1
danarTi 1
aknes marTva pirvelad
jandacvaSi
klinikuri praqtikis erovnuli rekomendacia
(gaidlaini)
damtkicebulia saqarTvelos Sromis janmrTelobisa da socialuri dacvis ministris 2010 wlis 24 seqtembris
302o brZanebiT
miRebulia ldquoklinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa marTvis saxelmwifo
standartebis (protokolebi) SemuSavebis Sefasebisa da danergvis erovnuli sabWos
2009 wlis 30 dekembris 2 sxdomis gadawyvetilebis Sesabamisad
2
aknes marTva pirvelad jandacvaSi
1 daavadebis ganmarteba
Sesavali
akne axalgazrda asakis pirebis kanis erT-erTi yvelaze xSiri daavadebaa samedicinosTan erTad igi mniSvnelovani fsiqologiuri problemaa pacientisTvis
gaidlaini gankuTvnilia pirvelad jandacvaSi momuSave ojaxis eqimebisaTvis
aRniSnul gaidlainSi ganxilulia aknes mkurnaloba mozardebsa da mozrdilebs Soris igi ar moicavs daavadebis Sedegebis (nawiburebi anTebisSemdgomi eriTema an hiperpigmentacia) marTvis sakiTxebs
ganmarteba
akne kanis cximovani jirkvlebis anTebiTi daavadebaa qronikuli dermatozia da xasiaTdeba Ria daan daxuruli komedonebiT papulebiT pustulebiTa da kvanZovani gamonayariT
simZimis mixedviT ganarCeven daavadebis Semdeg formebs
msubuqi akne ndash komedonebi lt 20 araanTebiTi papulebi lt 15 an dazianebaTa ricxvi lt 30
saSualo simZimis Aakne ndash 15-50 papula da pustula komedonebiT iSviaTi kistebi totaluri dazianebebis ricxvi 30-125
mZime akne ndash pirveladi anTebiTi kvanZebi da kistebi aseve komedonebi papulebi da pustulebi totaluri dazianebebis ricxvi gt125
aknes dros ganviTarebuli gamonayaris tipebi
araanTebiTi
TeTri (anu daxuruli) komedonebi (araanTebiTi folikulebi romelTa Sesavali Seicavs keratinul sacobebs da dafarulia Txeli epidermuli membraniT)
Savi (anu Ria) komedonebi (araanTebiTi folikulebi romelTa Sesavali Seicavs keratinul sacobebs da Savi Seferiloba aqvs)
anTebiTi
papulebi
pustulebi
kvanZebi daan kistebi
3
2 epidemiologia
aSS-Si pirveladi jandacvis dawesebulebebis momarTvianobis 10 ukavSirdeba aknes rac warmoadgens weliwadSi 48 mln vizits1 es daavadeba mozardebis 85-s aReniSneba mozrdilebSi akne mamakacebTan SedarebiT qalebs Soris ufro xSirad gvxdeba (20-29 wlis asakSi - 43-51 30-39 wlis asakSi 20-35) pacientTa 83 gamwvavebas ukavSirebs menstrualur cikls 67 - stress 26 - kvebas2
sxvadasxva monacemebiT saqarTvelos 12-25 wlamde mosaxleobis 80-s aqvs aknes gamovlineba
prognozi
akne TandaTan gaivlis sicocxlis mesame dekadaSi (dehidroepiandrosteronis donis TandaTan Semcirebis gamo) Tumca SesaZlebelia mozrdilobis periodSi misi persistireba an de novo ganviTareba mozrdilTa akne upiratesad qalebs Soris aRiniSneba (pubertuli periodis daavadebisagan gansxvavebiT romelic ufro xSirad biWebs Soris gvxvdeba6) aknes premenstrualuri gamwvavebebi upiratesad ufrosi asakis qalebs Soris vlindeba
3 etiopaTogenezi
akne kanis cximovani folikulebis daavadebaa mis ganviTarebaSi
Semdegi oTxi faqtori monawileobs
retenciuli hiperkeratozi
cximis gaZlierebuli produqcia
dazianebuli aris kolonizacia baqteriebiT (Propionibacterium acne)
anTebiTi procesi
cximovan jirkvalSi cvlilebebi hiperkeratoziT iwyeba igi vlindeba folikulis Sesavalis keratinocitebis gaZlierebuli proliferaciiT da deskvamaciis SeferxebiT Sedegad jirkvlis arxSi yalibdeba sacobi romelic cximisa da keratinisgan Sedgeba (mikrokomedonebi)
sqesobrivi momwifebis periodSi cximovani jirkvlebi diddeba da cximis produqciac Zlierdeba mikrokomedonebi qmnian anaerobul cximiT mdidar garemos igi kargi niadagia baqteriebis zrdisTvis romlebic kvebis wyarod trigliceridebs iyeneben da Slian maT hidrolizis gziT cximovan mJavebad da glicerinad baqteriebi ZiriTadad warmodgenilia Propionibacterium acne-Ti (P acne) romelic kanis
normaluri floris Semadgeneli komponentia
mikroorganizmebi (P acne da aseve sxva kokebi) aTavisufleben qemoatraqtantebs romlebic infeqciis areSi neitrofilebs moizidavs3
Tavisufali cximovani mJavebi da lizosomuri fermentebi (gamoTavisufldeba neotrofilebis mier) folikulis epiTelis dazianebas (rupturas) iwvevs ris gamoc keratini da lipidebi
4
CaiRvreba irgvlivmdebare dermaSi da warmoiqmneba papulebi an kvanZebi
folikulis hiperkeratozis xarisxis cximis produqciis mikroorganizmis zrdis da anTebis mixedviT mikrokomedonebi iyofa araanTebiTad (Ria da daxuruli komedonebi) da anTebiTad (pustulebi papulebi an kvanZebi)
cximis dagrovebis Sedegad mikrokomedonebi daxurul (TeTr) komedonebad gadaiqceva
folikulis SesarTavi TandaTan ixsneba (gaWimvis gamo) da Ria (Savi) komedonebi yalibdeba maT muq Seferilobas Calagebuli keratinocitebi daJanguli cximebi da melanini aniWebs
anTebiTi dazianeba (kistebi) folikulis SigTavsis garemomcvel dermaSi CaRvris Sedegad viTardeba yalibdeba zedapiruli pustulebi Rrma papulebi an kidev ufro Rrma kistebi (rupturis donidan gamomdinare)
aknes mqone pacientebis umravlesobas androgenebis hiperproduqcia ar aReniSneba am dros cximovani jirkvlebis mgrZnobeloba androgenebisadmi momatebulia (hipersensitiuloba) Tumca androgenebis siWarbem (sxvadasxva daavadebebis dros) SeiZleba aknes ganviTareba gamoiwvios
aknes mqone prepubertuli asakis gogonebis sisxlSi nanaxia dehidroepiandrosteronis (dhea) sulfatis ufro maRali done vidre daavadebis armqoneTa Soris4 aRniSnuli hormonis maRali maCvenebelis dros mZime akne viTardeba5
daavadebis ganviTarebis xelSemwyobi faqtorebi
daavadebis ganviTarebaSi mniSvnelovani roli eniWeba genetikur faqtors
garemo faqtorebi kosmetikuri saSualebebis gamoyenebam SeiZleba xeli Seuwyos aknes ganviTarebas zeTovani cximovani komponentebi da saRebavebis Semcveloba am saSualebebSi iwvevs kanis dazianebis gamwvavebas xolo wyalze damzadebuli ndash naklebad komedogenuria8
sapnebi sxvadasxva detergentebi da Semkvrelebi iwveven cximis mocilebas kanis zedapiridan magram cximis produqciaze gavlenas ar axdenen daavadebas auaresebs9 ganmeorebiTi meqanikuri travma (uxeSi jagrisis gamoyenebis Sedegad) amgvari gziT kanis maceraciis Sedegad ew meqanikuri aknes (acne mechanica) ganviTareba SeiZleba gamoiwvios perangis sayelom samxreebma sportuli Cafxutis tarebam da a S Sesabamisad pacientebi unda moeridon mWidro tansacmlis tarebas da Tavi Seikavon saxis kanis travmirebisgan (gaxexva da aS)
aseve amwvavebs daavadebas tenianoba da Zlieri ofli qlorakne gamowveulia halogenirebuli hidrokarbonatebis dioqsinis zemoqmedebis Sedegad (kanTan kontaqtis inhalaciis an organizmSi moxvedris gziT) aRniSnuli qimiuri nivTierebebi gvxvdeba sawarmoo
5
produqtebSi dabinZurebul sakvebSi da aS klinikurad qlorakne farTo monomorfuli komedonebiT xasiaTdeba romelic mZime anTebad dazianebebad transformirdeba da nawiburebs warmoqmnis
dieta aknes ganviTarebaSi kvebiTi faqtorebis mniSvnelobis Sesaxeb urTierTsawinaaRmdego monacemebi arsebobs101112 sakmarisi mtkicebulebebi ara arsebobs raimes akrZalvisTvis erT-erTi kvlevis Sedegad gamovlinda kavSiri aknes ganviTarebasa da rZis miRebas Soris13 avtorebis mosazrebiT daavadebis gamwvavebas rZis hormonuli komponentebi daan sxva bioaqtiuri molekulebi iwvevs sxva kvlevebiT aknes ganviTareba SeiZleba insulinismagvarma zrdis faqtorma gamoiwvios
pica Txili tkbileuli Sokoladi aknes mizezs ar warmoadgens14
stresi stresi iwvevs daavadebis gamwvavebas1516 prospeqtuli
kohortuli kvlevis mixedviT romelSic 94 saSualo skolis moswavles ikvlevdnen dardeboda aknes simZime da kanis mier cximis producireba Zlieri (Sualeduri gamocdebi) da msubuqi stresis dros (sazafxulo ardadagebi)17 kanis mier cximis producireba ar iyo dakavSirebuli xolo aknes simZime kavSirSi iyo stresTan gansakuTrebiT vaJebs Soris aRniSnuli kvlevis msgavsad 22 umaRlesi saswavleblis studentis multivariantulma analizma gamoavlina aknes simZimis korelacia stresTan (mag gamocdebis periodSi)18
4 klinikuri simptomatika
akne viTardeba tipur agdilebze ndash sxeulis im nawilebze sadac kani didi raodenobiT Seicavs cximovan jirkvlebs esenia saxe kiseri gulmkerdi zurgis zeda nawili mxrebi
aknesTvis damaxasiaTebel dazianebasTan (TeTrTaviani SavTaviani komedonebi da anTebiTi kerebi) erTad aRiniSneba nawiburebi da hiperpigmentacia hiperpigmentacia ufro metad vlindeba muqi feris kanis mqoneTa Soris
5 daavadebis diagnozi
pacientis Sefaseba anamnezis detalurad SegrovebiT iwyeba daavadebis diagnozi kanis daTvalierebiT ismeba
fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
kvlevebis Catareba Cveulebriv saWiro ara aris maTi Catarebis saWiroeba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag
6
hirsutizmi an virilizaciis arseboba Semdgom laboratoriuli da gamosaxulebiTi kvlevebs saWiroebs)
ganxiluli unda iqnes endokrinuli daavadebebis SesaZlo arsebobac magaliTad qalebs Soris polikisturi sakvercxeebis sindromi (pss) hiperandrogenizmis erT-erTi mizezia es sindromi menstrualuri funqciis darRveviT hirsutizmiT aknes ganviTarebiT sakvercxis kistebiT sxvadasxva xarisxis insulinisadmi rezistentobiT da Savi akanToziT xasiaTdeba erT-erTi kvlevis mixedviT 51 aknes mqone qals Soris 39 hqonda menstrualuri ciklis darRveva da 37-s pss19 aRniSnuli dakvirvebis Sedegebi mowmobs rom yvela qalis romelsac akne da oligomenorea aReniSneba gamokvleuli unda iqnes pss-ze
aknes swrafi ganviTareba virilizaciasTan erTad Tirkmelzeda an sakvercxis simsivnisaTvisaa damaxasiaTebeli aseve akne uviTardebaT pacientebs kuSingis daavadebis an sindromis mqoneT an adrenerguli hiperplaziis dros virilizaciis simtomebs miekuTvneba xmis Secvla sarZeve jirkvlebis zomaSi Semcireba klitoromegalia alopecia oligomenorea da hirsutiazmi aseT pacientebs Tirkmelzeda jirkvlebis da sakvercxeebis radiologiuri da hormonuli kvlevebis Catareba esaWiroebaT
anamnezis Segrovebisas yuradReba unda gamaxvildes sxvadasxva samkurnalo saSualebebis miRebaze aknes ganviTarebis mizezi SesaZloa iyos iseTi samkurnalo saSualebebis xangrZlivad moxmareba rogoricaa adenokortikotropuli hormoni androgenebi azaTiopreni barbituratebi bromidebi kortikosteroidebi ciklosporini disulfirami halogenebi iodidebi izoniazidi liTiumi feniTioni vitaminebi B2 B6 da B12
20
gamokvlevebis gegma
mikrobiologiuri kvleva rutinulad ar tardeba (rekomendacia II
B) mikrobiologiuri kvlevis Catareba esaWiroebaT pacientebs romelTac aqvT aknesmagvari gram-uaryofiTi floriT gamowveuli folikuliti
androgenebis donis gansazRvra sisxlSi rutinulad ar tardeba (rekomendacia I A) kvlevis Catareba marTebulia rodesac pacients aknesTan erTad androgenebis siWarbis sxva niSnebic aqvs bavSvebSi igi SeiZleba gamovlindes Tmianobis matebiT iRliaSi an boqvenze klitoromegaliiT mozrdil qalebSi ndash menstrualuri ciklis gaiSviaTebiT hirsutizmiT alopeciiT unayofobiT Savi akanToziT simsuqniT da aS
cxrili 1 rekomendacia mikrobiologiuri testirebis Casatareblad
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
mikrobiologiuri testireba B II 21-24
7
6 mkurnaloba
mkurnalobis mizania pacientis zogadi mdgomareobis gaumjobeseba gamonayaris kontroli diskomfortis da fsiqosocialuri stresis Semcireba nawiburebis prevencia
aknes samkurnalod mowodebulia rigi adgilobrivi da sistemuri saSualebebi (ix cxrili 5) maTi arCevani damokidebulia klinikurad gamovlenili dazianebis tipsa da simZimeze25 (ix sqema 1 2 3) mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
mkurnaloba diagnostikis Semdgom rac SeiZleba male unda daiwyos da yovel 2-3 TveSi Sefasdes da gadaixedos iSviaTad Tumca aRwerilia SemTxvevebi roca mkurnaloba ramodenime wels gagrelda26
istoriuli mimoxilva Zveli egviptisa da saberZneTis istoriul ZeglebSi mocemulia informacia kanis daavadebis Sesaxeb romelsac axla aknes vuwodebT antikur romSi aknes mkurnalobdnen cxel mineralur an gogirdis abazanebiT 1800 wels dermatologebma oficialurad aRiares gogirdi rogorc aknes samkurnalo saSualeba 1920 wlidan ki farTo gamoyeneba hpova benzoil peroqsidma 1930 wlidan am mimarTulebiT gamoiyeneboda safaRaraTo saSualebebi da radiaqtiuli nivTierebebi 1950 wlidan farTod daiwyes antibiotokebis gamoyeneba amave droidan gamoixata tetraciklinis jgufis antibiotikebis upiratesi efeqti anTebiTi aknes mkurnalobisTvis mogvianebiT Sesabamisi farmakologiuri formebis SemuSavebis Semdgom dainerga adgilobrivi antibiotikebis gamoyeneba 1970 wels moxmarebaSi Semovida tretinoini M
mkurnalobis saxe (adgilorivi sistemuri) daavadebis simZimiTa da dazianebis lokalizaciiT ganisazRvreba
medikamentebi adgilobrivi mkurnalobisaTvis
mkurnalobisTvis adgilobrivi (lokaluri) saSualebis saxeobis arCeva pacientis kanis tipis da survilis gaTvaliswinebiT xdeba geli iwvevs kanis gamoSrobas amitom misi gamoyeneba umjobesia cximiani kanis SemTxvevaSi malamo da losionebi kans anotiveben da upiratesoba maT mSrali kanis SemTxvevaSi eniWebaT adgilobrivi saSualebebis umetesoba dReSi orjeradad gamoiyeneba Tumca SesaZlebelia dReSi erTjeradi an dRegamoSvebiT gamoyeneba Tu xSiri moxmarebisas kanis gaRizianeba viTardeba amasTan ufro efeqturia adgilobrivi saSualebebis kombinacia vidre maTi damoukideblad calk-calke gamoyeneba miRebuli kombinaciebia retinoidebi benzoil peroqsidi da topikuri antibiotikebi
kombinacia iZleva ufro gamoxatul Terapiul efeqts vidre TiToeuli agentis damoukidebeli gamoyeneba
erTze meti adgilobrivi saSualebis gamoyenebisas ndash erTi gamoiyeneba diliT meore ndash saRamos rogorc wesi adgilobrivi retinoidebi saRamos iniSneba
8
benzoilis zeJangi
benzoilis zeJangi gamoiyeneba sxvadasxva koncentraciiTa da SemavsebeliT am etapze ar arsebobs mtkicebuleba romelic sxvadasxva formulebis upiratesobas gansazRvravs msoflios bevr qveyanaSi gaicema ureceptod xasiaTdeba baqtericiduli moqmedebiT ainhibirebs axali komedonebis warmoqmnas amcirebs folikulur lipidebsa da Tavisufal cximovan mJavebs rac Tavis mxriv epiTelis deskvamacias iwvevs arCevis preparatia mkurnalobis dawyebisas da nebismieri simZimis aknes dros gamoiyeneba xsnarebi da malamoebi gelTan SedarebiT naklebad iwveven kanis iritacias Tumca mainc SeiZleba gamoiwvion eriTema aqercvla da iSviaTad ndash kontaqturi reaqcia27 gamoiyeneba dReSi 2-jer adgilobriv retinoidebTan kombinaciaSi gamoyenebisas kanis gaRizianebisa da fotoreaqciis Tavidan acilebis mizniT benzoilis zeJangi diliT xolo retinoidebi saRamos iniSneba benzoilis zeJangisa da retinoidebis (adapaleni-retinoidebis sinTezuri analogi tretinoini) erTdrouli gamoyeneba ufro efeqturia vidre TiToeuli agentisa calk-calke2829
adgilobrivi retinoidebi
adgilobrivi retinoidebi Tavisi qimiuri formuliT enaTesavebian A
vitamins maTi efeqturoba aknes mkurnalobaSi araerTi mtkicebulebiTaa dadasturebuli34-50 isini erTaderTi saSualebebia romlebic folikuluri epiTelis terminaluri diferenciaciaze axdens gavlenas da arCevis preparatebia araanTebiTi aknes mkurnalobisTvis amasTan gamoiyenebian anTebiTi aknes samkurnalodac retinoidebi axdenen obstruqciis Semcirebas folikulSi keratinizaciis procesis normalizebis gziT aferxeben komedonebis progresirebas anTebad dazianebamde aumjobeseben komedonebis drenaJs aferxeben axali komedonebis warmoqmnas5152 rigi SedarebiTi kvlevebiT ar gamovlinda romelime retinoidis upiratesoba meoresTan SedarebiT
erTerTi kvleviT tazarotenis geli ufro efeqturi aRmoCnda tretinoinis gelTan SedarebiT (araanTebiTi da anTebiTi dazianebebis Semcireba)53 Tumca sxva kvleviT dRegamoSvebiT tazaroteniT mkurnaloba iseTive efeqturi iyo rogorc adapaleniT yoveldRiuri mkurnaloba54 eriTema wva qavili tretinoinTan da adapalenTan SedarebiT ufro gamoxatuli iyo tazarotenis gelis SemTxvevaSi gverdiTi efeqtebi mcirdeba tazarotenis malamos gamoyenebisas Tumca SedarebiTi kvlevebi am agentisa da sxva adgilobrivi retinoidebiT ar Catarebula
sxva kvleviT adapaleni (01 geli) ufro efeqturi aRmoCnda tretinoinTan SedarebiT (0025 geli)55
gverdiTi efeqtebis Semcireba SeiZleba dabali koncentraciis (0025) saSualebebis gamoyenebiT da amtanobis SemTxvevaSi koncentraciis TandaTan gazrdiT (0025 malamo Semdeg 001 geli 005 kremi 0025 geli 01 kremi 005 xsnari) yvela retinoids gaaCnia kanis gamaRizianebeli moqmedeba SeiZleba gamoiwvion kanis siwiTle
9
gaRizianeba damwvroba zrdian fotosensitiurobas amitom maTi gamoyeneba unda moxdes saRamos xolo dRis ganmavlobaSi mzisagan damcav saSualebebTan (kremebTan) erTad mkurnalobis dasawyisSi SesaZloa mdgomareobis gauareseba ukunaCvenebia orsulobis dros
cxrili 2 rekomendaciebi adgilobrivi mkurnalobisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
benzoilis zeJangi A I 30-33
retinoidebi A I 34374750
antibiotikebi A I 61-69
sxva adgilobrivi saSualebebi A I 70-77
adgilobrivi antibiotikebi
adgilobrivi antibiotikebis damateba P acne-s cximovani folikulidan eliminaciis mizniT xdeba anTebiTi da papuluri aknes mkurnalobis dros adgilobrivi eriTromicini gamoiyeneba dReSi erTxel an orjer adgilobrivi 1-iani klindamicini gamoiyeneba RamiT an dReSi orjer
aRsaniSnavia rom adgilobrivi antibiotikebis gamoyenebam SesaZloa xeli Seuwyos P acne-s rezistentuli Stamebis gaCenas rezistentoba mcirdeba adgilobrivi antibiotikebis sxva saSualebebTan kombinaciaSi daniSvnisas amasTan kombinirebuli mkurnaloba ufro efeqturia vidre am saSualebebis calk-calke gamoyeneba
56-59 magaliTad erTerTi kvleviT gamovlinda rom 3-iani eriTromicinis da benzoilis zeJngis 5-iani geliT kombinirebuli mkurnaloba ara marto aRemateboda efeqturobiT TiToeul agents calk-calke aramed gaumjobesebas iZleoda rezistentuli Stamebis SemTxvevaSic60 aseve klindamicinibenzoilis zeJangis geliT mkurnaloba efeqturi iyo TiToeul agentTan SedarebiT59 sxva kvleviT klindamicini da adapalenis kombinacia ufro efeqturi iyo mxolod klindamicinTan SedarebiT Tumca kanismxrivi gverdiTi efeqtebi (aqercvla simSrale wva) ramdenadme gauaresda kombinirebuli mkurnalobis dros
sxva adgilobrivi saSualebebi
salicilis mJava - istoriulad erTerTi Zveli agentia romelic aknes mkurnalobisTvis gamoiyeneboda Tumca retinoidebTan SedarebiT misi komedolizuri moqmedeba ufro sustia is warmoadgens retinoidebis alternativas rodesac pacientebs aReniSnebaT autanloba retinoidebis mimarT rac kanis iritaciiT vindeba70
azelainis mJava (II) ndash aqvs antikomedonuri da antibaqteriuli Tvisebebi amitom gamoiyeneba rogorc anTebiTi aseve araanTebiTi aknes dros rigi klinikuri kvlevebiT nanaxia misi efeqturoba71-73 amcirebs
10
kanis pigmentacias da ufro efeqturia misi gamoyeneba aknesTan asocirebuli hiperpigmentaciis dros74
aluminis qlorids antibaqteriuli moqmedeba gaaCnia Tumca kvlevebma gansxvavebuli Sedegebi aCvena ndash erT SemTxvevaSi misi efeqturoba gamovlinda75 meoreSi76 ndash ara
sistemuri mkurnaloba
sistemuri antibiotikebi
sistemuri antibiotikebi anTebiTi aknes mkurnalobisaTvis gamoiyeneba ainhibireben P acnes zrdas folikulSi sistemuri antibiotikoTerapia adgilobriv saSualebebTan SedarebiT ufro swraf klinikur gaumjobesebas iZleva Tumca SesaZlebelia antibiotikebis gverdiTi efeqtebis gamovlineba rogoricaa vaginaluri kandidozi gastrointestinuli darRvevebi da aS es saSualebebi iniSneba yoveldRiurad 4-6 Tvis manZilze mdgomareobis gaumjobesebisas TandaTan xdeba dozis Semcireba da Sewyveta maTi Sewyvetis Semdeg mgomareobis SenarCuneba SesaZlebelia adgilobrivi retinoidebis an
benzoilis zeJangis saSualebiT77-79
sistemuri mkurnalobisaTvis gamoiyeneba tetraciklini doqsiciklini minociklini eriTromicini trimetoprim-sulfameToqsazoli da klindamicini
tetraciklins (I A) upiratesoba eniWeba dabali fasis da kvlevebiT dadasturebuli maRali efeqturobis gamo mkurnaloba iwyeba doziT 500 mg orjer dReSi Tumca 250 mg 2-jer ndash SesaZloa aseve efeqturi iyos absorbcias amcirebs sakvebi rZis produqtebi antacidebi rkina iniSneba uzmoze misaRebad ukunaCvenebia orsulobis dros da 12 wlis asakamde vinaidan iwvevs kbilis minanqaris feris Secvlas
doqsiciklini (I) da minocilkini (B) tetraciklinTan SedarebiT ufro metad xsnadia cximSi da gamoiyeneba ufro mcire dozebiTac (100 mg 2-jer an 50 mg 2-jer) am saSualebebis miReba sakvebTan erTadac SeiZleba vinaidan sakvebi ar amcirebs mis absorbcias minociklini arCevis pirveli rigis preparati araa maRali fasisa da tetraciklinTan SedarebiT metad efeqturobis Sesaxeb zusti monacemebis ararsebobis8182 agreTve toqsikurobis gamo8384 doqsiciklini da minocilkini iniSneba tetracikliniT mkurnalobis araefeqturobis SemTxvevaSi doqsiciklini iwvevs fotosensibilizacias saylapavis wylulis ganviTarebis Tavidan acilebis mizniT sakmao odenobis wyalTan erTad unda iqnes miRebuli
SesaZloa gamoiwvios Tavbruxveva pseudotumor cerebri kbilebis feris cvlileba mgluras magvari sindromi85-87 sifrTxiliT unda iqnes gamoyenebuli mgluras mqone pacientebs Soris aknes mkurnalobis mizniT
eriTromicini SesaZlebelia dainiSnos 250-1500 mg dRiuri doziT (or miRebad) misi anTebis sawinaaRmdego moqmedeba tetraciklinTan
11
SedarebiT mcirea amasTan xSirad viTardeba rezistentuli Stamebi88 da gastrointestinuri gverdiTi efeqtebi eriTromicini arCevis saSualebaa im SemTxvevebSi roca SezRudulia tetraciklinis daniSvna (orsuli 8 wlamde bavSvi) mimdinareobs kvleva azitromicinis efeqturobis Sesaxeb maqsimaluri doza 60 g 10 kviris ganmavlobaSi89
trimetoprim-sulfameToqsazoli arCevis meore rigis preparatia (40080mg erTjer an orjer dReSi) efeqturi saSualebaa mZime aknes mkurnalobisaTvis Tumca misi gamoyeneba SezRudulia iseTi seriozuli gverdiTi efeqtebis gamo rogoricaa Zvlis tvinis supresia da toqsikuri epidermuli nekrozi amis msgavsad SezRudulia oraluri klindamicinis gamoyeneba fsevdomembranozuli kolitis ganviTarebis riskis gamo
aknes mqone pacientebis mkurnalobis procesSi seriozul problemas warmoadgens mikrobTa rezistentoba misi xelSemwyobia antibiotikebis farTod gamoyeneba da maTi monacvleoba SedarebiT xSiria rezistentobis ganviTareba eriTromicinis xolo iSviaTi ndash minociklinis mimarT antibiotikoTerapiam SesaZloa xeli Seuwyos Streptococcus pyogenes-is rezistentuli StamebiT xaxis kolonizacias90 rezistentobis problema SeiZleba Semcirdes Semdegi gziT
antibiotikis daniSvna misi absoluturi saWiroebis SemTxvevaSi SeZlebisdagvarad xanmokle mkunalobis kursi (Tumca aranakleb 3 Tvisa) SesaZleblobis mixedviT adgilobrivi saSualebebis
gamoyeneba
benzoilis zeJangis gamoyenebam SeiZleba Seamciros rezistentobis sixSire
oraluri saSualebebis Sewyvetis Semdeg Tu dgeba misi ganaxlebis saWiroeba umjobesia isev imave antibiotikis daniSvna manam sanam igi efeqturi darCeba
cxrili 3 rekomendaciebi sistemuri antibiotikoTerapiisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
tetraciklinebi A I 91-94
makrolidebi A I 95-98
trimetoprim-sulfameToqsazoli A I 99100
12
sistemuri retinoidebi
sistemuri retinoidebi mZime formis aknes mkurnalobisaTvis gamoiyeneba aseve SeiZleba misi gamoyeneba naklebad mZime magram mkurnalobisadmi rezistuli formis dros nawiburovani aknes an daavadebasTan dakavSirebuli Zlieri fsiqo-socialuri stresis SemTvevaSi amcirebs cximis sekrecias misi efeqti samkurnalo saSualebis miRebis Sewyvetidan 1 wlamde grZeldeba cximis Semcireba Tavis mxriv iwvevs proliferaciis Semcirebas samkurnalo saSualebas anTebis sawinaaRmdego moqmedebac gaaCnia da komedonebis warmoqmnas aferxebs101
sistemuri izotretinoinis daniSvnis Cvenebebia
mZime kvanZovan-cisturi akne
akne romelic mxolod mcired gaumjobesda sistemuri antibiotikoTerapiis 6 Tviani kursis Semdeg
nawiburovani akne
akneTi gamowveuli mZime stresi
ganmeorebiTi akne
fulminanturi akne
gram-uaryofiTi folikuliti
mkurnaloba iwyeba 05 mgkg dRiuri doziT da SeiZleba 2 mgkg dozamde gaizardos iniSneba 2 miRebad sakvebTan erTad Cveulebriv mkurnalobis xangrZlivoba 20 kviramdea arsebobs mtkicebulebebi rom efeqturi SeiZleba iyos ufro dabali dozebiT mkurnalobac102 mkurnalobis dawyebisas SesaZloa aknes gauareseba aseT SemTxvevebSi naCvenebia sistemuri kortikosteroidebis daniSvna an mkurnalobis ufro dabali dozebiT (05 mgkgdR-ze naklebi) dawyeba mkurnalobis kumulaciuri doza 120-150 mgkg-ia
pacientebis 80-ze mets mkurnalobis erTi kursis Semdeg xangrZlivi remisia aReniSneba gaumjobeseba mkurnalobis Sewyvetidan ramdenime Tve grZeldeba saWiroebisas kursis ganaxlebamde 4-5 Tve unda iyos gasuli recidivebis umetesoba (96) mkurnalobis Sewyvetidan pirveli 3 Tvis ganmavlobaSi aRmocendeba103 da misi sixSire gansakuTrebiT maRalia pacientebs Soris romelTac akne upiratesad torsze aReniSnebaT an samkurnalo saSualebis kumulaciuri doza 120 mgkg-ze naklebia
izotretinoinis kursis Semdeg remisiis maRali sixSiris miuxedavad pacientebis mxolod 39-s aReniSneba sruli gamojanmrTeleba 61-s ki kvlav esaWiroeba adgilobrivi an sistemuri antibiotikebiT mkurnalobis gagrZeleba104 izotretinoinis maRali Rirebulebis miuxedavad am saSualebiT Catarebuli mkurnaloba mainc xarjTefeqturad SeiZleba CaiTvalos vinaidan es erTaderTi saSualebaa romelic aknes ganviTarebis meqanizmze moqmedebs Tumca aRsaniSnavia isic rom izotretinoinTan dakavSirebulia sakmaod seriozuli da mZime gverdiTi efeqtebi rac zRudavs mis gamoyenebas
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
2
aknes marTva pirvelad jandacvaSi
1 daavadebis ganmarteba
Sesavali
akne axalgazrda asakis pirebis kanis erT-erTi yvelaze xSiri daavadebaa samedicinosTan erTad igi mniSvnelovani fsiqologiuri problemaa pacientisTvis
gaidlaini gankuTvnilia pirvelad jandacvaSi momuSave ojaxis eqimebisaTvis
aRniSnul gaidlainSi ganxilulia aknes mkurnaloba mozardebsa da mozrdilebs Soris igi ar moicavs daavadebis Sedegebis (nawiburebi anTebisSemdgomi eriTema an hiperpigmentacia) marTvis sakiTxebs
ganmarteba
akne kanis cximovani jirkvlebis anTebiTi daavadebaa qronikuli dermatozia da xasiaTdeba Ria daan daxuruli komedonebiT papulebiT pustulebiTa da kvanZovani gamonayariT
simZimis mixedviT ganarCeven daavadebis Semdeg formebs
msubuqi akne ndash komedonebi lt 20 araanTebiTi papulebi lt 15 an dazianebaTa ricxvi lt 30
saSualo simZimis Aakne ndash 15-50 papula da pustula komedonebiT iSviaTi kistebi totaluri dazianebebis ricxvi 30-125
mZime akne ndash pirveladi anTebiTi kvanZebi da kistebi aseve komedonebi papulebi da pustulebi totaluri dazianebebis ricxvi gt125
aknes dros ganviTarebuli gamonayaris tipebi
araanTebiTi
TeTri (anu daxuruli) komedonebi (araanTebiTi folikulebi romelTa Sesavali Seicavs keratinul sacobebs da dafarulia Txeli epidermuli membraniT)
Savi (anu Ria) komedonebi (araanTebiTi folikulebi romelTa Sesavali Seicavs keratinul sacobebs da Savi Seferiloba aqvs)
anTebiTi
papulebi
pustulebi
kvanZebi daan kistebi
3
2 epidemiologia
aSS-Si pirveladi jandacvis dawesebulebebis momarTvianobis 10 ukavSirdeba aknes rac warmoadgens weliwadSi 48 mln vizits1 es daavadeba mozardebis 85-s aReniSneba mozrdilebSi akne mamakacebTan SedarebiT qalebs Soris ufro xSirad gvxdeba (20-29 wlis asakSi - 43-51 30-39 wlis asakSi 20-35) pacientTa 83 gamwvavebas ukavSirebs menstrualur cikls 67 - stress 26 - kvebas2
sxvadasxva monacemebiT saqarTvelos 12-25 wlamde mosaxleobis 80-s aqvs aknes gamovlineba
prognozi
akne TandaTan gaivlis sicocxlis mesame dekadaSi (dehidroepiandrosteronis donis TandaTan Semcirebis gamo) Tumca SesaZlebelia mozrdilobis periodSi misi persistireba an de novo ganviTareba mozrdilTa akne upiratesad qalebs Soris aRiniSneba (pubertuli periodis daavadebisagan gansxvavebiT romelic ufro xSirad biWebs Soris gvxvdeba6) aknes premenstrualuri gamwvavebebi upiratesad ufrosi asakis qalebs Soris vlindeba
3 etiopaTogenezi
akne kanis cximovani folikulebis daavadebaa mis ganviTarebaSi
Semdegi oTxi faqtori monawileobs
retenciuli hiperkeratozi
cximis gaZlierebuli produqcia
dazianebuli aris kolonizacia baqteriebiT (Propionibacterium acne)
anTebiTi procesi
cximovan jirkvalSi cvlilebebi hiperkeratoziT iwyeba igi vlindeba folikulis Sesavalis keratinocitebis gaZlierebuli proliferaciiT da deskvamaciis SeferxebiT Sedegad jirkvlis arxSi yalibdeba sacobi romelic cximisa da keratinisgan Sedgeba (mikrokomedonebi)
sqesobrivi momwifebis periodSi cximovani jirkvlebi diddeba da cximis produqciac Zlierdeba mikrokomedonebi qmnian anaerobul cximiT mdidar garemos igi kargi niadagia baqteriebis zrdisTvis romlebic kvebis wyarod trigliceridebs iyeneben da Slian maT hidrolizis gziT cximovan mJavebad da glicerinad baqteriebi ZiriTadad warmodgenilia Propionibacterium acne-Ti (P acne) romelic kanis
normaluri floris Semadgeneli komponentia
mikroorganizmebi (P acne da aseve sxva kokebi) aTavisufleben qemoatraqtantebs romlebic infeqciis areSi neitrofilebs moizidavs3
Tavisufali cximovani mJavebi da lizosomuri fermentebi (gamoTavisufldeba neotrofilebis mier) folikulis epiTelis dazianebas (rupturas) iwvevs ris gamoc keratini da lipidebi
4
CaiRvreba irgvlivmdebare dermaSi da warmoiqmneba papulebi an kvanZebi
folikulis hiperkeratozis xarisxis cximis produqciis mikroorganizmis zrdis da anTebis mixedviT mikrokomedonebi iyofa araanTebiTad (Ria da daxuruli komedonebi) da anTebiTad (pustulebi papulebi an kvanZebi)
cximis dagrovebis Sedegad mikrokomedonebi daxurul (TeTr) komedonebad gadaiqceva
folikulis SesarTavi TandaTan ixsneba (gaWimvis gamo) da Ria (Savi) komedonebi yalibdeba maT muq Seferilobas Calagebuli keratinocitebi daJanguli cximebi da melanini aniWebs
anTebiTi dazianeba (kistebi) folikulis SigTavsis garemomcvel dermaSi CaRvris Sedegad viTardeba yalibdeba zedapiruli pustulebi Rrma papulebi an kidev ufro Rrma kistebi (rupturis donidan gamomdinare)
aknes mqone pacientebis umravlesobas androgenebis hiperproduqcia ar aReniSneba am dros cximovani jirkvlebis mgrZnobeloba androgenebisadmi momatebulia (hipersensitiuloba) Tumca androgenebis siWarbem (sxvadasxva daavadebebis dros) SeiZleba aknes ganviTareba gamoiwvios
aknes mqone prepubertuli asakis gogonebis sisxlSi nanaxia dehidroepiandrosteronis (dhea) sulfatis ufro maRali done vidre daavadebis armqoneTa Soris4 aRniSnuli hormonis maRali maCvenebelis dros mZime akne viTardeba5
daavadebis ganviTarebis xelSemwyobi faqtorebi
daavadebis ganviTarebaSi mniSvnelovani roli eniWeba genetikur faqtors
garemo faqtorebi kosmetikuri saSualebebis gamoyenebam SeiZleba xeli Seuwyos aknes ganviTarebas zeTovani cximovani komponentebi da saRebavebis Semcveloba am saSualebebSi iwvevs kanis dazianebis gamwvavebas xolo wyalze damzadebuli ndash naklebad komedogenuria8
sapnebi sxvadasxva detergentebi da Semkvrelebi iwveven cximis mocilebas kanis zedapiridan magram cximis produqciaze gavlenas ar axdenen daavadebas auaresebs9 ganmeorebiTi meqanikuri travma (uxeSi jagrisis gamoyenebis Sedegad) amgvari gziT kanis maceraciis Sedegad ew meqanikuri aknes (acne mechanica) ganviTareba SeiZleba gamoiwvios perangis sayelom samxreebma sportuli Cafxutis tarebam da a S Sesabamisad pacientebi unda moeridon mWidro tansacmlis tarebas da Tavi Seikavon saxis kanis travmirebisgan (gaxexva da aS)
aseve amwvavebs daavadebas tenianoba da Zlieri ofli qlorakne gamowveulia halogenirebuli hidrokarbonatebis dioqsinis zemoqmedebis Sedegad (kanTan kontaqtis inhalaciis an organizmSi moxvedris gziT) aRniSnuli qimiuri nivTierebebi gvxvdeba sawarmoo
5
produqtebSi dabinZurebul sakvebSi da aS klinikurad qlorakne farTo monomorfuli komedonebiT xasiaTdeba romelic mZime anTebad dazianebebad transformirdeba da nawiburebs warmoqmnis
dieta aknes ganviTarebaSi kvebiTi faqtorebis mniSvnelobis Sesaxeb urTierTsawinaaRmdego monacemebi arsebobs101112 sakmarisi mtkicebulebebi ara arsebobs raimes akrZalvisTvis erT-erTi kvlevis Sedegad gamovlinda kavSiri aknes ganviTarebasa da rZis miRebas Soris13 avtorebis mosazrebiT daavadebis gamwvavebas rZis hormonuli komponentebi daan sxva bioaqtiuri molekulebi iwvevs sxva kvlevebiT aknes ganviTareba SeiZleba insulinismagvarma zrdis faqtorma gamoiwvios
pica Txili tkbileuli Sokoladi aknes mizezs ar warmoadgens14
stresi stresi iwvevs daavadebis gamwvavebas1516 prospeqtuli
kohortuli kvlevis mixedviT romelSic 94 saSualo skolis moswavles ikvlevdnen dardeboda aknes simZime da kanis mier cximis producireba Zlieri (Sualeduri gamocdebi) da msubuqi stresis dros (sazafxulo ardadagebi)17 kanis mier cximis producireba ar iyo dakavSirebuli xolo aknes simZime kavSirSi iyo stresTan gansakuTrebiT vaJebs Soris aRniSnuli kvlevis msgavsad 22 umaRlesi saswavleblis studentis multivariantulma analizma gamoavlina aknes simZimis korelacia stresTan (mag gamocdebis periodSi)18
4 klinikuri simptomatika
akne viTardeba tipur agdilebze ndash sxeulis im nawilebze sadac kani didi raodenobiT Seicavs cximovan jirkvlebs esenia saxe kiseri gulmkerdi zurgis zeda nawili mxrebi
aknesTvis damaxasiaTebel dazianebasTan (TeTrTaviani SavTaviani komedonebi da anTebiTi kerebi) erTad aRiniSneba nawiburebi da hiperpigmentacia hiperpigmentacia ufro metad vlindeba muqi feris kanis mqoneTa Soris
5 daavadebis diagnozi
pacientis Sefaseba anamnezis detalurad SegrovebiT iwyeba daavadebis diagnozi kanis daTvalierebiT ismeba
fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
kvlevebis Catareba Cveulebriv saWiro ara aris maTi Catarebis saWiroeba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag
6
hirsutizmi an virilizaciis arseboba Semdgom laboratoriuli da gamosaxulebiTi kvlevebs saWiroebs)
ganxiluli unda iqnes endokrinuli daavadebebis SesaZlo arsebobac magaliTad qalebs Soris polikisturi sakvercxeebis sindromi (pss) hiperandrogenizmis erT-erTi mizezia es sindromi menstrualuri funqciis darRveviT hirsutizmiT aknes ganviTarebiT sakvercxis kistebiT sxvadasxva xarisxis insulinisadmi rezistentobiT da Savi akanToziT xasiaTdeba erT-erTi kvlevis mixedviT 51 aknes mqone qals Soris 39 hqonda menstrualuri ciklis darRveva da 37-s pss19 aRniSnuli dakvirvebis Sedegebi mowmobs rom yvela qalis romelsac akne da oligomenorea aReniSneba gamokvleuli unda iqnes pss-ze
aknes swrafi ganviTareba virilizaciasTan erTad Tirkmelzeda an sakvercxis simsivnisaTvisaa damaxasiaTebeli aseve akne uviTardebaT pacientebs kuSingis daavadebis an sindromis mqoneT an adrenerguli hiperplaziis dros virilizaciis simtomebs miekuTvneba xmis Secvla sarZeve jirkvlebis zomaSi Semcireba klitoromegalia alopecia oligomenorea da hirsutiazmi aseT pacientebs Tirkmelzeda jirkvlebis da sakvercxeebis radiologiuri da hormonuli kvlevebis Catareba esaWiroebaT
anamnezis Segrovebisas yuradReba unda gamaxvildes sxvadasxva samkurnalo saSualebebis miRebaze aknes ganviTarebis mizezi SesaZloa iyos iseTi samkurnalo saSualebebis xangrZlivad moxmareba rogoricaa adenokortikotropuli hormoni androgenebi azaTiopreni barbituratebi bromidebi kortikosteroidebi ciklosporini disulfirami halogenebi iodidebi izoniazidi liTiumi feniTioni vitaminebi B2 B6 da B12
20
gamokvlevebis gegma
mikrobiologiuri kvleva rutinulad ar tardeba (rekomendacia II
B) mikrobiologiuri kvlevis Catareba esaWiroebaT pacientebs romelTac aqvT aknesmagvari gram-uaryofiTi floriT gamowveuli folikuliti
androgenebis donis gansazRvra sisxlSi rutinulad ar tardeba (rekomendacia I A) kvlevis Catareba marTebulia rodesac pacients aknesTan erTad androgenebis siWarbis sxva niSnebic aqvs bavSvebSi igi SeiZleba gamovlindes Tmianobis matebiT iRliaSi an boqvenze klitoromegaliiT mozrdil qalebSi ndash menstrualuri ciklis gaiSviaTebiT hirsutizmiT alopeciiT unayofobiT Savi akanToziT simsuqniT da aS
cxrili 1 rekomendacia mikrobiologiuri testirebis Casatareblad
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
mikrobiologiuri testireba B II 21-24
7
6 mkurnaloba
mkurnalobis mizania pacientis zogadi mdgomareobis gaumjobeseba gamonayaris kontroli diskomfortis da fsiqosocialuri stresis Semcireba nawiburebis prevencia
aknes samkurnalod mowodebulia rigi adgilobrivi da sistemuri saSualebebi (ix cxrili 5) maTi arCevani damokidebulia klinikurad gamovlenili dazianebis tipsa da simZimeze25 (ix sqema 1 2 3) mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
mkurnaloba diagnostikis Semdgom rac SeiZleba male unda daiwyos da yovel 2-3 TveSi Sefasdes da gadaixedos iSviaTad Tumca aRwerilia SemTxvevebi roca mkurnaloba ramodenime wels gagrelda26
istoriuli mimoxilva Zveli egviptisa da saberZneTis istoriul ZeglebSi mocemulia informacia kanis daavadebis Sesaxeb romelsac axla aknes vuwodebT antikur romSi aknes mkurnalobdnen cxel mineralur an gogirdis abazanebiT 1800 wels dermatologebma oficialurad aRiares gogirdi rogorc aknes samkurnalo saSualeba 1920 wlidan ki farTo gamoyeneba hpova benzoil peroqsidma 1930 wlidan am mimarTulebiT gamoiyeneboda safaRaraTo saSualebebi da radiaqtiuli nivTierebebi 1950 wlidan farTod daiwyes antibiotokebis gamoyeneba amave droidan gamoixata tetraciklinis jgufis antibiotikebis upiratesi efeqti anTebiTi aknes mkurnalobisTvis mogvianebiT Sesabamisi farmakologiuri formebis SemuSavebis Semdgom dainerga adgilobrivi antibiotikebis gamoyeneba 1970 wels moxmarebaSi Semovida tretinoini M
mkurnalobis saxe (adgilorivi sistemuri) daavadebis simZimiTa da dazianebis lokalizaciiT ganisazRvreba
medikamentebi adgilobrivi mkurnalobisaTvis
mkurnalobisTvis adgilobrivi (lokaluri) saSualebis saxeobis arCeva pacientis kanis tipis da survilis gaTvaliswinebiT xdeba geli iwvevs kanis gamoSrobas amitom misi gamoyeneba umjobesia cximiani kanis SemTxvevaSi malamo da losionebi kans anotiveben da upiratesoba maT mSrali kanis SemTxvevaSi eniWebaT adgilobrivi saSualebebis umetesoba dReSi orjeradad gamoiyeneba Tumca SesaZlebelia dReSi erTjeradi an dRegamoSvebiT gamoyeneba Tu xSiri moxmarebisas kanis gaRizianeba viTardeba amasTan ufro efeqturia adgilobrivi saSualebebis kombinacia vidre maTi damoukideblad calk-calke gamoyeneba miRebuli kombinaciebia retinoidebi benzoil peroqsidi da topikuri antibiotikebi
kombinacia iZleva ufro gamoxatul Terapiul efeqts vidre TiToeuli agentis damoukidebeli gamoyeneba
erTze meti adgilobrivi saSualebis gamoyenebisas ndash erTi gamoiyeneba diliT meore ndash saRamos rogorc wesi adgilobrivi retinoidebi saRamos iniSneba
8
benzoilis zeJangi
benzoilis zeJangi gamoiyeneba sxvadasxva koncentraciiTa da SemavsebeliT am etapze ar arsebobs mtkicebuleba romelic sxvadasxva formulebis upiratesobas gansazRvravs msoflios bevr qveyanaSi gaicema ureceptod xasiaTdeba baqtericiduli moqmedebiT ainhibirebs axali komedonebis warmoqmnas amcirebs folikulur lipidebsa da Tavisufal cximovan mJavebs rac Tavis mxriv epiTelis deskvamacias iwvevs arCevis preparatia mkurnalobis dawyebisas da nebismieri simZimis aknes dros gamoiyeneba xsnarebi da malamoebi gelTan SedarebiT naklebad iwveven kanis iritacias Tumca mainc SeiZleba gamoiwvion eriTema aqercvla da iSviaTad ndash kontaqturi reaqcia27 gamoiyeneba dReSi 2-jer adgilobriv retinoidebTan kombinaciaSi gamoyenebisas kanis gaRizianebisa da fotoreaqciis Tavidan acilebis mizniT benzoilis zeJangi diliT xolo retinoidebi saRamos iniSneba benzoilis zeJangisa da retinoidebis (adapaleni-retinoidebis sinTezuri analogi tretinoini) erTdrouli gamoyeneba ufro efeqturia vidre TiToeuli agentisa calk-calke2829
adgilobrivi retinoidebi
adgilobrivi retinoidebi Tavisi qimiuri formuliT enaTesavebian A
vitamins maTi efeqturoba aknes mkurnalobaSi araerTi mtkicebulebiTaa dadasturebuli34-50 isini erTaderTi saSualebebia romlebic folikuluri epiTelis terminaluri diferenciaciaze axdens gavlenas da arCevis preparatebia araanTebiTi aknes mkurnalobisTvis amasTan gamoiyenebian anTebiTi aknes samkurnalodac retinoidebi axdenen obstruqciis Semcirebas folikulSi keratinizaciis procesis normalizebis gziT aferxeben komedonebis progresirebas anTebad dazianebamde aumjobeseben komedonebis drenaJs aferxeben axali komedonebis warmoqmnas5152 rigi SedarebiTi kvlevebiT ar gamovlinda romelime retinoidis upiratesoba meoresTan SedarebiT
erTerTi kvleviT tazarotenis geli ufro efeqturi aRmoCnda tretinoinis gelTan SedarebiT (araanTebiTi da anTebiTi dazianebebis Semcireba)53 Tumca sxva kvleviT dRegamoSvebiT tazaroteniT mkurnaloba iseTive efeqturi iyo rogorc adapaleniT yoveldRiuri mkurnaloba54 eriTema wva qavili tretinoinTan da adapalenTan SedarebiT ufro gamoxatuli iyo tazarotenis gelis SemTxvevaSi gverdiTi efeqtebi mcirdeba tazarotenis malamos gamoyenebisas Tumca SedarebiTi kvlevebi am agentisa da sxva adgilobrivi retinoidebiT ar Catarebula
sxva kvleviT adapaleni (01 geli) ufro efeqturi aRmoCnda tretinoinTan SedarebiT (0025 geli)55
gverdiTi efeqtebis Semcireba SeiZleba dabali koncentraciis (0025) saSualebebis gamoyenebiT da amtanobis SemTxvevaSi koncentraciis TandaTan gazrdiT (0025 malamo Semdeg 001 geli 005 kremi 0025 geli 01 kremi 005 xsnari) yvela retinoids gaaCnia kanis gamaRizianebeli moqmedeba SeiZleba gamoiwvion kanis siwiTle
9
gaRizianeba damwvroba zrdian fotosensitiurobas amitom maTi gamoyeneba unda moxdes saRamos xolo dRis ganmavlobaSi mzisagan damcav saSualebebTan (kremebTan) erTad mkurnalobis dasawyisSi SesaZloa mdgomareobis gauareseba ukunaCvenebia orsulobis dros
cxrili 2 rekomendaciebi adgilobrivi mkurnalobisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
benzoilis zeJangi A I 30-33
retinoidebi A I 34374750
antibiotikebi A I 61-69
sxva adgilobrivi saSualebebi A I 70-77
adgilobrivi antibiotikebi
adgilobrivi antibiotikebis damateba P acne-s cximovani folikulidan eliminaciis mizniT xdeba anTebiTi da papuluri aknes mkurnalobis dros adgilobrivi eriTromicini gamoiyeneba dReSi erTxel an orjer adgilobrivi 1-iani klindamicini gamoiyeneba RamiT an dReSi orjer
aRsaniSnavia rom adgilobrivi antibiotikebis gamoyenebam SesaZloa xeli Seuwyos P acne-s rezistentuli Stamebis gaCenas rezistentoba mcirdeba adgilobrivi antibiotikebis sxva saSualebebTan kombinaciaSi daniSvnisas amasTan kombinirebuli mkurnaloba ufro efeqturia vidre am saSualebebis calk-calke gamoyeneba
56-59 magaliTad erTerTi kvleviT gamovlinda rom 3-iani eriTromicinis da benzoilis zeJngis 5-iani geliT kombinirebuli mkurnaloba ara marto aRemateboda efeqturobiT TiToeul agents calk-calke aramed gaumjobesebas iZleoda rezistentuli Stamebis SemTxvevaSic60 aseve klindamicinibenzoilis zeJangis geliT mkurnaloba efeqturi iyo TiToeul agentTan SedarebiT59 sxva kvleviT klindamicini da adapalenis kombinacia ufro efeqturi iyo mxolod klindamicinTan SedarebiT Tumca kanismxrivi gverdiTi efeqtebi (aqercvla simSrale wva) ramdenadme gauaresda kombinirebuli mkurnalobis dros
sxva adgilobrivi saSualebebi
salicilis mJava - istoriulad erTerTi Zveli agentia romelic aknes mkurnalobisTvis gamoiyeneboda Tumca retinoidebTan SedarebiT misi komedolizuri moqmedeba ufro sustia is warmoadgens retinoidebis alternativas rodesac pacientebs aReniSnebaT autanloba retinoidebis mimarT rac kanis iritaciiT vindeba70
azelainis mJava (II) ndash aqvs antikomedonuri da antibaqteriuli Tvisebebi amitom gamoiyeneba rogorc anTebiTi aseve araanTebiTi aknes dros rigi klinikuri kvlevebiT nanaxia misi efeqturoba71-73 amcirebs
10
kanis pigmentacias da ufro efeqturia misi gamoyeneba aknesTan asocirebuli hiperpigmentaciis dros74
aluminis qlorids antibaqteriuli moqmedeba gaaCnia Tumca kvlevebma gansxvavebuli Sedegebi aCvena ndash erT SemTxvevaSi misi efeqturoba gamovlinda75 meoreSi76 ndash ara
sistemuri mkurnaloba
sistemuri antibiotikebi
sistemuri antibiotikebi anTebiTi aknes mkurnalobisaTvis gamoiyeneba ainhibireben P acnes zrdas folikulSi sistemuri antibiotikoTerapia adgilobriv saSualebebTan SedarebiT ufro swraf klinikur gaumjobesebas iZleva Tumca SesaZlebelia antibiotikebis gverdiTi efeqtebis gamovlineba rogoricaa vaginaluri kandidozi gastrointestinuli darRvevebi da aS es saSualebebi iniSneba yoveldRiurad 4-6 Tvis manZilze mdgomareobis gaumjobesebisas TandaTan xdeba dozis Semcireba da Sewyveta maTi Sewyvetis Semdeg mgomareobis SenarCuneba SesaZlebelia adgilobrivi retinoidebis an
benzoilis zeJangis saSualebiT77-79
sistemuri mkurnalobisaTvis gamoiyeneba tetraciklini doqsiciklini minociklini eriTromicini trimetoprim-sulfameToqsazoli da klindamicini
tetraciklins (I A) upiratesoba eniWeba dabali fasis da kvlevebiT dadasturebuli maRali efeqturobis gamo mkurnaloba iwyeba doziT 500 mg orjer dReSi Tumca 250 mg 2-jer ndash SesaZloa aseve efeqturi iyos absorbcias amcirebs sakvebi rZis produqtebi antacidebi rkina iniSneba uzmoze misaRebad ukunaCvenebia orsulobis dros da 12 wlis asakamde vinaidan iwvevs kbilis minanqaris feris Secvlas
doqsiciklini (I) da minocilkini (B) tetraciklinTan SedarebiT ufro metad xsnadia cximSi da gamoiyeneba ufro mcire dozebiTac (100 mg 2-jer an 50 mg 2-jer) am saSualebebis miReba sakvebTan erTadac SeiZleba vinaidan sakvebi ar amcirebs mis absorbcias minociklini arCevis pirveli rigis preparati araa maRali fasisa da tetraciklinTan SedarebiT metad efeqturobis Sesaxeb zusti monacemebis ararsebobis8182 agreTve toqsikurobis gamo8384 doqsiciklini da minocilkini iniSneba tetracikliniT mkurnalobis araefeqturobis SemTxvevaSi doqsiciklini iwvevs fotosensibilizacias saylapavis wylulis ganviTarebis Tavidan acilebis mizniT sakmao odenobis wyalTan erTad unda iqnes miRebuli
SesaZloa gamoiwvios Tavbruxveva pseudotumor cerebri kbilebis feris cvlileba mgluras magvari sindromi85-87 sifrTxiliT unda iqnes gamoyenebuli mgluras mqone pacientebs Soris aknes mkurnalobis mizniT
eriTromicini SesaZlebelia dainiSnos 250-1500 mg dRiuri doziT (or miRebad) misi anTebis sawinaaRmdego moqmedeba tetraciklinTan
11
SedarebiT mcirea amasTan xSirad viTardeba rezistentuli Stamebi88 da gastrointestinuri gverdiTi efeqtebi eriTromicini arCevis saSualebaa im SemTxvevebSi roca SezRudulia tetraciklinis daniSvna (orsuli 8 wlamde bavSvi) mimdinareobs kvleva azitromicinis efeqturobis Sesaxeb maqsimaluri doza 60 g 10 kviris ganmavlobaSi89
trimetoprim-sulfameToqsazoli arCevis meore rigis preparatia (40080mg erTjer an orjer dReSi) efeqturi saSualebaa mZime aknes mkurnalobisaTvis Tumca misi gamoyeneba SezRudulia iseTi seriozuli gverdiTi efeqtebis gamo rogoricaa Zvlis tvinis supresia da toqsikuri epidermuli nekrozi amis msgavsad SezRudulia oraluri klindamicinis gamoyeneba fsevdomembranozuli kolitis ganviTarebis riskis gamo
aknes mqone pacientebis mkurnalobis procesSi seriozul problemas warmoadgens mikrobTa rezistentoba misi xelSemwyobia antibiotikebis farTod gamoyeneba da maTi monacvleoba SedarebiT xSiria rezistentobis ganviTareba eriTromicinis xolo iSviaTi ndash minociklinis mimarT antibiotikoTerapiam SesaZloa xeli Seuwyos Streptococcus pyogenes-is rezistentuli StamebiT xaxis kolonizacias90 rezistentobis problema SeiZleba Semcirdes Semdegi gziT
antibiotikis daniSvna misi absoluturi saWiroebis SemTxvevaSi SeZlebisdagvarad xanmokle mkunalobis kursi (Tumca aranakleb 3 Tvisa) SesaZleblobis mixedviT adgilobrivi saSualebebis
gamoyeneba
benzoilis zeJangis gamoyenebam SeiZleba Seamciros rezistentobis sixSire
oraluri saSualebebis Sewyvetis Semdeg Tu dgeba misi ganaxlebis saWiroeba umjobesia isev imave antibiotikis daniSvna manam sanam igi efeqturi darCeba
cxrili 3 rekomendaciebi sistemuri antibiotikoTerapiisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
tetraciklinebi A I 91-94
makrolidebi A I 95-98
trimetoprim-sulfameToqsazoli A I 99100
12
sistemuri retinoidebi
sistemuri retinoidebi mZime formis aknes mkurnalobisaTvis gamoiyeneba aseve SeiZleba misi gamoyeneba naklebad mZime magram mkurnalobisadmi rezistuli formis dros nawiburovani aknes an daavadebasTan dakavSirebuli Zlieri fsiqo-socialuri stresis SemTvevaSi amcirebs cximis sekrecias misi efeqti samkurnalo saSualebis miRebis Sewyvetidan 1 wlamde grZeldeba cximis Semcireba Tavis mxriv iwvevs proliferaciis Semcirebas samkurnalo saSualebas anTebis sawinaaRmdego moqmedebac gaaCnia da komedonebis warmoqmnas aferxebs101
sistemuri izotretinoinis daniSvnis Cvenebebia
mZime kvanZovan-cisturi akne
akne romelic mxolod mcired gaumjobesda sistemuri antibiotikoTerapiis 6 Tviani kursis Semdeg
nawiburovani akne
akneTi gamowveuli mZime stresi
ganmeorebiTi akne
fulminanturi akne
gram-uaryofiTi folikuliti
mkurnaloba iwyeba 05 mgkg dRiuri doziT da SeiZleba 2 mgkg dozamde gaizardos iniSneba 2 miRebad sakvebTan erTad Cveulebriv mkurnalobis xangrZlivoba 20 kviramdea arsebobs mtkicebulebebi rom efeqturi SeiZleba iyos ufro dabali dozebiT mkurnalobac102 mkurnalobis dawyebisas SesaZloa aknes gauareseba aseT SemTxvevebSi naCvenebia sistemuri kortikosteroidebis daniSvna an mkurnalobis ufro dabali dozebiT (05 mgkgdR-ze naklebi) dawyeba mkurnalobis kumulaciuri doza 120-150 mgkg-ia
pacientebis 80-ze mets mkurnalobis erTi kursis Semdeg xangrZlivi remisia aReniSneba gaumjobeseba mkurnalobis Sewyvetidan ramdenime Tve grZeldeba saWiroebisas kursis ganaxlebamde 4-5 Tve unda iyos gasuli recidivebis umetesoba (96) mkurnalobis Sewyvetidan pirveli 3 Tvis ganmavlobaSi aRmocendeba103 da misi sixSire gansakuTrebiT maRalia pacientebs Soris romelTac akne upiratesad torsze aReniSnebaT an samkurnalo saSualebis kumulaciuri doza 120 mgkg-ze naklebia
izotretinoinis kursis Semdeg remisiis maRali sixSiris miuxedavad pacientebis mxolod 39-s aReniSneba sruli gamojanmrTeleba 61-s ki kvlav esaWiroeba adgilobrivi an sistemuri antibiotikebiT mkurnalobis gagrZeleba104 izotretinoinis maRali Rirebulebis miuxedavad am saSualebiT Catarebuli mkurnaloba mainc xarjTefeqturad SeiZleba CaiTvalos vinaidan es erTaderTi saSualebaa romelic aknes ganviTarebis meqanizmze moqmedebs Tumca aRsaniSnavia isic rom izotretinoinTan dakavSirebulia sakmaod seriozuli da mZime gverdiTi efeqtebi rac zRudavs mis gamoyenebas
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
3
2 epidemiologia
aSS-Si pirveladi jandacvis dawesebulebebis momarTvianobis 10 ukavSirdeba aknes rac warmoadgens weliwadSi 48 mln vizits1 es daavadeba mozardebis 85-s aReniSneba mozrdilebSi akne mamakacebTan SedarebiT qalebs Soris ufro xSirad gvxdeba (20-29 wlis asakSi - 43-51 30-39 wlis asakSi 20-35) pacientTa 83 gamwvavebas ukavSirebs menstrualur cikls 67 - stress 26 - kvebas2
sxvadasxva monacemebiT saqarTvelos 12-25 wlamde mosaxleobis 80-s aqvs aknes gamovlineba
prognozi
akne TandaTan gaivlis sicocxlis mesame dekadaSi (dehidroepiandrosteronis donis TandaTan Semcirebis gamo) Tumca SesaZlebelia mozrdilobis periodSi misi persistireba an de novo ganviTareba mozrdilTa akne upiratesad qalebs Soris aRiniSneba (pubertuli periodis daavadebisagan gansxvavebiT romelic ufro xSirad biWebs Soris gvxvdeba6) aknes premenstrualuri gamwvavebebi upiratesad ufrosi asakis qalebs Soris vlindeba
3 etiopaTogenezi
akne kanis cximovani folikulebis daavadebaa mis ganviTarebaSi
Semdegi oTxi faqtori monawileobs
retenciuli hiperkeratozi
cximis gaZlierebuli produqcia
dazianebuli aris kolonizacia baqteriebiT (Propionibacterium acne)
anTebiTi procesi
cximovan jirkvalSi cvlilebebi hiperkeratoziT iwyeba igi vlindeba folikulis Sesavalis keratinocitebis gaZlierebuli proliferaciiT da deskvamaciis SeferxebiT Sedegad jirkvlis arxSi yalibdeba sacobi romelic cximisa da keratinisgan Sedgeba (mikrokomedonebi)
sqesobrivi momwifebis periodSi cximovani jirkvlebi diddeba da cximis produqciac Zlierdeba mikrokomedonebi qmnian anaerobul cximiT mdidar garemos igi kargi niadagia baqteriebis zrdisTvis romlebic kvebis wyarod trigliceridebs iyeneben da Slian maT hidrolizis gziT cximovan mJavebad da glicerinad baqteriebi ZiriTadad warmodgenilia Propionibacterium acne-Ti (P acne) romelic kanis
normaluri floris Semadgeneli komponentia
mikroorganizmebi (P acne da aseve sxva kokebi) aTavisufleben qemoatraqtantebs romlebic infeqciis areSi neitrofilebs moizidavs3
Tavisufali cximovani mJavebi da lizosomuri fermentebi (gamoTavisufldeba neotrofilebis mier) folikulis epiTelis dazianebas (rupturas) iwvevs ris gamoc keratini da lipidebi
4
CaiRvreba irgvlivmdebare dermaSi da warmoiqmneba papulebi an kvanZebi
folikulis hiperkeratozis xarisxis cximis produqciis mikroorganizmis zrdis da anTebis mixedviT mikrokomedonebi iyofa araanTebiTad (Ria da daxuruli komedonebi) da anTebiTad (pustulebi papulebi an kvanZebi)
cximis dagrovebis Sedegad mikrokomedonebi daxurul (TeTr) komedonebad gadaiqceva
folikulis SesarTavi TandaTan ixsneba (gaWimvis gamo) da Ria (Savi) komedonebi yalibdeba maT muq Seferilobas Calagebuli keratinocitebi daJanguli cximebi da melanini aniWebs
anTebiTi dazianeba (kistebi) folikulis SigTavsis garemomcvel dermaSi CaRvris Sedegad viTardeba yalibdeba zedapiruli pustulebi Rrma papulebi an kidev ufro Rrma kistebi (rupturis donidan gamomdinare)
aknes mqone pacientebis umravlesobas androgenebis hiperproduqcia ar aReniSneba am dros cximovani jirkvlebis mgrZnobeloba androgenebisadmi momatebulia (hipersensitiuloba) Tumca androgenebis siWarbem (sxvadasxva daavadebebis dros) SeiZleba aknes ganviTareba gamoiwvios
aknes mqone prepubertuli asakis gogonebis sisxlSi nanaxia dehidroepiandrosteronis (dhea) sulfatis ufro maRali done vidre daavadebis armqoneTa Soris4 aRniSnuli hormonis maRali maCvenebelis dros mZime akne viTardeba5
daavadebis ganviTarebis xelSemwyobi faqtorebi
daavadebis ganviTarebaSi mniSvnelovani roli eniWeba genetikur faqtors
garemo faqtorebi kosmetikuri saSualebebis gamoyenebam SeiZleba xeli Seuwyos aknes ganviTarebas zeTovani cximovani komponentebi da saRebavebis Semcveloba am saSualebebSi iwvevs kanis dazianebis gamwvavebas xolo wyalze damzadebuli ndash naklebad komedogenuria8
sapnebi sxvadasxva detergentebi da Semkvrelebi iwveven cximis mocilebas kanis zedapiridan magram cximis produqciaze gavlenas ar axdenen daavadebas auaresebs9 ganmeorebiTi meqanikuri travma (uxeSi jagrisis gamoyenebis Sedegad) amgvari gziT kanis maceraciis Sedegad ew meqanikuri aknes (acne mechanica) ganviTareba SeiZleba gamoiwvios perangis sayelom samxreebma sportuli Cafxutis tarebam da a S Sesabamisad pacientebi unda moeridon mWidro tansacmlis tarebas da Tavi Seikavon saxis kanis travmirebisgan (gaxexva da aS)
aseve amwvavebs daavadebas tenianoba da Zlieri ofli qlorakne gamowveulia halogenirebuli hidrokarbonatebis dioqsinis zemoqmedebis Sedegad (kanTan kontaqtis inhalaciis an organizmSi moxvedris gziT) aRniSnuli qimiuri nivTierebebi gvxvdeba sawarmoo
5
produqtebSi dabinZurebul sakvebSi da aS klinikurad qlorakne farTo monomorfuli komedonebiT xasiaTdeba romelic mZime anTebad dazianebebad transformirdeba da nawiburebs warmoqmnis
dieta aknes ganviTarebaSi kvebiTi faqtorebis mniSvnelobis Sesaxeb urTierTsawinaaRmdego monacemebi arsebobs101112 sakmarisi mtkicebulebebi ara arsebobs raimes akrZalvisTvis erT-erTi kvlevis Sedegad gamovlinda kavSiri aknes ganviTarebasa da rZis miRebas Soris13 avtorebis mosazrebiT daavadebis gamwvavebas rZis hormonuli komponentebi daan sxva bioaqtiuri molekulebi iwvevs sxva kvlevebiT aknes ganviTareba SeiZleba insulinismagvarma zrdis faqtorma gamoiwvios
pica Txili tkbileuli Sokoladi aknes mizezs ar warmoadgens14
stresi stresi iwvevs daavadebis gamwvavebas1516 prospeqtuli
kohortuli kvlevis mixedviT romelSic 94 saSualo skolis moswavles ikvlevdnen dardeboda aknes simZime da kanis mier cximis producireba Zlieri (Sualeduri gamocdebi) da msubuqi stresis dros (sazafxulo ardadagebi)17 kanis mier cximis producireba ar iyo dakavSirebuli xolo aknes simZime kavSirSi iyo stresTan gansakuTrebiT vaJebs Soris aRniSnuli kvlevis msgavsad 22 umaRlesi saswavleblis studentis multivariantulma analizma gamoavlina aknes simZimis korelacia stresTan (mag gamocdebis periodSi)18
4 klinikuri simptomatika
akne viTardeba tipur agdilebze ndash sxeulis im nawilebze sadac kani didi raodenobiT Seicavs cximovan jirkvlebs esenia saxe kiseri gulmkerdi zurgis zeda nawili mxrebi
aknesTvis damaxasiaTebel dazianebasTan (TeTrTaviani SavTaviani komedonebi da anTebiTi kerebi) erTad aRiniSneba nawiburebi da hiperpigmentacia hiperpigmentacia ufro metad vlindeba muqi feris kanis mqoneTa Soris
5 daavadebis diagnozi
pacientis Sefaseba anamnezis detalurad SegrovebiT iwyeba daavadebis diagnozi kanis daTvalierebiT ismeba
fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
kvlevebis Catareba Cveulebriv saWiro ara aris maTi Catarebis saWiroeba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag
6
hirsutizmi an virilizaciis arseboba Semdgom laboratoriuli da gamosaxulebiTi kvlevebs saWiroebs)
ganxiluli unda iqnes endokrinuli daavadebebis SesaZlo arsebobac magaliTad qalebs Soris polikisturi sakvercxeebis sindromi (pss) hiperandrogenizmis erT-erTi mizezia es sindromi menstrualuri funqciis darRveviT hirsutizmiT aknes ganviTarebiT sakvercxis kistebiT sxvadasxva xarisxis insulinisadmi rezistentobiT da Savi akanToziT xasiaTdeba erT-erTi kvlevis mixedviT 51 aknes mqone qals Soris 39 hqonda menstrualuri ciklis darRveva da 37-s pss19 aRniSnuli dakvirvebis Sedegebi mowmobs rom yvela qalis romelsac akne da oligomenorea aReniSneba gamokvleuli unda iqnes pss-ze
aknes swrafi ganviTareba virilizaciasTan erTad Tirkmelzeda an sakvercxis simsivnisaTvisaa damaxasiaTebeli aseve akne uviTardebaT pacientebs kuSingis daavadebis an sindromis mqoneT an adrenerguli hiperplaziis dros virilizaciis simtomebs miekuTvneba xmis Secvla sarZeve jirkvlebis zomaSi Semcireba klitoromegalia alopecia oligomenorea da hirsutiazmi aseT pacientebs Tirkmelzeda jirkvlebis da sakvercxeebis radiologiuri da hormonuli kvlevebis Catareba esaWiroebaT
anamnezis Segrovebisas yuradReba unda gamaxvildes sxvadasxva samkurnalo saSualebebis miRebaze aknes ganviTarebis mizezi SesaZloa iyos iseTi samkurnalo saSualebebis xangrZlivad moxmareba rogoricaa adenokortikotropuli hormoni androgenebi azaTiopreni barbituratebi bromidebi kortikosteroidebi ciklosporini disulfirami halogenebi iodidebi izoniazidi liTiumi feniTioni vitaminebi B2 B6 da B12
20
gamokvlevebis gegma
mikrobiologiuri kvleva rutinulad ar tardeba (rekomendacia II
B) mikrobiologiuri kvlevis Catareba esaWiroebaT pacientebs romelTac aqvT aknesmagvari gram-uaryofiTi floriT gamowveuli folikuliti
androgenebis donis gansazRvra sisxlSi rutinulad ar tardeba (rekomendacia I A) kvlevis Catareba marTebulia rodesac pacients aknesTan erTad androgenebis siWarbis sxva niSnebic aqvs bavSvebSi igi SeiZleba gamovlindes Tmianobis matebiT iRliaSi an boqvenze klitoromegaliiT mozrdil qalebSi ndash menstrualuri ciklis gaiSviaTebiT hirsutizmiT alopeciiT unayofobiT Savi akanToziT simsuqniT da aS
cxrili 1 rekomendacia mikrobiologiuri testirebis Casatareblad
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
mikrobiologiuri testireba B II 21-24
7
6 mkurnaloba
mkurnalobis mizania pacientis zogadi mdgomareobis gaumjobeseba gamonayaris kontroli diskomfortis da fsiqosocialuri stresis Semcireba nawiburebis prevencia
aknes samkurnalod mowodebulia rigi adgilobrivi da sistemuri saSualebebi (ix cxrili 5) maTi arCevani damokidebulia klinikurad gamovlenili dazianebis tipsa da simZimeze25 (ix sqema 1 2 3) mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
mkurnaloba diagnostikis Semdgom rac SeiZleba male unda daiwyos da yovel 2-3 TveSi Sefasdes da gadaixedos iSviaTad Tumca aRwerilia SemTxvevebi roca mkurnaloba ramodenime wels gagrelda26
istoriuli mimoxilva Zveli egviptisa da saberZneTis istoriul ZeglebSi mocemulia informacia kanis daavadebis Sesaxeb romelsac axla aknes vuwodebT antikur romSi aknes mkurnalobdnen cxel mineralur an gogirdis abazanebiT 1800 wels dermatologebma oficialurad aRiares gogirdi rogorc aknes samkurnalo saSualeba 1920 wlidan ki farTo gamoyeneba hpova benzoil peroqsidma 1930 wlidan am mimarTulebiT gamoiyeneboda safaRaraTo saSualebebi da radiaqtiuli nivTierebebi 1950 wlidan farTod daiwyes antibiotokebis gamoyeneba amave droidan gamoixata tetraciklinis jgufis antibiotikebis upiratesi efeqti anTebiTi aknes mkurnalobisTvis mogvianebiT Sesabamisi farmakologiuri formebis SemuSavebis Semdgom dainerga adgilobrivi antibiotikebis gamoyeneba 1970 wels moxmarebaSi Semovida tretinoini M
mkurnalobis saxe (adgilorivi sistemuri) daavadebis simZimiTa da dazianebis lokalizaciiT ganisazRvreba
medikamentebi adgilobrivi mkurnalobisaTvis
mkurnalobisTvis adgilobrivi (lokaluri) saSualebis saxeobis arCeva pacientis kanis tipis da survilis gaTvaliswinebiT xdeba geli iwvevs kanis gamoSrobas amitom misi gamoyeneba umjobesia cximiani kanis SemTxvevaSi malamo da losionebi kans anotiveben da upiratesoba maT mSrali kanis SemTxvevaSi eniWebaT adgilobrivi saSualebebis umetesoba dReSi orjeradad gamoiyeneba Tumca SesaZlebelia dReSi erTjeradi an dRegamoSvebiT gamoyeneba Tu xSiri moxmarebisas kanis gaRizianeba viTardeba amasTan ufro efeqturia adgilobrivi saSualebebis kombinacia vidre maTi damoukideblad calk-calke gamoyeneba miRebuli kombinaciebia retinoidebi benzoil peroqsidi da topikuri antibiotikebi
kombinacia iZleva ufro gamoxatul Terapiul efeqts vidre TiToeuli agentis damoukidebeli gamoyeneba
erTze meti adgilobrivi saSualebis gamoyenebisas ndash erTi gamoiyeneba diliT meore ndash saRamos rogorc wesi adgilobrivi retinoidebi saRamos iniSneba
8
benzoilis zeJangi
benzoilis zeJangi gamoiyeneba sxvadasxva koncentraciiTa da SemavsebeliT am etapze ar arsebobs mtkicebuleba romelic sxvadasxva formulebis upiratesobas gansazRvravs msoflios bevr qveyanaSi gaicema ureceptod xasiaTdeba baqtericiduli moqmedebiT ainhibirebs axali komedonebis warmoqmnas amcirebs folikulur lipidebsa da Tavisufal cximovan mJavebs rac Tavis mxriv epiTelis deskvamacias iwvevs arCevis preparatia mkurnalobis dawyebisas da nebismieri simZimis aknes dros gamoiyeneba xsnarebi da malamoebi gelTan SedarebiT naklebad iwveven kanis iritacias Tumca mainc SeiZleba gamoiwvion eriTema aqercvla da iSviaTad ndash kontaqturi reaqcia27 gamoiyeneba dReSi 2-jer adgilobriv retinoidebTan kombinaciaSi gamoyenebisas kanis gaRizianebisa da fotoreaqciis Tavidan acilebis mizniT benzoilis zeJangi diliT xolo retinoidebi saRamos iniSneba benzoilis zeJangisa da retinoidebis (adapaleni-retinoidebis sinTezuri analogi tretinoini) erTdrouli gamoyeneba ufro efeqturia vidre TiToeuli agentisa calk-calke2829
adgilobrivi retinoidebi
adgilobrivi retinoidebi Tavisi qimiuri formuliT enaTesavebian A
vitamins maTi efeqturoba aknes mkurnalobaSi araerTi mtkicebulebiTaa dadasturebuli34-50 isini erTaderTi saSualebebia romlebic folikuluri epiTelis terminaluri diferenciaciaze axdens gavlenas da arCevis preparatebia araanTebiTi aknes mkurnalobisTvis amasTan gamoiyenebian anTebiTi aknes samkurnalodac retinoidebi axdenen obstruqciis Semcirebas folikulSi keratinizaciis procesis normalizebis gziT aferxeben komedonebis progresirebas anTebad dazianebamde aumjobeseben komedonebis drenaJs aferxeben axali komedonebis warmoqmnas5152 rigi SedarebiTi kvlevebiT ar gamovlinda romelime retinoidis upiratesoba meoresTan SedarebiT
erTerTi kvleviT tazarotenis geli ufro efeqturi aRmoCnda tretinoinis gelTan SedarebiT (araanTebiTi da anTebiTi dazianebebis Semcireba)53 Tumca sxva kvleviT dRegamoSvebiT tazaroteniT mkurnaloba iseTive efeqturi iyo rogorc adapaleniT yoveldRiuri mkurnaloba54 eriTema wva qavili tretinoinTan da adapalenTan SedarebiT ufro gamoxatuli iyo tazarotenis gelis SemTxvevaSi gverdiTi efeqtebi mcirdeba tazarotenis malamos gamoyenebisas Tumca SedarebiTi kvlevebi am agentisa da sxva adgilobrivi retinoidebiT ar Catarebula
sxva kvleviT adapaleni (01 geli) ufro efeqturi aRmoCnda tretinoinTan SedarebiT (0025 geli)55
gverdiTi efeqtebis Semcireba SeiZleba dabali koncentraciis (0025) saSualebebis gamoyenebiT da amtanobis SemTxvevaSi koncentraciis TandaTan gazrdiT (0025 malamo Semdeg 001 geli 005 kremi 0025 geli 01 kremi 005 xsnari) yvela retinoids gaaCnia kanis gamaRizianebeli moqmedeba SeiZleba gamoiwvion kanis siwiTle
9
gaRizianeba damwvroba zrdian fotosensitiurobas amitom maTi gamoyeneba unda moxdes saRamos xolo dRis ganmavlobaSi mzisagan damcav saSualebebTan (kremebTan) erTad mkurnalobis dasawyisSi SesaZloa mdgomareobis gauareseba ukunaCvenebia orsulobis dros
cxrili 2 rekomendaciebi adgilobrivi mkurnalobisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
benzoilis zeJangi A I 30-33
retinoidebi A I 34374750
antibiotikebi A I 61-69
sxva adgilobrivi saSualebebi A I 70-77
adgilobrivi antibiotikebi
adgilobrivi antibiotikebis damateba P acne-s cximovani folikulidan eliminaciis mizniT xdeba anTebiTi da papuluri aknes mkurnalobis dros adgilobrivi eriTromicini gamoiyeneba dReSi erTxel an orjer adgilobrivi 1-iani klindamicini gamoiyeneba RamiT an dReSi orjer
aRsaniSnavia rom adgilobrivi antibiotikebis gamoyenebam SesaZloa xeli Seuwyos P acne-s rezistentuli Stamebis gaCenas rezistentoba mcirdeba adgilobrivi antibiotikebis sxva saSualebebTan kombinaciaSi daniSvnisas amasTan kombinirebuli mkurnaloba ufro efeqturia vidre am saSualebebis calk-calke gamoyeneba
56-59 magaliTad erTerTi kvleviT gamovlinda rom 3-iani eriTromicinis da benzoilis zeJngis 5-iani geliT kombinirebuli mkurnaloba ara marto aRemateboda efeqturobiT TiToeul agents calk-calke aramed gaumjobesebas iZleoda rezistentuli Stamebis SemTxvevaSic60 aseve klindamicinibenzoilis zeJangis geliT mkurnaloba efeqturi iyo TiToeul agentTan SedarebiT59 sxva kvleviT klindamicini da adapalenis kombinacia ufro efeqturi iyo mxolod klindamicinTan SedarebiT Tumca kanismxrivi gverdiTi efeqtebi (aqercvla simSrale wva) ramdenadme gauaresda kombinirebuli mkurnalobis dros
sxva adgilobrivi saSualebebi
salicilis mJava - istoriulad erTerTi Zveli agentia romelic aknes mkurnalobisTvis gamoiyeneboda Tumca retinoidebTan SedarebiT misi komedolizuri moqmedeba ufro sustia is warmoadgens retinoidebis alternativas rodesac pacientebs aReniSnebaT autanloba retinoidebis mimarT rac kanis iritaciiT vindeba70
azelainis mJava (II) ndash aqvs antikomedonuri da antibaqteriuli Tvisebebi amitom gamoiyeneba rogorc anTebiTi aseve araanTebiTi aknes dros rigi klinikuri kvlevebiT nanaxia misi efeqturoba71-73 amcirebs
10
kanis pigmentacias da ufro efeqturia misi gamoyeneba aknesTan asocirebuli hiperpigmentaciis dros74
aluminis qlorids antibaqteriuli moqmedeba gaaCnia Tumca kvlevebma gansxvavebuli Sedegebi aCvena ndash erT SemTxvevaSi misi efeqturoba gamovlinda75 meoreSi76 ndash ara
sistemuri mkurnaloba
sistemuri antibiotikebi
sistemuri antibiotikebi anTebiTi aknes mkurnalobisaTvis gamoiyeneba ainhibireben P acnes zrdas folikulSi sistemuri antibiotikoTerapia adgilobriv saSualebebTan SedarebiT ufro swraf klinikur gaumjobesebas iZleva Tumca SesaZlebelia antibiotikebis gverdiTi efeqtebis gamovlineba rogoricaa vaginaluri kandidozi gastrointestinuli darRvevebi da aS es saSualebebi iniSneba yoveldRiurad 4-6 Tvis manZilze mdgomareobis gaumjobesebisas TandaTan xdeba dozis Semcireba da Sewyveta maTi Sewyvetis Semdeg mgomareobis SenarCuneba SesaZlebelia adgilobrivi retinoidebis an
benzoilis zeJangis saSualebiT77-79
sistemuri mkurnalobisaTvis gamoiyeneba tetraciklini doqsiciklini minociklini eriTromicini trimetoprim-sulfameToqsazoli da klindamicini
tetraciklins (I A) upiratesoba eniWeba dabali fasis da kvlevebiT dadasturebuli maRali efeqturobis gamo mkurnaloba iwyeba doziT 500 mg orjer dReSi Tumca 250 mg 2-jer ndash SesaZloa aseve efeqturi iyos absorbcias amcirebs sakvebi rZis produqtebi antacidebi rkina iniSneba uzmoze misaRebad ukunaCvenebia orsulobis dros da 12 wlis asakamde vinaidan iwvevs kbilis minanqaris feris Secvlas
doqsiciklini (I) da minocilkini (B) tetraciklinTan SedarebiT ufro metad xsnadia cximSi da gamoiyeneba ufro mcire dozebiTac (100 mg 2-jer an 50 mg 2-jer) am saSualebebis miReba sakvebTan erTadac SeiZleba vinaidan sakvebi ar amcirebs mis absorbcias minociklini arCevis pirveli rigis preparati araa maRali fasisa da tetraciklinTan SedarebiT metad efeqturobis Sesaxeb zusti monacemebis ararsebobis8182 agreTve toqsikurobis gamo8384 doqsiciklini da minocilkini iniSneba tetracikliniT mkurnalobis araefeqturobis SemTxvevaSi doqsiciklini iwvevs fotosensibilizacias saylapavis wylulis ganviTarebis Tavidan acilebis mizniT sakmao odenobis wyalTan erTad unda iqnes miRebuli
SesaZloa gamoiwvios Tavbruxveva pseudotumor cerebri kbilebis feris cvlileba mgluras magvari sindromi85-87 sifrTxiliT unda iqnes gamoyenebuli mgluras mqone pacientebs Soris aknes mkurnalobis mizniT
eriTromicini SesaZlebelia dainiSnos 250-1500 mg dRiuri doziT (or miRebad) misi anTebis sawinaaRmdego moqmedeba tetraciklinTan
11
SedarebiT mcirea amasTan xSirad viTardeba rezistentuli Stamebi88 da gastrointestinuri gverdiTi efeqtebi eriTromicini arCevis saSualebaa im SemTxvevebSi roca SezRudulia tetraciklinis daniSvna (orsuli 8 wlamde bavSvi) mimdinareobs kvleva azitromicinis efeqturobis Sesaxeb maqsimaluri doza 60 g 10 kviris ganmavlobaSi89
trimetoprim-sulfameToqsazoli arCevis meore rigis preparatia (40080mg erTjer an orjer dReSi) efeqturi saSualebaa mZime aknes mkurnalobisaTvis Tumca misi gamoyeneba SezRudulia iseTi seriozuli gverdiTi efeqtebis gamo rogoricaa Zvlis tvinis supresia da toqsikuri epidermuli nekrozi amis msgavsad SezRudulia oraluri klindamicinis gamoyeneba fsevdomembranozuli kolitis ganviTarebis riskis gamo
aknes mqone pacientebis mkurnalobis procesSi seriozul problemas warmoadgens mikrobTa rezistentoba misi xelSemwyobia antibiotikebis farTod gamoyeneba da maTi monacvleoba SedarebiT xSiria rezistentobis ganviTareba eriTromicinis xolo iSviaTi ndash minociklinis mimarT antibiotikoTerapiam SesaZloa xeli Seuwyos Streptococcus pyogenes-is rezistentuli StamebiT xaxis kolonizacias90 rezistentobis problema SeiZleba Semcirdes Semdegi gziT
antibiotikis daniSvna misi absoluturi saWiroebis SemTxvevaSi SeZlebisdagvarad xanmokle mkunalobis kursi (Tumca aranakleb 3 Tvisa) SesaZleblobis mixedviT adgilobrivi saSualebebis
gamoyeneba
benzoilis zeJangis gamoyenebam SeiZleba Seamciros rezistentobis sixSire
oraluri saSualebebis Sewyvetis Semdeg Tu dgeba misi ganaxlebis saWiroeba umjobesia isev imave antibiotikis daniSvna manam sanam igi efeqturi darCeba
cxrili 3 rekomendaciebi sistemuri antibiotikoTerapiisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
tetraciklinebi A I 91-94
makrolidebi A I 95-98
trimetoprim-sulfameToqsazoli A I 99100
12
sistemuri retinoidebi
sistemuri retinoidebi mZime formis aknes mkurnalobisaTvis gamoiyeneba aseve SeiZleba misi gamoyeneba naklebad mZime magram mkurnalobisadmi rezistuli formis dros nawiburovani aknes an daavadebasTan dakavSirebuli Zlieri fsiqo-socialuri stresis SemTvevaSi amcirebs cximis sekrecias misi efeqti samkurnalo saSualebis miRebis Sewyvetidan 1 wlamde grZeldeba cximis Semcireba Tavis mxriv iwvevs proliferaciis Semcirebas samkurnalo saSualebas anTebis sawinaaRmdego moqmedebac gaaCnia da komedonebis warmoqmnas aferxebs101
sistemuri izotretinoinis daniSvnis Cvenebebia
mZime kvanZovan-cisturi akne
akne romelic mxolod mcired gaumjobesda sistemuri antibiotikoTerapiis 6 Tviani kursis Semdeg
nawiburovani akne
akneTi gamowveuli mZime stresi
ganmeorebiTi akne
fulminanturi akne
gram-uaryofiTi folikuliti
mkurnaloba iwyeba 05 mgkg dRiuri doziT da SeiZleba 2 mgkg dozamde gaizardos iniSneba 2 miRebad sakvebTan erTad Cveulebriv mkurnalobis xangrZlivoba 20 kviramdea arsebobs mtkicebulebebi rom efeqturi SeiZleba iyos ufro dabali dozebiT mkurnalobac102 mkurnalobis dawyebisas SesaZloa aknes gauareseba aseT SemTxvevebSi naCvenebia sistemuri kortikosteroidebis daniSvna an mkurnalobis ufro dabali dozebiT (05 mgkgdR-ze naklebi) dawyeba mkurnalobis kumulaciuri doza 120-150 mgkg-ia
pacientebis 80-ze mets mkurnalobis erTi kursis Semdeg xangrZlivi remisia aReniSneba gaumjobeseba mkurnalobis Sewyvetidan ramdenime Tve grZeldeba saWiroebisas kursis ganaxlebamde 4-5 Tve unda iyos gasuli recidivebis umetesoba (96) mkurnalobis Sewyvetidan pirveli 3 Tvis ganmavlobaSi aRmocendeba103 da misi sixSire gansakuTrebiT maRalia pacientebs Soris romelTac akne upiratesad torsze aReniSnebaT an samkurnalo saSualebis kumulaciuri doza 120 mgkg-ze naklebia
izotretinoinis kursis Semdeg remisiis maRali sixSiris miuxedavad pacientebis mxolod 39-s aReniSneba sruli gamojanmrTeleba 61-s ki kvlav esaWiroeba adgilobrivi an sistemuri antibiotikebiT mkurnalobis gagrZeleba104 izotretinoinis maRali Rirebulebis miuxedavad am saSualebiT Catarebuli mkurnaloba mainc xarjTefeqturad SeiZleba CaiTvalos vinaidan es erTaderTi saSualebaa romelic aknes ganviTarebis meqanizmze moqmedebs Tumca aRsaniSnavia isic rom izotretinoinTan dakavSirebulia sakmaod seriozuli da mZime gverdiTi efeqtebi rac zRudavs mis gamoyenebas
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
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15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
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eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
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s Semcireba
an mkurnalo
bis Sewyveta
4
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folikulis hiperkeratozis xarisxis cximis produqciis mikroorganizmis zrdis da anTebis mixedviT mikrokomedonebi iyofa araanTebiTad (Ria da daxuruli komedonebi) da anTebiTad (pustulebi papulebi an kvanZebi)
cximis dagrovebis Sedegad mikrokomedonebi daxurul (TeTr) komedonebad gadaiqceva
folikulis SesarTavi TandaTan ixsneba (gaWimvis gamo) da Ria (Savi) komedonebi yalibdeba maT muq Seferilobas Calagebuli keratinocitebi daJanguli cximebi da melanini aniWebs
anTebiTi dazianeba (kistebi) folikulis SigTavsis garemomcvel dermaSi CaRvris Sedegad viTardeba yalibdeba zedapiruli pustulebi Rrma papulebi an kidev ufro Rrma kistebi (rupturis donidan gamomdinare)
aknes mqone pacientebis umravlesobas androgenebis hiperproduqcia ar aReniSneba am dros cximovani jirkvlebis mgrZnobeloba androgenebisadmi momatebulia (hipersensitiuloba) Tumca androgenebis siWarbem (sxvadasxva daavadebebis dros) SeiZleba aknes ganviTareba gamoiwvios
aknes mqone prepubertuli asakis gogonebis sisxlSi nanaxia dehidroepiandrosteronis (dhea) sulfatis ufro maRali done vidre daavadebis armqoneTa Soris4 aRniSnuli hormonis maRali maCvenebelis dros mZime akne viTardeba5
daavadebis ganviTarebis xelSemwyobi faqtorebi
daavadebis ganviTarebaSi mniSvnelovani roli eniWeba genetikur faqtors
garemo faqtorebi kosmetikuri saSualebebis gamoyenebam SeiZleba xeli Seuwyos aknes ganviTarebas zeTovani cximovani komponentebi da saRebavebis Semcveloba am saSualebebSi iwvevs kanis dazianebis gamwvavebas xolo wyalze damzadebuli ndash naklebad komedogenuria8
sapnebi sxvadasxva detergentebi da Semkvrelebi iwveven cximis mocilebas kanis zedapiridan magram cximis produqciaze gavlenas ar axdenen daavadebas auaresebs9 ganmeorebiTi meqanikuri travma (uxeSi jagrisis gamoyenebis Sedegad) amgvari gziT kanis maceraciis Sedegad ew meqanikuri aknes (acne mechanica) ganviTareba SeiZleba gamoiwvios perangis sayelom samxreebma sportuli Cafxutis tarebam da a S Sesabamisad pacientebi unda moeridon mWidro tansacmlis tarebas da Tavi Seikavon saxis kanis travmirebisgan (gaxexva da aS)
aseve amwvavebs daavadebas tenianoba da Zlieri ofli qlorakne gamowveulia halogenirebuli hidrokarbonatebis dioqsinis zemoqmedebis Sedegad (kanTan kontaqtis inhalaciis an organizmSi moxvedris gziT) aRniSnuli qimiuri nivTierebebi gvxvdeba sawarmoo
5
produqtebSi dabinZurebul sakvebSi da aS klinikurad qlorakne farTo monomorfuli komedonebiT xasiaTdeba romelic mZime anTebad dazianebebad transformirdeba da nawiburebs warmoqmnis
dieta aknes ganviTarebaSi kvebiTi faqtorebis mniSvnelobis Sesaxeb urTierTsawinaaRmdego monacemebi arsebobs101112 sakmarisi mtkicebulebebi ara arsebobs raimes akrZalvisTvis erT-erTi kvlevis Sedegad gamovlinda kavSiri aknes ganviTarebasa da rZis miRebas Soris13 avtorebis mosazrebiT daavadebis gamwvavebas rZis hormonuli komponentebi daan sxva bioaqtiuri molekulebi iwvevs sxva kvlevebiT aknes ganviTareba SeiZleba insulinismagvarma zrdis faqtorma gamoiwvios
pica Txili tkbileuli Sokoladi aknes mizezs ar warmoadgens14
stresi stresi iwvevs daavadebis gamwvavebas1516 prospeqtuli
kohortuli kvlevis mixedviT romelSic 94 saSualo skolis moswavles ikvlevdnen dardeboda aknes simZime da kanis mier cximis producireba Zlieri (Sualeduri gamocdebi) da msubuqi stresis dros (sazafxulo ardadagebi)17 kanis mier cximis producireba ar iyo dakavSirebuli xolo aknes simZime kavSirSi iyo stresTan gansakuTrebiT vaJebs Soris aRniSnuli kvlevis msgavsad 22 umaRlesi saswavleblis studentis multivariantulma analizma gamoavlina aknes simZimis korelacia stresTan (mag gamocdebis periodSi)18
4 klinikuri simptomatika
akne viTardeba tipur agdilebze ndash sxeulis im nawilebze sadac kani didi raodenobiT Seicavs cximovan jirkvlebs esenia saxe kiseri gulmkerdi zurgis zeda nawili mxrebi
aknesTvis damaxasiaTebel dazianebasTan (TeTrTaviani SavTaviani komedonebi da anTebiTi kerebi) erTad aRiniSneba nawiburebi da hiperpigmentacia hiperpigmentacia ufro metad vlindeba muqi feris kanis mqoneTa Soris
5 daavadebis diagnozi
pacientis Sefaseba anamnezis detalurad SegrovebiT iwyeba daavadebis diagnozi kanis daTvalierebiT ismeba
fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
kvlevebis Catareba Cveulebriv saWiro ara aris maTi Catarebis saWiroeba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag
6
hirsutizmi an virilizaciis arseboba Semdgom laboratoriuli da gamosaxulebiTi kvlevebs saWiroebs)
ganxiluli unda iqnes endokrinuli daavadebebis SesaZlo arsebobac magaliTad qalebs Soris polikisturi sakvercxeebis sindromi (pss) hiperandrogenizmis erT-erTi mizezia es sindromi menstrualuri funqciis darRveviT hirsutizmiT aknes ganviTarebiT sakvercxis kistebiT sxvadasxva xarisxis insulinisadmi rezistentobiT da Savi akanToziT xasiaTdeba erT-erTi kvlevis mixedviT 51 aknes mqone qals Soris 39 hqonda menstrualuri ciklis darRveva da 37-s pss19 aRniSnuli dakvirvebis Sedegebi mowmobs rom yvela qalis romelsac akne da oligomenorea aReniSneba gamokvleuli unda iqnes pss-ze
aknes swrafi ganviTareba virilizaciasTan erTad Tirkmelzeda an sakvercxis simsivnisaTvisaa damaxasiaTebeli aseve akne uviTardebaT pacientebs kuSingis daavadebis an sindromis mqoneT an adrenerguli hiperplaziis dros virilizaciis simtomebs miekuTvneba xmis Secvla sarZeve jirkvlebis zomaSi Semcireba klitoromegalia alopecia oligomenorea da hirsutiazmi aseT pacientebs Tirkmelzeda jirkvlebis da sakvercxeebis radiologiuri da hormonuli kvlevebis Catareba esaWiroebaT
anamnezis Segrovebisas yuradReba unda gamaxvildes sxvadasxva samkurnalo saSualebebis miRebaze aknes ganviTarebis mizezi SesaZloa iyos iseTi samkurnalo saSualebebis xangrZlivad moxmareba rogoricaa adenokortikotropuli hormoni androgenebi azaTiopreni barbituratebi bromidebi kortikosteroidebi ciklosporini disulfirami halogenebi iodidebi izoniazidi liTiumi feniTioni vitaminebi B2 B6 da B12
20
gamokvlevebis gegma
mikrobiologiuri kvleva rutinulad ar tardeba (rekomendacia II
B) mikrobiologiuri kvlevis Catareba esaWiroebaT pacientebs romelTac aqvT aknesmagvari gram-uaryofiTi floriT gamowveuli folikuliti
androgenebis donis gansazRvra sisxlSi rutinulad ar tardeba (rekomendacia I A) kvlevis Catareba marTebulia rodesac pacients aknesTan erTad androgenebis siWarbis sxva niSnebic aqvs bavSvebSi igi SeiZleba gamovlindes Tmianobis matebiT iRliaSi an boqvenze klitoromegaliiT mozrdil qalebSi ndash menstrualuri ciklis gaiSviaTebiT hirsutizmiT alopeciiT unayofobiT Savi akanToziT simsuqniT da aS
cxrili 1 rekomendacia mikrobiologiuri testirebis Casatareblad
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
mikrobiologiuri testireba B II 21-24
7
6 mkurnaloba
mkurnalobis mizania pacientis zogadi mdgomareobis gaumjobeseba gamonayaris kontroli diskomfortis da fsiqosocialuri stresis Semcireba nawiburebis prevencia
aknes samkurnalod mowodebulia rigi adgilobrivi da sistemuri saSualebebi (ix cxrili 5) maTi arCevani damokidebulia klinikurad gamovlenili dazianebis tipsa da simZimeze25 (ix sqema 1 2 3) mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
mkurnaloba diagnostikis Semdgom rac SeiZleba male unda daiwyos da yovel 2-3 TveSi Sefasdes da gadaixedos iSviaTad Tumca aRwerilia SemTxvevebi roca mkurnaloba ramodenime wels gagrelda26
istoriuli mimoxilva Zveli egviptisa da saberZneTis istoriul ZeglebSi mocemulia informacia kanis daavadebis Sesaxeb romelsac axla aknes vuwodebT antikur romSi aknes mkurnalobdnen cxel mineralur an gogirdis abazanebiT 1800 wels dermatologebma oficialurad aRiares gogirdi rogorc aknes samkurnalo saSualeba 1920 wlidan ki farTo gamoyeneba hpova benzoil peroqsidma 1930 wlidan am mimarTulebiT gamoiyeneboda safaRaraTo saSualebebi da radiaqtiuli nivTierebebi 1950 wlidan farTod daiwyes antibiotokebis gamoyeneba amave droidan gamoixata tetraciklinis jgufis antibiotikebis upiratesi efeqti anTebiTi aknes mkurnalobisTvis mogvianebiT Sesabamisi farmakologiuri formebis SemuSavebis Semdgom dainerga adgilobrivi antibiotikebis gamoyeneba 1970 wels moxmarebaSi Semovida tretinoini M
mkurnalobis saxe (adgilorivi sistemuri) daavadebis simZimiTa da dazianebis lokalizaciiT ganisazRvreba
medikamentebi adgilobrivi mkurnalobisaTvis
mkurnalobisTvis adgilobrivi (lokaluri) saSualebis saxeobis arCeva pacientis kanis tipis da survilis gaTvaliswinebiT xdeba geli iwvevs kanis gamoSrobas amitom misi gamoyeneba umjobesia cximiani kanis SemTxvevaSi malamo da losionebi kans anotiveben da upiratesoba maT mSrali kanis SemTxvevaSi eniWebaT adgilobrivi saSualebebis umetesoba dReSi orjeradad gamoiyeneba Tumca SesaZlebelia dReSi erTjeradi an dRegamoSvebiT gamoyeneba Tu xSiri moxmarebisas kanis gaRizianeba viTardeba amasTan ufro efeqturia adgilobrivi saSualebebis kombinacia vidre maTi damoukideblad calk-calke gamoyeneba miRebuli kombinaciebia retinoidebi benzoil peroqsidi da topikuri antibiotikebi
kombinacia iZleva ufro gamoxatul Terapiul efeqts vidre TiToeuli agentis damoukidebeli gamoyeneba
erTze meti adgilobrivi saSualebis gamoyenebisas ndash erTi gamoiyeneba diliT meore ndash saRamos rogorc wesi adgilobrivi retinoidebi saRamos iniSneba
8
benzoilis zeJangi
benzoilis zeJangi gamoiyeneba sxvadasxva koncentraciiTa da SemavsebeliT am etapze ar arsebobs mtkicebuleba romelic sxvadasxva formulebis upiratesobas gansazRvravs msoflios bevr qveyanaSi gaicema ureceptod xasiaTdeba baqtericiduli moqmedebiT ainhibirebs axali komedonebis warmoqmnas amcirebs folikulur lipidebsa da Tavisufal cximovan mJavebs rac Tavis mxriv epiTelis deskvamacias iwvevs arCevis preparatia mkurnalobis dawyebisas da nebismieri simZimis aknes dros gamoiyeneba xsnarebi da malamoebi gelTan SedarebiT naklebad iwveven kanis iritacias Tumca mainc SeiZleba gamoiwvion eriTema aqercvla da iSviaTad ndash kontaqturi reaqcia27 gamoiyeneba dReSi 2-jer adgilobriv retinoidebTan kombinaciaSi gamoyenebisas kanis gaRizianebisa da fotoreaqciis Tavidan acilebis mizniT benzoilis zeJangi diliT xolo retinoidebi saRamos iniSneba benzoilis zeJangisa da retinoidebis (adapaleni-retinoidebis sinTezuri analogi tretinoini) erTdrouli gamoyeneba ufro efeqturia vidre TiToeuli agentisa calk-calke2829
adgilobrivi retinoidebi
adgilobrivi retinoidebi Tavisi qimiuri formuliT enaTesavebian A
vitamins maTi efeqturoba aknes mkurnalobaSi araerTi mtkicebulebiTaa dadasturebuli34-50 isini erTaderTi saSualebebia romlebic folikuluri epiTelis terminaluri diferenciaciaze axdens gavlenas da arCevis preparatebia araanTebiTi aknes mkurnalobisTvis amasTan gamoiyenebian anTebiTi aknes samkurnalodac retinoidebi axdenen obstruqciis Semcirebas folikulSi keratinizaciis procesis normalizebis gziT aferxeben komedonebis progresirebas anTebad dazianebamde aumjobeseben komedonebis drenaJs aferxeben axali komedonebis warmoqmnas5152 rigi SedarebiTi kvlevebiT ar gamovlinda romelime retinoidis upiratesoba meoresTan SedarebiT
erTerTi kvleviT tazarotenis geli ufro efeqturi aRmoCnda tretinoinis gelTan SedarebiT (araanTebiTi da anTebiTi dazianebebis Semcireba)53 Tumca sxva kvleviT dRegamoSvebiT tazaroteniT mkurnaloba iseTive efeqturi iyo rogorc adapaleniT yoveldRiuri mkurnaloba54 eriTema wva qavili tretinoinTan da adapalenTan SedarebiT ufro gamoxatuli iyo tazarotenis gelis SemTxvevaSi gverdiTi efeqtebi mcirdeba tazarotenis malamos gamoyenebisas Tumca SedarebiTi kvlevebi am agentisa da sxva adgilobrivi retinoidebiT ar Catarebula
sxva kvleviT adapaleni (01 geli) ufro efeqturi aRmoCnda tretinoinTan SedarebiT (0025 geli)55
gverdiTi efeqtebis Semcireba SeiZleba dabali koncentraciis (0025) saSualebebis gamoyenebiT da amtanobis SemTxvevaSi koncentraciis TandaTan gazrdiT (0025 malamo Semdeg 001 geli 005 kremi 0025 geli 01 kremi 005 xsnari) yvela retinoids gaaCnia kanis gamaRizianebeli moqmedeba SeiZleba gamoiwvion kanis siwiTle
9
gaRizianeba damwvroba zrdian fotosensitiurobas amitom maTi gamoyeneba unda moxdes saRamos xolo dRis ganmavlobaSi mzisagan damcav saSualebebTan (kremebTan) erTad mkurnalobis dasawyisSi SesaZloa mdgomareobis gauareseba ukunaCvenebia orsulobis dros
cxrili 2 rekomendaciebi adgilobrivi mkurnalobisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
benzoilis zeJangi A I 30-33
retinoidebi A I 34374750
antibiotikebi A I 61-69
sxva adgilobrivi saSualebebi A I 70-77
adgilobrivi antibiotikebi
adgilobrivi antibiotikebis damateba P acne-s cximovani folikulidan eliminaciis mizniT xdeba anTebiTi da papuluri aknes mkurnalobis dros adgilobrivi eriTromicini gamoiyeneba dReSi erTxel an orjer adgilobrivi 1-iani klindamicini gamoiyeneba RamiT an dReSi orjer
aRsaniSnavia rom adgilobrivi antibiotikebis gamoyenebam SesaZloa xeli Seuwyos P acne-s rezistentuli Stamebis gaCenas rezistentoba mcirdeba adgilobrivi antibiotikebis sxva saSualebebTan kombinaciaSi daniSvnisas amasTan kombinirebuli mkurnaloba ufro efeqturia vidre am saSualebebis calk-calke gamoyeneba
56-59 magaliTad erTerTi kvleviT gamovlinda rom 3-iani eriTromicinis da benzoilis zeJngis 5-iani geliT kombinirebuli mkurnaloba ara marto aRemateboda efeqturobiT TiToeul agents calk-calke aramed gaumjobesebas iZleoda rezistentuli Stamebis SemTxvevaSic60 aseve klindamicinibenzoilis zeJangis geliT mkurnaloba efeqturi iyo TiToeul agentTan SedarebiT59 sxva kvleviT klindamicini da adapalenis kombinacia ufro efeqturi iyo mxolod klindamicinTan SedarebiT Tumca kanismxrivi gverdiTi efeqtebi (aqercvla simSrale wva) ramdenadme gauaresda kombinirebuli mkurnalobis dros
sxva adgilobrivi saSualebebi
salicilis mJava - istoriulad erTerTi Zveli agentia romelic aknes mkurnalobisTvis gamoiyeneboda Tumca retinoidebTan SedarebiT misi komedolizuri moqmedeba ufro sustia is warmoadgens retinoidebis alternativas rodesac pacientebs aReniSnebaT autanloba retinoidebis mimarT rac kanis iritaciiT vindeba70
azelainis mJava (II) ndash aqvs antikomedonuri da antibaqteriuli Tvisebebi amitom gamoiyeneba rogorc anTebiTi aseve araanTebiTi aknes dros rigi klinikuri kvlevebiT nanaxia misi efeqturoba71-73 amcirebs
10
kanis pigmentacias da ufro efeqturia misi gamoyeneba aknesTan asocirebuli hiperpigmentaciis dros74
aluminis qlorids antibaqteriuli moqmedeba gaaCnia Tumca kvlevebma gansxvavebuli Sedegebi aCvena ndash erT SemTxvevaSi misi efeqturoba gamovlinda75 meoreSi76 ndash ara
sistemuri mkurnaloba
sistemuri antibiotikebi
sistemuri antibiotikebi anTebiTi aknes mkurnalobisaTvis gamoiyeneba ainhibireben P acnes zrdas folikulSi sistemuri antibiotikoTerapia adgilobriv saSualebebTan SedarebiT ufro swraf klinikur gaumjobesebas iZleva Tumca SesaZlebelia antibiotikebis gverdiTi efeqtebis gamovlineba rogoricaa vaginaluri kandidozi gastrointestinuli darRvevebi da aS es saSualebebi iniSneba yoveldRiurad 4-6 Tvis manZilze mdgomareobis gaumjobesebisas TandaTan xdeba dozis Semcireba da Sewyveta maTi Sewyvetis Semdeg mgomareobis SenarCuneba SesaZlebelia adgilobrivi retinoidebis an
benzoilis zeJangis saSualebiT77-79
sistemuri mkurnalobisaTvis gamoiyeneba tetraciklini doqsiciklini minociklini eriTromicini trimetoprim-sulfameToqsazoli da klindamicini
tetraciklins (I A) upiratesoba eniWeba dabali fasis da kvlevebiT dadasturebuli maRali efeqturobis gamo mkurnaloba iwyeba doziT 500 mg orjer dReSi Tumca 250 mg 2-jer ndash SesaZloa aseve efeqturi iyos absorbcias amcirebs sakvebi rZis produqtebi antacidebi rkina iniSneba uzmoze misaRebad ukunaCvenebia orsulobis dros da 12 wlis asakamde vinaidan iwvevs kbilis minanqaris feris Secvlas
doqsiciklini (I) da minocilkini (B) tetraciklinTan SedarebiT ufro metad xsnadia cximSi da gamoiyeneba ufro mcire dozebiTac (100 mg 2-jer an 50 mg 2-jer) am saSualebebis miReba sakvebTan erTadac SeiZleba vinaidan sakvebi ar amcirebs mis absorbcias minociklini arCevis pirveli rigis preparati araa maRali fasisa da tetraciklinTan SedarebiT metad efeqturobis Sesaxeb zusti monacemebis ararsebobis8182 agreTve toqsikurobis gamo8384 doqsiciklini da minocilkini iniSneba tetracikliniT mkurnalobis araefeqturobis SemTxvevaSi doqsiciklini iwvevs fotosensibilizacias saylapavis wylulis ganviTarebis Tavidan acilebis mizniT sakmao odenobis wyalTan erTad unda iqnes miRebuli
SesaZloa gamoiwvios Tavbruxveva pseudotumor cerebri kbilebis feris cvlileba mgluras magvari sindromi85-87 sifrTxiliT unda iqnes gamoyenebuli mgluras mqone pacientebs Soris aknes mkurnalobis mizniT
eriTromicini SesaZlebelia dainiSnos 250-1500 mg dRiuri doziT (or miRebad) misi anTebis sawinaaRmdego moqmedeba tetraciklinTan
11
SedarebiT mcirea amasTan xSirad viTardeba rezistentuli Stamebi88 da gastrointestinuri gverdiTi efeqtebi eriTromicini arCevis saSualebaa im SemTxvevebSi roca SezRudulia tetraciklinis daniSvna (orsuli 8 wlamde bavSvi) mimdinareobs kvleva azitromicinis efeqturobis Sesaxeb maqsimaluri doza 60 g 10 kviris ganmavlobaSi89
trimetoprim-sulfameToqsazoli arCevis meore rigis preparatia (40080mg erTjer an orjer dReSi) efeqturi saSualebaa mZime aknes mkurnalobisaTvis Tumca misi gamoyeneba SezRudulia iseTi seriozuli gverdiTi efeqtebis gamo rogoricaa Zvlis tvinis supresia da toqsikuri epidermuli nekrozi amis msgavsad SezRudulia oraluri klindamicinis gamoyeneba fsevdomembranozuli kolitis ganviTarebis riskis gamo
aknes mqone pacientebis mkurnalobis procesSi seriozul problemas warmoadgens mikrobTa rezistentoba misi xelSemwyobia antibiotikebis farTod gamoyeneba da maTi monacvleoba SedarebiT xSiria rezistentobis ganviTareba eriTromicinis xolo iSviaTi ndash minociklinis mimarT antibiotikoTerapiam SesaZloa xeli Seuwyos Streptococcus pyogenes-is rezistentuli StamebiT xaxis kolonizacias90 rezistentobis problema SeiZleba Semcirdes Semdegi gziT
antibiotikis daniSvna misi absoluturi saWiroebis SemTxvevaSi SeZlebisdagvarad xanmokle mkunalobis kursi (Tumca aranakleb 3 Tvisa) SesaZleblobis mixedviT adgilobrivi saSualebebis
gamoyeneba
benzoilis zeJangis gamoyenebam SeiZleba Seamciros rezistentobis sixSire
oraluri saSualebebis Sewyvetis Semdeg Tu dgeba misi ganaxlebis saWiroeba umjobesia isev imave antibiotikis daniSvna manam sanam igi efeqturi darCeba
cxrili 3 rekomendaciebi sistemuri antibiotikoTerapiisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
tetraciklinebi A I 91-94
makrolidebi A I 95-98
trimetoprim-sulfameToqsazoli A I 99100
12
sistemuri retinoidebi
sistemuri retinoidebi mZime formis aknes mkurnalobisaTvis gamoiyeneba aseve SeiZleba misi gamoyeneba naklebad mZime magram mkurnalobisadmi rezistuli formis dros nawiburovani aknes an daavadebasTan dakavSirebuli Zlieri fsiqo-socialuri stresis SemTvevaSi amcirebs cximis sekrecias misi efeqti samkurnalo saSualebis miRebis Sewyvetidan 1 wlamde grZeldeba cximis Semcireba Tavis mxriv iwvevs proliferaciis Semcirebas samkurnalo saSualebas anTebis sawinaaRmdego moqmedebac gaaCnia da komedonebis warmoqmnas aferxebs101
sistemuri izotretinoinis daniSvnis Cvenebebia
mZime kvanZovan-cisturi akne
akne romelic mxolod mcired gaumjobesda sistemuri antibiotikoTerapiis 6 Tviani kursis Semdeg
nawiburovani akne
akneTi gamowveuli mZime stresi
ganmeorebiTi akne
fulminanturi akne
gram-uaryofiTi folikuliti
mkurnaloba iwyeba 05 mgkg dRiuri doziT da SeiZleba 2 mgkg dozamde gaizardos iniSneba 2 miRebad sakvebTan erTad Cveulebriv mkurnalobis xangrZlivoba 20 kviramdea arsebobs mtkicebulebebi rom efeqturi SeiZleba iyos ufro dabali dozebiT mkurnalobac102 mkurnalobis dawyebisas SesaZloa aknes gauareseba aseT SemTxvevebSi naCvenebia sistemuri kortikosteroidebis daniSvna an mkurnalobis ufro dabali dozebiT (05 mgkgdR-ze naklebi) dawyeba mkurnalobis kumulaciuri doza 120-150 mgkg-ia
pacientebis 80-ze mets mkurnalobis erTi kursis Semdeg xangrZlivi remisia aReniSneba gaumjobeseba mkurnalobis Sewyvetidan ramdenime Tve grZeldeba saWiroebisas kursis ganaxlebamde 4-5 Tve unda iyos gasuli recidivebis umetesoba (96) mkurnalobis Sewyvetidan pirveli 3 Tvis ganmavlobaSi aRmocendeba103 da misi sixSire gansakuTrebiT maRalia pacientebs Soris romelTac akne upiratesad torsze aReniSnebaT an samkurnalo saSualebis kumulaciuri doza 120 mgkg-ze naklebia
izotretinoinis kursis Semdeg remisiis maRali sixSiris miuxedavad pacientebis mxolod 39-s aReniSneba sruli gamojanmrTeleba 61-s ki kvlav esaWiroeba adgilobrivi an sistemuri antibiotikebiT mkurnalobis gagrZeleba104 izotretinoinis maRali Rirebulebis miuxedavad am saSualebiT Catarebuli mkurnaloba mainc xarjTefeqturad SeiZleba CaiTvalos vinaidan es erTaderTi saSualebaa romelic aknes ganviTarebis meqanizmze moqmedebs Tumca aRsaniSnavia isic rom izotretinoinTan dakavSirebulia sakmaod seriozuli da mZime gverdiTi efeqtebi rac zRudavs mis gamoyenebas
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
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13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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ganxiluli unda iqnes endokrinuli daavadebebis SesaZlo arsebobac magaliTad qalebs Soris polikisturi sakvercxeebis sindromi (pss) hiperandrogenizmis erT-erTi mizezia es sindromi menstrualuri funqciis darRveviT hirsutizmiT aknes ganviTarebiT sakvercxis kistebiT sxvadasxva xarisxis insulinisadmi rezistentobiT da Savi akanToziT xasiaTdeba erT-erTi kvlevis mixedviT 51 aknes mqone qals Soris 39 hqonda menstrualuri ciklis darRveva da 37-s pss19 aRniSnuli dakvirvebis Sedegebi mowmobs rom yvela qalis romelsac akne da oligomenorea aReniSneba gamokvleuli unda iqnes pss-ze
aknes swrafi ganviTareba virilizaciasTan erTad Tirkmelzeda an sakvercxis simsivnisaTvisaa damaxasiaTebeli aseve akne uviTardebaT pacientebs kuSingis daavadebis an sindromis mqoneT an adrenerguli hiperplaziis dros virilizaciis simtomebs miekuTvneba xmis Secvla sarZeve jirkvlebis zomaSi Semcireba klitoromegalia alopecia oligomenorea da hirsutiazmi aseT pacientebs Tirkmelzeda jirkvlebis da sakvercxeebis radiologiuri da hormonuli kvlevebis Catareba esaWiroebaT
anamnezis Segrovebisas yuradReba unda gamaxvildes sxvadasxva samkurnalo saSualebebis miRebaze aknes ganviTarebis mizezi SesaZloa iyos iseTi samkurnalo saSualebebis xangrZlivad moxmareba rogoricaa adenokortikotropuli hormoni androgenebi azaTiopreni barbituratebi bromidebi kortikosteroidebi ciklosporini disulfirami halogenebi iodidebi izoniazidi liTiumi feniTioni vitaminebi B2 B6 da B12
20
gamokvlevebis gegma
mikrobiologiuri kvleva rutinulad ar tardeba (rekomendacia II
B) mikrobiologiuri kvlevis Catareba esaWiroebaT pacientebs romelTac aqvT aknesmagvari gram-uaryofiTi floriT gamowveuli folikuliti
androgenebis donis gansazRvra sisxlSi rutinulad ar tardeba (rekomendacia I A) kvlevis Catareba marTebulia rodesac pacients aknesTan erTad androgenebis siWarbis sxva niSnebic aqvs bavSvebSi igi SeiZleba gamovlindes Tmianobis matebiT iRliaSi an boqvenze klitoromegaliiT mozrdil qalebSi ndash menstrualuri ciklis gaiSviaTebiT hirsutizmiT alopeciiT unayofobiT Savi akanToziT simsuqniT da aS
cxrili 1 rekomendacia mikrobiologiuri testirebis Casatareblad
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
mikrobiologiuri testireba B II 21-24
7
6 mkurnaloba
mkurnalobis mizania pacientis zogadi mdgomareobis gaumjobeseba gamonayaris kontroli diskomfortis da fsiqosocialuri stresis Semcireba nawiburebis prevencia
aknes samkurnalod mowodebulia rigi adgilobrivi da sistemuri saSualebebi (ix cxrili 5) maTi arCevani damokidebulia klinikurad gamovlenili dazianebis tipsa da simZimeze25 (ix sqema 1 2 3) mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
mkurnaloba diagnostikis Semdgom rac SeiZleba male unda daiwyos da yovel 2-3 TveSi Sefasdes da gadaixedos iSviaTad Tumca aRwerilia SemTxvevebi roca mkurnaloba ramodenime wels gagrelda26
istoriuli mimoxilva Zveli egviptisa da saberZneTis istoriul ZeglebSi mocemulia informacia kanis daavadebis Sesaxeb romelsac axla aknes vuwodebT antikur romSi aknes mkurnalobdnen cxel mineralur an gogirdis abazanebiT 1800 wels dermatologebma oficialurad aRiares gogirdi rogorc aknes samkurnalo saSualeba 1920 wlidan ki farTo gamoyeneba hpova benzoil peroqsidma 1930 wlidan am mimarTulebiT gamoiyeneboda safaRaraTo saSualebebi da radiaqtiuli nivTierebebi 1950 wlidan farTod daiwyes antibiotokebis gamoyeneba amave droidan gamoixata tetraciklinis jgufis antibiotikebis upiratesi efeqti anTebiTi aknes mkurnalobisTvis mogvianebiT Sesabamisi farmakologiuri formebis SemuSavebis Semdgom dainerga adgilobrivi antibiotikebis gamoyeneba 1970 wels moxmarebaSi Semovida tretinoini M
mkurnalobis saxe (adgilorivi sistemuri) daavadebis simZimiTa da dazianebis lokalizaciiT ganisazRvreba
medikamentebi adgilobrivi mkurnalobisaTvis
mkurnalobisTvis adgilobrivi (lokaluri) saSualebis saxeobis arCeva pacientis kanis tipis da survilis gaTvaliswinebiT xdeba geli iwvevs kanis gamoSrobas amitom misi gamoyeneba umjobesia cximiani kanis SemTxvevaSi malamo da losionebi kans anotiveben da upiratesoba maT mSrali kanis SemTxvevaSi eniWebaT adgilobrivi saSualebebis umetesoba dReSi orjeradad gamoiyeneba Tumca SesaZlebelia dReSi erTjeradi an dRegamoSvebiT gamoyeneba Tu xSiri moxmarebisas kanis gaRizianeba viTardeba amasTan ufro efeqturia adgilobrivi saSualebebis kombinacia vidre maTi damoukideblad calk-calke gamoyeneba miRebuli kombinaciebia retinoidebi benzoil peroqsidi da topikuri antibiotikebi
kombinacia iZleva ufro gamoxatul Terapiul efeqts vidre TiToeuli agentis damoukidebeli gamoyeneba
erTze meti adgilobrivi saSualebis gamoyenebisas ndash erTi gamoiyeneba diliT meore ndash saRamos rogorc wesi adgilobrivi retinoidebi saRamos iniSneba
8
benzoilis zeJangi
benzoilis zeJangi gamoiyeneba sxvadasxva koncentraciiTa da SemavsebeliT am etapze ar arsebobs mtkicebuleba romelic sxvadasxva formulebis upiratesobas gansazRvravs msoflios bevr qveyanaSi gaicema ureceptod xasiaTdeba baqtericiduli moqmedebiT ainhibirebs axali komedonebis warmoqmnas amcirebs folikulur lipidebsa da Tavisufal cximovan mJavebs rac Tavis mxriv epiTelis deskvamacias iwvevs arCevis preparatia mkurnalobis dawyebisas da nebismieri simZimis aknes dros gamoiyeneba xsnarebi da malamoebi gelTan SedarebiT naklebad iwveven kanis iritacias Tumca mainc SeiZleba gamoiwvion eriTema aqercvla da iSviaTad ndash kontaqturi reaqcia27 gamoiyeneba dReSi 2-jer adgilobriv retinoidebTan kombinaciaSi gamoyenebisas kanis gaRizianebisa da fotoreaqciis Tavidan acilebis mizniT benzoilis zeJangi diliT xolo retinoidebi saRamos iniSneba benzoilis zeJangisa da retinoidebis (adapaleni-retinoidebis sinTezuri analogi tretinoini) erTdrouli gamoyeneba ufro efeqturia vidre TiToeuli agentisa calk-calke2829
adgilobrivi retinoidebi
adgilobrivi retinoidebi Tavisi qimiuri formuliT enaTesavebian A
vitamins maTi efeqturoba aknes mkurnalobaSi araerTi mtkicebulebiTaa dadasturebuli34-50 isini erTaderTi saSualebebia romlebic folikuluri epiTelis terminaluri diferenciaciaze axdens gavlenas da arCevis preparatebia araanTebiTi aknes mkurnalobisTvis amasTan gamoiyenebian anTebiTi aknes samkurnalodac retinoidebi axdenen obstruqciis Semcirebas folikulSi keratinizaciis procesis normalizebis gziT aferxeben komedonebis progresirebas anTebad dazianebamde aumjobeseben komedonebis drenaJs aferxeben axali komedonebis warmoqmnas5152 rigi SedarebiTi kvlevebiT ar gamovlinda romelime retinoidis upiratesoba meoresTan SedarebiT
erTerTi kvleviT tazarotenis geli ufro efeqturi aRmoCnda tretinoinis gelTan SedarebiT (araanTebiTi da anTebiTi dazianebebis Semcireba)53 Tumca sxva kvleviT dRegamoSvebiT tazaroteniT mkurnaloba iseTive efeqturi iyo rogorc adapaleniT yoveldRiuri mkurnaloba54 eriTema wva qavili tretinoinTan da adapalenTan SedarebiT ufro gamoxatuli iyo tazarotenis gelis SemTxvevaSi gverdiTi efeqtebi mcirdeba tazarotenis malamos gamoyenebisas Tumca SedarebiTi kvlevebi am agentisa da sxva adgilobrivi retinoidebiT ar Catarebula
sxva kvleviT adapaleni (01 geli) ufro efeqturi aRmoCnda tretinoinTan SedarebiT (0025 geli)55
gverdiTi efeqtebis Semcireba SeiZleba dabali koncentraciis (0025) saSualebebis gamoyenebiT da amtanobis SemTxvevaSi koncentraciis TandaTan gazrdiT (0025 malamo Semdeg 001 geli 005 kremi 0025 geli 01 kremi 005 xsnari) yvela retinoids gaaCnia kanis gamaRizianebeli moqmedeba SeiZleba gamoiwvion kanis siwiTle
9
gaRizianeba damwvroba zrdian fotosensitiurobas amitom maTi gamoyeneba unda moxdes saRamos xolo dRis ganmavlobaSi mzisagan damcav saSualebebTan (kremebTan) erTad mkurnalobis dasawyisSi SesaZloa mdgomareobis gauareseba ukunaCvenebia orsulobis dros
cxrili 2 rekomendaciebi adgilobrivi mkurnalobisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
benzoilis zeJangi A I 30-33
retinoidebi A I 34374750
antibiotikebi A I 61-69
sxva adgilobrivi saSualebebi A I 70-77
adgilobrivi antibiotikebi
adgilobrivi antibiotikebis damateba P acne-s cximovani folikulidan eliminaciis mizniT xdeba anTebiTi da papuluri aknes mkurnalobis dros adgilobrivi eriTromicini gamoiyeneba dReSi erTxel an orjer adgilobrivi 1-iani klindamicini gamoiyeneba RamiT an dReSi orjer
aRsaniSnavia rom adgilobrivi antibiotikebis gamoyenebam SesaZloa xeli Seuwyos P acne-s rezistentuli Stamebis gaCenas rezistentoba mcirdeba adgilobrivi antibiotikebis sxva saSualebebTan kombinaciaSi daniSvnisas amasTan kombinirebuli mkurnaloba ufro efeqturia vidre am saSualebebis calk-calke gamoyeneba
56-59 magaliTad erTerTi kvleviT gamovlinda rom 3-iani eriTromicinis da benzoilis zeJngis 5-iani geliT kombinirebuli mkurnaloba ara marto aRemateboda efeqturobiT TiToeul agents calk-calke aramed gaumjobesebas iZleoda rezistentuli Stamebis SemTxvevaSic60 aseve klindamicinibenzoilis zeJangis geliT mkurnaloba efeqturi iyo TiToeul agentTan SedarebiT59 sxva kvleviT klindamicini da adapalenis kombinacia ufro efeqturi iyo mxolod klindamicinTan SedarebiT Tumca kanismxrivi gverdiTi efeqtebi (aqercvla simSrale wva) ramdenadme gauaresda kombinirebuli mkurnalobis dros
sxva adgilobrivi saSualebebi
salicilis mJava - istoriulad erTerTi Zveli agentia romelic aknes mkurnalobisTvis gamoiyeneboda Tumca retinoidebTan SedarebiT misi komedolizuri moqmedeba ufro sustia is warmoadgens retinoidebis alternativas rodesac pacientebs aReniSnebaT autanloba retinoidebis mimarT rac kanis iritaciiT vindeba70
azelainis mJava (II) ndash aqvs antikomedonuri da antibaqteriuli Tvisebebi amitom gamoiyeneba rogorc anTebiTi aseve araanTebiTi aknes dros rigi klinikuri kvlevebiT nanaxia misi efeqturoba71-73 amcirebs
10
kanis pigmentacias da ufro efeqturia misi gamoyeneba aknesTan asocirebuli hiperpigmentaciis dros74
aluminis qlorids antibaqteriuli moqmedeba gaaCnia Tumca kvlevebma gansxvavebuli Sedegebi aCvena ndash erT SemTxvevaSi misi efeqturoba gamovlinda75 meoreSi76 ndash ara
sistemuri mkurnaloba
sistemuri antibiotikebi
sistemuri antibiotikebi anTebiTi aknes mkurnalobisaTvis gamoiyeneba ainhibireben P acnes zrdas folikulSi sistemuri antibiotikoTerapia adgilobriv saSualebebTan SedarebiT ufro swraf klinikur gaumjobesebas iZleva Tumca SesaZlebelia antibiotikebis gverdiTi efeqtebis gamovlineba rogoricaa vaginaluri kandidozi gastrointestinuli darRvevebi da aS es saSualebebi iniSneba yoveldRiurad 4-6 Tvis manZilze mdgomareobis gaumjobesebisas TandaTan xdeba dozis Semcireba da Sewyveta maTi Sewyvetis Semdeg mgomareobis SenarCuneba SesaZlebelia adgilobrivi retinoidebis an
benzoilis zeJangis saSualebiT77-79
sistemuri mkurnalobisaTvis gamoiyeneba tetraciklini doqsiciklini minociklini eriTromicini trimetoprim-sulfameToqsazoli da klindamicini
tetraciklins (I A) upiratesoba eniWeba dabali fasis da kvlevebiT dadasturebuli maRali efeqturobis gamo mkurnaloba iwyeba doziT 500 mg orjer dReSi Tumca 250 mg 2-jer ndash SesaZloa aseve efeqturi iyos absorbcias amcirebs sakvebi rZis produqtebi antacidebi rkina iniSneba uzmoze misaRebad ukunaCvenebia orsulobis dros da 12 wlis asakamde vinaidan iwvevs kbilis minanqaris feris Secvlas
doqsiciklini (I) da minocilkini (B) tetraciklinTan SedarebiT ufro metad xsnadia cximSi da gamoiyeneba ufro mcire dozebiTac (100 mg 2-jer an 50 mg 2-jer) am saSualebebis miReba sakvebTan erTadac SeiZleba vinaidan sakvebi ar amcirebs mis absorbcias minociklini arCevis pirveli rigis preparati araa maRali fasisa da tetraciklinTan SedarebiT metad efeqturobis Sesaxeb zusti monacemebis ararsebobis8182 agreTve toqsikurobis gamo8384 doqsiciklini da minocilkini iniSneba tetracikliniT mkurnalobis araefeqturobis SemTxvevaSi doqsiciklini iwvevs fotosensibilizacias saylapavis wylulis ganviTarebis Tavidan acilebis mizniT sakmao odenobis wyalTan erTad unda iqnes miRebuli
SesaZloa gamoiwvios Tavbruxveva pseudotumor cerebri kbilebis feris cvlileba mgluras magvari sindromi85-87 sifrTxiliT unda iqnes gamoyenebuli mgluras mqone pacientebs Soris aknes mkurnalobis mizniT
eriTromicini SesaZlebelia dainiSnos 250-1500 mg dRiuri doziT (or miRebad) misi anTebis sawinaaRmdego moqmedeba tetraciklinTan
11
SedarebiT mcirea amasTan xSirad viTardeba rezistentuli Stamebi88 da gastrointestinuri gverdiTi efeqtebi eriTromicini arCevis saSualebaa im SemTxvevebSi roca SezRudulia tetraciklinis daniSvna (orsuli 8 wlamde bavSvi) mimdinareobs kvleva azitromicinis efeqturobis Sesaxeb maqsimaluri doza 60 g 10 kviris ganmavlobaSi89
trimetoprim-sulfameToqsazoli arCevis meore rigis preparatia (40080mg erTjer an orjer dReSi) efeqturi saSualebaa mZime aknes mkurnalobisaTvis Tumca misi gamoyeneba SezRudulia iseTi seriozuli gverdiTi efeqtebis gamo rogoricaa Zvlis tvinis supresia da toqsikuri epidermuli nekrozi amis msgavsad SezRudulia oraluri klindamicinis gamoyeneba fsevdomembranozuli kolitis ganviTarebis riskis gamo
aknes mqone pacientebis mkurnalobis procesSi seriozul problemas warmoadgens mikrobTa rezistentoba misi xelSemwyobia antibiotikebis farTod gamoyeneba da maTi monacvleoba SedarebiT xSiria rezistentobis ganviTareba eriTromicinis xolo iSviaTi ndash minociklinis mimarT antibiotikoTerapiam SesaZloa xeli Seuwyos Streptococcus pyogenes-is rezistentuli StamebiT xaxis kolonizacias90 rezistentobis problema SeiZleba Semcirdes Semdegi gziT
antibiotikis daniSvna misi absoluturi saWiroebis SemTxvevaSi SeZlebisdagvarad xanmokle mkunalobis kursi (Tumca aranakleb 3 Tvisa) SesaZleblobis mixedviT adgilobrivi saSualebebis
gamoyeneba
benzoilis zeJangis gamoyenebam SeiZleba Seamciros rezistentobis sixSire
oraluri saSualebebis Sewyvetis Semdeg Tu dgeba misi ganaxlebis saWiroeba umjobesia isev imave antibiotikis daniSvna manam sanam igi efeqturi darCeba
cxrili 3 rekomendaciebi sistemuri antibiotikoTerapiisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
tetraciklinebi A I 91-94
makrolidebi A I 95-98
trimetoprim-sulfameToqsazoli A I 99100
12
sistemuri retinoidebi
sistemuri retinoidebi mZime formis aknes mkurnalobisaTvis gamoiyeneba aseve SeiZleba misi gamoyeneba naklebad mZime magram mkurnalobisadmi rezistuli formis dros nawiburovani aknes an daavadebasTan dakavSirebuli Zlieri fsiqo-socialuri stresis SemTvevaSi amcirebs cximis sekrecias misi efeqti samkurnalo saSualebis miRebis Sewyvetidan 1 wlamde grZeldeba cximis Semcireba Tavis mxriv iwvevs proliferaciis Semcirebas samkurnalo saSualebas anTebis sawinaaRmdego moqmedebac gaaCnia da komedonebis warmoqmnas aferxebs101
sistemuri izotretinoinis daniSvnis Cvenebebia
mZime kvanZovan-cisturi akne
akne romelic mxolod mcired gaumjobesda sistemuri antibiotikoTerapiis 6 Tviani kursis Semdeg
nawiburovani akne
akneTi gamowveuli mZime stresi
ganmeorebiTi akne
fulminanturi akne
gram-uaryofiTi folikuliti
mkurnaloba iwyeba 05 mgkg dRiuri doziT da SeiZleba 2 mgkg dozamde gaizardos iniSneba 2 miRebad sakvebTan erTad Cveulebriv mkurnalobis xangrZlivoba 20 kviramdea arsebobs mtkicebulebebi rom efeqturi SeiZleba iyos ufro dabali dozebiT mkurnalobac102 mkurnalobis dawyebisas SesaZloa aknes gauareseba aseT SemTxvevebSi naCvenebia sistemuri kortikosteroidebis daniSvna an mkurnalobis ufro dabali dozebiT (05 mgkgdR-ze naklebi) dawyeba mkurnalobis kumulaciuri doza 120-150 mgkg-ia
pacientebis 80-ze mets mkurnalobis erTi kursis Semdeg xangrZlivi remisia aReniSneba gaumjobeseba mkurnalobis Sewyvetidan ramdenime Tve grZeldeba saWiroebisas kursis ganaxlebamde 4-5 Tve unda iyos gasuli recidivebis umetesoba (96) mkurnalobis Sewyvetidan pirveli 3 Tvis ganmavlobaSi aRmocendeba103 da misi sixSire gansakuTrebiT maRalia pacientebs Soris romelTac akne upiratesad torsze aReniSnebaT an samkurnalo saSualebis kumulaciuri doza 120 mgkg-ze naklebia
izotretinoinis kursis Semdeg remisiis maRali sixSiris miuxedavad pacientebis mxolod 39-s aReniSneba sruli gamojanmrTeleba 61-s ki kvlav esaWiroeba adgilobrivi an sistemuri antibiotikebiT mkurnalobis gagrZeleba104 izotretinoinis maRali Rirebulebis miuxedavad am saSualebiT Catarebuli mkurnaloba mainc xarjTefeqturad SeiZleba CaiTvalos vinaidan es erTaderTi saSualebaa romelic aknes ganviTarebis meqanizmze moqmedebs Tumca aRsaniSnavia isic rom izotretinoinTan dakavSirebulia sakmaod seriozuli da mZime gverdiTi efeqtebi rac zRudavs mis gamoyenebas
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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11 Thiboutot DM Strauss JS Diet and acne revisited Arch Dermatol 2002 1381591
27
12 Bershad S The unwelcome return of the acne diet Arch Dermatol 2003 139940
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CoMedica Inc New York 1994 p 55
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Dermatol 1980 102277-80
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26 32 MeReC Bulletin Volume 10 Number 8 1999
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28 Hurwitz S Acne vulgaris pathogenesis and management Pediatr Rev 1994 1547
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34 Christiansen JV Gadborg E Ludvigsen K Meier CH Norholm A Pedersen D et al Topical
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197414882-9
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37 Chalker DK Lesher JL Jr Smith JG Jr Klauda HC Pochi PE Jacoby WS et al Efficacy of topical
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Acad Dermatol 198717251-4
28
38 Shalita A Weiss JS Chalker DK Ellis CN Greenspan A Katz HI et al A comparison of the
efficacy and safety of adapalene gel 01 and tretinoin gel 0025 in the treatment of acne vulgaris
a multicenter trial J Am Acad Dermatol 199634482-5
39 Clucas A Verschoore M Sorba V Poncet M Baker M Czernielewski J Adapalene 01 gel is
better tolerated than tretinoin 0025 gel in acne patients J Am Acad Dermatol 199736S116-8
40 Cunliffe WJ Caputo R Dreno B Forstrom L Heenen M Orfanos CE et al Clinical efficacy and
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US multicenter trials J Am Acad Dermatol 199736S126-34
41 Dunlap FE Mills OH Tuley MR Baker MD Plott RT Adapalene 01 gel for the treatment of acne
vulgaris its superiority compared to tretinoin 0025 cream in skin tolerance and patient preference
Br J Dermatol 1998139(suppl 52)17-22
42 Galvin SA Gilbert R Baker M Guibal F Tuley MR Comparative tolerance of adapalene 01 gel
and six different tretinoin formulations Br J Dermatol 1998139(suppl 52)34-40
43 Grosshans E Marks R Mascaro JM Torras H Meynadier J Alirezai M et al Evaluation of clinical
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vulgaris with particular reference to the onset of action and impact on quality of life Br J
Dermatol1998139(suppl 52)26-33
44 Mills OH Jr Berger RS Irritation potential of a new topical tretinoin formulation and a
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46 Kakita L Tazarotene versus tretinoin or adapalene in the treatment of acne vulgaris J Am Acad
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47 Shalita AR Chalker DK Griffith RF Herbert AA Hickman JG Maloney JM et al Tazarotene gel is
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48 Ellis CN Millikan LE Smith EB Chalker DM Swinyer LJ Katz IH et al Comparison of adapalene
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49 Webster GF Berson D Stein LF Fivenson DP Tanghetti EA Ling M Efficacy and tolerability of
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50 Lucky AW Cullen SI Jarratt MT Quigley JW Comparative efficacy and safety of two 0025
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51 Leyden JJ Therapy for acne vulgaris N Engl J Med 1997 3361156
52 Shalita AR Chalker DK Griffith RF et al Tazarotene gel is safe and effective in the treatment of
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53 Webster GF Berson D Stein LF et al Efficacy and tolerability of once-daily tazarotene 01 gel
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54 Leyden J Lowe N Kakita L Draelos Z Comparison of treatment of acne vulgaris with alternate-
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55 Shalita A Weiss JS Chalker DK et al A comparison of the efficacy and safety of adapalene gel
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56 Chalker DK Shalita A Smith JG Jr Swann RW A double-blind study of the effectiveness of a 3
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61 Bernstein JE Shalita AR Topically applied erythromycin in inflammatory acne vulgaris J Am Acad
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62 Jones EL Crumley AF Topical erythromycin vs blank vehicle in a multiclinic acne study Arch
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63 Prince RA Busch DA Hepler CD Feldick HG Clinical trial of topical erythromycin in
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65 Pochi PE Bagatell FK Ellis CN Stoughton RB Whitmore CG Saatjian GD et al Erythromycin 2
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66 Dobson RL Belknap BS Topical erythromycin solution in acne Results of a multiclinic trial J Am
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67 Mills O Jr Thornsberry C Cardin CW Smiles KA Leyden JJ Bacterial resistance and therapeutic
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68 Leyden JJ Shalita AR Saatjian GD Sefton J Erythromycin 2 gel in comparison with clindamycin
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70 Shalita AR Treatment of mild and moderate acne vulgaris with salicylic acid in an alcohol-detergent
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76 Hurley HJ Shelley WB Special topical approach to the treatment of acne Suppression of sweating
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77 Hjorth N Storm D Dela K Topical anhydrous aluminum chloride formulation in the treatment of
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78 Thiboutot DM Shalita AR Yamauchi PS et al Adapalene gel 01 as maintenance therapy for
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79 Leyden J Thiboutot DM Shalita AR et al Comparison of tazarotene and minocycline
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80 Zane LT Acne maintenance therapy expanding the role of topical retinoids Arch Dermatol 2006
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81 Simonart T Dramaix M De Maertelaer V Br J Dermatol 2008 Feb158(2)208-16
82 Epub 2007 Nov 6 Garner SE Eady EA Popescu C et al Minocycline for acne vulgaris efficacy
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83 McManus P Iheanacho I Dont use minocycline as first line oral antibiotic in acne BMJ 2007
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84 Purdy S de Berker D Acne BMJ 2006 333949
85 Gough A Chapman S Wagstaff K et al Minocycline induced autoimmune hepatitis and systemic
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86 Elkayam O Levartovsky D Brautbar C et al Clinical and immunological study of 7 patients with
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87 Sturkenboom MC Meier CR Jick H Stricker BH Minocycline and lupuslike syndrome in acne
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88 Eady EA Cove JH Holland KT Cunliffe WJ Erythromycin resistant propionibacteria in
antibiotic treated acne patients Association with therapeutic failure Br J Dermatol 1989 12151
89 Basta-Juzbasic A Lipozencic J Oremovic L Kotrulja L Gruber F Brajac I et al A dose-finding
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90 Levy RM Huang EY Roling D et al Effect of antibiotics on the oropharyngeal flora in patients
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91 Smith JG Jr Chalker DK Wehr RF The effectiveness of topical and oral tetracycline for acne South
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92 Gratton D Raymond GP Guertin-Larochelle S Maddin SW Leneck CM Warner J et al Topical
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93 Blaney DJ Cook CH Topical use of tetracycline in the treatment of acne a double-blind study
comparing topical and oral tetracycline therapy and placebo Arch Dermatol 1976112971-3
94 Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ Sequential antibiotic therapy
for acne promotes the carriage of resistant staphylococci on the skin of contacts J Antimicrob
Chemother 199638829-37
95 Skidmore R Kovach R Walker C Thomas J Bradshaw M Leyden J et al Effects of
subantimicrobial-dose doxycycline in the treatment of moderate acne Arch Dermatol 2003139459-
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96 Gammon WR Meyer C Lantis S Shenefelt P Reizner G Cripps DJ Comparative efficacy of oral
erythromycin versus oral tetracycline in the treatment of acne vulgaris A doubleblind study J Am
Acad Dermatol 198614183-6
97 Christian GL Krueger GG Clindamycin vs placebo as adjunctive therapy in moderately severe acne
Arch Dermatol 1975111997-1000
98 Stoughton RB Cornell RC Gange RW Walter JF Doubleblind comparison of topical 1 percent
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vulgaris Cutis 198026424-5 429
99 Hersle K Trimethoprim-sulphamethoxazole in acne vulgaris A double-blind study Dermatologica
1972145187-91
100 Cotterill JA Cunliffe WJ Forster RA Williamson DM Bulusu L A comparison of trimethoprim-
sulphamethoxazole with oxytetracycline in acne vulgaris Br J Dermatol 197184366-9
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101 Ward A Brogden RN Heel RC et al Isotretinoin a review of its pharmacological properties and
therapeutic efficacy in acne and other skin disorders Drugs 1984 286
102 Amichai B Shemer A Grunwald MH Low-dose isotretinoin in the treatment of acne vulgaris J
Am Acad Dermatol 2006 54644
103 Layton AM Knaggs H Taylor J Cunliffe WJ Isotretinoin for acne vulgaris - 10 years later a safe
and successful treatment Br J Dermatol 1993 129292
104 White GM Chen W Yao J Wolde-Tsadik G Recurrence rates after the first course of isotretinoin
Arch Dermatol 1998 134376
105 McCarter TL Chen YK Marked hyperlipidemia and pancreatitis associated with isotretinoin
therapy Am J Gastroenterol 1992 871855
106 Rodondi N Darioli R Ramelet AA et al High risk for hyperlipidemia and the metabolic syndrome
after an episode of hypertriglyceridemia during 13-cis retinoic acid therapy for acne a
pharmacogenetic study Ann Intern Med 2002 136582
107 Strauss JS Leyden JJ Lucky AW et al Safety of a new micronized formulation of isotretinoin in
patients with severe recalcitrant nodular acne a randomized trial comparing micronized isotretinoin
with standard isotretinoin J Am Acad Dermatol 2001 45196
108 Peck GL Olsen TG Butkus D Pandya M Arnaud-Battandier J Gross EG et al Isotretinoin versus
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109 Lehucher-Ceyrac D Weber-Buisset MJ Isotretinoin and acne in practice a prospective analysis of
188 cases over 9 yearsDermatology 1993186123-8
110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
Br J Dermatol 1997137106-8
111 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al A randomized trial
of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in
patients with severe recalcitrant nodular acne J Am Acad Dermatol 200145187-95
112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
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113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
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114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
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200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
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117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
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lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
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129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
6
hirsutizmi an virilizaciis arseboba Semdgom laboratoriuli da gamosaxulebiTi kvlevebs saWiroebs)
ganxiluli unda iqnes endokrinuli daavadebebis SesaZlo arsebobac magaliTad qalebs Soris polikisturi sakvercxeebis sindromi (pss) hiperandrogenizmis erT-erTi mizezia es sindromi menstrualuri funqciis darRveviT hirsutizmiT aknes ganviTarebiT sakvercxis kistebiT sxvadasxva xarisxis insulinisadmi rezistentobiT da Savi akanToziT xasiaTdeba erT-erTi kvlevis mixedviT 51 aknes mqone qals Soris 39 hqonda menstrualuri ciklis darRveva da 37-s pss19 aRniSnuli dakvirvebis Sedegebi mowmobs rom yvela qalis romelsac akne da oligomenorea aReniSneba gamokvleuli unda iqnes pss-ze
aknes swrafi ganviTareba virilizaciasTan erTad Tirkmelzeda an sakvercxis simsivnisaTvisaa damaxasiaTebeli aseve akne uviTardebaT pacientebs kuSingis daavadebis an sindromis mqoneT an adrenerguli hiperplaziis dros virilizaciis simtomebs miekuTvneba xmis Secvla sarZeve jirkvlebis zomaSi Semcireba klitoromegalia alopecia oligomenorea da hirsutiazmi aseT pacientebs Tirkmelzeda jirkvlebis da sakvercxeebis radiologiuri da hormonuli kvlevebis Catareba esaWiroebaT
anamnezis Segrovebisas yuradReba unda gamaxvildes sxvadasxva samkurnalo saSualebebis miRebaze aknes ganviTarebis mizezi SesaZloa iyos iseTi samkurnalo saSualebebis xangrZlivad moxmareba rogoricaa adenokortikotropuli hormoni androgenebi azaTiopreni barbituratebi bromidebi kortikosteroidebi ciklosporini disulfirami halogenebi iodidebi izoniazidi liTiumi feniTioni vitaminebi B2 B6 da B12
20
gamokvlevebis gegma
mikrobiologiuri kvleva rutinulad ar tardeba (rekomendacia II
B) mikrobiologiuri kvlevis Catareba esaWiroebaT pacientebs romelTac aqvT aknesmagvari gram-uaryofiTi floriT gamowveuli folikuliti
androgenebis donis gansazRvra sisxlSi rutinulad ar tardeba (rekomendacia I A) kvlevis Catareba marTebulia rodesac pacients aknesTan erTad androgenebis siWarbis sxva niSnebic aqvs bavSvebSi igi SeiZleba gamovlindes Tmianobis matebiT iRliaSi an boqvenze klitoromegaliiT mozrdil qalebSi ndash menstrualuri ciklis gaiSviaTebiT hirsutizmiT alopeciiT unayofobiT Savi akanToziT simsuqniT da aS
cxrili 1 rekomendacia mikrobiologiuri testirebis Casatareblad
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
mikrobiologiuri testireba B II 21-24
7
6 mkurnaloba
mkurnalobis mizania pacientis zogadi mdgomareobis gaumjobeseba gamonayaris kontroli diskomfortis da fsiqosocialuri stresis Semcireba nawiburebis prevencia
aknes samkurnalod mowodebulia rigi adgilobrivi da sistemuri saSualebebi (ix cxrili 5) maTi arCevani damokidebulia klinikurad gamovlenili dazianebis tipsa da simZimeze25 (ix sqema 1 2 3) mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
mkurnaloba diagnostikis Semdgom rac SeiZleba male unda daiwyos da yovel 2-3 TveSi Sefasdes da gadaixedos iSviaTad Tumca aRwerilia SemTxvevebi roca mkurnaloba ramodenime wels gagrelda26
istoriuli mimoxilva Zveli egviptisa da saberZneTis istoriul ZeglebSi mocemulia informacia kanis daavadebis Sesaxeb romelsac axla aknes vuwodebT antikur romSi aknes mkurnalobdnen cxel mineralur an gogirdis abazanebiT 1800 wels dermatologebma oficialurad aRiares gogirdi rogorc aknes samkurnalo saSualeba 1920 wlidan ki farTo gamoyeneba hpova benzoil peroqsidma 1930 wlidan am mimarTulebiT gamoiyeneboda safaRaraTo saSualebebi da radiaqtiuli nivTierebebi 1950 wlidan farTod daiwyes antibiotokebis gamoyeneba amave droidan gamoixata tetraciklinis jgufis antibiotikebis upiratesi efeqti anTebiTi aknes mkurnalobisTvis mogvianebiT Sesabamisi farmakologiuri formebis SemuSavebis Semdgom dainerga adgilobrivi antibiotikebis gamoyeneba 1970 wels moxmarebaSi Semovida tretinoini M
mkurnalobis saxe (adgilorivi sistemuri) daavadebis simZimiTa da dazianebis lokalizaciiT ganisazRvreba
medikamentebi adgilobrivi mkurnalobisaTvis
mkurnalobisTvis adgilobrivi (lokaluri) saSualebis saxeobis arCeva pacientis kanis tipis da survilis gaTvaliswinebiT xdeba geli iwvevs kanis gamoSrobas amitom misi gamoyeneba umjobesia cximiani kanis SemTxvevaSi malamo da losionebi kans anotiveben da upiratesoba maT mSrali kanis SemTxvevaSi eniWebaT adgilobrivi saSualebebis umetesoba dReSi orjeradad gamoiyeneba Tumca SesaZlebelia dReSi erTjeradi an dRegamoSvebiT gamoyeneba Tu xSiri moxmarebisas kanis gaRizianeba viTardeba amasTan ufro efeqturia adgilobrivi saSualebebis kombinacia vidre maTi damoukideblad calk-calke gamoyeneba miRebuli kombinaciebia retinoidebi benzoil peroqsidi da topikuri antibiotikebi
kombinacia iZleva ufro gamoxatul Terapiul efeqts vidre TiToeuli agentis damoukidebeli gamoyeneba
erTze meti adgilobrivi saSualebis gamoyenebisas ndash erTi gamoiyeneba diliT meore ndash saRamos rogorc wesi adgilobrivi retinoidebi saRamos iniSneba
8
benzoilis zeJangi
benzoilis zeJangi gamoiyeneba sxvadasxva koncentraciiTa da SemavsebeliT am etapze ar arsebobs mtkicebuleba romelic sxvadasxva formulebis upiratesobas gansazRvravs msoflios bevr qveyanaSi gaicema ureceptod xasiaTdeba baqtericiduli moqmedebiT ainhibirebs axali komedonebis warmoqmnas amcirebs folikulur lipidebsa da Tavisufal cximovan mJavebs rac Tavis mxriv epiTelis deskvamacias iwvevs arCevis preparatia mkurnalobis dawyebisas da nebismieri simZimis aknes dros gamoiyeneba xsnarebi da malamoebi gelTan SedarebiT naklebad iwveven kanis iritacias Tumca mainc SeiZleba gamoiwvion eriTema aqercvla da iSviaTad ndash kontaqturi reaqcia27 gamoiyeneba dReSi 2-jer adgilobriv retinoidebTan kombinaciaSi gamoyenebisas kanis gaRizianebisa da fotoreaqciis Tavidan acilebis mizniT benzoilis zeJangi diliT xolo retinoidebi saRamos iniSneba benzoilis zeJangisa da retinoidebis (adapaleni-retinoidebis sinTezuri analogi tretinoini) erTdrouli gamoyeneba ufro efeqturia vidre TiToeuli agentisa calk-calke2829
adgilobrivi retinoidebi
adgilobrivi retinoidebi Tavisi qimiuri formuliT enaTesavebian A
vitamins maTi efeqturoba aknes mkurnalobaSi araerTi mtkicebulebiTaa dadasturebuli34-50 isini erTaderTi saSualebebia romlebic folikuluri epiTelis terminaluri diferenciaciaze axdens gavlenas da arCevis preparatebia araanTebiTi aknes mkurnalobisTvis amasTan gamoiyenebian anTebiTi aknes samkurnalodac retinoidebi axdenen obstruqciis Semcirebas folikulSi keratinizaciis procesis normalizebis gziT aferxeben komedonebis progresirebas anTebad dazianebamde aumjobeseben komedonebis drenaJs aferxeben axali komedonebis warmoqmnas5152 rigi SedarebiTi kvlevebiT ar gamovlinda romelime retinoidis upiratesoba meoresTan SedarebiT
erTerTi kvleviT tazarotenis geli ufro efeqturi aRmoCnda tretinoinis gelTan SedarebiT (araanTebiTi da anTebiTi dazianebebis Semcireba)53 Tumca sxva kvleviT dRegamoSvebiT tazaroteniT mkurnaloba iseTive efeqturi iyo rogorc adapaleniT yoveldRiuri mkurnaloba54 eriTema wva qavili tretinoinTan da adapalenTan SedarebiT ufro gamoxatuli iyo tazarotenis gelis SemTxvevaSi gverdiTi efeqtebi mcirdeba tazarotenis malamos gamoyenebisas Tumca SedarebiTi kvlevebi am agentisa da sxva adgilobrivi retinoidebiT ar Catarebula
sxva kvleviT adapaleni (01 geli) ufro efeqturi aRmoCnda tretinoinTan SedarebiT (0025 geli)55
gverdiTi efeqtebis Semcireba SeiZleba dabali koncentraciis (0025) saSualebebis gamoyenebiT da amtanobis SemTxvevaSi koncentraciis TandaTan gazrdiT (0025 malamo Semdeg 001 geli 005 kremi 0025 geli 01 kremi 005 xsnari) yvela retinoids gaaCnia kanis gamaRizianebeli moqmedeba SeiZleba gamoiwvion kanis siwiTle
9
gaRizianeba damwvroba zrdian fotosensitiurobas amitom maTi gamoyeneba unda moxdes saRamos xolo dRis ganmavlobaSi mzisagan damcav saSualebebTan (kremebTan) erTad mkurnalobis dasawyisSi SesaZloa mdgomareobis gauareseba ukunaCvenebia orsulobis dros
cxrili 2 rekomendaciebi adgilobrivi mkurnalobisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
benzoilis zeJangi A I 30-33
retinoidebi A I 34374750
antibiotikebi A I 61-69
sxva adgilobrivi saSualebebi A I 70-77
adgilobrivi antibiotikebi
adgilobrivi antibiotikebis damateba P acne-s cximovani folikulidan eliminaciis mizniT xdeba anTebiTi da papuluri aknes mkurnalobis dros adgilobrivi eriTromicini gamoiyeneba dReSi erTxel an orjer adgilobrivi 1-iani klindamicini gamoiyeneba RamiT an dReSi orjer
aRsaniSnavia rom adgilobrivi antibiotikebis gamoyenebam SesaZloa xeli Seuwyos P acne-s rezistentuli Stamebis gaCenas rezistentoba mcirdeba adgilobrivi antibiotikebis sxva saSualebebTan kombinaciaSi daniSvnisas amasTan kombinirebuli mkurnaloba ufro efeqturia vidre am saSualebebis calk-calke gamoyeneba
56-59 magaliTad erTerTi kvleviT gamovlinda rom 3-iani eriTromicinis da benzoilis zeJngis 5-iani geliT kombinirebuli mkurnaloba ara marto aRemateboda efeqturobiT TiToeul agents calk-calke aramed gaumjobesebas iZleoda rezistentuli Stamebis SemTxvevaSic60 aseve klindamicinibenzoilis zeJangis geliT mkurnaloba efeqturi iyo TiToeul agentTan SedarebiT59 sxva kvleviT klindamicini da adapalenis kombinacia ufro efeqturi iyo mxolod klindamicinTan SedarebiT Tumca kanismxrivi gverdiTi efeqtebi (aqercvla simSrale wva) ramdenadme gauaresda kombinirebuli mkurnalobis dros
sxva adgilobrivi saSualebebi
salicilis mJava - istoriulad erTerTi Zveli agentia romelic aknes mkurnalobisTvis gamoiyeneboda Tumca retinoidebTan SedarebiT misi komedolizuri moqmedeba ufro sustia is warmoadgens retinoidebis alternativas rodesac pacientebs aReniSnebaT autanloba retinoidebis mimarT rac kanis iritaciiT vindeba70
azelainis mJava (II) ndash aqvs antikomedonuri da antibaqteriuli Tvisebebi amitom gamoiyeneba rogorc anTebiTi aseve araanTebiTi aknes dros rigi klinikuri kvlevebiT nanaxia misi efeqturoba71-73 amcirebs
10
kanis pigmentacias da ufro efeqturia misi gamoyeneba aknesTan asocirebuli hiperpigmentaciis dros74
aluminis qlorids antibaqteriuli moqmedeba gaaCnia Tumca kvlevebma gansxvavebuli Sedegebi aCvena ndash erT SemTxvevaSi misi efeqturoba gamovlinda75 meoreSi76 ndash ara
sistemuri mkurnaloba
sistemuri antibiotikebi
sistemuri antibiotikebi anTebiTi aknes mkurnalobisaTvis gamoiyeneba ainhibireben P acnes zrdas folikulSi sistemuri antibiotikoTerapia adgilobriv saSualebebTan SedarebiT ufro swraf klinikur gaumjobesebas iZleva Tumca SesaZlebelia antibiotikebis gverdiTi efeqtebis gamovlineba rogoricaa vaginaluri kandidozi gastrointestinuli darRvevebi da aS es saSualebebi iniSneba yoveldRiurad 4-6 Tvis manZilze mdgomareobis gaumjobesebisas TandaTan xdeba dozis Semcireba da Sewyveta maTi Sewyvetis Semdeg mgomareobis SenarCuneba SesaZlebelia adgilobrivi retinoidebis an
benzoilis zeJangis saSualebiT77-79
sistemuri mkurnalobisaTvis gamoiyeneba tetraciklini doqsiciklini minociklini eriTromicini trimetoprim-sulfameToqsazoli da klindamicini
tetraciklins (I A) upiratesoba eniWeba dabali fasis da kvlevebiT dadasturebuli maRali efeqturobis gamo mkurnaloba iwyeba doziT 500 mg orjer dReSi Tumca 250 mg 2-jer ndash SesaZloa aseve efeqturi iyos absorbcias amcirebs sakvebi rZis produqtebi antacidebi rkina iniSneba uzmoze misaRebad ukunaCvenebia orsulobis dros da 12 wlis asakamde vinaidan iwvevs kbilis minanqaris feris Secvlas
doqsiciklini (I) da minocilkini (B) tetraciklinTan SedarebiT ufro metad xsnadia cximSi da gamoiyeneba ufro mcire dozebiTac (100 mg 2-jer an 50 mg 2-jer) am saSualebebis miReba sakvebTan erTadac SeiZleba vinaidan sakvebi ar amcirebs mis absorbcias minociklini arCevis pirveli rigis preparati araa maRali fasisa da tetraciklinTan SedarebiT metad efeqturobis Sesaxeb zusti monacemebis ararsebobis8182 agreTve toqsikurobis gamo8384 doqsiciklini da minocilkini iniSneba tetracikliniT mkurnalobis araefeqturobis SemTxvevaSi doqsiciklini iwvevs fotosensibilizacias saylapavis wylulis ganviTarebis Tavidan acilebis mizniT sakmao odenobis wyalTan erTad unda iqnes miRebuli
SesaZloa gamoiwvios Tavbruxveva pseudotumor cerebri kbilebis feris cvlileba mgluras magvari sindromi85-87 sifrTxiliT unda iqnes gamoyenebuli mgluras mqone pacientebs Soris aknes mkurnalobis mizniT
eriTromicini SesaZlebelia dainiSnos 250-1500 mg dRiuri doziT (or miRebad) misi anTebis sawinaaRmdego moqmedeba tetraciklinTan
11
SedarebiT mcirea amasTan xSirad viTardeba rezistentuli Stamebi88 da gastrointestinuri gverdiTi efeqtebi eriTromicini arCevis saSualebaa im SemTxvevebSi roca SezRudulia tetraciklinis daniSvna (orsuli 8 wlamde bavSvi) mimdinareobs kvleva azitromicinis efeqturobis Sesaxeb maqsimaluri doza 60 g 10 kviris ganmavlobaSi89
trimetoprim-sulfameToqsazoli arCevis meore rigis preparatia (40080mg erTjer an orjer dReSi) efeqturi saSualebaa mZime aknes mkurnalobisaTvis Tumca misi gamoyeneba SezRudulia iseTi seriozuli gverdiTi efeqtebis gamo rogoricaa Zvlis tvinis supresia da toqsikuri epidermuli nekrozi amis msgavsad SezRudulia oraluri klindamicinis gamoyeneba fsevdomembranozuli kolitis ganviTarebis riskis gamo
aknes mqone pacientebis mkurnalobis procesSi seriozul problemas warmoadgens mikrobTa rezistentoba misi xelSemwyobia antibiotikebis farTod gamoyeneba da maTi monacvleoba SedarebiT xSiria rezistentobis ganviTareba eriTromicinis xolo iSviaTi ndash minociklinis mimarT antibiotikoTerapiam SesaZloa xeli Seuwyos Streptococcus pyogenes-is rezistentuli StamebiT xaxis kolonizacias90 rezistentobis problema SeiZleba Semcirdes Semdegi gziT
antibiotikis daniSvna misi absoluturi saWiroebis SemTxvevaSi SeZlebisdagvarad xanmokle mkunalobis kursi (Tumca aranakleb 3 Tvisa) SesaZleblobis mixedviT adgilobrivi saSualebebis
gamoyeneba
benzoilis zeJangis gamoyenebam SeiZleba Seamciros rezistentobis sixSire
oraluri saSualebebis Sewyvetis Semdeg Tu dgeba misi ganaxlebis saWiroeba umjobesia isev imave antibiotikis daniSvna manam sanam igi efeqturi darCeba
cxrili 3 rekomendaciebi sistemuri antibiotikoTerapiisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
tetraciklinebi A I 91-94
makrolidebi A I 95-98
trimetoprim-sulfameToqsazoli A I 99100
12
sistemuri retinoidebi
sistemuri retinoidebi mZime formis aknes mkurnalobisaTvis gamoiyeneba aseve SeiZleba misi gamoyeneba naklebad mZime magram mkurnalobisadmi rezistuli formis dros nawiburovani aknes an daavadebasTan dakavSirebuli Zlieri fsiqo-socialuri stresis SemTvevaSi amcirebs cximis sekrecias misi efeqti samkurnalo saSualebis miRebis Sewyvetidan 1 wlamde grZeldeba cximis Semcireba Tavis mxriv iwvevs proliferaciis Semcirebas samkurnalo saSualebas anTebis sawinaaRmdego moqmedebac gaaCnia da komedonebis warmoqmnas aferxebs101
sistemuri izotretinoinis daniSvnis Cvenebebia
mZime kvanZovan-cisturi akne
akne romelic mxolod mcired gaumjobesda sistemuri antibiotikoTerapiis 6 Tviani kursis Semdeg
nawiburovani akne
akneTi gamowveuli mZime stresi
ganmeorebiTi akne
fulminanturi akne
gram-uaryofiTi folikuliti
mkurnaloba iwyeba 05 mgkg dRiuri doziT da SeiZleba 2 mgkg dozamde gaizardos iniSneba 2 miRebad sakvebTan erTad Cveulebriv mkurnalobis xangrZlivoba 20 kviramdea arsebobs mtkicebulebebi rom efeqturi SeiZleba iyos ufro dabali dozebiT mkurnalobac102 mkurnalobis dawyebisas SesaZloa aknes gauareseba aseT SemTxvevebSi naCvenebia sistemuri kortikosteroidebis daniSvna an mkurnalobis ufro dabali dozebiT (05 mgkgdR-ze naklebi) dawyeba mkurnalobis kumulaciuri doza 120-150 mgkg-ia
pacientebis 80-ze mets mkurnalobis erTi kursis Semdeg xangrZlivi remisia aReniSneba gaumjobeseba mkurnalobis Sewyvetidan ramdenime Tve grZeldeba saWiroebisas kursis ganaxlebamde 4-5 Tve unda iyos gasuli recidivebis umetesoba (96) mkurnalobis Sewyvetidan pirveli 3 Tvis ganmavlobaSi aRmocendeba103 da misi sixSire gansakuTrebiT maRalia pacientebs Soris romelTac akne upiratesad torsze aReniSnebaT an samkurnalo saSualebis kumulaciuri doza 120 mgkg-ze naklebia
izotretinoinis kursis Semdeg remisiis maRali sixSiris miuxedavad pacientebis mxolod 39-s aReniSneba sruli gamojanmrTeleba 61-s ki kvlav esaWiroeba adgilobrivi an sistemuri antibiotikebiT mkurnalobis gagrZeleba104 izotretinoinis maRali Rirebulebis miuxedavad am saSualebiT Catarebuli mkurnaloba mainc xarjTefeqturad SeiZleba CaiTvalos vinaidan es erTaderTi saSualebaa romelic aknes ganviTarebis meqanizmze moqmedebs Tumca aRsaniSnavia isic rom izotretinoinTan dakavSirebulia sakmaod seriozuli da mZime gverdiTi efeqtebi rac zRudavs mis gamoyenebas
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in
patients with severe recalcitrant nodular acne J Am Acad Dermatol 200145187-95
112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
randomized trial comparing micronized isotretinoin with standard isotretinoin J Am Acad Dermatol
200145196-207
114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
Acad Dermatol 199226599-606
115 Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW et al American Academy
of Dermatology Consensus Conference on the safe and optimal use of isotretinoinsummary and
recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
118 Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ Effectiveness of
norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
7
6 mkurnaloba
mkurnalobis mizania pacientis zogadi mdgomareobis gaumjobeseba gamonayaris kontroli diskomfortis da fsiqosocialuri stresis Semcireba nawiburebis prevencia
aknes samkurnalod mowodebulia rigi adgilobrivi da sistemuri saSualebebi (ix cxrili 5) maTi arCevani damokidebulia klinikurad gamovlenili dazianebis tipsa da simZimeze25 (ix sqema 1 2 3) mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
mkurnaloba diagnostikis Semdgom rac SeiZleba male unda daiwyos da yovel 2-3 TveSi Sefasdes da gadaixedos iSviaTad Tumca aRwerilia SemTxvevebi roca mkurnaloba ramodenime wels gagrelda26
istoriuli mimoxilva Zveli egviptisa da saberZneTis istoriul ZeglebSi mocemulia informacia kanis daavadebis Sesaxeb romelsac axla aknes vuwodebT antikur romSi aknes mkurnalobdnen cxel mineralur an gogirdis abazanebiT 1800 wels dermatologebma oficialurad aRiares gogirdi rogorc aknes samkurnalo saSualeba 1920 wlidan ki farTo gamoyeneba hpova benzoil peroqsidma 1930 wlidan am mimarTulebiT gamoiyeneboda safaRaraTo saSualebebi da radiaqtiuli nivTierebebi 1950 wlidan farTod daiwyes antibiotokebis gamoyeneba amave droidan gamoixata tetraciklinis jgufis antibiotikebis upiratesi efeqti anTebiTi aknes mkurnalobisTvis mogvianebiT Sesabamisi farmakologiuri formebis SemuSavebis Semdgom dainerga adgilobrivi antibiotikebis gamoyeneba 1970 wels moxmarebaSi Semovida tretinoini M
mkurnalobis saxe (adgilorivi sistemuri) daavadebis simZimiTa da dazianebis lokalizaciiT ganisazRvreba
medikamentebi adgilobrivi mkurnalobisaTvis
mkurnalobisTvis adgilobrivi (lokaluri) saSualebis saxeobis arCeva pacientis kanis tipis da survilis gaTvaliswinebiT xdeba geli iwvevs kanis gamoSrobas amitom misi gamoyeneba umjobesia cximiani kanis SemTxvevaSi malamo da losionebi kans anotiveben da upiratesoba maT mSrali kanis SemTxvevaSi eniWebaT adgilobrivi saSualebebis umetesoba dReSi orjeradad gamoiyeneba Tumca SesaZlebelia dReSi erTjeradi an dRegamoSvebiT gamoyeneba Tu xSiri moxmarebisas kanis gaRizianeba viTardeba amasTan ufro efeqturia adgilobrivi saSualebebis kombinacia vidre maTi damoukideblad calk-calke gamoyeneba miRebuli kombinaciebia retinoidebi benzoil peroqsidi da topikuri antibiotikebi
kombinacia iZleva ufro gamoxatul Terapiul efeqts vidre TiToeuli agentis damoukidebeli gamoyeneba
erTze meti adgilobrivi saSualebis gamoyenebisas ndash erTi gamoiyeneba diliT meore ndash saRamos rogorc wesi adgilobrivi retinoidebi saRamos iniSneba
8
benzoilis zeJangi
benzoilis zeJangi gamoiyeneba sxvadasxva koncentraciiTa da SemavsebeliT am etapze ar arsebobs mtkicebuleba romelic sxvadasxva formulebis upiratesobas gansazRvravs msoflios bevr qveyanaSi gaicema ureceptod xasiaTdeba baqtericiduli moqmedebiT ainhibirebs axali komedonebis warmoqmnas amcirebs folikulur lipidebsa da Tavisufal cximovan mJavebs rac Tavis mxriv epiTelis deskvamacias iwvevs arCevis preparatia mkurnalobis dawyebisas da nebismieri simZimis aknes dros gamoiyeneba xsnarebi da malamoebi gelTan SedarebiT naklebad iwveven kanis iritacias Tumca mainc SeiZleba gamoiwvion eriTema aqercvla da iSviaTad ndash kontaqturi reaqcia27 gamoiyeneba dReSi 2-jer adgilobriv retinoidebTan kombinaciaSi gamoyenebisas kanis gaRizianebisa da fotoreaqciis Tavidan acilebis mizniT benzoilis zeJangi diliT xolo retinoidebi saRamos iniSneba benzoilis zeJangisa da retinoidebis (adapaleni-retinoidebis sinTezuri analogi tretinoini) erTdrouli gamoyeneba ufro efeqturia vidre TiToeuli agentisa calk-calke2829
adgilobrivi retinoidebi
adgilobrivi retinoidebi Tavisi qimiuri formuliT enaTesavebian A
vitamins maTi efeqturoba aknes mkurnalobaSi araerTi mtkicebulebiTaa dadasturebuli34-50 isini erTaderTi saSualebebia romlebic folikuluri epiTelis terminaluri diferenciaciaze axdens gavlenas da arCevis preparatebia araanTebiTi aknes mkurnalobisTvis amasTan gamoiyenebian anTebiTi aknes samkurnalodac retinoidebi axdenen obstruqciis Semcirebas folikulSi keratinizaciis procesis normalizebis gziT aferxeben komedonebis progresirebas anTebad dazianebamde aumjobeseben komedonebis drenaJs aferxeben axali komedonebis warmoqmnas5152 rigi SedarebiTi kvlevebiT ar gamovlinda romelime retinoidis upiratesoba meoresTan SedarebiT
erTerTi kvleviT tazarotenis geli ufro efeqturi aRmoCnda tretinoinis gelTan SedarebiT (araanTebiTi da anTebiTi dazianebebis Semcireba)53 Tumca sxva kvleviT dRegamoSvebiT tazaroteniT mkurnaloba iseTive efeqturi iyo rogorc adapaleniT yoveldRiuri mkurnaloba54 eriTema wva qavili tretinoinTan da adapalenTan SedarebiT ufro gamoxatuli iyo tazarotenis gelis SemTxvevaSi gverdiTi efeqtebi mcirdeba tazarotenis malamos gamoyenebisas Tumca SedarebiTi kvlevebi am agentisa da sxva adgilobrivi retinoidebiT ar Catarebula
sxva kvleviT adapaleni (01 geli) ufro efeqturi aRmoCnda tretinoinTan SedarebiT (0025 geli)55
gverdiTi efeqtebis Semcireba SeiZleba dabali koncentraciis (0025) saSualebebis gamoyenebiT da amtanobis SemTxvevaSi koncentraciis TandaTan gazrdiT (0025 malamo Semdeg 001 geli 005 kremi 0025 geli 01 kremi 005 xsnari) yvela retinoids gaaCnia kanis gamaRizianebeli moqmedeba SeiZleba gamoiwvion kanis siwiTle
9
gaRizianeba damwvroba zrdian fotosensitiurobas amitom maTi gamoyeneba unda moxdes saRamos xolo dRis ganmavlobaSi mzisagan damcav saSualebebTan (kremebTan) erTad mkurnalobis dasawyisSi SesaZloa mdgomareobis gauareseba ukunaCvenebia orsulobis dros
cxrili 2 rekomendaciebi adgilobrivi mkurnalobisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
benzoilis zeJangi A I 30-33
retinoidebi A I 34374750
antibiotikebi A I 61-69
sxva adgilobrivi saSualebebi A I 70-77
adgilobrivi antibiotikebi
adgilobrivi antibiotikebis damateba P acne-s cximovani folikulidan eliminaciis mizniT xdeba anTebiTi da papuluri aknes mkurnalobis dros adgilobrivi eriTromicini gamoiyeneba dReSi erTxel an orjer adgilobrivi 1-iani klindamicini gamoiyeneba RamiT an dReSi orjer
aRsaniSnavia rom adgilobrivi antibiotikebis gamoyenebam SesaZloa xeli Seuwyos P acne-s rezistentuli Stamebis gaCenas rezistentoba mcirdeba adgilobrivi antibiotikebis sxva saSualebebTan kombinaciaSi daniSvnisas amasTan kombinirebuli mkurnaloba ufro efeqturia vidre am saSualebebis calk-calke gamoyeneba
56-59 magaliTad erTerTi kvleviT gamovlinda rom 3-iani eriTromicinis da benzoilis zeJngis 5-iani geliT kombinirebuli mkurnaloba ara marto aRemateboda efeqturobiT TiToeul agents calk-calke aramed gaumjobesebas iZleoda rezistentuli Stamebis SemTxvevaSic60 aseve klindamicinibenzoilis zeJangis geliT mkurnaloba efeqturi iyo TiToeul agentTan SedarebiT59 sxva kvleviT klindamicini da adapalenis kombinacia ufro efeqturi iyo mxolod klindamicinTan SedarebiT Tumca kanismxrivi gverdiTi efeqtebi (aqercvla simSrale wva) ramdenadme gauaresda kombinirebuli mkurnalobis dros
sxva adgilobrivi saSualebebi
salicilis mJava - istoriulad erTerTi Zveli agentia romelic aknes mkurnalobisTvis gamoiyeneboda Tumca retinoidebTan SedarebiT misi komedolizuri moqmedeba ufro sustia is warmoadgens retinoidebis alternativas rodesac pacientebs aReniSnebaT autanloba retinoidebis mimarT rac kanis iritaciiT vindeba70
azelainis mJava (II) ndash aqvs antikomedonuri da antibaqteriuli Tvisebebi amitom gamoiyeneba rogorc anTebiTi aseve araanTebiTi aknes dros rigi klinikuri kvlevebiT nanaxia misi efeqturoba71-73 amcirebs
10
kanis pigmentacias da ufro efeqturia misi gamoyeneba aknesTan asocirebuli hiperpigmentaciis dros74
aluminis qlorids antibaqteriuli moqmedeba gaaCnia Tumca kvlevebma gansxvavebuli Sedegebi aCvena ndash erT SemTxvevaSi misi efeqturoba gamovlinda75 meoreSi76 ndash ara
sistemuri mkurnaloba
sistemuri antibiotikebi
sistemuri antibiotikebi anTebiTi aknes mkurnalobisaTvis gamoiyeneba ainhibireben P acnes zrdas folikulSi sistemuri antibiotikoTerapia adgilobriv saSualebebTan SedarebiT ufro swraf klinikur gaumjobesebas iZleva Tumca SesaZlebelia antibiotikebis gverdiTi efeqtebis gamovlineba rogoricaa vaginaluri kandidozi gastrointestinuli darRvevebi da aS es saSualebebi iniSneba yoveldRiurad 4-6 Tvis manZilze mdgomareobis gaumjobesebisas TandaTan xdeba dozis Semcireba da Sewyveta maTi Sewyvetis Semdeg mgomareobis SenarCuneba SesaZlebelia adgilobrivi retinoidebis an
benzoilis zeJangis saSualebiT77-79
sistemuri mkurnalobisaTvis gamoiyeneba tetraciklini doqsiciklini minociklini eriTromicini trimetoprim-sulfameToqsazoli da klindamicini
tetraciklins (I A) upiratesoba eniWeba dabali fasis da kvlevebiT dadasturebuli maRali efeqturobis gamo mkurnaloba iwyeba doziT 500 mg orjer dReSi Tumca 250 mg 2-jer ndash SesaZloa aseve efeqturi iyos absorbcias amcirebs sakvebi rZis produqtebi antacidebi rkina iniSneba uzmoze misaRebad ukunaCvenebia orsulobis dros da 12 wlis asakamde vinaidan iwvevs kbilis minanqaris feris Secvlas
doqsiciklini (I) da minocilkini (B) tetraciklinTan SedarebiT ufro metad xsnadia cximSi da gamoiyeneba ufro mcire dozebiTac (100 mg 2-jer an 50 mg 2-jer) am saSualebebis miReba sakvebTan erTadac SeiZleba vinaidan sakvebi ar amcirebs mis absorbcias minociklini arCevis pirveli rigis preparati araa maRali fasisa da tetraciklinTan SedarebiT metad efeqturobis Sesaxeb zusti monacemebis ararsebobis8182 agreTve toqsikurobis gamo8384 doqsiciklini da minocilkini iniSneba tetracikliniT mkurnalobis araefeqturobis SemTxvevaSi doqsiciklini iwvevs fotosensibilizacias saylapavis wylulis ganviTarebis Tavidan acilebis mizniT sakmao odenobis wyalTan erTad unda iqnes miRebuli
SesaZloa gamoiwvios Tavbruxveva pseudotumor cerebri kbilebis feris cvlileba mgluras magvari sindromi85-87 sifrTxiliT unda iqnes gamoyenebuli mgluras mqone pacientebs Soris aknes mkurnalobis mizniT
eriTromicini SesaZlebelia dainiSnos 250-1500 mg dRiuri doziT (or miRebad) misi anTebis sawinaaRmdego moqmedeba tetraciklinTan
11
SedarebiT mcirea amasTan xSirad viTardeba rezistentuli Stamebi88 da gastrointestinuri gverdiTi efeqtebi eriTromicini arCevis saSualebaa im SemTxvevebSi roca SezRudulia tetraciklinis daniSvna (orsuli 8 wlamde bavSvi) mimdinareobs kvleva azitromicinis efeqturobis Sesaxeb maqsimaluri doza 60 g 10 kviris ganmavlobaSi89
trimetoprim-sulfameToqsazoli arCevis meore rigis preparatia (40080mg erTjer an orjer dReSi) efeqturi saSualebaa mZime aknes mkurnalobisaTvis Tumca misi gamoyeneba SezRudulia iseTi seriozuli gverdiTi efeqtebis gamo rogoricaa Zvlis tvinis supresia da toqsikuri epidermuli nekrozi amis msgavsad SezRudulia oraluri klindamicinis gamoyeneba fsevdomembranozuli kolitis ganviTarebis riskis gamo
aknes mqone pacientebis mkurnalobis procesSi seriozul problemas warmoadgens mikrobTa rezistentoba misi xelSemwyobia antibiotikebis farTod gamoyeneba da maTi monacvleoba SedarebiT xSiria rezistentobis ganviTareba eriTromicinis xolo iSviaTi ndash minociklinis mimarT antibiotikoTerapiam SesaZloa xeli Seuwyos Streptococcus pyogenes-is rezistentuli StamebiT xaxis kolonizacias90 rezistentobis problema SeiZleba Semcirdes Semdegi gziT
antibiotikis daniSvna misi absoluturi saWiroebis SemTxvevaSi SeZlebisdagvarad xanmokle mkunalobis kursi (Tumca aranakleb 3 Tvisa) SesaZleblobis mixedviT adgilobrivi saSualebebis
gamoyeneba
benzoilis zeJangis gamoyenebam SeiZleba Seamciros rezistentobis sixSire
oraluri saSualebebis Sewyvetis Semdeg Tu dgeba misi ganaxlebis saWiroeba umjobesia isev imave antibiotikis daniSvna manam sanam igi efeqturi darCeba
cxrili 3 rekomendaciebi sistemuri antibiotikoTerapiisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
tetraciklinebi A I 91-94
makrolidebi A I 95-98
trimetoprim-sulfameToqsazoli A I 99100
12
sistemuri retinoidebi
sistemuri retinoidebi mZime formis aknes mkurnalobisaTvis gamoiyeneba aseve SeiZleba misi gamoyeneba naklebad mZime magram mkurnalobisadmi rezistuli formis dros nawiburovani aknes an daavadebasTan dakavSirebuli Zlieri fsiqo-socialuri stresis SemTvevaSi amcirebs cximis sekrecias misi efeqti samkurnalo saSualebis miRebis Sewyvetidan 1 wlamde grZeldeba cximis Semcireba Tavis mxriv iwvevs proliferaciis Semcirebas samkurnalo saSualebas anTebis sawinaaRmdego moqmedebac gaaCnia da komedonebis warmoqmnas aferxebs101
sistemuri izotretinoinis daniSvnis Cvenebebia
mZime kvanZovan-cisturi akne
akne romelic mxolod mcired gaumjobesda sistemuri antibiotikoTerapiis 6 Tviani kursis Semdeg
nawiburovani akne
akneTi gamowveuli mZime stresi
ganmeorebiTi akne
fulminanturi akne
gram-uaryofiTi folikuliti
mkurnaloba iwyeba 05 mgkg dRiuri doziT da SeiZleba 2 mgkg dozamde gaizardos iniSneba 2 miRebad sakvebTan erTad Cveulebriv mkurnalobis xangrZlivoba 20 kviramdea arsebobs mtkicebulebebi rom efeqturi SeiZleba iyos ufro dabali dozebiT mkurnalobac102 mkurnalobis dawyebisas SesaZloa aknes gauareseba aseT SemTxvevebSi naCvenebia sistemuri kortikosteroidebis daniSvna an mkurnalobis ufro dabali dozebiT (05 mgkgdR-ze naklebi) dawyeba mkurnalobis kumulaciuri doza 120-150 mgkg-ia
pacientebis 80-ze mets mkurnalobis erTi kursis Semdeg xangrZlivi remisia aReniSneba gaumjobeseba mkurnalobis Sewyvetidan ramdenime Tve grZeldeba saWiroebisas kursis ganaxlebamde 4-5 Tve unda iyos gasuli recidivebis umetesoba (96) mkurnalobis Sewyvetidan pirveli 3 Tvis ganmavlobaSi aRmocendeba103 da misi sixSire gansakuTrebiT maRalia pacientebs Soris romelTac akne upiratesad torsze aReniSnebaT an samkurnalo saSualebis kumulaciuri doza 120 mgkg-ze naklebia
izotretinoinis kursis Semdeg remisiis maRali sixSiris miuxedavad pacientebis mxolod 39-s aReniSneba sruli gamojanmrTeleba 61-s ki kvlav esaWiroeba adgilobrivi an sistemuri antibiotikebiT mkurnalobis gagrZeleba104 izotretinoinis maRali Rirebulebis miuxedavad am saSualebiT Catarebuli mkurnaloba mainc xarjTefeqturad SeiZleba CaiTvalos vinaidan es erTaderTi saSualebaa romelic aknes ganviTarebis meqanizmze moqmedebs Tumca aRsaniSnavia isic rom izotretinoinTan dakavSirebulia sakmaod seriozuli da mZime gverdiTi efeqtebi rac zRudavs mis gamoyenebas
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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2 CN Harper JC Cantrell WC et al The prevalence of acne in adults 20 years and older
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Dermatol 1978 71324
4 Lucky AW Biro FM Huster GA et al Acne vulgaris in premenarchal girls an early sign of
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5 Lucky AW Biro FM Simbartl LA et al Predictors of severity of acne vulgaris in young
adolescent girls results of a five-year longitudinal study J Pediatr 1997 13030
6 Goulden V Clark SM Cunliffe WJ Post-adolescent acne a review of clinical features Br J
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7 Stoll S Shalita AR Webster GF et al The effect of the menstrual cycle on acne J Am Acad
Dermatol 2001 45957
8 Nguyen QH Kim YA Schwartz RA Management of acne vulgaris Am Fam Phys 1994 5089
9 Vowels BR Yang S Leyden JJ Induction of proinflammatory cytokines by a soluble factor of
Propionibacterium acnes implications for chronic inflammatory acne Infect Immun 1995 633158
10 Cordain L Lindeberg S Hurtado M et al Acne vulgaris a disease of Western civilization Arch Dermatol 2002 1381584
11 Thiboutot DM Strauss JS Diet and acne revisited Arch Dermatol 2002 1381591
27
12 Bershad S The unwelcome return of the acne diet Arch Dermatol 2003 139940
13 Adebamowo CA Spiegelman D Danby FW et al High school dietary dairy intake and teenage
acne J Am Acad Dermatol 2005 52207
14 2008 Family Practice Notebook LLC
15 Rasmussen JE Smith SB Patient concepts and misconceptions about acne Arch Dermatol 1983
119570
16 Green J Sinclair RD Perceptions of acne vulgaris in final year medical student written examination
answers Australas J Dermatol 2001 4298
17 Yosipovitch G Tang M Dawn AG et al Study of psychological stress sebum production and
acne vulgaris in adolescents Acta Derm Venereol 2007 87135
18 Chiu A Chon SY Kimball AB The response of skin disease to stress changes in the severity of
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19 Timpatanapong P Rojanasakul A Hormonal profiles and prevalence of polycystic ovary syndrome
in women with acne J Dermatol 1997 24223
20 Goldstein SM Wintroub BU Adverse Cutaneous Reactions to Medication A Physicians Guide
CoMedica Inc New York 1994 p 55
21 Cove JH Cunliffe WJ Holland KT Acne vulgaris is the bacterial population size significant Br J
Dermatol 1980 102277-80
22 Bojar RA Hittel N Cunliffe WJ Holland KT Direct analysis of resistance in the cutaneous
microflora during treatment of acne vulgaris with topical 1 nadifloxacin and 2 erythromycin
Drugs 199549(suppl 2)164-7
23 Eady EA Cove JH Holland KT Cunliffe WJ Erythromycin resistant propionibacteria in antibiotic
treated acne patients association with therapeutic failure Br J Dermatol 1989121 51-7
24 Harkaway KS McGinley KJ Foglia AN Lee WL Fried F Shalita AR et al Antibiotic resistance
patterns in coagulase-negative staphylococci after treatment with topical erythromycin benzoyl
peroxide and combination therapy Br J Dermatol 1992126586-90
25 Goldstein SM Wintroub BU Adverse Cutaneous Reactions to Medication A Physicians Guide
CoMedica Inc New York 1994 p 55
26 32 MeReC Bulletin Volume 10 Number 8 1999
27 Nguyen QH Kim YA Schwartz RA Management of acne vulgaris Am Fam Phys 1994 5089
28 Hurwitz S Acne vulgaris pathogenesis and management Pediatr Rev 1994 1547
29 Thiboutot DM Weiss J Bucko A et al Adapalene-benzoyl peroxide a fixed-dose combination for
the treatment of acne vulgaris results of a multicenter randomized double-blind controlled study J
Am Acad Dermatol 2007 57791
30 Belknap BS Treatment of acne with 5 benzoyl peroxide gel or 005 retinoic acid cream Cutis
197923856-9
31 Schutte H Cunliffe WJ Forster RA The short-term effects of benzoyl peroxide lotion on the
resolution of inflamed acne lesions Br J Dermatol 198210691-4
32 Smith EB Padilla RS McCabe JM Becker LE Benzoyl peroxide lotion (20 percent) in acne Cutis
19802590-2
33 Mills OH Jr Kligman AM Pochi P Comite H Comparing 25 5 and 10 benzoyl peroxide on
inflammatory acne vulgaris Int J Dermatol 198625664-7
34 Christiansen JV Gadborg E Ludvigsen K Meier CH Norholm A Pedersen D et al Topical
tretinoin vitamin A acid (Airol) in acne vulgaris A controlled clinical trial Dermatologica
197414882-9
35 Bradford LG Montes LF Topical application of vitamin A acid in acne vulgaris South Med J
197467683-7
36 Krishnan G Comparison of two concentrations of tretinoin solution in the topical treatment of acne
vulgaris Practitioner 1976216106-9
37 Chalker DK Lesher JL Jr Smith JG Jr Klauda HC Pochi PE Jacoby WS et al Efficacy of topical
isotretinoin 005 gel in acne vulgaris results of a multicenter doubleblind investigation J Am
Acad Dermatol 198717251-4
28
38 Shalita A Weiss JS Chalker DK Ellis CN Greenspan A Katz HI et al A comparison of the
efficacy and safety of adapalene gel 01 and tretinoin gel 0025 in the treatment of acne vulgaris
a multicenter trial J Am Acad Dermatol 199634482-5
39 Clucas A Verschoore M Sorba V Poncet M Baker M Czernielewski J Adapalene 01 gel is
better tolerated than tretinoin 0025 gel in acne patients J Am Acad Dermatol 199736S116-8
40 Cunliffe WJ Caputo R Dreno B Forstrom L Heenen M Orfanos CE et al Clinical efficacy and
safety comparison of adapalene gel and tretinoin gel in the treatment of acne vulgaris Europe and
US multicenter trials J Am Acad Dermatol 199736S126-34
41 Dunlap FE Mills OH Tuley MR Baker MD Plott RT Adapalene 01 gel for the treatment of acne
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15 avtorTa jgufi
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doqsiciklini (I) da minocilkini (B) tetraciklinTan SedarebiT ufro metad xsnadia cximSi da gamoiyeneba ufro mcire dozebiTac (100 mg 2-jer an 50 mg 2-jer) am saSualebebis miReba sakvebTan erTadac SeiZleba vinaidan sakvebi ar amcirebs mis absorbcias minociklini arCevis pirveli rigis preparati araa maRali fasisa da tetraciklinTan SedarebiT metad efeqturobis Sesaxeb zusti monacemebis ararsebobis8182 agreTve toqsikurobis gamo8384 doqsiciklini da minocilkini iniSneba tetracikliniT mkurnalobis araefeqturobis SemTxvevaSi doqsiciklini iwvevs fotosensibilizacias saylapavis wylulis ganviTarebis Tavidan acilebis mizniT sakmao odenobis wyalTan erTad unda iqnes miRebuli
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eriTromicini SesaZlebelia dainiSnos 250-1500 mg dRiuri doziT (or miRebad) misi anTebis sawinaaRmdego moqmedeba tetraciklinTan
11
SedarebiT mcirea amasTan xSirad viTardeba rezistentuli Stamebi88 da gastrointestinuri gverdiTi efeqtebi eriTromicini arCevis saSualebaa im SemTxvevebSi roca SezRudulia tetraciklinis daniSvna (orsuli 8 wlamde bavSvi) mimdinareobs kvleva azitromicinis efeqturobis Sesaxeb maqsimaluri doza 60 g 10 kviris ganmavlobaSi89
trimetoprim-sulfameToqsazoli arCevis meore rigis preparatia (40080mg erTjer an orjer dReSi) efeqturi saSualebaa mZime aknes mkurnalobisaTvis Tumca misi gamoyeneba SezRudulia iseTi seriozuli gverdiTi efeqtebis gamo rogoricaa Zvlis tvinis supresia da toqsikuri epidermuli nekrozi amis msgavsad SezRudulia oraluri klindamicinis gamoyeneba fsevdomembranozuli kolitis ganviTarebis riskis gamo
aknes mqone pacientebis mkurnalobis procesSi seriozul problemas warmoadgens mikrobTa rezistentoba misi xelSemwyobia antibiotikebis farTod gamoyeneba da maTi monacvleoba SedarebiT xSiria rezistentobis ganviTareba eriTromicinis xolo iSviaTi ndash minociklinis mimarT antibiotikoTerapiam SesaZloa xeli Seuwyos Streptococcus pyogenes-is rezistentuli StamebiT xaxis kolonizacias90 rezistentobis problema SeiZleba Semcirdes Semdegi gziT
antibiotikis daniSvna misi absoluturi saWiroebis SemTxvevaSi SeZlebisdagvarad xanmokle mkunalobis kursi (Tumca aranakleb 3 Tvisa) SesaZleblobis mixedviT adgilobrivi saSualebebis
gamoyeneba
benzoilis zeJangis gamoyenebam SeiZleba Seamciros rezistentobis sixSire
oraluri saSualebebis Sewyvetis Semdeg Tu dgeba misi ganaxlebis saWiroeba umjobesia isev imave antibiotikis daniSvna manam sanam igi efeqturi darCeba
cxrili 3 rekomendaciebi sistemuri antibiotikoTerapiisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
tetraciklinebi A I 91-94
makrolidebi A I 95-98
trimetoprim-sulfameToqsazoli A I 99100
12
sistemuri retinoidebi
sistemuri retinoidebi mZime formis aknes mkurnalobisaTvis gamoiyeneba aseve SeiZleba misi gamoyeneba naklebad mZime magram mkurnalobisadmi rezistuli formis dros nawiburovani aknes an daavadebasTan dakavSirebuli Zlieri fsiqo-socialuri stresis SemTvevaSi amcirebs cximis sekrecias misi efeqti samkurnalo saSualebis miRebis Sewyvetidan 1 wlamde grZeldeba cximis Semcireba Tavis mxriv iwvevs proliferaciis Semcirebas samkurnalo saSualebas anTebis sawinaaRmdego moqmedebac gaaCnia da komedonebis warmoqmnas aferxebs101
sistemuri izotretinoinis daniSvnis Cvenebebia
mZime kvanZovan-cisturi akne
akne romelic mxolod mcired gaumjobesda sistemuri antibiotikoTerapiis 6 Tviani kursis Semdeg
nawiburovani akne
akneTi gamowveuli mZime stresi
ganmeorebiTi akne
fulminanturi akne
gram-uaryofiTi folikuliti
mkurnaloba iwyeba 05 mgkg dRiuri doziT da SeiZleba 2 mgkg dozamde gaizardos iniSneba 2 miRebad sakvebTan erTad Cveulebriv mkurnalobis xangrZlivoba 20 kviramdea arsebobs mtkicebulebebi rom efeqturi SeiZleba iyos ufro dabali dozebiT mkurnalobac102 mkurnalobis dawyebisas SesaZloa aknes gauareseba aseT SemTxvevebSi naCvenebia sistemuri kortikosteroidebis daniSvna an mkurnalobis ufro dabali dozebiT (05 mgkgdR-ze naklebi) dawyeba mkurnalobis kumulaciuri doza 120-150 mgkg-ia
pacientebis 80-ze mets mkurnalobis erTi kursis Semdeg xangrZlivi remisia aReniSneba gaumjobeseba mkurnalobis Sewyvetidan ramdenime Tve grZeldeba saWiroebisas kursis ganaxlebamde 4-5 Tve unda iyos gasuli recidivebis umetesoba (96) mkurnalobis Sewyvetidan pirveli 3 Tvis ganmavlobaSi aRmocendeba103 da misi sixSire gansakuTrebiT maRalia pacientebs Soris romelTac akne upiratesad torsze aReniSnebaT an samkurnalo saSualebis kumulaciuri doza 120 mgkg-ze naklebia
izotretinoinis kursis Semdeg remisiis maRali sixSiris miuxedavad pacientebis mxolod 39-s aReniSneba sruli gamojanmrTeleba 61-s ki kvlav esaWiroeba adgilobrivi an sistemuri antibiotikebiT mkurnalobis gagrZeleba104 izotretinoinis maRali Rirebulebis miuxedavad am saSualebiT Catarebuli mkurnaloba mainc xarjTefeqturad SeiZleba CaiTvalos vinaidan es erTaderTi saSualebaa romelic aknes ganviTarebis meqanizmze moqmedebs Tumca aRsaniSnavia isic rom izotretinoinTan dakavSirebulia sakmaod seriozuli da mZime gverdiTi efeqtebi rac zRudavs mis gamoyenebas
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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200451348
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199737746-54
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121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
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200247399-409
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vulgaris in women Br J Dermatol 1986115227-32
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19852911231-5
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treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
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lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
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200277713-716
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mtkicebulebis
done literatura
benzoilis zeJangi A I 30-33
retinoidebi A I 34374750
antibiotikebi A I 61-69
sxva adgilobrivi saSualebebi A I 70-77
adgilobrivi antibiotikebi
adgilobrivi antibiotikebis damateba P acne-s cximovani folikulidan eliminaciis mizniT xdeba anTebiTi da papuluri aknes mkurnalobis dros adgilobrivi eriTromicini gamoiyeneba dReSi erTxel an orjer adgilobrivi 1-iani klindamicini gamoiyeneba RamiT an dReSi orjer
aRsaniSnavia rom adgilobrivi antibiotikebis gamoyenebam SesaZloa xeli Seuwyos P acne-s rezistentuli Stamebis gaCenas rezistentoba mcirdeba adgilobrivi antibiotikebis sxva saSualebebTan kombinaciaSi daniSvnisas amasTan kombinirebuli mkurnaloba ufro efeqturia vidre am saSualebebis calk-calke gamoyeneba
56-59 magaliTad erTerTi kvleviT gamovlinda rom 3-iani eriTromicinis da benzoilis zeJngis 5-iani geliT kombinirebuli mkurnaloba ara marto aRemateboda efeqturobiT TiToeul agents calk-calke aramed gaumjobesebas iZleoda rezistentuli Stamebis SemTxvevaSic60 aseve klindamicinibenzoilis zeJangis geliT mkurnaloba efeqturi iyo TiToeul agentTan SedarebiT59 sxva kvleviT klindamicini da adapalenis kombinacia ufro efeqturi iyo mxolod klindamicinTan SedarebiT Tumca kanismxrivi gverdiTi efeqtebi (aqercvla simSrale wva) ramdenadme gauaresda kombinirebuli mkurnalobis dros
sxva adgilobrivi saSualebebi
salicilis mJava - istoriulad erTerTi Zveli agentia romelic aknes mkurnalobisTvis gamoiyeneboda Tumca retinoidebTan SedarebiT misi komedolizuri moqmedeba ufro sustia is warmoadgens retinoidebis alternativas rodesac pacientebs aReniSnebaT autanloba retinoidebis mimarT rac kanis iritaciiT vindeba70
azelainis mJava (II) ndash aqvs antikomedonuri da antibaqteriuli Tvisebebi amitom gamoiyeneba rogorc anTebiTi aseve araanTebiTi aknes dros rigi klinikuri kvlevebiT nanaxia misi efeqturoba71-73 amcirebs
10
kanis pigmentacias da ufro efeqturia misi gamoyeneba aknesTan asocirebuli hiperpigmentaciis dros74
aluminis qlorids antibaqteriuli moqmedeba gaaCnia Tumca kvlevebma gansxvavebuli Sedegebi aCvena ndash erT SemTxvevaSi misi efeqturoba gamovlinda75 meoreSi76 ndash ara
sistemuri mkurnaloba
sistemuri antibiotikebi
sistemuri antibiotikebi anTebiTi aknes mkurnalobisaTvis gamoiyeneba ainhibireben P acnes zrdas folikulSi sistemuri antibiotikoTerapia adgilobriv saSualebebTan SedarebiT ufro swraf klinikur gaumjobesebas iZleva Tumca SesaZlebelia antibiotikebis gverdiTi efeqtebis gamovlineba rogoricaa vaginaluri kandidozi gastrointestinuli darRvevebi da aS es saSualebebi iniSneba yoveldRiurad 4-6 Tvis manZilze mdgomareobis gaumjobesebisas TandaTan xdeba dozis Semcireba da Sewyveta maTi Sewyvetis Semdeg mgomareobis SenarCuneba SesaZlebelia adgilobrivi retinoidebis an
benzoilis zeJangis saSualebiT77-79
sistemuri mkurnalobisaTvis gamoiyeneba tetraciklini doqsiciklini minociklini eriTromicini trimetoprim-sulfameToqsazoli da klindamicini
tetraciklins (I A) upiratesoba eniWeba dabali fasis da kvlevebiT dadasturebuli maRali efeqturobis gamo mkurnaloba iwyeba doziT 500 mg orjer dReSi Tumca 250 mg 2-jer ndash SesaZloa aseve efeqturi iyos absorbcias amcirebs sakvebi rZis produqtebi antacidebi rkina iniSneba uzmoze misaRebad ukunaCvenebia orsulobis dros da 12 wlis asakamde vinaidan iwvevs kbilis minanqaris feris Secvlas
doqsiciklini (I) da minocilkini (B) tetraciklinTan SedarebiT ufro metad xsnadia cximSi da gamoiyeneba ufro mcire dozebiTac (100 mg 2-jer an 50 mg 2-jer) am saSualebebis miReba sakvebTan erTadac SeiZleba vinaidan sakvebi ar amcirebs mis absorbcias minociklini arCevis pirveli rigis preparati araa maRali fasisa da tetraciklinTan SedarebiT metad efeqturobis Sesaxeb zusti monacemebis ararsebobis8182 agreTve toqsikurobis gamo8384 doqsiciklini da minocilkini iniSneba tetracikliniT mkurnalobis araefeqturobis SemTxvevaSi doqsiciklini iwvevs fotosensibilizacias saylapavis wylulis ganviTarebis Tavidan acilebis mizniT sakmao odenobis wyalTan erTad unda iqnes miRebuli
SesaZloa gamoiwvios Tavbruxveva pseudotumor cerebri kbilebis feris cvlileba mgluras magvari sindromi85-87 sifrTxiliT unda iqnes gamoyenebuli mgluras mqone pacientebs Soris aknes mkurnalobis mizniT
eriTromicini SesaZlebelia dainiSnos 250-1500 mg dRiuri doziT (or miRebad) misi anTebis sawinaaRmdego moqmedeba tetraciklinTan
11
SedarebiT mcirea amasTan xSirad viTardeba rezistentuli Stamebi88 da gastrointestinuri gverdiTi efeqtebi eriTromicini arCevis saSualebaa im SemTxvevebSi roca SezRudulia tetraciklinis daniSvna (orsuli 8 wlamde bavSvi) mimdinareobs kvleva azitromicinis efeqturobis Sesaxeb maqsimaluri doza 60 g 10 kviris ganmavlobaSi89
trimetoprim-sulfameToqsazoli arCevis meore rigis preparatia (40080mg erTjer an orjer dReSi) efeqturi saSualebaa mZime aknes mkurnalobisaTvis Tumca misi gamoyeneba SezRudulia iseTi seriozuli gverdiTi efeqtebis gamo rogoricaa Zvlis tvinis supresia da toqsikuri epidermuli nekrozi amis msgavsad SezRudulia oraluri klindamicinis gamoyeneba fsevdomembranozuli kolitis ganviTarebis riskis gamo
aknes mqone pacientebis mkurnalobis procesSi seriozul problemas warmoadgens mikrobTa rezistentoba misi xelSemwyobia antibiotikebis farTod gamoyeneba da maTi monacvleoba SedarebiT xSiria rezistentobis ganviTareba eriTromicinis xolo iSviaTi ndash minociklinis mimarT antibiotikoTerapiam SesaZloa xeli Seuwyos Streptococcus pyogenes-is rezistentuli StamebiT xaxis kolonizacias90 rezistentobis problema SeiZleba Semcirdes Semdegi gziT
antibiotikis daniSvna misi absoluturi saWiroebis SemTxvevaSi SeZlebisdagvarad xanmokle mkunalobis kursi (Tumca aranakleb 3 Tvisa) SesaZleblobis mixedviT adgilobrivi saSualebebis
gamoyeneba
benzoilis zeJangis gamoyenebam SeiZleba Seamciros rezistentobis sixSire
oraluri saSualebebis Sewyvetis Semdeg Tu dgeba misi ganaxlebis saWiroeba umjobesia isev imave antibiotikis daniSvna manam sanam igi efeqturi darCeba
cxrili 3 rekomendaciebi sistemuri antibiotikoTerapiisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
tetraciklinebi A I 91-94
makrolidebi A I 95-98
trimetoprim-sulfameToqsazoli A I 99100
12
sistemuri retinoidebi
sistemuri retinoidebi mZime formis aknes mkurnalobisaTvis gamoiyeneba aseve SeiZleba misi gamoyeneba naklebad mZime magram mkurnalobisadmi rezistuli formis dros nawiburovani aknes an daavadebasTan dakavSirebuli Zlieri fsiqo-socialuri stresis SemTvevaSi amcirebs cximis sekrecias misi efeqti samkurnalo saSualebis miRebis Sewyvetidan 1 wlamde grZeldeba cximis Semcireba Tavis mxriv iwvevs proliferaciis Semcirebas samkurnalo saSualebas anTebis sawinaaRmdego moqmedebac gaaCnia da komedonebis warmoqmnas aferxebs101
sistemuri izotretinoinis daniSvnis Cvenebebia
mZime kvanZovan-cisturi akne
akne romelic mxolod mcired gaumjobesda sistemuri antibiotikoTerapiis 6 Tviani kursis Semdeg
nawiburovani akne
akneTi gamowveuli mZime stresi
ganmeorebiTi akne
fulminanturi akne
gram-uaryofiTi folikuliti
mkurnaloba iwyeba 05 mgkg dRiuri doziT da SeiZleba 2 mgkg dozamde gaizardos iniSneba 2 miRebad sakvebTan erTad Cveulebriv mkurnalobis xangrZlivoba 20 kviramdea arsebobs mtkicebulebebi rom efeqturi SeiZleba iyos ufro dabali dozebiT mkurnalobac102 mkurnalobis dawyebisas SesaZloa aknes gauareseba aseT SemTxvevebSi naCvenebia sistemuri kortikosteroidebis daniSvna an mkurnalobis ufro dabali dozebiT (05 mgkgdR-ze naklebi) dawyeba mkurnalobis kumulaciuri doza 120-150 mgkg-ia
pacientebis 80-ze mets mkurnalobis erTi kursis Semdeg xangrZlivi remisia aReniSneba gaumjobeseba mkurnalobis Sewyvetidan ramdenime Tve grZeldeba saWiroebisas kursis ganaxlebamde 4-5 Tve unda iyos gasuli recidivebis umetesoba (96) mkurnalobis Sewyvetidan pirveli 3 Tvis ganmavlobaSi aRmocendeba103 da misi sixSire gansakuTrebiT maRalia pacientebs Soris romelTac akne upiratesad torsze aReniSnebaT an samkurnalo saSualebis kumulaciuri doza 120 mgkg-ze naklebia
izotretinoinis kursis Semdeg remisiis maRali sixSiris miuxedavad pacientebis mxolod 39-s aReniSneba sruli gamojanmrTeleba 61-s ki kvlav esaWiroeba adgilobrivi an sistemuri antibiotikebiT mkurnalobis gagrZeleba104 izotretinoinis maRali Rirebulebis miuxedavad am saSualebiT Catarebuli mkurnaloba mainc xarjTefeqturad SeiZleba CaiTvalos vinaidan es erTaderTi saSualebaa romelic aknes ganviTarebis meqanizmze moqmedebs Tumca aRsaniSnavia isic rom izotretinoinTan dakavSirebulia sakmaod seriozuli da mZime gverdiTi efeqtebi rac zRudavs mis gamoyenebas
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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pharmacogenetic study Ann Intern Med 2002 136582
107 Strauss JS Leyden JJ Lucky AW et al Safety of a new micronized formulation of isotretinoin in
patients with severe recalcitrant nodular acne a randomized trial comparing micronized isotretinoin
with standard isotretinoin J Am Acad Dermatol 2001 45196
108 Peck GL Olsen TG Butkus D Pandya M Arnaud-Battandier J Gross EG et al Isotretinoin versus
placebo in the treatment of cystic acne A randomized double-blind study J Am Acad Dermatol
19826735-45
109 Lehucher-Ceyrac D Weber-Buisset MJ Isotretinoin and acne in practice a prospective analysis of
188 cases over 9 yearsDermatology 1993186123-8
110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
Br J Dermatol 1997137106-8
111 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al A randomized trial
of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in
patients with severe recalcitrant nodular acne J Am Acad Dermatol 200145187-95
112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
randomized trial comparing micronized isotretinoin with standard isotretinoin J Am Acad Dermatol
200145196-207
114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
Acad Dermatol 199226599-606
115 Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW et al American Academy
of Dermatology Consensus Conference on the safe and optimal use of isotretinoinsummary and
recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
118 Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ Effectiveness of
norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
10
kanis pigmentacias da ufro efeqturia misi gamoyeneba aknesTan asocirebuli hiperpigmentaciis dros74
aluminis qlorids antibaqteriuli moqmedeba gaaCnia Tumca kvlevebma gansxvavebuli Sedegebi aCvena ndash erT SemTxvevaSi misi efeqturoba gamovlinda75 meoreSi76 ndash ara
sistemuri mkurnaloba
sistemuri antibiotikebi
sistemuri antibiotikebi anTebiTi aknes mkurnalobisaTvis gamoiyeneba ainhibireben P acnes zrdas folikulSi sistemuri antibiotikoTerapia adgilobriv saSualebebTan SedarebiT ufro swraf klinikur gaumjobesebas iZleva Tumca SesaZlebelia antibiotikebis gverdiTi efeqtebis gamovlineba rogoricaa vaginaluri kandidozi gastrointestinuli darRvevebi da aS es saSualebebi iniSneba yoveldRiurad 4-6 Tvis manZilze mdgomareobis gaumjobesebisas TandaTan xdeba dozis Semcireba da Sewyveta maTi Sewyvetis Semdeg mgomareobis SenarCuneba SesaZlebelia adgilobrivi retinoidebis an
benzoilis zeJangis saSualebiT77-79
sistemuri mkurnalobisaTvis gamoiyeneba tetraciklini doqsiciklini minociklini eriTromicini trimetoprim-sulfameToqsazoli da klindamicini
tetraciklins (I A) upiratesoba eniWeba dabali fasis da kvlevebiT dadasturebuli maRali efeqturobis gamo mkurnaloba iwyeba doziT 500 mg orjer dReSi Tumca 250 mg 2-jer ndash SesaZloa aseve efeqturi iyos absorbcias amcirebs sakvebi rZis produqtebi antacidebi rkina iniSneba uzmoze misaRebad ukunaCvenebia orsulobis dros da 12 wlis asakamde vinaidan iwvevs kbilis minanqaris feris Secvlas
doqsiciklini (I) da minocilkini (B) tetraciklinTan SedarebiT ufro metad xsnadia cximSi da gamoiyeneba ufro mcire dozebiTac (100 mg 2-jer an 50 mg 2-jer) am saSualebebis miReba sakvebTan erTadac SeiZleba vinaidan sakvebi ar amcirebs mis absorbcias minociklini arCevis pirveli rigis preparati araa maRali fasisa da tetraciklinTan SedarebiT metad efeqturobis Sesaxeb zusti monacemebis ararsebobis8182 agreTve toqsikurobis gamo8384 doqsiciklini da minocilkini iniSneba tetracikliniT mkurnalobis araefeqturobis SemTxvevaSi doqsiciklini iwvevs fotosensibilizacias saylapavis wylulis ganviTarebis Tavidan acilebis mizniT sakmao odenobis wyalTan erTad unda iqnes miRebuli
SesaZloa gamoiwvios Tavbruxveva pseudotumor cerebri kbilebis feris cvlileba mgluras magvari sindromi85-87 sifrTxiliT unda iqnes gamoyenebuli mgluras mqone pacientebs Soris aknes mkurnalobis mizniT
eriTromicini SesaZlebelia dainiSnos 250-1500 mg dRiuri doziT (or miRebad) misi anTebis sawinaaRmdego moqmedeba tetraciklinTan
11
SedarebiT mcirea amasTan xSirad viTardeba rezistentuli Stamebi88 da gastrointestinuri gverdiTi efeqtebi eriTromicini arCevis saSualebaa im SemTxvevebSi roca SezRudulia tetraciklinis daniSvna (orsuli 8 wlamde bavSvi) mimdinareobs kvleva azitromicinis efeqturobis Sesaxeb maqsimaluri doza 60 g 10 kviris ganmavlobaSi89
trimetoprim-sulfameToqsazoli arCevis meore rigis preparatia (40080mg erTjer an orjer dReSi) efeqturi saSualebaa mZime aknes mkurnalobisaTvis Tumca misi gamoyeneba SezRudulia iseTi seriozuli gverdiTi efeqtebis gamo rogoricaa Zvlis tvinis supresia da toqsikuri epidermuli nekrozi amis msgavsad SezRudulia oraluri klindamicinis gamoyeneba fsevdomembranozuli kolitis ganviTarebis riskis gamo
aknes mqone pacientebis mkurnalobis procesSi seriozul problemas warmoadgens mikrobTa rezistentoba misi xelSemwyobia antibiotikebis farTod gamoyeneba da maTi monacvleoba SedarebiT xSiria rezistentobis ganviTareba eriTromicinis xolo iSviaTi ndash minociklinis mimarT antibiotikoTerapiam SesaZloa xeli Seuwyos Streptococcus pyogenes-is rezistentuli StamebiT xaxis kolonizacias90 rezistentobis problema SeiZleba Semcirdes Semdegi gziT
antibiotikis daniSvna misi absoluturi saWiroebis SemTxvevaSi SeZlebisdagvarad xanmokle mkunalobis kursi (Tumca aranakleb 3 Tvisa) SesaZleblobis mixedviT adgilobrivi saSualebebis
gamoyeneba
benzoilis zeJangis gamoyenebam SeiZleba Seamciros rezistentobis sixSire
oraluri saSualebebis Sewyvetis Semdeg Tu dgeba misi ganaxlebis saWiroeba umjobesia isev imave antibiotikis daniSvna manam sanam igi efeqturi darCeba
cxrili 3 rekomendaciebi sistemuri antibiotikoTerapiisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
tetraciklinebi A I 91-94
makrolidebi A I 95-98
trimetoprim-sulfameToqsazoli A I 99100
12
sistemuri retinoidebi
sistemuri retinoidebi mZime formis aknes mkurnalobisaTvis gamoiyeneba aseve SeiZleba misi gamoyeneba naklebad mZime magram mkurnalobisadmi rezistuli formis dros nawiburovani aknes an daavadebasTan dakavSirebuli Zlieri fsiqo-socialuri stresis SemTvevaSi amcirebs cximis sekrecias misi efeqti samkurnalo saSualebis miRebis Sewyvetidan 1 wlamde grZeldeba cximis Semcireba Tavis mxriv iwvevs proliferaciis Semcirebas samkurnalo saSualebas anTebis sawinaaRmdego moqmedebac gaaCnia da komedonebis warmoqmnas aferxebs101
sistemuri izotretinoinis daniSvnis Cvenebebia
mZime kvanZovan-cisturi akne
akne romelic mxolod mcired gaumjobesda sistemuri antibiotikoTerapiis 6 Tviani kursis Semdeg
nawiburovani akne
akneTi gamowveuli mZime stresi
ganmeorebiTi akne
fulminanturi akne
gram-uaryofiTi folikuliti
mkurnaloba iwyeba 05 mgkg dRiuri doziT da SeiZleba 2 mgkg dozamde gaizardos iniSneba 2 miRebad sakvebTan erTad Cveulebriv mkurnalobis xangrZlivoba 20 kviramdea arsebobs mtkicebulebebi rom efeqturi SeiZleba iyos ufro dabali dozebiT mkurnalobac102 mkurnalobis dawyebisas SesaZloa aknes gauareseba aseT SemTxvevebSi naCvenebia sistemuri kortikosteroidebis daniSvna an mkurnalobis ufro dabali dozebiT (05 mgkgdR-ze naklebi) dawyeba mkurnalobis kumulaciuri doza 120-150 mgkg-ia
pacientebis 80-ze mets mkurnalobis erTi kursis Semdeg xangrZlivi remisia aReniSneba gaumjobeseba mkurnalobis Sewyvetidan ramdenime Tve grZeldeba saWiroebisas kursis ganaxlebamde 4-5 Tve unda iyos gasuli recidivebis umetesoba (96) mkurnalobis Sewyvetidan pirveli 3 Tvis ganmavlobaSi aRmocendeba103 da misi sixSire gansakuTrebiT maRalia pacientebs Soris romelTac akne upiratesad torsze aReniSnebaT an samkurnalo saSualebis kumulaciuri doza 120 mgkg-ze naklebia
izotretinoinis kursis Semdeg remisiis maRali sixSiris miuxedavad pacientebis mxolod 39-s aReniSneba sruli gamojanmrTeleba 61-s ki kvlav esaWiroeba adgilobrivi an sistemuri antibiotikebiT mkurnalobis gagrZeleba104 izotretinoinis maRali Rirebulebis miuxedavad am saSualebiT Catarebuli mkurnaloba mainc xarjTefeqturad SeiZleba CaiTvalos vinaidan es erTaderTi saSualebaa romelic aknes ganviTarebis meqanizmze moqmedebs Tumca aRsaniSnavia isic rom izotretinoinTan dakavSirebulia sakmaod seriozuli da mZime gverdiTi efeqtebi rac zRudavs mis gamoyenebas
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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Acad Dermatol 1982750-3
93 Blaney DJ Cook CH Topical use of tetracycline in the treatment of acne a double-blind study
comparing topical and oral tetracycline therapy and placebo Arch Dermatol 1976112971-3
94 Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ Sequential antibiotic therapy
for acne promotes the carriage of resistant staphylococci on the skin of contacts J Antimicrob
Chemother 199638829-37
95 Skidmore R Kovach R Walker C Thomas J Bradshaw M Leyden J et al Effects of
subantimicrobial-dose doxycycline in the treatment of moderate acne Arch Dermatol 2003139459-
64
96 Gammon WR Meyer C Lantis S Shenefelt P Reizner G Cripps DJ Comparative efficacy of oral
erythromycin versus oral tetracycline in the treatment of acne vulgaris A doubleblind study J Am
Acad Dermatol 198614183-6
97 Christian GL Krueger GG Clindamycin vs placebo as adjunctive therapy in moderately severe acne
Arch Dermatol 1975111997-1000
98 Stoughton RB Cornell RC Gange RW Walter JF Doubleblind comparison of topical 1 percent
clindamycin phosphate (Cleocin T) and oral tetracycline 500 mgday in the treatment of acne
vulgaris Cutis 198026424-5 429
99 Hersle K Trimethoprim-sulphamethoxazole in acne vulgaris A double-blind study Dermatologica
1972145187-91
100 Cotterill JA Cunliffe WJ Forster RA Williamson DM Bulusu L A comparison of trimethoprim-
sulphamethoxazole with oxytetracycline in acne vulgaris Br J Dermatol 197184366-9
31
101 Ward A Brogden RN Heel RC et al Isotretinoin a review of its pharmacological properties and
therapeutic efficacy in acne and other skin disorders Drugs 1984 286
102 Amichai B Shemer A Grunwald MH Low-dose isotretinoin in the treatment of acne vulgaris J
Am Acad Dermatol 2006 54644
103 Layton AM Knaggs H Taylor J Cunliffe WJ Isotretinoin for acne vulgaris - 10 years later a safe
and successful treatment Br J Dermatol 1993 129292
104 White GM Chen W Yao J Wolde-Tsadik G Recurrence rates after the first course of isotretinoin
Arch Dermatol 1998 134376
105 McCarter TL Chen YK Marked hyperlipidemia and pancreatitis associated with isotretinoin
therapy Am J Gastroenterol 1992 871855
106 Rodondi N Darioli R Ramelet AA et al High risk for hyperlipidemia and the metabolic syndrome
after an episode of hypertriglyceridemia during 13-cis retinoic acid therapy for acne a
pharmacogenetic study Ann Intern Med 2002 136582
107 Strauss JS Leyden JJ Lucky AW et al Safety of a new micronized formulation of isotretinoin in
patients with severe recalcitrant nodular acne a randomized trial comparing micronized isotretinoin
with standard isotretinoin J Am Acad Dermatol 2001 45196
108 Peck GL Olsen TG Butkus D Pandya M Arnaud-Battandier J Gross EG et al Isotretinoin versus
placebo in the treatment of cystic acne A randomized double-blind study J Am Acad Dermatol
19826735-45
109 Lehucher-Ceyrac D Weber-Buisset MJ Isotretinoin and acne in practice a prospective analysis of
188 cases over 9 yearsDermatology 1993186123-8
110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
Br J Dermatol 1997137106-8
111 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al A randomized trial
of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in
patients with severe recalcitrant nodular acne J Am Acad Dermatol 200145187-95
112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
randomized trial comparing micronized isotretinoin with standard isotretinoin J Am Acad Dermatol
200145196-207
114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
Acad Dermatol 199226599-606
115 Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW et al American Academy
of Dermatology Consensus Conference on the safe and optimal use of isotretinoinsummary and
recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
118 Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ Effectiveness of
norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
11
SedarebiT mcirea amasTan xSirad viTardeba rezistentuli Stamebi88 da gastrointestinuri gverdiTi efeqtebi eriTromicini arCevis saSualebaa im SemTxvevebSi roca SezRudulia tetraciklinis daniSvna (orsuli 8 wlamde bavSvi) mimdinareobs kvleva azitromicinis efeqturobis Sesaxeb maqsimaluri doza 60 g 10 kviris ganmavlobaSi89
trimetoprim-sulfameToqsazoli arCevis meore rigis preparatia (40080mg erTjer an orjer dReSi) efeqturi saSualebaa mZime aknes mkurnalobisaTvis Tumca misi gamoyeneba SezRudulia iseTi seriozuli gverdiTi efeqtebis gamo rogoricaa Zvlis tvinis supresia da toqsikuri epidermuli nekrozi amis msgavsad SezRudulia oraluri klindamicinis gamoyeneba fsevdomembranozuli kolitis ganviTarebis riskis gamo
aknes mqone pacientebis mkurnalobis procesSi seriozul problemas warmoadgens mikrobTa rezistentoba misi xelSemwyobia antibiotikebis farTod gamoyeneba da maTi monacvleoba SedarebiT xSiria rezistentobis ganviTareba eriTromicinis xolo iSviaTi ndash minociklinis mimarT antibiotikoTerapiam SesaZloa xeli Seuwyos Streptococcus pyogenes-is rezistentuli StamebiT xaxis kolonizacias90 rezistentobis problema SeiZleba Semcirdes Semdegi gziT
antibiotikis daniSvna misi absoluturi saWiroebis SemTxvevaSi SeZlebisdagvarad xanmokle mkunalobis kursi (Tumca aranakleb 3 Tvisa) SesaZleblobis mixedviT adgilobrivi saSualebebis
gamoyeneba
benzoilis zeJangis gamoyenebam SeiZleba Seamciros rezistentobis sixSire
oraluri saSualebebis Sewyvetis Semdeg Tu dgeba misi ganaxlebis saWiroeba umjobesia isev imave antibiotikis daniSvna manam sanam igi efeqturi darCeba
cxrili 3 rekomendaciebi sistemuri antibiotikoTerapiisaTvis
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done literatura
tetraciklinebi A I 91-94
makrolidebi A I 95-98
trimetoprim-sulfameToqsazoli A I 99100
12
sistemuri retinoidebi
sistemuri retinoidebi mZime formis aknes mkurnalobisaTvis gamoiyeneba aseve SeiZleba misi gamoyeneba naklebad mZime magram mkurnalobisadmi rezistuli formis dros nawiburovani aknes an daavadebasTan dakavSirebuli Zlieri fsiqo-socialuri stresis SemTvevaSi amcirebs cximis sekrecias misi efeqti samkurnalo saSualebis miRebis Sewyvetidan 1 wlamde grZeldeba cximis Semcireba Tavis mxriv iwvevs proliferaciis Semcirebas samkurnalo saSualebas anTebis sawinaaRmdego moqmedebac gaaCnia da komedonebis warmoqmnas aferxebs101
sistemuri izotretinoinis daniSvnis Cvenebebia
mZime kvanZovan-cisturi akne
akne romelic mxolod mcired gaumjobesda sistemuri antibiotikoTerapiis 6 Tviani kursis Semdeg
nawiburovani akne
akneTi gamowveuli mZime stresi
ganmeorebiTi akne
fulminanturi akne
gram-uaryofiTi folikuliti
mkurnaloba iwyeba 05 mgkg dRiuri doziT da SeiZleba 2 mgkg dozamde gaizardos iniSneba 2 miRebad sakvebTan erTad Cveulebriv mkurnalobis xangrZlivoba 20 kviramdea arsebobs mtkicebulebebi rom efeqturi SeiZleba iyos ufro dabali dozebiT mkurnalobac102 mkurnalobis dawyebisas SesaZloa aknes gauareseba aseT SemTxvevebSi naCvenebia sistemuri kortikosteroidebis daniSvna an mkurnalobis ufro dabali dozebiT (05 mgkgdR-ze naklebi) dawyeba mkurnalobis kumulaciuri doza 120-150 mgkg-ia
pacientebis 80-ze mets mkurnalobis erTi kursis Semdeg xangrZlivi remisia aReniSneba gaumjobeseba mkurnalobis Sewyvetidan ramdenime Tve grZeldeba saWiroebisas kursis ganaxlebamde 4-5 Tve unda iyos gasuli recidivebis umetesoba (96) mkurnalobis Sewyvetidan pirveli 3 Tvis ganmavlobaSi aRmocendeba103 da misi sixSire gansakuTrebiT maRalia pacientebs Soris romelTac akne upiratesad torsze aReniSnebaT an samkurnalo saSualebis kumulaciuri doza 120 mgkg-ze naklebia
izotretinoinis kursis Semdeg remisiis maRali sixSiris miuxedavad pacientebis mxolod 39-s aReniSneba sruli gamojanmrTeleba 61-s ki kvlav esaWiroeba adgilobrivi an sistemuri antibiotikebiT mkurnalobis gagrZeleba104 izotretinoinis maRali Rirebulebis miuxedavad am saSualebiT Catarebuli mkurnaloba mainc xarjTefeqturad SeiZleba CaiTvalos vinaidan es erTaderTi saSualebaa romelic aknes ganviTarebis meqanizmze moqmedebs Tumca aRsaniSnavia isic rom izotretinoinTan dakavSirebulia sakmaod seriozuli da mZime gverdiTi efeqtebi rac zRudavs mis gamoyenebas
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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93 Blaney DJ Cook CH Topical use of tetracycline in the treatment of acne a double-blind study
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94 Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ Sequential antibiotic therapy
for acne promotes the carriage of resistant staphylococci on the skin of contacts J Antimicrob
Chemother 199638829-37
95 Skidmore R Kovach R Walker C Thomas J Bradshaw M Leyden J et al Effects of
subantimicrobial-dose doxycycline in the treatment of moderate acne Arch Dermatol 2003139459-
64
96 Gammon WR Meyer C Lantis S Shenefelt P Reizner G Cripps DJ Comparative efficacy of oral
erythromycin versus oral tetracycline in the treatment of acne vulgaris A doubleblind study J Am
Acad Dermatol 198614183-6
97 Christian GL Krueger GG Clindamycin vs placebo as adjunctive therapy in moderately severe acne
Arch Dermatol 1975111997-1000
98 Stoughton RB Cornell RC Gange RW Walter JF Doubleblind comparison of topical 1 percent
clindamycin phosphate (Cleocin T) and oral tetracycline 500 mgday in the treatment of acne
vulgaris Cutis 198026424-5 429
99 Hersle K Trimethoprim-sulphamethoxazole in acne vulgaris A double-blind study Dermatologica
1972145187-91
100 Cotterill JA Cunliffe WJ Forster RA Williamson DM Bulusu L A comparison of trimethoprim-
sulphamethoxazole with oxytetracycline in acne vulgaris Br J Dermatol 197184366-9
31
101 Ward A Brogden RN Heel RC et al Isotretinoin a review of its pharmacological properties and
therapeutic efficacy in acne and other skin disorders Drugs 1984 286
102 Amichai B Shemer A Grunwald MH Low-dose isotretinoin in the treatment of acne vulgaris J
Am Acad Dermatol 2006 54644
103 Layton AM Knaggs H Taylor J Cunliffe WJ Isotretinoin for acne vulgaris - 10 years later a safe
and successful treatment Br J Dermatol 1993 129292
104 White GM Chen W Yao J Wolde-Tsadik G Recurrence rates after the first course of isotretinoin
Arch Dermatol 1998 134376
105 McCarter TL Chen YK Marked hyperlipidemia and pancreatitis associated with isotretinoin
therapy Am J Gastroenterol 1992 871855
106 Rodondi N Darioli R Ramelet AA et al High risk for hyperlipidemia and the metabolic syndrome
after an episode of hypertriglyceridemia during 13-cis retinoic acid therapy for acne a
pharmacogenetic study Ann Intern Med 2002 136582
107 Strauss JS Leyden JJ Lucky AW et al Safety of a new micronized formulation of isotretinoin in
patients with severe recalcitrant nodular acne a randomized trial comparing micronized isotretinoin
with standard isotretinoin J Am Acad Dermatol 2001 45196
108 Peck GL Olsen TG Butkus D Pandya M Arnaud-Battandier J Gross EG et al Isotretinoin versus
placebo in the treatment of cystic acne A randomized double-blind study J Am Acad Dermatol
19826735-45
109 Lehucher-Ceyrac D Weber-Buisset MJ Isotretinoin and acne in practice a prospective analysis of
188 cases over 9 yearsDermatology 1993186123-8
110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
Br J Dermatol 1997137106-8
111 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al A randomized trial
of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in
patients with severe recalcitrant nodular acne J Am Acad Dermatol 200145187-95
112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
randomized trial comparing micronized isotretinoin with standard isotretinoin J Am Acad Dermatol
200145196-207
114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
Acad Dermatol 199226599-606
115 Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW et al American Academy
of Dermatology Consensus Conference on the safe and optimal use of isotretinoinsummary and
recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
118 Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ Effectiveness of
norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
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128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
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129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
12
sistemuri retinoidebi
sistemuri retinoidebi mZime formis aknes mkurnalobisaTvis gamoiyeneba aseve SeiZleba misi gamoyeneba naklebad mZime magram mkurnalobisadmi rezistuli formis dros nawiburovani aknes an daavadebasTan dakavSirebuli Zlieri fsiqo-socialuri stresis SemTvevaSi amcirebs cximis sekrecias misi efeqti samkurnalo saSualebis miRebis Sewyvetidan 1 wlamde grZeldeba cximis Semcireba Tavis mxriv iwvevs proliferaciis Semcirebas samkurnalo saSualebas anTebis sawinaaRmdego moqmedebac gaaCnia da komedonebis warmoqmnas aferxebs101
sistemuri izotretinoinis daniSvnis Cvenebebia
mZime kvanZovan-cisturi akne
akne romelic mxolod mcired gaumjobesda sistemuri antibiotikoTerapiis 6 Tviani kursis Semdeg
nawiburovani akne
akneTi gamowveuli mZime stresi
ganmeorebiTi akne
fulminanturi akne
gram-uaryofiTi folikuliti
mkurnaloba iwyeba 05 mgkg dRiuri doziT da SeiZleba 2 mgkg dozamde gaizardos iniSneba 2 miRebad sakvebTan erTad Cveulebriv mkurnalobis xangrZlivoba 20 kviramdea arsebobs mtkicebulebebi rom efeqturi SeiZleba iyos ufro dabali dozebiT mkurnalobac102 mkurnalobis dawyebisas SesaZloa aknes gauareseba aseT SemTxvevebSi naCvenebia sistemuri kortikosteroidebis daniSvna an mkurnalobis ufro dabali dozebiT (05 mgkgdR-ze naklebi) dawyeba mkurnalobis kumulaciuri doza 120-150 mgkg-ia
pacientebis 80-ze mets mkurnalobis erTi kursis Semdeg xangrZlivi remisia aReniSneba gaumjobeseba mkurnalobis Sewyvetidan ramdenime Tve grZeldeba saWiroebisas kursis ganaxlebamde 4-5 Tve unda iyos gasuli recidivebis umetesoba (96) mkurnalobis Sewyvetidan pirveli 3 Tvis ganmavlobaSi aRmocendeba103 da misi sixSire gansakuTrebiT maRalia pacientebs Soris romelTac akne upiratesad torsze aReniSnebaT an samkurnalo saSualebis kumulaciuri doza 120 mgkg-ze naklebia
izotretinoinis kursis Semdeg remisiis maRali sixSiris miuxedavad pacientebis mxolod 39-s aReniSneba sruli gamojanmrTeleba 61-s ki kvlav esaWiroeba adgilobrivi an sistemuri antibiotikebiT mkurnalobis gagrZeleba104 izotretinoinis maRali Rirebulebis miuxedavad am saSualebiT Catarebuli mkurnaloba mainc xarjTefeqturad SeiZleba CaiTvalos vinaidan es erTaderTi saSualebaa romelic aknes ganviTarebis meqanizmze moqmedebs Tumca aRsaniSnavia isic rom izotretinoinTan dakavSirebulia sakmaod seriozuli da mZime gverdiTi efeqtebi rac zRudavs mis gamoyenebas
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
randomized trial comparing micronized isotretinoin with standard isotretinoin J Am Acad Dermatol
200145196-207
114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
Acad Dermatol 199226599-606
115 Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW et al American Academy
of Dermatology Consensus Conference on the safe and optimal use of isotretinoinsummary and
recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
118 Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ Effectiveness of
norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
13
igi sakmaod Zlieri teratogenia sxva gverdiT efeqtebs miekuTvneba kankunTovani ConCxovani Tvalis cns-is mxrivi efeqtebi aseve Tavis tkivili aRniSnuli gverdiTi efeqtebi droebiTia da mkurnalobis SewyvetasTan erTad gaivlis erTeul SemTxvevebSi aRwerilia guneba-ganwyobis cvlileba suiciduri ideebi da suicidi aqedan gamomdinare aRniSnuli saSualeba daniSneuli unda iqnes saTanado kompetenciis mqone eqimis mier
cxrili 4 izotretinoiniT mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis xarisxi
mtkicebulebis done
literatura
izotretinoini A I 108-116
izotretinoinis gverdiTi efeqtebis umetesobis marTva (mag damarbilebeli saSualebebi mSrali kanisTvis aass-ebi mialgiis an arTalgiis sakvebi racionis cvlileba lipidur speqtrSi cvlilebebis dros) mkurnalobis Sewyvetis gareSec aris SesaZlebeli
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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27
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200451348
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patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
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in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
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trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
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contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
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vulgaris in women Br J Dermatol 1986115227-32
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19852911231-5
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treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
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lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
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200277713-716
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Pediatr 2000136688-690
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15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
14
cxrili 5 adgilobrivi da sistemuri saSualebebi
samkurnalo
saSualeba dozireba
gamoSvebis
forma gverdiTi movlenebi
adgilobrivi retinoidebi
tretinoini
(Tretinoin)
Cveulebriv dReSi orjer (SeiZleba yoveldRiuri an autanlobis SemTxvevaSi dRegamoSvebiT gamoyeneba)
0025 kremi
001 geli
005 kremi
0025 geli
01 kremi
005 xsnari
adgilobrivi iritacia fotosensitiuroba
adapaleni
(Adapalene)
yoveldRiurad an dReSi orjer
01 geli adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba
tazaroteni
(Tazarotene) yoveldRiurad
005 geli
01 geli
adgilobrivi iritacia (tretinoinTan SedarebiT naklebad) fotosensitiuroba ukunaCvenebia orsulobis da ZuZuTi kvebis dros
benzoilis
zeJangi (Benzoyl
peroxide)
yoveldRiurad an dReSi orjer
25 5 da 10 geli losioni
5 xsnari + 3 eriTromicini
6 da 10 geli + glikolis mJava
adgilobrivi iritacia SeiZleba gamoiwvios kanisa da tansacmlis gauferuleba
adgilobrivi antibiotikebi
metronidazoli
(Metronidazole) dReSi orjer
1 kremi
075 geli
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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2 CN Harper JC Cantrell WC et al The prevalence of acne in adults 20 years and older
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Dermatol 1978 71324
4 Lucky AW Biro FM Huster GA et al Acne vulgaris in premenarchal girls an early sign of
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5 Lucky AW Biro FM Simbartl LA et al Predictors of severity of acne vulgaris in young
adolescent girls results of a five-year longitudinal study J Pediatr 1997 13030
6 Goulden V Clark SM Cunliffe WJ Post-adolescent acne a review of clinical features Br J
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7 Stoll S Shalita AR Webster GF et al The effect of the menstrual cycle on acne J Am Acad
Dermatol 2001 45957
8 Nguyen QH Kim YA Schwartz RA Management of acne vulgaris Am Fam Phys 1994 5089
9 Vowels BR Yang S Leyden JJ Induction of proinflammatory cytokines by a soluble factor of
Propionibacterium acnes implications for chronic inflammatory acne Infect Immun 1995 633158
10 Cordain L Lindeberg S Hurtado M et al Acne vulgaris a disease of Western civilization Arch Dermatol 2002 1381584
11 Thiboutot DM Strauss JS Diet and acne revisited Arch Dermatol 2002 1381591
27
12 Bershad S The unwelcome return of the acne diet Arch Dermatol 2003 139940
13 Adebamowo CA Spiegelman D Danby FW et al High school dietary dairy intake and teenage
acne J Am Acad Dermatol 2005 52207
14 2008 Family Practice Notebook LLC
15 Rasmussen JE Smith SB Patient concepts and misconceptions about acne Arch Dermatol 1983
119570
16 Green J Sinclair RD Perceptions of acne vulgaris in final year medical student written examination
answers Australas J Dermatol 2001 4298
17 Yosipovitch G Tang M Dawn AG et al Study of psychological stress sebum production and
acne vulgaris in adolescents Acta Derm Venereol 2007 87135
18 Chiu A Chon SY Kimball AB The response of skin disease to stress changes in the severity of
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19 Timpatanapong P Rojanasakul A Hormonal profiles and prevalence of polycystic ovary syndrome
in women with acne J Dermatol 1997 24223
20 Goldstein SM Wintroub BU Adverse Cutaneous Reactions to Medication A Physicians Guide
CoMedica Inc New York 1994 p 55
21 Cove JH Cunliffe WJ Holland KT Acne vulgaris is the bacterial population size significant Br J
Dermatol 1980 102277-80
22 Bojar RA Hittel N Cunliffe WJ Holland KT Direct analysis of resistance in the cutaneous
microflora during treatment of acne vulgaris with topical 1 nadifloxacin and 2 erythromycin
Drugs 199549(suppl 2)164-7
23 Eady EA Cove JH Holland KT Cunliffe WJ Erythromycin resistant propionibacteria in antibiotic
treated acne patients association with therapeutic failure Br J Dermatol 1989121 51-7
24 Harkaway KS McGinley KJ Foglia AN Lee WL Fried F Shalita AR et al Antibiotic resistance
patterns in coagulase-negative staphylococci after treatment with topical erythromycin benzoyl
peroxide and combination therapy Br J Dermatol 1992126586-90
25 Goldstein SM Wintroub BU Adverse Cutaneous Reactions to Medication A Physicians Guide
CoMedica Inc New York 1994 p 55
26 32 MeReC Bulletin Volume 10 Number 8 1999
27 Nguyen QH Kim YA Schwartz RA Management of acne vulgaris Am Fam Phys 1994 5089
28 Hurwitz S Acne vulgaris pathogenesis and management Pediatr Rev 1994 1547
29 Thiboutot DM Weiss J Bucko A et al Adapalene-benzoyl peroxide a fixed-dose combination for
the treatment of acne vulgaris results of a multicenter randomized double-blind controlled study J
Am Acad Dermatol 2007 57791
30 Belknap BS Treatment of acne with 5 benzoyl peroxide gel or 005 retinoic acid cream Cutis
197923856-9
31 Schutte H Cunliffe WJ Forster RA The short-term effects of benzoyl peroxide lotion on the
resolution of inflamed acne lesions Br J Dermatol 198210691-4
32 Smith EB Padilla RS McCabe JM Becker LE Benzoyl peroxide lotion (20 percent) in acne Cutis
19802590-2
33 Mills OH Jr Kligman AM Pochi P Comite H Comparing 25 5 and 10 benzoyl peroxide on
inflammatory acne vulgaris Int J Dermatol 198625664-7
34 Christiansen JV Gadborg E Ludvigsen K Meier CH Norholm A Pedersen D et al Topical
tretinoin vitamin A acid (Airol) in acne vulgaris A controlled clinical trial Dermatologica
197414882-9
35 Bradford LG Montes LF Topical application of vitamin A acid in acne vulgaris South Med J
197467683-7
36 Krishnan G Comparison of two concentrations of tretinoin solution in the topical treatment of acne
vulgaris Practitioner 1976216106-9
37 Chalker DK Lesher JL Jr Smith JG Jr Klauda HC Pochi PE Jacoby WS et al Efficacy of topical
isotretinoin 005 gel in acne vulgaris results of a multicenter doubleblind investigation J Am
Acad Dermatol 198717251-4
28
38 Shalita A Weiss JS Chalker DK Ellis CN Greenspan A Katz HI et al A comparison of the
efficacy and safety of adapalene gel 01 and tretinoin gel 0025 in the treatment of acne vulgaris
a multicenter trial J Am Acad Dermatol 199634482-5
39 Clucas A Verschoore M Sorba V Poncet M Baker M Czernielewski J Adapalene 01 gel is
better tolerated than tretinoin 0025 gel in acne patients J Am Acad Dermatol 199736S116-8
40 Cunliffe WJ Caputo R Dreno B Forstrom L Heenen M Orfanos CE et al Clinical efficacy and
safety comparison of adapalene gel and tretinoin gel in the treatment of acne vulgaris Europe and
US multicenter trials J Am Acad Dermatol 199736S126-34
41 Dunlap FE Mills OH Tuley MR Baker MD Plott RT Adapalene 01 gel for the treatment of acne
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42 Galvin SA Gilbert R Baker M Guibal F Tuley MR Comparative tolerance of adapalene 01 gel
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43 Grosshans E Marks R Mascaro JM Torras H Meynadier J Alirezai M et al Evaluation of clinical
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44 Mills OH Jr Berger RS Irritation potential of a new topical tretinoin formulation and a
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45 Ioannides D Rigopoulos D Katsambas A Topical adapalene gel 01 vs isotretinoin gel 005 in
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46 Kakita L Tazarotene versus tretinoin or adapalene in the treatment of acne vulgaris J Am Acad
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47 Shalita AR Chalker DK Griffith RF Herbert AA Hickman JG Maloney JM et al Tazarotene gel is
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48 Ellis CN Millikan LE Smith EB Chalker DM Swinyer LJ Katz IH et al Comparison of adapalene
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1998139(suppl 52)41-7
49 Webster GF Berson D Stein LF Fivenson DP Tanghetti EA Ling M Efficacy and tolerability of
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50 Lucky AW Cullen SI Jarratt MT Quigley JW Comparative efficacy and safety of two 0025
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53 Webster GF Berson D Stein LF et al Efficacy and tolerability of once-daily tazarotene 01 gel
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55 Shalita A Weiss JS Chalker DK et al A comparison of the efficacy and safety of adapalene gel
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79 Leyden J Thiboutot DM Shalita AR et al Comparison of tazarotene and minocycline
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86 Elkayam O Levartovsky D Brautbar C et al Clinical and immunological study of 7 patients with
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87 Sturkenboom MC Meier CR Jick H Stricker BH Minocycline and lupuslike syndrome in acne
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89 Basta-Juzbasic A Lipozencic J Oremovic L Kotrulja L Gruber F Brajac I et al A dose-finding
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90 Levy RM Huang EY Roling D et al Effect of antibiotics on the oropharyngeal flora in patients
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91 Smith JG Jr Chalker DK Wehr RF The effectiveness of topical and oral tetracycline for acne South
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93 Blaney DJ Cook CH Topical use of tetracycline in the treatment of acne a double-blind study
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94 Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ Sequential antibiotic therapy
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95 Skidmore R Kovach R Walker C Thomas J Bradshaw M Leyden J et al Effects of
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96 Gammon WR Meyer C Lantis S Shenefelt P Reizner G Cripps DJ Comparative efficacy of oral
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97 Christian GL Krueger GG Clindamycin vs placebo as adjunctive therapy in moderately severe acne
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98 Stoughton RB Cornell RC Gange RW Walter JF Doubleblind comparison of topical 1 percent
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99 Hersle K Trimethoprim-sulphamethoxazole in acne vulgaris A double-blind study Dermatologica
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100 Cotterill JA Cunliffe WJ Forster RA Williamson DM Bulusu L A comparison of trimethoprim-
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101 Ward A Brogden RN Heel RC et al Isotretinoin a review of its pharmacological properties and
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103 Layton AM Knaggs H Taylor J Cunliffe WJ Isotretinoin for acne vulgaris - 10 years later a safe
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104 White GM Chen W Yao J Wolde-Tsadik G Recurrence rates after the first course of isotretinoin
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105 McCarter TL Chen YK Marked hyperlipidemia and pancreatitis associated with isotretinoin
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110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
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lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
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15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
15
klindamicini
(Clindamycin) dReSi orjer
10 mgml geli
10mgml losioni
10 mgmL adgilobrivad saxmari xsnari
Teoriulad - fsevdomembranozuli koliti
eriTromicini
(Erythromycin) dReSi orjer
15 xsnari
2 xsnari
2 geli
2 malamo
2 kompresi
azelainis mJava
(Azelaic acid) dReSi orjer 20 kremi
oraluri antibiotikebi
tetraciklini
(Tetracycline)
500 mg orjer dReSi (an 250 mg orjer dReSi)
ukunaCvenebia orsulobis da 12 wlis asakamde radgan SesaZlebelia gamoiwvios kbilebis feris Secvla
doqsiciklini
(Doxycycline) 100 mg orjer dReSi fototoqsikuroba saylapavis dawyluleba
minociklini
(Minocycline)
50 dan 100 mg-mde orjer dReSi
vertigo pseudotumor kbilebis feris cvlileba
eriTromicini
(Erythromycin)
250 dan 750 mg-mde orjer dReSi
gastrointestinuri Civilebi
oraluri retinoidi
izotretinoini
(Isotretinoin)
05 mgkg izrdeba 1 mgkg-mde saerTo doza 120 dan 150 mgkg-mde aranakleb 20 kviris manZilze
teratogenoba (absoloturad ukunaCvenebia orsulobisa da ZuZuTi kvebis dros) kan-kunTovani gverdiTi efeqtebi hipertrigliceridemia depresia Zvlis tvinis supresia sxva (ix teqstSi)
aRniSnuli saSualebebi saqarTveloSi registrirebuli ar aris
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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93 Blaney DJ Cook CH Topical use of tetracycline in the treatment of acne a double-blind study
comparing topical and oral tetracycline therapy and placebo Arch Dermatol 1976112971-3
94 Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ Sequential antibiotic therapy
for acne promotes the carriage of resistant staphylococci on the skin of contacts J Antimicrob
Chemother 199638829-37
95 Skidmore R Kovach R Walker C Thomas J Bradshaw M Leyden J et al Effects of
subantimicrobial-dose doxycycline in the treatment of moderate acne Arch Dermatol 2003139459-
64
96 Gammon WR Meyer C Lantis S Shenefelt P Reizner G Cripps DJ Comparative efficacy of oral
erythromycin versus oral tetracycline in the treatment of acne vulgaris A doubleblind study J Am
Acad Dermatol 198614183-6
97 Christian GL Krueger GG Clindamycin vs placebo as adjunctive therapy in moderately severe acne
Arch Dermatol 1975111997-1000
98 Stoughton RB Cornell RC Gange RW Walter JF Doubleblind comparison of topical 1 percent
clindamycin phosphate (Cleocin T) and oral tetracycline 500 mgday in the treatment of acne
vulgaris Cutis 198026424-5 429
99 Hersle K Trimethoprim-sulphamethoxazole in acne vulgaris A double-blind study Dermatologica
1972145187-91
100 Cotterill JA Cunliffe WJ Forster RA Williamson DM Bulusu L A comparison of trimethoprim-
sulphamethoxazole with oxytetracycline in acne vulgaris Br J Dermatol 197184366-9
31
101 Ward A Brogden RN Heel RC et al Isotretinoin a review of its pharmacological properties and
therapeutic efficacy in acne and other skin disorders Drugs 1984 286
102 Amichai B Shemer A Grunwald MH Low-dose isotretinoin in the treatment of acne vulgaris J
Am Acad Dermatol 2006 54644
103 Layton AM Knaggs H Taylor J Cunliffe WJ Isotretinoin for acne vulgaris - 10 years later a safe
and successful treatment Br J Dermatol 1993 129292
104 White GM Chen W Yao J Wolde-Tsadik G Recurrence rates after the first course of isotretinoin
Arch Dermatol 1998 134376
105 McCarter TL Chen YK Marked hyperlipidemia and pancreatitis associated with isotretinoin
therapy Am J Gastroenterol 1992 871855
106 Rodondi N Darioli R Ramelet AA et al High risk for hyperlipidemia and the metabolic syndrome
after an episode of hypertriglyceridemia during 13-cis retinoic acid therapy for acne a
pharmacogenetic study Ann Intern Med 2002 136582
107 Strauss JS Leyden JJ Lucky AW et al Safety of a new micronized formulation of isotretinoin in
patients with severe recalcitrant nodular acne a randomized trial comparing micronized isotretinoin
with standard isotretinoin J Am Acad Dermatol 2001 45196
108 Peck GL Olsen TG Butkus D Pandya M Arnaud-Battandier J Gross EG et al Isotretinoin versus
placebo in the treatment of cystic acne A randomized double-blind study J Am Acad Dermatol
19826735-45
109 Lehucher-Ceyrac D Weber-Buisset MJ Isotretinoin and acne in practice a prospective analysis of
188 cases over 9 yearsDermatology 1993186123-8
110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
Br J Dermatol 1997137106-8
111 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al A randomized trial
of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in
patients with severe recalcitrant nodular acne J Am Acad Dermatol 200145187-95
112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
randomized trial comparing micronized isotretinoin with standard isotretinoin J Am Acad Dermatol
200145196-207
114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
Acad Dermatol 199226599-606
115 Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW et al American Academy
of Dermatology Consensus Conference on the safe and optimal use of isotretinoinsummary and
recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
118 Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ Effectiveness of
norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
16
sxva mkurnaloba
kombinirebuli oraluri kontraceptivebiT mkurnaloba (estrogeni progestini) alternatiuli meTodia qalebisTvis romelTvisac klasikuri mkurnaloba arasakmarisia oraluri kontraceptivebi gamoiyeneba maTi antiandrogenuli efeqtis gamo estrogenuli komponenti amcirebs androgenebis produqcias Tavisufal testosteronsMmarto progestinis Semcveli kontraceptivebi araefeqturia SesaZloa maTi gamoyenebis fonze mdgomareobis gauaresebaAaseve ar arsebobs kvleva romelic sxva saxis kontraceptivebis efeqturobas adasturebs pasuxi mkurnalobaze 3-6 Tvis Semdgom miiReba araerTi kvleva adasturebs insulinorezistentobisa da aknes korelacias Sesabamisad metformini am SemTxvevaSi arCevis pirveli rigis preparatia Sedegi Zlierdeba metforminisa da oraluri kontraceptivebis kombinirebuli gamoyenebisas117
spironolaqtoni ndash misi antiandrogenuli efeqtis gamo gamoiyeneba qalebSi rodesac mkurnalobis sxva saxe araefeqturia axdens testosteronis mier cximovani jirkvlebisa da Tmis folikulebis stimulaciis SeCerebas Ooptimaluri doza 50-200mg pasuxi mkurnalobaze mosalodnelia 2-3 TveSi Aar gamoiyereba orsulebSi fertiluri asakis qalebSi misi gamoyenebisas rekomendebulia orsulobisagan Tavis Sekaveba gverdiTi efeqtebi iSviaTia SesaZloa araregularuli menstruacia Tavis tkivili dispepsia spironolaqtoni kaliumis Semnaxveli Sarmdenia Sesabamisad SesaZloa kaliumis donis mateba rekomendebulia eleqtrolitebis donis monitoringi dasaSvebia xangrZlivi gamoyeneba (1-2 weli) mokle SesvenebebiT122
flutamidi arasteroiduli antiandrogenia ZiriTadad prostatis hipertrofiisa da hirsutizmis samkurnalod gamoiyeneba efeqturia aknes mkurnalobaSi mis gamoyenebas zRudavs RviZlis ukmarisobis ganviTarebis maRali riski
cxrili 6 hormonul mkurnalobasTan dakavSirebuli rekomendaciebi
rekomendacia rekomendaciis
xarisxi
mtkicebulebis
done
literatura
kontraceptivebi A I 118-121
spironolaqtoni B II 123
antianrogenebi B II 124 125
oraluri kortikosteroidebi B II 126
17
oraluri kortikosteroidebi gamoiyeneba ori mizeziT antianTebiTi efeqti da adrenaluri aqtivobis supresia maRali doziT xanmokle kursi rekomendebulia Zlier gamoxatuli anTebiTi dazianebebis dros
kvlevebi adasturebs rom aknes mqone pacientebs TuTiis normaze naklebi Semcveloba aqvT Tumca es faqti ar aris TuTiis Semcveli medikamentebis an biodanamatebis daniSvnis Cveneba ramodenime ormagi brma-randomizebuli kvleviT dadasturebulia rom TuTia ufro efeqturia vidre placebo magram naklebefeqturia antibiotikebTan SedarebiT amave dros sainteresoa is faqtic rom yvela kvlevaSi romelic sustad magram mainc adasturebs TuTiis dadebiT efeqts igi gamoyenebuli iqna doziT romelic DdRiur moTxovnas aRemateba da SesaZloa toqsikuri iyos127128129
aknes mkurnaloba simZimis mixedviT (algoriTmebi)
sqema 1 msubuqi aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
saSualo simZimis aknes
mkurnaloba ix Sesabamisi algoriTmi
sqema 2
arCevis saSualebaa adgilobrivi retinoidebi
aseve SesaZlebelia benzoilis zeJangi azelainis
mJava an salicilis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
upiratesad komedonebi iSviaTi anTebiTi papulebi an pustulebi
nawiburebi ar vlindeba
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
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13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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27
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30
78 Thiboutot DM Shalita AR Yamauchi PS et al Adapalene gel 01 as maintenance therapy for
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79 Leyden J Thiboutot DM Shalita AR et al Comparison of tazarotene and minocycline
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80 Zane LT Acne maintenance therapy expanding the role of topical retinoids Arch Dermatol 2006
142638
81 Simonart T Dramaix M De Maertelaer V Br J Dermatol 2008 Feb158(2)208-16
82 Epub 2007 Nov 6 Garner SE Eady EA Popescu C et al Minocycline for acne vulgaris efficacy
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83 McManus P Iheanacho I Dont use minocycline as first line oral antibiotic in acne BMJ 2007
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84 Purdy S de Berker D Acne BMJ 2006 333949
85 Gough A Chapman S Wagstaff K et al Minocycline induced autoimmune hepatitis and systemic
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86 Elkayam O Levartovsky D Brautbar C et al Clinical and immunological study of 7 patients with
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87 Sturkenboom MC Meier CR Jick H Stricker BH Minocycline and lupuslike syndrome in acne
patients Arch Intern Med 1999 159493
88 Eady EA Cove JH Holland KT Cunliffe WJ Erythromycin resistant propionibacteria in
antibiotic treated acne patients Association with therapeutic failure Br J Dermatol 1989 12151
89 Basta-Juzbasic A Lipozencic J Oremovic L Kotrulja L Gruber F Brajac I et al A dose-finding
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7
90 Levy RM Huang EY Roling D et al Effect of antibiotics on the oropharyngeal flora in patients
with acne Arch Dermatol 2003 139467
91 Smith JG Jr Chalker DK Wehr RF The effectiveness of topical and oral tetracycline for acne South
Med J 197669695-7
92 Gratton D Raymond GP Guertin-Larochelle S Maddin SW Leneck CM Warner J et al Topical
clindamycin versus systemic tetracycline in the treatment of acne Results of a multiclinic trial J Am
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93 Blaney DJ Cook CH Topical use of tetracycline in the treatment of acne a double-blind study
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94 Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ Sequential antibiotic therapy
for acne promotes the carriage of resistant staphylococci on the skin of contacts J Antimicrob
Chemother 199638829-37
95 Skidmore R Kovach R Walker C Thomas J Bradshaw M Leyden J et al Effects of
subantimicrobial-dose doxycycline in the treatment of moderate acne Arch Dermatol 2003139459-
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96 Gammon WR Meyer C Lantis S Shenefelt P Reizner G Cripps DJ Comparative efficacy of oral
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97 Christian GL Krueger GG Clindamycin vs placebo as adjunctive therapy in moderately severe acne
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98 Stoughton RB Cornell RC Gange RW Walter JF Doubleblind comparison of topical 1 percent
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99 Hersle K Trimethoprim-sulphamethoxazole in acne vulgaris A double-blind study Dermatologica
1972145187-91
100 Cotterill JA Cunliffe WJ Forster RA Williamson DM Bulusu L A comparison of trimethoprim-
sulphamethoxazole with oxytetracycline in acne vulgaris Br J Dermatol 197184366-9
31
101 Ward A Brogden RN Heel RC et al Isotretinoin a review of its pharmacological properties and
therapeutic efficacy in acne and other skin disorders Drugs 1984 286
102 Amichai B Shemer A Grunwald MH Low-dose isotretinoin in the treatment of acne vulgaris J
Am Acad Dermatol 2006 54644
103 Layton AM Knaggs H Taylor J Cunliffe WJ Isotretinoin for acne vulgaris - 10 years later a safe
and successful treatment Br J Dermatol 1993 129292
104 White GM Chen W Yao J Wolde-Tsadik G Recurrence rates after the first course of isotretinoin
Arch Dermatol 1998 134376
105 McCarter TL Chen YK Marked hyperlipidemia and pancreatitis associated with isotretinoin
therapy Am J Gastroenterol 1992 871855
106 Rodondi N Darioli R Ramelet AA et al High risk for hyperlipidemia and the metabolic syndrome
after an episode of hypertriglyceridemia during 13-cis retinoic acid therapy for acne a
pharmacogenetic study Ann Intern Med 2002 136582
107 Strauss JS Leyden JJ Lucky AW et al Safety of a new micronized formulation of isotretinoin in
patients with severe recalcitrant nodular acne a randomized trial comparing micronized isotretinoin
with standard isotretinoin J Am Acad Dermatol 2001 45196
108 Peck GL Olsen TG Butkus D Pandya M Arnaud-Battandier J Gross EG et al Isotretinoin versus
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19826735-45
109 Lehucher-Ceyrac D Weber-Buisset MJ Isotretinoin and acne in practice a prospective analysis of
188 cases over 9 yearsDermatology 1993186123-8
110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
Br J Dermatol 1997137106-8
111 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al A randomized trial
of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in
patients with severe recalcitrant nodular acne J Am Acad Dermatol 200145187-95
112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
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200145196-207
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recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
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patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
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norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
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trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
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200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
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vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
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19852911231-5
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lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
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15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
18
sqema 2 saSualo simZimis aknes mkurnalobis algoriTmi
mkurnalobis gagrZeleba dazianebis srul
aRmofxvramde da Semdgom dozirebis Semcireba an mkurnalobis Sewyveta
mZime aknes mkurnaloba ix Sesabamisi
algoriTmi sqema 3
referalis saWiroebis
gansazRvra
adgilobrivi retinoidebi
+
benzoilis zeJangi adgilobrivi antibiotikebi
an azelainis mJava
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
komedonebi da didi raodenobiT papulebi da pustulebi
(upiratesad saxeze) vlindeba nawiburebi
19
sqema 3 mZime aknes mkurnalobis algoriTmi
oraluri antibiotikebi iniSneba yoveldRiurad
4-6 Tvis manZilze gaumjobesebis
SemTxvevaSi dozis TandaTan Semcireba da mkurnalobis Sewyveta
sxva saSualebebis dozirebis Semcireba an mkurnalobis Sewyveta
referali
oraluri kontraceptivebi an antiandrogenebi
(mxolod qalebs Soris)
pasuxi mkurnalobaze
3 Tviani mkurnaloba uSedegoa
didi raodenobiT komedonebi papulebi da pustulebi saxeze kiserze da torsze gamoxatuli
nawiburebi
adgilobrivi retinoidebi
+ benzoilis zeJangi
+ adgilobrivi antibiotikebi
oraluri izotretinoini (araorsulebSi)
sistemuri antibiotikebi
+ adgilobrivi retinoidebi
benzoilis zeJangi an azelainis mJava
an
araadekvaturi pasuxi mkurnalobaze
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
aknes stabilizacia
SerCeulia Terapiis gaumjobesebuli reJimi
damTavrebulia sistemuri izotretinoiniT mkurnalobis kursi
laboratoriuli kvlevebi (garkveuli periodulobiT) sistemuri izotretinoiniT mkurnalobis procesSi
referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
1 Kaminer MS Gilchrest BA The many faces of acne J Am Acad Dermatol 1995 32S6
2 CN Harper JC Cantrell WC et al The prevalence of acne in adults 20 years and older
3 Puhvel SM Sakamato M The chemoattractant properties of comedonal components JInvest
Dermatol 1978 71324
4 Lucky AW Biro FM Huster GA et al Acne vulgaris in premenarchal girls an early sign of
puberty associated with rising levels of dehydroepiandrosterone Arch Dermatol 1994 130308
5 Lucky AW Biro FM Simbartl LA et al Predictors of severity of acne vulgaris in young
adolescent girls results of a five-year longitudinal study J Pediatr 1997 13030
6 Goulden V Clark SM Cunliffe WJ Post-adolescent acne a review of clinical features Br J
Dermatol 1997 13666
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aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
aknes gaidlainis danergva unda daiwyos miznebis dasaxviT da strategiis SemuSavebiT romelSic pirveladi jadacvis profesionalebTan erTad monawileobas miiReben meoreuli jandacvis profesionalebi pacientebi da aS
rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
gaidlainebis gavrcelebaxelmisawvdomobis uzrunvelyofa
gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqt-diskze) gamravleba da samizne kontingentSi maTi gavrceleba
ganaTleba da treiningi
gaidlainSi mocemuli rekomendaciebis amsaxveli saganmanaTleblo masalebis gavrceleba
gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi maT Soris moklevadiani (gadamzadebis) programaSi
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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31
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pharmacogenetic study Ann Intern Med 2002 136582
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109 Lehucher-Ceyrac D Weber-Buisset MJ Isotretinoin and acne in practice a prospective analysis of
188 cases over 9 yearsDermatology 1993186123-8
110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
Br J Dermatol 1997137106-8
111 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al A randomized trial
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112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
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114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
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recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
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117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
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199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
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121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
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122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
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124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
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19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
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129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
20
7 referali
referalis Cveneba mudmivi kamaTis sagania sadReisod ojaxis eqimis kompetencia da resursi saSualebas iZleva marTos nebismieri simZimis akne Tumca dermatologis CarTva SesaZlebelia mkurnalobis nebismier fazaSi gasaTvaliswinebelia isic rom pacientebis didi nawili garkveuli drois ganmavlobaSi TviTmkurnalobas eweva da am procesSi TviTon Rebulobs gadawyvetilebas vis mimarTos pirveladad ojaxis
eqims Tu dermatologs137 praqtika gviCvenebs rom ojaxis eqims aramarto dermatologTan aramed SesaZloa sxva specialistebTanac dasWirdes pacientis referali
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
pacientebi sistemuri izotretinoiniT kursis daniSvnisas ndash am SemTxvevaSi mkurnalobis meTods irCevs dermatologi magram gamomdinare medikamentis teratogenuli efeqtebidan izotretinoiniT mkurnalobis dawyebabmde erTi TviT adre fertiluri asakis qalebisaTvis aucilebelia kontraceptivebis daniSvna am periodiT pacienti meTvalyureobisaTvis kvlav ubrundeba pjd-s
pirveladi jandacvis doneze pacientis dabrunebis kriteriumebi
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SerCeulia Terapiis gaumjobesebuli reJimi
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referali endokrinologTan
saxezea hiperandrogenemiis niSnebi
referali fsiqologTan
saxezea fsiqikis sxvadasxva saxis dazianeba
21
8 xangrZlivi meTvalyureoba
mkurnalobis efeqturobis Sefaseba da gegmis gadaxedva yovel 2-3 TveSi erTxelaa saWiro
pacientebi romelTac mkurnaloba sistemuri retinoidebiT utardebaT mkurnalobis dawyebamde da Semdgom garkveuli periodulobiT unda CautardeT sisxlis saerTo analizi Sratis trigliceridebis qolesterinis RviZlis funqciuri testebis gansazRvra zogadad janmrTel asimptomur pirebs Soris romelTac diabetis an dislipidemiis ojxuri anamnezi ar aqvT laboratoriuli kvlevebis Catareba SesaZlebelia TveSi erTxel sxva SemTxvevaSi ki yovelkvireulad an or kviraSi erTxel manam sanam maCveneblebi rekomendebul zRvars ar miuaxlovdeba
izotretinoiniT mkurnalobis Sewyvetis Cvenebaa mZime hipertrigliceridemia (mag gt800 mgdl an 9 mmoll ndash mwvave pankreatitis ganviTarebis riskis gamo)105 an sxva gamoxatuli laboratoriuli cvlilebebi miuxedavad imisa rom izotretinoiniT mkurnalobis Sewyvetis Sedegad hipertrigliceridemia TandaTan wesrigdeba pacientebs mainc esaWiroebaT Semdgomi meTvalyureoba vinaidan erT-erTi kvlevis mixedviT maT momavalSi hiperlipidemiis da metaboluri sindromis ganviTarebis maRali riski aqvT106 rogorc aRmoCnda mikronizebuli izotretinoinis gamoyenebis SemTxvevaSi naklebia kankunTovani gverdiTi efeqtebis da hipertrigliceridemis ganviTarebis riski107
spironolaqtoniT mkurnalobis SemTxvevaSi Terapiis dawyebamde da Semdgom periodulad unda ganisazRvros sisxlSi eleqtrolitebis done
trimetroprimsulfomeToqsazoliT mkurnalobis dros saWiroa sisxlis saerTo analizis monitoringi
minocikliniT xangrZlivad sistemuri mkurnalobis (1 welze meti) SemTxvevaSi rekomendebulia antinuklearuli antisxeulebis da RviZlis transaminazebis gansazRvra
9 eTikur-samarTlebrivi sakiTxebi
aknes marTvis dros wamlis SerCevisas Zalze mniSvnelovania mkurnalobis sargeblobisa da riskis Sedareba radgan aknes samkurnalod gamoyenebuli wamlebis did nawils gamoxatuli gverdiTi efeqtebi axlavs Tan (sistemuri retinoidebi antibiotikebi spironolaqtoni da sxva) aucilebelia pacientis srulyofili informireba mkurnalobis miznebisa da yvela SesaZlo garTulebis agreTve samkurnalo saSualebebis xelmisawvdomobis Sesaxeb da misgan
22
informirebuli Tanxmobis miReba pacienti CarTuli unda iyos mkurnalobis Sesaxeb gadawyvetilebis miRebaSi sayuradReboa rom aknes samkurnalod mowodebuli wamlebis didi nawili Cveni qveynis farmacevtul bazarze registrirebuli araa rac SesaZlebelia gaidlainis implementaciis procesSi ganxorcieldes
10 praqtikaSi adaptaciis da protokolis SemuSavebis
rekomendaciebi
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rekomendaciebi gaidlainis implementaciis Sesaxeb
gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi
daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
gaidlainis gamoyeneba ar saWiroebs raime axali unar-Cvevis aTvisebas
pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
gaidlainis implementaciis rekomendebuli meTodebi
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gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT asociaciis veb-gverdi saministro da aS
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ganaTleba da treiningi
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23
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proeqtis pilotireba da profesiuli konsensusis miRweva
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24
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plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
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4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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27
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26 32 MeReC Bulletin Volume 10 Number 8 1999
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28
38 Shalita A Weiss JS Chalker DK Ellis CN Greenspan A Katz HI et al A comparison of the
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Acad Dermatol 199838S11-6
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97 Christian GL Krueger GG Clindamycin vs placebo as adjunctive therapy in moderately severe acne
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99 Hersle K Trimethoprim-sulphamethoxazole in acne vulgaris A double-blind study Dermatologica
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104 White GM Chen W Yao J Wolde-Tsadik G Recurrence rates after the first course of isotretinoin
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105 McCarter TL Chen YK Marked hyperlipidemia and pancreatitis associated with isotretinoin
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110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
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15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
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21
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rekomendaciebi gaidlainis implementaciis Sesaxeb
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daavadebis gavrcelebisa da problemurobis gamo misadmi gamoxatuli interesi samedicino profesionalebis mxridan
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pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~)
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23
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24
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1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
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msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
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mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
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11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
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eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
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eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
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IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
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13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
23
gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis
Tanmxlebi sainformacio sistemebis da Semaxseneblebis SemuSaveba da gavrceleba rogorc calkeuli eqimebis ise ganyofilebis doneze saqmianobis marTvisaTvis
saxelmwifo sasertifikacio gamocda
gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~
proeqtis pilotireba da profesiuli konsensusis miRweva
pirvel etapze romelime regionSi an pirveladi jandacvis ramdenime centrSi aknes marTvis gaidlainis pilotireba eqimisa da eqTnis gundis momzadeba Sesabamis specialistebTan ndash dermatologi endokrinologi fsiqologi TanamSromlobis uzrunvelyofa Sesabamisi wamlebis xelmisawvdomobis uzrunvelyofa xarisxis monitoringi
meore etapze pilitur proeqtSi monawile eqimebis Sexvedra pirveladi jandacvis sistemaSi momuSave sxva eqimebTan da gamocdilebis gaziareba sasurvelia Catardes konferencia sadac moxdeba gamocdilebis gaziareba
eqimebis CarTva gaidlainze dafuZnebuli auditis CatarebaSi informaciis moZieba da gamoqveyneba calkeul SemTxvevebSi eqimebis mier gaidlainis praqtikaSi gamoyenebis dadebiT Sedegebis Sesaxeb
sazogadoebis informireba
pacientebisaTvis sainformacio broSurebis momzadeba gaidlainebSi asaxuli rekomendaciebis Sesaxeb da im dawesebulebebSi myofi pacientebis gamoZaxilis moZieba da gamoqveyneba sadac gaidlaini dainerga
sadazRvevo kompaniebis informireba
gaidlainze dafuZnebiT auditis Catareba pirveladi jandacvis dawesebulebebSi
ukve momzadebuli kirteriumebis (ix zemoT) gamoyeneba auditisaTvis ojaxis eqimTa moklevadiani mzadebis programaSi CarTuli iqneba auditi aknes marTvis sakiTxebze
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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200145196-207
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119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
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trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
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121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
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treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
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treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
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129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
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s Semcireba
an mkurnalo
bis Sewyveta
24
ew Semaxseneblebi samedicino personalisaTvis
plakatebis dabeWdva ojaxis eqimebisaTvis kanis daTvalierebisa da aknes diagnozis Sesaxeb agreTve aknes medikamenturi mkurnalobis algoirTmebis da adgilobrivi da sistemuri gamoyenebis wamlebis dozebis Sesaxeb
samkurnalo saSualebebis xelmisawvdomobis uzrunvelyofa
klinikuri praqtikis auditis kriteriumebi
auditis mizania gamovlindes ramdenad Seesabameba pirveladi jandacvis dawesebulebebis doneze Catarebuli aknes mkurnaloba gaidlainiT mowodebul rekomendaciebs
1 aknes identifikacia
12-25 wlis kontingentSi 80 aqvs sxvadasxva simZimis akne
2 pacientTa ra raodenobaSi moxda diagnostireba kanis SefasebiT
daavadebis diagnostika ZiriTadad kanis SefasebiT xdeba fizikuri gasinjvisas ganisazRvreba dazianebebis lokalizacia tipi (anTebiTi araanTebiTi) zoma (mcire lt5 mm ndash papulebi an pustulebi didi zomis gt5 mm ndash kvanZebi) daavadebis Sedegebi nawiburebi (atrofiuli gavrcelebuli hipertrofuli keloidi) hiperpigmentacia anTebisSemdgomi eriTema
3 pacientTa ra raodenobaSi moxda diagnostikisaTvis klinikur-laboratoriuli kvlevebis (androgenebis koncentracia sisxlSi) Catareba
klinikur-laboratoriuli kvlevebis Catareba (mag androgenebis koncentraciis gansazRvra sisxlSi) rutinulad saWiro araa maTi aucilebloba sxva Tanmxlebi niSnebis arsebobis SemTxvevaSi dgeba (mag hirsutizmi virilizaciis arseboba menstrualuri ciklis darRveva)
4 msubuqi aknes mqone pacientebis ra raodenobaSi dainiSna mkurnaloba daavadebis simZimis Sesabamisad
msubuqi araanTebiTi aknes dros mkurnaloba tardeba adgilobrivi komedolizuri saSualebebiT (adgilobrivi retinoidi benzoilis zeJangi azelainis mJava da aS)
msubuqi anebiTi aknes dros zemoT moxseniebul mkurnalobas emateba adgilobrivi antibaqteriuli saSualeba (eriTromicini klindamicini da aS)
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
randomized trial comparing micronized isotretinoin with standard isotretinoin J Am Acad Dermatol
200145196-207
114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
Acad Dermatol 199226599-606
115 Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW et al American Academy
of Dermatology Consensus Conference on the safe and optimal use of isotretinoinsummary and
recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
118 Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ Effectiveness of
norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
25
5 pacientebis ra raodenobas Cautarda mkurnaloba aranakleb 8 kviris xangrZlivobiT
mikrokomedonebis maturacia 8 kviramde grZeldeba da aqedan gamomdinare efeqtis misaRebd mkurnalobis xangrZlivoba am periodze naklebi ar unda iyos
6 pacientebis ra raodenoba gaigzavna konsultaciis daan Semdgomi mkurnalobisaTvis specialistTan
dermatologTan referals saWiroeben
pacientebi msubuqi da saSualo simZimis akneTi rodesac eqvsTviani konservatuli Terapiis Semdeg efeqti ar vlindeba
pacientebi romelTa daavadeba refraqterulia mkurnalobis mimarT gansakuTrebiT mZime aknes da nawiburebis SemTxvevaSi
daavadebis atipiuri formis dros
sistemuri izotretinoiniT mkurnalobis saWiroebisas
referali endokrinologTan rodesac saxezea hiperandrogenemiis niSnebi
referali fsiqologTan - saxezea fsiqikis sxvadasxva saxis dazianeba
7 pacientebis ra raodenobas Soris Sefasda mkurnalobis efeqturoba 2-3 TveSi erTxel
11 gaidlainis gadasinjvis da ganaxlebis vada - 2 weli
12 gaidlainis miRebis xerxiwyaro
gaidlaini warmoadgens sxvadasxva gaidlainebis (ix literatura) Sejerebis da adaptaciis Sedegs
1 Guidelines of care for acne vulgaris management (AM ACAD DERMATOL Apr 2007)
2 Acne management (Institute for Clinical Systems Improvement (AHRQ (US) ndash Agency
for Healthcare Research and Quality 01 January 2006)
3 Acne management (GAC (CA) ndash Guidelines Advisory Committee 01 October
2007 Canada)
4 acne vulgaris (PRODIGY Guidance) (SCHIN (GB) ndash Sowerby Centre for Health
Informatics at Newcastle Guideline 01 July 2006 United Kingdom)
26
mtkicebulebis done da rekomendaciebis xarisxi
done mtkicebulebis done xaris-
xi rekomendaciis xarisxi
I
Zlieri mtkicebuleba eyrdnoba minimum erT sistemur mimoxilvas romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas
A
eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia
II Zlieri mtkicebuleba eyrdnoba minimum erT swori dizainis mqone randomizebul kontrolirebad kvlevas
B
eyrdnoba II donis mtkicebulebas da Sesabamisad rekomendebulia
III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
C
eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad
IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
Vბ klinikuri gamocdileba aRwerilobiTi kvlevebi an eqspertTa angariSi
13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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patients with severe recalcitrant nodular acne J Am Acad Dermatol 200145187-95
112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
randomized trial comparing micronized isotretinoin with standard isotretinoin J Am Acad Dermatol
200145196-207
114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
Acad Dermatol 199226599-606
115 Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW et al American Academy
of Dermatology Consensus Conference on the safe and optimal use of isotretinoinsummary and
recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
118 Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ Effectiveness of
norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
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eqspertebi
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saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
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s Semcireba
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III klinikuri kvleva randomizaciis gareSe kohortuli da SemTxveva-kontrolis kvlevebi
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IV araeqsperimentuli multicentruli kvlevebi D
eyrdnoba IV da V donis mtkicebulebas saWiroebs konsesuss
Vა avtoritetul profesionalTa mosazreba
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13 alternatiuli gaidlaini ar arsebobs
14 gamoyenebuli literatura
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acne J Am Acad Dermatol 2005 52207
14 2008 Family Practice Notebook LLC
15 Rasmussen JE Smith SB Patient concepts and misconceptions about acne Arch Dermatol 1983
119570
16 Green J Sinclair RD Perceptions of acne vulgaris in final year medical student written examination
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CoMedica Inc New York 1994 p 55
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121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
27
12 Bershad S The unwelcome return of the acne diet Arch Dermatol 2003 139940
13 Adebamowo CA Spiegelman D Danby FW et al High school dietary dairy intake and teenage
acne J Am Acad Dermatol 2005 52207
14 2008 Family Practice Notebook LLC
15 Rasmussen JE Smith SB Patient concepts and misconceptions about acne Arch Dermatol 1983
119570
16 Green J Sinclair RD Perceptions of acne vulgaris in final year medical student written examination
answers Australas J Dermatol 2001 4298
17 Yosipovitch G Tang M Dawn AG et al Study of psychological stress sebum production and
acne vulgaris in adolescents Acta Derm Venereol 2007 87135
18 Chiu A Chon SY Kimball AB The response of skin disease to stress changes in the severity of
acne vulgaris as affected by examination stress Arch Dermatol 2003 139897
19 Timpatanapong P Rojanasakul A Hormonal profiles and prevalence of polycystic ovary syndrome
in women with acne J Dermatol 1997 24223
20 Goldstein SM Wintroub BU Adverse Cutaneous Reactions to Medication A Physicians Guide
CoMedica Inc New York 1994 p 55
21 Cove JH Cunliffe WJ Holland KT Acne vulgaris is the bacterial population size significant Br J
Dermatol 1980 102277-80
22 Bojar RA Hittel N Cunliffe WJ Holland KT Direct analysis of resistance in the cutaneous
microflora during treatment of acne vulgaris with topical 1 nadifloxacin and 2 erythromycin
Drugs 199549(suppl 2)164-7
23 Eady EA Cove JH Holland KT Cunliffe WJ Erythromycin resistant propionibacteria in antibiotic
treated acne patients association with therapeutic failure Br J Dermatol 1989121 51-7
24 Harkaway KS McGinley KJ Foglia AN Lee WL Fried F Shalita AR et al Antibiotic resistance
patterns in coagulase-negative staphylococci after treatment with topical erythromycin benzoyl
peroxide and combination therapy Br J Dermatol 1992126586-90
25 Goldstein SM Wintroub BU Adverse Cutaneous Reactions to Medication A Physicians Guide
CoMedica Inc New York 1994 p 55
26 32 MeReC Bulletin Volume 10 Number 8 1999
27 Nguyen QH Kim YA Schwartz RA Management of acne vulgaris Am Fam Phys 1994 5089
28 Hurwitz S Acne vulgaris pathogenesis and management Pediatr Rev 1994 1547
29 Thiboutot DM Weiss J Bucko A et al Adapalene-benzoyl peroxide a fixed-dose combination for
the treatment of acne vulgaris results of a multicenter randomized double-blind controlled study J
Am Acad Dermatol 2007 57791
30 Belknap BS Treatment of acne with 5 benzoyl peroxide gel or 005 retinoic acid cream Cutis
197923856-9
31 Schutte H Cunliffe WJ Forster RA The short-term effects of benzoyl peroxide lotion on the
resolution of inflamed acne lesions Br J Dermatol 198210691-4
32 Smith EB Padilla RS McCabe JM Becker LE Benzoyl peroxide lotion (20 percent) in acne Cutis
19802590-2
33 Mills OH Jr Kligman AM Pochi P Comite H Comparing 25 5 and 10 benzoyl peroxide on
inflammatory acne vulgaris Int J Dermatol 198625664-7
34 Christiansen JV Gadborg E Ludvigsen K Meier CH Norholm A Pedersen D et al Topical
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197414882-9
35 Bradford LG Montes LF Topical application of vitamin A acid in acne vulgaris South Med J
197467683-7
36 Krishnan G Comparison of two concentrations of tretinoin solution in the topical treatment of acne
vulgaris Practitioner 1976216106-9
37 Chalker DK Lesher JL Jr Smith JG Jr Klauda HC Pochi PE Jacoby WS et al Efficacy of topical
isotretinoin 005 gel in acne vulgaris results of a multicenter doubleblind investigation J Am
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28
38 Shalita A Weiss JS Chalker DK Ellis CN Greenspan A Katz HI et al A comparison of the
efficacy and safety of adapalene gel 01 and tretinoin gel 0025 in the treatment of acne vulgaris
a multicenter trial J Am Acad Dermatol 199634482-5
39 Clucas A Verschoore M Sorba V Poncet M Baker M Czernielewski J Adapalene 01 gel is
better tolerated than tretinoin 0025 gel in acne patients J Am Acad Dermatol 199736S116-8
40 Cunliffe WJ Caputo R Dreno B Forstrom L Heenen M Orfanos CE et al Clinical efficacy and
safety comparison of adapalene gel and tretinoin gel in the treatment of acne vulgaris Europe and
US multicenter trials J Am Acad Dermatol 199736S126-34
41 Dunlap FE Mills OH Tuley MR Baker MD Plott RT Adapalene 01 gel for the treatment of acne
vulgaris its superiority compared to tretinoin 0025 cream in skin tolerance and patient preference
Br J Dermatol 1998139(suppl 52)17-22
42 Galvin SA Gilbert R Baker M Guibal F Tuley MR Comparative tolerance of adapalene 01 gel
and six different tretinoin formulations Br J Dermatol 1998139(suppl 52)34-40
43 Grosshans E Marks R Mascaro JM Torras H Meynadier J Alirezai M et al Evaluation of clinical
efficacy and safety of adapalene 01 gel versus tretinoin 0025 gel in the treatment of acne
vulgaris with particular reference to the onset of action and impact on quality of life Br J
Dermatol1998139(suppl 52)26-33
44 Mills OH Jr Berger RS Irritation potential of a new topical tretinoin formulation and a
commercially-available tretinoin formulation as measured by patch testing in human subjects J Am
Acad Dermatol 199838S11-6
45 Ioannides D Rigopoulos D Katsambas A Topical adapalene gel 01 vs isotretinoin gel 005 in
the treatment of acne vulgaris a randomized open-label clinical trial Br J Dermatol 2002147523-7
46 Kakita L Tazarotene versus tretinoin or adapalene in the treatment of acne vulgaris J Am Acad
Dermatol 200043S51-4
47 Shalita AR Chalker DK Griffith RF Herbert AA Hickman JG Maloney JM et al Tazarotene gel is
safe and effective in the treatment of acne vulgaris a multicenter double-blind vehicle-controlled
study Cutis 199963349-55
48 Ellis CN Millikan LE Smith EB Chalker DM Swinyer LJ Katz IH et al Comparison of adapalene
01 solution and tretinoin 0025 gel in the topical treatment of acne vulgaris Br J Dermatol
1998139(suppl 52)41-7
49 Webster GF Berson D Stein LF Fivenson DP Tanghetti EA Ling M Efficacy and tolerability of
once-daily tazarotene 01 gel versus once-daily tretinoin 0025 gel in the treatment of facial acne
vulgaris a randomized trial Cutis 2001 67(Suppl 6)4-9
50 Lucky AW Cullen SI Jarratt MT Quigley JW Comparative efficacy and safety of two 0025
tretinoin gels results from a multicenter double-blind parallel study J Am Acad Dermatol
199838S17-23
51 Leyden JJ Therapy for acne vulgaris N Engl J Med 1997 3361156
52 Shalita AR Chalker DK Griffith RF et al Tazarotene gel is safe and effective in the treatment of
acne vulgaris a multicenter double-blind vehicle-controlled study Cutis 1999 63349
53 Webster GF Berson D Stein LF et al Efficacy and tolerability of once-daily tazarotene 01 gel
versus once-daily tretinoin 0025 gel in the treatment of facial acne vulgaris a randomized trial
Cutis 2001 674
54 Leyden J Lowe N Kakita L Draelos Z Comparison of treatment of acne vulgaris with alternate-
day applications of tazarotene 01 gel and once-daily applications of adapalene 01 gel a
randomized trial Cutis 2001 6710
55 Shalita A Weiss JS Chalker DK et al A comparison of the efficacy and safety of adapalene gel
01 and tretinoin gel 0025 in the treatment of acne vulgaris a multicenter trial J Am Acad
Dermatol 1996 34482
56 Chalker DK Shalita A Smith JG Jr Swann RW A double-blind study of the effectiveness of a 3
erythromycin and 5 benzoyl peroxide combination in the treatment of acne vulgaris J Am Acad
Dermatol 19839933-6
29
57 Tschen EH Katz HI Jones TM Monroe EW Kraus SJ Connolly MA et al A combination benzoyl
peroxide and clindamycin topical gel compared with benzoyl peroxide clindamycin phosphate and
vehicle in the treatment of acne vulgaris Cutis 200167165-9
58 Leyden JJ Hickman JG Jarratt MT Stewart DM Levy SF The efficacy and safety of a combination
benzoyl peroxideclindamycin topical gel compared with benzoyl peroxide alone and a benzoyl
peroxideerythromycin combination product J Cutan Med Surg 2001537-42
59 Lookingbill DP Chalker DK Lindholm JS Katz HI Kempers SE Huerter CJ et al Treatment of
acne with a combination clindamycinbenzoyl peroxide gel compared with clindamycin gel benzoyl
peroxide gel and vehicle gel combined results of two double-blind investigations J Am Acad
Dermatol 199737590-5)
60 Eady EA Bojar RA Jones CE et al The effects of acne treatment with a combination of benzoyl
peroxide and erythromycin on skin carriage of erythromycin-resistant propionibacteria Br J
Dermatol 1996 134107
61 Bernstein JE Shalita AR Topically applied erythromycin in inflammatory acne vulgaris J Am Acad
Dermatol 19802318-21
62 Jones EL Crumley AF Topical erythromycin vs blank vehicle in a multiclinic acne study Arch
Dermatol 1981117551-3
63 Prince RA Busch DA Hepler CD Feldick HG Clinical trial of topical erythromycin in
inflammatory acne Drug Intell Clin Pharm 198115372-6
64 Lesher JL Jr Chalker DK Smith JG Jr Guenther LC Ellis CN Voorhees JJ et al An evaluation of
a 2 erythromycin ointment in the topical therapy of acne vulgaris J Am Acad Dermatol
198512526-31
65 Pochi PE Bagatell FK Ellis CN Stoughton RB Whitmore CG Saatjian GD et al Erythromycin 2
percent gel in the treatment of acne vulgaris Cutis 198841132-6
66 Dobson RL Belknap BS Topical erythromycin solution in acne Results of a multiclinic trial J Am
Acad Dermatol 19803478-82
67 Mills O Jr Thornsberry C Cardin CW Smiles KA Leyden JJ Bacterial resistance and therapeutic
outcome following three months of topical acne therapy with 2 erythromycin gel versus its vehicle
Acta Derm Venereol 2002 82260-5
68 Leyden JJ Shalita AR Saatjian GD Sefton J Erythromycin 2 gel in comparison with clindamycin
phosphate 1 solution in acne vulgaris J Am Acad Dermatol 198716822-7
69 Becker LE Bergstresser PR Whiting DA Clendenning WE Dobson RL Jordan WP et al Topical
clindamycin therapy for acne vulgaris A cooperative clinical study Arch Dermatol 1981117482-5
70 Shalita AR Treatment of mild and moderate acne vulgaris with salicylic acid in an alcohol-detergent
vehicle Cutis 198128556-8 561
71 Cunliffe WJ Holland KT Clinical and laboratory studies on treatment with 20 azelaic acid cream
for acne Acta Derm Venereol Suppl (Stockh) 198914331-4
72 Katsambas A Graupe K Stratigos J Clinical studies of 20 azelaic acid cream in the treatment of
acne vulgaris Comparison with vehicle and topical tretinoin Acta Derm Venereol Suppl (Stockh)
198914335-9
73 Hjorth N Graupe K Azelaic acid for the treatment of acne A clinical comparison with oral
tetracycline Acta Derm Venereol Suppl (Stockh) 198914345-8
74 Weiss JS Current options for the topical treatment of acne vulgaris Pediatr Dermatol 1997 14480
75 Zouboulis CC Derumeaux L Decroix J Maciejewska-Udziela B Cambazard F Stuhlert A A
multicentre single-blindrandomized comparison of a fixed clindamycin phosphatetretinoin gel
formulation (Velac) applied once daily and a clindamycin lotion formulation (Dalacin T) applied
twice daily in the topical treatment of acne vulgaris Br J Dermatol 2000143498-505
76 Hurley HJ Shelley WB Special topical approach to the treatment of acne Suppression of sweating
with aluminum chloride in an anhydrous formulation Cutis 197822 696-703
77 Hjorth N Storm D Dela K Topical anhydrous aluminum chloride formulation in the treatment of
acne vulgaris a double-blind study Cutis 198535499-500
30
78 Thiboutot DM Shalita AR Yamauchi PS et al Adapalene gel 01 as maintenance therapy for
acne vulgaris a randomized controlled investigator-blind follow-up of a recent combination study
Arch Dermatol 2006 142597
79 Leyden J Thiboutot DM Shalita AR et al Comparison of tazarotene and minocycline
maintenance therapies in acne vulgaris a multicenter double-blind randomized parallel-group study
Arch Dermatol 2006 142605
80 Zane LT Acne maintenance therapy expanding the role of topical retinoids Arch Dermatol 2006
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81 Simonart T Dramaix M De Maertelaer V Br J Dermatol 2008 Feb158(2)208-16
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83 McManus P Iheanacho I Dont use minocycline as first line oral antibiotic in acne BMJ 2007
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84 Purdy S de Berker D Acne BMJ 2006 333949
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88 Eady EA Cove JH Holland KT Cunliffe WJ Erythromycin resistant propionibacteria in
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89 Basta-Juzbasic A Lipozencic J Oremovic L Kotrulja L Gruber F Brajac I et al A dose-finding
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93 Blaney DJ Cook CH Topical use of tetracycline in the treatment of acne a double-blind study
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94 Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ Sequential antibiotic therapy
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95 Skidmore R Kovach R Walker C Thomas J Bradshaw M Leyden J et al Effects of
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96 Gammon WR Meyer C Lantis S Shenefelt P Reizner G Cripps DJ Comparative efficacy of oral
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97 Christian GL Krueger GG Clindamycin vs placebo as adjunctive therapy in moderately severe acne
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98 Stoughton RB Cornell RC Gange RW Walter JF Doubleblind comparison of topical 1 percent
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99 Hersle K Trimethoprim-sulphamethoxazole in acne vulgaris A double-blind study Dermatologica
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100 Cotterill JA Cunliffe WJ Forster RA Williamson DM Bulusu L A comparison of trimethoprim-
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101 Ward A Brogden RN Heel RC et al Isotretinoin a review of its pharmacological properties and
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104 White GM Chen W Yao J Wolde-Tsadik G Recurrence rates after the first course of isotretinoin
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105 McCarter TL Chen YK Marked hyperlipidemia and pancreatitis associated with isotretinoin
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121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
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vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
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28
38 Shalita A Weiss JS Chalker DK Ellis CN Greenspan A Katz HI et al A comparison of the
efficacy and safety of adapalene gel 01 and tretinoin gel 0025 in the treatment of acne vulgaris
a multicenter trial J Am Acad Dermatol 199634482-5
39 Clucas A Verschoore M Sorba V Poncet M Baker M Czernielewski J Adapalene 01 gel is
better tolerated than tretinoin 0025 gel in acne patients J Am Acad Dermatol 199736S116-8
40 Cunliffe WJ Caputo R Dreno B Forstrom L Heenen M Orfanos CE et al Clinical efficacy and
safety comparison of adapalene gel and tretinoin gel in the treatment of acne vulgaris Europe and
US multicenter trials J Am Acad Dermatol 199736S126-34
41 Dunlap FE Mills OH Tuley MR Baker MD Plott RT Adapalene 01 gel for the treatment of acne
vulgaris its superiority compared to tretinoin 0025 cream in skin tolerance and patient preference
Br J Dermatol 1998139(suppl 52)17-22
42 Galvin SA Gilbert R Baker M Guibal F Tuley MR Comparative tolerance of adapalene 01 gel
and six different tretinoin formulations Br J Dermatol 1998139(suppl 52)34-40
43 Grosshans E Marks R Mascaro JM Torras H Meynadier J Alirezai M et al Evaluation of clinical
efficacy and safety of adapalene 01 gel versus tretinoin 0025 gel in the treatment of acne
vulgaris with particular reference to the onset of action and impact on quality of life Br J
Dermatol1998139(suppl 52)26-33
44 Mills OH Jr Berger RS Irritation potential of a new topical tretinoin formulation and a
commercially-available tretinoin formulation as measured by patch testing in human subjects J Am
Acad Dermatol 199838S11-6
45 Ioannides D Rigopoulos D Katsambas A Topical adapalene gel 01 vs isotretinoin gel 005 in
the treatment of acne vulgaris a randomized open-label clinical trial Br J Dermatol 2002147523-7
46 Kakita L Tazarotene versus tretinoin or adapalene in the treatment of acne vulgaris J Am Acad
Dermatol 200043S51-4
47 Shalita AR Chalker DK Griffith RF Herbert AA Hickman JG Maloney JM et al Tazarotene gel is
safe and effective in the treatment of acne vulgaris a multicenter double-blind vehicle-controlled
study Cutis 199963349-55
48 Ellis CN Millikan LE Smith EB Chalker DM Swinyer LJ Katz IH et al Comparison of adapalene
01 solution and tretinoin 0025 gel in the topical treatment of acne vulgaris Br J Dermatol
1998139(suppl 52)41-7
49 Webster GF Berson D Stein LF Fivenson DP Tanghetti EA Ling M Efficacy and tolerability of
once-daily tazarotene 01 gel versus once-daily tretinoin 0025 gel in the treatment of facial acne
vulgaris a randomized trial Cutis 2001 67(Suppl 6)4-9
50 Lucky AW Cullen SI Jarratt MT Quigley JW Comparative efficacy and safety of two 0025
tretinoin gels results from a multicenter double-blind parallel study J Am Acad Dermatol
199838S17-23
51 Leyden JJ Therapy for acne vulgaris N Engl J Med 1997 3361156
52 Shalita AR Chalker DK Griffith RF et al Tazarotene gel is safe and effective in the treatment of
acne vulgaris a multicenter double-blind vehicle-controlled study Cutis 1999 63349
53 Webster GF Berson D Stein LF et al Efficacy and tolerability of once-daily tazarotene 01 gel
versus once-daily tretinoin 0025 gel in the treatment of facial acne vulgaris a randomized trial
Cutis 2001 674
54 Leyden J Lowe N Kakita L Draelos Z Comparison of treatment of acne vulgaris with alternate-
day applications of tazarotene 01 gel and once-daily applications of adapalene 01 gel a
randomized trial Cutis 2001 6710
55 Shalita A Weiss JS Chalker DK et al A comparison of the efficacy and safety of adapalene gel
01 and tretinoin gel 0025 in the treatment of acne vulgaris a multicenter trial J Am Acad
Dermatol 1996 34482
56 Chalker DK Shalita A Smith JG Jr Swann RW A double-blind study of the effectiveness of a 3
erythromycin and 5 benzoyl peroxide combination in the treatment of acne vulgaris J Am Acad
Dermatol 19839933-6
29
57 Tschen EH Katz HI Jones TM Monroe EW Kraus SJ Connolly MA et al A combination benzoyl
peroxide and clindamycin topical gel compared with benzoyl peroxide clindamycin phosphate and
vehicle in the treatment of acne vulgaris Cutis 200167165-9
58 Leyden JJ Hickman JG Jarratt MT Stewart DM Levy SF The efficacy and safety of a combination
benzoyl peroxideclindamycin topical gel compared with benzoyl peroxide alone and a benzoyl
peroxideerythromycin combination product J Cutan Med Surg 2001537-42
59 Lookingbill DP Chalker DK Lindholm JS Katz HI Kempers SE Huerter CJ et al Treatment of
acne with a combination clindamycinbenzoyl peroxide gel compared with clindamycin gel benzoyl
peroxide gel and vehicle gel combined results of two double-blind investigations J Am Acad
Dermatol 199737590-5)
60 Eady EA Bojar RA Jones CE et al The effects of acne treatment with a combination of benzoyl
peroxide and erythromycin on skin carriage of erythromycin-resistant propionibacteria Br J
Dermatol 1996 134107
61 Bernstein JE Shalita AR Topically applied erythromycin in inflammatory acne vulgaris J Am Acad
Dermatol 19802318-21
62 Jones EL Crumley AF Topical erythromycin vs blank vehicle in a multiclinic acne study Arch
Dermatol 1981117551-3
63 Prince RA Busch DA Hepler CD Feldick HG Clinical trial of topical erythromycin in
inflammatory acne Drug Intell Clin Pharm 198115372-6
64 Lesher JL Jr Chalker DK Smith JG Jr Guenther LC Ellis CN Voorhees JJ et al An evaluation of
a 2 erythromycin ointment in the topical therapy of acne vulgaris J Am Acad Dermatol
198512526-31
65 Pochi PE Bagatell FK Ellis CN Stoughton RB Whitmore CG Saatjian GD et al Erythromycin 2
percent gel in the treatment of acne vulgaris Cutis 198841132-6
66 Dobson RL Belknap BS Topical erythromycin solution in acne Results of a multiclinic trial J Am
Acad Dermatol 19803478-82
67 Mills O Jr Thornsberry C Cardin CW Smiles KA Leyden JJ Bacterial resistance and therapeutic
outcome following three months of topical acne therapy with 2 erythromycin gel versus its vehicle
Acta Derm Venereol 2002 82260-5
68 Leyden JJ Shalita AR Saatjian GD Sefton J Erythromycin 2 gel in comparison with clindamycin
phosphate 1 solution in acne vulgaris J Am Acad Dermatol 198716822-7
69 Becker LE Bergstresser PR Whiting DA Clendenning WE Dobson RL Jordan WP et al Topical
clindamycin therapy for acne vulgaris A cooperative clinical study Arch Dermatol 1981117482-5
70 Shalita AR Treatment of mild and moderate acne vulgaris with salicylic acid in an alcohol-detergent
vehicle Cutis 198128556-8 561
71 Cunliffe WJ Holland KT Clinical and laboratory studies on treatment with 20 azelaic acid cream
for acne Acta Derm Venereol Suppl (Stockh) 198914331-4
72 Katsambas A Graupe K Stratigos J Clinical studies of 20 azelaic acid cream in the treatment of
acne vulgaris Comparison with vehicle and topical tretinoin Acta Derm Venereol Suppl (Stockh)
198914335-9
73 Hjorth N Graupe K Azelaic acid for the treatment of acne A clinical comparison with oral
tetracycline Acta Derm Venereol Suppl (Stockh) 198914345-8
74 Weiss JS Current options for the topical treatment of acne vulgaris Pediatr Dermatol 1997 14480
75 Zouboulis CC Derumeaux L Decroix J Maciejewska-Udziela B Cambazard F Stuhlert A A
multicentre single-blindrandomized comparison of a fixed clindamycin phosphatetretinoin gel
formulation (Velac) applied once daily and a clindamycin lotion formulation (Dalacin T) applied
twice daily in the topical treatment of acne vulgaris Br J Dermatol 2000143498-505
76 Hurley HJ Shelley WB Special topical approach to the treatment of acne Suppression of sweating
with aluminum chloride in an anhydrous formulation Cutis 197822 696-703
77 Hjorth N Storm D Dela K Topical anhydrous aluminum chloride formulation in the treatment of
acne vulgaris a double-blind study Cutis 198535499-500
30
78 Thiboutot DM Shalita AR Yamauchi PS et al Adapalene gel 01 as maintenance therapy for
acne vulgaris a randomized controlled investigator-blind follow-up of a recent combination study
Arch Dermatol 2006 142597
79 Leyden J Thiboutot DM Shalita AR et al Comparison of tazarotene and minocycline
maintenance therapies in acne vulgaris a multicenter double-blind randomized parallel-group study
Arch Dermatol 2006 142605
80 Zane LT Acne maintenance therapy expanding the role of topical retinoids Arch Dermatol 2006
142638
81 Simonart T Dramaix M De Maertelaer V Br J Dermatol 2008 Feb158(2)208-16
82 Epub 2007 Nov 6 Garner SE Eady EA Popescu C et al Minocycline for acne vulgaris efficacy
and safety Cochrane Database Syst Rev 2000CD002086
83 McManus P Iheanacho I Dont use minocycline as first line oral antibiotic in acne BMJ 2007
334154
84 Purdy S de Berker D Acne BMJ 2006 333949
85 Gough A Chapman S Wagstaff K et al Minocycline induced autoimmune hepatitis and systemic
lupus erythematosus-like syndrome BMJ 1996 312169
86 Elkayam O Levartovsky D Brautbar C et al Clinical and immunological study of 7 patients with
minocycline-induced autoimmune phenomena Am J Med 1998 105484
87 Sturkenboom MC Meier CR Jick H Stricker BH Minocycline and lupuslike syndrome in acne
patients Arch Intern Med 1999 159493
88 Eady EA Cove JH Holland KT Cunliffe WJ Erythromycin resistant propionibacteria in
antibiotic treated acne patients Association with therapeutic failure Br J Dermatol 1989 12151
89 Basta-Juzbasic A Lipozencic J Oremovic L Kotrulja L Gruber F Brajac I et al A dose-finding
study of azithromycin in the treatment of acne vulgaris Acta Dermatovenerol Croat 200715(3)141-
7
90 Levy RM Huang EY Roling D et al Effect of antibiotics on the oropharyngeal flora in patients
with acne Arch Dermatol 2003 139467
91 Smith JG Jr Chalker DK Wehr RF The effectiveness of topical and oral tetracycline for acne South
Med J 197669695-7
92 Gratton D Raymond GP Guertin-Larochelle S Maddin SW Leneck CM Warner J et al Topical
clindamycin versus systemic tetracycline in the treatment of acne Results of a multiclinic trial J Am
Acad Dermatol 1982750-3
93 Blaney DJ Cook CH Topical use of tetracycline in the treatment of acne a double-blind study
comparing topical and oral tetracycline therapy and placebo Arch Dermatol 1976112971-3
94 Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ Sequential antibiotic therapy
for acne promotes the carriage of resistant staphylococci on the skin of contacts J Antimicrob
Chemother 199638829-37
95 Skidmore R Kovach R Walker C Thomas J Bradshaw M Leyden J et al Effects of
subantimicrobial-dose doxycycline in the treatment of moderate acne Arch Dermatol 2003139459-
64
96 Gammon WR Meyer C Lantis S Shenefelt P Reizner G Cripps DJ Comparative efficacy of oral
erythromycin versus oral tetracycline in the treatment of acne vulgaris A doubleblind study J Am
Acad Dermatol 198614183-6
97 Christian GL Krueger GG Clindamycin vs placebo as adjunctive therapy in moderately severe acne
Arch Dermatol 1975111997-1000
98 Stoughton RB Cornell RC Gange RW Walter JF Doubleblind comparison of topical 1 percent
clindamycin phosphate (Cleocin T) and oral tetracycline 500 mgday in the treatment of acne
vulgaris Cutis 198026424-5 429
99 Hersle K Trimethoprim-sulphamethoxazole in acne vulgaris A double-blind study Dermatologica
1972145187-91
100 Cotterill JA Cunliffe WJ Forster RA Williamson DM Bulusu L A comparison of trimethoprim-
sulphamethoxazole with oxytetracycline in acne vulgaris Br J Dermatol 197184366-9
31
101 Ward A Brogden RN Heel RC et al Isotretinoin a review of its pharmacological properties and
therapeutic efficacy in acne and other skin disorders Drugs 1984 286
102 Amichai B Shemer A Grunwald MH Low-dose isotretinoin in the treatment of acne vulgaris J
Am Acad Dermatol 2006 54644
103 Layton AM Knaggs H Taylor J Cunliffe WJ Isotretinoin for acne vulgaris - 10 years later a safe
and successful treatment Br J Dermatol 1993 129292
104 White GM Chen W Yao J Wolde-Tsadik G Recurrence rates after the first course of isotretinoin
Arch Dermatol 1998 134376
105 McCarter TL Chen YK Marked hyperlipidemia and pancreatitis associated with isotretinoin
therapy Am J Gastroenterol 1992 871855
106 Rodondi N Darioli R Ramelet AA et al High risk for hyperlipidemia and the metabolic syndrome
after an episode of hypertriglyceridemia during 13-cis retinoic acid therapy for acne a
pharmacogenetic study Ann Intern Med 2002 136582
107 Strauss JS Leyden JJ Lucky AW et al Safety of a new micronized formulation of isotretinoin in
patients with severe recalcitrant nodular acne a randomized trial comparing micronized isotretinoin
with standard isotretinoin J Am Acad Dermatol 2001 45196
108 Peck GL Olsen TG Butkus D Pandya M Arnaud-Battandier J Gross EG et al Isotretinoin versus
placebo in the treatment of cystic acne A randomized double-blind study J Am Acad Dermatol
19826735-45
109 Lehucher-Ceyrac D Weber-Buisset MJ Isotretinoin and acne in practice a prospective analysis of
188 cases over 9 yearsDermatology 1993186123-8
110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
Br J Dermatol 1997137106-8
111 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al A randomized trial
of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in
patients with severe recalcitrant nodular acne J Am Acad Dermatol 200145187-95
112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
randomized trial comparing micronized isotretinoin with standard isotretinoin J Am Acad Dermatol
200145196-207
114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
Acad Dermatol 199226599-606
115 Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW et al American Academy
of Dermatology Consensus Conference on the safe and optimal use of isotretinoinsummary and
recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
118 Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ Effectiveness of
norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
29
57 Tschen EH Katz HI Jones TM Monroe EW Kraus SJ Connolly MA et al A combination benzoyl
peroxide and clindamycin topical gel compared with benzoyl peroxide clindamycin phosphate and
vehicle in the treatment of acne vulgaris Cutis 200167165-9
58 Leyden JJ Hickman JG Jarratt MT Stewart DM Levy SF The efficacy and safety of a combination
benzoyl peroxideclindamycin topical gel compared with benzoyl peroxide alone and a benzoyl
peroxideerythromycin combination product J Cutan Med Surg 2001537-42
59 Lookingbill DP Chalker DK Lindholm JS Katz HI Kempers SE Huerter CJ et al Treatment of
acne with a combination clindamycinbenzoyl peroxide gel compared with clindamycin gel benzoyl
peroxide gel and vehicle gel combined results of two double-blind investigations J Am Acad
Dermatol 199737590-5)
60 Eady EA Bojar RA Jones CE et al The effects of acne treatment with a combination of benzoyl
peroxide and erythromycin on skin carriage of erythromycin-resistant propionibacteria Br J
Dermatol 1996 134107
61 Bernstein JE Shalita AR Topically applied erythromycin in inflammatory acne vulgaris J Am Acad
Dermatol 19802318-21
62 Jones EL Crumley AF Topical erythromycin vs blank vehicle in a multiclinic acne study Arch
Dermatol 1981117551-3
63 Prince RA Busch DA Hepler CD Feldick HG Clinical trial of topical erythromycin in
inflammatory acne Drug Intell Clin Pharm 198115372-6
64 Lesher JL Jr Chalker DK Smith JG Jr Guenther LC Ellis CN Voorhees JJ et al An evaluation of
a 2 erythromycin ointment in the topical therapy of acne vulgaris J Am Acad Dermatol
198512526-31
65 Pochi PE Bagatell FK Ellis CN Stoughton RB Whitmore CG Saatjian GD et al Erythromycin 2
percent gel in the treatment of acne vulgaris Cutis 198841132-6
66 Dobson RL Belknap BS Topical erythromycin solution in acne Results of a multiclinic trial J Am
Acad Dermatol 19803478-82
67 Mills O Jr Thornsberry C Cardin CW Smiles KA Leyden JJ Bacterial resistance and therapeutic
outcome following three months of topical acne therapy with 2 erythromycin gel versus its vehicle
Acta Derm Venereol 2002 82260-5
68 Leyden JJ Shalita AR Saatjian GD Sefton J Erythromycin 2 gel in comparison with clindamycin
phosphate 1 solution in acne vulgaris J Am Acad Dermatol 198716822-7
69 Becker LE Bergstresser PR Whiting DA Clendenning WE Dobson RL Jordan WP et al Topical
clindamycin therapy for acne vulgaris A cooperative clinical study Arch Dermatol 1981117482-5
70 Shalita AR Treatment of mild and moderate acne vulgaris with salicylic acid in an alcohol-detergent
vehicle Cutis 198128556-8 561
71 Cunliffe WJ Holland KT Clinical and laboratory studies on treatment with 20 azelaic acid cream
for acne Acta Derm Venereol Suppl (Stockh) 198914331-4
72 Katsambas A Graupe K Stratigos J Clinical studies of 20 azelaic acid cream in the treatment of
acne vulgaris Comparison with vehicle and topical tretinoin Acta Derm Venereol Suppl (Stockh)
198914335-9
73 Hjorth N Graupe K Azelaic acid for the treatment of acne A clinical comparison with oral
tetracycline Acta Derm Venereol Suppl (Stockh) 198914345-8
74 Weiss JS Current options for the topical treatment of acne vulgaris Pediatr Dermatol 1997 14480
75 Zouboulis CC Derumeaux L Decroix J Maciejewska-Udziela B Cambazard F Stuhlert A A
multicentre single-blindrandomized comparison of a fixed clindamycin phosphatetretinoin gel
formulation (Velac) applied once daily and a clindamycin lotion formulation (Dalacin T) applied
twice daily in the topical treatment of acne vulgaris Br J Dermatol 2000143498-505
76 Hurley HJ Shelley WB Special topical approach to the treatment of acne Suppression of sweating
with aluminum chloride in an anhydrous formulation Cutis 197822 696-703
77 Hjorth N Storm D Dela K Topical anhydrous aluminum chloride formulation in the treatment of
acne vulgaris a double-blind study Cutis 198535499-500
30
78 Thiboutot DM Shalita AR Yamauchi PS et al Adapalene gel 01 as maintenance therapy for
acne vulgaris a randomized controlled investigator-blind follow-up of a recent combination study
Arch Dermatol 2006 142597
79 Leyden J Thiboutot DM Shalita AR et al Comparison of tazarotene and minocycline
maintenance therapies in acne vulgaris a multicenter double-blind randomized parallel-group study
Arch Dermatol 2006 142605
80 Zane LT Acne maintenance therapy expanding the role of topical retinoids Arch Dermatol 2006
142638
81 Simonart T Dramaix M De Maertelaer V Br J Dermatol 2008 Feb158(2)208-16
82 Epub 2007 Nov 6 Garner SE Eady EA Popescu C et al Minocycline for acne vulgaris efficacy
and safety Cochrane Database Syst Rev 2000CD002086
83 McManus P Iheanacho I Dont use minocycline as first line oral antibiotic in acne BMJ 2007
334154
84 Purdy S de Berker D Acne BMJ 2006 333949
85 Gough A Chapman S Wagstaff K et al Minocycline induced autoimmune hepatitis and systemic
lupus erythematosus-like syndrome BMJ 1996 312169
86 Elkayam O Levartovsky D Brautbar C et al Clinical and immunological study of 7 patients with
minocycline-induced autoimmune phenomena Am J Med 1998 105484
87 Sturkenboom MC Meier CR Jick H Stricker BH Minocycline and lupuslike syndrome in acne
patients Arch Intern Med 1999 159493
88 Eady EA Cove JH Holland KT Cunliffe WJ Erythromycin resistant propionibacteria in
antibiotic treated acne patients Association with therapeutic failure Br J Dermatol 1989 12151
89 Basta-Juzbasic A Lipozencic J Oremovic L Kotrulja L Gruber F Brajac I et al A dose-finding
study of azithromycin in the treatment of acne vulgaris Acta Dermatovenerol Croat 200715(3)141-
7
90 Levy RM Huang EY Roling D et al Effect of antibiotics on the oropharyngeal flora in patients
with acne Arch Dermatol 2003 139467
91 Smith JG Jr Chalker DK Wehr RF The effectiveness of topical and oral tetracycline for acne South
Med J 197669695-7
92 Gratton D Raymond GP Guertin-Larochelle S Maddin SW Leneck CM Warner J et al Topical
clindamycin versus systemic tetracycline in the treatment of acne Results of a multiclinic trial J Am
Acad Dermatol 1982750-3
93 Blaney DJ Cook CH Topical use of tetracycline in the treatment of acne a double-blind study
comparing topical and oral tetracycline therapy and placebo Arch Dermatol 1976112971-3
94 Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ Sequential antibiotic therapy
for acne promotes the carriage of resistant staphylococci on the skin of contacts J Antimicrob
Chemother 199638829-37
95 Skidmore R Kovach R Walker C Thomas J Bradshaw M Leyden J et al Effects of
subantimicrobial-dose doxycycline in the treatment of moderate acne Arch Dermatol 2003139459-
64
96 Gammon WR Meyer C Lantis S Shenefelt P Reizner G Cripps DJ Comparative efficacy of oral
erythromycin versus oral tetracycline in the treatment of acne vulgaris A doubleblind study J Am
Acad Dermatol 198614183-6
97 Christian GL Krueger GG Clindamycin vs placebo as adjunctive therapy in moderately severe acne
Arch Dermatol 1975111997-1000
98 Stoughton RB Cornell RC Gange RW Walter JF Doubleblind comparison of topical 1 percent
clindamycin phosphate (Cleocin T) and oral tetracycline 500 mgday in the treatment of acne
vulgaris Cutis 198026424-5 429
99 Hersle K Trimethoprim-sulphamethoxazole in acne vulgaris A double-blind study Dermatologica
1972145187-91
100 Cotterill JA Cunliffe WJ Forster RA Williamson DM Bulusu L A comparison of trimethoprim-
sulphamethoxazole with oxytetracycline in acne vulgaris Br J Dermatol 197184366-9
31
101 Ward A Brogden RN Heel RC et al Isotretinoin a review of its pharmacological properties and
therapeutic efficacy in acne and other skin disorders Drugs 1984 286
102 Amichai B Shemer A Grunwald MH Low-dose isotretinoin in the treatment of acne vulgaris J
Am Acad Dermatol 2006 54644
103 Layton AM Knaggs H Taylor J Cunliffe WJ Isotretinoin for acne vulgaris - 10 years later a safe
and successful treatment Br J Dermatol 1993 129292
104 White GM Chen W Yao J Wolde-Tsadik G Recurrence rates after the first course of isotretinoin
Arch Dermatol 1998 134376
105 McCarter TL Chen YK Marked hyperlipidemia and pancreatitis associated with isotretinoin
therapy Am J Gastroenterol 1992 871855
106 Rodondi N Darioli R Ramelet AA et al High risk for hyperlipidemia and the metabolic syndrome
after an episode of hypertriglyceridemia during 13-cis retinoic acid therapy for acne a
pharmacogenetic study Ann Intern Med 2002 136582
107 Strauss JS Leyden JJ Lucky AW et al Safety of a new micronized formulation of isotretinoin in
patients with severe recalcitrant nodular acne a randomized trial comparing micronized isotretinoin
with standard isotretinoin J Am Acad Dermatol 2001 45196
108 Peck GL Olsen TG Butkus D Pandya M Arnaud-Battandier J Gross EG et al Isotretinoin versus
placebo in the treatment of cystic acne A randomized double-blind study J Am Acad Dermatol
19826735-45
109 Lehucher-Ceyrac D Weber-Buisset MJ Isotretinoin and acne in practice a prospective analysis of
188 cases over 9 yearsDermatology 1993186123-8
110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
Br J Dermatol 1997137106-8
111 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al A randomized trial
of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in
patients with severe recalcitrant nodular acne J Am Acad Dermatol 200145187-95
112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
randomized trial comparing micronized isotretinoin with standard isotretinoin J Am Acad Dermatol
200145196-207
114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
Acad Dermatol 199226599-606
115 Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW et al American Academy
of Dermatology Consensus Conference on the safe and optimal use of isotretinoinsummary and
recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
118 Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ Effectiveness of
norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
30
78 Thiboutot DM Shalita AR Yamauchi PS et al Adapalene gel 01 as maintenance therapy for
acne vulgaris a randomized controlled investigator-blind follow-up of a recent combination study
Arch Dermatol 2006 142597
79 Leyden J Thiboutot DM Shalita AR et al Comparison of tazarotene and minocycline
maintenance therapies in acne vulgaris a multicenter double-blind randomized parallel-group study
Arch Dermatol 2006 142605
80 Zane LT Acne maintenance therapy expanding the role of topical retinoids Arch Dermatol 2006
142638
81 Simonart T Dramaix M De Maertelaer V Br J Dermatol 2008 Feb158(2)208-16
82 Epub 2007 Nov 6 Garner SE Eady EA Popescu C et al Minocycline for acne vulgaris efficacy
and safety Cochrane Database Syst Rev 2000CD002086
83 McManus P Iheanacho I Dont use minocycline as first line oral antibiotic in acne BMJ 2007
334154
84 Purdy S de Berker D Acne BMJ 2006 333949
85 Gough A Chapman S Wagstaff K et al Minocycline induced autoimmune hepatitis and systemic
lupus erythematosus-like syndrome BMJ 1996 312169
86 Elkayam O Levartovsky D Brautbar C et al Clinical and immunological study of 7 patients with
minocycline-induced autoimmune phenomena Am J Med 1998 105484
87 Sturkenboom MC Meier CR Jick H Stricker BH Minocycline and lupuslike syndrome in acne
patients Arch Intern Med 1999 159493
88 Eady EA Cove JH Holland KT Cunliffe WJ Erythromycin resistant propionibacteria in
antibiotic treated acne patients Association with therapeutic failure Br J Dermatol 1989 12151
89 Basta-Juzbasic A Lipozencic J Oremovic L Kotrulja L Gruber F Brajac I et al A dose-finding
study of azithromycin in the treatment of acne vulgaris Acta Dermatovenerol Croat 200715(3)141-
7
90 Levy RM Huang EY Roling D et al Effect of antibiotics on the oropharyngeal flora in patients
with acne Arch Dermatol 2003 139467
91 Smith JG Jr Chalker DK Wehr RF The effectiveness of topical and oral tetracycline for acne South
Med J 197669695-7
92 Gratton D Raymond GP Guertin-Larochelle S Maddin SW Leneck CM Warner J et al Topical
clindamycin versus systemic tetracycline in the treatment of acne Results of a multiclinic trial J Am
Acad Dermatol 1982750-3
93 Blaney DJ Cook CH Topical use of tetracycline in the treatment of acne a double-blind study
comparing topical and oral tetracycline therapy and placebo Arch Dermatol 1976112971-3
94 Miller YW Eady EA Lacey RW Cove JH Joanes DN Cunliffe WJ Sequential antibiotic therapy
for acne promotes the carriage of resistant staphylococci on the skin of contacts J Antimicrob
Chemother 199638829-37
95 Skidmore R Kovach R Walker C Thomas J Bradshaw M Leyden J et al Effects of
subantimicrobial-dose doxycycline in the treatment of moderate acne Arch Dermatol 2003139459-
64
96 Gammon WR Meyer C Lantis S Shenefelt P Reizner G Cripps DJ Comparative efficacy of oral
erythromycin versus oral tetracycline in the treatment of acne vulgaris A doubleblind study J Am
Acad Dermatol 198614183-6
97 Christian GL Krueger GG Clindamycin vs placebo as adjunctive therapy in moderately severe acne
Arch Dermatol 1975111997-1000
98 Stoughton RB Cornell RC Gange RW Walter JF Doubleblind comparison of topical 1 percent
clindamycin phosphate (Cleocin T) and oral tetracycline 500 mgday in the treatment of acne
vulgaris Cutis 198026424-5 429
99 Hersle K Trimethoprim-sulphamethoxazole in acne vulgaris A double-blind study Dermatologica
1972145187-91
100 Cotterill JA Cunliffe WJ Forster RA Williamson DM Bulusu L A comparison of trimethoprim-
sulphamethoxazole with oxytetracycline in acne vulgaris Br J Dermatol 197184366-9
31
101 Ward A Brogden RN Heel RC et al Isotretinoin a review of its pharmacological properties and
therapeutic efficacy in acne and other skin disorders Drugs 1984 286
102 Amichai B Shemer A Grunwald MH Low-dose isotretinoin in the treatment of acne vulgaris J
Am Acad Dermatol 2006 54644
103 Layton AM Knaggs H Taylor J Cunliffe WJ Isotretinoin for acne vulgaris - 10 years later a safe
and successful treatment Br J Dermatol 1993 129292
104 White GM Chen W Yao J Wolde-Tsadik G Recurrence rates after the first course of isotretinoin
Arch Dermatol 1998 134376
105 McCarter TL Chen YK Marked hyperlipidemia and pancreatitis associated with isotretinoin
therapy Am J Gastroenterol 1992 871855
106 Rodondi N Darioli R Ramelet AA et al High risk for hyperlipidemia and the metabolic syndrome
after an episode of hypertriglyceridemia during 13-cis retinoic acid therapy for acne a
pharmacogenetic study Ann Intern Med 2002 136582
107 Strauss JS Leyden JJ Lucky AW et al Safety of a new micronized formulation of isotretinoin in
patients with severe recalcitrant nodular acne a randomized trial comparing micronized isotretinoin
with standard isotretinoin J Am Acad Dermatol 2001 45196
108 Peck GL Olsen TG Butkus D Pandya M Arnaud-Battandier J Gross EG et al Isotretinoin versus
placebo in the treatment of cystic acne A randomized double-blind study J Am Acad Dermatol
19826735-45
109 Lehucher-Ceyrac D Weber-Buisset MJ Isotretinoin and acne in practice a prospective analysis of
188 cases over 9 yearsDermatology 1993186123-8
110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
Br J Dermatol 1997137106-8
111 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al A randomized trial
of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in
patients with severe recalcitrant nodular acne J Am Acad Dermatol 200145187-95
112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
randomized trial comparing micronized isotretinoin with standard isotretinoin J Am Acad Dermatol
200145196-207
114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
Acad Dermatol 199226599-606
115 Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW et al American Academy
of Dermatology Consensus Conference on the safe and optimal use of isotretinoinsummary and
recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
118 Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ Effectiveness of
norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
31
101 Ward A Brogden RN Heel RC et al Isotretinoin a review of its pharmacological properties and
therapeutic efficacy in acne and other skin disorders Drugs 1984 286
102 Amichai B Shemer A Grunwald MH Low-dose isotretinoin in the treatment of acne vulgaris J
Am Acad Dermatol 2006 54644
103 Layton AM Knaggs H Taylor J Cunliffe WJ Isotretinoin for acne vulgaris - 10 years later a safe
and successful treatment Br J Dermatol 1993 129292
104 White GM Chen W Yao J Wolde-Tsadik G Recurrence rates after the first course of isotretinoin
Arch Dermatol 1998 134376
105 McCarter TL Chen YK Marked hyperlipidemia and pancreatitis associated with isotretinoin
therapy Am J Gastroenterol 1992 871855
106 Rodondi N Darioli R Ramelet AA et al High risk for hyperlipidemia and the metabolic syndrome
after an episode of hypertriglyceridemia during 13-cis retinoic acid therapy for acne a
pharmacogenetic study Ann Intern Med 2002 136582
107 Strauss JS Leyden JJ Lucky AW et al Safety of a new micronized formulation of isotretinoin in
patients with severe recalcitrant nodular acne a randomized trial comparing micronized isotretinoin
with standard isotretinoin J Am Acad Dermatol 2001 45196
108 Peck GL Olsen TG Butkus D Pandya M Arnaud-Battandier J Gross EG et al Isotretinoin versus
placebo in the treatment of cystic acne A randomized double-blind study J Am Acad Dermatol
19826735-45
109 Lehucher-Ceyrac D Weber-Buisset MJ Isotretinoin and acne in practice a prospective analysis of
188 cases over 9 yearsDermatology 1993186123-8
110 Goulden V Clark SM McGeown C Cunliffe WJ Treatment of acne with intermittent isotretinoin
Br J Dermatol 1997137106-8
111 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al A randomized trial
of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in
patients with severe recalcitrant nodular acne J Am Acad Dermatol 200145187-95
112 McElwee NE Schumacher MC Johnson SC Weir TW Greene SL Scotvold MJ et al An
observational study of isotretinoin recipients treated for acne in a health maintenance
organizationArch Dermatol 1991127341-6
113 Strauss JS Leyden JJ Lucky AW Lookingbill DP Drake LA Hanifin JM et al Safety of a new
micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne A
randomized trial comparing micronized isotretinoin with standard isotretinoin J Am Acad Dermatol
200145196-207
114 Dai WS LaBraico JM Stern RS Epidemiology of isotretinoin exposure during pregnancy J Am
Acad Dermatol 199226599-606
115 Goldsmith LA Bolognia JL Callen JP Chen SC Feldman SR Lim HW et al American Academy
of Dermatology Consensus Conference on the safe and optimal use of isotretinoinsummary and
recommendations J Am Acad Dermatol 200450900-6 Erratum in J Am Acad Dermatol
200451348
116 Rubinow DR Peck GL Squillace KM Gantt GG Reduced anxiety and depression in cystic acne
patients after successful treatment with oral isotretinoin J Am Acad Dermatol 19871725-32
117 Costello MF Shrestha B Eden J Sjoblom P Johnson N Moran LJ Insulin-sensitising drugs versus
the combined oral contraceptive pill for hirsutism acne and risk of diabetes cardiovascular disease
and endometrial cancer in polycystic ovary syndrome Cochrane Database of Systematic Reviews
2007 Issue 1 Art No CD005552 DOI 10100214651858CD005552pub2
118 Lucky AW Henderson TA Olson WH Robisch DM Lebwohl M Swinyer LJ Effectiveness of
norgestimate and ethinyl estradiol in treating moderate acne vulgaris J Am Acad Dermatol
199737746-54
119 Olson WH Lippman JS Robisch DM The duration of response to norgestimate and ethinyl estradiol
in the treatment of acne vulgaris Int J Fertil Womens Med 199843286-90
120 Thiboutot D Archer DF Lemay A Washenik K Roberts J Harrison DD A randomized controlled
trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of
levonorgestrel for acne treatment Fertil Steril 200176461-8
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
32
121 Leyden J Shalita A Hordinsky M Swinyer L Stanczyk FZ Weber ME Efficacy of a low-dose oral
contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the
treatment of moderate acne A randomized placebo-controlled trial J Am Acad Dermatol
200247399-409
122 Cochrane Database Syst Rev 2009 Jan 21(1)CD000194 ACP J Club 2004 May-Jun140(3)74
123 Muhlemann MF Carter GD Cream JJ Wise P Oral spironolactone an effective treatment for acne
vulgaris in women Br J Dermatol 1986115227-32
124 Greenwood R Brummitt L Burke B Cunliffe WJ Acne double blind clinical and laboratory trial of
tetracycline oestrogencyproterone acetate and combined treatment Br Med J (Clin Res Ed)
19852911231-5
125 Miller JA Wojnarowska FT Dowd PM Ashton RE OrsquoBrien TJ Griffiths WA et al Anti-androgen
treatment in women with acne a controlled trial Br J Dermatol 1986114705-16
126 Nader S Rodriguez-Rigau LJ Smith KD Steinberger E Acne and hyperandrogenism impact of
lowering androgen levels with glucocorticoid treatment J Am Acad Dermatol 1984 11256-9
127 Igic PG Lee E Harper W et al Toxic effects associated with consumption of zinc Mayo Clin Proc
200277713-716
128 Porea TJ Belmont JW Mahoney DH Jr Zinc-induced anemia and neutropenia in an adolescent J
Pediatr 2000136688-690
129 Pohit J Saha KC Pal B Zinc status of acne vulgaris patients J Appl Nutr 19853718-25
15 avtorTa jgufi
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier
avtorebi
Tamar meliqiZe (ojaxis eqimi) Tamar mxatvari (ojaxis eqimi) nino kiknaZe (ojaxis eqimi) soso kobaxiZe (dermatovenerologi) givi javaSvili (redaqtori) guram kiknaZe (redaqtori)
eqspertebi
Tbilisis dermatovenerologTa asociacia
saqarTvelos saojaxo medicinis profesionalTa kavSiri
lela woworia _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
Tea TavidaSvili _ saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti
mkurnalobis
gagrZeleba
dazianebis srul aRmofxvramde da Semdgom dozirebi
s Semcireba
an mkurnalo
bis Sewyveta
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