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Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

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Definice

Disease of the pilosebaceous unit
Seboroická lokalizace
Chronická zánětlivá porucha pilosebaceosní jednotky

Dg. kriteria

Four recognized pathogenic factors:

Hyperkeratinization

Plugging of the pilosebaceous follicles

Increased testosterone

Induces hyperseborrhea

Colonization with the bacterium Propionibacterium acnes
Inflammation

Epidemiologie

Typically appears at puberty

Po ll – l2 roce věku

Less active as adolescence is ending
85% - 90% mládeže
Can persist into middle age

12% of women
3% of men

Etiopatogeneze

Detailní obrázky

Abnormální rohovatění - retenční hyperkeratoza

Hromadění mazu v chlupových foliklech

Zánětlivé změny

Tlak zadržovaného mazu
Maz s hyperkeratotickými hmotami

Biochemické změny v dlouho retinovaném mazu

Anerobní bakterie - Propionibacterium acnes

Propionibacterium acnes

produkují t10, c12 CLA (konjugovaná linolová kyselina)

T10 např. potlačuje růst nádorů tlustéo střeva

Prasknutí stěny folikulu

Imunologická pohotovost

Zánětlivá reakce jako na cizí těleso
Reakce na antigeny P. acne
Různé typy klinických obrazů akné

Akne jako důsledek infekce parazitem Demodex

alternativní terapie zde (neověřené informace)

"Voda + epsomská sůl + MSM + niacinamid/acylpyrin + borax: zhruba v poměru 65:20:15:1:2 (bez niacinamidu pro získání roztoku výrazně zklidňujícího podrážděnou pokožku). Preferováno by mělo být DMSO místo MSM.
Roztok boraxu + mýdlo se sírou (příp. ichtamolem) + krém se zinkem. Nejdříve nanesu krém, pak ho rozetřu mýdlem a roztokem boraxu. Vytvoří se vrstva, která penetruje a po zaschnutí není viditelná.
Zelený čaj + acylpirin (zhruba 100:1)
Cold krém, jemuž je věnován samostatný článek.
Na vlasy: mýdlo se sírou + roztok boraxu."

Klinický obraz

Klasifikace lézí - polymorfní projevy akné

Inflammatory

Inflammatory papules - papuly
Pustules - pustuly
Nodules/cysts - ndouly / cysty
Makuly
Pozánětlivé hyperpigmentaceme
Pyogenní granulomy

Noninflammatory

Open (blackheads) - černé komedony

0,1 – 3 mm v průměru dle ústí chlupového folikulu

Closed (whiteheads) comedones - bílé komedony
jizvy

Lokace:

Face - obličej
Less frequently the back - záda
Chest - hrudník
Shoulders - ramena
Na pažích, hýždích a stehnech ojediněle

Další nálezy

Výrazný mazotok v obličeji a ve kštici

Klinické klasifikace anglická literatura:

Mild

Comedones
Occasional small inflamed papule or pustule
No scarring

Moderate

Comedones
More numerous papules and pustules (mainly facial)
Mild scarring

Moderately Severe

Numerous comedones
Papules and pustules, spreading to the back, chest and shoulders
Occasional cyst or nodule
Moderate scarring

Severe - Acne Vulgaris

Numerous large cysts on the face, neck and upper trunk
Severe scarring
Závažné formy častější u chlapců

Bolestivé infiltráty v obličeji a na trupu

V některých případech přetrvávají do dospělosti
Zjizvení kůže celoživotně
Zánětlivé projevy nacházejí na nose, boltcích a šíji

Typy akné dle českých standardů:

Acne comedonica
Acne papulopustulosa I – IV stupně
Acne conglobata

Acne inversa

Hnisavé záněty apokrinních žláz
S tvorbou píštělí a abscesů
Píštěle i v krajině kostrče
Chronický průběh, většinou celý život

Acne fulminans

Celkový těžký stav

Vysoké teploty
Artralgie
Tvorba infiltrátů, abscesů až nekróz
Leukocytóza a vysoká sedimentace

Acne neonatorum
Acne infantum
Acne excoriata
Acne postpubertalis

Po 18 roce
Papulopustulky v nosolícních rýhách a na bradě
Nemusí být spojeno se seboreou ani komedony

Acne androgenica

U virililizujících syndromů

Diferenciální diagnostika akneiformních projevů

Polékové akneiformní erupce

Antiepileptika
Glukokortikoidy
Léky s obsahem brómu nebo jódu
Anabolika

Zevní příčiny

Acne picea
Acne oleosa
Acne chlorina
Acne mechanica
Mallorca acne aj

Další onemocnění obličeje

Rosacea
Periorální dermatitida
Demodecidosis
Acne necrotisans
Folikulitidy

Vyšetření

Především u závažnějších forem akné
Biochemické a hematologické vyšetření

FW, KO
Moč + sed.
glykemie
Jaterní testy, transaminasy
Triglyceridy, cholesterol
Imunologický profil

Imunoglobuliny
Typizace lymfocytů
Hladina zinku

Ev. hladiny pohlavních hormonů

Mikrobiologické vyšetření ze zanícených morf
Ev.

Gynekologické vyš.
Endokrinologické
Fokusy

Rizikové / zhoršující faktory akne

Stress

cortisol

Increased glucose production
Immune-system suppression
Nerve-cell damage
Some cases of female adult acne

Diet - controversial

Inorganic iron - inactivates vitamin E
mléko

Milk may also worsen acne due to its high progesterone and fat content (Proc Soc Exp Biol Med, 1972; 139: 745)
Female hormones also in milk
Antagonistic to vitamin E
Associated with acne because it contains growth hormones (both synthetically added and naturally occurring)

jód

In some table salts

Bróm

Commercial carbonated drinks

Usually contain brominated vegetable oils

Food sensitivities

almonds, malt, cheese, mustard, red pepper and wheat flour

Caused the greatest exacerbations of acne (Dermatologica, 1978; 157: 294-5).

Chocolate may also be a culprit (JAMA, 1970; 211: 1856).
Nedostatek zinku
Nedostatek vit. B2

Chocola BB od Eisai(vitamin B2, B1 a B6)

Zmírňování akné, stomatitidy, zjemňování pokožky a odstraňování známek únavy pleti

vitamin B12
Regional diets low in processed foods and sugars (with an overall low glycemic load) are associated with decreased acne risk

Studies using similar low glycemic load meals have reported improvements

Hyperkeratóza

Ucpávání pilosebaceosních folikulů

Seborea – zvýšenou činností mazových žláz

androgeny

Zvýšená aktivita 5-alfa-reduktázy

Konverze testosteronu na aktivní dihydrotestosteron

Vyšší androgenní citlivost mazových žláz

Hormony hypofýzy

Hormony štítné žlázy

Glukokortikoidy a gestageny

Mohou podléhat periferní konverzi na androgeny

Bakteriální flóra folikulů

Nepřímé působení Propionibacterium acnes

Produkce lipázy

štěpení triglyceridů kožního mazu na volné mastné kyseliny

Komedogenně
Agresivně na stěnu folikulů - ruptury
Zánětlivé reakce dermis

Imunologická odezva

Antigeny Propionibacterium acnes
Interleukin 1 (IL-1)

Produced by the cells lining the follicle [1]

Genetická dispozice

Polygenní
V 60% případů těžké akné 1 - oba rodiče prodělali akné

Změna složení mazu

Reduced levels of linoleate

A component of sebum [1]

Free fatty acids

Made from sebum by bacteria [1]

Rupture of the follicle

By injury eg by excessive squeezing of pimples
After abrasive washing
Chemical peels
Laser resurfacing
Presence of hard dried-up sebum poking through the wall of the follicle [1]
Overhydrated skin

Premenstrually [1]

Contact with certain chemicals

Isopropyl myristate
Propylene glycol
Some dyes found in certain cosmetics [1]
Prašné ovzduší
Minerální oleje
Dehet
Chlorované deriváty
Sálavé teplo
Hair products with oil
Suntan lotions

Can worsen acne (Am Fam Phys, 2002; 61: 357-66)

Synthetic lanolins

Acetylated lanolin alcohol
Lanolic acid
Anhydrous lanolin

Butyl stearate
Capric/caprylic triglyceride
Octyl palmitate and stearate
Certain D&C red pigments
water-based cosmetics products are less comedogenic
Soaps, detergents and astringents

Remove sebum

Not alter sebum production

Repetitive mechanical trauma by scrubbing

Promote hyperkeratózu

Bifidobacterium longum and Lactobacillus paracasei

Can attenuate skin inflammation
Mediated by substance P
Substance P may be a primary mediator of stress-induced amplification of inflammation and sebum production in acne

Experimental alterations to the normal gut microbiota can increase substance P release in the nervous system and promote behaviors reflective of anxiety

Substance P - SP

SP causes vasodilation, edema and pain through activation of tissular Neurokinin 1 receptors
SP proinflammatory effects

Substance P release

Capsaicin
Vanilloid
Activation of sensory nerves

Substance P inhibition of release

Olopatadine hydrochloride (antihistamine drug)

Substance P proteolyse

Angiotensin converting enzyme (ACE)

Mají pacienti léčení ACEI vyšší hladiny SP ? Popřípadě i častěji akne ?

Neutral endopeptidase (NEP)

Osobní názory a postřehy:

Zhoršení akné s komedony jako projev aktivace mazových žláz a snaha organismu vyloučit touto cestou cizorodé látky rozpustné v tucích (???))

1) U mne dochází k největšímu zhoršení především po vypití plnotučného farmářského mléka / po konzumaci jiných plnotučných farmářských výrobků

V.s. v důsledku vyšší koncetrace tuků

Tedy i vyšší koncetrace polychlorovaných látek, které hojně kontaminují ČR bez ohledu na to, zda je výrobek "bio" nebo "nebio"

2) Těhotenství a kojení souvisí se zlepšením akne na obličeji ?

Zvýšená kumulace v tuku rozpustných látek v plodu a potom v mléku pro kojence

3) Terapie Roacutanem a snížení aktivity mazových žláz

Vyšší riziko vyšších hladin cholesterolu, karidovaskulárních rizik, zvětšení jater aj.

4) Zohršení akne po vit. B12 a vit. D, hormonech štítné žlázy aj. ?

Zvyšují spalování energie i v tukové tkáni - uvolnění v tuku rozp. látek
Aktivují mazové žlázy k vyšší produkci mazu
Nedostatek ať B12, D, nebo hormonů štítnice vždy opět vyšší karidovaskulární riziko

5) Zhoršení akné po zahájení programu metabolic balance®

Vyšší koncentrace polychlorovaných látek v krvi při spalování tuku v tukové tkáni?

Zpočátku programu metabolic balance® dochází k intenzivnímu spalování tukové tkáně a zátěž polychlorovanými látkami z vlastní tukové tkáně je nejvyšší

Po nějaké době v 2. fázi metabolic balance® dojde ke zmírnění akné a posléze je pokožka lepší kvality než před zahájením programu.

V jídelních plánech metabolic balance® se vyskytuje relativně málo živočišných tuků a je kladen důraz na dostatek kvalitních rostlinných tuků a po zredukování většího množství vlastní tukové tkáně je pokožka zatížena vylučováním polychlorovaných látek mnohem méně.

Další z mnoha důvodů, proč ženám doporučit redukci hmotnosti před plánovaným otěhotněním a ne to okdládat až na potom.

Standard lékařské péče

Dermatolog s atestací I. a II. stupně, který má k sobě zdravotní sestru
Ev. ústavní léčení

Kožní klinika
Kožní lůžkové oddělení

Topická terapie

Zásady

Cleansing

Peeling ovocnými kyselinami
Hluboké čištění pleti
CO2 sněžení (fyzikální peeling)

Keratolytika

K. retinová (tretinoin) - topical retinoid

Microcomedony dobře reagují
topical retinoid increases the risk of sunburn

Adapalene

Synthetic retinoid
Gel or cream
Unclogs pores
Moderate to potent anti-inflammatory abilities
Improvement in 8 - 12 weeks
Side effects

Minor skin irritation and dryness

Tazarotene

Synthetic retinoid
Gel or cream
Keep the skin’s pores clear
Skin irritation is a possible side effect
Teratogenic

Tretinoin

First developed
Natural retinoid
Side effects

Redness
Scaling
Dryness
Itching and burning

K. azelainová - Azelaic acid

Naturally occurring in the skin
In whole-grain cereals and animal products
Antibacterial properties
20% cream seems to be as effective as many other conventional acne treatments

K. salicylová

Síra - sulfur

Rezorcinol

Antiflogistika

K. azelainová

Zinek

Rezorcinol

Hibiscus sabdariffa L.(Roselle)

Used as food, drink and topical formulation for skin infection in Thai traditional medicine
Extract from calyces contained polyphenolic compounds and anthocyanins
Antioxidant and keratolytic activities
Might be benefit to acne by loosen comedone

Reduce Propionibacterium acne
Prevent keratinocyte injury

Antibiotika

Doxycyklin

Minocyklin

Klindamycin

A semi-synthetic antibiotic
Reducing P. acnes
Decreasing inflammation
Skin dryness and irritation

Erytromycin

Skin dryness and possible irritation
Bacterial resistance can occur

Benzoylperoxid

Killing P. acnes
No anti-inflammatory abilities
Gel, lotion, cleanser, cream and wash
Increases the effectiveness of erythromycin and clindamycin
Snižuje riziko resistance to the antibiotic
NÚ:

Irritation
Allergic reaction

Sodium sulfacetamide

Topical antibiotic
Inhibits P. acnes
Opens clogged pores
Effective in treating inflammatory acne
Newer products that contain sulfur and smell well

Možné nežádoucí účinky lokální terapie

Irritant reaction
Zvýšení hyperkaratozy a zhoršení akne

často jen zpočátku

Chirurgické a fyzikální zásahy

Punkce cyst
Intralesional glucocorticoids
Kryoterapie
Incise a kontraincise infiltrátů
Chirurgické odstranění ateromů
Dermabraze frézou
úprava zjizvené pokožky

Intralezionální aplikace kolagenu
Suspenze vlastních adipocytů aj.
Laser a dermabraze

Fototerapie
Klimatická či přímořská terapie
UV záření- slunění- olupování kůže

U někt. lidí zhoršení

Magistraliter

Rp:

Chloramphenicoli 2,0
Vaselini flavi ad 100,0
M.D.S. Mast

Rp:

Chloramphenicoli 0,2
Cremoris aquasorb P.P. ad 20,0
M.f. cremor
D.s. 3xdenně aplikovat na choré místo

Rp:

Neomycini 1,0
(Dexamethazoni acetici 0,01)
Ambidermani (Cremoris aquas.) ad 100,0
M.f. ung
D.s. k potírání

Rp:

Hydrargyri sulfur. rubri 0,6
Sulfur praec. 3,5
Tetracyklini pulv. 1,5
Ichtamoli 5,0
Syndermani 5,0
Ol. olivae 20,0
Zinci oxydati
Talci aa 17,0
M.f. pasta
D.s. Tetracyklínová pasta.

Rp:

Tetracyklini 1,0 (nebo Chloramphenikoli 0,5-1,0)
(Dexamethazoni 0,01
Hydrofilní podklad ad 50,0
M.f. ung.
D.s.

Mikrobiální ekzém aj. citlivé na ATB

Rp:

Sulphuris praecip. 5,0
Zinci oxydati
Talci
Glycerini aa 20,0
Magmatis bentoniti 40,0
M.f. susp.
D.s. na akné [1]

Rp:

Dichlorochinolinoli 0,6
Ung. simplicis (seu lanalcoli) ad 30,0
M.f. ung.
D.s. mast [1]

Rp:

Resorcini
Sulphuris preac. aa 1,0
Zinci oxydati
Talci aa 7,0
Ung. simplicis 30,0
M.f. pasta
D.S. na vřídky při akné [1]

Rp:

Spir. dil.
Spir. menthae pip.
Aetheris sulfur. aa 5,0-10,0 (nebo Sulfuris praacip.)
D.s. na akne [1]

Rp:

Acidi salicylici 1,0-3,0
Spir, conc. ad 100,0
(Resorcin 1,0-2,0)
D.s. při akne [1]

Rp:

Sulfuris praec. 2,0-5,0
Acidi salicylici 1,0-2,0
Pasta zinci mollis ad 50,0
(možno přidat Resorcin 0,5-1,0)
D.s. pasta na akne [1]

Rp:

Sulfuris praec. 2,5-7,5
Acidi salicylici 2,5-5,0
Vaselini ad 50,0
D.s. na hlubokou formu akne, na noc [1]

Pudry na akne

Pityol
Sulfathion [1]

Rp:

Sulfuris praec. 5,0-10,0
Zinci oxydati
Talci aa 20,0
Spir. conc. 10,0
Glycerini
Aq. destillatae aa ad 100,0
D.s. Tekutý pudr při akné [1]

Rp:

Dexamethazoni ac 0,01-0,02
Ac. salicylici
Sulphur. praec. aa 1,0
Talci
Zinci oxydati aa 7,0
Ambidermani 30,0
M.f. pasta
D.s. na vřídky (acne vulgaris)

HVLP

Přípravky obsahující síru

Aknepur plv. adsp.

Retinoidy k zevnímu použití

Infadolan ung
Tretinoin

Airol crm, lot
Derugin gel
Locacid crm, lig
Retin A crm, sol

Peroxidy

Benzoyl peroxid

Akneroxid 5 gel, 10 gel
Antopar gel
Antopar U susp
Eclaran 5, 10 gel
Inoxitan lotio

Antibiotika a chemoterapeutike pro léčbu akne

Clindamycin

Dalacin T liq
Dalacin T topical lotion 1% lot

Erythromycin

Aknefug-El liq.
Aknefug-oxid 10% gel
Aknefug-oxid mild 3, 5, 10% gel
Aknemycin liq, 2 000 ung
Clinofug Gel 2, 4% gel
Eryfluid sol
Zineryt lot

Jiné přípravky proti akne

Kyselina azelaová

Skinoren crm

Alternativní lokální terapie

Tea tree oil

Gely s 5 % tea tree oilem
Rizika

Kontkatní dermatitida
Breast development in young boys
Zhoršení acne rosacea

Alpha hydroxy acids - Glycolic acid and lactic acid

V citrusech a grepech
sugar cane
Apples
Peeling ev. mírně zlepšení jizev po akne
Rizika

Redness
Mild stinging
Skin irritation

Brewer's yeast CBS 5926

Help decrease acne
Rizika

Migraines in susceptible people
Intestinal upset

Topical bacteriotherapy

Lactobacillus bulgaricus

Local application
Helpful in acne and seborrhea (1912)
Skin-specific benefits of lactic acid

Streptococcus thermophilus

In most yogurts
Skin-specific benefits of lactic acid
Can increase ceramide production when applied to the skin for 7 days as a cream
Some of the ceramide sphingolipids, most notably phytosphingosine (PS)

Antimicrobial activity against Propionibacterium acnes
Direct anti-inflammatory activity

Topically applied probiotics

Enterococcus faecalis probiotic lotion

Topical application
8 weeks
Reduced inflammatory lesions by over 50% vs. placebo

Streptococcus salivarius

Prominent member of the oral microbiota of healthy humans
Secrete a bacteriocin-like inhibitory substance (BLIS-like substance)

Capable of inhibiting P. acnes

S. salivarius bacterial cells themselves

Inhibit a number of inflammatory pathways

Acting as immune modulators

Sfingolipidy

Low in acne
Seasonal loss of ceramides

Acne during winter months

Topical application of 0.2% phytosphingosine - (PS) reduced papules and pustules by 89% in a recent 2-month pilot study

Literatura:

[1] MUDR. BĚRSKÝ, Kamil. MUDr. Kamil Běrský : Kůže [online]. Listopad 2008 [cit. 2011-03-20]. Kůže. Dostupné z WWW: < www.bersky.cz/index.php?option=com_content&view=article&id=144:kuze&catid=45:farmacie&Itemid=65 >. [webová stránka]

Systémová terapie

Antibiotika

Riziko vzniku resistence Propionibacterium acnes
Kombinace a střídání terapie

Erythromycin

Resistance of P. acnes to erythromycin approaches 50%

Tetracyklinové deriváty

Několik měsíců

Těžších a těžkých zánětlivých projevů
V sestupných dávkách
Tetracycline inhibition by food is 46 %
With dairy intake inhibition increases to 65%
Doxycycline
May cause gastrointestinal disturbance
Minocycline
Not approved for aviation usage secondary to an elevated incidence of vertigo and a myriad of central nervous system anomalies

Klindamycin

Retinoidy

Isotretinoin - l3 cis retinová kyselina (Roaccutane cps., Accutane®)

Vynikající výsledky v léčbě i nejtěžších forem akné
Vesměs trvalé výsledky
Dávkování dle závažnosti akne
Délka léčby min. 3 měsíce
Laboratorní kontrola před zahájením léčby a pak 1x měsíčně

Jaterních testů
Transaminas
Triglyceridů
cholesterolu HDL, LDL cholesterolu
KO
HCG u žen 14 dnů před terapií, pak 1 x měsíčně

Nežádoucí účinky a rizika

Can cause a sudden onset of decreased night vision
Corneal opacities
Inflammatory bowel disease
Elevated lipids
Hepatotoxicity
Musculoskeletal symptoms
Pruritus
Epistaxis
Dryness of skin, nose, and mouth
Highly teratogenic

Zahájení léčby měsíc po nasazení HAK

Suchost rtů, sliznic, pálení očí
Bolesti hlavy, svalů a kloubů
Fragile (easily injured) skin, itching or rash
Increased sensitivity to the sun (easily sunburned)
Peeling skin on your palms and soles
Thinning hair
Dry, red eyes
Nosebleeds
Bleeding gums

Hormonal therapy - antiandrogeny

Cyproteronacetát

Kontraceptiva pro ženy

Diane 35
Cilest

Stupně terapie

Noninflammatory lesions

Extraction or gentle expression
Topical therapies

Topical retinoid
Benzoyl peroxide
Salicylic acid

Mild inflammatory

Gradation of topical retinoid
Benzoyl peroxide
Azelaic acid
Salicylic acid

Moderate inflammatory

Gradation of topical retinoid
Benzoyl peroxide
Topical antibiotic or combination.

Moderately severe

Previous regime + oral antibiotics

Severe/nodulocystic

Aggressive treatment by a dermatologist
Isotretinonin (Accutane®)
Oral corticosteroids
Intralesional steroid injection
Oral antibiotics
Hormonal therapies are used in women only

Estrogen-containing oral contraceptives

Low in androgenic progestin (e.g. Ortho tri-cyclen®, Yasmin®)

Spironolactone

Is not an approved medication

Terapie za hospitalizace

UVA
Isotretinoin
Prednison
Laser
Bioptron lampa
Operační sálek
Návaznost na laboratoře

Acne fulminas

Kombinovaná celková terapie

Steroidny + isotretinoin
častější laboratorní kontroly

Alternativní systémová - pomocná terapie akné

Selen

selenium

Vitamín E

vitamin E

Zinek

B1

B2

Pyridoxine - B6 vitamín

eliminating or reducing acne, especially during premenstrual flare ups

K. listová

Folic acid

Vitamin A

Daily doses of 100,000 IU or more beneficial in acne in well controlled studies

Do not use - potential toxicity !!!

A low fat diet

Corn oil (omega-6 fatty acid) supplementation was also shown to improve patients

Hydrochloric acid

Low stomach acid can exacerbate acne
Hydrochloric acid + vitamin B complex, can improve rosacea
40% of those with acne have hypochlorhydria

Pancreatic digestive enzymes

Especially fat-digesting lipases

Acne sufferers may be lacking (Dermatologica, 1982; 165: 601-6)

Akupunktura

8 - 15 treatments can improve acne in up to 80 % (J Tradit Chin Med, 1993; 13: 187-8).

Ayurvedic herb guggul (Commiphora mukul)

500 mg twice a day
May be as effective as tetracycline in some people (J Dermatol, 1994; 21: 729-31)

Burdock

2-4 mL of the tincture
3-6 g/day of the dried herb
Alone or in combination with yellow dock, red clover or cleavers, and Vitex agnus castus

40 drops/day of tincture made from the berries

Clear premenstrual acne

Pantothenic acid (vitamin B5)

Vital for both fatty-acid metabolism
Formation of sex hormones
Deficiency may be a cause of acne
Dosages (2000-10,000 mg daily)
Topical cream can clear up acne (Med Hypoth, 1995; 44: 490-2)

Zabránit přerůstání bakteriální flóry v tenkém střevě

Probiotika a prebiotika
Dostatek draslíku
Chůze
Prokinetika
vláknina ve stravě
dostatek tekutin (prevence obstipace)
Lecithiny

Saccharomyces cerevisiae

Kvasinka
Could improve both acne vulgaris and constipation when orally consumed

Laktobacillus bifidus

Aeromedical Concerns - Akne a pilotování letadla

Wear of protective aviation equipment
Exacerbation of acne due to rubbing, pressure, exposure to hot and humid environments;
Psychological factors
Acne medications that are incompatible with flying duties
Extended grounding due to a difficult or prolonged treatment course
Lesions on the face may interfere with mask or respirator seal and helmet wear (chin straps).
Lesions on the shoulder, chest, and back may cause discomfort and distraction when wearing restraint or parachute harnesses or with prolonged sitting.
Prolonged rubbing or pressure against the skin can produce or exacerbate an eruption (mechanical acne) with striking inflammation
Tropical acne may occur, typically after several months’ exposure to a hot, humid environment, can be a major cause of disability. Patients often feel quite ill with tropical acne, antibiotic therapy is not effective, and removal from the environment is often necessary as the only effective treatment.

The aeromedical summary:

Extent of lesions, locations, and a description of current therapy - all medications including dosage, and frequency, and side effects.
Comments addressing interference with use of aviation equipment.
Dermatology consult if individual has recalcitrant moderate to severe inflammatory or severe/nodulocystic acne.

Není možné létat když:

Acne is controlled on oral antibiotics
Controlled by oral contraceptives
Interferes with the wearing of flying equipment
Waiver will not be granted if acne is controlled on isotretinonin (Accutane®) or minocycline.

Waiver Considerations.

FLYING CLASS TREATMENT OF ACNE POTENTIAL WAIVER

WAIVER AUTHORITY TREATMENT WAITING PERIOD AND SPECIAL REGULATIONS

FC I, IA

Topical treatment

Topical retinoids

Tretinoin
Adapalene
Tazarotene

Benzoyl peroxide
Salicylic acid
Azelaic acid
Topical antibiotics

Clindamycin
Erythromycin
Sulfacetamide-sulfur

Oral contraceptive (female only)
Oral antibiotics

Tetracycline
Erythromycin
Doxycycline
Trimethoprim-sulfamethoxazole

No documented adverse effects from medication
No difficulty with wearing of aviation equipment
7-day ground trial

FC IIC

Aviator does not have to wear helmet/mask on routine basis
Minocycline is not approved for flying duties.
Treatment with approved topical agents does not require a waiver.
The local flight surgeon must confirm, however, there are no adverse effects and the disease itself does not interfere with use of aviation equipment or safe mission completion.
Systemic maintenance agents such as

Oral erythromycin
Tetracycline
Doxycycline
Trimethoprim-sulfamethoxazole

Require a waiver

They are compatible with flying once it is confirmed that side effects are absent or acceptable in severity.
Isotretinoin therapy

Is not compatible with flying duties
Would require prolonged grounding (usually 20 weeks) if used when clinically indicated.

Oral contraceptives may be considered for women.
In rare cases severe nodulocystic acne or scarring may require a categorical waiver to avoid routine use of a helmet or mask.

Literatura:

[1] WAIVER GUIDE, Last Update:11 Apr 2008, By: Dr Karen Fox “This document primarily provides guidance for waivers on trained flying class II and III personnel, and where specifically stated applies to flying class I/IA applicants and other special duty personnel. This waiver guide does not cover general military entrance, commissioning, or enlistment.” Reviewed by Maj Sylvia Parra, Dermatologist at Wilford Hall Medical Center. Air Force Waiver Guide[2] Akne vulgaris; Autor standardu : MUDr. Jarmila Rulcová CSc, Garant standardu : Česká dermatovenerologická společnost

Kontakty

Specializované dermatologické poradny

FN Motol, Praha 5

Akné poradna==

Klinické studie - terapie

Akcen vulgaris

MUDr. Dana Maňasková

Akné

Definice

Dg. kriteria

Epidemiologie

Etiopatogeneze

Abnormální rohovatění - retenční hyperkeratoza

Hromadění mazu v chlupových foliklech

Zánětlivé změny

Anerobní bakterie - Propionibacterium acnes

Prasknutí stěny folikulu

Imunologická pohotovost

Akne jako důsledek infekce parazitem Demodex

Klinický obraz

Klasifikace lézí - polymorfní projevy akné

Lokace:

Další nálezy

Klinické klasifikace anglická literatura:

Mild

Moderate

Moderately Severe

Severe - Acne Vulgaris

Typy akné dle českých standardů:

Diferenciální diagnostika akneiformních projevů

Vyšetření

Rizikové / zhoršující faktory akne

Stress

Diet - controversial

Hyperkeratóza

Seborea – zvýšenou činností mazových žláz

androgeny

Vyšší androgenní citlivost mazových žláz

Hormony hypofýzy

Hormony štítné žlázy

Glukokortikoidy a gestageny

Bakteriální flóra folikulů

Imunologická odezva

Genetická dispozice

Změna složení mazu

Rupture of the follicle

Contact with certain chemicals

Bifidobacterium longum and Lactobacillus paracasei

Substance P - SP

Substance P release

Substance P inhibition of release

Substance P proteolyse

Osobní názory a postřehy:

Zhoršení akné s komedony jako projev aktivace mazových žláz a snaha organismu vyloučit touto cestou cizorodé látky rozpustné v tucích (???))

Standard lékařské péče

Topická terapie

Cleansing

Keratolytika

K. retinová (tretinoin) - topical retinoid

K. azelainová - Azelaic acid

K. salicylová

Síra - sulfur

Rezorcinol

Antiflogistika

K. azelainová

Zinek

Rezorcinol

Hibiscus sabdariffa L.(Roselle)

Antibiotika

Doxycyklin

Minocyklin

Klindamycin

Erytromycin

Benzoylperoxid

Sodium sulfacetamide

Možné nežádoucí účinky lokální terapie

Chirurgické a fyzikální zásahy

Magistraliter

Rp:

Rp:

Rp:

Rp:

Rp:

Rp:

Rp:

Rp: