The importance of basic skin care in the management of patients with acne.

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Acne vulgaris (aspe vulgaris) is a chronic inflammatory disease manifested by open or closed comedones and inflammatory skin lesions in the form of papules, pustules, nodules [1].

Currently, acne is one of the most common dermatoses in the world (it occurs in 9.4% of the population). Almost 100% of girls and 90% of boys of the puberty period have this skin disease.  [2].  According to The Global Burden of Disease Project, acne is one of the ten most common diseases, ranking eighth [3]. According to J. Leyden's research, 85% of people aged 12 to 24 years, 8% of people aged 25 to 34 years and 3% of people aged 35 to 44 years suffer from this dermatosis [4, 5, 6]. Starting at puberty, the disease resolves independently in 60% of patients as they grow older, but in 40% of patients it can occur up to the third decade of life and longer [5, 6].

  If in adolescence dermatosis occurs in almost equal proportions in boys and girls, then with late acne, the incidence in women is significantly higher than in men [5, 6].

Acne is a dermatosis of a multifactorial nature, in the pathogenesis of which the dominant role belongs to genetically determined hyperandrogenism and a genetically determined type of sebaceous gland secretion [1].

Currently, it has been proven that inflammation in acne is primary and precedes follicular hyperkeratosis [7]. According to the conducted studies, patients with acne on apparently healthy skin in the follicle area have an increased number of T cells and macrophages in the perifollicular and papillary dermis, as well as increased expression of E-selectin and Il-1 [7, 8]. These data allow us to conclude that acne patients develop subclinical inflammation in the skin. Il-6 and TNF-a are also involved in the development of this inflammation.In addition, C. is involved in the development of inflammation. acnes, antigens that attract neutrophils and phagocytes from peripheral blood to the sebaceous hair follicle. Interleukins are produced and the compliment system is stimulated. Proinflammatory cytokines activate cyclooxygenase, resulting in the formation of the main inflammatory mediator, leukotriene B4 [7.8].

 

Thus, the leading role in the pathogenesis of dermatosis belongs to an increase in sebum production, excessive follicular hyperkeratosis, the proliferation of Cutibacterium acnes (C. acnes) and inflammation [9.10.11].

It is important not only the hyperproduction of sebum, but also the violation of its composition and the ratio of oxidants /antioxidants in the lipids of the skin surface.  Sebocyte function is regulated by various factors - sebum production is influenced by the expression of sebaceous gland receptors: neuromodulatory receptors for substance P and corticotropin –releasing hormone, receptors for dehydrotestosterone, receptors for histamine, receptors for insulin-like growth factor and receptors activated by peroxisomal proliferator [12]. According to research results, androgens promote sebum hyperproduction by reducing the concentration of linoleic acid, the main regulator of keratinocyte differentiation of the follicle duct and increasing the expression of the transglutaminase enzyme. This leads to the predominance of the processes of dyskeratosis and proliferation over desquamation of the epithelium of the sebaceous hair follicle and, consequently, the formation of follicular hyperkeratosis.  The development of follicular hyperkeratosis is also facilitated by an increase in the level of interleukin – 1 [8, 12].

Cutibacterium acnes – (a gram-positive facultative anaerobe belonging to actinobacteria, found mainly in hair follicles) acts as a trigger factor. This microorganism is a commensal and part of the skin microbiota present in the hair follicles of most healthy adults.  However, many researchers point to the production of a number of enzymes by this microorganism, such as esterases, lipases, proteinases, hemolysin and others, initiating the development of inflammation and leading to a violation of the barrier function of the follicle [13, 14]. In addition, C. acnes regulate keratinocyte differentiation and are involved in the formation of microcomedones [8].

Acne rashes are represented by comedones, papules, pustules, nodes and are localized mainly on the skin of the face, upper extremities, upper chest and back. The course of the disease can vary from mild forms (comedonal) to severe (nodular and conglobate).

 

Due to the predominant localization of rashes with dermatosis in open, aesthetically significant areas of the skin, acne in most cases is accompanied by psycho -emotional disorders, up to severe depression, the extreme manifestation of which can be suicide. At the same time, according to the conducted studies, there is no direct relationship between the severity and prevalence of dermatosis with the degree of severity of psycho-emotional disorders [15]. According to some authors, psycho-emotional and social problems in patients with acne are higher than in patients with atopic dermatitis and psoriasis and are comparable to the problems of patients with bronchial asthma, arthritis and diabetes mellitus [16].

Thus, given the high prevalence of the disease, the emergence of difficulties in social and professional adaptation, as well as a decrease in the quality of life in patients with acne, the problem of timely, effective and safe therapy of this dermatosis is urgent.

Modern acne treatment includes the use of both external and systemic medications. The amount of therapy depends on the severity of the disease and the patient's motivation. However, in all cases of the disease, according to federal clinical guidelines, regardless of the severity of the disease, when prescribing external or systemic drug therapy, basic skin care products are recommended, including preparations for gentle cleansing and moisturizing [1]. The use of dermatocosmetics helps to restore the barrier properties of the skin, has an anti-inflammatory effect, increases the tolerance of systemic and external medications for the treatment of acne. Skin care products should not contain irritating components (alcohol, keratolytic agents in high concentrations, etc.), as well as comedogenic substances [1].

Based on the recommendations of the Global Alliance for Improving Acne Treatment Outcomes, the addition of skin care products such as moisturizers and pH-balanced cleansers increases the effectiveness of disease therapy [17].

Such recommendations have been confirmed by many years of research. More in the works of Yu.F.Korolev in 1958 showed that with increased sebum secretion, the content of unsaturated fatty acids in the composition of sebum decreases [18]. Later, Yamamoto proved that a decrease in the level of a number of ceramides and free sphingosine in the area of the sebaceous hair follicle in acne patients is accompanied by a violation of the function of the skin barrier [19], which requires correction.

In addition, it has been shown that drugs with keratolytic and comedolytic effects used in the treatment of acne contribute to thinning of the stratum corneum, qualitative changes in the composition of highly specialized lipids, as well as to increased permeability of the skin barrier [8, 17]. This, in our opinion, explains the irritating effect of such drugs and the violation of adherence to therapy on the part of the patient.

Taking antibacterial drugs, in turn, reduces the amount of free fatty acids and increases the level of triglycerides in the surface lipids of the skin [8, 17], which again requires appropriate correction.

The works of many authors confirm that the lack of skin care during treatment leads to an exacerbation of dermatosis [20, 21].

However, the skin care products used to moisturize and restore the skin barrier for acne patients should be of a light texture that does not have an obese effect on the skin (gels or emulsions of the "oil in water" type).

Adequate photoprotection is essential in the skin care of acne patients. There are many works on the negative effect of ultraviolet rays on the skin, which consists in suppressing local skin immunity, oxidation of squalene of sebum, leading to an exacerbation of acne, the appearance of signs of photoaging of the skin, direct cytotoxic effect [8, 22].

In recent years, an important role in the treatment of dermatological diseases has been assigned to the restoration of the skin microbiome. Dysbiosis of the skin surface and sebaceous hair follicle leads to a violation of the barrier properties of the skin, microbial contamination, the development of inflammation and exacerbation of dermatosis. According to the conducted studies, the addition of bacterial lysates to dermatocosmetics helps to restore the skin barrier, reduce inflammation and is promising in the treatment of acne patients [23].

Treatment is prescribed based on the severity of the disease and includes systemic and external therapy.

In most cases, external therapy is fundamental in the management of acne patients. Modern topical drugs affect almost all links in the pathogenesis of the disease.  The first-line drugs are topical retinoids, azelaic acid, benzoyl peroxide and antibacterial agents. It is possible to use these drugs as monotherapy, but combination therapy proved to be more effective and in the conducted studies had a faster and longer therapeutic effect [24].

Systemic therapy drugs include antibiotics, hormonal agents and isotretinoin [1]. Antibiotics are recommended in the treatment of moderate forms of acne, especially in inflammatory forms of the disease. Tetracyclines are the first-line drugs, and macrolides are recommended if they cannot be prescribed. In pregnant women and in the presence of allergic reactions to tetracyclines and macrolides, penicillins and cephalosporins may be prescribed [1, 8].

 

About the authors

Natalya A. Kholodilova

Federal State Budgetary Educational Institution of Higher Education "First St. Petersburg State Medical University named after Academician I.P. Pavlov" of the Ministry of Health of the Russian Federation

Author for correspondence.
Email: kholodilova83@list.ru
ORCID iD: 0000-0002-7765-7487
SPIN-code: 7601-0687

Candidate of Medical Sciences, Associate Professor of the Department of Dermatovenerology with the clinic

Россия, 6/8 Leo Tolstoy street, 197022 St.-Petersburg, Russia

Konstantin N. Monakhov

Federal State Budgetary Educational Institution of Higher Education "First St. Petersburg State Medical University named after Academician I.P. Pavlov" of the Ministry of Health of the Russian Federation

Email: knmonakhov@mail.ru
ORCID iD: 0000-0002-8211-1665
SPIN-code: 1837-2098

Doctor of Medical Sciences, Professor of the Department of Dermatovenerology with Clinic

Россия, 6/8 Leo Tolstoy street, 197022 St.-Petersburg, Russia

References

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