Treatment of acne with isotretinoin. Treatment of severe acne Low-dose regimens with Roaccutane

Acne is a multifactorial disease, the main development factors of which are:

• advanced education,
• violation of the hair follicles,
• with the development of inflammation.

Among the drugs used, only act on ALL factors in the development of acne. The rest of the drugs for the treatment of acne have one-way activity, so these drugs have to be combined.

Treatment of mild to moderate acne

For effective acne treatment light degree enough 1 drug. For acne middle severity, it is necessary to combine drugs to influence all factors of pathogenesis. The most successful combination is with:

• retinoids slow down the formation of comedones, reduce the formation of sebum and improve the exfoliation of the epithelium.
• antibiotics and antimicrobials number of bacteria on the skin and have an anti-inflammatory effect.

Solutions are usually given in the morning and creams or gels overnight:

• Zinerit solution + Retinoic ointment,
• Zenerite + adapalene (Differin gel / cream or Klenzit gel),
• (gel Baziron AS) + Retinoic ointment,
• gel Baziron AC + adapalene,
• Retasol solution + gel / cream with clindamycin (Dalacin, Klindavit).

Retinoids(and to a lesser extent salicylic acid) reduce the formation of comedones, so they are very important for the long-term treatment of acne. Retinoids also thin the superficial (horny) layer of the epidermis, which facilitates the penetration of other drugs and enhances the overall effect of the treatment.

With a more severe course of acne, they are prescribed, and locally - external retinoids 2 times a day.

Treatment of severe acne

• benzoyl peroxide + external antibiotics (erythromycin or clindamycin),
• or topical retinoids + topical antibiotics.

As supportive treatment after the end of systemic therapy is used:

• in the morning - an external antibiotic or benzoyl peroxide,
• at night - an external retinoid.

Selection bases of preparations (solutions, gels, creams, ointments) should provide the best tolerance for acne treatment. With seborrhea ( increased function of the sebaceous glands) in the morning, solutions are prescribed for a neat and dry appearance of the skin, and gels or creams are recommended in the evening to prevent peeling and excessive dryness. A combination of 2 forms with isotretinoin is considered successful: Retasol solution + Retinoic ointment.

It turned out to be effective external treatment with a combination of:

• clindamycin phosphate
• + benzoyl peroxide
• + salicylic acid.

Are used finished combination preparations:

• gel Klenzit S (adapalene + clindamycin),
• gel Isotrexin (isotretinoin + erythromycin),
• solution Zenerite (zinc acetate + erythromycin),
• new gel Effezel (0.1% adapalene + 2.5% benzoyl peroxide).

Retinoids are widely used in traditional medicine in the treatment of acne. But the greatest therapeutic effect is achieved in combination with other drugs. Retinoids from the word "retinol", which means vitamin A. They always include this vitamin, its synthetic analogues or biological forms. By its action, vitamin A gives the skin a healthy look, but it is not recommended to use it in its pure form, as this can provoke side effects.

Description and properties

Retinoids were discovered in 1909. Scientists have identified the properties of vitamin A for the skin. Its insufficient amount provokes follicular hyperkeratosis. It is considered one of the main causes of acne and acne. In the lumen of the hair follicles, an excessive amount of desquamated epithelial cells accumulates. They clog pores and predispose to acne.

But dermatologists, in addition to the therapeutic effect, have discovered other cosmetic properties - the skin becomes elastic and smooth, acquires radiance. Wrinkles are less pronounced, age spots lighten, and signs of skin aging are reduced. Retinoids in cosmetology are used to combat age-related changes in the skin.

Therapeutic use:

1. For acne therapy, retinoids in this case reduce the production of sebaceous glands, normalize the process of keratinization of the skin of the hair follicles, exfoliate dead skin cells.
2. For rejuvenation - reactions provoked by retinoids increase the elasticity of the skin, make wrinkles less noticeable. Accelerate the production of collagen, acid hyaluronate and elastin. The tone of the skin is evened out, keratinized particles are removed, regenerative processes in the skin are accelerated, and the negative effect of ultraviolet radiation on the epidermis is reduced.

Retinoids at any age can be used throughout life.

Classification

For external use for acne, 2 groups of drugs are used:

1. Natural. These include two isomers of retinoic acid - isotretinoin ("Isotrexin", "Retinoic ointment") and tretinoin ("Airol", "Retin-A").
2. Synthetic. These include Adapalen (Klenzit C, Differin) and Tazaroten (not imported into the Russian Federation).

"Retasol" and "Retinoic ointment" can be used in the treatment of children. "Klenzit" is appointed only from the age of seven. With oily skin type, the presence of abscesses and comedones, Retasol is more effective. For moderate skin types and with an excessive number of nodules, it is better to treat with Retinoic Ointment. Mild acne is treated with topical retinoids. And for an average degree of acne damage, treatment can be supplemented with drugs such as Zinerit, Isotrexin gel, Dalacin.

Operating principle

Retinoids for acne treatment work on the skin in several stages:

1. For the first few days of using the remedy, symptoms such as skin peeling, redness or signs of irritation may cause concern. These symptoms are accompanied by an acceleration of the process of death of keratinized cells. As a result, the skin looks healthier and younger. The pores are cleansed due to the splitting of fatty plugs and the elimination of impurities. After a month, acne treatment will give the first visible results. A pronounced effect will be noticeable after 8-10 weeks.
2. Stimulates the production of collagen. Retinoids penetrate deep into the dermis, stimulating collagen production. The skin becomes elastic, the severity of wrinkles decreases. Closer to 40 years, the content of collagen decreases by half. This is clearly visible in the condition of the skin. It becomes less elastic and thickens. The first results after the procedure will be noticeable after 2-3 months, and pronounced results after 9 months.
3. The skin is moisturized. The hydration process occurs for two reasons. The first is to stimulate the secretion of nonsulfonated glycosaminoglycan. It is she who moisturizes the dermis and maintains the necessary level of hydration of collagen fibers with water. This is especially important for the elasticity of the epidermis. The second reason is the ability of most retinoids to speed up the process of stem cell division. The deep layers of the epidermis thicken. Moisture evaporates less from the surface of the skin. A thoroughly moisturized dermis looks young.

For acne, different preparations based on Vitamin A are used.

Application features

Preparations should be used in compliance with some recommendations:

1. Apply the product to clean skin 1 to 2 times a day. The course of therapy varies from 12 to 16 weeks.
2. There may be adverse reactions on the skin, but there are no general negative effects.
3. To cleanse the skin, it is better to use gels or foam for washing, an alcohol-free tonic.
4. Since there is a high probability of overdrying of the skin, the use of alcohol solutions and soap in solid form is not recommended.
5. Make sure that the product does not get on the mucous membranes.
6. In the first two weeks of therapy, an exacerbation reaction may occur. It is manifested by peeling, itching and redness. It resolves on its own within seven days. Therefore, there is no need to refuse the drug.
7. When the desired effect is achieved, the use of the drug can be reduced or its concentration reduced.
8. Systemic retinoids are used as prescribed by a doctor.

Following these tips will help cure acne faster.

Effective drugs

Retinoids for signs of skin aging and acne:

All drugs have a later therapeutic effect. Before use, it is better to consult a doctor.

Systemic retinoids are used for whole body therapy. These include "Isotretinoin", which has several names - "Acnecutane" or "Roaccutane". Due to serious negative consequences, self-medication is not recommended. "Roaccutane" is available in capsules. It suppresses the production of sebum, reduces the number of comedones, stops inflammation. The course of therapy is from 16 weeks twice a day in equal parts after meals. "Acnecutane" is similar to "Roaccutane". The drug is better absorbed, less dependent on food intake. Take the entire daily dose at one time during a meal. If desired, the dose can be divided into two equal parts.

Isotretinoin enters the market under the name Roaccutane. The drug belongs to the group of synthetic retinoids.

Mechanism of action of isotretinoin

The main mechanism of action of isotretinoin is the suppression of sebum production. The degree of suppression of sebum formation depends on the dose of the drug and is most pronounced 2 weeks after the start of therapy (decrease in sebum production by 90%). Sebum suppression is observed for several months after isotretinoin withdrawal, but over time, sebum production returns to normal or close to normal.

1. Against the background of taking isotretinoin, the number of P. acnes decreases, which is directly related, apparently, to a decrease in sebum secretion, since this microorganism uses sebum as a source of nutrition. A decrease in the number of P.acnes also exists for a long time after the therapy is discontinued.
2. Isotretinoin reduces the formation of comedones as a result of the normalization of the level of differentiation of epithelial cells of the wall and mouth of the hair follicle.
3. Isotretinoin has a general anti-inflammatory effect due to the regulatory effect on the processes of chemotaxis and phagocytosis, which are changed in patients with acne.

Dosage of Isotretinoin

The optimal dose is 1.0 mg / kg body weight per day for young men with rashes on the trunk, 0.5 mg / kg for women and older men, especially if the rash is localized only on the face, for 3-4 weeks. The subsequent dosage depends on the clinical effect and tolerability. In most cases, a course of treatment of at least 4 months is required, in 10% of cases - 6 months and in 3% of cases - more than 10 months. Doses exceeding 1.0 mg / kg per day are undesirable. Residual acne gradually resolved after discontinuation of the drug. Remission in many cases lasts for several years. To reduce the likelihood of relapse, the total dose of the drug should reach at least 120 g / kg. A large total dose is often required to treat severe acne on the skin of the trunk.

Indications for Isotretinoin

1. Severe forms of acne;
2. Moderate forms of acne, if within 18 months there is no effect from conventional therapy;
3. Moderate forms of acne, if after several successful courses of conventional therapy, relapses quickly occurred;
4. Acne in combination with dysmorphophobia;
5. Gram-negative folliculitis resistant to antibiotic therapy;
6. Acne fiilminans and pyoderma faciale - added 1 month after the start of general glucocorticoid therapy (starting at 40 mg / day with a gradual withdrawal of the drug by the end of 6 weeks).

Side effects of isotretinoin

Most often, symptoms similar to those observed in hypervitaminosis A are observed. Such symptoms include dry lips, dry mucous membranes (including the nasal mucosa, leading to nosebleeds). Changes in the eyes are also described: conjunctivitis, photophobia, decreased twilight vision, impaired dark adaptation, cataracts. In addition, anemia and neutropenia, an increase and decrease in the number of platelets, an acceleration of ESR, an increase in the activity of aminotransferases, as well as levels of serum triglycerides and cholesterol, were noted. There were toxicoderma, facial dermatitis, reversible alopecia, acne fulminans, hirsutism, dystrophic changes in the nails, hyperpigmentation (on the face), muscle and joint pain, hyperostosis, hearing loss at certain sound frequencies, local or systemic infections caused by gram-positive microorganisms (Staphylococcus aureus ). There are indications that inflammatory bowel disease, hyperuricemia, benign intracranial hypertension, nausea, and headache occurred while taking isotretinoin. The drug is also highly teratogenic. It causes severe anomalies in the development of the fetus (primarily from the side of the central nervous system, heart, large blood vessels).

Contraindications

Roaccutane is contraindicated in pregnant and lactating mothers. It is also contraindicated in women who may become pregnant during treatment. The drug should not be combined with vitamin A because of the risk of hypervitaminosis A and tetracyclines because of the risk of increased intracranial pressure. Roaccutane is not recommended for patients with hepatic and renal insufficiency, hyperlipidemia and diabetes mellitus. Isotretinoin is also contraindicated in cases of hypervitaminosis A and hypersensitivity to the active substance of the drug.

Patient management

1. Before treatment it is necessary to examine the patient's ALT, ACT, triglycerides, cholesterol, creatinine. In female patients of childbearing potential, Roaccutane should not be administered until each of the following conditions is met:

• The patient suffers from a severe form of acne, resistant to conventional treatments.
• You can rely on the fact that the patient understands and follows the doctor's instructions.
• The patient is able to use contraceptives prescribed without fail.
• The patient was informed by her doctor about the dangers of pregnancy during treatment with Roaccutane and within one month after the end of its use, in addition, she was warned about the possibility of failure of contraceptives.
• The patient confirmed that she understands the essence of precautionary measures.
• A pregnancy test performed within two weeks prior to treatment was negative.
• Within a month before starting treatment with Roaccutane, during treatment and within a month after stopping treatment, she takes effective contraceptive measures without interruption.
• Treatment with the drug begins only on the second or third day of the next normal menstrual cycle.
• In case of recurrence of the disease, the patient uses the same effective contraceptives without interruption for one month before the start of treatment with Roaccutane, during treatment and within a month after stopping treatment.

Compliance with these precautions during treatment should be recommended even to women who usually do not use contraceptives due to infertility (from the manufacturer's recommendations).

I talked about the main causes of acne. Brief summery: the cause of acne is a true or false hormonal imbalance. In the comments there was something like: “well, I don’t know, they found dysbacteriosis in a girlfriend, they treated it, everything returned to normal.”

Here I want a little about the sore: the diagnosis of "dysbacteriosis" or "dysbiosis" is a myth of Russian medicine, more precisely, of its individual representatives. In the international classification of diseases of the tenth revision (ICD-10 ICD-10), there is no such disease. Moreover, it is not in the regulatory document of the Ministry of Health of the Russian Federation "Standards (protocols) for the diagnosis and treatment of diseases of the digestive system." Therefore, it is not necessary to treat it and it cannot affect acne. You can drink kefir for complacency.

And a little from myself: I have never had any stomach problems in my life, not even gastritis. And there were pimples. Se la vie.

Let's return to our acne, that is, sheep. The main areas of systemic therapy are retinoids, antiandrogens and antibiotics. Systemic therapy is an effect on the whole body, in this case it is mostly oral. I will only focus on systemic retinoids in detail. Your gynecologist will tell you about antiandrogens (oral contraceptives) better than me, I will only say that they work, yes (I hope you understand why?). Taking antibiotics orally is pointless. As an external agent as monotherapy - too. This is my personal opinion. I'll explain why in the next post.

However, despite the impressive results of systemic basic therapy, it is impossible to achieve an aesthetic result of treatment without external influence.*

*Protsenko T. V., Kaplan A. V. Innovative approaches to external therapy of acne vulgaris //Ukrainian Journal of Dermatology, Venereology, Cosmetology. - 2007. - no. 2. - S. 12-14.

So, the gold standard for acne treatment is retinoids and benzoyl peroxide.

In this post, I will talk about retinoids.

Retinoids have been very widely used in dermatological practice since 1963, when retinoic acid was proven effective for acne.*

* Protsenko T.V. Local therapy of acne vulgaris using fixed combinations of drugs (literature review) //Ukr. magazine dermatol., venerol., kosmetol. - 2010. - T. 2010. - S. 55t61.

Retinoids are a class of compounds chemically related to retinol, its biological forms, as well as structural synthetic derivatives, which differ significantly from the isoprene structure of natural vitamin A, but act in a similar way: through the activation of nuclear retinoic receptors, they regulate the processes of proliferation, differentiation and intercellular communication.*

*Batkaev E. A., Molodova Yu. S. Aknekutan in acne therapy: a new low-dose regimen //Clin. dermatol. and venerol. - 2014. - T. 2014. - P. 84t89.

Simply put, retinoids are structural analogues of vitamin A.

The term "retinoid" is used as a general term for any substance, both synthetic and natural. The mechanism of action of retinoids is based on the reduction of fat excretion, the normalization of follicular hyperkeratosis and the suppression of bacterial activity. In addition, it has an anti-inflammatory effect*

*Korneva L. V. Treatment of severe forms of acne vulgaris // Almanac of Clinical Medicine. 2007. No. 15. pp.194-198

All retinoids can be divided into 3 (some authors divide into 4) generations:

1) derivatives of retinoic acid - retinol (aka vitamin A), retinal (aka retinaldehyde), tretinoin (aka all-trans retinoic acid, or ATRA), isotretinoin (aka 13-cis-retinoic acid), alitretinoin;

2) etretinate and its metabolite acitretin;

3) adapalene, bexarotene, tazarotene.

Retinoids are also divided into natural, which are synthesized in the human body, and synthetic, which are obtained in the laboratory. Natural retinoids are the first generation, synthetic retinoids are the second and subsequent generations.

Some first-generation retinoids are widely used to treat acne, second-generation retinoids are used as systemic drugs for the treatment of psoriasis and dermatosis, tretinoin, isotretinoin, bexarotene and alitretinoin are also used in oncological practice, and adapalene, although not a retinoid in essence, has proven itself. excellent acne treatment.

Since the topic of our meeting is the treatment of acne, I will dwell in detail on those retinoids that are effective in the treatment of acne.

Retinol is a true vitamin A. Fat-soluble vitamin, antioxidant. In its pure form, it is unstable, found in both plant products and animal sources. Participates in redox processes, regulation of protein synthesis, contributes to normal metabolism, the function of cell and subcellular membranes, plays an important role in the formation of bones and teeth, as well as body fat; necessary for the growth of new cells, slows down the aging process.

Retinaldehyde/retinal is an aldehyde of retinoic acid, which is very actively used in cosmetology. Upon penetration into the dermis, it easily turns into retinoic acid with subsequent beneficial and side effects.

Isotretinoin - 13-cis-retinoic acid. Biologically active, naturally synthesized in small quantities in the human body form of retinoic acid; positively affects the differentiation of keratinocytes and inhibits the production of sebaceous glands. In many cases, it allows you to completely inhibit excessive production of sebum, normalize the regenerative functions of the skin. The form is unstable and, when interacting with the internal microflora of the body, it turns into tretinoin (transretinoic acid), therefore, compared to tretinoin, it is less active.

Tretinoin is trans retinoic acid. The carboxylic acid form of vitamin A is a natural metabolite of retinol. When applied externally, it enhances cell proliferation in the papillary layer of the skin, reduces the adhesion of cells involved in the formation of acne vulgaris. When treating open acne, it helps to smooth the surface of the skin without signs of inflammation. In the treatment of closed blackheads, it promotes their transition to open blackheads or papules, which then heal without scarring after the removal of the keratin plug. Prevents the formation of new acne. Retinoic acid, in addition to its therapeutic effect on acne, has a stimulating effect on fibroblasts that synthesize extracellular matrix, including collagen, hyaluronic acid and elastin.

Adapalene is a derivative of naphthoic acid with retinoid-like action. Adapalene molecules are resistant to sunlight and oxygen, and thanks to their lipophilicity, they quickly penetrate into the upper layers of the skin. It is believed that it does not enter the deep layers of the skin well, which ensures its high concentration in the upper layers, therefore it is more suitable for acne therapy.

Retinoids are topical (for external use) and systemic (for oral administration). When applied externally and systemically, retinoids have anti-comedogenic, sebostatic, anti-inflammatory, kerato- and immunomodulatory effects, activate regeneration processes in the skin, stimulate collagen synthesis, increase the production of mucopolysaccharides and glycosaminoglycans.

To one degree or another, all the drugs in this group have the listed effects, but they are most pronounced in retinoic acid. Retinoic acid exists as two isomers: all-trans retinoic acid (tretinoin) and 13-cis retinoic acid (isotretinoin). Both isomers are used in dermatology for the treatment of acne. 13-cis-retinoic acid has better bioavailability.*

*Albanova V.I., Sazykina L.N. TREATMENT OF ACNE //NEW DOMESTIC DRUG FOR SCABIES. - T. 13.

In topical retinoids, retinol, retinal, tretinoin, isotretinoin, adapalene are used as an active ingredient. Existing in different forms of release (ointments, creams, gels) and under different trademarks. Let's dwell on some of them.

Retinol is widely used in cosmetics. It has a similar effect on the skin as tretinoin, although it is needed in higher concentrations. It has proven effective in thickening the epidermis, improving skin structure and lightening pigmentation. The market is full of funds, there are plenty to choose from. I can't recommend anything as retinol has never been of interest to me.

Adapalene was developed by the French company Galderma Laboratories. Produced in the form of cream and gel in various concentrations, in Russia and some other countries it is registered under the name "Differin". There is a generic from the Israeli company Teva, not available in Russia.

Tretinoin is available in cream, gel, liquid and solid form. The most famous trademarks are: Retin-A (Cilag, Switzerland, a division of Johnson and Johnson), Retin-A micro (patent of Valent Pharmaceuticals, Canada) Airol (Roche, Switzerland), Lokacid (Pierre Fabre, France), Renova (Valent Pharmaceuticals, Canada). Not registered in Russia and a number of other countries. In the US, it is issued by prescription.

Isotretinoin is a topical and systemic retinoid. Registered in Russia. As a means for external use, it is available in the form of ointments. The most well-known brand in Russia is Retinoic ointment (FNPP Retinoids), also available under the name Isotrex (GlaxoSmithKline, UK), in combination with erythromycin - under the name Isotrexin (GlaxoSmithKline, UK).

As a systemic retinoid, it is known under the brands Roaccutane (Roche, Switzerland), Aknekutan (Jadran, Croatia), Kurakne (Pierre Fabre, France). It is prescribed by a doctor and issued strictly according to the prescription.

Important note: all retinoids (including seemingly harmless vitamin A in large doses) cause side effects and are teratogens, that is, they can cause irreversible defects in the fetus. A reservation, perhaps, can be made only for Adapalene, in which the teratogenic effect has not been proven. Most likely, this is due to the fact that not enough research has been done. Therefore, we conditionally attribute it also to teratogens. In this regard, women of childbearing age are prescribed systemic retinoids with reliable contraception and a negative pregnancy test. In the medical history, a note is usually made about the woman's awareness of possible side effects. Retinoids do not have a negative effect on the reproductive function of men. *

* Albanova V.I., Sazykina L.N. TREATMENT OF ACNE //NEW DOMESTIC DRUG FOR SCABIES. - T. 13.

Retinoids also cause the following side effects: dry skin, mucous membranes, including lips (cheilitis), nasal cavity (bleeding), laryngopharynx (hoarseness), eyes (conjunctivitis, intolerance to contact lenses). An exacerbation reaction may occur, expressed in redness, moderate itching of the skin, the appearance of additional rashes. Usually, after some time, side effects disappear or are minimized. *

* Safonova T. G. et al. Systemic retinoids in the treatment of severe and resistant forms of acne // Clinical dermatology and venereology. - 2013. - T. 11. - No. 3. - S. 60-62.

All retinoids increase photosensitivity, so during the treatment period it is necessary to protect yourself from the sun and avoid direct sunlight (and it is better to do this all your life).

Many people are afraid of systemic retinoids, especially when they open the instructions from the box. Where complications and side effects are written in bold red font. And not all doctors have complete information.

But in some cases, systemic retinoids are practically the only remedy that can lead to a stable remission. Now microdoses are used to achieve the effect and side effects occur much less frequently. There is a misconception that isotretinoin has a long half-life, that you can’t get pregnant for another 2 years, but this is not true. “The half-life of isotretinoin is only 19 hours, but protection from pregnancy is necessary for the entire period of therapy and 1 month. after its completion. Side effects can indeed accompany the course of treatment, but in most cases we are talking about cheilitis and dry skin. Other side effects, such as a transient change in transaminases, headache, myalgia, worsening of night vision, described in the instructions for use of the drug, are much less common and, as a rule, do not require discontinuation of treatment. In order to minimize the risks of developing side effects from the liver and pancreas during treatment with isotretinoin, manufacturers recommend continuous monitoring of blood biochemical parameters.*

*Olisova O.Yu. Effectiveness of systemic retinoids in acne // BC. Dermatology. 2016. No. 10. S. 602–606.

Therefore, if you have severe acne with cysts and a lot of inflammatory elements, and the doctor mentioned systemic retinoids, do not rush to run away, flashing your heels, but think it over carefully. Prescribing retinoids for concomitant indications is a clear sign that the doctor is up to date with the latest trends. But if in the same case the doctor continues to talk about cleansing - feel free to send him somewhere far away. Twenty-first century in the yard. If treatment doesn't work, change doctor!

At the moment, moderate and even mild acne is treated with systemic retinoids, prescribing microdoses, but I did without it. The doctor prescribed me adapalene, later I switched to tretinoin. There was a slight discomfort at the first time of use: the skin was dry, the eyes were dry (well, there is an aggravating circumstance - I had laser correction), my whole face seemed to hurt a little, it was unpleasant to touch it. But soon the discomfort passed. I didn't have any peeling.

A month later, I switched to 0.25% tretinoin under the brand name Retin-A. I still use it at a concentration of 0.5%. It's been about 3 years. The skin has objectively become better: cleaner, healthier, tighter. Tretinoin has also been proven to slow down the aging process* and lighten pigmentation, so I plan to use it for the rest of my life with a break for pregnancy and lactation, if I decide. I always use reliable mineral sunscreen - even in winter in Moscow.

* Berardesca E. et al. In vivo tretinoin-induced changes in skin mechanical properties // British Journal of Dermatology. - 1990. - T. 122. - No. 4. - S. 525-529.

In addition, I use other acne products, which I will talk about next time.

P.S. I ask everyone to turn their heads. All information provided in this post is not a treatment recommendation, it is just an overview and some personal experience. Treatment is prescribed only by a doctor.

P.P.S. I accidentally discovered the name of my doctor among the authors of the articles)

All beauty!

In the absence of timely and adequate treatment in a significant proportion of patients, the disease takes on a persistent course. In the age period of 30-39 years, acne occurs in 44% of the population, at the age of 40-49 years - in 24%. Damage to open areas of the skin significantly reduces the quality of life of patients with acne, causes aesthetic discomfort in patients, and in more severe cases, the development of anxiety-depressive and hypochondriacal conditions.

In the pathogenesis of acne, the following stages are distinguished:

1. Initiation of subclinical inflammation in the skin (Toll-like receptors TLR2, inflammatory mediators IL1α, IL8, IL12 are involved, CD3 + CD4 ± cells migrate and accumulate in the area of ​​the sebaceous and hairy apparatus).

2. Increased production of sebum and imbalance of lipid secretion of the sebaceous glands.

3. Follicular hyperkeratosis and obstruction of the ducts of the sebaceous glands (a microcomedo is formed, then a comedo).

4. Reproduction of bacteria (P. acnes).

5. Development of a clinically significant inflammatory process in the area of ​​the sebaceous hair follicle (IL8, neutrophilic leukocytes).

The bacteria P. acnes increase inflammation, but are not a necessary component of it. In skin biopsy samples, these microorganisms are found in the inflammatory elements of acne on the 1st day in 68%, and on the 3rd day - in 79% of cases. P. acnes colonization may trigger inflammation through activation of TLRs, protease receptors (PAR-2), induction of defensins (antimicrobial peptides), cytokines IL1, IL8, IL12, and TNFa. It must be remembered that the formation of comedones and the development of inflammation can occur under sterile conditions. The sequence of immunochemical reactions under aseptic conditions is triggered by the activation of peroxidases by sebum lipids or pro-inflammatory neuropeptides released by the free nerve endings of the skin.

In 2012, the European Academy of Dermatology and Venereology proposed a classification of acne, according to which four classes of the disease are distinguished:

1. Comedonal acne.

2. Papulo-pustular acne mild to moderate.

3. Severe papulo-pustular acne. Moderate nodular acne.

4. Nodular acne severe. Conglobate acne.

This classification was created in order to give recommendations for the treatment of acne, depending on the inflammatory activity of the disease. Acne therapy of the first two classes is carried out mainly with topical drugs. In more severe manifestations of the disease, the appointment of systemic drugs is required. There are three groups of drugs used for systemic acne treatment: retinoids (isotretinoin), antibiotics, and antiandrogens. It should be noted that the last two groups of drugs have limited indications for use. Systemic isotretinoin monotherapy is the most effective treatment and is highly recommended for the treatment of severe acne. Isotretinoin has a powerful anti-inflammatory and immunomodulatory effect (decrease in TLR2 expression on keratinocytes and histiocytes, decrease in cytokine production), inhibits the function of sebocytes, reduces the size of the sebaceous glands, and normalizes the differentiation of keratinocytes in the area of ​​the mouth of the hair follicles. According to experts, with proper monitoring, systemic isotretinoin therapy is safe and effective, prevents scarring, and significantly improves the quality of life of patients.

Sotret is the first generic isotretinoin in Russia, identical to the original drug in terms of composition and efficacy.

The aim of our study was to study the clinical efficacy, safety and tolerability of Sotret (isotretinoin) in the treatment of acne patients.

Material and methods

The study involved 50 acne patients aged 18 to 37 years (mean age 24±4.16 years): 23 (46%) women (mean age 25±5.27 years) and 27 (54%) men (mean age 22±3.74 years). 27 (54%) patients had a severe papulo-pustular form, 12 (24%) had a moderate nodular form, 8 (16%) had a severe nodular form, and 3 (6%) had a conglobate form of acne. Inclusion criteria: the patient's desire to participate in the study (signing of informed consent); absence of pregnancy and lactation at screening, the use of adequate methods of contraception (at least 2, including the barrier method) for 1 month. before treatment, during therapy and within 1 month. after treatment; ability to follow protocol requirements. Criteria for exclusion of patients from the study: hypersensitivity to any of the components of the drug; pregnancy, including planned, lactation period, refusal to use contraceptive methods during treatment; the presence of hepatic and severe renal failure; severe hyperlipidemia; availability of data on the abuse of alcohol, drugs; the presence of other skin conditions that may interfere with the assessment of acne.

The algorithm for examining patients before the start of treatment included taking a medical history, assessing dermatological status and conducting laboratory tests: complete blood count and urine, biochemical blood test (lipidogram, ALT, AST, GGTP, total bilirubin, glucose, urea, creatinine), pregnancy test among women. All patients received monotherapy with Sotret at the rate of 0.5–0.7 mg/kg/day until a course dose of 120 mg/kg was reached. The selection of the daily dose was carried out individually, the decision on correction was considered once a month, focusing on the severity of the disease, the dynamics of the clinical picture and the severity of side effects. Repeated laboratory studies were performed in all patients after 1 and 3 months. after the start of therapy and after 1 month. after the end of treatment. Evaluation of the effectiveness of therapy with Sotret was carried out monthly by counting the number of inflammatory and non-inflammatory elements on one half of the face. The duration of treatment averaged 6.8±0.52 months.

results

There were no adverse reactions requiring discontinuation of the drug during the reporting period. Side effects that developed while taking Sotret are presented in Table 1.

When analyzing biochemical parameters of blood in patients after 1 month. after the start of treatment, lipid profile changes were revealed: total cholesterol - increased by 38% in 18 (36%) patients, LDL - by 36% in 16 (32%), VLDL - by 28% in 6 (12%), triglycerides - by 22 % in 7 (14%) patients. After 3 months therapy with Sotret, changes in blood biochemical parameters were similar: total cholesterol was increased by 33% in 19 (38%) patients, LDL - by 34% in 17 (34%), VLDL - by 25% in 6 (12%) , triglycerides - by 21% in 8 (16%) patients. In 6 (12%) patients during the treatment period, transient changes in the level of ALT, AST, GGTP were noted - an increase of 20–30% above the norm. Special correction of these changes was not carried out. After 1 month after the end of the course of treatment, all biochemical blood parameters returned to their original values. There were no abnormalities in the general clinical analysis of blood and urine.

As a result of the treatment, all patients achieved clinical recovery (Fig. 1–4). Against the background of ongoing therapy with Sotret, a rapid regression of skin rashes was observed. Differences in the average number of open (22.3±3.4) and closed (11.8±2.3) comedones, papules (24.3±3.1), pustules (14.7±2.4) and nodules (2.4±0.4) before treatment and after 90 days of therapy (4.8±0.7, 8.2±1.1, 5.6±0.8, 2.9±0.4 , 0, respectively) were statistically significant (p<0,05 при каждом сравнении). Динамика количества элементов сыпи у больных акне на фоне терапии Сотретом представлена на рисунке 5.

conclusions

1. The results of the study convincingly indicate a high level of safety and good tolerability of the drug Sotret (isotretinoin).

2. Monotherapy with Sotret (isotretinoin) at a course dose of 120 mg/kg of the patient's weight is an effective treatment for severe acne.

3. The obtained clinical results allow recommending Sotret (isotretinoin) as the drug of choice for the treatment of severe papulopustular acne, nodular and conglobate acne.