JERAWAT / ACNE

Lembaga Estetika Medik Indonesia

Patogenesis
Penyumbatan duktus polisebaseus.
Meningkatnya produksi sebum.
Perubahan biokimia susunan lemak-
lemak permukaan kulit/perubahan lipd
bilayer.
Kolonisasi kuman didalam folikel
polisebaseus.( P acne makannya
sebum )
Proliferasi folikuler ( karena keratinosit
nempel kuat tidak bisa lepas)
Inflamasi
Penanganan acne
Penanganan dilakukan sesuai
penyebab/ patogenesis
Penyumbatan duktus polisebaseus.
Menyingkirkan sumbatan dengan
Retinoid
Salicilic acid(BHA),
AHA(lactid,Glycolic,azeleic acid)
BHA more efective reducing
number of comedo than AHA
azeleic acid
5 STep
1.Normalizing
keratinization/exfoliation
Product that blocks step1
( Retinoid)
tretinoin,adaphalen,tazarotene,
retinol,retynil linoleate,retinyl
palmitat,
oral retinoid:iso tretinoin (if
needed)
2. Eliminating/ reducing P. Acne
topical antibiotic:clinda,eritro
solution, combination with
BPO/clinda,eritro
Azeleic acid
sodium sulfacetamide
sulfur
oral antibiotik
light therapy
3. Removing material that clogs the
pores (comedolitik)
Retinoid
Salicilic acid(BHA),
AHA(lactid,Glycolic,azeleic acid)
BHA more efective reducing
number of comedo than AHA
azeleic acid
4. Attacking the inflamatory
respons
salicilic acid (OTC,acne
wash,lotion,gel,mask)
in office BHA peels
oralNSAIDs
anti inflamatory agents : aloe
vera,chamomile,coenzym Q
10,cucumber
extract,feverfew,green
tea,licorice extract,
mushrooms,niacinamide,pycnoge
nol,silymarin
5. Decreasing level of sebum
oral kontraseptive,retinoid

Other
Pepaya enzim papain
proteolisis dari keratin
Clay mengurangi produksi
sebum
Aloe and ice twice daily ( anti
inflamatory, opens stratum
corneum)
Acne
Peradangan pada unit kelenjar
polisebaseus disertai penyumbatan
dan penimbunan bahan keratin
Letak: muka, leher, dada, lengan
atas dan punggung.
Gambaran klinis ditandai adanya
erupsi komedo, papel, pustul,
nodulus dan kiste serta jaringan
parut hipotrofik maupun
hipertrofik.
A normal follicle looks like this:
85 % : 12-25 th
15 % s/d 35 th
Tidak teratasi s/d 40 th
Mitos akne
Penyakit remaja hilang sendiri
Masalah kosmetika saja its no
big deal
Makanan
Stress
Higiene yang kurang baik,
Make up
Acne dapat sembuh
Medications that can cause acne

ACTH
Azathioprine
Barbiturates
Isoniazid Disulfiram
Lithium Halogens
phenytoin Iodides
Steroids
Cyclosporine
Vitamins B2,6,12
Keratinisasitidak
normal itu genetik
Pembagian Acne
Ringan
non inflamasi, komedo, milia.
Sedang
inflamasi +
Berat
Nodulocystic
 Major Oral Antibiotics Used for Treatment of Acne
Vulgaris by Dermatologists in The United State
Drug Usual dosage Comments Refs
range

Minocycline 50-100 mg once or Vestibular reactions may be 11,19-

(Immediate twice daily dose related and may be more 22,26
release) common with immediate-
release formulations
(especially generic
formulations with rapid
release properties.

Minocycline 1 mg/kg/day (45- Efficacy comparable to 2 17,18

(extended 135 mg once daily) mg/kg/day and 3 mg/kg/day:
release) potential for vestibular
reactiones appear to be lower
than with immediate-release
formulations

Doxycycline 75-100 mg once or Photosensitivity reported to 19-22, 26

twice daily 150 mg be dose related (higher
once daily. potential at 100 mg/day)
 Recommended Laboratory Evaluations For Patients With Acne and
Possible Hormonal Abnormalities

Labs to be considered when evaluating a patient with androgen excess

Dehydroepiandrosterone Sulfate (DHEAS)
Follicle-stimulating Hormon (FSH)
Luteinzing Hormone (LH)
Prolactin
17-Hydroxyprogesterone
Androstenedione
Free and total testosterone
Sex Hormone-binding globulin
In a patient where polycystic ovarian syndrome (PCOS) is
A consideration, add:
Fasting insulin
Fasting lipids
In a patient where cushings syndrome is considered, add Midnight
salivary cortisol level (new test approved by FDA)
 FDA Drug Risk Classification System for acne
Medications
Drug Definition Medication
classific
ation
A Controled studies show no fetal Zinc salts
risk.
B No evidence of risk to human Azelaic acid,
fetus erythromycin,
clindamycin,
metronidazole
C Risk to human fetus cannot be Adapalene, benzoyl
ruled out. peroxide, salicylic
acid,
tretinoin.sulfur.sodiu
m sulfacetamide
D Positive evidence of risk to human Tetracycline
fetus : however, potential benefits
may outweigh the potential risk.
X Contraindicated in pregnant Isotretinoin,
tazarotene
Guide for Evaluation of Mid-child hod AcneA
Bone Age
Accelerated with androgen excess
Delayed in Cushings syndrome Growth chart.
Height crossing percentiles upward in androgen excess
Weight crossing percentiles upward and height downward in
Cushings syndrome hormone levels
High levels of androgens such as free testosterone and DHEAS in
tumors and PCOS
High levels of 17- hydroxyprogesterone in CAH

------------------------------------------------------------
Abbereviations :DHEAS, dehydroepiandrosterone sulfate, PCOS,
polycistic ovary syndrome; CAH, Congenital adrenal hyperplasia.
Ringan : komedo< 20 atau lesi
inflamasi < 15 atau total
lesi <30
Sedang : komedo 20-100,lesi
inflamasi 15-20 atau total lesi 30-
125
Berat : kista > 5 atau
komedo>100 atau lesi inflamasi
>50 atau total lesi >125
Sebaseus hiperplasia neonatal
acne ( hilang sendiri) ~biang
keringat
There are various benign
tumours derived from adnexal
structures. Various combinations
of follicular, sebaceous, apocrine
and eccrine differentiation occur
commonly (mixed tumour or
chondroid syringoma).
milia
Histologically, milia are retention
cyst of pilocebaseous follicle,
usually seen in term infants and
scattered in nose, chin and
forehead. They exfoliate and
disappear within first few weeks
of life. No treatment is required.
Sebaceus hiperplasia
Epidermal cyst
kecil-kecil. kalo dipencet keluar yang putih2 panjang
kayak benang.
siringoma
syringoma
glication
Microcomedones become non-
inflamed skin blemishes called
comedones--either a whitehead
or a blackhead:
 For reasons no one completely understands, follicles,
often called pores, sometimes get blocked. Sebum
(oil) which normally drains to the surface gets
blocked and bacteria begins to grow. Both
whiteheads and blackheads start out as a
microcomedone. The picture below is a
microcomedone:
 A blackhead occurs when the pore opens to the
surface, and the sebum, which contains the
skin pigment melanin, oxidizes and turns a
brown/black color. It is not dirt and can not be
washed away. Blackheads can last for a long
time because the contents very slowly drain to
the surface.
 A papule occurs when there is a break in the
follicular wall. White blood cells rush in and the pore
becomes inflamed.
 A pustule forms several days later when white
blood cells make their way to the surface of the
skin. This is what people usually refer to as a
"zit" or a "pimple".
An inflamed lesion can sometimes completely collapse or explode, severely
inflaming the surrounding skin, and sometimes engulfing neighboring follicles.
These lesions are called nodules or cysts:

Nodule
When a follicle breaks along the bottom, total collapse can
occur, causing a large, inflamed bump that can be sore to
the touch
Development: A nodule occurs when the follicle wall
ruptures deep within the dermis. Contaminated debris from
the follicle empties into the dermis and infects adjoining
follicles. A nodule is a severe form of an acne lesion.
Cyst
Sometimes a severe inflammatory reaction can result in
very large pus filled lesions.
Development: Like nodules, cysts begin as a deep break
in the follicle wall. A membrane develops around the
infection in the dermis. As a cyst works its way to the
surface, it damages healthy skin tissue, destroying the
follicle. The likelihood of scarring is very high.
Ringan
Sedang
Berat
 Penatalaksanaan acne

Preventif
Kuratif
Tata laksana acne

Perawatankulit (Skin care)

Nasehat makanan
Medikamentosa
Pembersihan
Cleansing
Facial Wash
Toner

Yang mengandung bahan

antiseptik atau obat obatan
Tea tree, klorofil, BPO, Antibiotik,
Sulfur
Gentle cleansing 2-3 x sehari
Medicated cleaser (BPO/SA)
No overcleasing
No picking
Put an ice and aloe twice daily
Ingredients in OTC
products
Sulfur;precipitated or colloidal, 2-10 %
other forms, such as zinc sulfide or
sodium thiosulfate, are milder. Sulfur
presents a paradox in that it helps
resolve formed comedones but may
promote the formation of new ones.
Due to this comedogenic effect, the use
of salicylic acid or resorcinol is
preferred.

Resorcinol and salicylic acid;

continue
Combination of resorcinol and salicylic acid in
ethanol solution is advantageous because it
dries quickly and does not leave a visible film.
Benzoyl peroxide;(5to 10% cream)a primary
irritant which increases the growth rate of
epithelial cells, causing an increased rate of
sloughing and promoting resolution of
comedones,
Salicylic acid is used in concentration of o.5 to
2%.
Applied at night after washing the affected area
with soap and water.
Resorcinol(1to 4%) may produce a dark brown
scale on some black- skinned people; reaction is
reversible when the condition is discontinued.
NB, the drug may produces a feeling of warmth,
slight stinging , and reddening of the skin . If this
action is excessive the preparation should be
removed with soap and water and not reapplied
Sodium sulfacetamide 10%
Tretinoin Transe retinoic acid
The acid form of vitamin A, is a strong primary
irritant , similar to benzoyl peroxide, but is more
effective. It is available as solution in aqueous gel
base (0.05%). Or as cream (0.1%). The products
are applied at night. They cause a feeling of
warmth or slight stinging . Optimum results occur
in3 to 4 months.
NB . Care should be taken to avoid touching with
eyes, nose, and mouth with tretinoin.
Should not used with other keratolytic
Should not be applied to wet skin as it cause
excessive irritation
Exposure to strong sunlight should be avoided
because of the increased sensitivity of the skin,.
Does not cause the toxic effects of a large doses
of vitamin a
Cleansing solution
Acid salicyl 2
Resorcin 2
Biboras natricus 4
Spirt. Camphoratus 5
Aqua rosarum 140
Spirt. Dilutus ad 200
Acne Lotion
Asam salisilat
Resorsinol
LCD
Sulfur praecipitatum
Tea tree
Antibiotika
Minyak terpen
Sediaan Krim
Tretinoin
BPO
Antibiotika
Kortikostreroid
Sulfur
Asam salisilat
Sediaan Oral
Antibiotika
Kortikostreroid
Isotretinoin
Zn Gluconas
Vitamin A
Patient Selection and Pre therapy
management Retinoid

Acne nodulocistic mild/ severe

recalcitrant ( min 3months oral AB+
tret/other topical, woman : 4 cycles anti
androgen-estrogen)
KONTRA INDICATION
absolut :pregnancy, breast feed woman,
under 12 years, hepatic and kidney
disorder, chronic sistemic disease (KI
relatif)
Pre therapy management of
retinoid
Patient selection
Lab exam
Photo before therapy
Inform concent
Contraseptif for productive aged
woman begin 1 months before
therapy
Pengobatan
Retinoid
oral : isotretinoin 0.5-1
mg/kgBB/hr
dosis kumulatif 120
mg.kbBB
mini dose < 0,5
mg/kgBB/hr ( eg 10 mg/hr)
Topikal tretinoin ( krim, gel, sol)
0.025%, 0.05 %, 0.1 %
adapalene ( gel ) 0.1 %, o.3 %
Therapy management of
Retinoid
Starting dose : 0.25-0.5 mg
/kgBW/day for 2 weeks
Effect + dose
0.25mg/kgBW/day for 2 weeks
total dose 120-150 mg/kgBW
Effect - dose 0.5-1
mg/kgBW/day for 2 weeks
STOP !!! After 4-6 weeks,
continous topical tretinoin
Maximal 3 cycles after 4-6 weeks
free
Monitoring lab exam : renal,
hepar,lipid blood profile, pregnancy
test
Post therapy management of
retinoid
Lab exam 1 month post tx
Topical tx keratolitik, retinoid with
or without BPO
Skin care instruction : emolien,
lipid containing make up
Cosmetic use instruction : SPF
15-30
SPO before,during after therapy
Antibiotik
oral tetrasikin doksisiklin 50-100
mg, 2x/hr
minosiklin 100-200mg/hr
Klindamisin
Eritromisin, Azitromisin
Topikal : klindamisin 1 % ( gel,sol )
eritromisin 1,5-2 %
( gel,sol)
kombinasi + BPO
Azeleac acid ( krim , gel ) 15 % ,
20 %- memperbaiki keratinisasi
& mencegah kumulasi p
acne...anti inflamasinya masih
diragukan
B PO ( cuci muka, gel,sol) 2,5-5
% mencegah kumulatif p acne
Hanya retinoid dan antibiotika
yang bersifat anti inflamasi dan
me<< koloni P.Acne
Komedo (open/closed) topikal
keratolitik , topical retinoid
Inflamasi ( papul, pustule) :
topikal BPO,topikal AB, topikal
retinoid
Nodulocystic : all topical
inflamation + oral tretinoid
Side Effek
Retinoid
oral : teratogenik,kekeringan kulit,
gangguan pertumbuhan tulang,
peningkatan kadar kolesterol darah,
hepatotoksisitas, dll
topikal : iritasi, fotosensitivitas
Antibiotik : fotosensitivitas, pigmentasi
biru kehitaman, ggg GIT, resistensi
AZA dan BPO ; iritas
 APA TUJUAN TERAPI ORAL ?

1. Menurunkan populasi mikroorganisme di

folikel pilosebasea dan permukaan kulit.
2. Menurunkan kadar asam lemak bebas.
3. Menekan peradangan.
4. Menginhibisi langsung ensim lipolitik
lipase.
KAPAN TERAPI ORAL DIBUTUHKAN ?

Bila terapi topikal tidak berhasil

Pada acne inflamasi
Pada acne gradasi sedang atau
berat
 Resep oral anti acne (1)
Acne lotion
S ue
Benzoil peroksida 5 %
S sore hari
Vit C 100 mg
Vit B compl 1 tb
Zn Gluconas 100 mg
S 3 dd 1
Vitamin A 20.000 IU
S 1 dd 1
Resep oral anti acne (2)
Tetrasiklin500 mg
S 4 dd 1 ac
Yeastafort
S 3 dd 1
Vitamin A 20.000 IU
S 1 dd 1
Resep oral anti acne (3)
Doksisiklin 100 mg
S 1 dd 1
Interhistin 50 mg
Medrol 4 mg
S 3 dd 1
Resep oral anti acne (4)
Clindamisin 300 mg
S 2 dd 1 ac
Loratadine 5 mg
Prednison 5 mg
S 2 dd 1
Sediaan Parenteral
Zn Gluconas
Kortikostreroid (KIL)
Tretinoin
Iritan
Meningkatkan pulih asal (turnover) sel
di dalam duktus polisebaseus,
Mengurangi perlekatan sel di
epidermis (decreased cohesiveness),
Mengeluarkan isi komedo,
Mengurangi proses radang,
Mempertinggi penetrasi
transepidermal untuk antibiotika dan
benzoil peroksida.
Benzoil Peroksida
Iritan
Deskuamasi intraepidermal,
Menekan asam lemak bebas,
Bakteriostatik terhadap
Propionibacterium acnes,
Mencegah hidrolisis
trigliserida.
Antibiotika
Tetrasiklin
Doksisiklin
Demeklosiklin
Minosiklin
Klindamisin Lincomisin
Erythromisin
Cotrimoxasol
Ciprofloxacin
Antibiotik Oral
a. Tetrasiklin hidroklorida
dosis tinggi 4x250 mg/hr 1jam ac 3-
6 mgg, diturunkan 250mg/hr 6-8
mgg
dosis rendah 250 mg/hr 1jam
ac/2jam pc 4-8 mgg
b. Eritromisin
dosis tinggi 4x250mg/hr 1 jam ac 2-
6 mgg, dosis disesuaikan 4-6 mgg
Kindamisin
Derivat Lincomisin
Mekanisme kerja : mengikat
ribosom, sehingga menghalangi
pemindahan RNA (Ribo Nucleic
Acid) untuk pembentukan
kompleks ribosomal / messenger-
RNA dari kuman akibatnya
mikroorganisme tidak dapat
membentuk protein essential.
No free radicals , low glicemic
diet
Daily skin care

Glicolic/microdermabrasion/extract
ion
Peeling ( progresif)
Light terapy ( LED,IPL,laser)
Bahan aktif Herbal Anti Acne
Antibakteri
Antiinflamasi
Mengurangi kelenjar keringat
Mempercepat penyembuhan luka
Contoh : witch hazel, centella
asiatica, tea tree,
curcuma( temulawak, kunyit)
Di tanaman ada senyawa2x aktif
yang berkhasiat obat dari
metabolisme sekunder,yang
digunakan untuk benteng
pertahanan tumbuhan dari pengaruh
buruk lingkungan luar
3 kelompok besar metabolit
sekunder : terpenoid/steroid, alkaloid
dan senyawa nitrogen terkait dan
fenilpropanoat dan senyawa fenolat
lain ( flavonoid, tanin)
 Adas
Efek herbal : antibakteri,
melancarkan peredaran
darah,mengobati gangguan lambung
2 macam ramuan yang dipakai :
diminimun dan masker wajah
Ramuan minum
adas 1 gr
temukunci 1,5 gr
jahe 5 gr
kayu secang 5 gr
kapulaga 1,5 gr
daun sembung 1,5 gr
Rebus semua bahan dengan 2 gelas air
hingga tersisa 1 gelas ( 200cc) minum
antara pk 18-19 wib.perbanyak minum
dan kurangi gula
Masker jerawat
Adas 1 gr ( 1 sdt)
Temugiring 5 gr ( 3 jari)
Temukunci 5 gr ( 3 jari)
Kayu rapet 5 gr ( 3 jari)
Pulosari 5 gr ( 1 sdm)
Klembak 5 gr ( 3 jari)
Cara membuat :
Haluskan semua bahan, ambil 1 sdm serbuk ramuan,
tambahkan air secukupnya, gunakan sebagai lulur wajah ,
diamkan 15 menit
Untuk hasil maksimal ditambahkan bolus alba yang bisa beli
di apotek
 Asam jawa
buah asam jawa 3 biji
daun sambiloto 11 lembar
pegagan 11 lembar
rimpang temu lawak sebesar telur itik 1 bji
Cara membuat :
Umbi temulawak dikupas,dicuci, lalu diiris tipiis-
tipis. Bersama bahan lain direbus dalam 5 gelas
air hingga tersisa 4 gelas, angkat, saring,
diminum 3x sehari gelas sesudah makan slm 2
mgg
 Major Oral Antibiotics Used for Treatment of Acne
Vulgaris by Dermatologists in The United State
Drug Usual dosage Comments Refs
range

Minocycline 50-100 mg once or Vestibular reactions may be 11,19-

(Immediate twice daily dose related and may be more 22,26
release) common with immediate-
release formulations
(especially generic
formulations with rapid
release properties.

Minocycline 1 mg/kg/day (45- Efficacy comparable to 2 17,18

(extended 135 mg once daily) mg/kg/day and 3 mg/kg/day:
release) potential for vestibular
reactiones appear to be lower
than with immediate-release
formulations

Doxycycline 75-100 mg once or Photosensitivity reported to 19-22, 26

twice daily 150 mg be dose related (higher
once daily. potential at 100 mg/day)
 Recommended Laboratory Evaluations For Patients With Acne and
Possible Hormonal Abnormalities

Labs to be considered when evaluating a patient with androgen excess

Dehydroepiandrosterone Sulfate (DHEAS)
Follicle-stimulating Hormon (FSH)
Luteinzing Hormone (LH)
Prolactin
17-Hydroxyprogesterone
Androstenedione
Free and total testosterone
Sex Hormone-binding globulin
In a patient where polycystic ovarian syndrome (PCOS) is
A consideration, add:
Fasting insulin
Fasting lipids
In a patient where cushings syndrome is considered, add Midnight
salivary cortisol level (new test approved by FDA)
FDA Drug Risk Classification System for acne
Medications
Drug Definition Medication
classific
ation
A Controled studies show no fetal Zinc salts
risk.
B No evidence of risk to human Azelaic acid,
fetus erythromycin,
clindamycin,
metronidazole
C Risk to human fetus cannot be Adapalene, benzoyl
ruled out. peroxide, salicylic
acid, tretinoin.Sulfur
D Positive evidence of risk to human Tetracycline
fetus : however, potential benefits
may outweigh the potential risk.
X Contraindicated in pregnant Isotretinoin,
tazarotene
Guide for Evaluation of Mid-child hod AcneA
Bone Age
Accelerated with androgen excess
Delayed in Cushings syndrome Growth chart.
Height crossing percentiles upward in androgen excess
Weight crossing percentiles upward and height downward in
Cushings syndrome hormone levels
High levels of androgens such as free testosterone and DHEAS in
tumors and PCOS
High levels of 17- hydroxyprogesterone in CAH

------------------------------------------------------------
Abbereviations :DHEAS, dehydroepiandrosterone sulfate, PCOS,
polycistic ovary syndrome; CAH, Congenital adrenal hyperplasia.
Terima kasih