Four interrelated factors are important in the pathogenesis of acne: pathological follicular hyperkeratosis, excessive secretion of sebaceous glands, proliferation of Propionibacterium acnes (P. acnes) and inflammation. In addition, androgens affect the nature and volume of sebaceous gland secretion, which can also play an important role in the pathogenesis of acne.
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If patients suffer from acne, then the formation of sebum increases significantly, which usually correlates with the severity of the disease. The secret of the sebaceous glands is a substrate for the reproduction of P. acnes. At the same time, there is the process of sebum lipolysis by bacterial lipases to free fatty acids, which, in turn, contribute to inflammation and the formation of comedones.
Systemic therapy is necessarily combined with local and is indicated for the treatment of patients with moderate and severe acne, especially in the case of scarring or a tendency to psychoemotional disorders. Many years of experience have shown that the most severe forms of acne are perfectly cured by a drug from the retinoid class – Accutane. Clinical experience shows that it can cause long-term remissions or even cure most patients. Accutane reduces sebum production by 80%. There is a significant decrease in comedogenesis and the number of P. acnes within 4-8 weeks from the start of treatment.
Treatment with this drug requires a lot of experience from the doctor, since an individual dose is selected for each patient depending on the severity, form of the disease and weight at each stage of treatment. During treatment, the doctor adjusts the dose taking into account the individual sensitivity to Accutane. Due to the action of Accutane, there is a significant decrease in sebaceous cysts, that is, those formations in the skin where inflammation is localized. This explains the persistent clinical effect after treatment, as the basic conditions for bacterial reproduction are eliminated.
Indications of the drug
When Accutane had just appeared, the selection of patients depended only on the clinical severity of acne. Over the past few years, the indications for the use of Accutane for acne have expanded. There are data in the literature on the safety and effectiveness of using Accutane for less severe forms of acne.
The criteria for the selection of patients with mild forms of acne in the treatment of Accutane are as follows:
• lack of effect or insufficient effect of traditional antibiotics
• relapse after traditional antibiotics
• tendency to form rough scars
• seborrhea, abundance of closed comedones, atheroma
• depressive state
Moreover, the main indication for the appointment of Accutane remains severe forms: nodular cystic acne, extensive lesions on the face, back, chest.
The side effects of Accutane are well known. Regardless of the severity of acne, the attending physician should discuss possible adverse reactions with patients.
Accutane is teratogenic. When prescribing it to women of childbearing age, it is necessary to exclude pregnancy within two weeks before treatment. However, the drug doesn’t remain in the tissues for a long time, and therefore, pregnancy is not prohibited within 1-2 months after the end of treatment with Accutane. The opinion of some gynecologists and a number of other specialists who do not recommend getting pregnant for the entire first year after treatment with Accutane is erroneous: the level of the drug in the blood returns to the physiological norm within two weeks after the drug is discontinued. As for men, Accutane has no contraindications in terms of childbirth, since it does not have an effect on spermatozoa.
Adverse reactions from the skin and mucous membranes (dryness, cheilitis, rarely conjunctivitis, nosebleeds, etc.) develop in all patients taking Accutane. Their symptoms depend on the dose and individual sensitivity. Therefore, some patients with mild forms of acne against the background of taking small doses of the drug may not notice these reactions. The severity of these reactions is a kind of marker for monitoring the selected dose in each case and suggests a decrease or increase in the doses of the drug during treatment.