Review literature Acne vulgaris in Adolescents

Review literature

Acne vulgaris in Adolescents

dr. MOH. IFNUDIN, SpKK

INTRODUCTION

Acne vulgaris is a disease that often seen in adolescent age. Kligman said that no one else in the same kehidupanya never suffered from this disease.

Acne mamiliki place predilection: face, neck, upper arms, chest and back, acne can also be found in infancy (neonatal acne), children, adolescents, adults and parents. This disease can heal itself without the aid of drugs or cosmetics, otherwise there is also a difficult to overcome.

The disease is not fatal, mild acne is often considered a physiological process, but often troubling because it can reduce self-confidence. Psychological problems of patients show the existence of disability (disability), which often appears in the form of anxiety, depression, loss of social environment and can not join the group. Odelesen acne can mnimbulkan presexsualrelationship related problems.

A Paediatric dermatology and the paediatrician has an important role in facing the problem of acne vulgaris in adolescents who gerjadi. Kira - about 40% of adolescents under age 15 will experience acne physiology and 15% of them feel they are suffering with acne is often annoying, so they need a doctor.

These physiological acne can be lost in 3-6 years, but acne vulgaris new clinically significant can be lost in the time period is longer. Therefore, initial therapy should be appropriate and adequate which will reduce the severity of the problem and the risk of scarring in the future.

In a girl, acne vulgaris can occur when premenarce, but 85% of patients who come to paedriatic dermatologist after they menstruate.

DEFINITIONS

Acne vulgaris is a chronic inflammatory disease of pilosebasea which generally occurs in adolescence and can heal itself, accompanied by clinical picture polimorfosis; consists of various skin disorders in the form of non-inflammatory lesions (whiteheads, blackhead), superficial inflammatory lesions (papules, pustules superficial) and in inflammatory lesions (nodules), premises where predilection: face, neck, upper arms, chest and back.

The term "vulgaris" is taken from the Latin words meaning kersakan forms of acne from the form usually found.

Limits the term teens by Hurwitz is a period of life between childhood - childhood and adulthood. Starting at puberty, with a limit of between 9-17 years of age. Medium according to WHO, adolesen or young adults are aged between 15-24 years.

Incidence

Acne more frequently in whites than blacks, oriental races (Japan, China, Korea) are more rarely suffer from acne vulgaris compared with Caucasian race (European, American). Medium cystic nodules in more whites than blacks.

Peak severity of acne vulgaris in women occurs at age 14-17 years and in men - men at the age of 16-19 years. Slightly more prevalent in men - male than female.Approximately 85% of high school students between the ages of 15-18 years experience this in varying degrees of severity.

ETIOPATOGENESIS

Etiological factor of acne is associated with increased production of sebum, increased channel kornifikasi pilosebasea, pilosebasea tract colonization with Prpionibacterium acnes and inflammation.

Increased Sebum Production

Sebaceous glands under endocrine control. Will stimulate the pituitary adrenal and gonads to produce estrogen and endrogen, which has a direct effect on the unit pilosebasea. The main androgens in early puberty is produced by the adrenal dehydroepiandrosterone (DHEA) is produced by the adrenal and has an important role, especially in stimulating the formation of blackheads. At puberty, testosterone is produced primarily by organ testes and ovaries. This produced hormone testosterone is converted by the enzyme 5 alpha reductase to dihydrotestosterone (DHT). DHT is what causes the sebum. There are two enzyme 5 alpha-reductase: type I and II. The most important and sebaceous glands are the type I 5 alpha reductase.

Patients with acne vulgaris have increased sebum production and is related to the severity of acne, although there are overlaps in the levels of sebum production in acne different levels. This can be caused by the production of androgen hormones penigkatan or a hyper-responsive to androgens in the sebaceous glands to normal levels. A third possibility is a combination of both.

The evidence for the hypothesis that acne vulgaris is caused by end organ hyper-resposif pilosebasea unit indicated by the location of the occurrence of acne vulgaris in most patients were only found in some places that are rich in sebaceous glands.

Acne vulgaris may also be associated with changes in fat composition. Komedogenik sebum which is composed of a mixture of skualen, candles (waks), esters of sterols, cholesterol, and polar lipids trigiserida. In patients with acne vulgaris there is a tendency to have content skualen and wax esters (waks) high, this is likely related to the occurrence hiperkeratinisasi pilosebasea tract.

Increased Kornifikasi Pilosebasea Channels

Improved clinical kornifikasi pilosebasea channel appears as comedones (whiteheads and blackhead) and preceded by mikrokomedo. Blackheads are caused by the accumulation of korneosit in pilosebasea channel. Increased proliferation korneosit, separation failure dri korneosit or combination of both.

This hiperprofilerasi Penyebaba multifactorial. Androgens stimulate the sebaceous glands in addition to also affect the channel hiperprofilerasi on these glands. Androgen receptor and increased activity of type I 5 alpha-reductase found in pilosebasea channel. In addition, antiandrogens will reduce blackheads.

In addition, fat kompposisi sebum plays an important role in the formation of blackheads. A number of fatty acids and skualen, including skualen-oxide are irritants to korneosit, thus encouraging the proliferation of channels pilosebasea.

Large sebaceous glands which will contain fewer linoleik acid than normal size gland.According to Downing, a result of increased sebum in acne vulgaris patients, will be a decrease linoleik acid concentration. This can lead local linoleik acid deficiency on apitel follicles, and this will cause follicular hyperkeratosis and decreased epithelial barrier function of.

Channels colonization Pilosebasea with P.acnes

Propineobacterium acnes plays an important role etiology of this disease. Especially the inflamas. Antibiotic therapy to reduce Staphylococcus epidermis and pityrsoporum ovale (Malassezia furfur) does not change with acne vulgaris, but therapeutic to reduce P.acnes will provide clinical changes and when there are suspected causes of treatment failure due to resistance against antibiotics digunkan P.acnes.

The number of bacteria on the skin surface is not related to the severity of acne vulgaris, but puberty with sebore usually accompanied by a rise in the number P.acnes (formerly called Corynebcterium acnes). From this it appears that these three kinds of bekteri is not a primary cause of the pathological process of acne vulgaris. Some acne lesions may occur in the absence mikrorganisme living, while at the other lesions microorganisms may play an important role. Cunliffe said, usually takes more than 10 / cm P.acnes for the occurrence of acne.

How P.acnes which is a non-motile organisms could have colonized is unknown, but said the bacteria that dwell in the follicle can mengdakan exacerbations depending on the microenvironment within the follicle. In in vitro studies have shown that the factors - factors such as pH, oksigensi and metabolites affect growth and metabolism.

Inflammation

Biopsy lesions performed in different stages, indicating that the initial cellular infiltrates in young lesions are T helper Lymphosit. Polimorfonukleosit have abnormalities in older lesions, usually a combination of Polimorfonukleosit and lymphocytes. Lymphocytes itself is the dominant cell found in papules and pustules Polimorfonukleosit dominant at.

First suspected in the early phase of inflammatory process of follicle rupture is required, but this time clearly indicated that in 70% of follicles, did not occur at the beginning of the outbreak seluran inflammatory process. Therefore allegedly inflammatory mediators through the channel into the dermis and stimulates an inflammatory response. Further studies showed that most patients with acne vulgaris had no immune abnormality, but the inflammation is a toxic material that is released from the channel pilosebasea.

Finally can be summarized, that in patients with acne vulgaris, sebaceous follicles specific over-response to normal circulating levels of hormones produced by the sebaceous glands are large. Fat from the sebaceous gland which helps induce kemodogenesis also stimulated by andogren and possibly by local changes sitokine.Blackheads mainly caused by increased proliferation korneosit, Eski needed further study to determine whether there is adequate separation failure of korneosit pilosebasea tract. These factors will change the environment that encourages colonization mikrokomedo with P.acnes which will give the role to the production of inflammatory mediators. When entering into the dermis will cover sitokine inflammatory activity and eventually produce inflammation.

Clinical manifestations

Clinical manifestations of acne in the form of non-inflammatory lesions (whiteheads, blackhead), superficial inflammatory lesions (papules, superficial pustules) and in inflammatory lesions (nodules). Primary lesions commonly occur in adolescents are in the face, upper chest and back, this distribution is similar to those seen in adults. On the type of adolescent acne, some lesions can occur at the same time, good blackhead (open, open comedo), whiteheads (closed, closed comedo), papules, pustules also nodules.

Sebore or oily skin occurs due to the excess production of sebum by the sebaceous follicles. This can be seen in the patient's face looking greasy.

The lesions are not accompanied by inflammation called a blackhead, when a blackhead or whitehead. Blackhead lesions appear as flat or slightly elevated with a central dark follicular containing keratin and lipids. Its size varies, with a microscopic diameter between 2-3mm. whitehead is contrary to blackwhite look more pale with little elevation or small papules and do not have a hole that can be seen clinically. Although very small, usually less than 1mm, but because this whitehead potential to become a larger inflammatory lesions is considered clinically important.

Superficial inflammatory lesions are usually easily recognizable. Papules acne vulgaris usually reddish, with a diameter of 0.5-9mm, rising up to 6mm which usually occurs 1-14 days. When the papules are actively going very red in color and reduced kemerahannya while less active. Pustules of acne vulgaris is a papule with a peak of pussy, divided in the form of active and less active pustules, usually shorter than the age of papules pustules because patients naturally want to push this type of lesion (usually 1-2 days or slightly longer). Acne vulgaris nodules showed large inflammatory lesions with a diameter of approximately 1 cm or more, raising more than 6mm with pain and can occur up to several weeks or months. These types of lesions usually cause scarring.

Location of early acne vulgaris often in the face, especially on the cheeks and forehead, but this next acne lesions often spread over all the parts of the face, neck and body as well. In the case - an extreme case, could extend to the forearm, on the buttocks and upper thighs bgian.

Early healing of acne vulgaris usually occurs post-inflammatory erythema, which can be nentinya hypopigmentation or hyperpigmentation.

Lesions can also end up being scarring, more frequently in nodular lesions and in patients who frequently manipulated the lesions. Skar often found in populations of children with acne accompanied by a loss or increase in collagen. The loss of collagen scarring form of depression that can be found with irregular shapes, especially in the face and scarring often called 'ice-pick'. Scarring that occurs due to increased collagen more rarely found in this population, called hypertrophic scarring if not extend beyond the actual size of the acne lesion, called keloids, which occur where the scarring extends beyond the size of the lesion inflasimasinya. Both hypertrophic and keloid, both felt strong and full of blood vessels in the first few months so that the red or purple. This color will be teenagers, keloid scarring most common in the sternum area.

According to Hurwitz, the severity of scarring depends on the depth and intensity of inflammation and sensitivity of patient to scarring, but Cunlife stated that the scarring is not always associated with the severity of acne inflammation, and scarring can occur at age whatever, including the age of 9 or 10.

Several variations of acne vulgaris commonly occurs in teenagers is acne due to friction from a headband, football helmet, a tight shirt. Cosmetics with oil-based komedona often cause acne.

While the clinical variation of which is the acne that occurs in children, among others, stated:

1. Acne neonatorum

Acne can occur in newborns or in infan aged under 3 months. Eruptions that occur are usually limited number of comedones, papules or pustules, the condition is regarded as a result of stimulation of the adrenal on the fetal or sebaceous glands by maternal hormones cross the placenta. No trapi needed because the resolution will happen by itself.

2. Acne infantum

Infan could experience an eruption akneiform after the age of 3 months. More lesions, more inflamed and more persistent compared with the neonatal acne. Therapy using topical substances commonly used in adolesen and seldom use systemic adntibiotik.

3. Akneiform eruptions induced by drugs - drugs that dberikan topical corticosteroids or systemic, androgens, iodid, bromide, rifampin, isoniazid, phenobarbinal, diphenylhydantion and lithium carbonate can cause eruption reported akneiform.Lesions in the form of reddish papules and small pustules - small. Blackheads and cystic nodules are rarely encountered. Predileksinya Location: body, shoulders, and upper arm. By histopathology, the lesions of acne can be found, except for blackheads.

4. Chlor-acne

This type of acne found in children - children Seveso, Italy in 1976 who accidentally exposed to chlorinated aromatic substances such as 2,3,7,8-tetrachlorodibenzo-p-dioxins. Children - children who are exposed to dioxin in a short time only to have lesions in the form of blackheads, while older children who are exposed will experience keratotik papules, pustules are large, nodules and cysts, especially in the face and dorsum manus.

5. Acne konglobata

Betuk severe acne is a chronic, characterized by the sinuses, abscesses and irregular scars. More common in males - males between the ages of 18-30. The exact cause is unknown, there may be peruahan reactivity against P.acnes. Lesions are often found on the face, neck, torso, upper arms, back even to the buttocks area. Nodulus the group will enlarge, remove the pus, forming a crust and leave a scar tissue. Konglobata acne is often accompanied by inflammation of the apocrine glands in the axilla and the perineum resulting in Hidradenitis supuratifa.

6. Acne fulminans

Variants of acne is more common in adolescent males - males, characterized by papules and nodules on the chest and back of redness and pain, often accompanied by ulceration, fever, sore muscles and joints.

7. Tropical acne

This term is used to describe the circumstances that arrive - arrived Caucasian experienced by soldiers who served in tropical regions, the lesion of reddish papules and nodules on the body and buttocks.

DIAGNOSIS

To uphold dignosis acne vulgaris, is required anamnesis, clinical examination and special examinations. Complaints itching or pain only sometimes - sometimes it happens in the skin lesions in the area predileksinya. Complaints reamaja usually for cosmetic reasons.

The first important thing that must be performed by a doctor is checking the patient's skin with adequate lighting in order to optimally assess the severity of acne and type - the type of lesions. Blackhead papules, pustules, and nodules are easily recognized, but whitehead difficult to see. For that doctors need to stretch the skin of patients with lege artist, giving radiation from different angles so that the whiteheads can be seen. In important especially in dark skinned individuals, where harder whiteheadnya examined.

Clinically visible oily skin, blackheads (typical for acne), papules, pustules, nodules, hyperpigmentation and scar tissue as a share of residual symptoms. Eruption of acne vulgaris is generally a combination that is dominated by one type of lesions (comedones, pappul, papulopustul, or nodules). In such circumstances, the diagnosis begantung dominant lesions, such as: acne vulgaris komedonal.

Special Investigations ekskokleasi form of blackheads, is easy to prove whether a small papule that occurs right a blackhead, because it is a symptom patogmonomis blackheads acne vulgaris. Lege premises inspection is done the way artists release of sebum from clogging with the help of blackhead extractor tool (spoon Unna). The clogged sebum in acne vulgaris appear as solid masses such as candles or soft rice which ends sometimes - sometimes black.

LABORATORY EXAMINATION

Variations of endorin imbalance in patients with acne vulgaris addressed with an increase in the ratio of androgens to estrogen. Total plasma testosterone and dehydroepiandrosterone sulfate increased in men and women; is free testosterone, delta-4-androstenedione, dehydroepiandrosteron, and 17 beta-hydroxysteroid Smoking increased in women with acne vulgaris. Improved conversion of testosterone to androstenediol and dihydrosterone by eptelium infundibulun and from sebaceous been reported. Than a third of women with mild acne who have hyperandrogenemic.

Microbiological examination of suspected microorganisms play an important role in the biochemical process of sebum (in which the germ alter triglyceride lipase into free fatty acids are more dense) can be done for etiological research and therapeutic purposes.Examination and lipid composition of skin surface (skin surface lipids) can also be done with similar objectives. In acne vulgaris free fatty acid content (free fatty acids) will be much improved, to various ways and medications that can degrade dihrapakan to prevent the occurrence of acne vulgaris is.

EXAMINATION histopathological

Histopathologic examination of acne is not specific, the form sebukan chronic inflammatory cells around the follicle pilosebasea with masses of sebum in the follicle.

Blackhead is a follicular infundibula that experienced by a number of dilatation because dibuntu orthokeratotic horn cell layer and densely arranged. In blackheads, besides the addition of horn cells are also found the existence of sebum and normal bacterial flora (Propionbacterium acnes and Staphylococcus epidermis), yeast (Pityrosporum ovale Pityrosporum Idan orbiclare), and sometimes mites (Demodex folliculorum).

Whitehead is a very small infundibular cyst, containing horn cells, sebum and normal flora microorganisms. Cyst wall contains infundibula follicular epithelium. In the histological cuts, if dilkukan serially to all parts of the cyst, infundibula, the new ostium can be seen.

Kkumpulan pustules is a fully on neutrophil infundibula follicles. Neutrophils are also found in the affected infundibula wall, also on the perifollicular dermis. In a mixed perivascular infiltrate superficial cells found the lymphocytes, histiocytes and neutrophils.

Papule - pustular acne is a result of the outbreak of blackheads in the dermis or interfollicular pustules of the expansion itself. Erdiri papular component of infundibula who experienced dilated by a number of cells increased by the horns and inflammatory cell infiltrate in the dermis, while pustular component is the result of the accumulation of neutrophils in infundibula.

Nodules of acne vulgaris is a result of the rupture of follicular cyst. The contents of these cysts: horn cells, sebum, bacteria, yeast and mites that enter the dermis.

So diagnosis of acne vulgaris is not made from histopathologic examination results but the suspicion of the diagnosis of acne vulgaris can be made from the histopathologic examination results.

DIAGNOSIS OF APPEAL

The condition is considered as an appeal of acne vulgaris is sebagaai follows:

1. Rosacea (formerly: acne rossea), is a chronic inflammatory disease with symptoms teleangiektasis, which peristen facial erythema and papules infalmasi, sometimes - sometimes accompanied sebase gland hypertrophy. Rosacea is considered as a result of the use of potent topical glokokortikoid type. There were no comedones except when combined with acne vulgaris.

2. Nevus comedones, which can occur simultaneously with acne, is a birthmark that can teresusun similar to the blackhead is usually unilateral.

3. Miliary also looks like acne lesions neonatal though only temporarily, lost less than 48 hours.

4. flat-wart that occurs face sometimes confused with acne, papules shape, flat-topped with a slightly darker skin color,

5. Angiofibron sometimes confused with acne vulgaris. Tampa erythematous, soft papule on the nasolabial folds on the chin and cheeks. Lesion onset is usually at the age of 7 or 8 years. Not only blackheads is important to diagnose.

6. Molluscum contagiosum by a more thorough inspection looked at the peak of the central umbilication papules that are typical for this disease.

7. Perioral dermatitis that occurs primarily in women with clinical symptoms of polymorphic erythema, papules, pustules around the mouth that feels itchy.

8. Venenata acne and acne due to physical stimulation. Generally monomorfis lesions, no itching, can be comedones or papules, with contacts in place where presileksi chemical or their physical stimuli.

9. Akneiforms eruptions caused by drugs, eg corticosteroids, INH, barbiturates, bromide, yodida, diphenyl hidnatoin, trimetadion, ACTH and others. Clinical form papulopustular eruption suddenly without any blackheads on almost all bgian body.

MANAGEMENT acne vulgaris

Therapy in adolescents depends on 3 main factors: the type of lesion, severity of acne vulgaris lesions that exist and psychological effects of their disease.

Selection of topical therapy depends on the dominant type of lesion. But for blackheads eterdiri from: azelaic acid or retinoids such as all-trans-retinoic acid, 13-cis-retinoic-acid and adapalene. Effective therapy for inflammatory lesions is a non-antibiotic-antimicrobials such as azelaic acid and benzoyl peroxide (the concentration bervarisi from 2.5 - 10%) or topical antibiotics. Topical antibiotics can be used single, for example clindamicyn, eritromicyn, tetracycline or a combination with benzoyl peroxide or zinc acetate.

Topical therapy can be used to improve acne and can be used for several years. Single Used in mild acne or as a custodian therapy when oral therapy is stopped.

All topical therapy, especially retinoids will lead to a primary irritant dermatitis, erythema and exfoliation of the oiled location. Often the selection of therapy will be given to patients based on personal experience and / or patients based on responses to previous therapy.

Cunliffe suggests doctors should provide treatment by using materials that have known very well and only use alternative therapies if the patient does not respond. Based on his experience, the choice of therapy for acne is topical retinoids and anti-inflammatory substances of the most potent is benzoyl peroxide 5%, topical clindamycin dn topical erythromycin is used alone or in combination with benzoyl peroxide or zinc aceteta.

The severity of acne that affects adolescents will determine what type of therapy will be used. Patients with mild acne vulgaris should be treated topically, whereas patients with moderate or severe acne vulgaris, or acne vulgaris is accompanied by mild psychological problems, with or without scarring should be combined between topical and oral therapy. The first drug choice is oksitetrasikin 500 mg 2 times per day, but not for children under the age of 10 years. Erythromycin 500 mg 2 times per day is an alternative, or doxycycline 100 mg per day. Second line antibiotic therapy is minocycline 100 mg per day and timetropin 400-600 mg daily.

Another type of therapy can be used for teenagers are hormonal therapy. Prednisolin in a dose of 5 mg per day will suppress the adrenal androgens. Dianette the contraceptive pill in the form (35 ugethinyloestradiol and 2 mg of antiandrogen cyoroternone acetate) could be used for adolescent female patients with menstrual problems. Oral therapy of acne vulgaris third row is oral isotretinoin.

Re-examination and additional therapy should be done at least every 3 months, especially if side effects occur or acne worse. Oral therapy with antibiotics can be used for 6 months, and can be used in a longer time is more than 48 months. Old safe this therapy if needed though in the age group of children.

Side effects of oral antibiotics that may occur include: GIT disturbances such as nausea, colic and diarrhea abnominal. Vaginal Candidiasis is common in adults, less common in children.

PROBLEMS IN THE TREATMENT of acne vulgaris

It said there are 6 main reasons why patients do not respond well to this therapy, namely:

1. Not following doctor's advice

Often patients do not follow what is recommended by doctors, this is a major problem in dealing with cases of chronic diseases including acne. Therefore it is important to emphasize to patients that the response to therapy was slow. Acne usually experience a 20% improvement after the therapy for 6 months. Also need to check whether the therapy has been used is correct, for example, by patients with topical therapy, otherwise how many tubes have been used. Usually when the treated face only needed 30-45 grams in 3 months, while for the face and body need a 90gr or more in the same period.

2. Multiple comedones

Multiple whitehead is another reason why the response is not good. Multiple makrokomedo therapy rarely respond well to topical retinoids. For that it takes light to terpinya Cauter, after using a local anesthetic cream (eutectic mixture of local anaesthetics or EMLA) in polythene occulusion 1.5 hours earlier. The purpose of this therapy is to induce thermal damage that encourages local immune mechanism to hold the resolution of komedonya.

3. Resistance antbiotik

Resistance to erythromycin P.acnes approximately 65%, clindamycin 65%, tetracycline 40% and 40% doxycycline. The combination of erythromycin and benzoyl peroxide can reduce P.acnes resistance to erythromycin.

4. Nodular cystic acne

Preferred Therapy potent steroid like clobetasol propionate cream, used 2 times a day for 5 days, or by intralesional injection with triamsinolon. Can jug dkatakan cyst aspiration with a large-bore needle to remove at least 1-2 ml of pus. When the lesions are large nodules persist for longer than 2 weeks, then cryotherapi a treatment option for patients with large lesions required oral isotretinoin.

5. Very severe acne and acne variants:

Very severe acne and acne variants, including fulminant acne and acne konglobata often respond poorly to conventional therapy.

Oral isotretinoin is an indication of severe acne vulgaris, acne vulgaris moderate who did not respond to repeated antibiotic therapy, the risk of scarring da patients with psychiatric disorders in connection with this aknenya. Isotertion effective against four major etiologic factor in acne, namely: the excretion of sebum, the formation of blackheads, P.acnes and inflammation. The recommended dose is 0.5 mg / kg bw / day - average 4-month period. The dose is set to optimize response and minimize side effects. Side effects that usually happens mainly in the form mokukotaneus symptoms, can be chelitis, xeroderma that can be treated with emollient; dermatitis and secondary infection can be treated with potent topical steroids moderate and can be combined with an antimicrobial. Systemic antibiotics, usually fluklosasilin sometimes - sometimes needed if there is a severe infection.

Isotretinoin can be used safely in children and adolescents. Clark and his friends - friends have conducted a study of 55 children who were treated with isotretinoin and are involved in its development for several years otherwise not experience significant side effects especially on growth or sexual disorders. Therapy of acne vulgaris scarring is usually difficult. Hypertrophic and keloid scarring may be able to respond to the application of clobetasol propionate cream used 2 times a day for a period of 3 months.Triamsinolon intralesional or cryotherapi an alternative. Atrophic or ice-pick scarring is more difficult, for it dermabrasion and laser CO ultrapulse might help, but this should not be done on memebantu, but this should not be performed in patients with younger age.

SIDE EFFECTS OF TREATMENT

Side effects are often encountered in the treatment of acne vulgaris is:

1. Dermal irritation

2. Resistant to certain antibiotics.

3. Gastro-intestinal disturbances such as nausea, vomiting and diarrhea due to the use of oral antibiotics, such as membrane due to the use of clindamycin colitis

4. Tooth discoloration from tetracycline administration in children under 9 years of age.

Prognosis

Travel acne vulgaris can not be predicted. Acne may disappear within a few weeks or persist for several years. Exacerbations may be caused ole stress, climate or hormonal fluctuations during menstruation, 70% of women with acne complained of illness becomes severe before menstruation.

A number of lesions in patients with acne vulgaris usually begin gradually - gradually decreases as the age of approximately 20 years. The condition usually improves during the summer, it is suspected as a response to the effects of sunlight is healthy.

CLOSING

Edting By: EnongXp