Curing Acne Permanently

Acne No More Ebook

Acne is not only a patch to the beauty of a person but a painful and ever growing disease which has been common problem. Lots of chemical products are available in the market which not makes a big hole in pocket but hardly gives promising results. Acne no more is indeed a book that will permanently solve your all acne problems in the most holistic way without using any drugs or ointments. No matter whatever the age or sex of the person, it works on all. In addition to acne treatment it includes all the remedies for blackhead removal, scar marks and excessive oiliness. It includes all the step by step holistic process to get the best glowing and healthy without using any chemicals. Indeed the best in the market and written by Mike Warden who is certified Nutrition Specialist, Health Consultant, Medical Researcher and Author. The fastest and permanent results are guaranteed by the author and have been used and trusted by thousands of readers of this book. Within 2 months get prepared to get the glowing and clean skin that you have ever wished for. Read more here...

Acne No More Ebook Summary


4.8 stars out of 24 votes

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Author: Mike Walden
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My Acne No More Ebook Review

Highly Recommended

All of the information that the author discovered has been compiled into a downloadable pdf so that purchasers of Acne No More Ebook can begin putting the methods it teaches to use as soon as possible.

When compared to other e-books and paper publications I have read, I consider this to be the bible for this topic. Get this and you will never regret the decision.

Clear Skin Secrets Revealed

Paleo Ballerina is a brand-new health and fitness program developed by a ballerina. The program is designed to help you embrace a healthier, much better, and also more energetic lifestyle to make sure that you can attain the body, skin, and state of mind that you've constantly wanted. While the adjustments at the beginning might be a big modification, once you get used of them you will certainly love them. The author of the program has actually fought with the exact same day-to-day problems that you deal with, such as acne, weight gain, as well as a state of mind swings. Consequently, when you adopt this program, you can feel great that you are getting one that comprehends you and your requirements.If you are searching for a system that is enjoyable, fascinating, and that gets you moving, then you should try the Paleo Ballerina. Read more here...

Clear Skin Secrets Revealed Summary

Contents: Online Program
Author: Harmony Patton
Official Website:
Price: $15.00

Propionibacterium acnes

Acne is the most common skin disease and affects approx. 80 of adolescents in the United States (Bruggemann et al. 2004). Surprisingly, the role played by the human skin-commensal bacterium, Propionibacterium acnes, in the development of acne is still debated. Some of the processes that may contribute to this skin disease and in which P. acnes may be involved include damage to host tissues due to bacterial lipases (Miskin et al. 1997) or inflammation caused by heat-shock proteins (Farrar et al. 2000). Notwithstanding the lack of clarity concerning its mode of action, this bacterial species likely plays a significant role in the development of acne as well as a plethora of other, more serious, human diseases (e.g. Yamada et al. 2002). Bruggemann et al. (2004) reported the entire genome sequence of P. acnes. In addition to their analysis of the genomic structure of this human commensal bacterium, these authors also discussed the interaction of genetic-exchange processes in the...

Miscellaneous conditions Acne

Feline acne is a well-recognised clinical entity with a poorly understood pathogenesis, although the current view is that it represents a form of keratinisation disorder with secondary bacterial infection. Lesions are usually localised to the chin, but may also be located on the upper and lower lips and commissures of the lips (White et al., 1997). Clinical signs may include pruritus, although this is not a consistent finding in some cases the signs of acne are part of a variety of clinical signs observed over the whole body. The clinical signs are similar to demodicosis, derma-tophytosis, Malassezia infection, eosinophilic granuloma and bacterial pyoderma. As such, it is unclear whether these diseases are a potential cause of the acne. Lesions observed include keratinous debris attached to the base of the hair shafts (i.e. follicular casts), comedones, papules, pustules to draining furuncles with a purulent exudate and swelling of the chin (Plate 6.20). When a purulent discharge is...

Acneiform Eruptions

Although acne vulgaris is a common chronic problem that likely would not be encountered as a chief complaint in the emergency department setting, several acneiform eruptions may develop with alarming clinical presentations prompting a patient to seek immediate attention. As these disorders are uncommon and require a dermatologic consultation, they are discussed only briefly. These disorders include acne fulminans, pyoderma faciale, dissecting cellulitis of the scalp, and acne keloidalis. Acne fulminans is a severe form of cystic acne with ulcerating cysts. It most commonly affects the chest and back of young males. Severe scarring may result. It may have systemic associations including fever, myalgias, arthralgias, malaise, and anorexia. Treatment includes systemic corticosteroids and isotretinoin (Accutane). As isotretinoin has potentially severe side effects, including devastating teratogenicity in women who become pregnant while on this medication, it should be administered only by...

Extremely common disorders

Skin diseases are very common in the general population. Prevalence surveys have shown that skin disorders may affect 20-30 of the general population at any one time.16 The most common diseases are also the most trivial ones. They include such conditions as mild eczematous lesions, mild to moderate acne, benign tumours and angiomatous lesions. More severe skin disorders which can cause physical disability or even death, are rare or very rare. They include, among others, bullous diseases such as pemphigus, severe pustular and erythrodermic psoriasis, and malignant tumours such as malignant melanoma and lymphoma. The disease frequency may vary according to age, sex and geographical area. In many cases, skin diseases are trivial health problems in comparison with more serious medical conditions. However, as already noted, because skin manifestations are visible they cause greater distress than more serious medical problems. The issue is complicated because many skin disorders are not a...

Back to the individual patient

What is the risk of extraspinal hyperostosis in a patient with psoriasis treated for several months with acitretin Does PUVA therapy increase the risk of non-melanoma skin cancer in a patient being treated for mycosis fungoides What is the chance of severe depression in an adolescent taking 13-c s-retinoic acid for acne To address these questions, physicians must effectively search for evidence and must be able to assess

Aetiologyrisk factors

Although the exact aetiological mechanism is unknown, it is accepted that acne is the result of the interaction of several processes, which centre on pathological changes in the pilosebaceous duct (PSD) in response to an as yet unidentified trigger mechanism. Thickening of the follicular stratum corneum (hypercornification) leads to blockage and accumulation of sebum, which is produced in large quantities in response to the androgen surges that accompany puberty. The resident skin commensal Propionibacterium acnes then proliferates in the lipid-rich sebaceous follicles and there is a build up of bacteria and their metabolites, sebum and dead cellular material. This cannot be discharged because of the blockage at the follicle opening and there is therefore an inflammatory response. The extent and duration of the inflammation, and hence the severity of the acne, may be determined by individual variation in the immune response to P. acnes, its metabolic products or any component of the...

Implications for clinical practice

In individuals with mild acne whose disease is not adversely affecting their quality of life, antibacterial washes should be considered in the choice of first-line management strategies in step-up approaches. They should also be considered in the maintenance of patients who have ceased therapy following response. They should not be prescribed routinely in patients who are receiving more aggressive therapy as there is no evidence of any additional benefit. Alkaline syndet bars may be preferential to soap in skin care routines. Mild acne consisting of open and closed comedones with a few inflammatory lesions is commonly treated with topical agents. A number of options have been shown to be effective in placebo-controlled RCTs, and all can be used either alone or in combination. Options include the topical retinoids (isotretinoin, tretinoin and adapalene), benzoyl peroxide, salicylic acid and azelaic acid. Topical antibiotic agents are discussed in the next question.

Implications for practice

However, as this activity halts subsequent lesion formation, they are also suitable for moderate-to-severe acne and can be used in conjunction with topical and oral antibiotics. Benzoyl peroxide inactivates tretinoin, so the two agents should not be applied simultaneously if used in combination, one should be applied in the morning and one at night. All topical retinoids cause local sensitivity reactions that appear to be less common with adapalene. To limit local sensitivity, topical retinoid therapy should start at a lower strength applied every third night and increase gradually.

Oral versus topical antibiotics

Six RCTs compared oral tetracycline 250 mg twice daily with 1 clindamycin twice daily.9091 127 147-149 Only one RCT was longer than 8 weeks duration149 and only one study was adequately powered (305 patients) but was of inadequate duration.91 This study found that at 8 weeks there was no significant difference in the percentage reductions obtained with either tetracycline 250 mg twice daily or 1 clindamycin applied twice daily in pustules (68 versus 76 ) and papules (63 versus 68 ) in patients with moderate-to-severe acne. However, the physician rated the clindamycin therapy as good to excellent in a greater number of cases -86 105 compared with 66 103 (P

Number needed to treat

It is also important that the dermatologist and patient decide for themselves as to what might constitute a useful NNT, rather than blindly accepting the sort of conventions that have been derived from acute medicine where the stakes are perhaps higher. So, although it may be perfectly justifiable to treat 200 patients with a low dose, aspiring to prevent one stroke, I would certainly not be willing to work with such an NNT for a new antibiotic if the gain was just one extra short-term remission of acne. In a pressurised health service I might even question the value of a new treatment for plaque psoriasis with an NNT of 20. Perhaps the opportunity costs associated with seeing the extra 20 patients needed in order to achieve one extra response from the new treatment could be better spent discussing other treatment options with them or assessing other new patients. Despite these caveats, the NNT is a more useful tool than measures of relative risk such as odds ratios to translate the...

Phylum Firmicutes The low GC Grampositive bacteria

The cells of staphylococci occur in irregular bunches rather than ordered chains. They also produce lactic acid but can additionally carry out aerobic respiration involving cytochromes, and lack the complex nutritional requirements of the lactic acid bacteria. They are resistant to drying and able to tolerate relatively high concentrations of salt. These properties allow Staphylococcus aureus to be a normal inhabitant of the human skin, where it can sometimes give rise to dermatological conditions such as acne, boils and impetigo. It is also found in the respiratory tract of many healthy individuals, to whom it poses no threat, but in people whose immune system has been in some way compromised, it can cause serious respiratory infections. S. aureus can also cause a type of food poisoning and is the causative agent of toxic shock syndrome. Widespread antibiotic use has been largely responsible for the development of resistant forms of S. aureus, which have become ubiquitous inhabitants...

Thirdgeneration progestins

The newer OCs are more effective in reducing acne and hirsutism in hyperandrogenic women. They are therefore an option for women who have difficulty tolerating older OCs. There is an increased risk of deep venous thrombosis with the use of these agents, and they should not be routinely used.

Oral contraceptive pills OCPs suppress LH and FSH

Danazol (Danocrine) has been highly effective in relieving the symptoms of endometriosis, but adverse effects may preclude its use. Adverse effects include headache, flushing, sweating and atrophic vaginitis. Androgenic side effects include acne, edema, hirsutism, deepening of the voice and weight gain. The initial dosage should be 800 mg per day, given in two divided oral doses. The overall response rate is 84 to 92 percent.

Step 2 Assess the history

Galactorrhea is suggestive of hyperprolactinemia. Hirsutism, acne, and a history of irregular menses are suggestive of hyperandrogenism. C. Step 3 Physical examination. Measurements of height and weight, signs of other illnesses, and evidence of cachexia should be assessed. The skin, breasts, and genital tissues should be evaluated for estrogen deficiency. The breasts should be palpated, including an attempt to express galactorrhea. The skin should be examined for hirsutism, acne, striae, acanthosis nigricans, vitiligo, thickness or thinness, and easy bruisability. D. Step 4 Basic laboratory testing. In addition to measurement of serum hCG to rule out pregnancy, minimal laboratory testing should include measurements of serum prolactin, thyrotropin, and FSH to rule out hyperprolactinemia, thyroid disease, and ovarian failure (high serum FSH). If there is hirsutism, acne or irregular menses, serum

Coryneform Bacteria Infection And Immunity

Propionibacterium spp. require lipid and anaerobic conditions for successful cultivation in vitro. P. acnes and P. granulosum are isolated from highly sebaceous areas of human skin in all those past puberty P. avidum is similarly found in the axilla. The first two species are associated with acne and are occasionally recovered from deep infections in humans. There is no consensus on the role of Propionibacteria in acne. Not all acne lesions contain microorganisms but a potential role for Propionibacteria may be as follows they reside in the ducts of sebaceous glands which become blocked as a result of changes in keratinization sebum continues to be produced so that the blocked duct forms a closed comedo. In vitro, P. acnes has sharp pH and p02 optima for the production of hyaluronidase and protease production of these enzymes in vivo, if it occurs, would render the comedo wall leaky to host-defense mechanisms triggering of the alternative complement pathway by the cell wall of P....

Pathology Pathogenesis and Carcinogenesis

The major risk factor for developing differentiated thyroid carcinoma is exposure to low-level external radiation. Enlargement of the thymus, scalp ringworm, recurrent tonsillitis, cervical adenopathy, facial acne and other head and neck disorders were commonly treated with 100-1500 cGy of external radiation from 1940 until the late 1960s. A dramatic increase in the diagnosis of differentiated thyroid carcinoma, predominately papillary carcinoma, resulted from these treatments and displayed an average latency period of 5 years from exposure to diagnosis. Young patients exposed between the ages of 5 and 15 seem to be at highest risk for developing radiation-associated thyroid carcinoma.6 This risk, which is increased after radiation exposure of as little as 10 cGy, is highest at 20 years after exposure and declines gradually thereafter. These same observations have been seen in Hiroshima and Nagasaki after the atomic bomb, in Nevada and in the Marshall Islands after atomic bomb testing...

Background Definition

Acne vulgaris is a pervasive disease of the pilosebaceous follicles of the skin, which are located on the face, back and chest. The disease has a range of clinical expression and can be classified according to the predominant lesion type. Non-inflammatory or comedonal acne is primarily composed of open comedones (blackheads) and closed comedones (whiteheads) with little or no inflammatory involvement. Inflammatory acne is characterised by inflamed lesions (pustules, papules and nodules) and can be further subdivided into papulopustular, nodular and conglobate depending on the predominant lesion type. Conglobate acne is characterised by clusters of lesions joined by sinus tracts. The older term nodulo-cystic acne is less used as it is accepted that the cysts are actually abscesses or granulomas.1

Cushings diseaseCushings syndrome

Clinically the patient presents with truncal obesity, moon face, hypertension, diabetes, abdominal striae, acne and a buffalo hump, and experiences profound weakness. Pituitary ACTH-producing tumours tend also to produce skin pigmentation as ACTH has a similar molecular structure to melanocyte-stimulating hormone (MSH). Because patients have a tendency to bruise easily with delicate skin which is easily damaged, and have an increased risk of infection, post-operative problems are increased.

Physiological Functions of atRA

Incidence of spontaneous and carcinogen-induced cancer. Chemopreventive trials in humans show some promise for retinoids in actinic keratoses, oral premalignant lesions, laryngeal leukoplakia, and cervical dysplasia. The US Food and Drug Administration has approved retinoids for acute promyelocytic leukemia and for non-life-threatening diseases, such as cystic acne and psoriasis. Retinoids also provide the active ingredients in agents to treat sun age-damaged skin.

Costeffectiveness analysis

CEAs provide information about the value of the therapeutic intervention in question by accounting for the outcomes of the therapy. However, the outcome measure is not standardised and therefore cannot be used to make comparisons with other disease processes. For example, even if a reasonable outcome measure for a new therapy for seborrhoeic dermatitis may be dollars per clear scalp, this measure cannot be used when the policymaker wants to compare the CE ratio with analyses of new therapies for disparate diseases such as onychomycosis, venous ulcers or acne. Even if clear skin is used as the outcome measure, it cannot be used to make Stern et al.3 published a CEA comparing topical versus systemic therapy for acne. Because of the lack of efficacy data, they had to rely on expert impressions. They calculated an incremental cost-effectiveness ratio, but used side-effect averted as their outcome measure. While this outcome may be useful for making comparisons with other acne therapies,...

Case Illustration

Michelle had been shy for as long as she could recall. During her adolescent years she was overweight and suffered from bad acne, which bought her ridicule and rejection from schoolmates. As a result of a series of particularly disturbing episodes of teasing during grades 10 through 12, she became increasingly anxious in social settings, including talking in groups and having one-to-one conversations, particularly with members of the opposite sex. Michelle also developed intense fear of eating in public after an episode in which she vomited during lunchtime in the school cafeteria. This appeared to have been the result of influenza combined with the effects of high anxiety.

Asking an answerable question By

Definition, the question generated within an evidence-based prescription is derived from a patient encounter. For example, a woman aged 32 years with facial acne may want to know whether it is safe to take a combined anti-androgen oestrogen pill, as opposed to continuing on prolonged oral antibiotics. Further discussion may reveal that she is mainly concerned about deep vein thrombosis as she has a family history of this. The structured evidence-based question emanating from this discussion would then be, What is the increased risk for a woman in her thirties to suffer a deep vein thrombosis when taking the combined anti-androgen oestrogen pill for her acne when compared with taking an oral antibiotic . This will, of course, depend on other factors

What are the patients values Values and belief models

Teenager who consults you with acne, whose friend developed pigmentation of the gums whilst taking minocycline, might initially refuse that treatment option. This does not mean that, if that drug is deemed to be the best choice in those circumstances, the dermatologist does not then go on to explain how rare such an event really is in order to reach a joint decision with the patient. Another patient with acne might come back demanding treatment with isotretinoin simply because his or her friend at school had similar treatment with excellent long-term results and tolerable side-effects. Again, although such a declaration might influence the consultation, this does not automatically mean that the dermatologist will concede to such a request if he or she feels that the treatment is not in the patient's best interest (for example very mild disease or a history of several unplanned pregnancies). The point here is that application of the best external evidence requires a dialogue with the...

The role of consumers

Consumer involvement has been a strong feature of the CSG from the very beginning. This is because skin disease greatly affects the quality of life of the individual and because much of the trial work in skin disease has been dominated by answering questions that are important to the pharmaceutical industry. Consumers help us to redress that imbalance. At present (Autumn 2002) the skin group has 55 groups working on topics, both common and rare, such as acne, alopecia, bullous pemphigoid, eczema, excessive sweating, psoriasis, skin cancer and vitiligo. About 30 active consumers are involved at many

The visible nature of skin disease

Dermatology differs notably from other branches of medicine in the way it shades off into borderlands of cosmetics and cosmetic surgery, and in the often blurred boundaries between treatment, prevention and aggravation of skin problems. Even something as innocuous as washing can be a form of prevention (for example washing a chemical off one's hand), treatment (for example ridding the skin of an accumulation of excess scale) or aggravation (causing irritant contact dermatitis through frequent hand-washing with soap). The dual function of the skin as both a large and important organ and a superficial covering of the body that is important in social display can lead to trivialisation. Some skin conditions, like acne and vitiligo, are often considered purely cosmetic problems, particularly by some general practitioners.

Transdermal contraceptive patch

Amenorrhea, irregular bleeding, and weight gain (typically 1 to 3 kg) are the most common adverse effects of DMPA. Adverse effects also include acne, headache, and depression. Fifty percent of women report amenorrhea by one year. Persistent bleeding may be treated with 50 g of ethinyl estradiol for 14 days.

Melanie L ONeill and Maureen L Whittal

Body Dysmorphic Disorder (BDD) is a fixation or preoccupation with an imagined defect in appearance or, if a physical defect or anomaly is present, the individual's concern is clearly excessive (APA, 2000). Although prevalence rates remain largely unknown, APA (2000) suggests that BDD may range from under 5 to a high of 15 in medical cosmetic settings. Individuals with BDD can focus on flaws of the head and face such as hair thinning, acne, asymmetry, excessive hairiness, or the shape and size of body parts including the eyes, mouth, head, buttocks, legs, or genitals. The concern may be limited to one or many areas and can range from extremely specific to vague and diffuse (APA, 2000).

Costutility analysis

Quality of life is measured by a set of weights called utilities, one for each possible health state, that reflect the relative desirability of the health state. The reader is encouraged to consult other references for a detail explanation of utilities.4,5 By incorporating quality of life and by standardising the outcome measure with QALYs, a dermatology CUA such as acne therapy can be compared with a mortality-impacting CUA such as breast cancer therapy.


Estimates of the overall prevalence vary considerably and depend on the study populations and epidemiological methodology used. The disease is probably best defined by a continuum of severity, along which all members of the adolescent population are placed it is estimated that up to 30 of teenagers have acne of sufficient severity to warrant medical treatment.1 An increasing number of women in their twenties develop late-onset acne and surveys of adults over the age of 25 years have reported prevalence of 22 in males and 40 in females.2,3


Most cases of acne clear spontaneously as an individual passes through adolescence and into their twenties. The reason for this is as yet undetermined, as there is no concurrent reduction in sebum production or change in its lipid composition. There are, however, two forms of post-adolescent acne in which the disease is evident in adulthood. Persistent acne commences in adolescence but does not resolve and is generally resistant to antibiotic therapy. Conversely, late-onset acne is generally less severe, evolves more commonly in women after 25 years of age, and has been linked to abnormalities in plasma androgens.11,12 The total burden of acne extends beyond financial costs the impact on the individual can be devastating as the disease occurs at an age when its effects are acutely felt. Depression and anxiety are clearly linked to severe acne, and personality and self-esteem issues may arise that can have long-lasting effects on functioning as an adult. It has also been reported that...

Aims of treatment

The large number of treatment options available act by correcting one or more of the mediating factors that have been implicated in the pathogenesis of acne, and are commonly classified according to their route of delivery and mode of action. It is difficult to define an optimum treatment strategy because there is wide variation between individuals in response finding the most suitable treatment is therefore a matter of trial and error. The comparative data on various therapies are limited and individual trials have obtained contradictory results, largely because of inadequate trial design and unfair comparisons in terms of dosage. Isotretinoin is the only acne treatment that can induce persistent remissions, but it is often unacceptable to patients because it has severe adverse effects. All other acne treatments are palliative and whilst improvement of symptoms and control of disease progression is possible, they need to be taken for prolonged periods.

Search methods

Evidence was reviewed according to the hierarchy of evidence whereby systematic reviews of randomised controlled trials (RCTs) are accepted as the most robust evidence, followed by individual RCTs. The primary source of evidence was therefore a recent systematic review of all acne therapies, prepared for the Agency for Healthcare Research and Quality (AHRQ).14 This was supplemented by evidence located by searches in the following databases Cochrane Library (Issue 1 2002), Cochrane Skin Group Specialist Trial Register, Medline (1966 to February 2002) and Embase (1980 to February 2002). An initial filter was applied to locate all acne trials ((study or trial) and acne).mp and then more specific terms were applied within this set for individual interventions. No exclusions on the basis of language or study type were made. Figure 13.1 Mild-to-moderate acne Figure 13.1 Mild-to-moderate acne


Only on comparisons that had at least two RCTs of acceptable quality showing moderate-to-strong statistical evidence, the authors of the AHRQ review concluded that 0-1 adapalene and 0-025 tretinoin were equally efficacious and that motretinide and tretinoin were equally effective. The second review24 evaluated five RCTs of 0-1 adapalene gel versus 0-025 tretinoin.29-31,34,46 All RCTs were investigator blind and a total of 900 individuals with mild-to-moderate acne were enrolled. Using data collected from intention-to-treat (ITT) analyses, equivalent efficacy against total lesion counts was demonstrated, with adapalene showing greater activity at 1 week. What is the role of topical non-antibiotic agents in the treatment of mild primarily noninflammatory acne enrolling a total of 186 patients with mild-to-severe acne.28,29,47 The higher strength produced greater reductions in IL and NIL counts but was associated with more irritation. Little comparative data for retinoids against other...

Salicylic acid

The AHRQ review14 located three RCTs (Table 13.3).66-68 The largest study found 2 salicylic acid to be more effective against all lesion types than the alcoholic lotion vehicle at 12 weeks in 114 paired individuals with mild-to-moderate acne.66 The second study enrolled 30 individuals and had major losses to follow up 68 1-5 salicylic acid was more beneficial than placebo. One further crossover RCT in 30 individuals with mild acne compared a 2 cleanser with 10 benzoyl peroxide facial wash neither product was therefore in prolonged contact with the skin.67 The results of the study cannot be considered as valid evidence, however, because the trial was only 4 weeks in total and there was no wash-out period between the 2-week treatment periods.


All of the agents reviewed have been shown to be effective in the treatment of mild and moderate acne vulgaris. There is very little data to support the use of one agent over another and there has only been one RCT of use of the agents The role of antibiotics in the management of acne is still debated, and although much evidence has been collected on the efficacy of individual agents, there is very little good-quality comparative data. Oral antibiotics were used initially in the 1950s because it was assumed that acne occurred as a result of bacterial infection. Whilst activity against P. acnes has been clearly demonstrated, there is evidence of an anti-inflammatory effect,80 which is still being investigated. A number of oral antibiotics have been used to treat acne but are no longer used because of their side-effects clindamycin and lincomycin are associated with an increased risk of pseudomembranous colitis dimethylchlortetra-cycline (demeclocycline) induces phototoxic skin...

Oral antibiotics

The AHRQ report reviewed 11 placebo-controlled trials of oral antibiotics82-92 and two others were located by searches9394 (see Web Table 13.4). All but two RCTs investigated tetracycline one evaluated minocycline83 and one doxycycline.95 All were double blind and most included patients with moderate-to-severe acne. Only three provided data at 12 weeks or more85,88,89 and only three included more than 50 patients in each arm.89,91,93 Tetracycline at total daily doses of 500 mg and 1 g was consistently superior to placebo in terms of overall grade and reduction in IL. The only data on NIL was from the doxycycline RCT,95 which indicated comparable efficacy at 4 weeks, but this is to be expected given the delayed onset of activity associated with oral antibiotics. What is the role of antibiotics in the management of acne vulgaris

Topical antibiotics

Was no more active than placebo in mild-to-moderate acne, neither producing statistically significant reductions in IL or NIL. The three tetracycline RCTs demonstrated that 0-5 tetracycline was approximately 50 more active than vehicle in terms of change in acne grade from baseline, although no intergroup statistical analyses were performed. Only one trial provided data on differential lesion counts the results suggested that again tetracycline was active against IL but not NIL. In the larger RCTs a 55-60 mean reduction in IL was consistently seen at 12 weeks.14 The AHRQ review located 14 head-to-head trials of topical antibiotics (see Web Table 13.7). There were no differences in efficacy between clindamycin hydrochloride and phosphate,117,118,122 or between different formulations121,138,139 in the six RCTs examined. Four large RCTS132 140-142 and one smaller study143 compared clindamycin and erythromycin all enrolled subjects had mild-to-severe acne. Several of the trials reported...

Combination therapy

A number of RCTs have investigated oral and topical antibiotics either against or in combination with other agents, (see Web Table 13.9) the rationale for this being that treatments that attack more than one factor implicated in the pathogenesis of acne will be more effective. The different mechanisms of action are summarised in Table 13.4. Table 13.4 Targets of acne therapies (adapted from Gollnick160) Sebum P. acnes Inflammation Table 13.4 Targets of acne therapies (adapted from Gollnick160) Sebum P. acnes Inflammation


A proportion of individuals fail to respond to antibiotics - epidemiological studies estimated that this is between 10 180 and 17 181 of individuals. Theories that have been proposed include individual differences in the absorption, distribution and elimination of the antibiotic as well as poor compliance, the follicular microenvironment and P. acnes resistance.180 The underlying severity of the disease may also determine response to antibiotics, as severe acne and acne of the trunk has been shown to respond less well than moderate acne,182,183 possibly as a result of the higher sebum excretion rate184 diluting follicular drug concentrations.180 Clinically another important impact of alteration in cutaneous microflora is the possibility of the development of gram-negative folliculitis, which presents with profuse

Embryo Research

The study of nonhuman animal embryos has provided a wealth of information about normal embryonic development. This basic research has important clinical relevance. For example, the research on fertilization in sea urchins and mice* has provided the data needed to develop methods for in vitro fertilization. Studies of the development of the nervous system in frogs (see Amphibians) have permitted researchers to identify the processes involved in a major birth defect, spina bifida, in which the spinal cord does not form normally. Limb development is another developmental process that has been extensively studied in nonhuman animal models (see ANIMAL MODELS, Biomedical and Behavioral Science). Basic research on chicken embryos first identified the importance of retinoic acid in limb formation. These studies made it clear that drugs containing forms of retinoic acid, often used in formulations designed to treat acne and wrinkling of the skin, are potentially dangerous to the unborn fetus.

Diet and Bed Rest

Many spironolactone side-effects result from its potent antiandrogenic activity. Indeed, this side-effect has been effectively employed to treat patients with hyperandrogenic hirsutism and or acne. This effect can cause painful gynecomastia in many patients receiving this drug. The electrolyte derangements produced by spironolactone include hyperkalemia and hyperchloremic metabolic acidosis. They occur with increased frequency in patients with a reduced renal function.

Cutaneous Cysts

Sequestration Dermoid

Epidermoid cyst (50,51) is a common cutaneous tumor derived from squamous epithelium. It is skin-colored or yellowish, dome-shaped, smooth, mobile, and ranges in size from 0.5 to 5 cm in diameter. Many lesions have a characteristic central punc-tum from which a cheeselike material can be expressed. They usually appear on the face or trunk. Epidermoid cysts develop in patients with acne conglobata or by implantation of squamous epithelium into the dermis secondary to sharp injury or trauma. Lesions are often inflamed or infected. The presence of multiple cysts is suggestive of Gardner's syndrome, which incorporates intestinal fibromatosis, jaw osteomas, and colonic polyps. Histological examination shows a cystic cavity lined by keratinizing squamous epithelium with intact granulosa, and the cavity is filled with well-defined keratin lamellae. They frequently appear in patients with acne, after application of occlusive ointments following resurfacing procedures, in patients with certain...

Adrenal Cortex

Cushing syndrome results from exogenous steroid administration or excess endogenous cortisol secretion. The clinical manifestations of Cushing syndrome include HTN, edema, muscle weakness, glucose intolerance, osteoporosis, easy bruising, cutaneous striae, and truncal obesity (buffalo hump, moon facies). Women may develop acne, hirsutism, and amenorrhea as a result of adrenal androgen excess.


One of the most important aspects of the past medical history, is whether the patient has received head or neck irradiation in childhood. Between 1940 and 1960, radiation was used as a treatment for thymic enlargement, recurrent tonsillitis, adenoiditis, otitis media, hemangiomas, ringworm, acne and dermatologic conditions. This therapy has now clearly been associated with an increased incidence of both benign and malignant nodules. If a patient with a solitary nodule has a history of radiation, the prevalence of cancer is 30-50 .2 Other factors to examine in the

Keloid Scars

Keloid scars represent a hyperproliferative response of connective tissue to trauma (22). Known stimuli include burns, inflammatory acne, surgery, and ear piercing. The tendency to form keloids is inherited, although a precise mode of transmission has not been defined. There is a racial predisposition, and African-American people are more susceptible. The most frequent locations are the chin, earlobe, neck, shoulders, upper back, and sternum, probably in relation to skin tension and mobility. The posterior scalp may also be involved (acne keloidalis nuchae). By definition, keloids spread beyond the area of initial trauma. Lesions are firm, thick, hyperpig-mented papules, nodules, or plaques. They have a characteristic shiny surface and may be confluent. Histological examination shows dense fibrous tissue composed of thick collagen bundles and variable inflammatory infiltrates.

Early descriptions

Autoimmune hepatitis (AH) is now the preferred name for the disease originally described as chronic active hepatitis (CAH) in the 1940s in reference to a protracted viral hepatitis among military personnel. However, CAH, as later understood, emerged from descriptions in the 1950s of a relapsing or progressive and usually fatal liver disease of young women of no ascertainable cause, but perhaps the result of subclinical viral hepatitis. Emphasis was given to endocrine abnormality, amenorrhea, striae and acne due to the diseased liver failing to metabolize steroid hormones, and to hyperglobulinemia with reversal of the albumin-globulin ratio in serum, a then popular liver functional index. Autoimmunity was later implicated because of findings of lupus erythematosus (LE) cells in the blood, and a positive serum complement fixation test with human tissue homogenates as antigen. Clinical and serological resemblances between CAH and systemic lupus erythematosus (SLE) led to the name lupoid...

David Veale

Body Dysmorphic Disorder (BDD) is characterized by a preoccupation with an imagined defect in one's appearance or, in the case of a slight physical anomaly, then the person's concern is markedly excessive (American Psychiatric Association, 1994). The most common preoccupations are with the nose, skin, or hair and other features on the face however, any part of the body may be involved and the preoccupation is frequently focused on several body parts simultaneously. Complaints typically involve perceived or slight flaws on the face, asymmetrical or disproportionate body features, thinning hair, acne, wrinkles, scars, vascular markings, pallor, or ruddiness of complexion.

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