Acne Vulgaris

Acne vulgaris (AV) is a disease of the pilosebaceous unit that causes noninflammatory lesions (open and closed comedones), inflammatory lesions (papules, pustules, and nodules), and varying degrees of scarring. 

The formation of acne lesions: 

• Alteration of follicular keratinization that leads to comedones 
• Increased and altered sebum production under androgen control (androgens stimulate sebum production via androgen receptors on the sebaceous glands).
• Follicular colonization by Propionibacterium acnes 
• Complex inflammatory responses

Risk factor

• Family history of severe acne 
• Diet (chocolate and dairy consumption) 
• Environmental factors (smoking, occlusive cosmetics, occupational exposures) 
• Hormone-based therapies such as oral contraceptive and anti-androgen medications in women with normal androgen levels

Comedones

Papules and pustules

Cysts and/or Nodules

Reference 

Tan, A. U. et al., 2018,'A review of diagnosis and treatment of acne in adult female patients', Int J Womens Dermatol, vol. 4, no. 2, pp. 56-71.

Beauty Corner : The Truth about Vitamin C

Vitamin C is a diva in natural skincare product. They have amazing benefits for our health especially for our skin. Uneven skin tone, rough texture, fine lines, acne scars, general dullness, any common complexion concern and there's a good chance that vitamin C is a recommended treatment. But, how actually vitamin C works? Do all product that contain vitamin C have the same potential effect ?  Does vitamin C have any adverse effect if we use for long time ? Okay before we discuss about that, let's find out about what is vitamin C.

What is Vitamin C?

Officially known as ascorbic acid, vitamin C is a water-soluble vitamin. Your body doesn’t produce it, so you must obtain it through your diet (from natural sources such as citrus fruits, green leafy vegetables, strawberries, papaya and broccoli). 

In nature, Vit. C is found in equal parts as LAA and D-ascorbic acid. However, only LAA is biologically active and thus useful in medical practice. 

How actually Vitamin C Works ?

• Vit C as Antioxidant

Vit C is very potent antioxidant. It protects the skin from oxidative stress by neutralized them. 

• Vit C as Photoprotector

Vit. C is equally effective against both UVB (290-320 nm) and UVA (320-400 nm). How about if we only use sunscreen ? Sunscreen is also photoprotector, right ? Sunscreens when properly applied prevent UV-induced erythema and cell mutations that contribute to skin cancer. However, sunscreens block only 55% of the free radicals produced by UV exposure. To optimize UV protection, it is important to use sunscreens combined with a topical antioxidant.

Although Vit. C alone can provide photoprotection, it works best in conjunction with Vitamin E (Vit. E), which potentiates the action of Vit. C four-fold.

• Vitamin C and Synthesis Collagen

Vit. C is essential for collagen biosynthesis. Clinical studies have shown that the topical use of Vit. C increases collagen production in young as well as aged human skin. Because of that, Vitamin C is known as anti-aging agent

• Vitamin C as a Depigmenting Agent

The action of vitamin C as a depigemented agent is interrupting the key steps of melanogenesis. However, Vit. C is an unstable compound. It is therefore often combined with other depigmenting agents such as soy and liquorice for better depigmenting effect.

• Anti-Inflammatory Action of Vitamin C

Vit. C has a potential anti-inflammatory activity and can be used in conditions like acne vulgaris and rosacea. It can promote wound healing and prevent post-inflammatory hyperpigmentation

Which form of Vitamin C skincare product that best to use ?

Vit. C is available in the market as a variety of creams, serum and transdermal patches. Of these, only the serum contains active Vit. C in an almost colorless form.The other form of vitamin C that you can find in skincare product is Magnesium ascorbyl phosphate (MAP). It is lipid-soluble form. It is stable and has hydrating effect. 

What is the adverse effect of vitamin C?

Topical Vit. C is largely safe to use on a daily basis for long durations. It can safely be used in conjunction with other common topical anti-ageing agents such as sunscreens, tretinoin, other antioxidants and alfa hydroxy acids such as glycolic acid. Stinging, erythema and dryness are very rare. But if this is happened, you can use moisturizer as the treatment. Care must be taken while applying Vit. C around the eyes.

Reference :

Telang, P.S, 2013, Vitamin C in Dermatology, Indian Dermatol Online J. 4(2): 143–146

www.healthline.com/nutrition/vitamin-c-for-acne#vitamin-c-skincare

Pemphigus vulgaris

Pemphigus vulgaris (PV) is rare autoimmune bullous dermatosis that results from the production of autoantibodies against desmogleins 1 and 3. It is the most frequent and most severe form of pemphigus, occurring usually between 40 and 60 years of age. PV is more prevalent among women. Lesions are usually flaccid blisters that are break easily and form painful erosions on the oral mucosa or the skin, which can be disseminated. Almost all patients present mucosal lesions (especially oral mucosa in 90% cases). The most affected areas are the buccal and palatine mucosa, lips, and gingivae. Beside oral mucosal, PV may be involved, including the conjunctiva, nasal mucosa, pharynx, larynx, esophagus, vagina, penis, and anus. The rare manifestations of PV are isolated crusted plaque on face and scalp, foot ulces, dyshidrotic eczema, macroglossia, nail dystrophy, paronychia, and subungual hematomas. 

Oral mucose manifestation

Skin manifestation

Nail manifestation

The treatments for PV are systemic corticosteroids and immunosuppressive drugs. Its mortality is 10% and the main cause of death is septicaemia. 

Reference 

Porro, A. M., 2019,'Pemphigus vulgaris', An Bras Dermatol, vol. 94, no. 3, pp. 264-278.

Hyperemesis Gravidarum (HG)

HG is persistent and excessive vomiting that occurs before 22nd week of pregnancy and there is no other possible causes (e.g., gastrointestinal tract problem). HG is related to dehydration, ketonuria, electrolyte imbalance, and more than 5% body weight loss in mother. Severe HG also can cause  preterm birth, low birth weight and small of gestasional age. 

Get pregnant in younger age, primiparous (first pregnancy) increase the risk of getting HG. High hCG serum reach the highest concentration in the first semester when the worst symptom occurs.

Treatment of mild to moderate HG is antiemetic drugs, such as promethazine, metocloperamide. Severe HG treatment is rehydration with 5% dextrose (for the first 24 hours) then use normal saline or use normal saline only, correction of electrolyte imbalance, antiemetic drugs, and nasograstic tube (if necessary for nutrional support).  

Reference

McCarthy, F. P. et al., 2014,' Hyperemesis gravidarum: current perspectives ', Int J Womens Health, vol. 6, pp. 719-725.

Beauty Corner : How to Deal with Dry Skin ?

Dry skin is often temporary (depend on the weather) but it may be a lifelong condition. The severity of dry skin depend on your age, your health, where you live, time spent outdoors and the cause of the problem. If you have dry skin, you may feel one or more of the following condition :

• A feeling of skin tightness, especially after showering, bathing or swimming
• Skin that feels and looks rough
• Itching 
• Slight to severe flaking, scaling or peeling
• Fine lines or cracks
• Gray, ashy skin
• Redness
• Deep cracks that may bleed

Risk Factor for Dry Skin

Everyone can have dry skin. You might have naturally dry skin. Even if your skin tends to be oily, you can develop dry skin from time to time. But there are some factors that might increase your chance to develop dry skin, such as : 

• Age. Older adults are more likely to develop dry skin. As you age, your pores naturally produce less oil, raising your risk of dry skin.
• Medical history. You’re more likely to experience eczema or allergic contact dermatitis if you have a history of these conditions or other allergic diseases in your family.
• Season. Dry skin is more common during the fall and winter months, when humidity levels are relatively low. In the summer, higher levels of humidity help stop your skin from drying out.
• Bathing habits. Taking frequent baths or washing with very hot water raises your risk of dry skin.

Can dry skin lead to serious skin problem ?

Dry skin is usually harmless. But when it's not cared for, dry skin may lead to:

• Atopic dermatitis (eczema). If you're prone to develop this condition, excessive dryness can lead to activation of the disease, causing redness, cracking and inflammation.
• Infections. Dry skin may crack, allowing bacteria to enter, causing infections.

These complications are most likely to occur when your skin's normal protective mechanisms are severely compromised. For example, severely dry skin can cause deep cracks or fissures, which can open and bleed, providing an avenue for invading bacteria.

So, what should I do to deal with dry skin?

• Prevent baths and showers from making dry skin worse. When your skin is dry, be sure to:
• Close the bathroom door
• Limit your time in the shower or bath to 5 or 10 minutes
• Use warm rather than hot water
• Wash with a gentle, fragrance-free cleanser
• Apply enough cleanser to remove dirt and oil, but avoid using so much that you see a thick lather
• Blot your skin gently dry with a towel
• Slather on the moisturizer immediately after drying your skin

• Apply moisturizer immediately after washing. Ointments, creams, and lotions (moisturizers) work by trapping existing moisture in your skin. To trap this much-needed moisture, you need to apply a moisturizer within few minutes of:

• Drying off after a shower or bath
• Washing your face or hands
• Use an ointment or cream rather than a lotion. Ointments and creams are more effective and less irritating than lotions. Look for a cream or ointment that contains an oil such as olive oil or jojoba oil. Shea butter also works well. Other ingredients that help to soothe dry skin include lactic acid, urea, hyaluronic acid, dimethicone, glycerin, lanolin, mineral oil, and petrolatum.
• Wear lip balm. Choose a lip balm that feels good on your lips

• Use only gentle, unscented skin care products. Some skin care products are too harsh for dry, sensitive skin. When your skin is dry, stop using:

• Deodorant soaps
• Skin care products that contain alcohol, fragrance, retinoids, or alpha-hydroxy acid (AHA)
• Wear gloves.
• Use non-irritating laundry detergent.
• Stay warm without cozying up to a fireplace or other heat source. Sitting in front of an open flame or other heat source can dry your skin.
• Add moisture to the air. Plug in a humidifier.
• Drink plenty of water

Reference :

www.aad.org/public/everyday-care/skin-care-basics/dry/dermatologists-tips-relieve-dry-skin

www.healthline.com/health/dry-skin#treatment

www.mayoclinic.org/diseases-conditions/dry-skin/symptoms-causes/syc-20353885

Difference Between Vitiligo and Pityiriasis alba

Vitiligo

Vitiligo is an idiopathic disorder characterized by the disappearance of melanocytes in lesional skin resulting in sharply demarcated depigmented macules and patches ( get bigger with time ). Although often fairly distinct clinically, the differential diagnosis includes postinflammatory hypopigmentation, tinea versicolor, pityriasis alba, and, less commonly, hypopigmented mycosis fungoides (MF) and leprosy, among other entities. 

Vitiligo can appear in any age (usually starts at twenties) and any area of the body. About 15 to 25 percent of people with vitiligo are also affected by at least one other autoimmune disorder, such as Hashimoto's disease , Rheumatiod arthritis, Type 1 diabetes meliitus, psoriasis, Addison disease, or Systemic Lupus Erythematosus. In the absence of  autoimmune conditions, vitiligo does not affect general health or physical functioning.

Pityriasis Alba

Pityriasis alba (PA) is an eczematous dermatosis characterized by patchy hypopigmentation. It is usually seen in children, although it may occur in all skin types. It usually worsens during the summer, as the contrast between normal and lesional skin becomes greater with sun exposure. Lesions are usually asymptomatic, although they can be slightly pruritic.

Lesion reveals multiple, ill-defined, finely scaling patches that are symmetrically distributed. Lesions are most commonly found on the face (especially the cheeks). They may be slightly erythematous early on, then become hypopigmented. Lesions may persist for months to years, with a chronic relapsing course, but eventually resolve spontaneously without any medication.

Reference 

Soro, L. A. et al., 2013,'Inflammatory vitiligo versus hypopigmented mycosis fungoides in a 58-year-old Indian female', Indian Dermatol Online J, vol. 4, no. 4, pp. 321-325.

www.dermatologyadvisor.com/home/decision-support-in-medicine/dermatology/pityriasis-alba/ (July 21, 2020, 20:21). 

Tinea Cruris

Dermatophytes are fungi that invade and multiply within keratinized tissues (skin, hair, and nails) causing infection. Dermatophytes can be classified into three groups: Trichophyton (which causes infections on skin, hair, and nails), epidermophyton (which causes infections on skin and nails), and Microsporum (which causes infections on skin and hair). Based upon the affected site, these have been classified clinically into tinea capitis (head), tinea faciei (face), tinea barbae (beard), tinea corporis (body), tinea manus (hand), tinea cruris (groin), tinea pedis (foot), and tinea unguium (nail). Trichophyton is the most common isolate with tinea corporis and cruris. 

Occlusive footwear and tight fashioned clothes, has been linked to this infection. However, all people are not equally susceptible to fungal infection, even when they have similar risk factors. There is evidence of familial or genetic predispositions that could be mediated by specific defects in innate and adaptive immunity.  Impaired function of Th17 cells leading decreased production of interleukin-17 (IL-17), IL-22 (key cytokine in clearing mucocutaneous fungal infection) results in persistence of infection.

The predisposition factors of infection are underlying diseases such as diabetes mellitus, lymphomas, immunocompromised status, or Cushing's syndrome, older age, which could produce severe, widespread, or recalcitrant dermatophytosis. The areas of the body are more susceptible to the development of dermatophyte infections such as intertriginous areas (web spaces and groins) where excess sweating, maceration, and alkaline pH favor the growth of the fungus.

Treatment

Non-pharmacology

1. Wear loose-fitting garments made of cotton or synthetic materials designed to wick moisture away from the surface.
2. Areas likely to become infected should be dried completely before being covered with clothes. 
3. Avoid walking barefoot and sharing garments.

Pharmacology

A meta-analysis by Rotta et al.(2013) shows topical antifungals for the outcome of fungal cure showed butenafine and terbinafine each to be superior to clotrimazole, oxiconazole, and sertaconazole; terbinafine to be superior to ciclopirox, and naftifine to be superior to oxiconazole.

Cochrane review by El-Gohary, M. et al. (2014), on the topical antifungal treatments for tinea cruris and tinea corporis suggests that the individual treatments with terbinafine and naftifine are effective with few adverse effects. Other topical antifungals like azoles treatments are also effective in terms of clinical and mycological cure rates. Regarding combinations therapy of topical steroids and antifungals though there is no standard guideline. Topical antifungal are usually given once or twice daily for 2–4 weeks. 

Reference

El-Gohary, M. et al., 2014,' Topical antifungal treatments for tinea cruris and tinea corporis', Cochrane Database Syst Rev., vol. 8. 

Rotta, I. et al., 2013,'Efficacy of topical antifungals in the treatment of dermatophytosis: A mixed-treatment comparison meta-analysis involving 14 treatments', JAMA Dermatol., vol. 149, no.-, pp. 341–9. 

Sahoo, A. K. & Mahajan, R., 2016,'Management of tinea corporis, tinea cruris, and tinea pedis: A comprehensive review', Indian Dermatol Online J., vol. 7, no. 2, pp. 77–86.