Androgens in women: Hormone-modulating therapies for skin disease.
Azarchi Sarah,Bienenfeld Amanda,Lo Sicco Kristen,Marchbein Shari,Shapiro Jerry,Nagler Arielle R
Journal of the American Academy of Dermatology
Androgen-mediated cutaneous disorders (AMCDs) in women, including acne, hirsutism, and female pattern hair loss, can be treated with hormone-modulating therapies. In the second article in this Continuing Medical Education series, we discuss the hormone-modulating therapies available to dermatologists for the treatment of AMCDs, including combined oral contraceptives, spironolactone, finasteride, dutasteride, and flutamide. Available hormone-modulating treatments used for each AMCDs are reviewed, along with mechanisms of androgen modulation, safety profile, contraindications, monitoring parameters, and evidence of efficacy. Medications discussed include those that are approved by the US Food and Drug Administration for certain AMCDs and some that are used off-label. Despite the ubiquity of hormone-modulating therapies used for AMCDs, this review highlights the need for more rigorous studies to evaluate these therapies for acne, hirsutism, and female pattern hair loss.
10.1016/j.jaad.2018.08.061
Androgens in women: Androgen-mediated skin disease and patient evaluation.
Bienenfeld Amanda,Azarchi Sarah,Lo Sicco Kristen,Marchbein Shari,Shapiro Jerry,Nagler Arielle R
Journal of the American Academy of Dermatology
Androgens are produced throughout the body in steroid-producing organs, such as the adrenal glands and ovaries, and in other tissues, like the skin. Several androgens are found normally in women, including dehydroepiandrosterone, dehydroepiandrosterone-sulfate, testosterone, dihydrotestosterone, and androstenedione. These androgens are essential in the development of several common cutaneous conditions in women, including acne, hirsutism, and female pattern hair loss (FPHL)-androgen-mediated cutaneous disorders (AMCDs). However, the role of androgens in the pathophysiology of these diseases is complicated and incompletely understood. In the first article in this Continuing Medical Education series, we discuss the role of the skin in androgen production and the impact of androgens on the skin in women. Specifically, we review the necessary but insufficient role that androgens play in the development of acne, hirsutism, and FPHL in women. Dermatologists face the challenge of differentiating physiologic from pathologic presentations of AMCDs in women. There are currently no dermatology guidelines outlining the indications for endocrinologic evaluation in women presenting with acne, hirsutism, or FPHL. We review the available evidence regarding when to consider an endocrinologic workup in women presenting with AMCDs, including the appropriate type and timing of testing.
10.1016/j.jaad.2018.08.062
Standardized laboratory monitoring with use of isotretinoin in acne.
Hansen Timothy J,Lucking SaraMarian,Miller Jeffrey J,Kirby Joslyn S,Thiboutot Diane M,Zaenglein Andrea L
Journal of the American Academy of Dermatology
BACKGROUND:Laboratory monitoring for adverse effects to isotretinoin occurs with variability. Standardization of laboratory monitoring practices represents an opportunity to improve quality of care. OBJECTIVE:We sought to develop an evidence-based approach to laboratory monitoring of patients receiving isotretinoin therapy for acne. METHODS:We reviewed laboratory data from 515 patients with acne undergoing 574 courses of isotretinoin from March 2003 to July 2011. Frequency, timing, and severity of abnormalities were determined. RESULTS:Clinically insignificant leukopenia or thrombocytopenia occurred in 1.4% and 0.9% of patients, respectively. Elevated liver transaminases were detected infrequently and not significantly increased compared with baseline detection rates (1.9% vs 1.6% at baseline). Significant elevations occurred with triglyceride (19.3%) and cholesterol (22.8%) levels. The most severe abnormalities were grade 2 (moderate). Mean duration of treatment before abnormalities were detected was 56.3 days for hypertriglyceridemia, 61.9 days for alanine transaminitis, and 50.1 days for hypercholesterolemia. LIMITATIONS:This was a single-center experience examining variable isotretinoin laboratory monitoring practices. CONCLUSIONS:In healthy patients with normal baseline lipid panel and liver function test results, repeated studies should be performed after 2 months of isotretinoin therapy. If findings are normal, no further testing may be required. Routine complete blood cell count monitoring is not recommended.
10.1016/j.jaad.2016.03.019
Light therapies for acne.
The Cochrane database of systematic reviews
BACKGROUND:Acne vulgaris is a very common skin problem that presents with blackheads, whiteheads, and inflamed spots. It frequently results in physical scarring and may cause psychological distress. The use of oral and topical treatments can be limited in some people due to ineffectiveness, inconvenience, poor tolerability or side-effects. Some studies have suggested promising results for light therapies. OBJECTIVES:To explore the effects of light treatment of different wavelengths for acne. SEARCH METHODS:We searched the following databases up to September 2015: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We searched ISI Web of Science and Dissertation Abstracts International (from inception). We also searched five trials registers, and grey literature sources. We checked the reference lists of studies and reviews and consulted study authors and other experts in the field to identify further references to relevant randomised controlled trials (RCTs). We updated these searches in July 2016 but these results have not yet been incorporated into the review. SELECTION CRITERIA:We included RCTs of light for treatment of acne vulgaris, regardless of language or publication status. DATA COLLECTION AND ANALYSIS:We used standard methodological procedures expected by Cochrane. MAIN RESULTS:We included 71 studies, randomising a total of 4211 participants.Most studies were small (median 31 participants) and included participants with mild to moderate acne of both sexes and with a mean age of 20 to 30 years. Light interventions differed greatly in wavelength, dose, active substances used in photodynamic therapy (PDT), and comparator interventions (most commonly no treatment, placebo, another light intervention, or various topical treatments). Numbers of light sessions varied from one to 112 (most commonly two to four). Frequency of application varied from twice daily to once monthly.Selection and performance bias were unclear in the majority of studies. Detection bias was unclear for participant-assessed outcomes and low for investigator-assessed outcomes in the majority of studies. Attrition and reporting bias were low in over half of the studies and unclear or high in the rest. Two thirds of studies were industry-sponsored; study authors either reported conflict of interest, or such information was not declared, so we judged the risk of bias as unclear.Comparisons of most interventions for our first primary outcome 'Participant's global assessment of improvement' were not possible due to the variation in the interventions and the way the studies' outcomes were measured. We did not combine the effect estimates but rated the quality of the evidence as very low for the comparison of light therapies, including PDT to placebo, no treatment, topical treatment or other comparators for this outcome. One study which included 266 participants with moderate to severe acne showed little or no difference in effectiveness for this outcome between 20% aminolevulinic acid (ALA)-PDT (activated by blue light) versus vehicle plus blue light (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.72 to 1.04, low-quality evidence). A study (n = 180) of a comparison of ALA-PDT (activated by red light) concentrations showed 20% ALA was no more effective than 15% (RR 1.05, 95% CI 0.96 to 1.15) but better than 10% ALA (RR 1.22, 95% CI 1.05 to 1.42) and 5% ALA (RR 1.47, 95% CI 1.19 to 1.81). The number needed to treat for an additional beneficial outcome (NNTB) was 6 (95% CI 3 to 19) and 4 (95% CI 2 to 6) for the comparison of 20% ALA with 10% and 5% ALA, respectively.For our second primary outcome 'Investigator-assessed changes in lesion counts', we combined three RCTs, with 360 participants with moderate to severe acne and found methyl aminolevulinate (MAL) PDT (activated by red light) was no different to placebo cream plus red light with regard to change in inflamed lesions (ILs) (mean difference (MD) -2.85, 95% CI -7.51 to 1.81), percentage change in ILs (MD -10.09, 95% CI -20.25 to 0.06), change in non-inflamed lesions (NILs) (MD -2.01, 95% CI -7.07 to 3.05), or in percentage change in NILs (MD -8.09, 95% CI -21.51 to 5.32). We assessed the evidence as moderate quality for these outcomes meaning that there is little or no clinical difference between these two interventions for lesion counts.Studies comparing the effects of other interventions were inconsistent or had small samples and high risk of bias. We performed only narrative synthesis for the results of the remaining trials, due to great variation in many aspects of the studies, poor reporting, and failure to obtain necessary data. Several studies compared yellow light to placebo or no treatment, infrared light to no treatment, gold microparticle suspension to vehicle, and clindamycin/benzoyl peroxide combined with pulsed dye laser to clindamycin/benzoyl peroxide alone. There were also several other studies comparing MAL-PDT to light-only treatment, to adapalene and in combination with long-pulsed dye laser to long-pulsed dye laser alone. None of these showed any clinically significant effects.Our third primary outcome was 'Investigator-assessed severe adverse effects'. Most studies reported adverse effects, but not adequately with scarring reported as absent, and blistering reported only in studies on intense pulsed light, infrared light and photodynamic therapies. We rated the quality of the evidence as very low, meaning we were uncertain of the adverse effects of the light therapies.Although our primary endpoint was long-term outcomes, less than half of the studies performed assessments later than eight weeks after final treatment. Only a few studies assessed outcomes at more than three months after final treatment, and longer-term assessments are mostly not covered in this review. AUTHORS' CONCLUSIONS:High-quality evidence on the use of light therapies for people with acne is lacking. There is low certainty of the usefulness of MAL-PDT (red light) or ALA-PDT (blue light) as standard therapies for people with moderate to severe acne.Carefully planned studies, using standardised outcome measures, comparing the effectiveness of common acne treatments with light therapies would be welcomed, together with adherence to the Consolidated Standards of Reporting Trials (CONSORT) guidelines.
10.1002/14651858.CD007917.pub2
The use of oral antibiotics before isotretinoin therapy in patients with acne.
Nagler Arielle R,Milam Emily C,Orlow Seth J
Journal of the American Academy of Dermatology
BACKGROUND:Systemic antibiotics are used widely to treat moderate to severe acne, but increasing antibiotic resistance makes appropriate use a priority. OBJECTIVE:We sought to determine the duration of systemic antibiotic use in patients with inflammatory/nodulocystic acne who eventually required isotretinoin. METHODS:We performed a retrospective, single-site chart review of patients with acne diagnostic codes evaluated January 1, 2005 to December 31, 2014, at a dermatology practice in an academic medical center. Included patients were prescribed isotretinoin during the study period and received 30 days or more of antibiotics. RESULTS:The average duration of antibiotic use was 331.3 days. In all, 21 patients (15.3%) were prescribed antibiotics for 3 months or less, 88 patients (64.2%) for 6 months or more, and 46 patients (33.6%) for 1 year or longer. Patients treated only at the study site had a mean duration of antibiotic treatment of 283.1 days whereas patients who also received antibiotics from another institution had a mean duration of 380.2 days. This difference approached statistical significance (P = .054). LIMITATIONS:This study was limited to a single center. CONCLUSION:Expert guidelines recommend responsible use of antibiotics in acne in light of emerging resistance. We found that patients who eventually received isotretinoin had extended exposure to antibiotics, exceeding recommendations. Early recognition of antibiotic failure and the need for isotretinoin can curtail antibiotic use.
10.1016/j.jaad.2015.09.046
Light Therapies for Acne.
Posadzki Pawel,Car Josip
JAMA dermatology
Clinical Question:Are light therapies effective and safe for treating acne? Bottom Line:The evidence for all light therapies remains weak and inconclusive. Red-light methyl aminolevulinate-photodynamic therapy (MAL-PDT) was the only treatment associated with a small though clinically insignificant reduction in the number of inflamed lesions and in global improvement as assessed by an investigator in moderate to severe acne. Red-light MAL-PDT was not associated with higher rates of severe adverse effects than placebo or no treatment. Owing to inadequate reporting of adverse effects such as scarring or blistering, the safety of all light therapies remains uncertain.
10.1001/jamadermatol.2018.0110
Interventions for acne scars.
The Cochrane database of systematic reviews
BACKGROUND:Acne scarring is a frequent complication of acne and resulting scars may negatively impact on an affected person's psychosocial and physical well-being. Although a wide range of interventions have been proposed, there is a lack of high-quality evidence on treatments for acne scars to better inform patients and their healthcare providers about the most effective and safe methods of managing this condition. This review aimed to examine treatments for atrophic and hypertrophic acne scars, but we have concentrated on facial atrophic scarring. OBJECTIVES:To assess the effects of interventions for treating acne scars. SEARCH METHODS:We searched the following databases up to November 2015: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), and LILACS (from 1982). We also searched five trials registers, and checked the reference lists of included studies and relevant reviews for further references to randomised controlled trials. SELECTION CRITERIA:We include randomised controlled trials (RCTs) which allocated participants (whether split-face or parallel arms) to any active intervention (or a combination) for treating acne scars. We excluded studies dealing only or mostly with keloid scars. DATA COLLECTION AND ANALYSIS:Three review authors independently extracted data from each of the studies included in this review and evaluated the risks of bias. We resolved disagreements by discussion and arbitration supported by a method expert as required. Our primary outcomes were participant-reported scar improvement and any adverse effects serious enough to cause participants to withdraw from the study. MAIN RESULTS:We included 24 trials with 789 adult participants aged 18 years or older. Twenty trials enrolled men and women, three trials enrolled only women and one trial enrolled only men. We judged eight studies to be at low risk of bias for both sequence generation and allocation concealment. With regard to blinding we judged 17 studies to be at high risk of performance bias, because the participants and dermatologists were not blinded to the treatments administered or received; however, we judged all 24 trials to be at a low risk of detection bias for outcome assessment. We evaluated 14 comparisons of seven interventions and four combinations of interventions. Nine studies provided no usable data on our outcomes and did not contribute further to this review's results.For our outcome 'Participant-reported scar improvement' in one study fractional laser was more effective in producing scar improvement than non-fractional non-ablative laser at week 24 (risk ratio (RR) 4.00, 95% confidence interval (CI) 1.25 to 12.84; n = 64; very low-quality evidence); fractional laser showed comparable scar improvement to fractional radiofrequency in one study at week eight (RR 0.78, 95% CI 0.36 to 1.68; n = 40; very low-quality evidence) and was comparable to combined chemical peeling with skin needling in a different study at week 48 (RR 1.00, 95% CI 0.60 to 1.67; n = 26; very low-quality evidence). In a further study chemical peeling showed comparable scar improvement to combined chemical peeling with skin needling at week 32 (RR 1.24, 95% CI 0.87 to 1.75; n = 20; very low-quality evidence). Chemical peeling in one study showed comparable scar improvement to skin needling at week four (RR 1.13, 95% CI 0.69 to 1.83; n = 27; very low-quality evidence). In another study, injectable fillers provided better scar improvement compared to placebo at week 24 (RR 1.84, 95% CI 1.31 to 2.59; n = 147 moderate-quality evidence).For our outcome 'Serious adverse effects' in one study chemical peeling was not tolerable in 7/43 (16%) participants (RR 5.45, 95% CI 0.33 to 90.14; n = 58; very low-quality evidence).For our secondary outcome 'Participant-reported short-term adverse events', all participants reported pain in the following studies: in one study comparing fractional laser to non-fractional non-ablative laser (RR 1.00, 95% CI 0.94 to 1.06; n = 64; very low-quality evidence); in another study comparing fractional laser to combined peeling plus needling (RR 1.00, 95% CI 0.86 to 1.16; n = 25; very low-quality evidence); in a study comparing chemical peeling plus needling to chemical peeling (RR 1.00, 95% CI 0.83 to 1.20; n = 20; very low-quality evidence); in a study comparing chemical peeling to skin needling (RR 1.00, 95% CI 0.87 to 1.15; n = 27; very low-quality evidence); and also in a study comparing injectable filler and placebo (RR 1.03, 95% CI 0.10 to 11.10; n = 147; low-quality evidence).For our outcome 'Investigator-assessed short-term adverse events', fractional laser (6/32) was associated with a reduced risk of hyperpigmentation than non-fractional non-ablative laser (10/32) in one study (RR 0.60, 95% CI 0.25 to 1.45; n = 64; very low-quality evidence); chemical peeling was associated with increased risk of hyperpigmentation (6/12) compared to skin needling (0/15) in one study (RR 16.00, 95% CI 0.99 to 258.36; n = 27; low-quality evidence). There was no difference in the reported adverse events with injectable filler (17/97) compared to placebo (13/50) (RR 0.67, 95% CI 0.36 to 1.27; n = 147; low-quality evidence). AUTHORS' CONCLUSIONS:There is a lack of high-quality evidence about the effects of different interventions for treating acne scars because of poor methodology, underpowered studies, lack of standardised improvement assessments, and different baseline variables.There is moderate-quality evidence that injectable filler might be effective for treating atrophic acne scars; however, no studies have assessed long-term effects, the longest follow-up being 48 weeks in one study only. Other studies included active comparators, but in the absence of studies that establish efficacy compared to placebo or sham interventions, it is possible that finding no evidence of difference between two active treatments could mean that neither approach works. The results of this review do not provide support for the first-line use of any intervention in the treatment of acne scars.Although our aim was to identify important gaps for further primary research, it might be that placebo and or sham trials are needed to establish whether any of the active treatments produce meaningful patient benefits over the long term.
10.1002/14651858.CD011946.pub2
Antibiotic Resistance in Acne Treatment.
Adler Brandon L,Kornmehl Heather,Armstrong April W
JAMA dermatology
Clinical Question:What is the evidence for antibiotic resistance in acne, and how does resistance affect treatment? Bottom Line:Use of topical and systemic antibiotics for acne is associated with formation of resistance in Propionibacterium acnes and other bacteria, with clinical consequences. Guidelines recommend resistance reduction strategies including avoidance of antibiotic monotherapy, combination treatment with topical modalities, and limiting the duration of oral antibiotic use.
10.1001/jamadermatol.2017.1297
Light therapies for acne: abridged Cochrane systematic review including GRADE assessments.
Barbaric J,Abbott R,Posadzki P,Car M,Gunn L H,Layton A M,Majeed A,Car J
The British journal of dermatology
We undertook a Cochrane review of randomized controlled trials (RCTs) evaluating the effects of light-based interventions for acne vulgaris. We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, ISI Web of Science and grey literature sources (September 2015). We used the Grading of Recommendations Assessment, Development and Evaluation Working Group approach to assess the quality of evidence (QoE). We included 71 RCTs (4211 participants, median sample size 31). Results from a single study (n = 266, low QoE) showed little or no difference in effectiveness on participants' assessment of improvement between 20% aminolaevulinic acid (ALA) photodynamic therapy (PDT), activated by blue light, vs. vehicle plus blue light, whereas another study (n = 180) comparing ALA-PDT (red light) concentrations showed that 20% ALA-PDT was no more effective than 15% ALA-PDT but better than 10% and 5% ALA-PDT. Pooled data from three studies (n = 360, moderate QoE) showed that methyl aminolaevulinate PDT, activated by red light, had a similar effect on changes in lesion counts vs. placebo cream with red light. Several studies compared yellow light with placebo or no treatment, infrared light with no treatment, gold microparticle suspension with vehicle and clindamycin/benzoyl peroxide (C/BPO) combined with pulsed dye laser with C/BPO alone. None of these showed any clinically significant effects. Most studies reported adverse effects, but inadequately, with scarring reported as absent, and blistering only in studies on intense pulsed light, infrared light and PDT (very low QoE). Carefully planned studies, using standardized outcome measures and common acne treatments as comparators, are needed.
10.1111/bjd.15495
Oral isotretinoin for acne.
The Cochrane database of systematic reviews
BACKGROUND:Acne vulgaris, a chronic inflammatory disease of the pilosebaceous unit associated with socialisation and mental health problems, may affect more than 80% of teenagers. Isotretinoin is the only drug that targets all primary causal factors of acne; however, it may cause adverse effects. OBJECTIVES:To assess efficacy and safety of oral isotretinoin for acne vulgaris. SEARCH METHODS:We searched the following databases up to July 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO and LILACS. We updated this search in March 2018, but these results have not yet been incorporated in the review. We also searched five trial registries, checked the reference lists of retrieved studies for further references to relevant trials, and handsearched dermatology conference proceedings. A separate search for adverse effects of oral isotretinoin was undertaken in MEDLINE and Embase up to September 2013. SELECTION CRITERIA:Randomised clinical trials (RCTs) of oral isotretinoin in participants with clinically diagnosed acne compared against placebo, any other systemic or topical active therapy, and itself in different formulation, doses, regimens, or course duration. DATA COLLECTION AND ANALYSIS:We used standard methodological procedures expected by Cochrane. MAIN RESULTS:We included 31 RCTs, involving 3836 participants (12 to 55 years) with mild to severe acne. There were twice as many male participants as females.Most studies were undertaken in Asia, Europe, and North America. Outcomes were generally measured between eight to 32 weeks (mean 19.7 weeks) of therapy.Assessed comparisons included oral isotretinoin versus placebo or other treatments such as antibiotics. In addition, different doses, regimens, or formulations of oral isotretinoin were assessed, as well as oral isotretinoin with the addition of topical agents.Pharmaceutical companies funded 12 included trials. All, except three studies, had high risk of bias in at least one domain.Oral isotretinoin compared with oral antibiotics plus topical agentsThese studies included participants with moderate or severe acne and assessed outcomes immediately after 20 to 24 weeks of treatment (short-term). Three studies (400 participants) showed isotretinoin makes no difference in terms of decreasing trial investigator-assessed inflammatory lesion count (RR 1.01 95% CI 0.96 to 1.06), with only one serious adverse effect found, which was Stevens-Johnson syndrome in the isotretinoin group (RR 3.00, 95% CI 0.12 to 72.98). However, we are uncertain about these results as they were based on very low-quality evidence.Isotretinoin may slightly improve (by 15%) acne severity, assessed by physician's global evaluation (RR 1.15, 95% CI 1.00 to 1.32; 351 participants; 2 studies), but resulted in more less serious adverse effects (67% higher risk) (RR 1.67, 95% CI 1.42 to 1.98; 351 participants; 2 studies), such as dry lips/skin, cheilitis, vomiting, nausea (both outcomes, low-quality evidence).Different doses/therapeutic regimens of oral isotretinoinFor our primary efficacy outcome, we found three RCTs, but heterogeneity precluded meta-analysis. One study (154 participants) reported 79%, 80% and 84% decrease in total inflammatory lesion count after 20 weeks of 0.05, 0.1, or 0.2 mg/kg/d of oral isotretinoin for severe acne (low-quality evidence). Another trial (150 participants, severe acne) compared 0.1, 0.5, and 1 mg/kg/d oral isotretinoin for 20 weeks and, respectively, 58%, 80% and 90% of participants achieved 95% decrease in total inflammatory lesion count. One RCT, of participants with moderate acne, compared isotretinoin for 24 weeks at (a) continuous low dose (0.25 to 0.4 mg/kg/day), (b) continuous conventional dose (0.5 to 0.7 mg/kg/day), and (c) intermittent regimen (0.5 to 0.7 mg/kg/day, for one week in a month). Continuous low dose (MD 3.72 lesions; 95% CI 2.13 to 5.31; 40 participants; one study) and conventional dose (MD 3.87 lesions; 95% CI 2.31 to 5.43; 40 participants; one study) had a greater decrease in inflammatory lesion counts compared to intermittent treatment (all outcomes, low-quality evidence).Fourteen RCTs (906 participants, severe and moderate acne) reported that no serious adverse events were observed when comparing different doses/therapeutic regimens of oral isotretinoin during treatment (from 12 to 32 weeks) or follow-up after end of treatment (up to 48 weeks). Thirteen RCTs (858 participants) analysed frequency of less serious adverse effects, which included skin dryness, hair loss, and itching, but heterogeneity regarding the assessment of the outcome precluded data pooling; hence, there is uncertainty about the results (low- to very-low quality evidence, where assessed).Improvement in acne severity, assessed by physician's global evaluation, was not measured for this comparison.None of the included RCTs reported birth defects. AUTHORS' CONCLUSIONS:Evidence was low-quality for most assessed outcomes.We are unsure if isotretinoin improves acne severity compared with standard oral antibiotic and topical treatment when assessed by a decrease in total inflammatory lesion count, but it may slightly improve physician-assessed acne severity. Only one serious adverse event was reported in the isotretinoin group, which means we are uncertain of the risk of serious adverse effects; however, isotretinoin may result in more minor adverse effects.Heterogeneity in the studies comparing different regimens, doses, or formulations of oral isotretinoin meant we were unable to undertake meta-analysis. Daily treatment may be more effective than treatment for one week each month. None of the studies in this comparison reported serious adverse effects, or measured improvement in acne severity assessed by physician's global evaluation. We are uncertain if there is a difference in number of minor adverse effects, such as skin dryness, between doses/regimens.Evidence quality was lessened due to imprecision and attrition bias. Further studies should ensure clearly reported long- and short-term standardised assessment of improvement in total inflammatory lesion counts, participant-reported outcomes, and full safety accounts. Oral isotretinoin for acne that has not responded to oral antibiotics plus topical agents needs further assessment, as well as different dose/regimens of oral isotretinoin in acne of all severities.
10.1002/14651858.CD009435.pub2
Isotretinoin treatment for acne and risk of depression: A systematic review and meta-analysis.
Huang Yu-Chen,Cheng Ying-Chih
Journal of the American Academy of Dermatology
BACKGROUND:The relationship between isotretinoin treatment for acne and depression is controversial. Quantitative analysis has not yet been conducted. OBJECTIVE:To conduct a meta-analysis, evidence-based examination of the relationship between isotretinoin and depression. METHOD:A systematic review and meta-analysis of the literature published from inception to September 30, 2016, was conducted. Controlled or prospective non-controlled trials on ≥15 acne patients receiving isotretinoin treatment were included. The prevalence of depression and change in depression scores were calculated. RESULT:Thirty-one studies met the inclusion criteria. In the controlled studies, the change in depression scores from baseline was not significantly different between patients receiving isotretinoin treatment and those receiving an alternative treatment (standardized mean difference [SMD] -0.334, 95% confidence interval [CI] -0.680 to 0.011). The prevalence of depression after isotretinoin treatment significantly declined (relative risk [RR] 0.588, 95% CI 0.382-0.904). The mean depression scores significantly decreased from baseline (SMD -0.335, 95% CI -0.498 to -0.172). LIMITATIONS:No randomized controlled trials were reviewed; a large inter-study variation was observed. CONCLUSIONS:Isotretinoin treatment for acne does not appear to be associated with an increased risk for depression. Moreover, the treatment of acne appears to ameliorate depressive symptoms.
10.1016/j.jaad.2016.12.028
Insulin Resistance and Metabolic Syndrome in Young Men With Acne.
Nagpal Mohit,De Dipankar,Handa Sanjeev,Pal Arnab,Sachdeva Naresh
JAMA dermatology
INTRODUCTION:Robust evidence of the association of insulin resistance and metabolic syndrome with acne in male patients is lacking. OBJECTIVE:To assess the prevalence of metabolic syndrome and insulin resistance in male patients 20 years or older with acne. DESIGN, SETTING, AND PARTICIPANTS:We performed a cross-sectional study in 100 male patients with acne and 100 age-matched male controls without acne from a dermatology outpatient department of a tertiary care institute. Postadolescent patients were recruited only to negate the effects of physiologic insulin resistance that are seen at the time of puberty and adolescence. Twenty-five patients were included in each of the 4 individual severity groups according to the Global Acne Grading System and were age matched to 100 male controls without acne. EXPOSURES:Clinical examination, Global Acne Rating System, National Cholesterol Education Programme Adult Treatment Panel III (NCEP-ATP III), and Homeostasis Model Assessment-Insulin Resistance (HOMA-IR). MAIN OUTCOMES AND MEASURES:Metabolic syndrome was diagnosed as per the criteria of the modified NCEP-ATP III. Insulin resistance was assessed by the HOMA-IR. A HOMA-IR value greater than 2.5 was arbitrarily considered as insulin resistance. RESULTS:Prevalence of insulin resistance was significantly higher in cases (22%) compared with controls (11%) (P = .03). The prevalence of metabolic syndrome was comparable between cases (17%) and controls (9%) (P = .09). Prevalence of insulin resistance and metabolic syndrome did not differ significantly among the acne severity groups. CONCLUSIONS AND RELEVANCE:Postadolescent male patients with acne more commonly have insulin resistance. This resistance may be a stage of prediabetes, and the patients may develop hyperinsulinemia or type 2 diabetes in the future. These patients should be followed up for a prolonged time to determine whether they develop conditions associated with insulin resistance.
10.1001/jamadermatol.2015.4499
Adult female acne and associated risk factors: Results of a multicenter case-control study in Italy.
Di Landro Anna,Cazzaniga Simone,Cusano Francesco,Bonci Angela,Carla Cardinali,Musumeci Maria Letizia,Patrizi Annalisa,Bettoli Vincenzo,Pezzarossa Enrico,Caproni Marzia,Fortina Anna Belloni,Campione Elena,Ingordo Vito,Naldi Luigi,
Journal of the American Academy of Dermatology
BACKGROUND:The reasons for the appearance of acne in adulthood are largely unknown. OBJECTIVE:We explored the role of personal and environmental factors in adult female acne. METHODS:We conducted a multicenter case-control study in the outpatient departments of 12 Italian cities. Cases (n = 248) were consecutive women ≥25 years of age with newly diagnosed acne of any grade. Controls (n = 270) were females diagnosed with conditions other than acne. RESULTS:In multivariate analysis, a history of acne in parents (odds ratio [OR] = 3.02) or siblings (OR = 2.40), history of acne during adolescence (OR = 5.44), having no previous pregnancies (OR = 1.71), having hirsutism (OR = 3.50), being an office worker versus being unemployed or being a housewife (OR = 2.24), and having a high level of reported psychological stress (OR = 2.95) were all associated with acne. A low weekly intake of fruits or vegetables (OR = 2.33) and low consumption of fresh fish (OR = 2.76) were also associated with acne. LIMITATIONS:We did not establish an onset date for acne. Some of our associations may reflect consequences of established acne. CONCLUSION:Lifestyle factors may play an important role for acne development in adulthood, but their role should be further assessed in prospective studies.
10.1016/j.jaad.2016.06.060
Efficacy and adverse events of oral isotretinoin for acne: a systematic review.
Vallerand I A,Lewinson R T,Farris M S,Sibley C D,Ramien M L,Bulloch A G M,Patten S B
The British journal of dermatology
Despite many years of clinical use of isotretinoin, a comprehensive review of evidence for isotretinoin therapy in patients with acne is lacking. We searched MEDLINE, Embase, Cochrane Central, relevant web pages and bibliographies for randomized controlled trials in acne evaluating isotretinoin vs. control (placebo or other therapy). Data were extracted and summarized descriptively. Eleven trials were identified (total 760 patients randomized), containing mostly men. Mean treatment ages ranged from 18 to 47·9 years and participants generally had moderate-to-severe acne. Across all trials, isotretinoin therapy reduced acne lesion counts by a clinically relevant amount, and always by a greater amount than control, which was either placebo (two studies), oral antibiotics (seven studies) or other control (two studies). Across trials with an overall low risk of bias, two of three demonstrated statistically significant differences between isotretinoin and control. The frequency of adverse events was twice as high with isotretinoin (751 events) than with control (388 events). More than half of all adverse events were dermatological and related to dryness. Adverse events from isotretinoin causing participant withdrawal from trials (12 patients) included Stevens-Johnson syndrome, cheilitis, xerosis, acne flare, photophobia, elevated liver enzymes, decreased appetite, headaches and depressed mood. This review suggests that isotretinoin is effective in reducing acne lesion counts, but adverse events are common. This study was registered with PROSPERO number CRD42015025080.
10.1111/bjd.15668
Atrophic scar formation in patients with acne involves long-acting immune responses with plasma cells and alteration of sebaceous glands.
Carlavan I,Bertino B,Rivier M,Martel P,Bourdes V,Motte M,Déret S,Reiniche P,Menigot C,Khammari A,Dreno B,Fogel P,Voegel J J
The British journal of dermatology
BACKGROUND:Possible outcomes of acne lesions are atrophic scars, which may cause serious psychological distress. Current treatments for postacne scarring often require invasive procedures. Pathophysiological studies on acne scarring have only investigated the first week of papule life. OBJECTIVES:To study the pathophysiology of atrophic scar formation to identify molecular and cellular pathways that can lead to new therapies for the prevention of acne scarring. METHODS:Large-scale gene expression profiling and immunohistochemistry analysis were performed on uninvolved skin and papules in both scar-prone (SP) and non-scar-prone (NSP) patients with acne, at different time points. RESULTS:Gene expression and immunohistochemistry analyses showed a very similar immune response in 48-h-old papules in SP and NSP populations, characterized by elevated numbers of T cells, neutrophils and macrophages. However, the immune response only persisted in SP patients in 3-week-old papules, and was characterized by an important B-cell infiltrate. Transient downmodulation of sebaceous gland markers related to lipid metabolism was observed in 48-h-old papules in NSP patients, followed by normalization after 3 weeks. In contrast, in SP patients a drastic reduction of these markers persisted in 3-week-old papules, suggesting an irreversible destruction of sebaceous gland structures after inflammatory remodelling in SP patients with acne. CONCLUSIONS:Long-lived acne papules are characterized by a B-cell infiltrate. A relationship exists between the duration and severity of inflammation and the alteration of sebaceous gland structures, leading to atrophic scar formation in acne.
10.1111/bjd.16680
Approaches to limit systemic antibiotic use in acne: Systemic alternatives, emerging topical therapies, dietary modification, and laser and light-based treatments.
Barbieri John S,Spaccarelli Natalie,Margolis David J,James William D
Journal of the American Academy of Dermatology
Acne is one of the most common diseases worldwide and affects ∼50 million individuals in the United States. Oral antibiotics are the most common systemic agent prescribed for the treatment of acne. However, their use might be associated with a variety of adverse outcomes including bacterial resistance and disruption of the microbiome. As a result, multiple treatment guidelines call for limiting the use of oral antibiotics in the treatment of acne, although actual prescribing often does not follow these guidelines. In this review, the rationale for concerns regarding the use of oral antibiotics for the management of acne is reviewed. In addition, we will discuss our approach to complying with the intent of the guidelines, with a focus on novel topical agents, dietary modification, laser and light-based modalities, and systemic medications, such as spironolactone, combined oral contraceptives, and oral isotretinoin.
10.1016/j.jaad.2018.09.055
Laboratory Monitoring During Isotretinoin Therapy for Acne: A Systematic Review and Meta-analysis.
Lee Young H,Scharnitz Thomas P,Muscat Joshua,Chen Allshine,Gupta-Elera Gaytri,Kirby Joslyn S
JAMA dermatology
IMPORTANCE:Oral isotretinoin has been associated with several adverse effects, but evidence-based estimates of laboratory changes during isotretinoin therapy in large patient samples are limited. OBJECTIVE:To develop estimates of the laboratory changes that occur during isotretinoin therapy for acne using extant data and meta-analytic methods. DATA SOURCES:A comprehensive search strategy using Ovid/MEDLINE, EMBASE, and gray literature was conducted (1960-August 1, 2013) to identify all relevant studies of isotretinoin use in acne vulgaris. Terms related to acne treatment, isotretinoin, and diagnostic procedures were searched with all available synonyms. STUDY SELECTION:Inclusion criteria consisted of clinical trials using oral isotretinoin, doses of 40 mg/d or more, duration of at least 4 weeks, patients aged 9 to 35 years with acne vulgaris, and 10 or more participants. Studies from all countries published in any language were included. Exclusion criteria were use of modified isotretinoin products, isotretinoin therapy for conditions other than acne vulgaris, and concomitant acne therapy. The initial search yielded 342 records; 116 of these were screened for full-text examination. DATA EXTRACTION AND SYNTHESIS:Two authors independently reviewed the publications to determine eligibility, and disagreements were resolved by a third author. Generated weighted means and 99% CIs were calculated using the reported means (SDs or SEs). A random effects model was created, and statistical heterogeneity was quantified. Data were analyzed from August 25, 2014, to December 4, 2015. MAIN OUTCOMES AND MEASURES:Laboratory values for lipid levels, hepatic function, and complete blood cell count were evaluated. RESULTS:Data from 61 of the 116 studies were evaluated; 26 studies (1574 patients) were included in the meta-analysis. The mean (99% CI) values during treatment (nonbaseline) for triglycerides was 119.98 mg/dL (98.58-141.39 mg/dL); for total cholesterol, 184.74 mg/dL (178.17-191.31 mg/dL); for low-density lipoprotein cholesterol, 109.23 mg/dL (103.68-114.79 mg/dL); for high-density lipoprotein cholesterol, 42.80 mg/dL (39.84-45.76 mg/dL); for aspartate aminotransferase, 22.67 U/L (19.94-25.41 U/L); for alanine aminotransferase, 21.77 U/L (18.96-24.59 U/L); for alkaline phosphatase, 88.35 U/L (58.94-117.76 U/L); and for white blood cell count, 6890/µL (5700/µL-8030/µL). This meta-analysis showed that (1) isotretinoin is associated with a statistically significant change in the mean value of several laboratory tests (white blood cell count and hepatic and lipid panels), yet (2) the mean changes across a patient group did not meet a priori criteria for high-risk and (3) the proportion of patients with laboratory abnormalities was low. CONCLUSIONS AND RELEVANCE:The evidence from this study does not support monthly laboratory testing for use of standard doses of oral isotretinoin for the standard patient with acne.
10.1001/jamadermatol.2015.3091
Platelet-rich plasma and its utility in the treatment of acne scars: A systematic review.
Hesseler Michael J,Shyam Nikhil
Journal of the American Academy of Dermatology
The field of dermatology has seen numerous therapeutic innovations in the past decade, with platelet-rich plasma recently garnering significant interest in acne scarring. This review consolidates the available evidence on platelet-rich plasma for the practicing dermatologist and evaluates the current evidence up to May 31, 2018. A search was conducted in the PubMed database for the terms platelet-rich plasma or platelet releasate or platelet gel or PRP and dermatology or skin or acne or scar or cutaneous, with 13 articles meeting the inclusion criteria. The quality of each individual study was evaluated, and levels of evidence were assigned according to the Centre for Evidence-Based Medicine, Oxford, United Kingdom. This review reveals that activated, leukocyte- and platelet-rich plasma in combination with fractional ablative laser treatment administered in 2 or 3 sequential sessions 1 month apart improves the appearance of acne scars. The evidence for the use of platelet-rich plasma with microneedling is less supportive. Because of the heterogeneity of the studies and widely variable outcome measures, comparison between platelet-rich plasma treatments and subsequent statistical analysis could not be performed. Although these studies use various subjective and objective evaluation methods, the addition of platelet-rich plasma provides improvements in acne scarring, higher patient satisfaction, and decreased postprocedure downtime.
10.1016/j.jaad.2018.11.029
What does acne genetics teach us about disease pathogenesis?
Common J E A,Barker J N,van Steensel M A M
The British journal of dermatology
BACKGROUND:Acne vulgaris is a highly prevalent inflammatory skin disorder with a complex pathogenesis, characterized by comedones, papules, pustules and nodules. Familial preponderance clearly indicates a genetic basis for acne vulgaris, but until recently solid genetic associations were lacking. RESULTS:The advent of high-resolution genotyping array technologies has allowed for large-scale studies with both family-based and cross-sectional designs. These studies have revealed genetic loci encompassing genes that could be active in biological pathways and processes underlying acne vulgaris. However, specific functional consequences of those variants remain elusive. In parallel, investigations into rare disorders and syndromes that incorporate features of acne or acne-like lesions have recently accelerated our understanding of disease pathogenesis. The genes revealed by these rare disorders highlight mechanisms cardinal for pilosebaceous biology and therefore anchor our insights from genetic association studies for acne vulgaris. CONCLUSIONS:The next phase of research will require more in-depth mechanistic investigations of loci and genes implicated in acne phenotypes to define the key molecular players driving the disorder. Concurrently, new treatments for acne vulgaris could be developed by dissecting the candidate molecular pathways to identify druggable targets.
10.1111/bjd.17721
Trends in prescribing behavior of systemic agents used in the treatment of acne among dermatologists and nondermatologists: A retrospective analysis, 2004-2013.
Barbieri John S,James William D,Margolis David J
Journal of the American Academy of Dermatology
BACKGROUND:Despite recommendations to limit the use of oral antibiotics and increasing support for hormonal agents in the treatment of acne, it is unclear whether there have been any significant changes in practice patterns. OBJECTIVE:To characterize changes in prescribing behavior for systemic agents in the treatment of acne in the United States between 2004 and 2013. METHODS:We conducted a retrospective analysis using the OptumInsight Clinformatics DataMart (Optum, Eden Prairie, MN). RESULTS:The number of courses of spironolactone prescribed per 100 female patients being managed for acne by dermatologists and nondermatologists increased from 2.08 to 8.13 and from 1.43 to 4.09, respectively. The median duration of therapy with oral antibiotics was 126 and 129 days among patients managed by dermatologists and nondermatologists, respectively, and did not change significantly over the study period. LIMITATIONS:The OptumInsight Clinformatics DataMart lacks information on acne severity and clinical outcomes. CONCLUSIONS:Additional work to identify patients who would benefit most from alternative therapies such as spironolactone, oral contraceptives, or isotretinoin represents a potential opportunity to improve the care of patients with acne.
10.1016/j.jaad.2017.04.016
Evidence-based recommendations for the management of acne fulminans and its variants.
Greywal Tanya,Zaenglein Andrea L,Baldwin Hilary E,Bhatia Neal,Chernoff Karen A,Del Rosso James Q,Eichenfield Lawrence F,Levin Marc H,Leyden James J,Thiboutot Diane M,Webster Guy F,Friedlander Sheila Fallon
Journal of the American Academy of Dermatology
BACKGROUND:Acne fulminans (AF) is a severe variant of inflammatory acne. It typically manifests as an explosive worsening and ulceration of skin lesions, and can be associated with systemic symptoms. However, there is a paucity of evidence-based information and no clear guidelines concerning the classification and treatment of AF. OBJECTIVE:To better define the spectrum of AF and its variants, devise optimal therapeutic approaches, and identify areas of future research. METHODS:A panel of physicians with expertise in severe acne vulgaris was convened after a comprehensive literature review of severe acne variants. Priority topics were reviewed and presented by each panelist at a 5-hour conference. Following review of the audiotape and scribed notes from the conference, surveys were utilized to address points of controversy and to clarify consensus recommendations. RESULTS:Appropriate clinical case presentations and consensus survey questions were utilized to create final recommendations based on both the literature and the expert consensus. LIMITATIONS:Limited evidenced-based data and prospective studies in the literature concerning the treatment of AF is available. CONCLUSION:These guidelines better characterize AF and provide health care practitioners approaches to the classification, treatment, and prevention of AF and its variants.
10.1016/j.jaad.2016.11.028
Acne and hidradenitis suppurativa.
Pink A,Anzengruber F,Navarini A A
The British journal of dermatology
Acne and hidradenitis suppurativa (HS) both centre on hair follicles. They often occur together as part of the acne tetrad, but are found in distinct localizations. Acne is primarily defined by the presence of comedones and inflammatory lesions. However, in HS the intertriginous localization and chronicity play equally important roles for the diagnosis to the inflammatory lesions. Genetics, bacteria, environmental factors and innate inflammation have all been found to play a role in acne and/or HS. Surprisingly, there is little overlap between the findings so far. The genetics of acne and HS are distinct, bacteria have not been shown convincingly to play a role in HS, and the important risk factors obesity and smoking in HS cannot be easily translated to acne. The one driving factor central to both diseases is innate inflammation, most strikingly involving interleukin-1. Hence the interleukin-1 family, as already shown in autoinflammatory conditions associated with acne, could represent attractive treatment targets.
10.1111/bjd.16231
Depression screening using health questionnaires in patients receiving oral isotretinoin for acne vulgaris.
Schrom Kory,Nagy Terri,Mostow Eliot
Journal of the American Academy of Dermatology
Isotretinoin is used to treat severe and recalcitrant acne. Possible side effects include depression, suicide, and suicidal ideation; however, other studies suggest isotretinoin may improve mood and quality of life. Although iPLEDGE consenting warns about the risk of depression and suicidal ideation, there is no recommendation for screening tools. The patient health questionnaire-2 and the patient health questionnaire-9 are validated instruments that enable dermatologists to efficiently screen for depression before and after isotretinoin is initiated.
10.1016/j.jaad.2016.02.1148
Randomized phase 3 evaluation of trifarotene 50 μg/g cream treatment of moderate facial and truncal acne.
Tan Jerry,Thiboutot Diane,Popp Georg,Gooderham Melinda,Lynde Charles,Del Rosso James,Weiss Jonathan,Blume-Peytavi Ulrike,Weglovska Jolanta,Johnson Sandra,Parish Lawrence,Witkowska Dagmara,Sanchez Colon Nestor,Alió Saenz Alessandra,Ahmad Faiz,Graeber Michael,Stein Gold Linda
Journal of the American Academy of Dermatology
BACKGROUND:Acne vulgaris often affects the face, shoulders, chest, and back, but treatment of nonfacial acne has not been rigorously studied. OBJECTIVES:Assess the safety and efficacy of trifarotene 50 μg/g cream, a novel topical retinoid, in moderate facial and truncal acne. METHODS:Two phase III double-blind, randomized, vehicle-controlled, 12-week studies of once-daily trifarotene cream versus vehicle in subjects aged 9 years or older. The primary end points were rate of success on the face, as determined by the Investigator's Global Assessment (clear or almost clear and ≥2-grade improvement), and absolute change from baseline in inflammatory and noninflammatory counts from baseline to week 12. The secondary end points were rate of success on the trunk (clear or almost clear and ≥2-grade improvement) and absolute change in truncal inflammatory and noninflammatory counts from baseline to week 12. Safety was assessed through adverse events, local tolerability, vital signs, and routine laboratory testing results. RESULTS:In both studies, at week 12 the facial success rates according to the Investigator's Global Assessment and truncal Physician's Global Assessment and change in inflammatory and noninflammatory lesion counts (both absolute and percentage) were all highly significant (P < .001) in favor of trifarotene when compared with the vehicle. LIMITATIONS:Adjunctive topical or systemic treatments were not studied. CONCLUSION:These studies demonstrate that trifarotene appears to be safe, effective, and well tolerated in treatment of both facial and truncal acne.
10.1016/j.jaad.2019.02.044
Efficacy and safety of a novel topical minocycline foam for the treatment of moderate to severe acne vulgaris: A phase 3 study.
Raoof Tooraj Joseph,Hooper Deirdre,Moore Angela,Zaiac Martin,Sullivan Tory,Kircik Leon,Lain Edward,Jankicevic Jasmina,Stuart Iain
Journal of the American Academy of Dermatology
BACKGROUND:FMX101 4% topical minocycline foam has been shown to be an effective and safe treatment for acne vulgaris (AV). OBJECTIVE:To further evaluate the efficacy and safety of FMX101 4% in treating moderate to severe acne vulgaris. METHODS:A 12-week, multicenter, randomized (1:1), double-blind, vehicle-controlled study was conducted. Coprimary end points were the absolute change in inflammatory lesion count from baseline and the rate of treatment success (Investigator's Global Assessment score of 0 or 1 with a ≥2-grade improvement). RESULTS:There were 1488 participants in the intent-to-treat population. The FMX101 4% group had significantly greater reductions in the number of inflammatory lesions from baseline (P < .0001) and a greater rate of treatment success based on Investigator's Global Assessment (P < .0001) versus the foam vehicle group at week 12. FMX101 4% was generally safe and well tolerated. LIMITATIONS:The efficacy and safety of FMX101 4% were not characterized in participants with mild AV. CONCLUSION:FMX101 4% topical minocycline foam was effective and safe for the treatment of moderate to severe AV.
10.1016/j.jaad.2019.05.078
Practical management of acne for clinicians: An international consensus from the Global Alliance to Improve Outcomes in Acne.
Thiboutot Diane M,Dréno Brigitte,Abanmi Abdullah,Alexis Andrew F,Araviiskaia Elena,Barona Cabal Maria Isabel,Bettoli Vincenzo,Casintahan Flordeliz,Chow Steven,da Costa Adilson,El Ouazzani Tam,Goh Chee-Leok,Gollnick Harald P M,Gomez Minerva,Hayashi Nobukazu,Herane Maria Isabel,Honeyman Juan,Kang Sewon,Kemeny Lajos,Kubba Raj,Lambert Julien,Layton Alison M,Leyden James J,López-Estebaranz Jose Luis,Noppakun Nopadon,Ochsendorf Falk,Oprica Cristina,Orozco Beatriz,Perez Montserrat,Piquero-Martin Jaime,See Jo-Ann,Suh Dae Hun,Tan Jerry,Lozada Vicente Torres,Troielli Patricia,Xiang Leihong Flora
Journal of the American Academy of Dermatology
Scientific advances are continually improving the knowledge of acne and contributing to the refinement of treatment options; it is important for clinicians to regularly update their practice patterns to reflect current standards. The Global Alliance to Improve Outcomes in Acne is an international group of dermatologists with an interest in acne research and education that has been meeting regularly since 2001. As a group, we have continuously evaluated the literature on acne. This supplement focuses on providing relevant clinical guidance to health care practitioners managing patients with acne, with an emphasis on areas where the evidence base may be sparse or need interpretation for daily practice.
10.1016/j.jaad.2017.09.078
Photodynamic therapy with methyl aminolaevulinate 80 mg g(-1) for severe facial acne vulgaris: a randomized vehicle-controlled study.
Pariser D M,Eichenfield L F,Bukhalo M,Waterman G,Jarratt M,
The British journal of dermatology
BACKGROUND:Severe acne vulgaris has limited therapeutic options. OBJECTIVES:To evaluate photodynamic therapy (PDT) using topical methyl aminolaevulinate (MAL, 80 mg g(-1) ) as the photosensitizer in severe facial acne. METHODS:A double-blind, randomized, vehicle-controlled multicentre trial in 153 patients (aged 12-35 years) with severe facial acne [Investigator's Global Assessment (IGA) score 4; 25-75 inflammatory lesions with ≤ 3 nodules; 20-100 noninflammatory lesions]. Treatment (four treatments 2 weeks apart) involved incubation with MAL (n = 100) or vehicle cream (n = 53) for 1·5 h under occlusion, then illumination (635-nm red light, total dose 37 J cm(-2) ). IGA assessment and standardized lesion counts were performed before each treatment and 12 weeks after the first treatment. Treatment success was defined as improvement from baseline in IGA by ≥ 2 grades at 12 weeks. Safety assessments were for pain (10-cm visual analogue scale, immediately after illumination), erythema (four-point rating scale) and adverse events. RESULTS:At 12 weeks, PDT using MAL 80 mg g(-1) reduced inflammatory lesions vs. vehicle PDT (mean change -15·6 vs. -7·8, P = 0·006; mean percentage change -37·3% vs. -16·2%, P = 0·003). However, noninflammatory lesions did not decrease significantly (mean change -11·8 vs. -10·7, P = 0·85; mean percentage change -28·6% vs. -24·9%, P = 0·72). Treatment success rates were greater with MAL-PDT 80 mg g(-1) (44% vs. 26%, P = 0·013). Pain was low and manageable by briefly pausing illumination. There was similar pain or erythema with successive treatments. CONCLUSIONS:PDT using topical MAL 80 mg g(-1) and red light may offer promise for severe acne vulgaris.
10.1111/bjd.14345
A novel topical minocycline foam for the treatment of moderate-to-severe acne vulgaris: Results of 2 randomized, double-blind, phase 3 studies.
Gold Linda Stein,Dhawan Sunil,Weiss Jonathan,Draelos Zoe Diana,Ellman Herman,Stuart Iain A
Journal of the American Academy of Dermatology
BACKGROUND:FMX101 4% is a topical minocycline foam for the treatment of moderate-to-severe acne. OBJECTIVE:Evaluate the efficacy and safety of FMX101 4% in treating moderate-to-severe acne vulgaris. METHODS:Two identical phase 3 studies were conducted. Subjects were randomized 2:1 to once-daily FMX101 4% or foam vehicle for 12 weeks. The coprimary end points were the change in inflammatory lesion count from baseline and the rate of treatment success according to the Investigator's Global Assessment (a score of 0 or 1 for clear or almost clear, with a ≥2-grade improvement) at week 12. RESULTS:A total of 961 subjects were enrolled (study 04, N = 466; study 05, N = 495). Compared with vehicle, FMX101 4% demonstrated a significantly greater reduction in inflammatory lesions in both studies (P < .05) and a greater rate of treatment success in study 05 according to the Investigator's Global Assessment (P < .05). Pooled analyses of the 2 studies demonstrated statistical significance for both coprimary end points (all P < .05). Noninflammatory lesion count was also significantly reduced with FMX101 4% versus with vehicle in both studies. FMX101 4% was generally safe and well tolerated. Skin-related adverse events were reported in less than 1% of subjects treated with FMX101 4%. LIMITATIONS:Longer-term efficacy and safety outcomes are needed (ongoing). CONCLUSION:FMX101 4% topical minocycline foam significantly reduced both inflammatory and noninflammatory lesions and improved Investigator's Global Assessment scores in patients with moderate-to-severe acne.
10.1016/j.jaad.2018.08.020
The management of acne vulgaris in primary care: a cohort study of consulting and prescribing patterns using the Clinical Practice Research Datalink.
Francis N A,Entwistle K,Santer M,Layton A M,Eady E A,Butler C C
The British journal of dermatology
BACKGROUND:Effective management of acne vulgaris in primary care involves support (usually provided over a number of consultations) and prescription of effective treatments. However, consulting and prescribing patterns for acne in primary care are not well described. OBJECTIVES:To describe the rate of primary-care consultations and follow-up consultations; prescribing patterns, including overall use of acne-related medications (ARMs); and initial and follow-up prescription for acne vulgaris in the U.K. METHODS:U.K. primary-care acne consultations and prescriptions for ARMs were identified in the Clinical Practice Research Datalink. Annual consultation rates (between 2004 and 2013) by age and sex, new consultations and consultations in the subsequent year were calculated, along with prescribing trends - during a new consultation and over the subsequent 90 days and year - using the number of registered patients as the denominator. RESULTS:Two-thirds (66·1%) of patients who had a new acne consultation had no further acne consultations in the subsequent year. Overall 26·7%, 24·9%, and 23·6% and 2·8% of patients were prescribed no ARM, an oral antibiotic, a topical antibiotic or an oral plus topical antibiotic, respectively, during a new acne consultation. In total 60·1% and 38·6% of patients prescribed an ARM received no further ARM prescriptions in the following 90 days and 1 year, respectively, despite most prescriptions being for 2 months or less. Prescribing rates for lymecycline and topical combined clindamycin and benzoyl peroxide increased substantially between 2004 and 2013. There were no important changes in consultation rates between 2004 and 2013. CONCLUSIONS:These data suggest that patients with acne are receiving a suboptimal initial choice of ARMs, longitudinal care and prescribing.
10.1111/bjd.15081
Guidelines of care for the management of acne vulgaris.
Zaenglein Andrea L,Pathy Arun L,Schlosser Bethanee J,Alikhan Ali,Baldwin Hilary E,Berson Diane S,Bowe Whitney P,Graber Emmy M,Harper Julie C,Kang Sewon,Keri Jonette E,Leyden James J,Reynolds Rachel V,Silverberg Nanette B,Stein Gold Linda F,Tollefson Megha M,Weiss Jonathan S,Dolan Nancy C,Sagan Andrew A,Stern Mackenzie,Boyer Kevin M,Bhushan Reva
Journal of the American Academy of Dermatology
Acne is one of the most common disorders treated by dermatologists and other health care providers. While it most often affects adolescents, it is not uncommon in adults and can also be seen in children. This evidence-based guideline addresses important clinical questions that arise in its management. Issues from grading of acne to the topical and systemic management of the disease are reviewed. Suggestions on use are provided based on available evidence.
10.1016/j.jaad.2015.12.037
Staphylococcus aureus carriage rates and antibiotic resistance patterns in patients with acne vulgaris.
Delost Gregory R,Delost Maria E,Armile James,Lloyd Jenifer
Journal of the American Academy of Dermatology
BACKGROUND:Overuse of antibiotics has led to the development of antibiotic-resistant strains of Staphylococcus aureus, which are occurring more frequently within the community. OBJECTIVE:We sought to determine whether long-term antibiotic therapy for acne alter the carriage rate and antibiotic resistance profiles of S aureus. METHODS:This was a prospective, cross-sectional, quasiexperimental study. Samples of anterior nares were obtained from dermatology patients given a diagnosis of acne vulgaris (n = 263) who were treated with antibiotics (n = 142) or who were not treated with antibiotics (n = 121). Specimens were tested for the presence of S aureus by growth on mannitol salt agar and then isolated on 5% sheep blood agar. Identification was confirmed based on colonial morphology, Gram stain, catalase, and coagulase testing. Antibiotic susceptibility testing was performed using the VITEK 2 system (bioMerieux, Marcy-l'Étoile, France). RESULTS:The S aureus carriage rate was significantly lower in patients with acne treated with antibiotics (6.3%) compared with those not treated with antibiotics (15.7%; P = .016). The percentage of S aureus isolates resistant to 1 or more antibiotics did not significantly differ between the 2 groups (P = .434). LIMITATIONS:Cross-sectional study, patient compliance, and effects of prior acne treatments are limitations. CONCLUSION:Treatment of patients with acne using antibiotics decreases the S aureus carriage rate but does not significantly alter the antibiotic resistance rates.
10.1016/j.jaad.2015.11.025
Dietary glycemic factors, insulin resistance, and adiponectin levels in acne vulgaris.
Çerman Aslı Aksu,Aktaş Ezgi,Altunay İlknur Kıvanç,Arıcı Janset Erkul,Tulunay Aysın,Ozturk Feyza Yener
Journal of the American Academy of Dermatology
BACKGROUND:There is increasing evidence to support the relationship between acne vulgaris and diet. OBJECTIVE:The aim of this study was to investigate possible associations among dietary glycemic index, glycemic load, milk consumption, insulin resistance, and adiponectin levels in the pathogenesis of acne vulgaris. METHODS:The dietary glycemic index, glycemic load, milk consumption, fasting glucose, insulin, insulin-like growth factor)-1, insulin-like growth factor binding protein-3, adiponectin, and homeostasis model assessment of insulin resistance values of 50 patients with acne vulgaris and 36 healthy control subjects were measured. RESULTS:Glycemic index and glycemic load levels were significantly higher (P = .022 and P = .001, respectively) and serum adiponectin levels were significantly lower (P = .015) in patients with acne than in the control subjects. There was an inverse correlation between serum adiponectin concentration and glycemic index (P = .049, r = -0.212). LIMITATIONS:This study used a cross-sectional design and the study population was limited to young, nonobese adults. CONCLUSION:A high-glycemic-index/-load diet was positively associated with acne vulgaris. Adiponectin may be a pathogenetic cofactor contributing to the development of the disease. Further research on adiponectin levels in patients with acne in terms of development of insulin resistance might be important in this possible relationship.
10.1016/j.jaad.2016.02.1220
Lactase Persistence, Milk Intake, and Adult Acne: A Mendelian Randomization Study of 20,416 Danish Adults.
Juhl Christian R,Bergholdt Helle K M,Miller Iben M,Jemec Gregor B E,Kanters Jørgen K,Ellervik Christina
Nutrients
Whether there is a causal relationship between milk intake and acne is unknown. We tested the hypothesis that genetically determined milk intake is associated with acne in adults using a Mendelian randomization design. (rs4988235) is associated with lactase persistence () in Northern Europeans. We investigated the association between milk intake, (rs4988235), and acne in 20,416 adults (age-range: 20⁻96) from The Danish General Suburban Population Study (GESUS). The adjusted observational odds ratio for acne in any milk intake vs. no milk intake was 0.93(95% confidence interval: 0.48⁻1.78) in females and 0.49(0.22⁻1.08) in males aged 20⁻39 years, and 1.15(95% confidence interval: 0.66⁻1.99) in females and 1.02(0.61⁻1.72) in males above 40 years. The unadjusted odds ratio for acne in TT+TC vs. CC was 0.84(0.43⁻1.62) in the age group 20⁻39 years, and 0.99(0.52⁻1.88) above 40 years. We did not find any observational or genetic association between milk intake and acne in our population of adults.
10.3390/nu10081041
Female type of adult acne: Physiological and psychological considerations and management.
Dreno Brigitte,Bagatin Edileia,Blume-Peytavi Ulrike,Rocha Marco,Gollnick Harald
Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG
Today we see more cases of acne after adolescence, with a greater prevalence in females than males. Adult female acne has a distinct clinical presentation and is associated with a number of specific pathophysiological features and gender-specific triggers. The psychological impact of acne is generally significant and largely underestimated; stress during professional and private life, anxiety and sleep quality, in particular, have a reciprocal relationship with disease susceptibility and severity. It is essential to compare with males. Acne in females often causes greater distress in adults than in adolescents. The impact of disease may therefore be greater for female patients, triggering higher levels of psychosocial anguish and increasing the likelihood of sequelae such as skin picking and the risks of cutaneous superinfection, scarring and PIH and acne recurrence. The management of adult female acne should encompass not just medical treatment of the symptoms, but also a comprehensive, holistic approach to the patient as a whole, her individual lifestyle factors and the impact of acne on her quality of life. Future management of this disease should aim to improve patient adherence to therapy and to develop validated outcomes of treatment regarding overall skin appearance and quality of life.
10.1111/ddg.13664
Abnormal plasma lipids profile in women with post-adolescent acne.
Romańska-Gocka Krystyna,Woźniak Magdalena,Kaczmarek-Skamira Elżbieta,Zegarska Barbara
Postepy dermatologii i alergologii
INTRODUCTION:Acne vulgaris is a multifactorial chronic inflammatory disease that is increasingly recognized in adult women. AIM:To investigate a relationship between plasma lipids profile and acne in women and a correlation between selected clinical features of acne (severity, age of onset, location of lesions and the presence of comedones) and lipids profile. MATERIAL AND METHODS:Sixty-four adult women with post-adolescent acne and 20 healthy controls were included in the study. Plasma total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) levels were determined in all the subjects. RESULTS:Adult women with acne had statistically significantly increased levels of TC, TG and LDL-C compared to healthy controls ( < 0.05). The level of HDL-C did not differ between the two groups. There was no relationship between higher levels of TC, TG and LDL-C and a clinical picture of acne. CONCLUSIONS:Acne in adult women is likely to be associated with increased levels of TC, TG and LDL-C. This abnormality seems to be important in the pathogenesis of adult acne and could be a result of high fatty acid diet. Performing a lipid profile examination in women with acne should be taken into account when screening patients and followed by appropriate dietary recommendations.
10.5114/ada.2018.77612
Adult female acne: a guide to clinical practice.
Anais brasileiros de dermatologia
BACKGROUND:Acne in women is often associated with anxiety and depression, and may persist from adolescence as well as manifest for the first time in adulthood. Genetic and hormonal factors contribute to its etiopathogenesis, and maintenance treatment is required, usually for years, due to its clinical evolution. OBJECTIVE:To develop a guide for the clinical practice of adult female acne. METHODS:A team of five experts with extensive experience in acne conducted a literature review of the main scientific evidence and met to discuss the best practices and personal experiences to develop a guide containing recommendations for the clinical practice of adult female acne. RESULTS:The group of specialists reached consensus on the main guidelines for clinical practice, providing detailed recommendations on clinical picture, etiopathogenesis, laboratory investigation and treatment of adult female acne. CONCLUSION:Different from teenage acne, adult female acne presents some characteristics and multiple etiopathogenic factors that make its management more complex. This guide provides recommendations for best clinical practices and therapeutic decisions. However, the authors consider that additional studies are needed in order to provide more evidence for adult female acne to be better understood.
10.1590/abd1806-4841.20198203
An Overview of Acne Therapy, Part 1: Topical therapy, Oral Antibiotics, Laser and Light Therapy, and Dietary Interventions.
Marson Justin W,Baldwin Hilary E
Dermatologic clinics
Therapeutic actives for acne have changed little in the last decade. Recognition that acne is an inflammatory condition, not an infectious one, has led to a call for reduction in antibiotic use. This has culminated in a re-evaluation of highly efficacious combination topical therapy and improved vehicle technology. Laser and light modalities, although not sufficiently studied for first-line use, show promise for the future. The role that diet plays in the initiation and continuation of acne is unclear but remains one of our patients' most frequently asked questions.
10.1016/j.det.2018.12.001
An Overview of Acne Therapy, Part 2: Hormonal Therapy and Isotretinoin.
Marson Justin W,Baldwin Hilary E
Dermatologic clinics
Therapeutic actives for acne have changed little in the last decade. Recognition that acne is an inflammatory condition, not an infectious one, has led to a call for reduction in antibiotic use, which has culminated in a re-evaluation of our nonantibiotic choices. Spironolactone and oral contraceptives have become more acceptable first-line choices, and earlier use of isotretinoin has been proposed.
10.1016/j.det.2018.12.002
Topical 2% ketoconazole cream monotherapy significantly improves adult female acne: A double-blind, randomized placebo-controlled trial.
Chottawornsak Natcha,Chongpison Yuda,Asawanonda Pravit,Kumtornrut Chanat
The Journal of dermatology
The emergence of bacterial resistance is a global crisis. Prolonged use of antibiotics especially in acne is one issue of concern among dermatologists. Ketoconazole (KTZ) cream, a topical antifungal with anti-inflammatory and antiandrogenic actions, can decrease lipase activity of Cutibacterium acnes in vitro. We evaluated the efficacy and safety of KTZ cream in mild adult female acne (AFA) by conducting a randomized, double-blind, placebo-controlled trial using KTZ 2% and placebo cream twice daily for 10 weeks. We assessed the improvement of clinical severity, measured by AFA score graded by investigators and participants, and the change of acne count. Forty-one participants enrolled in our study. The proportion of participants with acne improvement from baseline (42.9% vs 9.5%, P = 0.015) and the success rate (45.0% vs 14.3%, P = 0.043) in the KTZ group were significantly higher than that of the placebo group. The most common adverse events were dryness and itching. The percentage change of acne count decreased significantly compared with baseline but did not differ statistically between the two groups (P = 0.268). We concluded that the KTZ monotherapy showed a plausible effect in improving AFA with excellent safety profile. It should be considered as a viable option for mild AFA treatment.
10.1111/1346-8138.15113
Difficulties in emotion regulation and quality of life in patients with acne.
Cengiz Gül Ferda,Gürel Gülhan
Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation
BACKGROUND:The psychological factors associated with the impairment of the quality of life (QoL) in acne vulgaris have not been fully elucidated, yet. The aim of the present study was to evaluate the performance of the difficulties in emotion regulation (DER) in predicting the QoL of patients with acne vulgaris and to examine the relationship between acne vulgaris and common psychopathologies, such as anxiety and depression. METHODS:A total of 141 patients were administered the difficulties in emotion regulation scale (DERS-Brief Form) (DERS-16), Hospital Anxiety and Depression Scale (HADS), and Acne Quality of Life (AQOL) Scale, while the control group including 102 participants was administered all scales other than the AQOL. RESULTS:The patients with acne vulgaris had significantly higher DERS scores than the control group. DER were found to predict quality of life more than acne severity. A strong positive correlation was found between the DERS and anxiety and depressive symptoms. There was no significant correlation between the acne severity and HADS and DERS scores, although only a weak correlation was found with the AQOL scores. The duration of acne showed no correlation with any of the variables. CONCLUSIONS:Our study results showed the relationship between the DER and acne vulgaris. The ignorance of this relationship while evaluating patients with acne may result in anxiety and depression symptoms and impairment in the QoL in the future. Hence, psychopathologies should be considered in acne treatment and patients should gain the ability of regulating their emotions through appropriate therapeutic approaches.
10.1007/s11136-019-02318-2
Sexual quality of life in female patients with acne.
Afsar F Sule,Seremet Sila,Demirlendi Duran Hatice,Karaca Semsettin,Mumcu Sonmez Nihal
Psychology, health & medicine
Acne is a common skin disease which can have a negative psychosocial impact on quality of life. Sexual health is an important part of overall health and little is known about the effects of acne on individual sexuality. We aimed to assess the sexual quality of life and general quality of life in female patients with acne and compare to those without acne. Sixty female participants with acne and age-matched 40 female controls were enrolled in the study and asked to complete the Sexual Quality of Life-Female Questionnaire and the Short Form-36 Health Survey. Acne severity was evaluated objectively by the Global Acne Grading System and subjectively by the Visual Analogue Scale. Participants reported a significantly worse sexual quality of life and had significantly decreased scores on the quality of life scales of Bodily Pain, General Perception of Health and the Physical Component Summary when compared to controls. Neither the sexual quality of life nor the quality of life was correlated with objective and subjective acne severity and duration of acne. Acne can negatively affect sexual quality of life in female patients as well as differentdimensions of quality of life. The sexual quality of life should be considered while evaluating acne in women irrespective of its severity.
10.1080/13548506.2019.1679845
Blue light for infectious diseases: Propionibacterium acnes, Helicobacter pylori, and beyond?
Dai Tianhong,Gupta Asheesh,Murray Clinton K,Vrahas Mark S,Tegos George P,Hamblin Michael R
Drug resistance updates : reviews and commentaries in antimicrobial and anticancer chemotherapy
Blue light, particularly in the wavelength range of 405-470 nm, has attracted increasing attention due to its intrinsic antimicrobial effect without the addition of exogenous photosensitizers. In addition, it is commonly accepted that blue light is much less detrimental to mammalian cells than ultraviolet irradiation, which is another light-based antimicrobial approach being investigated. In this review, we discussed the blue light sensing systems in microbial cells, antimicrobial efficacy of blue light, the mechanism of antimicrobial effect of blue light, the effects of blue light on mammalian cells, and the effects of blue light on wound healing. It has been reported that blue light can regulate multi-cellular behavior involving cell-to-cell communication via blue light receptors in bacteria, and inhibit biofilm formation and subsequently potentiate light inactivation. At higher radiant exposures, blue light exhibits a broad-spectrum antimicrobial effect against both Gram-positive and Gram-negative bacteria. Blue light therapy is a clinically accepted approach for Propionibacterium acnes infections. Clinical trials have also been conducted to investigate the use of blue light for Helicobacter pylori stomach infections and have shown promising results. Studies on blue light inactivation of important wound pathogenic bacteria, including Staphylococcus aureus and Pseudomonas aeruginosa have also been reported. The mechanism of blue light inactivation of P. acnes, H. pylori, and some oral bacteria is proved to be the photo-excitation of intracellular porphyrins and the subsequent production of cytotoxic reactive oxygen species. Although it may be the case that the mechanism of blue light inactivation of wound pathogens (e.g., S. aureus, P. aeruginosa) is the same as that of P. acnes, this hypothesis has not been rigorously tested. Limited and discordant results have been reported regarding the effects of blue light on mammalian cells and wound healing. Under certain wavelengths and radiant exposures, blue light may cause cell dysfunction by the photo-excitation of blue light sensitizing chromophores, including flavins and cytochromes, within mitochondria or/and peroxisomes. Further studies should be performed to optimize the optical parameters (e.g., wavelength, radiant exposure) to ensure effective and safe blue light therapies for infectious disease. In addition, studies are also needed to verify the lack of development of microbial resistance to blue light.
10.1016/j.drup.2012.07.001
Vitamin B12 modulates the transcriptome of the skin microbiota in acne pathogenesis.
Kang Dezhi,Shi Baochen,Erfe Marie C,Craft Noah,Li Huiying
Science translational medicine
Various diseases have been linked to the human microbiota, but the underlying molecular mechanisms of the microbiota in disease pathogenesis are often poorly understood. Using acne as a disease model, we aimed to understand the molecular response of the skin microbiota to host metabolite signaling in disease pathogenesis. Metatranscriptomic analysis revealed that the transcriptional profiles of the skin microbiota separated acne patients from healthy individuals. The vitamin B12 biosynthesis pathway in the skin bacterium Propionibacterium acnes was significantly down-regulated in acne patients. We hypothesized that host vitamin B12 modulates the activities of the skin microbiota and contributes to acne pathogenesis. To test this hypothesis, we analyzed the skin microbiota in healthy subjects supplemented with vitamin B12. We found that the supplementation repressed the expression of vitamin B12 biosynthesis genes in P. acnes and altered the transcriptome of the skin microbiota. One of the 10 subjects studied developed acne 1 week after vitamin B12 supplementation. To further understand the molecular mechanism, we revealed that vitamin B12 supplementation in P. acnes cultures promoted the production of porphyrins, which have been shown to induce inflammation in acne. Our findings suggest a new bacterial pathogenesis pathway in acne and provide one molecular explanation for the long-standing clinical observation that vitamin B12 supplementation leads to acne development in a subset of individuals. Our study discovered that vitamin B12, an essential nutrient in humans, modulates the transcriptional activities of skin bacteria, and provided evidence that metabolite-mediated interactions between the host and the skin microbiota play essential roles in disease development.
10.1126/scitranslmed.aab2009
Systematic review of antibiotic resistance in acne: an increasing topical and oral threat.
Walsh Timothy R,Efthimiou John,Dréno Brigitte
The Lancet. Infectious diseases
Topical and oral antibiotics are routinely used to treat acne. However, antibiotic resistance is increasing, with many countries reporting that more than 50% of Propionibacterium acnes strains are resistant to topical macrolides, making them less effective. We reviewed the current scientific literature to enable proposal of recommendations for antibiotic use in acne treatment. References were identified through PubMed searches for articles published from January, 1954, to March 7, 2015, using four multiword searches. Ideally, benzoyl peroxide in combination with a topical retinoid should be used instead of a topical antibiotic to minimise the impact of resistance. Oral antibiotics still have a role in the treatment of moderate-to-severe acne, but only with a topical retinoid, benzoyl peroxide, or their combination, and ideally for no longer than 3 months. To limit resistance, it is recommended that benzoyl peroxide should always be added when long-term oral antibiotic use is deemed necessary. The benefit-to-risk ratio of long-term antibiotic use should be carefully considered and, in particular, use alone avoided where possible. There is a need to treat acne with effective alternatives to antibiotics to reduce the likelihood of resistance.
10.1016/S1473-3099(15)00527-7
Acne vulgaris.
Williams Hywel C,Dellavalle Robert P,Garner Sarah
Lancet (London, England)
Acne is a chronic inflammatory disease of the pilosebaceous unit resulting from androgen-induced increased sebum production, altered keratinisation, inflammation, and bacterial colonisation of hair follicles on the face, neck, chest, and back by Propionibacterium acnes. Although early colonisation with P acnes and family history might have important roles in the disease, exactly what triggers acne and how treatment affects the course of the disease remain unclear. Other factors such as diet have been implicated, but not proven. Facial scarring due to acne affects up to 20% of teenagers. Acne can persist into adulthood, with detrimental effects on self-esteem. There is no ideal treatment for acne, although a suitable regimen for reducing lesions can be found for most patients. Good quality evidence on comparative effectiveness of common topical and systemic acne therapies is scarce. Topical therapies including benzoyl peroxide, retinoids, and antibiotics when used in combination usually improve control of mild to moderate acne. Treatment with combined oral contraceptives can help women with acne. Patients with more severe inflammatory acne usually need oral antibiotics combined with topical benzoyl peroxide to decrease antibiotic-resistant organisms. Oral isotretinoin is the most effective therapy and is used early in severe disease, although its use is limited by teratogenicity and other side-effects. Availability, adverse effects, and cost, limit the use of photodynamic therapy. New research is needed into the therapeutic comparative effectiveness and safety of the many products available, and to better understand the natural history, subtypes, and triggers of acne.
10.1016/S0140-6736(11)60321-8
Acne vulgaris.
Moradi Tuchayi Sara,Makrantonaki Evgenia,Ganceviciene Ruta,Dessinioti Clio,Feldman Steven R,Zouboulis Christos C
Nature reviews. Disease primers
Acne vulgaris is a chronic inflammatory disease - rather than a natural part of the life cycle as colloquially viewed - of the pilosebaceous unit (comprising the hair follicle, hair shaft and sebaceous gland) and is among the most common dermatological conditions worldwide. Some of the key mechanisms involved in the development of acne include disturbed sebaceous gland activity associated with hyperseborrhoea (that is, increased sebum production) and alterations in sebum fatty acid composition, dysregulation of the hormone microenvironment, interaction with neuropeptides, follicular hyperkeratinization, induction of inflammation and dysfunction of the innate and adaptive immunity. Grading of acne involves lesion counting and photographic methods. However, there is a lack of consensus on the exact grading criteria, which hampers the conduction and comparison of randomized controlled clinical trials evaluating treatments. Prevention of acne relies on the successful management of modifiable risk factors, such as underlying systemic diseases and lifestyle factors. Several treatments are available, but guidelines suffer from a lack of data to make evidence-based recommendations. In addition, the complex combination treatment regimens required to target different aspects of acne pathophysiology lead to poor adherence, which undermines treatment success. Acne commonly causes scarring and reduces the quality of life of patients. New treatment options with a shift towards targeting the early processes involved in acne development instead of suppressing the effects of end products will enhance our ability to improve the outcomes for patients with acne.
10.1038/nrdp.2015.29