The Study of Acne Conglobata

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The issue

Acne Conglobata is a rare and highly inflammatory disease, also negatively impacted in a way that it has burrowing and interconnecting abscesses and also uneven scars (both keloidal and atrophic), often creating disfigurement (3a). Of all acne types, it is the most severe. Patients will be impaired with pimples appearing at almost all the parts of body such as face, neck, chest and more. They are large and engorged with fluid, and may be sensitive to touch. There will be a slow increment in size and then they burst letting out a repulsive smell. The irregular and deep scars are formed from abscesses (1b). The cause of this disease remains unknown but some think that high level of testosterone and androgen, genes and uncured case of less-severe acne seem to be connected with acne conglobata. This disease can be treated but how do we amend it?

Example of a person suffering Fig. 1 (Transition of normal follicle to

from acne conglobata formation of pustule)

Figure 1 shows how normal follicle, A changes to pustule, E. Pustule cause severe damage to the skin (3l).

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A Possible Solution

The most recommended treatment for acne conglobata is the acne medication isotretinoin. Isotretinoin is a retinoid and is derived from Vitamin A (3e) (3c). It suppresses sebaceous glands from bringing out excess oil to prevent the formation of new blemishes (1c). Isotretinoin also defends against the occurrence of unusual hardening of skin. There are several types of isotretinoin like Accutane, Amnesteem, Claravis and Sotret. Therefore, the manufacturing of Accutane has been discontinued and is replaced by cheaper generic versions (3d).

A sheet called medication Guide always comes with the isotretinoin. It must be read every time isotretinoin is filled. A consent form must be signed signifying that the doctor's instructions must be followed before start using isotretinoin. This procedure is required every time the prescription is stocked. Usually, patients will only get a 30-day supply of the capsules. Whenever dose is missed, patients must go back to constant dosing schedule. 2 doses at a shot are not allowed. Isotretinoin must be taken after meal. There must not be any damage done to the capsule before it is swallowed such as crushing or breaking it because the filling inside the capsule might cause irritation to the throat. Other than that, Isotretinoin should be taken regularly at possibly the same time each day.

Therefore, some medicines like tetracyclines, St. John's wort, Vitamin-A type medicines, corticosteroids and progestin-only birth control cannot be used with isotretinoin seeing that they may affect isotretinoin. Not only those, certain medical conditions such as pregnancy, allergies, diabetics, a family history of diabetes and others will also interact with isotretinoin (3f).

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Women who take isotretinoin must sign up for the iPledge program because isotretinoin causes miscarriage and birth defects (2a). It is a compulsory program in the United States to ensure that no women get pregnant using isotretinoin.

The effectiveness of isotretinoin is wholly confirmed through the diagram below.

Fig. 2 (http://www.cosmeticskin.com/skin-acne4.shtml)

Fig. 2 shows that the percentage of absolute satisfactory using isotretinoin for treatment of acne scars is the highest which is more than 70%. This shows that isotretinoin works in curing scars and most importantly, acne conglobata. The main aim of treating acne conglobata is prevention of scarring (1a).

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Furthermore, there was a study done in Turkey to prove how effective isotretinoin was towards the treatment of mild or moderate acne. The result clearly showed an improvement.

RESULTS: 41 out of the 60 patients completed the 6-month therapy which isotretinoin, 0.5-0.75 mg/kg per day, is applied according to the degree of acne and number of inflammatory lesions. At the end of the treatment complete improvement was observed in 34 patients out of 41. All negative effects were mild.

CONCLUSION: Isotretinoin can be used for patients with mild or moderate acne (2b).

There is also an article proving that acne conglobata can be cured with isotretinoin. 198 acne conglobata patients in 19 departments were tested with isotretinoin and 75 percent improvement was seen at the end result (2c).

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Social and Economic Implications

People suffering from acne conglobata have been coping through embarrassment, less confidence in communication and financial problems. Embarrassment is due to the condition of one's face and body because acne conglobata isn't just another normal acne problem. People who live with the sufferers of acne conglobata will have to endure the revolting smell and unpleasant sight of the skin. Of course, the victims will have fewer friends because people will think that they care less about their skin condition. Less confidence can be seen when the sufferers have problem juggling between communicating and thinking of the perception of people towards them. Lastly, financial problems happen when the sufferers spend a lot of cash on expensive skin treatments, facial and body cleansers, and acne gels.

Isotretinoin can reduce the deep scars and acne on their skins. An obvious improvement can be seen after a few months of isotretinoin usage. The patients will gain their confidence back. Even though there are generic versions of Accutane, they are still expensive if one has to pay without insurance. Usually, it will cost around $500 to $600 monthly, depending on the strength of the pills. So, I suggest anyone intending to buy these pills to sign up for medical insurance as some of the medical insurances will cover the majority of the price. This is really convenient because one will not have to put too much money on the medicine. The sufferers do not have to waste money on skin treatments or expensive shower foams that do not guarantee improvement of the skin condition.

I have included two tables regarding the price of the generic Accutane in the USA and in the UK.

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Fig. 3 (Price of Generic Accutane in UK) (3m)

Fig. 4 (Price of generic Accutane in USA) (3n)

Both figures show a huge difference of the price of these generic Accutane in the USA and the UK. From both tables, it can be seen from the price of 10mg of 30 pills, the price in UK is much expensive which is £57.60 while the price of 10mg of 30 pills in USA is $40.00. If both prices were to be converted to Malaysian ringgit, they would be RM 277.14 and RM 124.70 respectively. The difference of the price is about 45%. With medical insurance, one will only have to pay about 5% of the price (3k).

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Benefits and risks

Isotretinoin is beneficial and it is totally confirmed to cure acne conglobata, severe acne. Scars will be reduced and there will be positive progress of the skin's state in a matter of months. Patients will not have to worry if it really works or not, it will. Additionally, the price of Accutane isn't as expensive as before because the marketing of the exclusive Accutane has been stopped since there are now affordable generic versions and most medical insurances can cover a greater part of the price. Sufferers of Acne Conglobata need not have to use a lot of money to buy them compared to before which the money was spent on unnecessary costly skin treatments, gels and shower foams.

Despite that, isotretinoin also has adverse outcomes.

"But as powerful as Accutane (isotretinoin) can be in improving patients' lives, the adverse effects can be just as powerful," states FDA Consumer Magazine http://isotretinoinsideeffects.com/

Isotretinoin has caused miscarriage, birth defects and hair-loss. Some users have also suffered from crucial problems regarding organs and serious psychiatric problems. This is because the drugs restrict body-cell growth and reproduction. They also decrease the water-holding molecules of the body (1c).

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Fig. 5 http://isotretinoinsideeffects.com/

Figure 5 shows that parabens are chemical preservatives and will interfere with the body's endocrine system. So that explains the other possible side effects of isotretinoin that are connected with the adrenal glands, the hypothalamus, the ovaries and testes, the pancreas, the stomach, the kidneys and virtually every body system.

There are also drugs forbidden to be taken with isotretinoin like tetracycline-type antibiotics, Vitamin A and exfoliants because they will give negative repercussions. If used with tetracycline-type antibiotics, the pressure within the skull will increase. Next, isotretinoin is derived from vitamin A so if combined with vitamin A will lead to vitamin A overdose and this change the bone structure (3e).

Finally, isotretinoin overdose will drive to vomiting, flushing, serious chapped lips, stomach pain, headache, dizziness and loss of coordination. Users must consult doctors or call healthcare hotlines if overdoses happen (3f).

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Alternative Solutions

Carbon Dioxide Laser

An alternative solution to treat this disease is by carbon dioxide laser and topical tretinoin therapy consequently. The CO2 laser produces a beam of infrared light with the principal wavelength bands centering around 9.4 and 10.6 micrometers. The high power levels available combined with the reasonable cost for the laser makes it frequently used (3h). Tretinoin is effective in getting rid of lesions. It is also easier to remove the keratinocytes on the skin (3g).

A study of treating Acne Conglobata by Carbon dioxide laser followed by topical tretinoin therapy was done in Japan. CO2 laser is used to open the cysts while topical tretinoin therapy is for preventing the appearance of new lesions. The case was successfully treated with CO2 by removing the top of the sinuses and their tracts (2d).

Carbon dioxide laser is a powerful treatment option for acne conglobata.

(http://onlinelibrary.wiley.com/doi/10.1111/j.1346-8138.2007.00337.x/abstract)

Cryotherapy or Intralesional Triamcinolone

Cryotheraphy is a form of surgery and the last option in treating Acne Conglobata. Only the affected areas are treated with liquid nitrogen. It is applied with a cryoprobe or cotton-tipped applicator and this freezes the pimples and makes them fall off like dead skin. Cryotheraphy effectively seals off the skin and is useful for reducing acne in the future as it removes the surface lesions (3i). Moreover, this surgery is affordable and highly effective.

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A test of cryotheraphy was conducted and the positive result supported cryotherapy's effectiveness in curing acne conglobata.

Twenty-five patients with acne conglobata were treated with cryotherapy delivered via probes. The probe was applied to nodular lesions for 20-25s without pressure. Freon, carbon dioxide and nitrous oxide were found to be therapeutically equivalent. Nodulo-cystic lesions resolved within 7-10 days leaving a thin atrophic scar on the back and no scar on the face. The treatment was almost painless; no recurrence has appeared in the treated areas (2e).

Skin Care

Hygiene must be properly taken care of to fight acne conglobata. Use facial washes that contain benzoyl peroxide or alpha hydroxyl. They unblock pores and also kill germs that cause the acne formation. Our faces must be washed only twice a day. Excessive washing can cause the skin to be dry. There are reports indicating that placing a clean towel over one's pillow every night can help prevent from contamination due to bacteria. Furthermore, to prevent transmission of the bacteria, one must always wash hands before touching the skin (3j). Besides that, frequent skin contact like rubbing and touching skin lesions must be avoid. Squeezing blemishes can worsen the acne site and leave scars. Facial scrubs can be used but only once a week as they tend to irritate skin which aggravates acne. Prevent using irritants and avoid using oily or greasy cosmetics, sunscreens, hair-styling products or acne concealers. Use products labelled "water-based" or "noncomedogenic."

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Evaluation

From the book 'Retinoids in Clinical Practice (Methods in Life Sciences - Toxicology Section)' reference to 1c, there was a point stating that isotretinoin which is a retinoid can inhibit sebum production. The book consists of the background of retinoids, the drawbacks and benefits. The earlier statement saying that isotretinoin lessens the production of excess oil from sebaceous glands can be supported. This source is very liable because it is a book and has been published. Therefore, the publication date of the book was in 1993.

In addition, the site http://www.drugs.com/cdi/isotretinoin.html also proves that the book was right about the function of retinoid which is to change the characteristics of the skin oil by holding back skin oil production. This site provides information on almost all sorts of drugs and is proven to be a trusted resource as the information available in the site is under licensing agreements with various publishers.

Other than that, http://www.nlm.nih.gov/medlineplus/druginfo/meds/a681043.html is specifically about isotretinoin. It is very clear that there are adverse outcomes such as pain and swelling of the red, cracked and sore lips, vision problems, alopecia (hair-thinning/ hair-loss/ baldness) and a lot more. Any information in this site is from the National Library of Medicine so they should be factual. To be more certain, the site http://isotretinoinsideeffects.com/ which is from a lot of solid sources including researches and magazines shows that some of the side effects of isotretinoin are swelling of lips, back pain and hair loss. Besides, the last update of the site was done in May 2010.

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