AV- Presentation1

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12/30/2010 1 Acne Vulgaris and its Management in Unani Medicine By Azad Hussain Lone P .G.Scholar , Deptt. Of Moalajat NIUM, Bangalore

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12/30/2010 2 CONTENTS Introduction Etiology and Pathogenesis Epidemology Clinical Presentation Interpretation with Unani Description Diagnosis D/D Management Prognosis.

Introduction : 

Introduction 12/30/2010 3 Acne vulgaris is the most common disorder treated by dermatologists. The term acne comes from a corruption of the Greek άκμή (acne in the sense of a skin eruption) in the writings of Aëtius Amidenus. Used by itself, the term "acne" refers to the presence of pustules and papules. The most common form of acne is known as "acne vulgaris", meaning "common acne". Use of the term "acne vulgaris" implies the presence of comedones.

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12/30/2010 4 Definition: Acne is a chronic inflammatory disease of the pilosebaceous units. It is characterized by seborrhoea, the formation of comedones, erythematous papules and pustules, less frequently by nodules, deep pustules, or pseudocysts and, in some cases, is accompanied by scarring. Acne is a disorder of the pilosebaceous apparatus characterized by comedones, papules, pustules, cysts and scars.

Epidemology : 

Epidemology 12/30/2010 5 Acne vulgaris is a common disorder that peaks in incidence around the time of puberty. Nearly all teenagers have some acne or acne vulgaris. It affects the sexes equally, starting usually between the ages of 12 and 14 years, tending to be earlier in females. The peak age for severity in females is 16–17 and in males 17–19 years. As many as 80 to 90% of all adolescent will have some type of acne and 30% will require medical treatment. Acne develops earlier in females than in males which may reflect the earlier onset of puberty.

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Cont…………. 12/30/2010 6 In one study prevalence of significant acne was 56% in boys and 45% in girls aged between 14 and 16 years, being moderate to severe in 11%. A peak in prevalence and severity occurs between 14 and 17 years in females, when 40% are affected, and 16 and 19 years in males, when 35% are affected. After the age of somewhere between 20 and 25 years the acne resolves slowly. However, in 7–17% of individuals clinical acne persists beyond the age of 25 years with physiological acne in females having a prevalence of 24%. Studies of European schoolchildren in Switzerland in 1931, Newcastle upon Tyne, England, in 1971 and Glasgow, Scotland, in 1989 have shown a consistent level of maximum prevalence, approaching 100% for 16–17-year-old boys and 85–100% in 16-year-old girls.

Etiopathogenesis : 

Etiopathogenesis 12/30/2010 7 Acne is not infectious. The three major organisms isolated from the surface of the skin and the pilosebaceous ducts of patients with acne are Propionibacterium acnes, Staphylococcus epidermidis and Malassezia furfur . The most common agent is P acnes, a normal skin commensal. It colonizes the pilosebaceous ducts, breaks down triglycerides releasing free fatty acids, produces substances chemotactic for inflammatory cells and induces the ductal epithelium to secrete pro-inflammatory cytokines.

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Cont………… 12/30/2010 8 Four major factors are involved in the pathogenesis viz: Increased sebum production, Seborrhoea Comedo formation (comedogenesis) due to hypercornification of the pilosebaceous duct, An abnormality of the microbial flora especially colonization of the duct with P. acnes, Production of inflammation. Many factors combine to cause acne characterized by chronic inflammation around pilosebaceous follicles. Hormones: Androgens (from the testes, ovaries and adrenals) are the main stimulants of sebum excretion, although other hormones (e.g. thyroid hormones and growth hormone) have minor effects too. Those castrated before puberty never develop acne.

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Cont…………. 12/30/2010 9 Poral occlusion: Both genetic and environmental factors (e.g. some cosmetics) cause the epithelium to overgrow the follicular surface. Follicles then retain sebum that has an increased concentration of bacteria and free fatty acids. Genetic: The condition is familial in about half of those with acne. There is a high concordance of the sebum excretion rate and acne in monozygotic, but not dizygotic, twins. Physiological and environmental factors thatinfluence acne. There are many myths about factors that might help or aggravate acne. These are Diet , Premenstrual flare , Sweating Ultraviolet radiation , Occupation , Smoking.

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Interpretation with Unani Description : 

Interpretation with Unani Description 12/30/2010 11 Acne Vulgaris is described with the names of Basoore Labaniya, Keel, Muhase in classical Unani books like Alhavi fi tib by Razi, Al Qanoon by Ibne Sina, Tibe Akbar by Akbar Arzani. In classical Unani literature, etiopathogenesis is attributed to Madae Sadeediya (pus) and Sue Mizaj Balgami . According to Ibn Sina, sometimes white eruptions appear on the nose and cheeks, just like freezed drops of milk. They are caused by maddae sadeediya (suppurative materials) which move towards the skin due to bukharat ( vapours) of the body.

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Cont……… 12/30/2010 12 Asbabe Mumiddah (Predisposing factors) Hiddate dam wa imtila (blood impairment) Sue hazam (digestive problems) Constipation, Menstrual irregularities Alcoholism Excess intake of hot , flatulent, oily and sweet food items. Heredity Environmental factors,

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12/30/2010 13 TYPES OF ACNE: Acne vulgaris : Affects comedogenic areas, occurs mainly in puberty, in boys more than girls, with amilial tendency. Infantile acne: May follow transplacental stimulation of a child’s sebaceous glands by maternal androgens, affects face only, and clears spontaneously. Severe acne: Acne conglobata , Pyoderma faciale, Gram negative folliculitis. Occupational acne Oils Coal and tar, Chlorinated phenols, DDT and weedkillers Hormones Combined type of oral contraceptives and androgeni. Mechanical. Excessive scrubbing, picking, or the rubbing of chin straps or a fiddle can rupture occluded follicles.

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12/30/2010 14 Drug-induced: Corticosteroids, androgenic and anabolic steroids, gonadotrophins, oral contraceptives, lithium, iodides, bromides, antituberculosis, anticonvulsant therapy and Steroids (Systemic or topical) can all cause an acneiform rash. Tropical: Heat and humidity are responsible for this variant, which affects Caucasoids with a tendency to acne. This occurs mainly on the trunk . Acne associated with virilization, including clitoromegaly, may be caused by an androgen-secreting tumour of the adrenals, ovaries or testes or, rarely, due to congenital adrenal hyperplasia caused by mild 21-hydroxylase deficiency. Acne accompanying the polycystic ovarian syndrome is caused by modestly raised circulating androgen levels.

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12/30/2010 15 Fulminans: Acne fulminans is a rare variant in which conglobate acne is accompanied by fever, joint pains and a high erythrocyte sedimentation rate(ESR). Exogenous: Tars, chlorinated hydrocarbons, oils, and oily cosmetics can cause or exacerbate acne. Suspicion should be raised if the distribution is odd or if comedones predominate . Excoriated: This is most common in young girls. Obsessional picking or rubbing leaves discrete denuded areas. Late onset: This too occurs mainly in women and is often limited to the chin. Nodular and cystic lesions predominate. It is stubborn and persistent. Acne associated with suppurative hidradenitis and perifolliculitis of scalp .

Clinical Presentation : 

Clinical Presentation 12/30/2010 16 Acne is a polymorphic disease, which occurs predominantly on the face (99% of sufferers) and, to a lesser extent, occurs on the back (60%) shoulders, and chest (15%). In young men, it affects mainly the face, and in older males the back is also significantly affected. Seborrhoea (a greasy skin ) is a frequent feature Non-inflamed lesions (comedones) develop earlier than inflamed lesions in younger patients Comedones may be blackheads (open comedones), in which the black colour may be due to the presence of melanin (not dirt or oxidized sebum), whiteheads (closed comedones) and intermediate non-inflamed lesions, which show features of both blackheads and whiteheads. Comedonal lesions called ‘sandpaper comedones’ consist of multiple very small whiteheads and are found most often on the forehead

Cont….. : 

Cont….. 12/30/2010 17 Inflammatory lesions may be superficial or deep, and many arise from non-inflamed lesions The superficial lesions are usually papules and pustules (5 mm or less in diameter) and the deep lesions are deep pustules and nodules, cysts leading to devastating cosmetic effects and scarring, Calcification and persistent post-inflammatory hyperpigmentation. Conglobate (gathered into balls; from the Latin globus meaning ‘ball’) is the name given to a severe form of acne with all of the above features as well as abscesses or cysts with intercommunicating sinuses that contain thick serosanguinous fluid or pus. On resolution, it leaves deeply pitted or hypertrophic scars, sometimes joined by keloidal bridges. Psychological depression is common in persistent acne, which need not necessarily be severe.

Psychosocial effects of acne : 

Psychosocial effects of acne 12/30/2010 18 In its more severe form, acne becomes a source of great anxiety to the young .They are profoundly disturbed by the disfiguring scares and the new “pimples “hence this condition can affect the emotional state of a patient. Although medically benign, acne in some patients is cosmetically and psychosocially malignant stress can induce acne. Questionnaire studies have shown that many acne patients experience shame (70%), embarrassment and anxiety (63%), lack of confidence (67%), impaired social contact (57%) and a significant problem with unemployment. Severe acne may be related to increased anger, social withdrawal, depression and anxiety. Acne also affects patients’ functional abilities. In addition, younger acne patients are subject to bullying, teasing and stigmatization from their peers.

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12/30/2010 19 Infantile acne. Pustulocystic lesions on the checks Steroid-induced acne in a seriously ill patient.

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Differential diagnosis Rosacea : It affects older individuals; comedones are absent; the papules and pustules occur only on the face; and the rash has an erythematous background. Pyogenic folliculitis can be excluded by culture. Hidradenitis suppurativa is associated with acne conglobata, but attacks the axillae and groin. Pseudofolliculitis barbae, caused by ingrowing hairs, occurs on the necks of men with curly facial hair and clears up if shaving is stopped. 12/30/2010 20

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12/30/2010 21 Acne grading Grading is very useful in the assessment of acne in the clinic, The acne can be graded on a 0–10 scale on the face, back and chest IGASS Mild Mild Moderate Severe

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12/30/2010 22 Leed’s acne grading technique: Counts and categorises lesions into inflammatory and non-inflammatory (ranges from 0-10). Cook's acne grading scale: Uses photographs to grade severity from 0 to 8 (0 being the least severe and 8 being the most severe). Pillsbury scale: Simply classifies the severity of the acne from 1 (least severe) to 4 (most severe).

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12/30/2010 23 A group of open comedones (blackheads) following the use of a greasy cosmetic. Late-onset acne in a woman. Often localized to the chin.

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12/30/2010 24 Course : Acne vulgaris clears by the age of 23–25 years in 90% of patients, but some 5% of women and 1% of men still need treatment in their thirties or even forties. Diagnosis: Diannosis is based on Clinical presentation Investigations : Cultures are occasionally needed to exclude a pyogenic infection, an anaerobic infection or Gram-negative folliculitis. Any acne, including infantile acne, which is associated with virilization, needs investigation to exclude an androgen-secreting tumour of the adrenals, ovaries or testes, and to rule out congenital adrenal hyperplasia caused by 21-hydroxylase deficiency.

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12/30/2010 25 Typical rosacea with papules and pustules on a background of erythema. Rosacea.

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12/30/2010 26 Treatment Local treatment: Regular gentle cleansing with soap and water should be encouraged, to remove surface sebum. Benzoyl peroxide, Retinoids, Azelaic acid , Sulphur Local antibiotics. These include topical clindamycin, erythromycin and sulfacetamide Systemic treatment Antibiotics: tetracyclines Oxytetracycline, Minocycline, Erythromycin Hormonal. A combined antiandrogen–oestrogen treatment

FACE BACK ARM : 

FACE BACK ARM 12/30/2010 27

FACE BACK CHEST : 

FACE BACK CHEST 12/30/2010 28

FACE : 

FACE 12/30/2010 29

FACE : 

FACE 12/30/2010 30

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FACE AND FOREHEAD : 

FACE AND FOREHEAD 12/30/2010 32

Management in Unani Medicine : 

Management in Unani Medicine 12/30/2010 33 Usoole Ilaj Treat the cause Istifragh Dimag wa badan (Tanqiyae mawad) Correction of digestion and constipation Dietary modifications (avoidance of oily, spicey and hot eatables) Tasfeye Dam Use of Muhalil, Mujaffif, Jali and Mussafi dam Advia both for topical and systemic administration. Oral Administration: Decoction of Mundi, Unnab, Shahitra, cheriata, Sarphooka, Barghe Neem along with Sharbate unnab, Arq Mussafi, Habe Mussafi,Majoon Ushba, Itrephal Shahitra etc

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12/30/2010 34 Local Application: Tilae Mohasa: Bekhe sosan, post saras, barghe neem Nakhood, Murdar sang, safeda kashgri with milk. Marhame Mohasa: Barghe neem, barghe kekar, piyaz, ghee. Ubtan: Husne yusuf, darcheeni, tukhme khashkhash and milk. Narkachoor, kafe darya and abe taza Zimade Mohasa: Post sars, barghe neem, Ghongche and Namke sambar

Clinical Studies : 

Clinical Studies 12/30/2010 35 Effectiveness of Herbal Medications (Clarina cream and Purim tablets ) in the Treatment of Acne Vulgaris – A Pilot Study by Gopal, M.G., MD, Professor & Head of the Department, Department of Skin and VD, Kempe Gowda Institute of Medical Sciences, V.V. Puram, Bangalore, [The Indian Practitioner (2001): (54), 10, 723] Clinical trial of Unani herbomineral cream to evualuate its topical effects on Acne vulgaris, by Shugufta Parveen, (IJTK, VOL8, 2009) Clinical Evualuation and Safety of a Pharmcoepal Unani Formulation (Zimade Mohasa and Habe Mussafi ) in the mangement of Acne vulgaris, JI M, vol 9 2010. "Tea tree oil reduces histamine-induced skin inflammation“ Koh KJ, Pearce AL, Marshman G, (December 2002) Br. J. Dermatol. 147 (6): 1212–7.

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12/30/2010 36 Thanks for Being so Patient