Acne Medications

Acta Dermatovenerol Croat. 2009; 17(1): 84Bukvić Mokos Z, Lipozencić JFor decades now, dermatologic offices are not only visited by patients with various dermatologic diseases but also by individuals wishing to improve their own appearance. At first, these were mostly persons with acne scars and pigmentation changes, later also those with changes associated with skin aging. The acquisition of new scientific concepts has been paralleled by novel scientific developments resulting in new therapeutic methods in corrective dermatology. Mechanical dermabrasion was one of the first therapeutic procedures in corrective dermatology. The skin is abraded to dermoepidermal junction by use of a metal, diamond or ruby grinder. The procedure is usually performed to remove scars or reduce wrinkles, the depth of abrasion depending on the indication. In Croatia, among the pioneers having introduced the method in corrective dermatology mention should be made of Professor Ante Vukas, MD, PhD, with more than 700 procedures and Professor Zdravko Peris, MD, PhD from University Department of Dermatology and Venereology, Rijeka University Hospital Center, who carried out more than 2000 procedures and published first professional papers in the field. Head Doctor Zdenka Jurin-Zmegac, MD, introduced the method at Outpatient Clinic of Medical Cosmetology, University Department of Dermatology and Venereology, Zagreb University Hospital Center in 1972. Chemical peeling is a method by which concentrated chemicals are applied to the skin to peel off the epidermis and dermis. This results in regeneration of the dermis and epidermis with synthesis of new collagenous and elastic fibers in the dermis. Chemical peeling is performed to remove acne and/or acne scars, hyperpigmentation and signs of skin aging. According to the depth of action, chemical peel can be superficial, medium depth and deep, depending on the chemical used and length of skin exposure. Superficial peel implies epidermal peel to the dermoepidermal junction, mostly by use of alpha-hydroxy acids in various concentrations. The objective of treatment is to achieve keratolytic effect with fibroblast stimulation, thus improving the skin texture, and reducing the number of comedones and hyperpigmentation. Medium depth peel results in necrosis of the epidermis and part of or entire papillary layer of the dermis. The procedure is usually performed by use of trichloroacetic acid at a concentration of up to 30%. The indications for medium depth peel include wrinkles, hyperpigmentation, shallow scars and signs of solar skin degeneration. Deep peel is used to remove deep scars. This procedure results in necrosis of the epidermis and the entire papillary dermis, also involving the upper part of reticular dermis. Deep peel is a demanding procedure that can only be carried out by experienced therapists using high concentrations of trichloroacetic acid (45%-50%) or phenol solution (Baker-Gordon formula). At Outpatient Clinic of Medical Cosmetology, University Department of Dermatology and Venereology, Zagreb University Hospital Center, chemical peeling has been performed since 1995, when Professor Aleksandra Basta-Juzbasić, MD, PhD introduced chemical peel with glycolic acid. Nowadays, corrective dermatology is almost inconceivable without the use of laser, one of the recent methods of treatment that has been rapidly and continuously developing over the past few decades. Target removal of various skin lesions is based on the theory of selective photothermolysis, set up by Anderson and Parrish in 1983. This revolutionary theory is based on the understanding that cutaneous chromophores (hemoglobin, melanin, water) absorb particular light wavelength applying a laser beam wavelength corresponding to maximal absorption of the chromophore contained in a particular lesion will lead to selective destruction of the target tissue. The greatest advantage of laser over other therapeutic methods is selectivity in removing target skin lesion with minimal thermal damage to the surrounding tissue. It should be noted that following laser treatment strict sun protection is required to avoid the unpleasant side effect of hyperpigmentation. Along with avoiding sun exposure for several weeks, irrespective of the season of the year, use of creams and emulsions with a >30 protection factor is recommended. The Center for Laser Use in Dermatology (Cosmetology) has been working at University Department of Dermatology and Venereology, Zagreb University Hospital Center for six years now, as the only university center in the region. During these six years, precious experience has been collected in the use of laser for removal of many congenital and acquired skin changes, including vascular and pigmented lesions, benign skin growths, laser epilation, and removal of wrinkles and scars (laser resurfacing). A variety of laser systems have been and are used, e.g., diode Nd:YVO4 532 laser, diode 810 nm laser, Q-switched ruby 694 nm laser, Er:YAG 2940 nm laser and CO2 10600 nm laser. Implants or fillers are various substances injected into the skin to fill in the wrinkles, atrophic scars and skin defects, skin rejuvenation (mesotherapy) and face remodeling (lip, zygomatic region, chin and nose enlargement). Implants are classified according to the process of degradation (biodegradable or non-biodegradable), origin (natural or synthetic), organic or inorganic character, and duration of effect (short-term, long-term or permanent). An ideal implant should be safe and of optimal duration, simple to apply with minimal discomfort, hypoallergenic and isovolemically degradable; upon the treatment, the face should have natural appearance, and the price of the treatment should be acceptable. After all, the ideal effect means stimulation of own fibroblasts for the synthesis of own collagen. Unfortunately, none of the agents available meets all the conditions mentioned above. Hyaluronic acid, a biodegradable implant, is currently most widely used because of its excellent therapeutic results associated with a very low risk of side effects. Therapeutic effect lasts for three months to two years in case of biodegradable implants, whereas non-biodegradable implants may last for years or even indefinitely. However, the application of non-biodegradable agents may be associated with the development of foreign-body granulomas, pseudocysts and abscesses. In addition to popular fillers, the clients show increasing interest in the use of botulinum toxin to correct mimicry wrinkles (around the eyes, between the eyebrows and forehead). Botulinum toxin is a potent neurotoxin produced by the bacterium Clostridium botulinum, which causes temporary paralysis of striated muscles. The main precondition for therapeutic success is proper training and experience of the physician, who should have profound knowledge of the treated area anatomy, be sure in choosing correct indication and agent dosage, and using appropriate injection technique. Therapeutic result in terms of wrinkle reduction can be observed within a week of the injection and lasts for several (4-12) months; the interval between two procedures should be at least three months. Recently, combinations of the methods listed above have been ever more employed, depending on indication. Proper choice of high quality treatments is the responsibility of dermatologist-venereologist specialized in the field of corrective dermatology, especially in the light of the great number of new therapeutic options offered by fast technological advancement. Unfortunately, these demanding corrective treatments are ever more frequently performed at non-medical institutions and by incompetent persons. Properly trained and experienced physician is fully aware of the crucial role of appropriate assessment of the patient and his/her expectations. He will explain to him/her the corrective procedure, the potential risks and the expected outcome. A predictable lack of patient compliance with proper skin care after the treatment and unrealistic expectations are considered absolute contraindications for any corrective treatment.