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
....
•
Vorwort/Suchen Zeichen/Abkürzungen Impressum