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Acne - something blooms on the skin

The etymology already reveals a lot about the clinical picture of acne: The word is derived from the Greek "akme" for "tip, blossom". The term stands for one of the most common dermatoses affecting sebum glands, hair follicles and surrounding tissue. The main localization is the skin regions rich in sebum glands on the face, décolleté and back. Over 80% of teenagers are affected by this multifaceted disease, boys mostly more intensely than girls. Around every third person needs treatment. The earlier acne starts, the more severe it is usually. During the third decade of life, the acne efflorescences usually subside spontaneously. In individual cases, however, they can persist beyond the age of 30.

Pathogenetic triad

The acne disposition is hereditary. If both parents were affected by this skin disease, the probability of puberty acne in their offspring is over 50%. The severity of acne is determined by the interaction of three pathogenetic core factors: seborrhea, follicular hyperkeratosis, proliferation of propionibacteria. The basis is androgen-related seborrhea. This also explains the peak of illness during puberty and the more pronounced symptoms of the disease in male patients. At the same time, androgen-provoked hyperkeratosis occurs in the sebum duct. It is postulated that the sebum glands and epithelia are individually more responsive to physiological androgen concentrations. If the follicle opening is closed by a plug of sebum, the sebum produced in the sebum glands, and exfoliated keratinocytes, sebum accumulates. The follicle contents can no longer flow outwards, the primary fluorescence of acne, a comedon (blackhead), has arisen.

Bacteria do the rest

In the comedone, anaerobic conditions prevail, under which certain germs of the skin flora, above all Propionibacterium acnes, gain the upper hand. Their bacterial lipases release fatty acids from the abundant sebum triglycerides, which irritate the tissue and attack the follicle wall. This activates components of the immune system - a local focus of inflammation has arisen and a pimple becomes visible. As the sebum infundibulum continues to expand due to the increasing sebum masses and the follicle wall is increasingly damaged by inflammation, sooner or later the follicle ruptures. The follicle infiltrate pours into the perifollicular connective tissue and causes further inflammation foci, which then shape the acne skin as papules and pustules. When these confluence, abscesses can develop, which leave crater-like scars after they heal.

Black and Whiteheads

The coarsening of the skin, which is typical for acne, is a consequence of the comedones, which over time stretch the surrounding elastic fibers of the corium. Comedones can be divided into open blackheads and closed whiteheads. Open comedones contain a sausage-shaped, compact mass of sebum, corneocytes and bacteria and are relatively easy to remove mechanically from the skin. Your black cap is not caused by dirt or oxidation products, but by melanin. Therefore, dark-skinned people often have particularly dark comedones. Blackheads are less prone to inflammation than whiteheads. The latter are closed by a thin, stretched epithelial layer through which their bag-shaped contents shimmer through. When tampering with, there is a risk that the follicle contents will not find their way to the outside, but will be pushed inwards and there will then result in even larger foci of inflammation.

Three clinically relevant forms

Acne vulgaris is a very polymorphic dermatosis. In order to be able to assess which form is still suitable for self-medication, one should know the three most important clinical forms:

  • Acne comedonica is characterized by open and closed comedones, which are mainly located on the forehead, nasolabial folds, nose and perioral. The appearance of the skin is impure, but not very inflammatory.
  • In addition to comedones, the appearance of papulopustular acne is characterized by inflammatory papules and pustules. In addition to the face and neck, the décolleté, back and upper arms are also often affected. Larger efflorescences can leave scarred changes.
  • The most severe form of acne, acne conglobata, primarily affects men. In addition to comedones, papules and pustules, confluent, hemorrhagic-purulent, painful lumps in the skin are characteristic. Lifelong scars are the result.

While acne comedonica almost always and very mild cases of acne papulopustulosa are sometimes amenable to self-medication, medical treatment is mandatory for acne conglobata.

Newborn acne

Infants sometimes develop acne-like pustules and papules (acne neonatorum), mainly on the cheeks, immediately after birth or in the first few weeks of life. One blames for these skin symptoms an increased temporary androgen release or an increased androgen sensitivity of the sebum glands. Newborn acne usually resolves spontaneously after a few months. Severe forms belong in the hands of a doctor.

Professional acne toilet

Ideally, you will be able to use sensitive, patient advice in the pharmacy to prevent acne patients from expressing pimples on their own and to induce them to place themselves in the hands of a professional beautician. This is also strongly recommended for patients with serious skin problems. The raised index finger is out of place, but clarification is required: "When squeezing pimples, the shot can easily backfire. If the contents are not pressed against the surface of the skin but deeper into the tissue, all the more inflammation foci form there. Despite convincing arguments, however, the reality shows that almost everyone who suffers from skin blemishes tries to get rid of them at some point. Then at least the basic rules of the acne toilet should be known:

  • Wash hands and face thoroughly
  • Soften the skin a little with a chamomile steam bath or warm, moist compresses
  • only tackle blackheads and ripe pimples
  • Carefully prick the surface of the whiteheads beforehand with a disinfected needle or sterile cannula
  • Use a comedone remover if possible
  • Lift the follicle contents laterally from the depth with light pressure
  • operate without violence and not with sharp fingernails
  • re-disinfect the treated area (e.g. ethanol 90%, disinfecting facial tonic)

A gentler alternative to squeezing it out is to carefully catapult the pimple out by carefully pulling away the surrounding skin in all four directions!

Tidying up old wives' tales

Even today there are numerous curious myths about the triggers and provocation factors of acne. Use the direct line to the customer in the pharmacy to clear it up! This skin disease definitely has nothing to do with poor hygiene (the opposite is often the case). In addition, acne is not an infectious disease and therefore not contagious! Pollution, frequent sex or masturbation do not affect the course of acne. In addition, especially with young patients, it is worthwhile to listen carefully to whether or which household remedies are used. Some have tried baking powder, vinegar, coffee grounds, sugar, salt and hemorrhoid ointment. The misconception that toothpaste is an effective remedy is particularly persistent. The only thing that helps is: Show those affected by effective alternatives!

Acne and diet

Up to now there is no scientific evidence for general nutritional influences on acne. The acne diets propagated in the past lack any rational basis. However, one often hears from patients that certain foods make their acne worse (e.g. chips, ice cream, candy, nuts, lemonade, shellfish, pork, ketchup, heavily smoked foods, hot spices, alcohol). Nevertheless, the influence that diet has on this skin disease is generally overestimated. Conclusion: In order to avoid an additional burden for acne patients, one should discourage them from strict diet regulations. However, it is important to respect the individual empiricism of those affected. Avoiding extremely fatty foods with a high proportion of saturated fatty acids can already be recommended under general health considerations.

Before you reach into the drawer ...

... you should clarify the following points:

  • Did the skin changes appear suddenly or are they accompanied by intense itching? Then there is probably another dermatosis, which must be clarified by a specialist.
  • Is the person affected at the typical acne age? People over the age of 20 with severe, age-atypical acne must first consult a dermatologist.
  • Do not comedones dominate the complexion, but rather inflammatory efflorescences? Then medical therapy is essential.
  • Is the person affected already receiving medical treatment? If so, your advice is by no means superfluous. Finally, suitable dermocosmetics can make a significant contribution to normalizing the skin.
  • Did the preparation recommendation from last time help you? If not, ask about the duration and frequency of use and possible side effects. Because acne therapy requires a lot of patience. By the way: According to studies, non-compliance in acne patients is quite high at 35 to 51%.

Versatile benzoyl peroxide

Benzoyl peroxide (BPO) is the drug of choice for topical acne self-treatment. The preparations available on the market contain concentrations between 2.5 and 10%. While suspensions and emulsions (e.g. Benzaknen® W, PanOxyl® W Emulsion) are thoroughly washed off after one to two minutes of exposure time, creams and gels (e.g. Benzoyt® Cream, sanoxit® Gel).

Benzoyl peroxide has an antibacterial effect by releasing active oxygen species and thus primarily affects anaerobic germs such as Propionibacterium acnes• BPO also inhibits follicular hyperkeratosis. A compliance-promoting note for first-time users: "At the beginning of the treatment, the complexion can temporarily worsen with reddening, burning and flaking. Please hold on anyway, because after four to six weeks comedones and pustules will increasingly go away."

This is what you should tell the BPO user

Initially, we recommend using 3% benzoyl peroxide formulations once a day, preferably in the evening 15 minutes after cleansing the skin. If this concentration is tolerated, you can switch to 5% twice a day if necessary. The 10% preparations are intended for the chest and back. Instruct your customer to leave out the eyes, nostrils and mouth when applying, as the active ingredient irritates the mucous membranes. Eroded areas of the skin must also be avoided because of the risk of sensitization. In addition, intensive UV exposure (sunbathing, solarium) of the treated areas is taboo. Also worth mentioning: "This agent bleaches textiles and hair on direct contact. Keep your eyebrows, beard or hairline at a safe distance!"

Plus there is ...

The keratolytic salicylic acid is also available for self-treatment of acne (e.g. Aknefug® -liquid). It is sometimes used in combination with other active ingredients such as lactic acid (e.g. Akaderm® Tincture N). Salicylic acid is supposed to soften the top layers of the skin and dissolve the sebum. However, no sweeping keratolytic effect can be expected from the usual 0.5 to 1% salicylic acid preparations.

Sulphonated shale oil also known as sodium bituminosulphonate (e.g. in Aknichthol® , Aknederm® Ointment New) has a long tradition in acne therapy. It is said to reduce the activity of the sebum glands and have a slight anti-inflammatory and antibacterial effect. Internal use is also possible (e.g. Ichthraletten®). However, due to reports of comedogenic and irritative effects, some experts reject sodium bituminosulfonate for acne treatment. The sulfur preparations that were popular in the past are now considered obsolete.

Cleaning is the be-all and end-all

Acne skin is particularly sensitive to unsuitable cosmetics. You should therefore orientate yourself in the HV on care products that have been specially developed for blemished skin. The be-all and end-all is the right skin cleansing twice a day. Since soaps leave behind comedogenic fatty acids, only soap-free, mild, sebum-reducing washing syndets (e.g. from Effaclar) are suitable® , Dermowas® , Sulfoderm® S complexion syndet soap), washing gels (e.g. Eucerin® sebum-reducing cleansing gel) or an O / W cleansing milk (e.g. Roche Posay Toleriane®). With their physiological pH value, they maintain the skin's natural protective acid mantle. A downstream, weakly alcoholic face tonic disinfects and tones the skin (e.g. Widmer® Tonique facial).

Abrasives mechanically remove superficial cornifications and comedones. They usually contain round abrasive particles made of aluminum oxide (e.g. Brasivil®) and can be used several times a week on blemished skin. In the highly inflammatory or purulent acne stage, however, peelings are contraindicated, as they would open the efflorescences and distribute their inflammatory contents.

More than just cosmetics

Basic rule for dermopharmaceutical advice: Acne patients must not use high-fat cosmetics, as their occlusive effect promotes acne. There are numerous low-fat, quickly absorbed, mattifying O / W creams to choose from on the market. Ask your customers about previous product experience before you make your own care suggestion.

For young acne patients in particular, it is important to know that there is basically nothing against applying a masking make-up (e.g. Normateint from Vichy). For this purpose, tinted powders or special concealer sticks (e.g. Sulfoderm® S Complexion Stick).

Caution comedogenic!

Anyone prone to blemishes should avoid dermatics with comedogenic ingredients such as petrolatum, lanolin, sodium lauryl sulfate, isopropyl myristate, etc. What is less well known is that apart from cortisone ("steroid acne") a number of other clinically important drugs can trigger or worsen acne when used systemically. These include: potassium iodide, vitamin B.1, B6, B12, Vitamin D, anti-thyroid drugs, lithium, phenytoin, cyclosporine A, quinine, phenobarbiturates, androgenic gestagens, anabolic steroids ("doping acne").

Recommendations outside of the box

Even if the data on this is still very thin: Oral zinc supplementation lasting several weeks is said to have a positive effect on inflammatory forms of acne. Saccharomyces boulardi (e.g. Perenterol®) is officially indicated as an adjuvant for chronic forms of acne. However, the exact mechanism of action has not yet been clarified.

It is well known that acne patients often suffer from greasy hair and dandruff at the same time. A special sebum-regulating anti-dandruff shampoo (e.g. Kerium® Shampoo gel) can therefore be a useful care supplement. And feel free to think of very practical things such as B. Disposable washcloths or towels (e.g. from Duniwell®), because this is the perfect way to put together an acne counseling package.

Sources Lennecke, K .: Self-medication for the smock pocket, Deutscher Apotheker Verlag, Stuttgart (2004). Schwabe, U .; Paffrath, D .: Drug Ordinance Report 2005, Springer Medizin Verlag, Heidelberg (2005). Gesenhues, S .; Ziesché, R .: General Practice Guide, Urban & Fischer Verlag, Munich (2006). Bender, S .: Body care customer, Wissenschaftliche Verlagsgesellschaft mbH, Stuttgart (2000). Lennecke, K .; Lengeling, S .; Hagel, K .; Grasmäder, K .; Liekweg, S .; Therapy profiles for the smock pocket, Wissenschaftliche Verlagsgesellschaft mbH, Stuttgart (2003). Braun-Falco, O .; Plewig, G .; Wolff, H.H .: Dermatology and Venereology, Springer Verlag Berlin Heidelberg New York (2002). Press release on compliance in acne therapy, Galderma GmbH Düsseldorf, October 26, 2006. DAZ 2006, No. 8, pp. 91-92.
Pharmacist Christiane Weber