over 15 minutes, followed in 45 minutes by a continuous infusion of 5.4 mg kg hr for 23 hrs. Clearance hepatic metabolism renal elimination. Contraindications serious infections except septic shock or tuberculous meningitis. Adverse effects may cause hypertension, pseudotumor cerebri, acne, Cushing's syndrome, adrenal axis suppression, GI bleeding, hyperglycemia, and osteoporosis. Comments use caution in hyperthyroidism, cirrhosis, nonspecific ulcerative colitis, hypertension, osteoporosis, thromboembolic tendencies, CHF, convulsive disorders, myasthenia gravis, thrombophlebitis, peptic ulcer, diabetes.


Possible associations with androgen levels have been explored, using proxies. Two presumed proxies for testosterone levels are a history of severe acne during puberty and male pattern baldness as both are associated with somewhat higher testosterone levels. A history of both conditions may be less frequent among men who develop testicular cancer.84 In addition, testicular germ cell tumors and CIS are observed in patients who are in a low-androgen state.89 While animal experiments show that androgen is required for testicular descent,90 a limited number of epidemiologic studies suggest that a high proportion of boys with cryptorchidism have normal androgen action and response.91,92 Some cases of hypospadias have been attributed to defects of androgen action or response, but this mechanism appears to account for only a small proportion of


I began to develop what I initially called acne and now know to be HS quite a number of years ago, probably when I was in my late 20s (I'll be 35 tomorrow). It began as very small cysts or pimples in my groin area or on my buttocks that initially would go away in a few days. I mentioned it briefly to a few doctors and was simply told I had ingrown hairs or folliculitis or it was from wearing jeans most of the time. Over the years, the frequency, size, and duration of them increased to the point where they became so


ACNEGENICITY 2 The hyperkeratotic plug results in sebum accumulating in the follicilar duct and the sebaceous gland. This enables the anaerobic bacteria, P. acnes, to proliferate. The follicular Figure 1 Examples of the different forms of comedones and acneform eruptions. (a) Closed and open comedones. (b) Papules. (c) Pustules. Figure 1 Examples of the different forms of comedones and acneform eruptions. (a) Closed and open comedones. (b) Papules. (c) Pustules. duct will expand until it ruptures, releasing the bacteria and their metabolic products into the surrounding dermis. Both immunological and irritant reactions occur. In severe acne, elevated levels of anti-P. acnes antibodies are detected. Irritation may come from the fatty acids that are the result of sebaceous triglyceride digestion by bacteria. Certainly at the histological level, the classic signs of inflammation such as a neutrophilic infiltrate are observed. The consumer recognizes this as acne pustules and papules.


There are no convincing data to suggest that HS is primarily an infectious disease (see Chap. 11). The polymicrobial infection (or colonization) of HS - Staphylococcus aureus, Gram-negative rods, anaerobic bacteria - is quite different from the usual colonization of acne by Propionibacte-rium acnes and coagulase-negative staphylococci. The role of bacteria in HS may therefore be either secondary to some as yet unknown mechanism, or purely secondary once anatomical disruptions are established. HS is not a primary infectious disease yet the initial inflammatory changes can be produced by a bacterial colonization of the follicular area similar to the triggering event of acne. The amount of inflamma tion and related pain is however quite different from what is observed in acne, even in the nodular variety. This may be due to the localization of the lesions but may also point to either a specific non-infectious inflammatory phenomenon, or a sequential series of events in which bacterial...

Hormonal Treatment

Contraindications to testosterone therapy include androgenic alopecia, seborrhea, or acne, hirsutism as well as a history of polycystic ovary syndrome, and estrogen depletion. Oral methyl testosterone therapy is contraindicated in women with hyperlipidemia or liver dysfunction. Regular follow up is both clinical inspection of skin and hair for seborrhea, acne, hirsutism, and alopecia and biochemical through monitoring of free bioavailable testosterone and SHBG, keeping these values within the normal range for premenopausal women. Of note, methyl-T is not included in the usual assays for T. Possibly, the target level for older women should be even lower but this remains unclear. Lipid profile and glucose tolerance are also monitored. The current recommendation is to prescribe only for 12 months owing to lack of long-term safety data (92).

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