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INFLUENCE OF SEX HORMONES LEVEL ON DEVELOPMENT AND CLINICAL MANIFESTATIONS OF ROSACEA, DEMODICOSIS AND PERIODIC DERMATITIS
Chornenka Zh.
Abstract
Introduction. Among the links of the pathogenesis of demodicosis include an increase in production and a change in the composition of sebum, which is explained by the characteristics of the metabolism and function of the sebaceous glands controlled by androgens. Such changes during puberty are due to an increase in the sensitivity of the androgen receptors of the sebaceous glands to male sex hormones, often with a normal physiological composition and level of blood androgens. However, in some patients, demodicosis occurs and persists against the background of pathological conditions caused by central hyperandrogenemia. Numerous researchers emphasize that the persistent course of demodicosis can support background diseases, the persistence of demodecosis after the end of the puberty is possible under the influence of additional trigger factors, which are important to identify during the examination. At the same time, in literary sources, algorithms for examining adolescents with demod-icosis are not adequately covered.
Keywords: demodicosis, rosacea, sex hormones, clinical manifestations.
The skin takes an active part in the metabolism of steroid hormones, and many skin functions (synthesis of intercellular lipids, hair growth, mitotic activity of the epidermis) are influenced by androgens. Under the influence of the enzyme 5-reductase from testosterone, its more active metabolite, dehydrotestosterone, arises. An increase in androgenic and enzymatic activity in puberty leads to the fact that more and more previously inactive sebaceous glands begin to produce sebum. The secretion of fat depends on many factors: ambient temperature, patient age, phase of the menstrual cycle, biological rhythm.
However, to date, there are no reports in the literature on the study of levels of sex hormones in the body of men suffering from rosacea, demodicosis and dermatitis perioral, in particular, depending on the severity of the clinical course of these dermatoses, as well as taking into account the presence of ticks-demicides.
The work presents the data of examination of 479 patients with inflammatory processes of the face skin, among which 227 were diagnosed with rosacea, in 196
- demodicosis, in 56 - perioral dermatitis. The age of the examined patients ranged from 28 to 76 years old, according to the sex of women it was 293 (61%), men
- 186 (39%).
Laboratory diagnostics for detection of D. follicu-lorum and D. brevis ticks was carried out by microscopic examination of pathological material taken from
patients with inflammatory process foci on the face skin and eyelids of eyes. The material for the study was scales, pus pustules, and the contents of the sebaceous gland outlet ducts.
The level of individual sex and gonadotropic hormones in the serum of male patients was studied using immunoassay test systems (DRG International. Inc., USA). An approximate estimation of hormonal (androgenic) saturation of patients was carried out by andro-genic intracellular sample and crystallographic method of biological substrates research.
Among the 227 patients tested for rosacea were 133 (59%) women and 94 (41%) men. The age of patients ranged from 34 to 76 years. Depending on the age, patients with rosacea were as follows: 34-39 years - 13 (6%), 40-49 years - 24 (11%), 50-59 years - 95 (41%), 60-69 years - 83 ( 37%), older than 70 years -12 (5%).
The average age of the surveyed women with rosacea was 47.8 years and men - 53.7 years. The distribution of patients depending on the duration of dermatosis was as follows: up to 1 year - 23 (10%), from 1 to 5 years - 66 (29%), from 5 to 10 years - 63 (28%), over 10 years - 75 (33%).
In determining the extended clinical diagnosis in our patients with rosacea, we followed the classification of this dermatosis used in Europe and the United States.
Among 196 surveyed patients with demodicosis women were 122 (62%), men - 74 (38%). The age of patients ranged from 30 to 74 years. Depending on their age, patients with demodicosis were as follows: 30-39 years - 14 (7%), 40-49 years - 29 (15%), 50-59 years -84 (43%), 60-69 years - 63 ( 32%), older than 70 years - 6 (3%). The average age of the surveyed women with demodicosis was 46.3 years and men - 51.6 years.
The distribution of patients depending on the duration of dermatosis was as follows: up to 1 year - 31 (16%), from 1 to 5 years - 91 (47%), from 5 to 10 years -64 (32%), over 10 years - 10 ( 5%).
An analysis of existing classifications of demod-icosis indicates that they are quite complex for the practical work of dermatological venereologists. Based on many years of clinical observations, we have developed our own classification of demodicosis. The main criterion taken into account in the development of this classification was the nature of the morphological elements of skin rash. According to the developed classification it is proposed to distinguish: erythematous, papular, pustular and combined forms of demodicosis.
According to the results of microscopic investigations, ticks-democicides were found in 441 (92%) of 479 examined patients. The species composition and abundance of the relevant parasites were characterized by some differences. In particular, the presence of ticks of D. folliculorum was diagnosed in 357 (81%) patients, D. brevis - in 58 (13%), and the combined para-sitization of both types of ticks - in 26 (6%) patients.
However, in establishing the final nosological diagnosis in the examined patients, we took into account not only the presence of tick-demicides, but also the number of these parasites in a limited area of the affected skin.
During microscopic examinations, mites-demodi-cides in different numbers were detected in 441 (92%) of 479 examined patients. In particular, in 196 patients, the number of mites-demicides was more than 5 individuals per 1 cm2 of affected skin, which served as a basis for establishing a diagnosis of "demodicosis".
In another 245 patients, the number of demicid ticks found per 1 cm2 of affected skin was less than 5 individuals. The criteria for establishing the final diagnosis in these patients were history data, clinical presentation and type of localization of the inflammatory process. Taking into account the relevant criteria, the diagnosis of rosacea was established in 227 patients examined, and the diagnosis of dermatitis perioral - in 18 patients.
It should also be noted that in 38 patients surveyed in the areas of the affected skin, no tick-demiciditis was detected. According to the anamnestic data, the clinical picture and the type of localization of the inflammatory process, these patients were diagnosed with periodic dermatitis. The duration of the inflammatory process in 34 patients ranged from 2 months to 1 year, and in 4 -more than 1 year.
The issue of diagnostics and differential diagnostics of lesions of the eyes and their appendages in the examined patients needs special coverage. In 113 (24%) of the 479 patients, symptoms of lesions of the eyes and their appendages were reported. According to
the opinion of an ophthalmologist, 42 of 113 patients were diagnosed with blepharoconjunctivitis uncomplicated and 71 with blepharoconjunctivitis.
According to the results of studies of several authors in the body of patients with rosacea of women of different age categories was found disturbance of the balance of sex hormones, which was characterized by a decrease in the level of estrogen hormone estradiol. Individual researchers have conducted studies on estra-diol and testosterone levels in men with rosacea and based on the results obtained, express an opinion on the effect of changes in sex hormone metabolism on the development of this dermatosis.
According to the results of the studies, an increase in testosterone levels and a decrease in estradiol levels were found in all surveyed male patients, with different clinical stages of rosacea, as well as with different clinical stages of demodicosis. The corresponding imbalance deepened in parallel with the severity of the clinical stages of dermatoses. Separate analysis requires revealed indicators of the level of sex hormones (testosterone, estradiol) in the surveyed men with dermatitis perioral. Men with periodontal dermatitis, with the presence of mites-demicides in areas of the inflammatory process on the skin of the face, also found an increase in testosterone levels and a decrease in estra-diol levels. However, in patients with dermatitis perioral, in which no ticks-demicides were detected, the levels of testosterone and estradiol practically coincided with the level of the corresponding indicators in almost healthy men.
Thus, established disorders of the balance of levels of sex hormones (androgens, estrogens) in the body of patients with rosacea and demodicosis and in part of patients with dermatitis periodically indicate a certain value of the relevant hormonal disorders in the patho-genesis of these dermatoses, as well as the possibility of influence of hormone fluctuations an organism for the biological cycle of tick-demicides, which needs to be taken into account when developing the tactics of complex individualized therapy.
Methodological approach to the development of tactics for the treatment of patients with rosacea, dermatitis, perioral and demodicosis was determined by the presence of a number of marked and similar eti-opathogenetic factors of the emergence and development of dermatoses, as well as the clinical picture of the inflammatory process. In addition, the results of para-clinic, laboratory and special methods of investigation, as well as the presence of concomitant pathology by different organs and systems of the patient's body were individually taken into account.
Analysis of the results of our microscopic studies and clinical observations indicates a significant eti-opathogenetic value of ticks-demodicides in the development of rosacea, demodicosis and perioral dermatitis. In this regard, when developing the tactics of complex therapy of the examined patients, we considered it necessary to carry out antiparasitic therapy for all patients who had found demicides, regardless of the number of these parasites detected in a limited area of the inflammatory process on the face or eyelashes, and eyelids forever.
Antiparasitic therapy was performed by combined topical administration of the drug "SpregaT' and 4% permethrin cream twice a day. The course of treatment was 18-20 days.
The development of antiparasitic tactics also took into account the presence of concomitant blepharocon-junctivitis and the detection of tick-demicides on epi-lated eyelashes in 42 patients with rosacea and 71 patients with demodicosis. These patients, along with the lubrication of the face with the drug "Spragal" and 4% permethrin cream recommended daily lubrication of the edges of the eyelashes and eyelashes cream "De-malan" 1-2 times a day for 18-20 days.
The effectiveness of antiparasitic therapy was determined after completion of appropriate courses of treatment. Microscopic examination of pathological material taken from patients with areas of the affected skin on the face, as well as microscopy of epilated eyelashes revealed no motile mature individuals or eggs and nymphs of tick-demicides. Only dead specimens of these parasites were recorded.
Further tactics of local therapy in patients with papulo-pustular and pustular-nodal stages of rosacea (177 patients) and papular, pustular and combined stages of demodicosis (169 patients), as well as in part of patients with dermatitis perioperative inflammation pustules and infiltration (22 patients) differed from the treatment of patients with erythematous stage of these dermatoses.
Local therapy in patients with rosacea, demodico-sis, and dermatitis perioral with appropriate clinical manifestations of the inflammatory process involved the use of Skinoren cream. Skinoren cream should be applied to the affected skin twice a day (in the morning and in the evening). The duration of local skin cream therapy in patients ranged from 6 to 12 weeks, which was determined individually, taking into account the severity of the clinical picture of dermatoses.
Important in the treatment of patients with rosacea, dermatitis, perioral and demodicosis was systemic therapy. Systemic therapy tactics were determined by the severity of the clinical picture and the inflammatory process.
General therapy in the examined patients with papulo-pustular stage of rosacea (168 patients), papular, pustular and combined stage of demodicosis (169 patients) and in patients with dermatitis perioral with the presence of inflammatory process of numerical papules in the areas of inflammatory process, antibiotic therapy.
Antibiotic therapy of the examined patients was carried out by applying the antibiotic of macrodil group - azithromycin.
For the first four weeks, azithromycin was given at a single dose of 500 mg once daily for three consecutive days with a further break of four days. For the next four weeks, the dose of azithromycin was reduced to 250 mg once daily for three days with a four-day interruption of the drug. For the last four weeks, patients have been prescribed azithromycin at a dose of 500 mg once a week. Thus, the total rate of admission to patients with azithromycin was 12 weeks.
After completion of azithromycin treatment, all 359 patients achieved complete clinical regression of papules, pustules, and infiltration in areas of the inflammatory process on the facial skin. At the same time in some patients on the skin of the person continued to remain residual manifestations of the inflammatory process, in particular telangiectasia and focal areas of secondary hyperpigmentation.
9 (5%) of the 227 patients with rosacea who were diagnosed with one of the most severe stages of dermatosis - pustular-nodular (conglobate), which combined with 4 rhinophyma, required special tactical approaches in general therapy.
Synthetic retinoid isotretinoin (roakutan) was used in the complex treatment of patients with pustular-nodal stage rosacea.
When administering isotretinoin 9 to the examined patients with pustular-nodal stage rosacea (5 women and 4 men), the daily dose of the drug was individually determined. The complete course of isotretinoin treatment in 2 patients was 4 months, in 3 patients - 5 months and in 4 patients - 6 months. The therapeutic criterion for the termination of patients receiving isotretinoin was the complete regression of pustules, nodes and infiltration on the skin of the face.
The treatment of concomitant pathology detected in part of the examined patients was carried out according to the prescriptions of doctors of specialty specialties.
The analysis of the characteristics of the examined patients with rosacea, demodicosis and dermatitis periodically according to age deserves attention in the aspect of hormonal supply of the body of women and men with sex hormones, in particular androgens and estrogens, at different periods of the life cycle, as well as taking into account these disturbances. in the pathogen-esis of dermatoses.
In the treatment of women with papulo-pustular and pustular-nodal stages of rosacea (102 patients) and women with pustular and combined stages of demod-icosis (73 patients), the combined drug "Dianestro-35", containing ethylene-35g, was used and antiandrogen -cyproterone acetate.
Patients with rosacea and demodicosis in women without violations of the physiological menstrual cycle drug "Diane-35" was administered orally 1 dragee per day. It is recommended to take Diane-35 within three cycles, ie 3 months.
For patients with the above severe stages of rosacea and demodicosis, women with natural premen-opausal or menopausal administration of the drug "Diane-35" was also prescribed courses of 1 pill a day for 21 days with subsequent
7-day break. After 7 days the reception of the pills was restored. The general course of treatment was 3 months.
Taking into account the existing reports and the results of personal researches in the literature, which indicate the presence of disorders of the metabolism of sex hormones in men suffering from papular-pustular and pustular-nodal stage of rosacea (75 patients), and men suffering from demiculosis and pustulosis 45 patients), in the treatment of these patients also used drugs
that have antiandrogenic properties. In particular, men treated with appropriate rosacea and demodicosis were prescribed oral administration of spironolactone 50 mg daily. The duration of spironolactone administration was determined individually. The minimum course of treatment was 3 months.
The analysis of the achieved therapeutic effect in the treatment of the examined patients in accordance with our original complex method of treatment indicates the achievement of clinical recovery in all 56 (100%) patients suffering from periodontal dermatitis, in 196 (86%) patients with rosacea and in 178 (91 %) patients with demodicosis. In the other surveyed patients, including 31 (14%) patients with rosacea and 18 (9%) patients with demodicosis, the treatment provided resulted in significant clinical improvement.
Conclusions. Thus, we have developed an original approach to the treatment of rosacea, dermatitis perioral and demodicosis, which involves the implementation of complex individualized therapy aimed at eliminating a number of possible factors for the emergence and development of these dermatoses, regression of their clinical manifestations, as well as correction and balance of organ levels patients, allows to achieve high therapeutic effect.
Our clinical observations suggest that one of the leading factors in the development of relapses of rosacea, demodicosis and perioral dermatitis is the inadequacy of antiparasitic therapy or the lack of effectiveness of a number of existing acaricidal agents.
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JUSTIFICATION OF THE EFFECTIVENESS OF THE USE OF INTERACTIVE TEACHING
METHODS IN HIGHER EDUCATION
Yasynska E., Vatsyk M.
Higher State Educational Institution of Ukraine «Bukovina State Medical University», Chernivtsi (Ukraine) Department of Social Medicine and Health Organization
Abstract
The article analyzes the use of interactive technologies in higher education. It shows the integration in an interdisciplinary aspect of such interactive methods as: trainings, situational tasks, case studies, master classes, press conferences, testing, game preparation, round tables, multimedia lectures and practical exercises, electronic educational publications.
Keywords: interactive teaching methods, interactive technologies, educational process optimization.
Modern world standards in the field of education provide for the training of highly qualified specialists who are able to integrate theoretical knowledge and practical skills into an integrated system, own new technologies. A modern student should be endowed with such qualities as mobility, critical thinking, the ability to generate new ideas, the ability to make innovative decisions and bear responsibility for them, the ability to work in a team, the ability to model profes-
sional situations. The solution to such problems is impossible without the use of interactive learning technologies.
Interactive learning is a special form of organization of cognitive activity, which has a specific, intended goal - to create comfortable learning conditions in which each student feels his success and intellectual ability. The peculiarity of interactive learning is that the educational process is carried out under the condition
