Management of acne: a report from a Global Alliance to Improve Outcomes in Acne

Newer approaches to the treatment of acne vulgaris

The multifactorial etiology of acne vulgaris makes it challenging to treat. Current treatments include topical retinoids, benzoyl peroxide, topical and systemic antibiotics, azelaic acid, and systemic isotretinoin. Adjunctive and/or emerging approaches include topical dapsone, taurine bromamine, resveratrol, chemical peels, optical treatments, as well as complementary and alternative medications. The purpose of this paper is to discuss the therapies available for acne and their latest developments, including new treatment strategies (i.e. re-evaluation of the use of oral antibiotics and avoidance of topical antibiotic monotherapy, use of subantimicrobial antibiotic dosing, use of low-dose isotretinoin, optical treatments), new formulations (microsponges, liposomes, nanoemulsions, aerosol foams), new combinations (fixed-combination products of topical retinoids and topical antibiotics [essentially clindamycin] or benzoyl peroxide), new agents (topical dapsone, taurine bromamine, resveratrol) and their rationale and likely place in treatment. Acne vaccines, topical natural antimicrobial peptides, and lauric acid represent other promising therapies.

Congenital adrenal hyperplasia

Congenital adrenal hyperplasia consists of a heterogenous group of inherited disorders due to enzymatic defects in the biosynthetic pathway of cortisol and/or aldosterone. This results in glucocorticoid deficiency, mineralocorticoid deficiency, and androgen excess. 95% of CAH cases are due to 21-hydroxylase deficiency. Clinical forms range from the severe, classical CAH associated with complete loss of enzyme function, to milder, non-classical forms (NCAH). Androgen excess affects the pilosebaceous unit, causing cutaneous manifestations such as acne, androgenetic alopecia and hirsutism. Clinical differential diagnosis between NCAH and polycystic ovary syndrome may be difficult. In this review, the evaluation of patients with suspected CAH, the clinical presentation of CAH forms, with emphasis on the cutaneous manifestations of the disease, and available treatment options, will be discussed.

Update on topical antibiotics in dermatology

Topical antibiotics are used for various purposes in dermatology. Some of the most common uses include treatment of acne, treatment and prevention of wound infection(s), impetigo or impetiginized dermatitis, and staphylococcal nasal carrier state. It is important for the dermatologist to be familiar with the spectrum of activity, the mechanism of action, and the variables that may interfere with the antibiotic of choice. The following discussion will review an update on topical antibiotic use in acne, wound care, impetigo, and in staphylococcal nasal carriers.

Tretinoin microsphere gel 0.04% pump for treating acne vulgaris in preadolescents: a randomized, controlled study

Although acne vulgaris is common in preadolescents (<13 yrs), few acne treatments are currently approved for children. This study assessed the safety and efficacy of tretinoin microsphere gel (TMG) 0.04% pump in children aged 9-11 with acne vulgaris. In this multicenter, randomized, double-blind, vehicle-controlled pilot study, patients applied TMG 0.04% pump or vehicle once daily to the face for 12 weeks. Efficacy measures were changes in facial lesion counts, Investigator Global Evaluation of acne severity using two scales, and Investigator Global Assessment of Improvement from baseline to week 12. Of the 110 patients enrolled, 55 received TMG 0.04% pump, and 55 received vehicle. At week 12, there was significantly greater improvement in the least-squares mean change in noninflammatory lesions with TMG 0.04% than with vehicle (-19.9 vs -9.7, p = 0.04) and a significant difference in Investigator Global Assessment of improvement at week 12 between the children treated with TMG 0.04% pump and those treated with vehicle (p = 0.02), but there were no discernible differences in static acne severity scales. Change from baseline in signs and symptoms of cutaneous irritation were similar between the active and vehicle arms at week 12. This study demonstrated statistically significant differences in the reduction of noninflammatory lesions between TMG 0.04% pump and vehicle in patients aged 9-11 with acne vulgaris. Additional studies are warranted to further characterize the safety and efficacy of TMG 0.04% pump for the treatment of acne in the preadolescent population.

Development and homeostasis of the sebaceous gland

The important role of epidermal appendages especially the sebaceous gland has only recently been recognized. In particular, it has been convincingly shown that normal development and maintenance of the sebaceous gland are required for skin homeostasis since atrophic sebaceous glands and disturbances in sebaceous lipid composition result in major defects of the physiological barrier and maintenance of the skin. Consequently, it is important to unravel the signaling network controlling proper sebaceous lineage differentiation in mammalian skin and to understand the underlying mechanisms leading to severe skin diseases, including abnormal proliferation and differentiation of the gland, defects of the lipid metabolism and barrier, as well as sebaceous tumor formation. Over the last years, results from transgenic and knock out mouse models manipulating distinct signaling pathways in the skin as well as the detailed analysis of human sebaceous gland-derived cell lines provided new insights into crucial mediators balancing proliferation and differentiation of the sebaceous gland. Here, we discuss our current knowledge of in vivo mechanisms of sebaceous gland development, maintenance and disorders and highlight recent contributions to the field of sebaceous gland biology.

Topical antimicrobial treatment of acne vulgaris: an evidence-based review

Topical antimicrobial treatment is indicated for mild to moderate acne vulgaris. Our literature review includes searches of Ovid, MEDLINE, EMBASE, and the databases of the Cochrane Library. A detailed search strategy is included. All searches were limited to controlled trials and systematic reviews. No year limits were applied to the searches, but we focused on trials, guidelines, and reviews published since 2004, the year that the last review of topical antimicrobials was published in this journal. Several controlled trials demonstrate that benzoyl peroxide, topical antibiotics, and topical retinoids used in combination provide the greatest efficacy and safety profile for the treatment of mild to moderate acne, but there are few trials directly comparing different combinations of these topical therapies with one another. Additionally, robust studies comparing cost and efficacy of generic combinations of the above agents with proprietary fixed-dose combination therapies that may increase compliance are also lacking. Although they have not been extensively studied, alternative agents including dapsone, salicylic acid, azelaic acid, and zinc are safe and efficacious when combined with traditional therapies.

Acne vulgaris

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.

Efficacy and safety of topical nadifloxacin and benzoyl peroxide versus clindamycin and benzoyl peroxide in acne vulgaris: A randomized controlled trial

Background:

Topical therapy with comedolytics and antibiotics are often advocated for mild and moderate severity acne vulgaris. Nadifloxacin, a new fluoroquinolone with anti-Propionibacterium acnes activity and additional anti-inflammatory activity, is approved for use in acne. This randomized controlled assessor blind trial compared the clinical effectiveness and safety of eight weeks therapy of nadifloxacin 1% versus clindamycin 1% as add-on therapy to benzoyl peroxide (2.5%) in mild to moderate grade acne.

Materials and Methods:

The efficacy parameters were changes in the total, inflammatory and non-inflammatory lesion counts, Investigator Global Assessment (IGA), and Cardiff Acne Disability Index (CADI) scales from baseline to study end (eight weeks). All treatment emergent dermatological adverse events were evaluated for safety assessment.

Results:

Out of 84 randomized subjects (43-nadifloxacin arm) and (41-clindamycin) 42 in nadifloxacin group, 37 in clindamycin group completed the study. Reduction from baseline of total, inflammatory and non-inflammatory lesion counts were highly significant in both the groups (P<0.0001), but between group differences were not significant. Significant improvement in CADI and IGA scales were noted in both groups. Between-group comparison showed no significant differences. The safety and tolerability profile of both regimens were good and statistically comparable.

Conclusions:

Topical nadifloxacin, a new fluoroquinolone is effective, tolerable, and safe for mild o moderate facial acne. Its clinical effectiveness is comparable to clindamycin when used as add-on therapy to benzoyl peroxide.

Association of pharyngitis with oral antibiotic use for the treatment of acne: a cross-sectional and prospective cohort study

OBJECTIVE

To prospectively evaluate the association between antibiotics used to treat acne and pharyngitis.

DESIGN

Cross-sectional and 9-month prospective cohort.

SETTING

Urban university setting.

PARTICIPANTS

University students.

INTERVENTION

Participants were asked to fill out a survey form, were swabbed for culture, and had a visual examination for acne.

MAIN OUTCOME MEASURE

Report of pharyngitis.

RESULTS

In the cross-sectional study, 10 of the 15 students receiving oral antibiotics for acne reported an episode of pharyngitis in the previous 30 days, whereas 47 of the 130 students not receiving oral antibiotics, but who had acne, reported an episode of pharyngitis in the prior month. The unadjusted odds ratio (OR) (95% CI) associating current oral antibiotic use in acne patients with a self-reported episode of pharyngitis was 3.53 (95% CI, 1.14-10.95). In the cohort study, there were 358 female and 218 male participants; 36 (6.2%) received oral antibiotics for acne during the study, and 96 (16.6%) received topical antibiotics for acne. Using mixed model logistic regression, the OR was 4.34 (95% CI, 1.51-12.47) associating oral antibiotic use with pharyngitis. Less than 1% of participants were colonized by group A streptococcus, which was not associated with pharyngitis.

CONCLUSIONS

Our studies show that that the odds of reporting pharyngitis is more than 3 times baseline in patients receiving oral antibiotics for acne vs those who are not receiving oral antibiotics. The true clinical importance of these findings needs to be evaluated further by prospective studies, but this finding is not associated with group A streptococcus.

Susceptibility of Propionibacterium acnes isolated from patients with acne vulgaris to zinc ascorbate and antibiotics

Purpose:

The in vitro antimicrobial activity of ascorbic acid derivatives against Propionibacterium acnes was tested either alone or in combination with a variety of antimicrobial agents, and their fractional inhibitory concentration index was determined using checkerboard tests. The antimicrobial effectiveness of zinc ascorbate in the treatment of acne vulgaris, either alone or in combination with antibiotics such as clindamycin that are commonly used in Japan for the treatment of acne vulgaris, was therefore examined.

Materials and methods:

The antimicrobial susceptibility of 41 strains of clindamycin-sensitive and/or clindamycin-resistant P. acnes isolated from acne vulgaris patients was tested, in comparison with a type strain of P. acnes.

Results:

Zinc ascorbate showed antimicrobial activity against a type strain of P. acnes and its concentration (0.064%) was sufficiently lower than the normal dose (5%) of other ascorbic acid derivatives. Combinations of zinc ascorbate with clindamycin, erythromycin, and chloramphenicol showed an additive effect, and zinc ascorbate alone effectively inhibited the growth of all P. acnes including clindamycin-resistant strains.

Conclusion:

The results provide novel evidence that the combination of zinc ascorbate and clindamycin is effective for acne vulgaris treatment.

Acne vulgaris: pathogenesis, treatment, and needs assessment

Acne vulgaris is a common skin condition with substantial cutaneous and psychologic disease burden. Studies suggest that the emotional impact of acne is comparable to that experienced by patients with systemic diseases, like diabetes and epilepsy. In conjunction with the considerable personal burden experienced by patients with acne, acne vulgaris also accounts for substantial societal and health care burden. The pathogenesis and existing treatment strategies for acne are complex. This article discusses the epidemiology, pathogenesis, and treatment of acne vulgaris. The burden of disease in the United States and future directions in the management of acne are also addressed.

Acne management in Japan: study of patient adherence

Obtaining good adherence to acne therapy is a challenge for all dermatologists. We studied 428 acne patients in Japan to determine the likelihood of good adherence and factors associated with medication-taking. This study utilized a simple validated questionnaire to assess risk of poor adherence; information about patient and treatment characteristics was also collected. There was an overall rate of poor adherence in 76% of subjects. Adherence to topical medication was poor in 52% of those treated with a topical agent only (n = 123). Among those taking combination therapies (n = 275), adherence to the topical portion of therapy was poor in 49% of subjects. The likelihood of poor adherence to oral medication was higher, both when administered alone (n = 30, 93% poor adherence) and when given as part of a combination regimen (n = 275, 86%). Factors with an impact on adherence included satisfaction with treatment (p = 0.023) and the experience of side effects (p = 0.027). Patients who felt they had a good understanding of acne and its treatment were more likely to have good adherence. These data suggest that there is significant room for improvement in acne adherence in Japan, as in other areas of the world, and that improved education may enhance adherence.

The effects of culture, skin color, and other nonclinical issues on acne treatment

The effective and safe treatment of acne vulgaris often is affected by individual patient characteristics, including skin color and cultural background. Skin of color is especially prone to hyperpigmentation, both from lesions and from irritating therapy. Clinicians also should be aware of cultural attitudes and folk remedies that may adversely affect dermatologic conditions such as acne.

Nanoparticles: small and mighty

The properties of engineered nanomaterials and nanoparticles such as zinc oxide and titanium dioxide may differ substantially from naturally occurring materials and particles. Nanoparticles have unique physical properties making them ideal for use in various skin care products currently on the market. Nano-preparations are currently under investigation as novel treatments of acne vulgaris, recurrent condyloma accuminata, atopic dermatitis, hyperpigmented skin lesions, and other non-dermatologic diseases. Because of their increased surface area, nanoparticles have increased reactivity and a small size allowing for enhanced mobility through the human body and environment. As their use becomes more prevalent, nanoparticles are being scrutinized for their safety and long-term effects. This review discusses the benefits of nanoparticles in dermatological therapies and skin care products as well as potential disadvantages and possible mechanisms of toxicity.

Retinoic acid as a vaccine adjuvant enhances CD8+ T cell response and mucosal protection from viral challenge

Vaccine-induced memory T cells localized at mucosal sites can provide rapid protection from viral infection. All-trans-retinoic acid (ATRA) has been shown to act physiologically to induce the expression of gut-homing receptors on lymphocytes. We tested whether the administration of exogenous ATRA during a systemic vaccination of mice could enhance the generation of mucosal CD8(+) T cell immunity, which might represent a strategy for establishing better protection from viral infection via mucosal routes. ATRA induced the expression of CCR9 and α4β7 on both mouse and human CD8(+) T cells activated in vitro. The administration of ATRA to mice during in vivo priming with a replication-defective recombinant adenovirus vector expressing the lymphocytic choriomeningitis virus glycoprotein (LCMVgp) (Ad5gp) increased numbers of both effector and memory T cells in intestinal mucosal tissues and showed higher frequencies of systemic central memory-like T cells that exhibited enhanced proliferation during boosting immunization with recombinant modified vaccinia virus Ankara expressing LCMVgp (MVAgp). Mice that received ATRA during Ad5gp vaccination were more resistant to intravaginal challenge by recombinant vaccinia virus expressing LCMVgp (VVgp), reflecting in part stronger T cell recall responses in situ. Thus, ATRA appears to be useful as an adjuvant during vaccination to increase memory T cell responses and protection from viral infection at mucosal sites and may facilitate the development of more effective vaccines against mucosally transmitted pathogens such as HIV.

Annual drug update: 2010 in review

In 2010, the FDA approved several new drugs and new indications for use in primary care. From new therapies for adults with rheumatoid arthritis to a combination drug for benign prostatic hyperplasia, NPs need to be aware of the latest medications now available.

Management strategies for acne vulgaris

CLINICAL QUESTION

What are the most effective treatment(s) for mild, moderate, severe, and hormonally driven acne?

RESULTS

Mild acne responds favorably to topical treatments such as benzoyl peroxide, salicylic acid, and a low-dose retinoid. Moderate acne responds well to combination therapy comprising-topical benzoyl peroxide, antibiotics, and/or retinoids, as well as oral antibiotics in refractory cases and oral contraceptive pills for female acne patients. Severe nodulocystic acne vulgaris responds best to oral isotretinoin therapy. In female patients with moderate to severe acne, facial hair, loss of scalp hair and irregular periods, polycystic ovarian syndrome should be considered and appropriate treatment with hormonal modulation given. Adjunctive procedures can also be considered for all acne patients.

IMPLEMENTATION

PITFALLS TO AVOID WHEN TREATING ACNE: treatment of acne in women of child-bearing age; familiarization of all acne treatments in order to individualize management for patients; indications for specialist referral.

Improved photostability and reduced skin permeation of tretinoin: development of a semisolid nanomedicine

The aims of this work were to increase the photostability and to reduce the skin permeation of tretinoin through nanoencapsulation. Tretinoin is widely used in the topical treatment of various dermatological diseases such as acne, psoriasis, skin cancer, and photoaging. Tretinoin-loaded lipid-core polymeric nanocapsules were prepared by interfacial deposition of a preformed polymer. Carbopol hydrogels containing nanoencapsulated tretinoin presented a pH value of 6.08±0.14, a drug content of 0.52±0.01 mg g(-1), pseudoplastic rheological behavior, and higher spreadability than a marketed formulation. Hydrogels containing nanoencapsulated tretinoin demonstrated a lower photodegradation (24.17±3.49%) than the formulation containing the non-encapsulated drug (68.64±2.92%) after 8h of ultraviolet A irradiation. The half-life of the former was seven times higher than the latter. There was a decrease in the skin permeability coefficient of the drug by nanoencapsulation, independently of the dosage form. The liquid suspension and the semisolid form provided K(p)=0.31±0.15 and K(p)=0.33±0.01 cm s(-1), respectively (p≤0.05), while the samples containing non-encapsulated tretinoin showed K(p)=1.80±0.27 and K(p)=0.73±0.12 cm s(-1) for tretinoin solution and hydrogel, respectively. Lag time was increased two times by nanoencapsulation, meaning that the drug is retained for a longer time on the skin surface.

[Treatment of acne in daily clinical practice: an opinion poll among Spanish dermatologists]

BACKGROUND AND OBJECTIVES

the aim of this study was to determine the approaches used to treat acne in clinical practice by Spanish dermatologists. A secondary objective of the study was to compare the practices of Spanish dermatologists with the Acne Global Alliance treatment algorithm and develop a Spanish treatment algorithm for acne.

PATIENTS AND METHODS

a multicenter, cross-sectional survey was undertaken among 872 Spanish dermatologists. The study comprised 4 randomly distributed questionnaires. The first 3 contained the following case descriptions: severe acne associated with masculinization (case 1), mild comedonal acne (case 2), and moderate papulopustular acne (case 3). The fourth questionnaire contained 5 photographs of different types of acne and an algorithm containing various treatment options, from which dermatologists were asked to choose the most appropriate.

RESULTS

for case 1, 55% of dermatologists chose oral antiandrogens/contraceptive drugs plus topical retinoids or topical benzoyl peroxide/antibiotics. In case 2, 62% chose topical retinoids and, in case 3, 68% chose systemic antibiotics plus benzoyl peroxide. Combination therapy was considered the treatment of choice in all types of acne, with topical retinoids as the initial treatment option for mild and moderate forms and the preferred option for maintenance therapy.

CONCLUSIONS

in general, Spanish dermatologists treat acne in accordance with the Acne Global Alliance treatment algorithm. The varying opinions reported in response to open questions, however, confirm the need to unify criteria for the treatment of acne.

Therapeutic considerations for severe nodular acne

Severe nodular acne, defined as grade 4 or 5 acne on the Investigator's Static Global Assessment scale, is a skin condition characterized by intense erythema, inflammation, nodules, cysts, and scarring. Both the well known risk of physical scarring and the more recent recognition that acne can be a chronic, psychologically distressing disease with significant adverse effects on a patient's quality of life, have prompted earlier, more aggressive treatment with more effective medications, in the hope of preventing progression to more severe, nodular forms of the disease. Oral antibacterials, primarily tetracyclines, have long been the first-line therapy for severe nodular acne, which frequently remained refractory to therapy. However, concerns of antibacterial adverse effects, patient adherence, and antimicrobial resistance prompted the search for alternate therapies and combinations thereof in order to target the multifactorial pathogenesis of the disease. Isotretinoin, an oral retinoid introduced in 1982, has since become the gold standard therapy in severe acne and has revolutionized its treatment. Several adjunctive agents exist. Oral antibacterials are indicated as an alternative for patients with severe acne who cannot tolerate oral retinoids, or for whom a contraindication exists. In order to prevent bacterial resistance, antibacterials should always be used in combination with benzoyl peroxide, a nonantibiotic antimicrobial agent with anti-inflammatory activity. Topical retinoids are often added to this regimen. In women, hormonal agents, which include oral contraceptives, spironolactone, and oral corticosteroids, and, in Europe, cyproterone acetate, may be used as monotherapy or concomitantly with isotretinoin. For rapid treatment of inflammatory nodules, intralesional corticosteroids are effective. These treatment modalities have been studied, refined, and combined in novel ways in order to target the multifactorial pathogenesis of the disease, and in this article we review each of their roles.

Changing the topography of acne with topical medications

PURPOSE OF REVIEW

Acne vulgaris is a common skin condition that affects approximately 40-50 million Americans annually. The peak incidence of acne occurs during adolescence and young adulthood, with approximately 80% of persons aged 11-30 years having at least minor acne. Because the onset of acne is typically in early adolescence, pediatricians are often at the front-lines in terms of caring for patients with this chief complaint.

RECENT FINDINGS

Over the last 2 years, new acne therapies have become available. These include new combination fixed-dose products, which may allow for greater flexibility in treatment and greater patient compliance. New topical antibiotics have also come to the market, providing more therapeutic options for mild to moderate inflammatory acne. Lastly, acne therapies involving the use of light sources and photosensitizers are currently being developed, which may provide a whole new modality for managing complicated patients.

SUMMARY

Successful management of acne requires the physician to make a thorough assessment of the patient's acne severity, predominant lesion type, skin type, and lifestyle in order to pair each individual patient's needs with the appropriate anti-acne therapy. This article provides an overview of the pathophysiology of acne and pre-existing topical therapies. It then discusses some novel acne therapies and outlines how they might fit into a physician's treatment strategy.

0.5% Liposome-encapsulated 5-aminolevulinic acid (ALA) photodynamic therapy for acne treatment

BACKGROUND

Photodynamic therapy using topical 5-aminolevulinic acid (ALA) has been successful in treating acne vulgaris, but sun avoidance for at least 48 hours after treatment is necessary due to the risk of post-treatment photosensitivity. Recently, a lower concentration of liposome-encapsulated 5-ALA was introduced to minimize this risk.

OBJECTIVES

To evaluate the efficacy and safety of liposome-encapsulated 0.5% 5-ALA in the photodynamic therapy of inflammatory acne and its effects on sebum secretion in Asian skin.

METHODS

Thirteen Korean subjects with inflammatory acne were administered 0.5% ALA spray before photoradiation treatment. Photoradiation was performed at 3.5-6.0 J/cm(2) three times during each of two visits, performed 2 weeks apart. Improvement of acne was evaluated subjectively and objectively based on the Korean Acne Grading System. Sebum secretion was measured quantitatively at each visit.

RESULTS

The mean reduction in acne grade at the end of the treatment was 43.2%. Of the patients, 69.2% reported improvements in subjective skin oiliness, but fewer showed objective reductions in sebum secretion as determined by the Sebumeter® SM10. No serious adverse events were observed.

CONCLUSION

Photodynamic therapy using liposome-encapsulated 0.5% 5-ALA improved inflammatory acne with minimal side effects in Asians.

Postprocedural wound-healing efficacy following removal of dermatosis papulosa nigra lesions in an African American population: a comparison of a skin protectant ointment and a topical antibiotic

BACKGROUND

Removal of dermatosis papulosa nigra (DPN) lesions results in superficial cutaneous wounds that are frequently treated with topical antibiotic ointments. We hypothesize that antibiotics are not necessary for effective and safe healing of such wounds.

OBJECTIVE

This study compared the wound healing efficacy and safety of the skin protectant Aquaphor Healing Ointment (AHO) (Beiersdorf Inc, Wilton, CT) and Polysporin first-aid ointment (Poly/Bac) (polymyxin B sulfate/bacitracin zinc) (Johnson & Johnson, New Brunswick, NJ) after removal of DPN lesions.

METHODS

This double-blind, split-face, pilot study removed two DPN lesions from each side of the face of 20 African American subjects. Wounds on opposite sides of the face were treated with AHO or Poly/Bac twice daily for 21 days. Wounds were evaluated for erythema, edema, crusting, scabbing, epithelial confluence, melanin confluence, general wound appearance, and subjective irritation on days 1, 3, 7, 10, 14, and 21 after surgery using 5-point scales.

RESULTS

Wound healing parameter assessments showed no differences between wounds treated with AHO versus Poly/Bac in erythema, edema, epithelial confluence, crusting, scabbing, melanin confluence, or postinflammatory hyperpigmentation at any time point. Subjective irritation was similar between treatments for burning, stinging, itching, tightness, tingling, and pain. No adverse events were reported.

LIMITATIONS

This was a small study in a homogenous population of African Americans.

CONCLUSIONS

Postprocedural treatment with AHO and Poly/Bac demonstrated equivalent wound healing in an African American population. These results support the hypothesis that antibiotics are not necessary for safe and effective healing of facial wounds resulting from removal of DPN lesions.

Acne vulgaris treatment : the current scenario

Acne Vulgaris is one of the most common skin disorders which dermatologists have to treat. It mainly affect adolescent, though may present at any age. In recent years, due to better understanding of the pathogenesis of acne, new therapeutic modalities and various permutation and combinations have been designed. In topical agents; benzoyl peroxide, antibiotics, retinoids, etc are the mainstay of treatment; can be given in combinations. While systemic therapy includes oral antibiotics, hormonal therapy, and isotretinoin, depending upon the need of patients it has to be selected. Physical treatment in the form of lesion removal, photo-therapy is also helpful in few of them. Since various old and new topical and systemic agents are available to treat acne, it sometime confuse treating dermatologist. To overcome this, panel of physicians and researchers worked together as a global alliance and task force to improve outcomes in acne treatment. They have tried to give consensus recommendation for the treatment of acne. Successful management of acne needs careful selection of anti-acne agents according to clinical presentation and individual patient needs.

Potential association between the oral tetracycline class of antimicrobials used to treat acne and inflammatory bowel disease

OBJECTIVES

Previous studies have shown an association between isotretinoin and inflammatory bowel disease (IBD). The majority of patients prescribed isotretinoin for their acne are previously on an extended course of antibiotics. Therefore, it is important to consider antibiotic use as a confounding variable for the development of IBD.

METHODS

We performed a retrospective cohort study using The Health Improvement Network database of the United Kingdom. We identified 94,487 individuals with acne who were followed up by a general practitioner for 406,294 person-years.

RESULTS

>A prescription for minocycline was received by 24,085 individuals, for tetracycline/oxytetracycline by 38,603 individuals, and doxycycline by 15,032 individuals. IBD was noted in 41 individuals exposed to minocycline, 79 individuals exposed to tetracycline/oxytetracycline, 32 individuals exposed to doxycycline, and 55 (0.11%) individuals not exposed to any of these antibiotics. The hazard ratio (HR) for developing IBD for any exposure to a tetracycline antibiotic was 1.39 (1.02, 1.90). HRs for individual antibiotics were 1.19 (0.79, 1.79) for minocycline, 1.43 (1.02, 2.02) for tetracycline/oxytetracycline, and 1.63 (1.05, 2.52) for doxycycline. For ulcerative colitis, the associations (HR) were 1.10 (0.76, 1.82) for minocycline, 1.27 (0.78, 2.07) for tetracycline/oxytetracycline, and 1.06 (0.53, 2.13) for doxycycline. For Crohn's disease (CD), the associations (HR) were 1.28 (0.72, 2.30) for minocycline, 1.61 (0.995, 2.63) for tetracycline/oxytetracycline, and 2.25 (1.27 4.00) for doxycycline.

CONCLUSIONS

Tetracycline class antibiotics, and particularly doxycycline use may be associated with the development of IBD, particularly CD. Potential confounding by previous doxycycline exposure should be considered when assessing whether treatment with other acne medications increases the risk of IBD.

Antibiotic susceptibility of Propionibacterium acnes isolated from acne vulgaris in Korea

Propionibacterium acnes plays an important role in the development of acne, and inflammatory lesions are improved by antibiotics. Long-term use of antibiotics may result in development of resistant strains and treatment failure. The aim of the present study was to investigate the isolation rate of P. acnes and to evaluate its antibiotic susceptibility to widely used antibiotics in acne in Korea. Among 46 patients, 31 P. acnes strains were cultured. Isolated P. acnes was measured for minimum inhibitory concentration (MIC) of tetracycline, doxycycline, minocycline, erythromycin and clindamycin using an Epsilometer test. Age, disease duration and previous history of antibiotic therapy for acne were compared in relation to the MIC. The mean MIC of tetracycline, minocyclines, doxycycline, clindamycin and erythromycin were all below the breakpoint of antibiotic resistance. The patients with acne vulgaris with disease duration of more than 2 years documented higher MIC values in doxycycline, erythromycin, and clindamycin than those of less than 2 years. The patients who were previously treated with topical or systemic antibiotics showed higher MIC in doxycycline. Antibiotic resistance of P. acnes is still low in Korea, but at this point, there is an increasing trend of MIC. Caution and acknowledgement of increased risk of antibiotic resistant P. acnes should be advised in acne antibiotic treatment to minimize and avoid the emergence of the resistant strain.

Current drugs for treatment of acne vulgaris

The author provides data about the efficacy and side effects of current drugs for treatment of acne. He pays special attention to the problem of developing resistance in case of application of antibiotics. The article describes current approaches to the reduction of this problem in patients with acne. It lists main currently available hormone drugs taking into account their efficacy and side effects. The article presents a current algorithm for evaluating possible side effects of application of isotretinoin and measures of their prevention, and describes a new form of isotretinoin with extra bioavailability - Acnecutan. It also discusses characteristics of external drugs.