Akne Anhang

 

[Govender Nervashnee]

https://ir.dut.ac.za/bitstream/10321/59/8/Govender_2003.pdf

1.1 INTRODUCTION

The skin functions to protect the body from injury, light, chemicals, extreme temperature and from invasion of micro-organisms and is responsible for the maintenance of a stable and harmonious internal environment and has the closest connection between the inner being and the outside world. The skin will often be an outer reflection of internal problems and must be treated as such. Orthodox medicine classes the different skin disease according to histological changes occurring in the skin tissue. This approach ignores to a large extent the idea that skin problems can be manifestations of internal problems and should be treated as such and not as local phenomena. Most of the chronic skin conditions that affect humanity are the result of internal processes and causes. As our skin is our interface with the world, it is often the site to manifest disharmony in one’s life (Hoffman, 1997:78-79). Skin eruptions are nature’s way of quieting an internal disease, which threatens vital organs, by developing an external malady. The homoeopathic remedy brings out the reappearance of skin eruptions, and many forms of suppression. It is important to allow internal disorders to be discharged through the skin, rather than suppressing them with treatments directed at the skin. In addition to purely mechanical protection, the skin also seems to have a specific biological function, designed to protect the internal organs from disease agents. By virtue of its chemical composition, the skin may possess the function of removing toxic substances introduced into the

body (Ghegas, 1994:A139; Watson, 1991:91).

The skin consists of a superficial layer, the epidermis (stratum corneum) and a deep connective tissue layer, the dermis. The fascia, lying deep to the skin consists of the superficial and deep fascia. The superficial fascia, extending between the dermis and underlying deep fascia, contains fat, sweat glands, blood and lymphatic vessels and nerves, whereas the deep fascia is thin and is loosely attachedto the superficial fascia and adherent to the underlying muscles, hence the periosteum of bone. The above structures are essential to hold the other structures or parts together and protect against infection by providing a barrier (Moore, 1992:33). The normal pilosebaceous unit

is made up of sebaceous glands, a rudimentary hair, and a wide piliary duct lined with stratified squamous epithelial cells (Cooley et al., 1998:38). The pilosebaceous unit

is composed of a hair follicle, the sebaceous glands and the products of these structures: hair and sebum. The sebaceous glands and follicular epithelia are responsive to circulating androgens and direct androgen stimulation with resultant sebaceous gland enlargement (Lassus, 1996:341).

According to McBride & Simpson (2000:8), 95% and 83% of 16 year-old boys and girls respectively are affected, and the increasing numbers of patients in the over-20 age group are being referred for specialist opinion. Significant lesions are also present in 1% of men and 5% of women at the age of 40 years. The prevalence of acne is similar to those 20 years ago; however it is milder in teenagers and is involving an older population who has high expectations of treatment. Brown & Shalita (1998:1871), agree that acne is a disease of adolescence (between 15-19 years). The incidence peaks at 18 years and improving around 20 years. Some have acne between 24-29 years, sometimes continuing into the 3rd – 4th decades.

While acne can’t be regarded as life threatening, affected individuals experience diminished self-esteem, depression, frustration, social withdrawal, embarrassment and physical scarring. Acne, is the common condition of spots with recurrent often itchy, round and red thickened areas of the skin, which may become infected and chronic.

It is common on the face, but may also occur on the chest and back or in any greasy areas of the skin. The condition is harmless and although the cause is still not clear, it is thought to be related to hormonal changes, or to a diet that is too high in sugar. It is a distressing condition, as people are preoccupied with their appearance, especially their hair and skin. Any form of spot or blemish may become a source of teasing or shame, embarrassment or awkwardness (Smith, 1994:6).

Acne vulgaris is an inflammatory condition of the hair follicle and its’ sebaceous gland is characterized by comedones, erythematous papules, pustules, nodules and cysts (Kaminer & Gilchrest, 1995:S7). Some dermatologists consider acne to be one disease, whereas it constitutes a spectrum, in its severity, in the type of lesions present and

the site involved (Cunliffe, 1989:6). There are many microorganisms involved in the pathogenesis i.e. Propionibacterium acnes, Staphylococcus epidermidis and Malassezia furfur but Propionibacterium acnes (P. acnes) is the most important one, thus many therapies have been designed to reduce the amount and function of this organism

(Sommer et al., 1997:211).There are many forms of orthodox treatment for Acne vulgaris, which often results in many side effects and resistance to therapy, but no cure

is offered thus there is an obvious need for alternative forms of treatment to be investigated i.e. Homoeopathy (Barklie, 1999:4). With Homoeopathic treatment, the patient

is assessed at all levels i.e. physical, mental and emotional, thus recognising the patients individuality, in the hope of more successful management of acne (Chatterjee,1993:1). Herbal remedies have been used for many years in the treatment of Acne vulgaris but they have only recently been clinically tested (Barklie,1999:2) and can be an effective adjunct to homoeopathic simillimum treatment. One needs to bear in mind the patients health and allopathic medicines’ side-effects (which are numerous and troublesome

and the result of many failures in treatment) since these need to be treated first before treating acne itself (McDavid, 1994:32). Master (1993:354), states that acne vulgaris

is one of the problems for which patients seek alternative treatment and often consult with the homoeopath. Several studies have been conducted on acne vulgaris.

McDavid (1994) investigated the effectiveness of homoeopathic simillimum in the treatment of acne vulgaris and had found that there was a statistically significant improvement in the clinical manifestations of acne vulgaris (p = 0.006). The frequently indicated remedies were Sulphur iodatum and Kalium bromatum. Lee (1997) investigated the role of a homoeopathic complex (Silicea 30CH, Selenium 9CH, Hepar sulphuris 30CH, Kalium bromatum 9CH, Arctium lappa 3CH and Pulsatilla 30CH)

in the treatment of acne vulgaris. The results showed no significant improvement over the period of 5 consultations within and between both groups. The effects of Kalium bromatum, used by McDavid (1994), were further elaborated upon in the above research.

In another clinical trial, van Niekerk (1999) investigated the effectiveness of miasmatic treatment as compared to homoeopathic simillimum in terms of the objective clinical findings in patients with acne vulgaris. There was no statistically significant difference between the 2 treatments but both were significant in reducing the clinical manifestations. The above research was an extension of McDavid’s (1994) research and further elaborated on the effect and importance of homoeopathic simillimum.

Barklie (1999) investigated the effectiveness of a homoeopathic complex (Silica terra 30CH, Natrium muriaticum 15CH, Sulphur iodatum 15CH, Kalium bromatum 9CH,

& Selenium 9CH) as compared to a herbal complex (Arctium lappa, Berberis aquifolium, Echinacea purpurea & Taraxacum officinale)in the treatment of acne vulgaris in

terms of its clinical manifestations. It was found that there was no significant difference between the herbal and homoeopathic group hence both were effective.

In the homoeopathic complex used, the 2 commonly used remedies in McDavid’s research (1994) was used and elaborated on and the knowledge of these remedies was further investigated. In the herbal-complex the remedy Arctium lappawas used by Lee (1997), thus further being an extension of the previous 3 studies.Although this herbal-complex (Arctium lappa, Berberis aquifolium, Echinacea purpurea &Taraxacum officinale) has been used for acne treatment prior to this, it has not been compared to homoeopathic simillimum before, and Barklie (1999) recommends that this complex be compared to homoeopathic simillimum for acne vulgaris treatment.

The above treatments have all been useful and successful in the treatment of Acne vulgaris. This research incorporates the findings of the above 4 trials, mostly 6 complementing Barklie’s research (1999), as the same herbal-complex was used, in order to further investigate its role in the treatment of Acne vulgaris. This study also further investigated and extended the role of homoeopathic simillimum as investigated by McDavid (1994) and van Niekerk (1999). A concurrent study on Acne vulgaris was done by Sewsunker (2003), at the Durban Institute of Technology-Steve Biko Campus Homoeopathic Day Clinic, which compared the effect of homoeopathic simillimum to miasmatic treatment in the treatment of Acne vulgaris. Miasmatic treatment in homoeopathy is based on the assumption that there exists in virtually everyone an inherited or acquired energy blockage or disturbance producing a predisposition towards a particular and recognizable pattern of illness (Watson, 1991:41). In patients with a chronic disease like acne vulgaris, it would mean that there is an inherited or acquired tendency to develop this disease and this predisposition must be treated in order to cure the patient.

The prescription is either nosodes made from disease products or miasmatic remedies. Sewsunker’s study will be an extension of and further reinstates van Niekerk’s research but, that trial will furtheruse the data from this research to ascertain and compare which treatment is the most effective in Acne vulgaris treatment i.e. homoeopathic simillimum, herbal-complex or miasmatic treatment.A search of the indexes of Medline (1993-2002) and British Homoeopathic Journal (1982-2002), LINKS (1987-2002) revealed no comparison being done on homoeopathic simillimum and a herbal complex (Arctium lappa, Berberis aquifolium, Echinacea purpureaand Taraxacum officinale)in the treatment of acne vulgaris thus stressing the need to compare the effectiveness of a herbal-complex (Arctium lappa, Berberis aquifolium, Echinacea purpureaand Taraxacum officinale) to homoeopathic simillimum.

This study was aimed at acne vulgaris specifically, between the ages of 18 and 40, as a chronic condition, other types of acne were excluded                                                

1.2.1 OBJECTIVES / PROBLEM STATEMENT

The purpose of this double-blind, randomized clinical trial was to compare the effectiveness of a herbal-complex (Arctium lappa, Berberis aquifolium, Echinacea purpurea & Taraxacum officinale) as compared to homeopathic simillimum, by measuring the reduction in the number of acne lesions on the patients’ faces and in terms of the patient’s perception of response to treatment, in the treatment of Acne vulgaris.

1.2.1.1 Subproblem

1:To investigate the effectiveness of a herbal-complex on the signs and symptoms of Acne vulgaris in terms of subjective and objective clinical findings, to establish the value of a herbal-complex (Arctium lappa, Berberis aquifolium, Echinacea purpurea & Taraxacum officinale) in the treatment of Acne vulgaris.

1.2.1.2 Subproblem

2:To investigate the effectiveness of homoeopathic simillimum on the signs and symptoms of Acne vulgaris in terms of subjective and objective clinical findings, to establish the value of homoeopathic simillimum in the treatment of Acne vulgaris.

CHAPTER TWO REVIEW OF THE RELATED LITERATURE

2.1 DEFINITION & INCIDENCE

Acne is a disorder of the sebaceous follicle. The word is derived from the Greek word acme, which means “prime of life” (Cooley et al., 1998:38). Acne vulgaris is an inflammatory disease of the pilosebaceous glands characterized by comedones, papules, pustules, inflamed nodules, pustular cysts and deep inflamed purulent sacs

(Berkow, 1999:811). According to Lehmann et al. (2002:231), an estimated 45 million people in the U.S. have acne vulgaris. According to Heyl & Swart (1990:149),

in Southern Africa, acne is usually noted to be a problem of the adolescent, with the onset shortly before puberty but usually begins after puberty and is at its worst

between the ages of 14 and 18 years. However it has been noticed, that acne is not only a problem of the teenager but is also seen in young people in their early twenties

and sometimes begins at a later age. Clinical evidence in South Africa, suggests that in men the condition tends to be worse and clears by the age of 25 and only a small percentage will suffer into middle age, and the onset after 25 is rare. In women there is a large percentage with active acne between the age group 24-29, with many developing acne after 34 years of age and some after 40 years of age, as menopause approaches (Presbury, 1993:2).It is estimated that facial acne affects between 67% and 100% of teenagers and remains a health problem for many into early adulthood (Martin et al., 2001:380). According to Fitzpatrick & Aeling (2001:146), 100% of boys and 90% of girls have some acne lesions during puberty but acne can affect any age group (neonates).

Nearly 85% of persons aged between 12 & 25 have some acne lesions. Tan et al.(2000:439), in accordance agrees that 91% of male and 79% of female adolescents, and 3%

of male and 12% of female adults. The success of acne therapy, both prescribed and over-the-counter, makes study of the incidence of acne and its natural evolution impossible. The peak incidence of acne is 14-17 years in girls with 40% of all females affected and 5% of women continue to have acne up to the age of 40 however there’s

no figures for the percentage of women who suffer from acne in their perimenopausal and menopausal years (Callan, 1997:23).Onset is often at puberty, with boys more frequently affected than girls. Some studies suggest that the prevalence of acne vulgaris in teenage boys approaches 100% by age 16 years. Acne may occur before puberty

and more commonly in females. It has been reported that 3% of female patients have clinical acne before the onset of other obvious features of puberty (Tan et al., 2000:439). Some girls experience their first acne vulgaris lesions more than 1 year before menarche, at the time of increased adrenal gland activity, referred to as adrenarche.

After peaking in the teenage years, the prevalence of the disease decreases. In adults 25 to 34 years of age, approximately 8% have acne, whereas it occurs in approximately 3% of adults 35 to 44 years old (Kaminer & Gilchrest, 1995:S8). The shift in the incidence of acne away from schoolchildren to an older age group has produced a much more demanding and articulate group of patients with high expectations for improvement (Healy & Simpson, 1994:831). According to Callan (1997:22), that while the clinical appearance of acne and the severity is the same in both sexes, 70% of females with acne experience worsening during the premenstrual week. Exacerbations may also be seen at times of hormonal change i.e. pregnancy and actation. Comedonal acne has a peak incidence at 12 years, papular acne at 16 years, pustular acne and nodular acne between 16 and 20 years (Cunliffe, 1989:3).

According to Douglass (1995:355), acne from a homoeopathic standpoint is known to be caused by various causative factors, e.g. menstruation and pregnancy, masturbation, food habits and allergies and emotions. According to Schroyens (1997:1636), remedies like Selenium and Staphysagria, are most commonly associated with ill effects of masturbation i.e. the rubric “ailments from masturbation”. Most of the remedies used as simillimum, in this research, are also included in that rubric. In Selenium, Phatak (1995:471-2), states, there are ill effects of debauchery, masturbation, loss of fluids, sexual excesses and has greasy skin with acne too and in Staphysagria, Phatak (1995:492), states it produces both physical and moral sexual disturbances, with a tendency to masturbation, and sexual excesses and the physical state corresponding to the effects of that habit, i.e. acne. In Staphysagria symptoms are also aggravated by masturbation.Fitzpatrick & Aeling (2001:6), believes that masturbation does not cause acne however they have made reference to and contradicted Dr. R.V. Pierce’s book, The People’s Common Sense Medical Adviser, that masturbation causes acne, blindness etc.

Other causes observed are during stressful situations especially amongst teenagers, after abuse of various cosmetics and occupational i.e. exposure to various organic and inorganic chemicals(Douglass, 1995:355).

2.2.7 Weather

Sunlight ultraviolet radiation (UVR) has been used in the treatment of acne for its effect of camouflage i.e. hiding or making lesions inconspicuous, produced by the erythema initially and the subsequent pigmentation is of marked help psychologically. UVR also influences the surface bacteria and penetrate lower epidermis and upper dermis therefore having an effect on bacteria located deeper in the sebaceous glands. Sunlight also has a scaling effect, which enhances the removal of follicular corneocytes but excess scaling may even potentiate ductal obstruction. Ultraviolet B (UVB) radiation enhances the „comedogenic’ potential of squalene (Cunliffe, 1989:8).

2.3 MYTHS

2.3.1 Diet It is helpful to discuss the myths about the causes of acne vulgaris with patients to alleviate fears and unnecessary behavioural modifications. Folklore has blamed the eating of chocolates and foods rich in fat and oils, but there is no scientific evidence to support these claims (Kaminer & Gilchrest, 1995:S8).

2.3.2 Cleansing & Hygiene

Many physicians have observed the patient with acne who has been told over and over by well-meaning family and friends that acne is caused by “dirty skin.” These unfortunate patients spend

hours cleaning and “sterilising” their skin. In fact, many of these therapies, including alcohol washes and intensive scrubbing, only serve to impair the skin’s natural barrier function, precipitate an apparent worsening of the disease, and limit tolerance for effective therapies (Kaminer & Gilchrest, 1995:S8). According to Smith (1994:14), and Barry (1983), many „work’ at their acne, rubbing, cleansing and applying endless creams and lotions which aggravate the condition, because a moist environment is created for bacteria in addition to the high

skin sugar levels to multiply hence the skin should be left alone when acne presents and the affected area kept clean with a cleansing cream rather than soap which blocks the pores. To prevent the risk of secondary infection, rubbing or endless touching of the skin should be avoided. There is no scientific evidence that frequent washing helps acne or that lack of bathing worsens the condition. The most frenetic cleansing only removes surface lipids, a process which is virtually complete within half a minute. The water does not reach the deep recesses of the hair follicle where the acne organism Propionibacterium acnes or Corynebacterium acnes, multiplies. Repeated washing with bactericidal soaps may reduce surface aerobic flora, but scrubbing has no effect on the real culprit, which proliferates in its follicular sanctuary.

2.3.3 Stress

According to Kaminer & Gilchrest (1995;S9), stress is commonly blamed for acne flares. Although it is not possible to state categorically that there is an association between stress and acne, many patients believe that this is the case. Some of these patients are experiencing stress about the appearance of their skin, or there may be an independent source of stress in their lives. Many patients resort to picking at their acne lesions when stressed, and this in turn might be responsible for the perceived flare.

2.3.4 Ultraviolet light

Many patients believe that sunlight improves their acne lesions and go to great lengths to find ultraviolet light sources. Although the beneficial effects on inflammatory or comedonal lesions are dubious and undocumented, there is likely to be a significant effect on the patient’s perception on how they look. A tan makes them feel good, and in turn they think their acne has improved. Although there is nothing inherently wrong with improving the patient’s self image, ultraviolet therapy incurs the risk of skin cancer and photoaging in the future. PUVA (psoralen and UVA) exposure can cause acne (Kaminer & Gilchrest, 1995:S9). Callan (1997:23), agrees that ultraviolet exposure has been accepted by patients as improving acne by increasing exfoliation and via the camouflage effect, i.e. covering or obscuring acne. Another myth is that acne primarily affects teenagers not adults that is untrue, as it is now seen more prevalent in adults (Fitzpatrick & Aeling, 2001:146).

2.4 VARIANTS AND SPECTRUM OF ACNE

1. Acne related to intrinsic causes

-Acne vulgaris

-Perioral dermatitis

-Acne conglobata-Hidradenitis suppurativa

-Acne fulminans-Pyoderma

Faciale

2. Acne related to extrinsic causes

-Acne excoriee des jeunes filles

-Acne mechanica (Immobility acne, frictional acne etc.)

-Acne tropicalis

-Acne aestivalis-Favre-Racouchot syndrome-Drug-induced acne (hormones, antiepileptic, lithium etc.)

-Acne cosmetica-Pomade acne-Occupational acne

-Chloracne

3.Childhood acne

-Neonatal acne

-Infantile acne

4. Acneiform eruptions

 -Rosacea-Acne keloidalis nuchae

-Gram-negative folliculitis

-Steroid acne syndrome

 

Adenoma sebaceum

Apert’s syndrome

Boils

Cushings syndrome

Dental sinus

Familial comedones

HIV infections

Hyperalimentation “acne

”Micropapular perioral „sarcoid’

Milia

Molluscum contagiosum

Perioral dermatitis

Pityrosporum folliculitis

Perioral eruption caused by Candida albicans

Plane wartsSeborrhoeic eczema

Senile (solar) comedones

Stein-Leventhal syndromeSycosis barbae

 

2.6 PATHOGENESISThe pathogenesis of acne is multifactorial, involving androgenic stimulation, sebaceous hypersecretion, follicular obstruction,

Propionibacterium acnes (P. acnes), and inflammatory mediators (Tan et al., 2001:42).

212.6.1 Increased sebum production

According to Callan (1997:22), and Brown & Shalita (1998:1871), sebum, the lipid-rich secretion product of sebaceous glands and provides a growth medium for P. acnes. There is a higher rate of sebum production in people with acne than unaffected individuals. At adrenarche, which can be as early as 8 or 9 years in females and marks the commencement of increased secretion of androgens by the adrenal glands, ovaries and other extra glandular sites, results in increased sebum production from androgen-stimulated sebaceous glands, which in turn enlarge and increase in activity. With the onset of puberty and menarche, androgen production starts in the ovaries. Increasing androgen production (prepubertal) increases pilosebaceous glandular activity and sebum production. Acne does not occur until the sebaceous glands have been stimulated by androgens to adult levels of function. The severity of acne is proportional to the amount of sebum production. Patients with complete androgen insensitivity have undetectable sebum production and do not have acne.

2.6.2 Blockage of pilosebaceous ducts (Ductal hypercornification)

Abnormal follicular-epithelial differentiation occurs forming a hyperkeratotic plug in the follicular canal leading to follicular and pilosebaceous duct blockage, in androgen-sensitive areas (i.e. face, chest and back). Ductal hypercornification (an increase in keratin within the follicular duct of the pilosebaceous unit) takes place and desquamated cornified cells of the follicle become adherent. There is hyperproliferation of corneocytes and retention of horny cell material (retention hyperkeratosis). Instead of undergoing shedding, emptying and discharging through the follicular orifice, these cells form a retained, microscopic hyperkeratotic plug (microcomedo) in the follicular canal (intra-follicular hyperkeratosis). Progressive enlargement of microcomedones gives rise to visible comedones composed of sebum, keratin and microorganisms by comedogenesis (Berkow, 1999:811; Brown & Shalita, 1998:1871; McBride & Simpson, 2000:10).2.6.3 Proliferation of bacteriaNormal skin is usually colonized with a variety of bacteria. Human skin is covered by a relatively dry and impermeable outer layer of keratinocytes, which are shed daily with attached colonies of bacteria. The low pH (5.5) skin and the presence of fatty acids inhibit microbial growth, butwet skin is permeable to microorganisms, and heat and humidity aggravates existing conditions like acne (Kumar et al., 1992:265). According to Brown & Shalita (1998:1871), acne is not infectious. Propionibacterium acnes, Staphylococcus epidermidis and Malassezia furfur are microflora isolated from the skin. These proliferate beneath the sebaceous blockage and produce mediators, which diffuse from the follicle into the surrounding dermis.

The pilosebaceous glands secrete sebum allowing for Propionibacteriumacnes (P. acnes) growth. P. acnes is an anaerobic diphtheroid that populates the androgen-stimulated sebaceous follicle and is a normal constituent of cutaneous flora. It is absent from the skin before the onset of puberty. Higher counts of P. acnes are seen in individuals with acne than those without. There is no relation between the number of bacteria and severity of acne, but a reduction in bacterial numbers with antibiotics use, causes a decrease

in acne severity. Sebaceous follicles with microcomedones provide an anaerobic, lipid-rich environment in which these bacteria flourish (Brown & Shalita 1998:1871; McBride & Simpson, 2000:10; Callan, 1997:22).

2.6.4 Inflammatory changes

Closed comedones have microscopically detectable openings on the skin surface, and are liable to cause breaks in the follicular wall. Sebaceous follicles provide a favourable environment in which P.acnes proliferates producing extracellular lipases that hydrolyse triglycerides to glycerol and free fatty acids, which are proinflammatory and comedogenic, which then provoke follicular hyperkeratosis, comedone formation, and rupture of the follicle. P. acnesproduces exoenzymes, prostaglandin-like mediators and a chemotactic factor. These attract neutrophils to the follicular lumen, which result in leucocyte hydrolytic enzyme release, finally causing damage to and rupture of the follicular wall. Follicular leakage and rupture excites inflammation. Ductal corneocytes produce interleukins and tumour necrosis factor (potent promoters ofinflammation). There is also a release of proteases (hydrolytic enzymes), an activation of complement pathways and a type III/IV host response to P. acnes. The premenstrual acne flare is thought to be caused by inflammatory effects of progesterone and oestrogen (McBride &Simpson, 2000:10; Brown & Shalita, 1998:1871; Callan, 1997:22; Lassus, 1996:341).

are liable to cause breaks in the follicular wall. Sebaceous follicles provide a favourable environment in which P. acnesproliferates producing extracellular lipases that hydrolyse triglycerides to glycerol and free fatty acids, which are proinflammatory and comedogenic, which then provoke follicular hyperkeratosis, comedone formation, and rupture of the follicle. P. acnesproduces exoenzymes, prostaglandin-like mediators and a chemotactic factor. These attract neutrophils to the follicular lumen, which result in leucocyte hydrolytic enzyme release, finally causing damage to and rupture of the follicular wall. Follicular leakage and rupture excites inflammation. Ductal corneocytes produce interleukins and tumour necrosis factor (potent promoters of inflammation). There is also a release of proteases (hydrolytic enzymes), an activation of complement pathways and a type III/IV host response to P. acnes. The premenstrual acne flare is thought to be caused by inflammatory effects of progesterone and oestrogen (McBride &Simpson, 2000:10; Brown & Shalita, 1998:1871; Callan, 1997:22; Lassus, 1996:341).

Closed comedones rupture before they become visible and the contents are spread into the surrounding tissue. The end result is an inflammatory reaction with acne lesion development. Follicular rupture and extension of the inflammatory process to the dermis, results in the formation of inflammatory acne vulgaris lesions i.e. papules, pustules, and nodules. If the rupture is superficial, a pustule develops andif the rupture is massive and occurs in the deeper dermis, nodules, abscesses and cysts form. Depending on the degree of inflammation and whether or not there is sebaceous gland involvement, lesions vary from small papules to large cysts with possible scarring (McBride & Simpson, 2000:10; Brown & Shalita, 1998:1871; Callan, 1997:22; Lassus, 1996:341).

2.7.2 SEVERITY OF ACNE

According to Lehmann et al.(2002:237), identifying acne severity is the most important patient characteristic (to determine treatment options). The method of categorizing

is varied and includes lesion counting on all or part of the face, comparison of patients to a photographic standard and comparison of patients to a text description. The terminology often used is mild, moderate, or severe while others use numerical scores e.g. 1-4, 0-10, etc. Healy & Simpson (1994:831), and McBride & Simpson (2000:11), grade the severity of acne for therapeutics according to the Leeds grading scale, but agree in the general treatment of acne vulgaris most doctors would divide the condition into mild, moderate, and severe. Mild disease consists of open and closed comedones and some papules and pustules, while moderate acne encompasses more frequent papules and pustules with mild scarring. Severe disease contains all of the above plus nodular abscesses and leads to more extensive scarring, which may be keloidal. The severity of acne increases gradually reaching a peak 3-5 years after the onset but sometimes a lot earlier.

2.8 PSYCHOLOGICAL ASPECTS

According to Brown & Shalita (1998:1871), the importance of acne should not be underestimated because the disease has important negative psychological consequences on the individual i.e. diminished self-esteem, social withdrawal due to embarrassment, depression and unemployment. There are many measures available for assessing changes

in acne severity e.g. Acne lesion counting and Acne grading, but the patient’s perception of changes includes factors other than lesion size and number according to Martin et al., (2001:380,383). As facial acne is clearly visible and with it comes a degree of social negativity, even mild acne can decrease a person’s self-confidence, body image, willingness to be seen in public and social interactions. Most Quality of Life questionnaires (QoL) correlate more strongly with patient-reported severity than with physician-reported severity thus suggesting that the patients’ perception of their disease is an important consideration in the evaluation and treatment of acne. The aspects, which prompt patients to seek care, are very often related to their psychosocial wellbeing. Acne-QoL (a disease-specific questionnaire) covers acne severity of the face and trunk and a broad age group, and is useful in assessing the impact of facial acneon health related quality of life and to evaluate therapeutic change. It also covers 4 domains (self-perception, role-social, role-emotional, acne symptoms. According to Girmanet al.(1996:481,487-9), the primary motivation for young adult acne patients to seek treatment is the associated negative impact on psychosocial and social wellbeing. Acne is associated with psychosocial distress, including anxiety, depression, self-consciousness, embarrassment, lowered self-concept, lack of self-confidence and perceived social rejection. There is also resultant lower academic performance and higher unemployment.

Other symptoms noted are feelings of unattractiveness and dissatisfaction, emotional distress, changes in social assertiveness, worry and concern about perceptions and opinions of others or in social interactions (social inhibition or phobia), and feelings of anger, frustration and aggravation. Due to the proximity of breakouts with stressful periods in the lives of acne patients, it has been suggested thatstress and anger exacerbate the condition. Some patients express concerns about interviewing for a job or a perceived reduction in opportunities due to acne. The preoccupation with acne and the concern about bodily functions are psychologically disabling symptoms of acne. Frustration about recurrence of lesions, annoyance about the time needed to cleanse and treat the face and worries about that the treatment will not work fast enough is particularly distressing (Girmanet al., 1996:487-9).According to Cotterhill & Cunliffe (1997:246,249,230), there is a popular view of dermatologists that their patients never die but they fail to realize that some patients with „skin failure’ become so disturbed that they commit suicide successfully. Skin disease, or perceived skin failure is now added to the list of mental disorders central to suicide. Patients with long-standing and debilitating skin disease may become depressed enough to commit suicide. There is a risk of suicide in patients with established psychiatric problems, referred to dermatologists with concurrent skin disorders i.e. acne. It is important that dermatologists recognize how mental disease can present in their patients. In acne, the face is very important in body image and it is not surprising, that young men with severe facial acne scarring, can become depressed and are at risk of suicide but women, concerned with facial complaints are more at risk of becoming depressed and attempting suicide, the only signs are when they are obsessed with facials and acne camouflage or cover-up. A simple psychological screening of acne patients, before being seen, can help identify severe depressive features. It is necessary to note the importance of skin/mind relationships and the importance of recognizing mental disease i.e. depression in patients. It serves to emphasize the need for the early treatment intervention to lessen acne scarring. Most dermatologists should be in a position to help patients with severe depression associated with skin problems and should appreciate that minor imperfections in major body image areas i.e. face, hands, scalp etc. may cause major distress.In contrast, it has been suggested that patients with facial acne may be less self-

conscious than those with acne on their back or chest as they adjust to its constant visibility. It has also been noticed in some studies that students with severe acne are more extroverted than the ones with milder acne. Patients with the same clinical criteria differ dramatically in terms of their clinical assessment of emotional wellbeing. Patients rate themselves more severely than the dermatologist and the psychological aspects of acne are more related to self-perception than to acne grading or lesion counts. These symptoms and aspects were not expressed before, possibly because the patients were not asked about them. Unstructured interviews allow patients to more freely discuss the impact of acne on their social and psychological wellbeing (Girman et al., 1996:481, 487-9). According to Oakley (1996:39), patients whose lives are significantly affected,

by their disease, even if mild, may be keen to bare with the inconvenience of oral retinoids hence benefit psychosocially, whereas those who are emotionally well adjusted to clinically severe disease, may fail to comply with potentially toxic or troublesome treatment. In order to rapidly assess the disability caused by acne, a questionnaire covering emotions, attitudes, daily activities, disabilities, financial considerations is necessary at the initial consultation and repeated often to assess whether the treatment has been beneficial (Oakley, 1996:39).

2.9 COURSE & PROGNOSIS

Many persons experience complete resolution of their lesions without any residual signs of the disease, whereas others have to deal with persistent acne vulgaris to the residual effects (scarring and keloids). There appears to be a subset of young women in whom lesions persist well beyond their teenage years, and a second subset of women who do not have their initial acne vulgaris episode until their late twenties or early thirties (Kaminer & Gilchrest, 1995:S8). Cunliffe (1989:3), states there is little information on the

33age at which spontaneous resolution of acne occurs but is usually possible in the late teens or early twenties. Berkow (1999:811) agrees that acne usually spontaneously remits but the time of remittance cannot be predicted. Douglass (1995:351), in accordance agrees, the peak activity of acne is in the mid or late teen years with a steady improvement starting around age 20 but the disease activity may continue into the 4thdecade. Women seem to be prone to this long lasting form of acne. Hormonal factors play a major role in the course of the disease. Acne seems to be more severe in men. Cystic lesions, which are common in men, are only rarely found in women. In women a monthly peak of acne activity often occurs during the week prior to their menses. Acne tends to improve during the 3rdto 9thmonth of pregnancy but rebound worsening sometimes occurs following parturition and cessation of lactation. It is difficult to predict the future severity of acne at the time a young patient is first seen. The presence of cysts and a family history of scarring acne are, however, bad prognostic signs. Callan (1997:23), in accordance agrees that there is no reliable guidelines for prognosis because in the majority of women, acne improves and disappears by the mid twenties, however some develop acne for the first time over the age of 20 and in a small percentage acne persists (modified in appearance) into the late twenties and thirties and some develop acne for the first time during pregnancy and around menopause.When acne is untreated, individual small papules and pustules resolve spontaneously in 7 to 10 days. Resolution of these lesions does not result in scarring even when some degree of picking is carried out. Large papules and cysts require several weeks to resolve and even then post-inflammatory colour changes may persist for months. Scarring is usually found at the site of deep-seated papules and is almost invariably present following resolution of fluctuant cysts. (Douglass, 1995:351).

342.10 TREATMENT

The aims of treatment are to prevent scarring, limit disease duration, reduce psychological stresses, decrease sebum output, control bacterial proliferation, and reduce/prevent comedones. Treatment should start early to prevent scarring because established scars are difficult to treat (Berkow, 1999:812). Callan (1997:28), agrees that the treatment of acne aims to inhibit androgen stimulation of sebaceous glands, reduce sebaceous blockages, decrease bacterial activity and suppress inflammation. Treatment should suite the individual patients’ needs and preference i.e. some are opposed to long-term antibiotic therapy in severe acne where as some with minimal acne demand more potent therapy. The other goal of treatment is to eliminate comedones, papules, pustules, cysts and nodules and to decrease the amount of hyperpigmented scarring (Cooleyet al., 1998:38). Healy & Simpson (1994:831) agrees that treatment should prevent scarring, limit disease duration, and reduce the impact of psychological stress, and that treatment should be administered early to prevent scarring since established scars have little improvement. According to Sommer et al.(1997:211), treatment measures include colony counts of P. acnes and micrococcaceae, measurements of skin surface lipid free fatty acids and sebum excretion rate. According to Cunliffe (1989:253), the patient should be told that acne is caused by his type of skin and by hormonal changes occurring in adolescence. These alterations are not due to abnormalities of sex hormones but to an overreaction of the sebaceous unit to normal levels. It is also necessary to explain to the patients that there are different sorts of acne, not just differences in severity and the types of acne lesions, and treatment is given is based upon the type of acne, its severity and location. For effective improvement, treatment needs to be for at least 6 months and compliance is important. The side-effects need to be discussed with patients as well.

2.10.1 ALLOPATHIC TREATMENT

According to Lehmannet al.(2002:237), the first-line therapy includes a cleanser, keratolytic, antibacterial (topical), and combinations. Second-line therapy includes retinoid (topical), antibacterial (oral) and combinations. Treatment prescribed at referrals i.e. for more severe acne, includes retinoid (oral) and antiandrogen treatment.2.10.1.1 Topical therapy: Used for mild to moderate acne, and are comedolytic and antimicrobial in action.

a) Benzoyl peroxide: is bactericidal for P. acnesbut causes irritation and contact dermatitis. It is a potent oxidizing agent with bacteriostatic, comedolytic and keratolytic properties, causes follicular desquamation, and reduces inflammatory and non-inflammatory lesions. Topical usage decreases P. acnescounts. It needs long-term usage, but does not alter the bacterial resistance pattern of antibiotic resistance and prevents resistance when used together witherythromycin. The adverse effects include bleaching of clothes and hair, skin irritation (redness and scaling) and allergic dermatitis (McBride & Simpson, 2000:11; Brown & Shalita, 1998:1872). Benzoyl peroxide, according to Cooley et al., (1998:40), eliminates bacteria at the skin surface but do not penetrate deep into the follicular orifice. It is beneficial when, a wide distribution of lesions, are present and when adherence to treatment is problematic. Eadyet al.(1994:334), agrees it is a broad spectrum antibacterial, which produces death via the interaction of oxidized intermediates with constituents of microbial cells, and bacterial resistance is unlikely to occur despite widespread usage.

b) Salicylic acid: is a peeling agent, and is useful against comedones and inflammatory lesions in acne. It is useful but less effective in patients who cannot tolerate tretinoin (Brown & Shalita, 1988:1872).

c) Azelaic acid: is antikeratinizing, antibacterial (against P. acnesand Staphylococcus epidermidis), comedolytic, keratolytic, antiproliferative and inhibits melanin production

in proliferating melanocytes. It is a dicarboxylic acid that is suitable for both non-inflammatory and inflammatory acne and is less irritant than benzoyl peroxide. It is useful in lightening postinflammatory hyperpigmentation (Brown & Shalita, 1998:1872; Callan,1997:28).

d) Silicol gel: according to Lassus (1996:343), has an effect on papulopustular acne on facial skin by means of a peeling effect, decreased sebum production, and an increase

in the water content in the stratum corneum.

e) Adapalene: it is agreed by Shalita et al.(1996:482-483), Brown & Shalita (1998:1872), and McBride & Simpson (2000:11), that adapalene is a napthoic acid derivative with retinoid-like properties but more tolerable than other retinoids. It is a potent modulator of cellular differentiation, keratinization, is comedolytic and anti-inflammatory in action, thus indicated for acne vulgaris treatment of the face, chest and back where comedones, pustules and papules predominate. It can be used alone or in combination with benzoyl peroxide and other preparations. It is non-photosensitizing and is more potent than tretinoin in reducing non-inflammatory and total acne lesion counts and has a milder irritant effect i.e. skin discomfort, erythema, skin dryness, and acne flare.

f) Fusidic acid: is useful in facial acne. It causes gradual reduction in lesion count especially inflamed lesions, and reduces micrococcaceae and has some reductions in acne grade and lesion count, but does not reduce P. acnes counts, surface free fatty acids or sebum excretion rate. Fusidic acid has been used for the treatment of boils and impetigo in the past and also suppresses P. acnesin vitrotherefore suggesting its use in acne treatment (Sommer et al., 1997:211,213).

g) Nicotinamide: is a potent anti-inflammatory agent for cutaneous disorders, topically and systemically. It is an active form of niacin and a source of vitamin B3. It serves as a precursor in the synthesis of coenzymes. There is similar efficacy to topical clindamycin in acne treatment, but unlike clindamycin, it doesn’t cause pseudomembranous colitis or resistance of microrganisms. Nicotinamide, by means of it anti-inflammatory effect, have the ability to contribute to the resolution and prevention of inflammatory acne lesions (Shalita et al., 1995:434,436).

h) Tretinoin: are vitamin A derivatives that reverses abnormal follicular keratinization, reduces micro-comedo formation (keratolytic), decreases sebaceous gland functioning and decreases inflammatory lesions, that results from microcomedone rupture, but is contraindicated in pregnancy, and causes local skin irritation (erythema, peeling and burning) and photoirritation i.e. ultraviolet light sensitivity. It lightens postinflammatory hyperpigmentation in black patients. The required time for improvement is 3-4 months (Brown & Shalita, 1998:1872; McBride & Simpson, 2000:11)

i) Topical isotretinoin: Brown & Shalita (1998:1872), Callan (1997:28), and McBride & Simpson (2000:11), agrees that this produces superficial peeling of the skin that unblocks follicles, is keratolytic, reduces comedogenesis and reduces both non-inflammatory and inflammatory lesions by affecting abnormal follicular keratinization,

It causes skin irritation, sensitivity to ultraviolet light, hyper-or hypopigmentation, are teratogenic in early pregnancy and is contraindicated during lactation. It is a safer alternative to oral isotretinoin without the side-effects but does not affect sebum production.

j) Topical antibiotics: for example clindamycin, and erythromycin and are bacteriostatic for P. acnes, reducing P. acnescounts and number of inflammatory lesions i.e. papules and pustules by altering the metabolic pathways of P acnes. Topical antibioticsare tolerated better than the systemic ones due to less severe side-effects. They offer an alternative treatment for patients who are allergic to benzoyl peroxide (Cooley et al., 1998:40; Brown & Shalita, 1998:1872-3).

i) Clindamycin: treats mild acne and is useful for pregnant women who are unable to tolerate oral tetracycline usage. It causes mild exfoliation (Callan, 1997:28).ii) Erythromycin: is useful in pregnancy but contraindicated during lactation. There are mild adverse effects thus very safe to use. The combination of erythromycin and benzoyl peroxide topically is more effective than erythromycin alone. They work synergistically together by reducing inflammatory lesions i.e. papules and pustules and have a slight effect on comedones. They act by means of an antibacterial-keratolytic effect. There is also a greater degree of penetration by erythromycin due to „loosening’ of stratum corneum by benzoyl peroxide and also there is reduction and prevention of erythromycin-resistant strains of P. acnes developing with benzoyl peroxide (Eady et al., 1994:331, 334-336).

 

McBride & Simpson (2000:11), states oral antibiotic courses should continue for a minimum of 3 months before accepting failure. Unwanted effects of systemic antibiotics include diarrhoea, dyspepsia, candidiasis and folliculitis.a) Tetracycline: is acommonly prescribed oral antibiotic but causes gastrointestinal upset (vomiting, diarrhea), sun sensitivity, vaginal candidosis and benign intracranial hypertension. Its absorption is impaired by food, milk etc. thus it needs to be taken before meals. Contraindicated in pregnancy, during lactation and children (Brown & Shalita, 1998:1873). It is inexpensive and relatively free from side effects according to, Cooley et al.(1998:40). Women on the oral contraceptive pill for contraception (i.e. birth control) should be advised that tetracyclines may decrease the effectiveness of the pill and that additional barrier contraception should be used. As tetracycline is contraindicated in pregnancy, topical clindamycin hydrochloride, benzoyl peroxide, or erythromycin are safer alternatives. Tetracycline causes fixed drug eruptions, headaches due to benign intracranial hypertension, phototoxicity, photo-onycholysis, oesophageal ulceration and Gram-negative folliculitis. Tetracycline therapy interferes with blood levels of lithium and causes idiosyncratic liver toxicity (Callan, 1997:30-4). b) Doxycycline: is better absorbed from the gastrointestinal tract and reduces inflammatory acne lesions (Brown & Shalita, 1998:1874)c) Minocycline: is the antimicrobial of choice due to its efficacy, has a lack of dietary restrictions, gastrointestinal problems and photosensitization (Berkow, 1999:812), and rapid reduction in P. acnescounts and inflammatory lesions. Side effects are reversible vestibular disturbances (e.g. dizziness, vertigo, ataxia), headaches, blue-grey discolouration or pigmentation of mucosa and inflamed or scarred or sun-exposed skin, hepatitis, systemic lupus erythematosus-like syndrome, liver disease and serum sickness etc. It is often used when patients are resistant to tetracycline and erythromycin(McBride & Simpson, 2000:11; Brown & Shalita, 1998:1874). According to Guttman (2000:S5), the lupus occurs over long-term exposure and resolves upon minocycline discontinuation and the bluish discoloration of soft tissues resolve with vitamin C usage. According to Sitbon et al.(1994:1633-9), minocycline, being a semisynthetic tetracycline derivative, causes vasculitis, reversible minocycline pneumonitis and eosinophilia. There have been evidence of pulmonary infiltrates, hypoxaemia and blood eosinophilia in patients treated with minocycline. In the study none of the patients had a history of lung or systemic disease, exposure to aerocontaminants, pneumotoxic drugs, radiation, or oxygen therapy. With the removal of the drug, patients recovered but severe cases needed steroid therapy. Adverse effects include respiratory symptoms, nausea, dyspnoea, fever, blood eosinophilia, transient vestibular symptoms, photosensitivity, hyperpigmentation, and skin rashes. As it induces teeth discoloration in the fetus, it is contraindicated in pregnancy. Minocycline, according to Beneton et al.(1997:1252), induces a hypersensitivity syndrome which is a severe adverse drug reaction characterized by a drug eruption, visceral involvement (cardiac, kidney, lung or liver) and eosinophilia or atypical lymphocytosis. Although these reactions are rare, given the number of times it has been prescribed, minocycline should not be used as a first-line antibiotic in acne vulgaris, as the reactions are severe.d) Lymecycline: is a second-generation tetracycline and has no dietary restriction. It has reduced gastrointestinal side effects and no effect on skin pigmentation (McBride & Simpson, 2000:11).

42e) Erythromycin: is equally effective in thetreatment of inflammatory acne but is used less frequently due to the emergence of resistant strains of P. acnesand intolerable gastrointestinal side-effects. It has been replaced by trimethoprim due to erythromycin having high bacterial resistance (Brown & Shalita, 1998:1874; McBride & Simpson, 2000:11). It is often used if tetracyclines are contraindicated i.e. children under 12 years of age. It is safe to use in pregnancy (Callan, 1997:30).f) Sulphonamides: can be used in resistant cases, but producemore side-effects with long-term use (Callan, 1997:30).g) Co-trimoxazole: treats inflammatory acne but causes hypersensitivity reactions (i.e. toxic epidermal necrolysis), rash and bone marrow suppression. If is often used in patients who did not respond well to other oral antibiotics (Brown & Shalita, 1998:1874).h) Trimethoprim: it is as effective as tetracycline and co-trimoxazole (Cunliffe, 1989:263).i) Clindamycin: improves inflammatory acne but causes pseudomembranous colitis (Brown & Shalita, 1998:1874).

2.10.1.2.2 Isotretinoin (Accutane/Roaccutane)

It is used for nodular and severe acne and reduces sebaceous gland size and activity by inhibiting sebocyte differentiation, decreasing sebum production, suppressing P. acnesproliferation and inhibiting comedogenesis and is anti-inflammatory. It is the only treatment that affects all major aetiological factors involved in acne. It is teratogenic and use during pregnancy causes spontaneous abortions and life-threatening congenital malformations. Females need to use 2 methods of contraception for 1 month before taking, while taking and at least 1 month after discontinuing the drug and must have a negative pregnancy test prior to therapy (Berkow, 1999:813; Brown & Shalita, 1998:1874). According to Callan (1997:34), women of childbearing age must be adequately protected against pregnancy with oral contraceptives, unless hysterectomy or tubal ligation has been done. Contraindications include patients with pseudotumor cerebri, inflammatory bowel disease, hyperlipidemia, hepatitis, children and pregnant females (Fitzpatrick & Aeling, 2001:152). Due to the potential severe adverse effects, it is reserved for severe nodulocystic acne, severe, inflammatory acne that is resistant to conventional therapy, late-onset acne (as this is often resistant to oral antibiotics) and have a potential for physical scarring or serious emotional consequences. It is often used when less severe acne is resistant to other conventional systemic treatments (Brown & Shalita, 1998:1874-5). Side effects include mucocutaneous effects (i.e. dryness or irritation of skin and mucous membranes, cheilitis, xerosis, blepharitis, blurred vision, nose bleeds, conjunctivitis, epistaxis), musculoskeletal pain and stiffness, eczema, hyperostosis, pruritis, photosensitivity, alopecia, anaemia, leukopenia, hypertriglyceridaemia, hypercholesterolaemia, hepatic dysfunction and acute pancreatitis etc. Benign intracranial hypertension is a side effect common to isotretinoin and tetracyclines, therefore concomitant use of both drugs is contraindicated (Brown & Shalita, 1998:1874-5; McBride & Simpson, 2000:12; Callan, 1997:34).

Blood lipids, liver enzymes, and blood counts monitored initially and once each month while the patient is taking isotretinoin, and 1 month after therapy has been stopped. Pretreatment investigations i.e. liver function and cholesterol tests (to exclude hypercholesterolaemia) are necessary, and need to be repeated during treatment. Frequently seen are transient rises in plasma, lipids, and liver enzymes during treatment (Cooley et al., 1998:40; Callan, 1997:34).According to Girman et al. (1996:487-489) and Martin et al. (2001:383), possible early intervention and medical attention, and the use of isotretinoin, decreases the severity of acne and decreases the risk of possible suicides, as it causes rapid reduction of the acne lesions thus improving self-confidence, decreasing embarrassment and frustration. Many are able to cope with the adverse effects of isotretinoin as their main concern is that the acne is permanently eradicated. To them the disadvantages of isotretinoin treatment do not outweigh the massive advantages gained.

2.10.1.2.3 Hormonal treatment improves acne by blocking androgen receptors, inhibiting androgen synthesis and decreasing androgen-induced sebum secretion. Side-effects are gynaecomastia, impotence, decreased libido, infertility, menstrual irregularities etc. It is useful when other therapies fail, acne began/worsened in adulthood, acne with premenstrual-flare, excessive facial oiliness, inflammatory lesions localised to the beard area and hirsuitism (Berkow, 1999:813; Brown & Shalita, 1998:1875). Birth control pills may affect the skin by causing hyperpigmentation and may change the amount of acne breakouts. It is important to note when someone who never experienced acne as

a teenager, but has noticed frequent breakouts after discontinuing a pill high in oestrogen, or starting a pill high in androgen (Wurward, 2001:6).

Spironolactone, oestrogen and cyproterone acetate are used (Brown & Shalita, 1998:1875).

a) Antiandrogensi) Spironolactone: blocks androgen receptors and inhibits androgen synthesis and is effective against inflammatory acne lesions. Side-effects include breast tenderness, menstrual irregularities and hyperkalaemia (Brown & Shalita, 1998:1875). Callan (1997:32), suggests its usage when the oral contraceptive is contraindicated or when the patient wishes not to use this type of hormone preparation, spironolactone can be used. It causes polymenorrhoea as a side effect. Due to the risk of hyperkalaemia and hyponatraemia, regular serum electrolyte monitoring and regular blood pressure check-ups are necessary and potassium supplements avoided. Antiandrogen therapy used alone or in conjunction with antibiotics, can cause breast soreness, weight gain and bleeding.

b) Oral contraceptivesi) Oestrogens: decrease serum concentrations of free androgens, by suppressing ovarian hormonal production and increasing concentration of sex-hormone binding globulin. Oestrogen and progestagen combination in oral contraceptives are useful in acne therapy (Brown & Shalita, 1998:1875). According to Callan (1997:32), in women with premenstrual flares of acne, who do not respond adequately to antibiotics plus topical therapy, oestrogen (a nonandrogenic oral contraceptive) may help.

Cyproterone acetate: is a potent androgen-receptor blocker and progestagen (Brown & Shalita, 1998:1875). According to Callan (1997:32), it is a combined oral contraceptive, which should be avoided until pubertal development is complete as it may affect longitudinal bone growth. In women who have had a hysterectomy or peri-and postmenopausal women, this preparation without oestrogen can be given. Although Diane-35 is a useful contraceptive, when used in conjunction with oral antibiotics, precautions should be taken. Oral contraceptives containing norethisterone or levonorgestrel may aggravate acne, according to McBride & Simpson (2000:11).

According to Callan (1997:32), oral contraceptive therapy should not be given to females before completing puberty or before reaching their full growth potential as these preparations can accelerate epiphyseal closure hence the „safe’ age to start hormone therapy depends on the individuals physical development and sexual maturity but a

good guide is menarche.

2.10.1.2.4 Oral steroids

Corticosteroids are used to suppress adrenal and ovarian androgens. They are indicated when other hormonal therapies fail (Brown & Shalita, 1998:1875). According to McBride & Simpson (2000:11), oral steroids are used in very inflammatory severe acne e.g. acne fulminans, in which patients develop an immune complex reaction to P. acnes. It is more usual as a side effect of steroid use, either for therapeuticpurposes (i.e. transplant patients) or with the abuse of anabolic steroids, then treated in terms of its severity. 2.10.1.3 Treatment of cysts and scarsComedone extraction is effective after tretinoin therapy. For macrocomedones (large

47whiteheads) hyfrecation of fine cold point cautery with local anaesthesia is useful (Healy & Simpson, 1994:832).Acne surgery, dermabrasion, chemical peeling, laser resurfacing, bovine collagen injections, punch grafts and ultraviolet light are helpful adjuvant for improving atrophic acne scars (Brown & Shalita, 1998:1875; Berkow, 1999:813). According to McBride & Simpson (2000:12), dermabrasion is useful in patients with extensive but superficial scarring and is performed when the disease is inactive but is less popular because of the risk of blood-borne infection in the operating theatre. Early keloid formation can be reduced by triamcinolone injections or excision. Cysts may be aspirated and injected with triamcinolone acetonide (intralesional corticosteroid injections) to reduce lesion (nodules and cysts) size and inflammation quickly but this results in deep scarring. They can be frozen with liquid nitrogen with resultant minimal scarring and to reduce inflammation. Local excision of cysts may be indicated in some patients (Brown & Shalita, 1998:1875; Berkow, 1999:813; McBride & Simpson, 2000:12). Radiation therapy i.e. X-ray therapy and ultraviolet radiation, are useful to reduce size of sebaceous glands and sebum output (Cunliffe, 1989:279). X-ray usually inhibits sebaceous gland activity. This has been noted after dental x-rays, whereby, a marked decrease in the amount of oil production and breakouts of the skin have been noticed according to Wurward, (2001, 5:60).

 

To achieve this:

don’t prescribe antibiotics unless absolutely necessarykeep treatment courses shortuse benzoyl peroxide as an antibacterial to control person-to-person transfer of antibiotic-resistant bacteria avoid concomitant oral and topical treatment with dissimilar antibiotics good compliance is necessaryre-educate patients not to expect an endless supply of alternative medications (Eady et al., 1993:555-6, Dawson, 1998:422). Benzoyl peroxide together with antibiotics controls transfer of resistant bacteria and prevents the induction of antibiotic resistance but this is only shown to be effective against Staphylococcus epidermis (Healy & Simpson, 1994:832).

 

2.10.2 HOMOEOPATHIC TREATMENT:

The aims of conventional treatment are to decrease androgen uptake and keratogenesis of the cells of the pilosebaceous glands. Homoeopathic treatment has the same effect, but is longer-lasting and non-toxic. Patients may be impatient to get results, hence a localtreatment to be prescribed at the same time as homeopathic treatment, is often requested. The substances used must be gentle to the skin. As acne can affect and cause strain on a person’s social and personal life, homoeopathic treatment often includes a remedy acting on the emotional sphere. Therapies should always include symptomatic and constitutional remedies (Jouanny, 1994:274). According to Douglass (1995:354), acne vulgaris is one of the common diagnoses brought forward by the patient to a homoeopath. The problem should never be tackled with superficial, local acting remedies, instead, deep acting constitutional remedies should be given as soon as the complete totality of the symptoms is available.

2.10.2.1 The Law of SimilarsIn homoeopathy, the concept of individual diseases is not often recognized and is not seen as the most important, when compared to individuality. The life giving principle or force (which Hahnemann called the vital force) maintains harmony in human beings, 53thus the disease stateis disequilibria of

the vital force. Homoeopathy based on the Law of Similars therefore the simillimum, which is similar to the person’s totality of symptoms is prescribed (Chatterjee, 1993:1-2). According to Watson (1991:92), the homoeopathic tenet that cure is through “similars”, means that the remedy for any disease or illness is the substance, which when administered to a healthy person yields precisely the symptom-pattern of a given case.

2.10.2.2 Suppression and Rebound

According to Ghegas (1994:A139, A140), “suppression” means symptoms may disappear while the pathological process continues. But when the suppressive medication is stopped the symptoms recur in a more intense and violent manner than prior to the therapy i.e. “rebound”. “Suppression” in homoeopathy means the suppression of the organism’s own self-healing effort and “rebound” means the desperate attempt of the body’s healing power to assert itself against both the “disease” and the improper suppressive medicine.

Suppression of skin disorders with steroid ointments etc. can have serious consequences for patient i.e. the disease is “pushed” inside. The best method to deal with this problem is by taking the complete history, and finding a constitutional remedy, the problem can be solved, or there can be a general amelioration of the patient without amelioration of the acne.

2.10.2.3 Totality of symptoms

The totality of symptoms insisted on by Hahnemann does not refer only their numerical sum, but to their relative importance. This method involves prescribing a remedy because the symptoms of the patient are similar to symptoms found within the remedy-picture. Hahnemann wrote “ so that each individual case of disease is most surely,

54radically, rapidly and permanently annihilated and removed only by a medicine capable of producing (in the human system) in the most similar and complete manner the totality of its symptoms, which at the same time are stronger than the disease” (Watson, 1991:89). According to Watson (1991:90-3), the totality of symptoms (all of them) must be taken down, but only a portion of those symptoms may then be selected and utilized for finding the simillimum i.e. a selected partiality of the given totality of symptoms. This provides a more reliable guide to the curative remedy than the totality itself. The symptom similarity includes characteristic, keynote, complete, strange, rare and peculiar, and three-legged stool symptoms. Characteristic symptoms serves to indicate character, distinguish, a distinct peculiarity or quality. Keynotes provide differentiation between several remedies, which appear to be well indicated on other grounds. Symptoms only become strange or rare or peculiar in the context of the individual in whom they are found. These are easy to locate provided the prescriber is familiar with the signs and symptoms common to disease. The emphasis is not

“what is present in this illness?” but rather “what is strange in this individual?”

According to Watson (1991:92), Boenninghausen had the idea that every symptom is a manifestation of the disorder in the whole person, and if each symptom is coming

from the same source then each could be used to lead back to that source i.e. concomitant, location, aetiology, modality, and sensation.

2.10.2.4 The Simillimum

The simillimum is the remedy that most closely corresponds to the totality of the symptoms. It is the most similar remedy corresponding to a case, and when found is always curative (or in incurable cases it is the best possible palliative remedy) (Yasgur, 551998:234). According to Chatterjee (1993:1-2), to assess the simillimum that needs to be prescribed, the patient is assessed on the mental, physical and emotional levels, thus recognizing the patient’s individuality and the cause of the disease, with the hope of successful management of the acne. Homoeopathic medication is given in a minimum dosage just sufficient to restore the vital force to its original state of dynamic equilibrium. Hahnemann advocated the single remedy on practical and theoretical grounds. He thought that the use of medical mixtures led to over-drugging of the patient, and realized the impossibility of predicting the synergistic effect of several drugs administered simultaneously. The homoeopathic provings are all of single substances and chemical compounds never as medicinal mixtures (Watson, 1991:92). Those symptoms or conditions which never appeared in the provings, but which have been repeatedly cured by the remedy, in practice, when prescribed on other symptoms present, can be used as simillimum prescribing (Watson, 1991:92). According to Watson (1991:92), while pathology is not altogether ignored, by homoeopaths, they rely on the symptoms for selecting the remedy.

The remedies have been proven for their sense-perceptible symptoms alone, and these are necessary for the physician’s guide to treatment. Homoeopaths claim that when the patient receives the one single remedy whose symptomatology most perfectly matches his own symptoms, the whole disease is entirely removed. The physician must be guided by the symptoms, and if he chooses a wrong remedy, it will usually have no effect.

2.10.2.5 Simillimum remedies dispensed:

The homoeopathic simillimum obtained by matching it to the patient’s totality of symptoms. There were many indicated remedies but the remedy most similar was selected. The frequency of remedies prescribed and dispensed appears in Table 3 in Chapter 4. The homoeopathic indications of the simillimum remedies listed below were obtained from various Materia Medicas.

Ars.: used in skin disorders which are burning and itching and > warmth (Ghegas, 1994:A138). Affects head, face, nose and neck areas. Skin dry, cold and bluish with inflamed spots. Conical pimples (whitish or reddish) with burning and itching. Eruption of small red pimples, painful black pimples, itchy pimples small and tickling.

Pustules filled with blood and pus (Clarke, 1999:186).

Calc.: flaccidity of the skin, burning, smarting, itching. Eruption of lenticular red and raised spots with great heat, much thirst. Skin hot and dry during motion. Skin of the body rough, dry and as if covered with a kind of miliary eruption. Skin unhealthy, every injury tends to ulcerate. Encysted tumours (Clarke, 1999:350).

Carc.: acne leaves keloid scars. Café au lait compexion. Moles numerous (Vermeulen, 1999:447)

Caus.: acne affects the nose area. Warts on nose. Violent itching in the back. Burning itching of body at night and suppressed by mercury and sulphur. Skin injuries which heal and become sore again (Clarke, 1999: vol 1, 440).

Ign.: itching easily better for scratching, disappears with sweat. Skin painful > pressure. Itching from becoming heated in open air and sensitive to drafts (Vermeulen, 1997:880; Clarke, 1999: vol 2, 14).

Lach.: little tumours in the skin with dark or blue spots between them on the face. The face is very red or bluish. Old scars show a blue colour. Except for the discoloration

the skin remains intact (Ghegas, 1994:A142). Papules raised and red. Skin very hard to heal, masses of blood pass through the pores. Ulcers surrounded by pimples.

Papulae, warts, hard swellings. Eruptions of vesicles of a yellow or of a bluish-black colour (Clarke, 1999: vol2, 226). Capillaries dilated, small wounds bleed much and sore places gangrenous. Pustular eruptions become black. Intense itching at night. Least touch or pressure produces black and blue spots. Confluent smooth, round, white pustules of size of a mustard seed, they contain a white fluid and itch intolerably (Vermeulen, 1997:1001-2)

Med.: yellowness of skin. Intense and incessant itching < night. Copper-coloured spots remain after eruption. Small pedunculated warts (Clarke, 1999: vol2, 418). Sycotic red nodes and skin cold. Red spots itching when scratched (Vermeulen, 1997:1098).

Nat-m.: it is the principal remedy in the treatment of acne vulgaris. The acne located on the face and back, do not have a very characteristic appearance but the patient’s appearance is notable. The skin on the face is hyperseborrheic, oily and dirty. The hairline of the scalp is marked by the coexistence of acne and scaly inflammatory lesions

and the hair is greasy. The lips are dry, cracked and there’s a medial fissure on the lower lip and the tongue is mapped. Palmo-plantar hyperhydrosis and hangnails are common. The upper part of the body is thin, despite a good appetite. There is a tendency to depression and introversion (Jouanny, 1994:277). Alopecia. Affects edge of scalp. Chronic comedonal acne. Greasy, oily esp. on oily parts. Dry eruptions on margin of scalp. Skin harsh, unhealthy or yellow. Painful scars and redness of old scars. Red spots preceded by sensation of heat in face. Comedones (Vermeulen, 1997:1182). Itching and pricking in skin. Pain and redness of an old cicatrix (Clarke, 1999: vol2, 561).

Phos.: desquamation of skin and burning in the skin. Red spots and pale skin. Wounds bleed much, heal and break out again. Thin, foul, bloody pus. Anaesthesia of skin and burning or formication. Red streaks after scratching (Clarke, 1999: vol3, 792; Vermeulen, 1997:1293)

Puls.: acne lesions have a cyanotic aspect, and are aggravated by foods rich in fat. Venous disorders and affections of the ear-nose-throat are seen and frequent menstrual disorders are experienced (Jouanny, 1994:276).Symptoms are variable, the acne intermittent, worse from a high intake of either sweet or hot foods, such as chocolate, also aggravated by heat (Smith, 1994:15). Menstrual disorders and acute ear-nose-throat complaints with acne. Chronic acne. Acne at puberty. Skin itches on being heated. Biting, itching < evening in bed and not > scratching (Vermeulen, 1997:1358). Paleskin. Itching, burning and pricking. Frequent redness when parts cold. Pus copious and yellow (Clarke, 1999: vol3, 924-5).

Staph.: tingling sensation. Unhealthy skin, easily suppurating. Itching eruptions (Clarke, 1999: vol3, 1262). Thick scabs, dry and itch violently. Itching changes location on scratching. Pedunculated figwarts. Skin symptoms alternating with joint pains. Itching eruptions, burning after scratching. Skin unhealthy, doesn’t heal (Vermeulen, 1997:1519).

 

2.10.2.6 Homoeopathic indications of Herbal remedies used in the complex

These homoeopathic indications were also obtained from various Materia Medicas.

a) Arct.: ”Inveterate acne > touch; pimples; dry scaly skin; pustular yellow scabs; eruptions sticky on face, head and neck” (Vermeulen, 1997:1012).

b) Berb.: The acne eruptions come in blotches. The rest of the skin is dry and scaly. Pimples extend from face towards the neck. It is an age-old remedy to clear the complexion of the face (Master, 1995:356). Acne; blotches and pimples; pimply, dry, rough, scaly skin; clears complexion” (Vermeulen, 1997:288)

c) Echi.: “Small, red pimples on neck and face; recurring boils; carbuncles” (Vermeulen, 1997:703-4)

d) Tarax.: “Purulent pimples on face, cheeks, alae-nasi, corners of mouth; pustules; unhealthy sycotic skins” (Vermeulen, 1997:1575-6).

 

2.10.3 Polypharmacy covers any prescribing technique in which two or more remedies are prescribed simultaneously, either in alternation with each other or as a combined formula (complex). The two methods of prescribing are according to individualization or diseased-based. Individualization prescribing is when several remedies are given concurrently or alternately according to each patient’s individual case. Diseased-based prescribing is whereby multiple remedies are prescribed on the basis that they all have a degree of similarity to a particular disease process without regard for individual peculiarities. Low potencies are more frequently employed, ranging from tincture to 6c, and the prescription is repeated on daily (Watson, 991:71).

Hahnemann was not averse to prescribing several remedies simultaneously or in alternation with one another, on the contrary. By combining several remedies together bearing much similarity to a specific disease/condition, i.e. acne, and prescribing them for that specific disease, the practitioner is able to avoid the necessity to individualize each case and is thus able to give every patient with acne, the same prescription. The assumption is that whichever remedy in the combination is most similar to the acne of the person being treated, will act or the other, non-indicated remedies will do nothing, or that a group of remedies known to bear similarity to the typical symptoms of acne will, collectively, bring about a curative response (Watson, 1991:73). According to Watson (1991:75-6), the main arguments against polypharmacy, is firstly that the remedies were proven singly, thus they ought only to be given singly, as no-one can predict how several remedies will act on an individual when given simultaneously. The worse that can happen after a combined prescription is that the patient didn’t get better which can also happen when a single remedy is administered. Secondly the practitioner will be uncertain as to which remedy worked, assuming a curative response takes place at all. Most patients couldn’t be bothered whether one remedy or six were prescribed, as long as they got better. Only the practitioners seem to be bothered and frustrated. Polypharmacy is best suited to serious case, where disease is presenting in several different ways simultaneously, and to cases in which palliation is more desirable or more likely than cure. Polypharmacy will in certain cases, achieve the desired result in a shorter period of time than would have been the case using single remedies.

 

The above studies are just a few of the many herbal studies conducted at the Durban Institute of Technology. Many studies using complexes or polypharmacy, were also conducted at the Durban Institute of Technology i.e. Barklie (1999) compared two complexes (homoeopathic complex vs. herbal complex) in the treatment of Acne vulgaris, and Lee (1997) investigated the effects of a different homoeopathic complex on Acne vulgaris.

2.10.4.1 Phytotherapy is an empirical system of medicine that uses plant remedies only destined to support the healing life-force, in disease treatment, thus complementary

to homoeopathy (Gaier, 1991:423). If herbs are looked at as sources of valuable chemicals, their healing power is limited, for beyond the physical level, they work on the level of the life force also. The herbs are used not so much to treat named diseases but to implement a shift in underlying physiological processes so the body can heal itself.

Herbs were traditionally used to affect organic physiological responses throughout the body thus reinforcing the body’s own curative powers. For many herbs the therapeutic reaction may be more in the relationship of the various constituents found in the formulations of multiple herbs, rather than on any particular biochemical agent.

These complementary actions or their combined action may have different effects depending on the condition and constitution of the individual. By treating not only the manifestations of disease but also its underlying cause, we can achieve true and lasting effects from herbal therapy [Hoffman, 1997:16; Tierra, 1999:11(1), 6-7].

The relationship between clinical observation and the knowledge of plant properties must be coherently integrated to achieve clinical outcomes consistent with botanical medicine (Kenner, 1998:188).All the symptom-pictures of remedies fitting the types of acne patients should be combined to form a synergistic remedy complex that cures

the signs and symptoms of Acne vulgaris. A herbal-complex (Arctium lappa, Berberis aquifolium, Echinacea purpurea and Taraxacum officinale) was used by Barklie (1999) and was compared to a homoeopathic complex. There were no statistically significant differences with respect to the 3 variables of interest i.e. non-inflamed, inflamed and total lesions, between the herbal and homoeopathic complexes. Both the complexes proved to be equally effective in reducing the acne lesions.

2.10.4.2 Herbal Remedies used in the Herbal-complex

2.10.4.2. a) Arctium lappa:(Burdock: Compositae family) acts as an alterative, antiseptic, anti-tumour, diaphoretic, antipyretic, diuretic, depurative, hypoglycemic and, thus useful for skin afflictions e.g. acne, dry scaly eruptions, abscesses, etc. (Hoffman, 1997:76-9). According to Wood (1997:137-151), it cleans the liver and kidney and corrects

a “polluted” bloodstream, ridding the system of toxic waste products thus restoring functions of the skin. It has a cooling and drying effect on the skin as well heals dry, scaly skin and poor healing wounds. Skin diseases depending upon a deprave state of the cutaneous tissue and less upon the state of the blood itself are conditions in which Burdock is used. According to Boericke it is very important in skin therapies. It is a strong plant with a slow, steady, and hardy influence, rejuvenating old chronic conditions by acting primarily on the liver, kidneys and skin. Hoffman (1997:76-9), states that Burdock will move the body to a state of integration and health, removing such indicators ofsystem imbalance as skin problems. Externally it may be used as a compress or poultice to speed up healing Burdock seeds (which are non-toxic) influences sebaceous glands thus useful in adult acne. The oily seeds are said to restore the smoothness of healthy skin. The local use of seedling roots is effective in acne. Combine with Echinacea

for skin complaints. Ramlachan (2002) found that Arctium lappa was an effective antifungal (in vitro) in reducing or inhibiting the growth of Candida albicans, when compared to 62% ethanol, over 18-36 hours. However there were no differences noted between the groups i.e. p= 0.050 and 1.000. When compared to Nystatin, Arctium lappa showed a milder antifungal effect i.e. p= 0.000, in reducing the growth, over 18-36 hours. Arctium lappa and Echinacea purpureashowed similar inhibitory effects on Candida albicans growth, over 18-36 hours i.e. p =.0.884 and 1.000, thus Arctium lappaia antifungal.2.10.4.2.b) Berberis aquifolium: (Mountain-Oregon grape: Berberidaceae family) acts as an alterative, anti-infective, anticonvulsant, carminative, antibiotic, and immune-stimulator and has antipyretic and anticancer effects and is non-toxic. Combine with Arctium lappafor chronic skin conditions e.g. acne (Murray, 1995:165; Hoffman, 1997:186). The effects of some alkaloids (berberine –an alkaloid of Berberis aquifolium) and flavonoids, which are major ingredients in some Japanese Kampoh drugs (Japanese – Chinese traditional herbal medicines) i.e. Seijo-bofu-to and Keigai-rengyo-to, are experientially known to be efficacious by internal use for the treatment of acne vulgaris, mediated by the inhibition of lipogenesis in the sebaceous glands of the hamster

ear, an excellent animal model of human sebaceous glands. In the study, by Seki & Morohashi (1993), it was found that there was a 54-64% inhibition of sebaceous

lipogenesis by berberine. Berberine one of the main ingredients of Coptidis rhizoma, which has been used as a folk medicine and belongs to the isoquinoline alkaloids, possesses antibacterial and anti-inflammatory activity. Both preparations of Japanese Kampoh drugs mentioned above, contain Coptidis rhizoma,which is rich in berberine (Seki & Morohashi, 1993:56-60). Hoffman (1997:186), states that, alteratives, like Berberis aquifolium, gradually alter and correct a “polluted” condition of the blood stream and restore a healthier functioning. It is most often used in the context of skin conditions, the roots of which lie deep within the metabolism of the individual. According to Murray (1995:165-6), Berberine exhibits a broad spectrum of antibiotic-activity. Its action against pathogens is actually stronger than that of antibiotics commonly used in the treatment of diseases caused by these pathogens. It also activates macrophages, which are responsible for engulfing and destroying bacteria, viruses etc. hence purifying the blood.2.10.4.2.c) Echinacea purpurea:(Compositae family)acts as an antimicrobial, antiseptic, alterative, anti-inflammatory, anaesthetic, blood purifier, immune-stimulator and has anti-cancer effects as well as used in wound healing (Hoffman, 1997:196-7). Echinacea purpureahas a potent antibody enhancing ability and indicates no immunosuppression with long-term use (Bodinet & Freudenstein, 1999:59). It is aremedy, according to Wood (1997:244-6), for autoinfection and where the bloodstream becomes slowly infected, elimination is imperfect, the body tissues become altered and there is septic action within the fluids and tissues, resulting in inflammatory and septicaemic processes. It’s used for abscesses, boils, poor wound healing, sloughing skin, pimples and dry, dirty skin, and clears eruptions. Echinacea, according to Murray (1995:95-103), promotes tissue regeneration, reduces inflammation and maintains the

66structure and integrity of the connective tissues and ground substance. It’s used internally for infections (mostly bacterial infections) and externally for burns, abscesses, and other inflammatory skin conditions. It is possible that it possesses some anti-infective properties that prevent bacterial adherence. It is non-toxic if used at recommended doses and parenteral administration is contraindicated in pregnancy and those with allergic tendencies especially to Asteraceae family. Ramlachan (2002) found that Echinacea purpurea was an effective antifungal (in vitro) in reducing or inhibiting the growth of Candida albicans, when compared to 62% ethanol, over 18-36 hours. However there were no differences noted between the groups i.e. p= 0.120 and 1.000. When compared to Nystatin, Echinacea purpurea showed a milder antifungal effect i.e. p= 0.000, in reducing the growth, over 18-36 hours. Dhanraj (2001) stated that Echinacea angustifolia, another herb of the Echinacea species, in 62% ethanol reduced the growth of Staphylococcus epidermidis (one of the microrganisms found in Acne vulgaris) and is able to influence bacterial growth, whereas the tincture in 30% ethanol is totally ineffective. It was noticed that the diameter of the inhibitory zones were increased and that Staphylococcus epidermidis (the normal commensal of skin) is sensitive to Echinacea angustifoliain 62% ethanol, thus Echinacea angustifoliais an effective antimicrobial.

2.10.4.2. d) Taraxacum officinale: (Dandelion: Compositae family) actsas an alterative, stimulant, bactericidal, intoxicant, and depurative thus useful for inflammation, abscesses, eczema, and is non-toxic (Hoffman, 1997:216). Its primary pharmacological activities relate to the liver function, digestion and diuresis (Murray, 1995:88).

While influencing the liver, dandelion purifies the blood thus assisting in acne (Wood, 671997:466). Vukovic (1999:146), agrees that dandelion root improves liver and digestive function. Like burdock root, it has gentle laxative and diuretic properties to flush toxins out of your system. Dandelion and burdock are rich in minerals, like potassium and magnesium, making them ideal not only for cleansing but strengthening too (Vukovic, 1999:146). Hoffman (1997:79), suggests the use of the above herbs for Acne treatment.

2.11 SUMMARY

Acne is an androgen-dependent inflammatory disease of the sebaceous glands, affecting women from adolescence to menopause with psychosocial implications due to cosmetic disfigurement, therefore and counselling should be tailored to the requirements of individual women (Callan, 1997:36). According to McBride & Simpson (2000:12), acne is a source of distress with considerable psychological and social impact. As a result of increased understanding of the disease, effective treatment options and referral, there has been significant reduction in the morbidity of the disease. If there is early and effective treatment with regular review and referral, the cosmetic effect and psychological effect of this common and disfiguring disease of acne is reduced thus ensuring long-term benefits for the patient. According to Tan et al. (2001:443), the delay in seeking medical attention for acne is very often an obstacle to cure and it is imperative that there is early intervention to prevent the risk of scarring and other consequences. Accessible, accurate, community-based education on the natural history of acne, pathogenesis, risk of sequelae, the effectiveness and expected duration of treatment, and the importance of prompt medical

68attention, is necessary for a complete understanding and removal of the disease. Due to the inadequacy of information by current, there are increasing misconceptions on the causality and perceptions of patients. By incorporating information on treatment preferences (in terms of severity and gender), patient input on treatment selection can be facilitated, understanding of treatment options enhanced and patient compliance. The present allopathic treatment of acne, brings with it severe side-effects, frequent relapses, and resultant frustration, thus causing patients to seek alternative forms of treatment. With dietary modifications, there has been significant improvement as well as with Ayurvedic medications. Homoeopathic simillimum, homoeopathic complexes and herbal complexes (i.e. McDavid (1994), Van Niekerk (1999), Lee (1997), and Barklie (1999) as mentioned earlier) have all shown to be effective in acne treatment, but there has not been a comparison done on homoeopathic simillimum and a herbal complex (Arctium lappa, Berberis aquifolium, Echinacea purpureaand Taraxacum officinale) for acne, to assess which was more effective, thus there is a need to compare them to assess their relative efficacy. The general health of the patient is to be considered in the treatment of Acne vulgaris, in terms of therapeutic measures. One cannot treat acne as a disease only, as it is only a manifestation of some internal disturbance which must be corrected, eventually resulting in the disappearance of acne, thus further emphasizing the need for alternative treatment i.e. homoeopathy (McDavid, 1994:32). A search of the indexes of Medline (1993-2003) and British Homoeopathic Journal (1982-2003) reveals no comparison being done on homoeopathic simillimum and a herbal complex (Arctium lappa, Berberis aquifolium, Echinacea purpurea and Taraxacum officinale) in the treatment of acne vulgaris thus stressing the need to compare the effectiveness of a herbal complex (Arctium lappa, Berberis aquifolium, Echinacea purpurea and Taraxacum officinale) to homoeopathic simillimum is apparently more prevalent in females than in males and in early to middle adulthood i.e. 18-30 years.5.3 DISCUSSION OF THE SUBJECTIVE AND OBJECTIVE DATAThe outcome of this clinical trial showed that there was an improvement in both the herbal-complex and homoeopathic simillimum treatment groups for the treatment and management of Acne vulgaris in all patients.5.3.1 Inter-group AnalysisThe data from all 4 consultations from both groups was assessed to determine if there was any difference between the 2 groups and which treatment protocol was more effective, in terms of the patients perception of treatment and clinical manifestations of the presenting condition. The 4 variables studied in this investigation were the perception questionnaires, the number of inflamed lesions, non-inflamed lesions and the total lesion count. It can be seen in Table 4, 5, 6 and 7 that there wasno statistically significant difference with respect to any of the 4 variables between the herbal-complex group (Group 1) and the homoeopathic simillimum group (Group 2). It was found that both treatment groups reduced the clinical manifestations of acne and the patients’ perception of treatment improved throughout the trial, thus showing that no difference could be found when comparing the effectiveness of a herbal-complex to homoeopathic simillimum in the treatment of Acne vulgaris. The treatment period of 9 weeks was long enough to observe the effect of either the herbal-complex or the homoeopathic simillimum, on the patient’s perception of treatment and the signs and symptoms of acne vulgaris.

1265.3.1.1 The Perception QuestionnaireThe inter-group relationships (Table 4) between Group 1 (herbal-complex) and Group 2 (homoeopathic simillimum) for the Perception Questionnaire (Appendix C) disclose that there was no statistical significant difference in the results between the 2 groups for all 4 consultations. This would indicate that the perception by the patient to the treatment was influenced similarly by both the herbal-complex and the homoeopathic simillimum. The mean values of the Perception Questionnaire for 4 consultations, during the trial, were used to present a visual illustration for the findings with bar charts (Figure 1). Both groups from the graph, showed a trend towards improvement. This graph incorporated data for both the herbal-complex and homoeopathic simillimum, allowing a comparison to be made between the 2 groups. In Figure 1 the inter-group relationship showed that Group 2 exhibited a slightly higher mean score than Group 1, except for consultation 3, where Group 1, had a slightly higher mean value than Group 2, thus indicating a greater improvement in the patients’ perception of treatment. However, both groups showed similar significant improvement in terms of the perception to treatment, thus the null hypothesis, which states that there is no statistical significant difference between the groups, was accepted and the alternative hypothesis rejected.5.3.1.2 The Inflamed LesionsThe inter-group relationships (Table 5) between Group 1 and Group 2 for the tabulation of the Inflamed Lesions (Appendix D & E) disclose that there was no statistical significant difference in the results between the 2 groups for all 4 consultations. The mean values of the Inflamed Lesions for 4 consultations, during the trial, were used to present a visual illustration for the findings with bar charts (Figure 2). Both groups from the graph, showed a trend towards improvement. This graph incorporated data for both

127the herbal-complex and homoeopathic simillimum, allowing a comparison to be made between the 2 groups. The inflamed lesions were sensitive and responded well to and improved on both forms of treatment. There was a marked and gradual reduction in inflamed lesions between the first and 4thconsultations. In figure 2, Group 2 showed a much better reduction, when compared to Group 1, in the number of inflamed lesions, in terms of the mean scores, in consultations 1 & 2, but Group 1 had a greater reduction in consultations 3 & 4. Both treatment groups are statistically significant in reducing the number of inflamed lesions, thus the null hypothesis is accepted and the alternative hypothesis is rejected. It can be concluded that the whole group showed a significant improvement over the observation period for inflamed lesions.5.3.1.3 The Non-inflamed Lesions The inter-group relationship (Table 6), between the herbal-complex group and homoeopathic simillimum group for the tabulation of the Non-inflamed Lesions (Appendix D & E), revealed that there was no significant difference between the first and 4thconsultations. The means scores for both groups, reflected on abarchart (Figure 3), reveals that there was a distinct trend towards a reduction of non-inflamed lesions, but Group 2 proved to have a slightly better reduction in non-inflamed lesions, in all consultations, when compared to Group 1. The non-inflamed lesions responded equally well to both treatments, and showed statistically significant reduction in number, thus the null hypothesis is accepted and the alternative hypothesis was rejected. It was evident that both treatment groups were effective and statistically significant in reducing the non-inflamed lesions. The overall reduction in the non-inflamed lesions in both groups was statistically significant, with no marked statistical difference between the 2 treatment groups.

5.3.1.4 Total Lesion Count

The inter-group comparison, between Group 1 and Group 2, for the Total Lesion Count (Appendix D & E), revealed that there was no significant difference between the first and 4thconsultations, when the 2 groups were compared. The mean values of the Total Lesion Count for 4 consultations, during the trial, were used to present a visual illustration for the findings with bar charts. As both the Non-inflamed and Inflamed Lesions, showed marked and gradual reduction during the trial, with both Group 1 & 2 showing similar reduction in the number of both lesions, thus the Total Lesions Count should show a similar reduction, as both the Inflamed and Non-inflamed lesions are added to give a Total Lesion Count. The results obtained show that there was a significant reduction in the total lesions for both the groups, thus there was not significant difference between the groups. The means scores for the Total Lesion Count reveal that Group 2 was slightly better in terms of the reduction of the lesions, for all 4 treatments, although both groups showed a similar trend towards reduction, towards the end of trial. It was evident, both treatment protocols were effective in reducing the total lesions, therefore the null hypothesis, which states that there is no statistical significant difference between the groups, was accepted, and the alternative hypothesis, which states that there was a difference between groups, was rejected. It can be concluded that the whole group showed a statistically significant improvement over the observation period for all the lesions.

5.3.2 Intra-group Analysis

The evaluation of the subjective and objective data obtained from the initial, second, third and final consultations represent the time response of the treatment. The analysis of the intra-group data between consultation 1 & 2, 1 & 3, 2 & 3 represents the initial relative effectiveness of the treatment protocol. The comparison of the data between consultations 1 & 4, 2 & 4, 3 & 4, represent the overall relative effectiveness of the treatment protocol, i.e. herbal-complex vs. homoeopathic simillimum, as a whole.

5.3.2.1 The Perception Questionnaire

An analysis of the results at consultations 1, 2, 3, and 4, revealed a statistically significant difference in both groups (p = 0.001 and p = 0.000 for groups 1 and 2 respectively), indicating that there was an improvement in the perception of treatment by patients in both groups. The results for Groups 1 and 2 were highly significant (p < 0.025), hence the Dunn procedure (a multiple comparison procedure) was carried out to determine at which stage maximum improvement occurred. The intra-group relationship within both groups for Perception Questionnaire, shows varying degrees of improvement over the trial period thus it is necessary to carry out the Dunn procedure. Within Group 1, the results from this procedure showed that between consultation 1 and 2, and consultation 2 and 3, there was no statistical significant improvement, but between consultation

1 and 3, 1 and 4, 2 and 4, and, 3 and 4 there was a statistically significant improvement. Within Group 2, the results from this procedure showed that between consultation 1 and 2, 1and 3, and, 2 and 3, there was no statistical significant improvement, whereas between consultation 1 and 4, 2 and 4, and 3 and 4, there was a statistically significant improvement. The possibility of a cyclic change occurring in the remedies’ duration of action and effectiveness is possibly the reason, for between consultation 2 and 3, that the result is statistically insignificant. An analysis of the data from the first to the final consultation showed an overall improvement in the patients’ perception of treatment, which was statistically significant, thus indicating that both the treatments were effective. The Perception Questionnaire monitored the patients’ perception of the treatment over the trial period. The Dunn procedure showed that the initial relative effectiveness of the treatment protocol of both the groups, especially Group 2, was not statistically significant, but as a whole, the relative effectiveness of the treatment, was statistically significant, thus the perception questionnaire is an effective tool to assess the effectiveness of the treatment administered.5.3.2.2 The Inflamed LesionsAn analysis of the results at consultations 1, 2, 3, and 4, revealed a statistically significant difference in both groups (p = 0.000 for both groups i.e. p< 0.025), indicating that there was a marked reduction in the number of inflamed lesions (according to the Leeds Counting Technique, Appendix D and E), in patients in both groups. The results for Group 1 and 2 were highly significant (p = 0.000 i.e. p< 0.025), hence the Dunn procedure (a multiple comparison procedure) was carried out to determine at which stage maximum improvement occurred. The intra-group relationship (Table 9) within both groups for Inflamed Lesions, shows varying degrees of reduction over the trial period thus it is necessary to carry out the Dunn procedure. Within Group 1, the results from this procedure showed that between consultation 2 and 3, there was no statistical significant improvement, but between consultation 1 and 2, 1 and 3, 1 and 4, 2 and 4, and, 3 and 4 there was a statistically significant improvement. Within Group 2, the results from this procedure also showed that between consultation 2 and 3, there was also no statistical significant improvement, whereas between consultation 1 and 2, 1 and 3, 1 and 4, 2 and 4, and 3 and 4, there was a statistically significant improvement. The possibility of a cyclic change occurring in the remedies’ duration of action and effectiveness is possibly the reason, for between consultation 2 and 3, that the result is statistically insignificant. An analysis of the data from the first to the final consultation showed an overall reduction in the number of inflamed lesions, in the patients, which was statistically significant. The comparison of the data showed a statistically significant improvement in both groups, indicating that both the treatments administered were as effective in the treatment

of Acne vulgaris.

5.3.2.3 The Non-inflamed LesionsAn analysis of the results at consultation 1, 2, 3, and 4, revealed a statistically significant difference in both groups (p = 0.000 for both groups, i.e. p<0.025), indicating that there was a marked reduction in the number of non-inflamed lesions (according to the Leeds Counting Technique, Appendix D and E),

in patients in both groups. The results for Group 1 and 2 were highly significant(p = 0.000, i.e. p<0.025), hence the Dunn procedure (a multiple comparison procedure) was carried out to determine at which stage maximum improvement occurred. The intra-group relationship (Table 10) within both groups for Non-inflamed Lesions, shows varying degrees of reduction over the trial period. Within Group 1, the results from this procedure showed that between consultation 2 and 3 and 3 and 4, there was no statistical significant improvement, but between consultation 1 and 2, 1 and 3, 1 and 4, and 2 and 4, there was a statistically significant improvement. Within Group 2, the results from this procedure also showed that between consultation 2 and 3, there was also no statistical significant improvement, whereas between consultation 1 and 2, 1 and 3,1 and 4, 2 and 4, and 3 and 4, there was a statistically significant improvement. The possibility of a cyclic change occurring in the remedies’ duration of action and effectiveness is possibly the reason, for between consultation 2 and 3, that the result is statistically insignificant. An analysis of the data from the first to the final consultation showed an overall reduction in the number of non-inflamed lesions in the patients, which was statistically significant. The comparison of

132the data showed a statistically significant improvement in both groups, indicating the treatment protocol administered to the patients, in both groups was effective in the treatment and management of Acne vulgaris.5.3.2.4 The Total Lesion CountAn analysis of the results atconsultation 1, 2, 3, and 4, revealed a statistically significant difference in both groups (p = 0.000 for both groups i.e. p<0.025), indicating that there was a marked reduction in both the number of inflamed and non-inflamed lesions (according to the Leeds Counting Technique, Appendix D and E), in patients in both groups. The results for Group 1 and 2 were highly significant (p = 0.000 i.e. p<0.025), hence the Dunn procedure (a multiple comparison procedure) was carried out to determine at which stage maximum improvement occurred. It is necessary to carry out the Dunn procedure as the intra-group relationship within both groups for the Total Lesion Count, shows varying degrees of reduction over the trial period. Within both Group 1 and 2, the results from this procedure showed that between consultation 2 and 3, there was no statistical significant improvement, but between consultation 1 and 2, 1 and 3, 1 and 4, 2 and 4, and 3 and 4 for both groups, there was a statistically significant improvement. The possibility of a cyclic change occurring in the remedies’ duration of action and effectiveness is possibly the reason, for between consultation 2 and 3, that the result is statistically insignificant. An analysis and comparison of the data from thefirst to the final consultation showed an overall reduction in the number of total lesions in the patients which was statistically significant, thus indicating that both the treatments administered were effective in the treatment and management of Acne vulgaris. The Dunn procedure showed that as a whole, the relative effectiveness of the treatment protocol of both the groups was statistically significant.

5.4 INTER-GROUP HYPOTHESIS

It was hypothesized that there would be a statistically significant difference between the two groups with respect to the objective and subjective clinical findings, showing

that the homoeopathic simillimum would be more effective than the herbal-complex (Arctium lappa, Berberis aquifolium, Echinacea purpurea & Taraxacum officinale), in the treatment of Acne vulgaris. Although the homoeopathic simillimum proved to be better (when comparing the mean values), than the herbal-complex, both treatment groups resulted in statistically significant improvement with regard to the patients’ perception of the treatment and the reduction of the specific lesions, however, there were no statistically significant differences between the two groups.

5.5 INTRA-GROUP HYPOTHESISIt was hypothesized that there would be a difference between consultations with regards to the variables of interest i.e. perception questionnaire, inflamed and non-inflamed lesions and total lesion count, in both groups, showing that the homoeopathic simillimum is more effective than the herbal-complex (Arctium lappa, Berberis aquifolium, Echinacea purpurea & Taraxacum officinale) in the treatment of Acne vulgaris. According to patients’ perception of treatment and the reduction of lesions, there was (according to the Dunn procedure), differences between consultations for both groups. Improvement was statistically insignificant, between consultations 2 and 3, for both groups with regard to all the variables of interest. The possibility of a cyclic change (i.e. the remedy reaches its duration of action, then slows down its activity for some time, then starts working again, thus at the second follow-up not much occurred) occurring in the remedies’ duration of action and effectiveness is possibly the reason for this. Although the p-values for the perception questionnaire, were different i.e. p=0.001 and p

134= 0.001, respectively, both groups were statistically significant, as p< 0.025. This is equally true for the other variables of interest, i.e. inflamed and non-inflamed lesions and total lesion count. An overall analysis of the data from the first to the 4thconsultations showed an overall improvement in both groups.

5.6 CONCLUSIONS

It can thus be seen that both the herbal-complex and homoeopathic simillimum, improved and reduced the inflamed, non-inflamed and totallesions and the patients’ perception of response to treatment improved over time, between the 1stand 4thconsultations. In each treatment group, when the clinical manifestations of the individual’s acne improved, so their perception to the treatment showed a similar improvement. It would seem with all the variables of interest that there was initially a large improvement, which made statistically significant difference, but after the third consultation it was not as significant an improvement between consultations, as betweenconsultations 1 and 2. All the results showed that the herbal-complex (Arctium lappa, Berberis aquifolium, Echinacea purpurea & Taraxacum officinale) was just as effective as the homoeopathic simillimum, in the treatment of Acne vulgaris, and that 9 weeks was adequate enough to obtain a positive response.

CHAPTER SIX

6.1 CONCLUSIONS

In this study the researcher compared the effectiveness of a herbal-complex (Arctium lappa, Berberis aquifolium, Echinacea purpurea & Taraxacum officinale), to homoeopathic simillimum in the treatment of acne vulgaris, in terms of the of clinical manifestations and patients perception of treatment. It was found that the herbal-complex showed a similar significant reduction in the number of lesions as the homoeopathic simillimum. This supports the findings of McDavid (1994) and van Niekerk (1999) that homoeopathic simillimum treatment significantly affects the clinical manifestations of Acne vulgaris (p = 0.006 and p = 0.0001 respectively), as well supports findings of Barklie (1999) that the herbal complex is also as effective in reducing or improving the clinical manifestations i.e. the lesions, of Acne vulgaris. In this study (herbal-complex vs. homoeopathic simillimum) both the inflamed lesions and the non-inflamed lesions were significantly reduced and the patients’ perception of both the treatments proved to be favourable over the duration of the trial.

The grading technique and Leeds Counting Technique plays a vital role in monitoring progress in acne patients and is a useful tool in the homoeopathic practice as recognised by previous researchers, McDavid (1994), Lee (1997), van Niekerk (1999) and Barklie (1999), as it provides an objective measurement of the changes in the clinical manifestations of Acne vulgaris. The above objective tools would prove to be more effective, however, if photography (i.e. before, during and after the trial) was also utilized as a further measurement of acne severity, as the results would achieve more objectivity and be more conclusive.

Acne vulgaris is an extremely common and distressing condition but is also a self-limiting, preventable disease with a good prognosis. While acne cannot be regarded as a life-threatening disease, it can severely disrupt the lives of sufferers, socially and psychologically, both young and old. The condition is as bad as the patient’s perception of it and needs to be dealt with at that level (Presbury, 1993:1-2; McBride & Simpson, 2000:12; Tan et al., 2001:443). The universality of acne has resulted in significant efforts to treat this disease, with particular interest in the understanding of the pathogenesis for the disease and the development of therapeutic strategies, but with a variable success rate, thus necessitating further improvements for treating the disease. Acne cannot be prevented, adequate and prompt treatment will prevent or minimize scarring (Callan, 1997:36). Treatment should be tailored around severity, age and sex of the sufferer, individualizing symptoms, and the psychosocial impact on the sufferer, with severity being one of the most powerful determinants. By matching the currently available treatment to the patient’s individual needs, one can almost ensure control, and that patients no longer need to suffer from active acne (Presbury, 1993:1-6).Time alone, without special medical treatment, is sufficient to bring about a cure, in most cases. The majority of patients prefer a quicker cure, and that is very often the reason for consulting a physician. The cure of acne involves the removal of the existing eruption, prevention of relapses, or frequent outbreaks of eruptions. The success will be due to the accuracy with which the practitioner unravels, removes or ameliorates the aetiological factors, thus removing

the whole disease (Douglass, 1995:427).

A concurrent study, by Sewsunker (2003) compared homoeopathic simillimum to miasmatic treatment in the treatment of Acne vulgaris, the result of which was further compared to this study toassess which treatment i.e. homoeopathic simillimum, miasmatic treatment or herbal-complex, was most effective in the treating Acne vulgaris.

It was concluded that all 4 treatment groups were effective in treating acne vulgaris. Each treatment group showed improvement in different aspects i.e. some were more effective in reducing particular types of lesion or in terms of the perception questionnaire, improvement in perception to the treatment administered. From this study, it can

be safe to state that as far as the perceptions of the patients and the clinical manifestations are concerned, homoeopathy and phytotherapy play both an observably notable

and statistically significant role, in the treatment and management of Acne vulgaris.

6.1.1 Limitations, drawbacks and arguments of this proposed study

The first limitation of the study was the sample size being too small. A larger sample size could have affected the conclusions derived from this study considerably. As acne is a common condition and affects a wide variety of people, with a large sample size a greater perspective of the disease, its control, treatment and prognosis would be obtained. The use of non-parametric statistical tests, due to the fact that a small sample size was used (less than 60), can prove to be unreliable hence unreliable results could be obtained (Barklie, 1999:45, Govender, 2002).

138The perception questionnaire should cover more of the psychological aspects experienced by the patients, thus new questionnaires need to be formulationto effectively measure these psychological aspects thus resulting in a more thorough measurement tool. The format and content of the questionnaires utilized in this research were informative and targeted many key factors but unfortunately didn’t cover much of the psychological aspects experienced by the patients. The questionnaires were most effective in assessing the patients’ perception of the treatment administered. The psychological aspects were however clearly expressed while taking case histories during consultations. Various factors could have influenced the patients’ perception to treatment, but due to this study being a double-blind study, one could not ascertain which factors were influencing the acne evolution and hence the perception towards the treatment.

 

[Gillies.Malcolrue M,cDavis]

http://ir.dut.ac.za/handle/10321/1910

Acne vulgaris is defined as a common inflammatory pilosebaceous disease characterized by comedones, papules, pustules, inflamed nodules, superficial pus-filled cysts, and,

in extreme cases, canalizing and deep, inflamed, sometimes purulent, sacs.

 

As many youth pass through puberty, many changes take place in the process of developing into adults.

One of those changes that take place is the altering of hormones in the body. These changing levels of hormones, primarily an increase in androgens, cause many things to develop,

one of them being acne (Acne vulgaris).

For many adolescents, acne can be a very unsightly and consequently a very embarrassing condition. It causes the adolescent to become withdrawn and very self-conscious

leading to possibly many developmental problems at a later stage, not only for the adolescents themselves but also for the parents of that child.

Acne has the capability of becoming very unsightly and may often leave the adolescent with unsightly scarring for, possibly, the rest of his/her life.

In the allopathic treatment of acne, many forms of medication are used, for example hormone therapy in young females.

The therapy may cause the acne to diminish or even disappear but there are often other effects on the body.

Other forms of treatment are often ineffective and detrimental to the patients, not physically and financially.

Homoeopathy can offer quite a number of inexpensive forms of treatment which, as is the point of this study, may be found to be very effective.

There are a number of people that are unaware of firstly Homoeopathy, and secondly that there may be a very effective and inexpensive form of treatment of acne in Homoeopathy.

 

1. A definition is required to introduce the manifestations of Acne vulgaris:

Acne vulgaris is a pleomorphic, multifactorial disease involving abnormalities in follicular keratinization, production of sebum, proliferation of propionibacterium acnes (P. acnes)

and inflammation affecting approximately 85% of teenagers manifesting at any time during life, even as early as the neonatal period and being perceived by many as a benign condition,

emotionally crippling the afflicted individual. It affects mainly the face, chest, back and shoulders and varies from the transient presence of a few comedones and papules to a severe

disabling and debilitating condition marked by persistent deep papules, nodules and cysts.

2. Aethiology

It is important to know and understand what causes acne.

Once the cause of the condition is reviewed, it will help in monitoring the progress (or lack thereof) of the patients and will also aid in the direction of the treatment.

"Classically, symptoms are classified in order of decreasing importance, as follows:

1) Aetiological symptoms

2) Psychic symptoms

3) Modalities

4) General and morphological symptoms

5) Local symptoms" (Jouanny, 1991)

As can be seen by the above quote, aetiological symptoms rank the highest in importance; thus necessitating the understanding and knowing of its aetiology.

'"SEBUM

The increased rate of sebum production is the most important factor.

The severity of acne is related to the degree of seborrhoea which in turn is directly dependent on the size and rate of growth of the sebaceous glands which are under the control

of androgenic hormones.

When acne remits spontaneously, sebum production remains higher in acne patients than in age-matched controls (Cunliffe and Shuster, 1969).

Although sebum excretion rate is under genetic control the development of clinical acne is modified by other factors.

*

HORMONES

Most research points to androgens as being the major stimulus to enlargement of sebaceous glands and to increased production of sebum. In girls the sebaceous glands become functional

as the levels of circulating androgens rise at adrenarche, which may develop as early as the 5th -8th year of life and may precede menarche by more than a year (Pochi et al. 1977).

In boys the onset of acne is associated with the rise in serum testosterone at puberty (Lee, 1976).

Androgens may be involved in two ways: excessive levels may drive . the sebaceous glands, or the glands themselves may be particularly sensitive to normal levels (end-organ hypersensitivity).

Acne may indeed result from androgen excess; after exogenous administration of testosterone; in androgen-secreting tumours or in other forms of androgenisation in women such as in polycystic

ovary syndrome (Rosenfield, 1986).

It is important to know the effect of hormones on the development of acne due to the fact that one of the orthodox forms of treatment is the administering the contraceptive pill to females.

This form of treatment can present the patient with many other common side effects such as nausea, weight gain and breast tenderness (Lever and Marks,1990). which the homeopathic

Practitioner has to take into account when deciding on the remedy for the patient.

*

FOLLICULA KERATINISATION (Knutson,1974)

Although the presence of p. acnes in comedones suggests that bacteria might provide the stimulus, bacteria cannot be detected in early comedones (Lavker et al.1981).

The end result of follicular hyperkeratinisation is the development of a comedo [an open comedo is known popularly as a black-head and a closed comedo is known as a white-head.]

*

Bacterien

Most, if not all, comedones are colonised by a gram-positive microaerophilic bacterium known as P. acnes (Imamura, et a1.1969).

Knowing that bacteria is an almost certain cause of acne can throw a new light on the particular course of treatment of the patient.

*

INFlammation

The inflammation in acne lesions may result from free fatty acids or from the release of other chemoattractants by the P. acnes in the follicle (Allaker et al,1985; Puhvel and Sakamoto, 1987).

Furthermore, rupture of the follicle is commonly seen and cornified epithelium itself can provoke an inflammatory reaction (Marks, et al,1984).

*

OTHER FACTORS

Acne can also be caused by external physical factors such as friction [acne mechanica] or contact with irritant oils or cosmetics [acne cosmetica] ( Fulton, et aI, 1984; Kligman and Mills, 1972).

Acneiform papules may also arise at the site of treatment with topical steroids.

A severe form of cystic acne occurs in individuals exposed to even minute amounts of halogenated phenolic compounds.

2.4.

pathogenesis

The steps through which an acneiform lesion passes must be understood so that any effects that the treatment might be, may be monitored in order to decide on stimulating the lesion to be

Pustule is formed.

With deeper and more extensive inflammatory infiltration, a nodule or cyst is produced.

A granulomatous and foreign body reaction supervenes. P. acnes further provokes the inflammatory response by activating complement through both the classical and alternative pathways.

2.5

Clinical manifestations, Diagnosis and Differentation of lesions

It is necessary that one be able to describe and recognise the different lesions diagnostically (clinical manifestations) in order to recognise any changes that may occur, be they bad or good.

Particular attention must be given to the distribution, morphology, and severity of lesions.

A review of the non-inflammatory and inflammatory lesions of acne is in order.

COMEDONES

These non inflammatory early lesions appear in two forms: closed and open comedones. The dilated, plugged follicle forms a closed comedo (a whitehead).

These lesions are pale, firm, 1mm to 2mm papules that are best visualized with proper lighting and gentle stretching of the skin.

With increasing dilation of the follicular orifice the comedonal contents become visible at the skin surface as deeply pigmented large pores. These open comedones or familiar blackheads

are often a source of cosmetic concern for the patient (Cunliffe, et al. 1991).

PUSTULES And Papules

Rupture of a comedo can produce various inflammatory lesions. If the process is superficial, a pustule forms.

These are raised white lesions filled with pus. Because of their location, pustules usually resolve within a few days without scarring. Papules, on the other hand, represent a deeper dermal

inflammatory reaction.

They appear as erythematous, raised solid lesions. They invariably take a longer time to heal and often do so with scarring.

*

NODULES

These are the most severe variants of acne. They are suppurative abscesses within the dermis that sometimes extend down to fat.

They are warm, tender, firm lesions. Significant scarring can be expected.

*

SCARS

Scars can manifest in multiple forms. They can be divided into atrophic and hypertrophic types.

In atrophic scars one finds either shallow, broad-based depressions or the deep, steep-sided pits with elevated thick fibrotic plaques often on the chest or back of the hypertrophic type.

Assessment of the severity of acne must be performed at each visit.

Newer systems now include lesional counts and lesion types.

Serial photographs are taken to follow a patient's progress (Gibson, et al,1984)

*

Acne fulminans

Occurring in male teenagers, acne fulminans is an explosive, devastating condition with acute onset of tender papules and nodulocystic lesions on the trunk and chest.

A history of mild preceding acne is noted in most patients.

Systemic symptoms of myalgia, arthralgia, fever, chills, leukocytosis, and even osteolytic bone lesions are not uncommon.

Therapeutic control is achieved with systemic corticosteroids and antibiotics.

It presents as a distinct entity because of its abrupt nature and location.

The following guidelines have been taken from the Journal of the American Academy of Dermatology on the care of acne vulgaris.

It is suggested that these guidelines be used for the diagnostic procedure of Acne Vulgaris in orthodox medicine.

 

2.

g)]

1HI[]lM

I[]

IH]

IFIAlTH

I [ TIR!IEIAlTM

IE~T

[]l1F

lAlC ~ IE IUlIUJUi IRIIRlIS:

Before

delving

into

this particular

aspect

of the treatment

of acne,

one

quote

is noted

from

probably

the worlds

most

esteemed

leaders:

" HOMOEOPATHY

ISTHEADVANCED

AND

REFINED

METHOD

OF

TREATING

PATIENTS

ECONOMICALLY

AND

NONVIOLENTLY."

(MAHATMA

GANDHI)

The

treatment

of acne

using

Homoeopathy

does

not differ

from

the

treatment

of any other

condition

as far as the finding

of the remedy

through

careful

case

taking

is concerned.

31

The

general

health

of the patient

above

everything

is to be consulted

in the treatment

of this

disease

as far as therapeutic

measures

are

concerned.

One

cannot

treat

acne

as a disease

as it is only

an

expression

of some

internal

disturbance

we must

necessarily

correct,

and

in proportion

as we correct

it the acne

will

disappear.

The

deepest

acting

long

term

remedies

will

have

to be studied

in these

chronic

cases,

as they

are

all dependent

on a deep-seated

constitutional

and general

hereditary

taint.

This

means

that

Hoinoeopathicaly

speaking,

one needs

to treat

every

patient

in a totally

different

way

as we all have

different

inherited

taints

as apposed

to treating

them

in the orthodox

fashion

of set rules

for set conditions.

Above

all things,

in these

cases

it is very

important

to give

oneself

plenty

of time,

as the patient

is very

apt to make

light

of the case

there

being

no special

constitutional

symptoms

to deal

with

present.

There

are certain

foods/stimulants

to be avoided

whilst

presenting

with

the condition

of acne

vulgaris

but,

due to the fact that

this study

is limiting

itself

to the effects

of Homoeopathy

and

not the

effects

of diet change

in the treatment

of acne,

the role

of diet

change

will

not be taken

into

consideration

as far treatment

is concerned.

Patients

will

however

undergo

screening

before

taking

part

in the

research

program

(Re:delimitation

1.4.2).

A few remedies

are noted

for interest

sake

only

and

not as a rule

for

the treatment

of the condition:

Arsenicum

Album,

Belladonna,

Carbo

vegetabilis,

Pulsatilla,

Sepia

officinalis,

Kali

iodatum

, Bryonia

alba,

Solanum

Dulcamara

....

32

THE

PlRCEBO

HNO

IT'S

ROILIE

MEDICINRl

TH IEIIUi lPlEUT

les:

Many

of the changes

which

follow

the taking

of drugs

are now

known

not to be caused

by the chemical

action

of the drug.

In fact,

the same

changes

occur

if the individual

takes

an inert

substance

which

has a

superficial

resemblance

in appearance

to the active

drug.

This

is the

phenomenon

known

as the placebo

response

and

its manifestations

are both

well

documented

and

dramatic.

The

placebo

response

can

involve

widespread

changes

in physiological

state,

behavioral

response

and

subjective

experience.

The

placebo

response

is clearly

not a fixed

personality

characteristic.

Placebo

responses

can involve

both

improvement

and deterioration

in

functioning.

On the one

hand,

placebo

responders

have

reported

marked

improvements

in mental

feelings

and

their

performance

is

more

efficient.

The

placebo

response

has

however

included

drowsiness,

nausea,

dizziness,

slowness,

and

a wide

range

of changes

including

a deterioration

in efficiency

(Griffiths,

1986)

.

The

use of placebo

in the management

of certain

difficult

patients

is

well

known

and

favourable

effects

can

be noted

in some

patients

following

the oral

administration

of placebos.

In contrast,

during

the

course

of double

blind

cross

over

studies

in drug

evaluation,

it is not

uncommon

to observe

"toxic

side

effects"

among

patients

receiving

placebos

(Remenchik

and Talso,

1968).

33

A small

number

of the patients

will

report

a worsening

of their

symptoms

following

placebo

administration

and

this

has

been

referred

to as the nocebo

effect

(Kissel

and Barrucand,

1974).

In any trial

though,

a proportion

of the patients

will fail to take

their

medication,i.e.

they

will

not comply

with

the treatment

given.

This

however

can be minimised

by ensuring

that

the patient

understands

what

is required

of him,

both

by explanation

and clear

labeling

of the

labels

(Lawson

and Richards,

1982).

In certain

conditions

such

as mild

depression

the placebo

factor

may

account

for over

40%

of the improvement

seen.

On the other

hand,

even

in conditions

such

as severe

cancer,

spontaneous

remissions,

although

rare,

are possible

(Lawson

and Richards,

1982).

However

the proportion

of placebo

responders

in particular

samples

may

vary

from

0 to 100%

although

the number

commonly

falls

in the

30%

to 50%

range;

where

psychiatric

disorders

are concerned

it is not

infrequently

as high

as 75%

(Jospe,

1978;

Parkhouse,1963;

Shapiro

and Morris,

1978).

 

2.

g)]

1HI[]lM

I[]

IH]

IFIAlTH

I [ TIR!IEIAlTM

IE~T

[]l1F

lAlC ~ IE IUlIUJUi IRIIRlIS:

Before

delving

into

this particular

aspect

of the treatment

of acne,

one

quote

is noted

from

probably

the worlds

most

esteemed

leaders:

" HOMOEOPATHY

ISTHEADVANCED

AND

REFINED

METHOD

OF

TREATING

PATIENTS

ECONOMICALLY

AND

NONVIOLENTLY."

(MAHATMA

GANDHI)

The

treatment

of acne

using

Homoeopathy

does

not differ

from

the

treatment

of any other

condition

as far as the finding

of the remedy

through

careful

case

taking

is concerned.

31

The

general

health

of the patient

above

everything

is to be consulted

in the treatment

of this

disease

as far as therapeutic

measures

are

concerned.

One

cannot

treat

acne

as a disease

as it is only

an

expression

of some

internal

disturbance

we must

necessarily

correct,

and

in proportion

as we correct

it the acne

will

disappear.

The

deepest

acting

long

term

remedies

will

have

to be studied

in these

chronic

cases,

as they

are

all dependent

on a deep-seated

constitutional

and general

hereditary

taint.

This

means

that

Hoinoeopathicaly

speaking,

one needs

to treat

every

patient

in a totally

different

way

as we all have

different

inherited

taints

as apposed

to treating

them

in the orthodox

fashion

of set rules

for set conditions.

Above

all things,

in these

cases

it is very

important

to give

oneself

plenty

of time,

as the patient

is very

apt to make

light

of the case

there

being

no special

constitutional

symptoms

to deal

with

present.

There

are certain

foods/stimulants

to be avoided

whilst

presenting

with

the condition

of acne

vulgaris

but,

due to the fact that

this study

is limiting

itself

to the effects

of Homoeopathy

and

not the

effects

of diet change

in the treatment

of acne,

the role

of diet

change

will

not be taken

into

consideration

as far treatment

is concerned.

Patients

will

however

undergo

screening

before

taking

part

in the

research

program

(Re:delimitation

1.4.2).

A few remedies

are noted

for interest

sake

only

and

not as a rule

for

the treatment

of the condition:

Arsenicum

Album,

Belladonna,

Carbo

vegetabilis,

Pulsatilla,

Sepia

officinalis,

Kali

iodatum

, Bryonia

alba,

Solanum

Dulcamara

....

 

 

 

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