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 kual 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,pycnogen
ol,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  Disulfiram
 Azathioprine  Halogens
 Barbiturates  Iodides
 Isoniazid  Steroids
 Lithium  Cyclosporine
 phenytoin  Vitamins B2,6,12
Keratinisasi
tidak
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 range Comments Refs

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 be 19-22, 26

twice daily 150 mg dose related (higher potential
once daily. 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 cushing’s syndrome is considered, add Midnight salivary
cortisol level (new test approved by FDA)
 FDA Drug Risk Classification System for acne
Medications
Drug Definition Medication
classificat
ion
A Controled studies show no fetal risk. Zinc salts
B No evidence of risk to human fetus Azelaic acid,
erythromycin,
clindamycin,
metronidazole
C Risk to human fetus cannot be ruled Adapalene, benzoyl
out. peroxide, salicylic
acid,
tretinoin.sulfur.sodium
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 Cushing’s syndrome Growth chart.
 Height crossing percentiles upward in androgen excess
 Weight crossing percentiles upward and height downward in
Cushing’s syndrome hormone levels
 High levels of androgens such as free testosterone and DHEAS in
tumors and PCOS
 High levels of 17-α 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

 Perawatan kulit (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
until the next day. It should not be used on the eye
lids, lips, or neck.
 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)
 Tetrasiklin 500 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  Lincomisin
 Doksisiklin  Erythromisin
 Demeklosiklin  Cotrimoxasol
 Minosiklin  Ciprofloxacin
 Klindamisin
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/extracti
on
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 ½ gelas sesudah makan slm 2 mgg
 Major Oral Antibiotics Used for Treatment of Acne
Vulgaris by Dermatologists in The United State
Drug Usual dosage range Comments Refs

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 be 19-22, 26

twice daily 150 mg dose related (higher potential
once daily. 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 cushing’s syndrome is considered, add Midnight salivary
cortisol level (new test approved by FDA)
 FDA Drug Risk Classification System for acne
Medications
Drug Definition Medication
classificat
ion
A Controled studies show no fetal risk. Zinc salts
B No evidence of risk to human fetus Azelaic acid,
erythromycin,
clindamycin,
metronidazole
C Risk to human fetus cannot be ruled Adapalene, benzoyl
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 Cushing’s syndrome Growth chart.
 Height crossing percentiles upward in androgen excess
 Weight crossing percentiles upward and height downward in
Cushing’s syndrome hormone levels
 High levels of androgens such as free testosterone and DHEAS in
tumors and PCOS
 High levels of 17-α hydroxyprogesterone in CAH

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