I have long had the idea that God created psoriasis and warts to teach dermatologists the merits of humility.
(Vincent Joseph Derbes, 1981)
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Friday, May 08, 2009
Phác đồ điều trị mụn trứng cá
Sau đây là các phác đồ điều trị mụn trứng cá. Các bác sĩ da liễu có thể tham khảo. Còn việc vân dụng cụ thể như thế nào là nghệ thuật của từng bác sĩ. Vì "Medicine is an Art", phải không quí đồng nghiệp?
Grading of acne severity and treatment
Mild acne
Moderate acne
Severe acne
Description
Open and closed comedones (whiteheads and blackheads), a few papules and pustules
Comedones, more frequent papules and pustules, but minimal scarring; can be subdivided into mainly comedonal or mainly inflammatory acne
Comedones, more pustules, and pustules plus nodular abscesses with more extensive scarring
Comedonal:
• BP + topical retinoid Inflammatory:
• BP + topical antibiotic
As for moderate acne, plus referral to a dermatologist for oral isotretinoin
Second line treatments
• Azelaic acid
• Oral antibiotic + BP ± topical retinoid • Azelaic acid • Consider combined oral contraceptive pill for female patients
As for moderate acne, plus referral to a dermatologist for oral isotretinoin
First line treatments
Topical retinoids, the first line treatment for mild acne, havecomedolytic, anti-comedogenic, and anti-inflammatory effectsand are good in early and established acne and as maintenancetherapy. The most common side effects are dryness and irritation,which can be avoided by application on alternate days initially.In theory retinoids are teratogenic, so women should be advisedabout this.
An alternative to topical retinoids is benzoylperoxide. Itis highly effective at reducing antibiotic sensitiveand resistantpropionibacterium acnes so is good for inflammatoryacne andis more effective than topical antibiotics. It hasmild comedolyticactivity but no anti-comedogenic action. Itcan cause drynessand irritation, so start with a low strengthcream formulationand titrate up. Advise that it can bleachclothes.
Topical antibiotics are also helpful in mild to moderateinflammatoryacne but should be used as combination formulationswith benzoylperoxide to help reduce the risk of bacterial resistance.
Second line treatments
Topical azelaic acid 20% works in a similar way to benzoyl peroxideand retinoids but is less irritating. It is likely to be muchless effective than retinoids and benzoyl peroxide but is helpfulin patients with post-inflammatory pigmentation.
For moderateacne a generic tetracycline (but not minocycline,because ofthe risk of skin pigmentation and other more seriousadverseeffects) is recommended for at least six weeks, in combinationwith topical treatment. Combining an oral antibiotic with benzoylperoxide helps to reduce the risk of bacterial resistance. Advisefemale patients that tetracyclines are contraindicated in pregnancyand that they should take adequate measures to avoid conceiving.Tetracyclines should not be prescribed to children aged under12 years, because of potential staining of teeth enamel.
Hormonaltreatment may improve acne in some women. There islittle evidencethat any is better than the others. Given thepotential foradverse effects, particularly venous thromboembolism(VTE),you should consider the risk-benefit ratio when prescribinghormonal treatment. Any hormonal treatment is contraindicatedin women with focal migraine or a higher than normal risk ofVTE. Co-cyprindiol has a product licence for severe acne andcan improve acne in up to 90% of female patients. Because ofconcerns about the risk of VTE, the advice is that this be givenfor 3-4 cycles after the acne is completely resolved then withdrawn(repeat courses may be given for recurrence). However, a recentpaper by S Franks and colleagues (see Further Reading) has shownthat this is not necessary, as there is no good evidence toconfirm an increased VTE risk, and there are moves to changethis recommendation.
Consider referral if the above describedtreatments do not resultin the desired outcomes (see box).
Guidance on referral to a specialist (based on NICE guidance,May 2001) Consider referral if the patient has:
Severe acneor painful nodulo-cystic acne, with potential or actual scarring.Such acne is likely to benefit from isotretinoin, an oral retinoidthat is very effective but can have serious side effects, rangingfrom dry skin, lips, and eyes to teratogenicity and possiblemood changes. It can be prescribed only by a dermatologist
Severesocial or psychological problems as a result of the acne
Moderateacne after six months of trying treatment in primary care, or
Asuspected underlying endocrine cause, such as polycystic ovariansyndrome.
*.General Surgeon (Hue,VN); *. ENT (Hue,VN); *. Leprosy Surgeon (I.L.A.D); *.Leprologist (C.E.S de Léprologie, Dakar, Senegal); *.Level II Dermatologist (HCMC);
*.Speaker at The Combined Congress of 27th Asean Orthopedic Association-6th Vietnamese Orthopedic Association-12th Spine society of HCM city (HCMC-December, 2007); *.International Hospital Federation 1996 Associate Fellow (Hongkong-London);
*.Fellowship in Saint- Louis Hospital at Department of Plastic Surgery and Department of Dermatology (Paris, 2008).
*.Fellow of Ho Chi Minh Society for Laser in Medicine and Surgery ;
*.Fellow of Vietnamese Society of Dermatology and Venereology;
*.International Fellow of American Academy of Dermatology