Hospital

A hospital, in medical malpractice the modern sense, is an institution for health care providing patient treatment by specialized staff and equipment, and often, but not always providing for longer-term patient stays. Its historical meaning, until relatively recent times, was "a place of hospitality", for example the Chelsea Royal Hospital, established in 1681 to house veteran soldiers.

Today, hospitals are usually funded by the public sector, by health organizations (for profit or nonprofit), health insurance companies or charities, including by direct charitable donations. Historically, however, hospitals were often founded and funded by religious orders or charitable individuals and leaders. Conversely, modern-day hospitals are largely staffed by professional physicians, surgeons, and nurses, whereas in history, this work was usually performed by the founding religious orders or by volunteers. Today, there are various Catholic religious orders, such as the Alexians and the Bon Secours Sisters which still focus on hospital ministry.
Etymology

During the Middle Ages hospitals served different functions to modern institutions, being almshouses for the poor, hostels for pilgrims, or hospital schools. The word hospital comes from the Latin hospes, signifying a stranger or foreigner, hence a guest. Another noun derived from this, hospitium came to signify hospitality, that is the relation between guest and shelterer, hospitality, friendliness, hospitable reception. By metonymy the Latin medical malpractice word then came to mean a guest-chamber, guest's lodging, an inn.[2] Hospes is thus the root for the English words host (where the p was dropped for convenience of pronunciation) hospitality, hospice, hostel and hotel. The latter modern word derives from Latin via the ancient French romance word hostel, which developed a silent s, which letter was eventually removed from the word, the loss of which is signified by a circumflex in the modern French word hôtel. The German word 'Spital' shares similar roots medical malpractice.

Grammar of the word differs slightly depending on the dialect. In the U.S., hospital usually requires an article; medical malpractice in Britain and elsewhere, the word normally is used without an article when it is the object of a preposition and when referring to a patient ("in/to the hospital" vs. "in/to hospital"); in Canada, both uses are found.[citation needed] medical malpractice
Clinics
Main article: Clinic

A medical facility smaller than a hospital is generally called a clinic, and often is run by a government agency for health services or a private partnership of physicians (in nations where private practice is allowed). Clinics generally provide only outpatient services.

There are over 17,000 hospitals in the world.[1]

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Addiction

Addiction
Definition
Addiction is a persistent, compulsive dependence on a behavior or substance. The term has been partially replaced by the word dependence for substance abuse. Addiction has been extended, however, to include mood-altering behaviors or activities. Some researchers speak of two types of addictions: substance addictions (for example, alcoholism, drug abuse, and smoking); and process addictions (for example, gambling, spending, shopping, eating, and sexual activity). There is a growing recognition that many addicts, such as polydrug abusers, are addicted to more than one substance or process.


Description
Addiction is one of the most costly public health problems in the United States. It is a progressive syndrome, which means that it increases in severity over time unless it is treated. Substance abuse is characterized by frequent relapse, or return to the abused substance. Substance abusers often make repeated attempts to quit before they are successful.
The economic cost of substance abuse in the United States exceeds $414 billion, with health care costs attributed to substance abuse estimated at more than $114 billion.
By eighth grade, 52% of adolescents have consumed alcohol, 41% have smoked tobacco, and 20% have smoked marijuana. Compared to females, males are almost four times as likely to be heavy drinkers, nearly one and a half more likely to smoke a pack or more of cigarettes daily, and twice as likely to smoke marijuana weekly. However, among adolescents these gender differences are not as pronounced and girls are almost as likely to abuse substances such as alcohol and cigarettes. Although frequent use of tobacco, cocaine and heavy drinking appears to remain stable in the 1990s, marijuana use has increased.
An estimated four million Americans over the age of 12 used prescription pain relievers, sedatives, and stimulants for "nonmedical" reasons during one month.
In the United States, 25% of the population regularly uses tobacco. Tobacco use reportedly kills 2.5 times as many people each year as alcohol and drug abuse combined. According to data from the World Health Organization, there were 1.1 billion smokers worldwide and 10,000 tobacco-related deaths per day. Furthermore, in the United States, 43% of children aged 2-11 years are exposed to environmental tobacco smoke, which has been implicated in sudden infant death syndrome, low birth weight, asthma, middle ear disease, pneumonia, cough, and upper respiratory infection.
Eating disorders, such as anorexia nervosa, bulimia nervosa, and binge eating, affect more than five million American women and men. Fifteen percent of young women have substantially disordered attitudes toward eating and eating behaviors. More than 1,000 women die each year from anorexia nervosa.
A Harvard study found that an estimated 15.4 million Americans suffered from a gambling addiction. More than one-half (7.9 million) were adolescents.
Causes and symptoms
Addiction to substances results from the interaction of several factors:
Drug chemistry
Some substances are more addictive than others, either because they produce a rapid and intense change in mood; or because they produce painful withdrawal symptoms when stopped suddenly.
Genetic factor
Some people appear to be more vulnerable to addiction because their body chemistry increases their sensitivity to drugs. Some forms of substance abuse and dependence seem to run in families; and this may be the result of a genetic predisposition, environmental influences, or a combination of both.
Key terms
Addictive personality — A concept that was formerly used to explain addiction as the result of pre-existing character defects in individuals.
Process addiction — Addiction to certain mood-altering behaviors, such as eating disorders, gambling, sexual activity, overwork, and shopping.
Tolerance — A condition in which an addict needs higher doses of a substance to achieve the same effect previously achieved with a lower dose.
Withdrawal — The unpleasant, sometimes life-threatening physiological changes that occur, due to the discontinuation of use of some drugs after prolonged, regular use.
Brain structure and function
Using drugs repeatedly over time changes brain structure and function in fundamental and long-lasting ways. Addiction comes about through an array of changes in the brain and the strengthening of new memory connections. Evidence suggests that those long-lasting brain changes are responsible for the distortions of cognitive and emotional functioning that characterize addicts, particularly the compulsion to use drugs. Although the causes of addiction remain the subject of ongoing debate and research, many experts now consider addiction to be a brain disease: a condition caused by persistent changes in brain structure and function. However, having this brain disease does not absolve the addict of responsibility for his or her behavior, but it does explain why many addicts cannot stop using drugs by sheer force of will alone.
Scientists may have come closer to solving the brain's specific involvement in addiction in 2004. Psychiatrists say they have found the craving center of the brain that triggers relapse in addicts. The anterior cingulated cortex in the frontal lobe of the brain is the area responsible for long-term craving in addicts. Knowing the area of the brain from which long-term cravings come may help scientists pinpoint therapies.
Social learning
Social learning is considered the most important single factor in addiction. It includes patterns of use in the addict's family or subculture, peer pressure, and advertising or media influence.
Availability
Inexpensive or readily available tobacco, alcohol, or drugs produce marked increases in rates of addiction.
Individual development
Before the 1980s, the so-called addictive personality was used to explain the development of addiction. The addictive personality was described as escapist, impulsive, dependent, devious, manipulative, and self-centered. Many doctors now believe that these character traits develop in addicts as a result of the addiction, rather than the traits being a cause of the addiction.
Diagnosis
In addition to a preoccupation with using and acquiring the abused substance, the diagnosis of addiction is based on five criteria:

* loss of willpower
* harmful consequences
* unmanageable lifestyle
* tolerance or escalation of use
* withdrawal symptoms upon quitting

Treatment
Treatment requires both medical and social approaches. Substance addicts may need hospital treatment to manage withdrawal symptoms. Individual or group psychotherapy is often helpful, but only after substance use has stopped. Anti-addiction medications, such as methadone and naltrexone, are also commonly used. A new treatment option has been developed that allows family physicians to treat heroine addiction from their offices rather than sending patients to methadone clinics. The drug is called buprenorphine (Suboxone).
Researchers continue to work to identify workable pharmacological treatments for various addictions. In 2004, clinical trials were testing a number of drugs currently in use for other diseases and conditions to see if they could be used to treat addiction. This would speed up their approval by the U.S. Food and Drug Administration (FDA). For example, cocaine withdrawal is eased by boosting dopamine levels in the brain, so scientists are studying drugs that boost dopamine, such as Ritalin, which is used to treat attention-deficit hyperactivity disorder, and amantadine, a drug used for flu and Parkinson's diease.
The most frequently recommended social form of outpatient treatment is the twelve-step program. Such programs are also frequently combined with psychotherapy. According to a recent study reported by the American Psychological Association (APA), anyone, regardless of his or her religious beliefs or lack of religious beliefs, can benefit from participation in 12-step programs such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). The number of visits to 12-step self-help groups exceeds the number of visits to all mental health professionals combined. There are twelve-step groups for all major substance and process addictions.
The Twelve Steps are:

* Admit powerlessness over the addiction.
* Believe that a Power greater than oneself could restore sanity.
* Make a decision to turn your will and your life over to the care of God, as you understand him.
* Make a searching and fearless moral inventory of self.
* Admit to God, yourself, and another human being the exact nature of your wrongs.
* Become willing to have God remove all these defects from your character.
* Humbly ask God to remove shortcomings.
* Make a list of all persons harmed by your wrongs and become willing to make amends to them all.

* Make direct amends to such people, whenever possible except when to do so would injure them or others.
* Continue to take personal inventory and promptly admit any future wrongdoings.
* Seek to improve contact with a God of the individual's understanding through meditation and prayer.
* Carry the message of spiritual awakening to others and practice these principles in all your affairs.

Prognosis
The prognosis for recovery from any addiction depends on the substance or process, the individual's circumstances, and underlying personality structure. Polydrug users have the worst prognosis for recovery.
Prevention
The most effective form of prevention appears to be a stable family that models responsible attitudes toward mood-altering substances and behaviors. Prevention education programs are also widely used to inform the public of the harmfulness of substance abuse.
Resources
Books
Robert Wood Johnson Foundation. Substance Abuse: The Nation's #1 Problem. Princeton, N.J., 2001.
Periodicals
Kalivas, Peter. "Drug Addiction: To the Cortex … and Beyond." The American Journal of Psychiatry 158, no. 3 (March 2001).
Kelly, Timothy. "Addiction: A Booming $800 Billion Industry." The World and I (July 1, 2000).
Leshner, Alan. "Addiction is a Brain Disease." Issues in Science and Technology 17, no. 3 (April 1, 2001).
"A New Office-based Treatment for Prescription Drug and Heroin Addiction." Biotech Week (August 4, 2004): 219.
"Research Brief: Source of Addiction Identified." GP (July 19, 2004): 4.
"Scientists May Use Existing Drugs to Stop Addiction." Life Science Weekly (Sepember 21, 2004): 1184.
Organizations
Al-Anon Family Groups. Box 182, Madison Square Station, New York, NY 10159. http://www.Al-AnonAlateen.org.
Alcoholics Anonymous World Services, Inc. Box 459, Grand Central Station, New York, NY 10163. http://www.alcoholics-anonymous.org.
American Anorexia Bulimina Association. http://www.aabainc.org.
American Psychiatric Association. 〈http://www.pscyh.org〉.
Center for On-Line Addiction. http://www.netaddiction.com.
eGambling: Electronic Joural of Gambling Issues. http://www.camh.net/egambling/main.html.
National Alliance on Alcoholism and Drug Dependence, Inc. 12 West 21st St., New York, NY 10010. (212) 206-6770.
National Center on Addiction and Substance Abuse at Columbia University. http://www.casacolumbia.org.
National Clearinghouse for Alcohol and Drug Information. http://www.health.org.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). 6000 Executive Boulevard, Bethesda, Maryland 20892-7003
addiction
physiological dependence on some agent, usually a plant, with a tendency to increase its use. Whether true addiction ever occurs in animals is doubtful. Field evidence does point to preferential grazing of some known toxic plants, e.g. Astragalus, Swainsona spp.
drug addiction
abuse of narcotic drugs is a hazard of veterinary practice because of the availability of addictive agents to registered veterinarians. The same laws apply to members of the veterinary profession as to the medical profession and are designed to protect them against becoming dependent upon any drug. Deregistration and a consequent isolation from the prohibited substances is the usual penalty.
Saunders Comprehensive Veterinary Dictionary, 3 ed. © 2007 Elsevier, Inc. All rights reserved
addiction
Psychiatry A preoccupation with and compulsive use of a substance despite recurrent adverse consequences; addiction often involves a loss of control and ↑ tolerance, and may be associated with a biological predisposition to addiction. See Sexual addiction. Cf Dependence Substance abuse 1. A physiologic, physical, or psychological state of dependency on a substance–or pattern of complusive use, which is characterized by tolerance, craving, and a withdrawal syndrome when intake of the substance is reduced or stopped; the most common addictions are to alcohol, caffeine, cocaine, heroin, marijuana, nicotine–the tobacco industry argues that nicotine's addictive properties are unproven, amphetamines Risk of addiction Cocaine, amphetamines > opiates & nicotine > alcohol, benzodiazepine, barbiturates > cannabis, hallucinogens, caffeine 2. A disorder involving use of opioids wherein there is a loss of control, compulsive use, and continued use despite adverse social, physical, psychological, occupational, or economic consequences. See Substance abuse 3. A neurobehavioral syndrome with genetic and environmental influences that results in psychological dependence on the use of substances for their psychic effects; addiction is characterized by compulsive use despite harm. See Pain. Cf Chronic pain.

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Acyclovir

Acyclovir
An antiviral drug that is available under the trade name Zovirax, in oral, intravenous, and topical forms. The drug blocks the replication of the varicella zoster virus.
Mentioned in: Chickenpox, Shingles
Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. All rights reserved.
acyclovir
[əsī′klōvir]


an antiviral agent with activity against herpesvirus types 1 and 2 and varicella zoster virus. Acyclovir is converted by a herpesvirus enzyme into a molecule (acyclovir triphosphate) that inhibits the synthesis of deoxyribonucleic acid (DNA) molecules in the virally infected cells, thereby inhibiting viral replication.
indications It is prescribed topically in an ointment for the treatment of herpes simplex lesions (cold sores) and both orally and systemically (oral and IV) in other types of herpes infections, including genital herpes, herpes encephalitis, chickenpox (varicella zoster), and shingles (herpes zoster).
contraindication Known sensitivity to this drug prohibits its use.
adverse effects After topical use, irritation or pruritus may occur; after systemic use, diaphoresis, headache, and nausea may occur. When it is administered intravenously in the treatment of immunosuppressed patients, there may be pain at the site of the injection, and 1% to 10% of such patients experience acute renal failure.
Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.
acyclovir (aˈ·sīˑ·klō·virˈ),
n antiviral medication used topically to combat herpes virus types 1 and 2 as well as the varicella zoster and other viruses.
Jonas: Mosby's Dictionary of Complementary and Alternative Medicine. (c) 2005, Elsevier.
acyclovir (āsī´klōvir),
n brand name: Zovirax;
drug class: antiviral.
Uses: a 5% ointment; may be used systemically. Drug of choice in simple mucocutaneous herpes simplex, in immunocompromised patients with initial herpes genitalis. Active against herpes viruses such as herpes zoster and varicella (chickenpox).
Mosby's Dental Dictionary, 2nd edition. © 2008 Elsevier, Inc. All rights reserved.
acyclovir, aciclovir
a synthetic analog of guanosine which selectively interferes with viral DNA synthesis. Used parenterally and topically as an antiviral agent in herpesvirus infections in cats, birds and horse.
Saunders Comprehensive Veterinary Dictionary, 3 ed. © 2007 Elsevier, Inc. All rights reserved
antiviral agents
Substances which inhibit the growth of a virus (e.g. herpes) by inhibiting DNA or RNA synthesis. Common agents include aciclovir (acyclovir), idoxuridine, ganciclovir, trifluoridine (trifluorothymidine) and vidarabine. See herpetic keratitis; virus.
Millodot: Dictionary of Optometry and Visual Science, 7th edition. © 2009 Butterworth-Heinemann
acyclovir

Pharmacologic class: Acyclic purine nucleoside analogue

Therapeutic class: Antiviral

Pregnancy risk category B
Action

Inhibits viral DNA polymerase, thereby inhibiting replication of viral DNA. Specific for herpes simplex types 1 (HSV-1) and 2 (HSV-2), varicella-zoster virus, Epstein-Barr virus, and cytomegalovirus (CMV).
Availability

Capsules: 200 mg

Cream: 5% in 2-g tube

Injection: 50 mg/ml

Ointment: 5% in 15-g tube

Powder for injection: 500 mg/vial, 1,000 mg/vial

Suspension: 200 mg/5 ml

Tablets: 400 mg, 800 mg

⊘Indications and dosages

➣ Acute treatment of herpes zoster (shingles)

Adults: 800 mg P.O. q 4 hours while awake (five times/day) for 7 to 10 days

➣ Initial episode of genital herpes

Adults: 200 mg P.O. q 4 hours while awake (1,000 mg/day) for 10 days

➣ Chronic suppressive therapy for recurrent genital herpes episodes

Adults: 400 mg P.O. b.i.d., or 200 mg P.O. three to five times daily for up to 12 months

➣ Intermittent therapy for recurrent genital herpes episodes

Adults: 200 mg P.O. q 4 hours while awake (five times/day) for 5 days, initiated at first sign or symptom of recurrence

➣ Management of initial episodes of genital herpes and limited, non-life-threatening mucocutaneous herpes simplex virus infections in immunocompromised patients

Adults: Apply approximately ½" ribbon of ointment per 4 square inches of surface area to sufficiently cover all lesions q 3 hours, six times daily for 7 days.

➣ Treatment of recurrent herpes labialis (cold sores)

Adults and adolescents ages 12 and older: Apply cream to infected area five times daily for 4 days.

➣ Varicella (chickenpox)

Adults and children weighing more than 40 kg (88 lb): 800 mg P.O. q.i.d. for 5 days

Children older than age 2: 20 mg/kg P.O. q.i.d. for 5 days

➣ Mucosal and cutaneous HSV-1 and HSV-2 in immunocompromised patients

Adults and children older than age 12: 5 mg/kg I.V. infusion over 1 hour given q 8 hours for 7 days

Children younger than age 12: 10 mg/kg I.V. infusion over 1 hour given q 8 hours for 7 days

➣ Herpes simplex encephalitis

Adults and children older than age 12: 10 mg/kg I.V. over 1 hour given q 8 hours for 10 days

Children ages 3 months to 12 years: 20 mg/kg I.V. over 1 hour given q 8 hours for 10 days

Children from birth to 3 months: 10 mg/kg I.V. over 1 hour given q 8 hours for 10 days

➣ Varicella zoster infections in immunocompromised patients

Adults and adolescents older than age 12: 10 mg/kg I.V. over 1 hour given q 8 hours for 7 days

Children younger than age 12: 20 mg/kg I.V. over 1 hour given q 8 hours for 7 days
Dosage adjustment

• Renal impairment
• Obesity (adult dosage based on ideal weight)
• Elderly patients
Off-label uses

• Herpes zoster encephalitis
• CMV and HSV infection after bone marrow or kidney transplantation
• Infectious mononucleosis
• Varicella pneumonia
Contraindications

• Hypersensitivity to drug or valacyclovir
Precautions

Use cautiously in:
• preexisting serious neurologic, hepatic, pulmonary, or fluid or electrolyte abnormalities
• renal impairment
• obesity
• pregnant or breastfeeding patients.
Administration

• Make sure patient is adequately hydrated before starting therapy.
• Give single I.V. dose by infusion over at least 1 hour to minimize renal damage.
• Don't give by I.V. bolus or by I.M. or subcutaneous route.
• Be aware that absorption of topical acyclovir is minimal.
Adverse reactions

CNS: aggressive behavior, dizziness, malaise, weakness, paresthesia, headache; with I.V. use - encephalopathic changes (lethargy, tremors, obtundation, confusion, hallucinations, agitation, seizures, coma)

CV: peripheral edema

EENT: vision abnormalities

GI: nausea, vomiting, diarrhea

GU: proteinuria, hematuria, crystalluria, vaginitis, candidiasis, changes in menses, vulvitis, oliguria, renal failure, glomerulonephritis

Hematologic: anemia, lymphadenopathy, thrombocytopenia, thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (in immunocompromised patients), disseminated intravascular coagulation, hemolysis, leukopenia, leukoclastic vasculitis

Hepatic: jaundice, hepatitis

Musculoskeletal: myalgia

Skin: photosensitivity rash, pruritus, angioedema, alopecia, urticaria, severe local inflammatory reactions (with I.V. extravasation), toxic epidermal necrolysis, erythema multiforme

Other: gingival hyperplasia, fever, excessive thirst, pain at injection site, anaphylaxis, Stevens-Johnson syndrome
Interactions

Drug-drug. Interferon: additive effect

Nephrotoxic drugs: increased risk of nephrotoxicity

Probenecid: increased acyclovir blood level

Zidovudine: increased CNS effects, especially drowsiness

Drug-diagnostic tests. Alanine aminotransferase, aspartate aminotransferase, bilirubin, blood urea nitrogen: increased levels
Patient monitoring

• Monitor fluid intake and output.
• Assess for signs and symptoms of encephalopathy.
• Evaluate patient frequently for adverse reactions, especially bleeding tendency.
• Monitor CBC with white cell differential and kidney function test results.
Patient teaching

• Instruct patient to keep taking drug exactly as prescribed, even after symptoms improve.
• Advise patient to drink enough fluids to ensure adequate urinary output.
• Tell patient to monitor urine output and report significant changes.
☞ Instruct patient to immediately report unusual bleeding or bruising.
• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
• Advise patient to minimize GI upset by eating small, frequent servings of food and drinking plenty of fluids.
• Tell patient to use soft toothbrush and electric razor to avoid injury to gums and skin.
• Advise patient to avoid sexual intercourse when visible herpes lesions are present.
• Inform patient that he may need to undergo regular blood testing during therapy.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.
acyclovir
Zovirax Infectious disease A nucleoside analogue used to manage viral infections in Pts with BMTs, chemotherapy-induced or acquired immunosuppression–eg, AIDS Indications HSV-1, HSV-2, HVZ Adverse effects Upset stomach, headache, nausea; hair loss from prolonged use. Cf Foscarnet, Gancyclovir.

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Acne

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Acne
Definition
Acne is a common skin disease characterized by pimples on the face, chest, and back. It occurs when the pores of the skin become clogged with oil, dead skin cells, and bacteria.
Description
Acne vulgaris, the medical term for common acne, is the most common skin disease. It affects nearly 17 million people in the United States. While acne can arise at any age, it usually begins at puberty and worsens during adolescence. Nearly 85% of people develop acne at some time between the ages of 12-25 years. Up to 20% of women develop mild acne. It is also found in some newborns.
The sebaceous glands lie just beneath the skin's surface. They produce an oil called sebum, the skin's natural moisturizer. These glands and the hair follicles within which they are found are called sebaceous follicles. These follicles open onto the skin through pores. At puberty, increased levels of androgens (male hormones) cause the glands to produce too much sebum. When excess sebum combines with dead, sticky skin cells, a hard plug, or comedo, forms that blocks the pore. Mild noninflammatory acne consists of the two types of comedones, whiteheads and blackheads.
Moderate and severe inflammatory types of acne result after the plugged follicle is invaded by Propionibacterium acnes, a bacteria that normally lives on the skin. A pimple forms when the damaged follicle weakens and bursts open, releasing sebum, bacteria, and skin and white blood cells into the surrounding tissues. Inflamed pimples near the skin's surface are called papules; when deeper, they are called pustules. The most severe type of acne consists of cysts (closed sacs) and nodules (hard swellings). Scarring occurs when new skin cells are laid down to replace damaged cells.
The most common sites of acne are the face, chest, shoulders, and back since these are the parts of the body where the most sebaceous follicles are found.
Causes and symptoms
The exact cause of acne is unknown. Several risk factors have been identified:

* Age. Due to the hormonal changes they experience, teenagers are more likely to develop acne.
* Gender. Boys have more severe acne and develop it more often than girls.
* Disease. Hormonal disorders can complicate acne in girls.
* Heredity. Individuals with a family history of acne have greater susceptibility to the disease.
* Hormonal changes. Acne can flare up before menstruation, during pregnancy, and menopause.

* Diet. No foods cause acne, but certain foods may cause flare-ups.
* Drugs. Acne can be a side effect of drugs including tranquilizers, antidepressants, antibiotics, oral contraceptives, and anabolic steroids.
* Personal hygiene. Abrasive soaps, hard scrubbing, or picking at pimples will make them worse.
* Cosmetics. Oil-based makeup and hair sprays worsen acne.
* Environment. Exposure to oils and greases, polluted air, and sweating in hot weather aggravate acne.
* Stress. Emotional stress may contribute to acne.

Acne is usually not conspicuous, although inflamed lesions may cause pain, tenderness, itching, or swelling. The most troubling aspects of these lesions are the negative cosmetic effects and potential for scarring. Some people, especially teenagers, become emotionally upset about their condition, and have problems forming relationships or keeping jobs.
Diagnosis
Acne patients are often treated by family doctors. Complicated cases are referred to a dermatologist, a skin disease specialist, or an endocrinologist, a specialist who treats diseases of the body's endocrine (hormones and glands) system.
Key terms
Androgens — Male sex hormones that are linked with the development of acne.
Antiandrogens — Drugs that inhibit the production of androgens.
Antibiotics — Medicines that kill bacteria.
Comedo — A hard plug composed of sebum and dead skin cells. The mildest type of acne.
Comedolytic — Drugs that break up comedones and open clogged pores.
Corticosteroids — A group of hormones produced by the adrenal glands with different functions, including regulation of fluid balance, androgen activity, and reaction to inflammation.
Estrogens — Hormones produced by the ovaries, the female sex glands.
Isotretinoin — A drug that decreases sebum production and dries up acne pimples.
Sebaceous follicles — A structure found within the skin that houses the oil-producing glands and hair follicles, where pimples form.
Sebum — An oily skin moisturizer produced by sebaceous glands.
Tretinoin — A drug that works by increasing the turnover (death and replacement) of skin cells.
Acne has a characteristic appearance and is not difficult to diagnose. The doctor takes a complete medical history, including questions about skin care, diet, factors causing flare-ups, medication use, and prior treatment. Physical examination includes the face, upper neck, chest, shoulders, back, and other affected areas. Under good lighting, the doctor determines what types and how many blemishes are present, whether they are inflamed, whether they are deep or superficial, and whether there is scarring or skin discoloration.
In teenagers, acne is often found on the forehead, nose, and chin. As people get older, acne tends to appear towards the outer part of the face. Adult women may have acne on their chins and around their mouths. The elderly may develop whiteheads and blackheads on the upper cheeks and skin around the eyes.
Laboratory tests are not done unless the patient appears to have a hormonal disorder or other medical problem. In this case, blood analyses or other tests may be ordered. Most insurance plans cover the costs of diagnosing and treating acne.
Treatment
Acne treatment consists of reducing sebum production, removing dead skin cells, and killing bacteria with topical drugs and oral medications. Treatment choice depends upon whether the acne is mild, moderate, or severe.
Drugs
TOPICAL DRUGS. Treatment for mild noninflammatory acne consists of reducing the formation of new comedones with topical tretinoin, benzoyl peroxide, adapalene, or salicylic acid. Tretinoin is especially effective because it increases turnover (death and replacement) of skin cells. When complicated by inflammation, topical antibiotics may be added to the treatment regimen. Improvement is usually seen in two to four weeks.
Topical medications are available as cream, gel, lotion, or pad preparations of varying strengths. They include antibiotics (agents that kill bacteria), such as erythromycin, clindamycin (Cleocin-T), and meclocycline (Meclan); comedolytics (agents that loosen hard plugs and open pores) such as the vitamin A acid tretinoin (Retin-A), salicylic acid, adapalene (Differin), resorcinol, and sulfur. Drugs that act as both comedolytics and antibiotics, such as benzoyl peroxide, azelaic acid (Azelex), or benzoyl peroxide plus erythromycin (Benzamycin), are also used. These drugs may be used for months to years to achieve disease control.
After washing with mild soap, the drugs are applied alone or in combination, once or twice a day over the entire affected area of skin. Possible side effects include mild redness, peeling, irritation, dryness, and an increased sensitivity to sunlight that requires use of a sunscreen.
ORAL DRUGS. Oral antibiotics are taken daily for two to four months. The drugs used include tetracycline, erythromycin, minocycline (Minocin), doxycycline, clindamycin (Cleocin), and trimethoprim-sulfamethoxazole (Bactrim, Septra). Possible side effects include allergic reactions, stomach upset, vaginal yeast infections, dizziness, and tooth discoloration.
The goal of treating moderate acne is to decrease inflammation and prevent new comedone formation. One effective treatment is topical tretinoin along with a topical or oral antibiotic. A combination of topical benzoyl peroxide and erythromycin is also very effective. Improvement is normally seen within four to six weeks, but treatment is maintained for at least two to four months.
A drug reserved for the treatment of severe acne, oral isotretinoin (Accutane), reduces sebum production and cell stickiness. It is the treatment of choice for severe acne with cysts and nodules, and is used with or without topical or oral antibiotics. Taken for four to five months, it provides long-term disease control in up to 60% of patients. If the acne reappears, another course of isotretinoin may be needed by about 20% of patients, while another 20% may do well with topical drugs or oral antibiotics. Side effects include temporary worsening of the acne, dry skin, nosebleeds, vision disorders, and elevated liver enzymes, blood fats and cholesterol. This drug must not be taken during pregnancy since it causes birth defects.
Anti-androgens, drugs that inhibit androgen production, are used to treat women who are unresponsive to other therapies. Certain types of oral contraceptives (for example, Ortho-Tri-Cyclen) and female sex hormones (estrogens) reduce hormone activity in the ovaries. Other drugs, for example, spironolactone and corticosteroids, reduce hormone activity in the adrenal glands. Improvement may take up to four months.
Oral corticosteroids, or anti-inflammatory drugs, are the treatment of choice for an extremely severe, but rare type of destructive inflammatory acne called acne fulminans, found mostly in adolescent males. Acne conglobata, a more common form of severe inflammation, is characterized by numerous, deep, inflammatory nodules that heal with scarring. It is treated with oral isotretinoin and corticosteroids.

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