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

Acne through the ages: case-based observations through childhood and adolescence

Acne vulgaris is a common disorder that affects more than 17 million individuals in the United States. Knowledge of the disease is an important part of clinical practice, particularly for the pediatric practitioner. Contrary to common belief, acne is not a disease limited to adolescents and young adults but can occur at any stage of life. This article is a case-based review of acne during childhood and adolescence. Workup is based on age and concurrent physical findings, whereas therapy depends on the type of skin lesions along with patient characteristics and preferences.

New insights into adolescent acne

PURPOSE OF REVIEW

Acne vulgaris remains one of the most common conditions affecting adolescents. The pediatric practitioner is the first to evaluate adolescent acne, making familiarity with the condition and its management essential. This review covers some of the recent literature regarding acne to help practitioners stay current on the issues regarding this topic.

RECENT FINDINGS

The pathogenesis of acne is multifactorial and complex, but recent advances in molecular genetics have provided additional information on the actions of Proprionibacterium acnes. Nutritional studies have reevaluated a possible role for diet and lifestyle factors in acne development. Many therapies are available to control acne and to limit associated scarring. Their appropriate use requires an understanding of not only the benefits but also the possible risks and adverse effects involved. Recent concerns regarding the use of antibiotics and isotretinoin will be addressed.

SUMMARY

This study reviews the recent literature regarding teenage acne, focusing on pathogenesis, associations, and controversies and considerations in therapy.

Experiência de 65 anos no tratamento da acne e de 26 anos com isotretinoína oral

Este artigo especial foi extraído de uma palestra proferida pelo Prof. Sebastião Sampaio e elaborado em conjunto com a Profa Edileia Bagatin. Reflete a experiência dos autores no tratamento das principais formas de acne nos períodos pré e pós a introdução da isotretinoína oral que revolucionou a abordagem da doença. Esta droga representa a única opção capaz de levar à remissão prolongada ou cura da acne por atuar em todos os mecanismos etiopatogênicos conhecidos até o momento. Evidentemente, deve ser prescrita de acordo com as recomendações vigentes e reservada para casos de difícil controle, com tendência a cicatrizes e com sérias repercussões psico-sociais. Outras modalidades terapêuticas, tópicas e/ou sistêmicas, devem ser consideradas no início do tratamento e nos casos de intensidade leve a moderada.

Practical considerations in acne treatment and the clinical impact of topical combination therapy

Acne vulgaris is a highly prevalent, multifactorial disease process affecting the pilosebaceous units of the dermis. The effects of acne are profound both physically and psychosocially across all age groups and ethnicities; therefore, prompt recognition and appropriate treatment are critical. Pharmacotherapeutic approaches range from simple monotherapy to multimodal treatments with a variety of topical and systemic agents. Optimal patient outcomes in acne management, however, are based both on treatment efficacy as well as overall patient satisfaction. In an effort to comprehensively address these key clinical considerations in acne management, we examine the diverse nature of acne patients, the factors in optimizing treatment outcomes, and the clinical impact of current medications, particularly topical combination therapy.

Pharmacotherapy of acne

BACKGROUND

Acne results from the interplay of several pathophysiologic factors, in particular seborrhoea, follicular hyperkeratosis, propionibacteria and inflammation. Recently, it has become clear that inflammatory events are important not only in the course, but also in the initiation of the disease.

OBJECTIVE

The study undertook an evaluation of the effectiveness of currently available pharmacotherapeutic treatment options for acne.

METHODS

After a Medline-based literature search, this article critically reviewed substances used topically (among others, retinoids, antimicrobials, salicylic acid and azelaic acid) and systemically (antibiotics, isotretinoin, hormones and zinc) as well as their combinations with respect to pharmacology, clinical efficacy and side effects.

RESULTS

Modern acne pharmacotherapy provides substances that antagonize one or more of the major pathophysiologic factors of acne. When the clinical picture but also patients' motivation and wishes are appropriately considered, current pharmacotherapy of acne is rational and effective.

Topical retinoids in acne--an evidence-based overview

Topical retinoids are important tools in the management of acne because they act against comedones and microcomedones and have direct anti-inflammatory effects. The substances approved for acne treatment comprise tretinoin (all-trans-retinoic acid), isotretinoin (13-cis retinoic acid) as well as the synthetic third-generation polyaromatic retinoids adapalene and tazarotene, the latter being approved for acne treatment in the US only. Retinaldehyde is used in cosmetic preparations against acne. All topical retinoids are effective as single agents in mild to moderate acne but differ in efficacy and tolerability. Tazarotene 0.1% is more effective than tretinoin 0.025% or 0.1% microsphere gel or adapalene 0.1% gel or cream (EBM-level 2c). Adapalene 0.1% is equally effective to tretinoin 0.025% or tretinoin microsphere 0.1% gel or tretinoin 0.05% cream or isotretinoin 0.05% gel (EBM-level 2c). Adapalene 0.1% gel is significantly better tolerated than tazarotene 0.1% gel, tretinoin 0.025% and tretinoin 0.05% gel, tretinoin 0.05% cream, tretinoin microsphere 0.1% gel or isotretinoin 0.05% gel (EBM-level 2c). The safety profile of topical retinoids differs from their systemic counterparts and is related mainly to local adverse effects, such as erythema, dryness, itching and stinging. The currently available evidence justifies the use of topical retinoids in most types of acne and during maintenance treatment.

Gender differences in skin: a review of the literature

BACKGROUND

There has been increasing interest in studying gender differences in skin to learn more about disease pathogenesis and to discover more effective treatments. Recent advances have been made in our understanding of these differences in skin histology, physiology, and immunology, and they have implications for diseases such as acne, eczema, alopecia, skin cancer, wound healing, and rheumatologic diseases with skin manifestations.

OBJECTIVE

This article reviews advances in our understanding of gender differences in skin.

METHODS

Using the PubMed database, broad searches for topics, with search terms such as gender differences in skin and sex differences in skin, as well as targeted searches for gender differences in specific dermatologic diseases, such as gender differences in melanoma, were performed. Additional articles were identified from cited references. Articles reporting gender differences in the following areas were reviewed: acne, skin cancer, wound healing, immunology, hair/alopecia, histology and skin physiology, disease-specific gender differences, and psychological responses to disease burden.

RESULTS

A recurring theme encountered in many of the articles reviewed referred to a delicate balance between normal and pathogenic conditions. This theme is highlighted by the complex interplay between estrogens and androgens in men and women, and how changes and adaptations with aging affect the disease process. Sex steroids modulate epidermal and dermal thickness as well as immune system function, and changes in these hormonal levels with aging and/or disease processes alter skin surface pH, quality of wound healing, and propensity to develop autoimmune disease, thereby significantly influencing potential for infection and other disease states. Gender differences in alopecia, acne, and skin cancers also distinguish hormonal interactions as a major target for which more research is needed to translate current findings to clinically significant diagnostic and therapeutic applications.

CONCLUSIONS

The published findings on gender differences in skin yielded many advances in our understanding of cancer, immunology, psychology, skin histology, and specific dermatologic diseases. These advances will enable us to learn more about disease pathogenesis, with the goal of offering better treatments. Although gender differences can help us to individually tailor clinical management of disease processes, it is important to remember that a patient's sex should not radically alter diagnostic or therapeutic efforts until clinically significant differences between males and females arise from these findings. Because many of the results reviewed did not originate from randomized controlled clinical trials, it is difficult to generalize the data to the general population. However, the pressing need for additional research in these areas becomes exceedingly clear, and there is already a strong foundation on which to base future investigations.

Development of a new solid lipid nanoparticle formulation containing retinoic acid for topical treatment of acne

The development of solid lipid nanoparticles (SLN) containing all-trans retinoic acid (RA) is an interesting approach to topical treatment of acne. SLN has potential for controlled release and follicular penetration, which can reduce adverse effects in comparison with conventional formulations. However, the encapsulation efficiency (EE) of RA in SLN is usually low, unless a high surfactant/lipid ratio is used. The aim of this work was to develop SLN with high EE using a low surfactant/lipid ratio. Different formulations of RA-loaded SLN were prepared using glyceryl behenate as lipid matrix. The particle size, EE, zeta potential and differential scanning calorimetry (DSC) were investigated. High EE in SLN was obtained with addition of amines. These results indicate that the utilization of amines is an interesting approach to improve the EE of RA in SLN using a low surfactant/lipid ratio.

Efficacy of tetracyclines in the treatment of acne vulgaris: a review

BACKGROUND

Oral tetracyclines are routinely used for the management of inflammatory acne. However, there is a lack of evidence-based data on their relative effectiveness and appropriate dosages.

OBJECTIVES

To assess the relative effectiveness and the optimal dosage of tetracyclines for the treatment of inflammatory acne.

METHODS

We designed a systematic review of the clinical trials (1962-2006) investigating oral tetracyclines for the treatment of inflammatory acne. We obtained data from MEDLINE, PubMed, Current Contents, reference lists and specialist textbooks.

RESULTS

There was substantial heterogeneity in the design of the trials. We identified only seven randomized trials which were set up to compare the efficacy of tetracyclines in reducing acne lesion counts. These showed no evidence of superiority of one tetracycline over another. Overall, there was also no significant difference between the available tetracyclines in terms of improvement in inflammatory (32 trials, P=0.898) and noninflammatory (23 trials, P=0.429) lesions. In the range of investigated dosages, the antibiotic dosage had no impact on efficacy in inflammatory (P=0.609) and noninflammatory (P=0.654) lesions. There was no decrease in efficacy during the study period.

CONCLUSIONS

There is insufficient evidence to support one tetracycline rather than another in terms of efficacy. In the range of investigated dosages, the antibiotic dosage seems to have no impact on efficacy. Despite increased resistance to antibiotics, oral tetracycline formulations displayed no change in efficacy during the study period. Further studies are, however, required to determine if the anti-inflammatory properties of tetracyclines are sufficient in managing acne.

Adapalene-benzoyl peroxide, a fixed-dose combination for the treatment of acne vulgaris: Results of a multicenter, randomized double-blind, controlled study

BACKGROUND

A fixed-dose combination gel with adapalene 0.1% and benzoyl peroxide (BPO) 2.5% has been developed for the once-daily treatment of acne.

OBJECTIVE

To evaluate the efficacy and safety of adapalene 0.1% -BPO 2.5% fixed combination gel (adapalene-BPO) for the treatment of acne.

METHODS

A total of 517 subjects were randomized in a double-blind controlled trial to receive either adapalene-BPO, adapalene, BPO, or vehicle for 12 weeks (2:2:2:1 randomization). Evaluation included success rate (subjects "clear" or "almost clear"), lesion count, cutaneous tolerability, and adverse events.

RESULTS

The fixed-dose combination gel of adapalene and BPO was significantly more effective than corresponding monotherapies, with significant differences in total lesion counts observed as early as 1 week. Adverse event frequency and cutaneous tolerability profile for adapalene-BPO were similar to adapalene monotherapy.

LIMITATIONS

These data were generated in a controlled trial. Results obtained in clinical practice could differ.

CONCLUSIONS

The fixed-dose combination of adapalene and BPO provides significantly greater efficacy for the treatment of acne vulgaris as early as week 1 relative to monotherapies, with a comparable safety profile to adapalene.

Association or lack of association between tetracycline class antibiotics used for acne vulgaris and lupus erythematosus

BACKGROUND

Previous studies have associated tetracyclines and, perhaps more specifically, minocycline use for the treatment of acne with onset of drug-induced lupus erythematosus (LE).

OBJECTIVES

To determine the frequency of LE among those with acne who used antibiotics from the tetracycline class of antibiotics.

METHODS

A retrospective cohort study of individuals aged 15-35 years with acne within the practices of the general practice physicians in the U.K. who participate in The Health Information Network (THIN). Our outcome measure was physician reports of LE.

RESULTS

We identified 97 694 subjects with acne who were followed for about 520 000 person-years. They were on average about 22 years old and 57.5% were female. Minocycline exposure was noted in 24.8% of our subjects, doxycycline exposure in 15.6%, other tetracyclines in 42.3%, and 17.3% had not received a tetracycline antibiotic. The overall hazard ratio for the association of minocycline to LE was 2.64 (95% confidence interval 1.51-4.66) and when adjusted for age and gender was 3.11 (1.77-5.48). Those affected were often treated for LE. No association was noted for doxycycline and the other tetracyclines.

CONCLUSIONS

The use of minocycline and not the other tetracyclines is associated with LE. LE as reported in THIN often required systemic therapy. Overall, the event is uncommon but the risk and benefit of minocycline therapy must be carefully considered.

Anti-inflammatory dose doxycycline (40 mg controlled-release) confers maximum anti-inflammatory efficacy in rosacea

BACKGROUND

Two large clinical trials have recently demonstrated the efficacy of a 40-mg controlled-release formulation of doxycycline in the treatment of rosacea, a dose well below the conventional level of 100 to 200 mg/d. Since no formal dose-response studies have been conducted, the authors analyzed phase 3 data to determine whether a dose-efficacy relationship exists.

METHODS

Standard parametric regression analyses were used to estimate the correlations between dose (mg/kg body weight) and overall drug exposure (area under the curve [AUC]) in a phase 1 pharmacokinetic study and between dose and efficacy (mean change from baseline in total inflammatory lesion count at week 16) in 2 pooled phase 3 clinical efficacy studies. Additional regressions were run at each visit for the clinical efficacy studies to determine whether results differed across visits. A regression analysis was also performed in a subset of patients who showed a greater efficacy response.

RESULTS

We found overall drug exposure (AUC) to have a highly significant correlation with dose (mg/kg) (r=0.49; P=.006). In contrast, clinical efficacy did not correlate with dose at any of the visits at week 3 (r=0.01; P=.85), week 6 (r=0.04; P=.53), week 12 (r<0.01; P=.98), and week 16 (r=0.03; P=.64) or among the subset of patients who showed greater clinical benefit.

CONCLUSIONS

Higher mg/kg doses led to higher plasma concentrations but did not lead to increased clinical efficacy. Anti-inflammatory dose doxycycline (40-mg controlled-release formulation) conferred peak anti-inflammatory efficacy in the treatment of rosacea.

Procedural Treatments for Acne Vulgaris

BACKGROUND

Simple procedural treatments such as comedone extraction and intralesional steroids have been utilized for many years as adjunctive therapy for acne. In the past 5 years, new technologies and procedures have become available that present new options for the treatment of acne.

OBJECTIVES

The objective was to review, summarize, and evaluate the key studies of procedural therapies for the treatment of acne as well as place them in perspective with current clinical practice.

METHODS

Studies selected for evaluation had at least 10 patients and clear statements of purpose, acne severity, patient selection, follow-up evaluations, previous and concurrent medications, treatment parameters, methods for evaluating results, and adverse effects. All studies were complete and published (in English) in peer-reviewed journals.

RESULTS AND CONCLUSIONS

Earlier procedural therapies were adjunctive to medical therapy, such as intralesional steroids, chemical peels, and microdermabrasion. Newer methods include radiofrequency, light or laser, and photodynamic therapy that represent treatment alternatives for systemic medications. Still early in their development, these new procedures provide an important, novel set of options for the treatment of acne. The most developed and studied therapies are blue or blue/red light combinations, 1,450-nm diode laser, and photodynamic therapy with 5-aminolevulinic acid or indocyanine green. Review of the literature of more up-to-date physical procedures provides a starting point for physicians seeking to treat their acne patients safely and effectively with these new methods.

A randomized, single-blind comparison of topical clindamycin + benzoyl peroxide (Duac) and erythromycin + zinc acetate (Zineryt) in the treatment of mild to moderate facial acne vulgaris

BACKGROUND

Antibiotics are often combined with other agents to provide topical acne treatments that are effective against both inflammatory and non-inflammatory lesions and minimize the development of antibiotic resistance.

OBJECTIVES

To compare the clinical effectiveness of two combination treatments for facial acne: a ready mixed, once daily gel containing clindamycin phosphate (1%) plus benzoyl peroxide (5%) (CDP + BPO) and a twice daily solution of erythromycin (4%) plus zinc acetate (1.2%) (ERY + Zn).

METHODS/PATIENTS

In this assessor-blind, randomized study, 73 patients were treated with CDP + BPO once daily and 75 patients with ERY + Zn twice daily. The treatment period was 12 weeks and lesion counts and global improvement were assessed at weeks 1, 2, 4, 8 and 12.

RESULTS

CDP + BPO showed an earlier onset of action with a faster significant reduction in total lesion counts than ERY + Zn. The proportion of patients with at least a 30% improvement in non-inflammatory lesions at week 1 was 31.5% for CDP + BPO and 17.3% for ERY + Zn; the corresponding percentages for inflammatory lesions were 39.7% and 29.3%. A difference was also observed at week 2 (53.4% vs. 36.0% for non-inflammatory lesions and 72.6% vs. 53.3% for inflammatory lesions). The trend in favour of CDP + BPO, although less marked, continued to the end of the study, with reductions in the total lesion count at endpoint of 69.8% for CDP + BPO group and 64.5% for ERY + Zn group. Both treatments were well tolerated.

CONCLUSIONS

CDP + BPO and ERY + Zn are effective treatments for acne but CDP + BPO has an earlier onset of action that should improve patient compliance.

Control of microcomedone formation throughout a maintenance treatment with adapalene gel, 0.1%

BACKGROUND

Microcomedones representing the clinically non-visible central precursor lesions of acne are induced by sebaceous hyperplasia as well as altered follicular growth and differentiation, and evolve into both comedones and inflammatory lesions. Thus, targeting microcomedone formation is essential in the prevention and therapeutic control of acne.

OBJECTIVE

The aim of this study was to assess the capacity of adapalene gel, 0.1%, to control the number of microcomedones after a combination treatment followed by a maintenance treatment.

METHODS

This was a single-site exploratory study in subjects with a diagnosis of mild to moderate acne vulgaris and the presence of at least 250 microcomedones per cm(2) at screening visit, counted via cyanoacrylate strips (CyASt). During the first 8 weeks, a combination of adapalene gel (0.1%) and benzoyl peroxide gel (2.5%) was applied. During the randomized, investigator-blinded, and vehicle-controlled 12-week maintenance phase, adapalene once daily (QD), or adapalene alternately with its vehicle once daily every other day (QoD), or vehicle QD were applied to the face. CyASt sampling on the forehead was done at baseline, week 8, and week 20. Lesion counting allowing calculating a defined success rate was done at all visits.

RESULTS

A total of 54 subjects entered the combination phase, and 49 subjects were randomized into the maintenance phase: 16 in both the adapalene QD and the QoD group and 17 subjects receiving the vehicle. The microcomedone median count decreased for all groups until week 8 (end of combination phase) from 319 to 157. Microcomedone counts at the end of the maintenance phase (week 20) showed a significant percent difference (P = 0.04) between adapalene QoD (-53.5) and the vehicle (-42.1) and between adapalene QD (-50.6) and the vehicle (P = 0.037) compared with baseline.

CONCLUSION

The application of adapalene gel, 0.1% monotherapy daily, or alternately every other day, significantly helps to control the microcomedone count during a 12-week maintenance treatment after a previous combination therapy with benzoyl peroxide in patients with mild to moderate acne.

The 1,450-nm diode laser reduces sebum production in facial skin: a possible mode of action of its effectiveness for the treatment of acne vulgaris

BACKGROUND AND OBJECTIVES

Over the last several years, several light-based systems have been employed for the treatment of acne vulgaris. The 1,450-nm diode laser has been shown to improve acne, and this has been suggested to be due to effects on sebaceous glands. However, an effect on sebum production has not been demonstrated. The objective of this study was to evaluate if the 1,450-nm diode laser indeed reduces sebum production.

STUDY DESIGN/MATERIALS AND METHODS

Eight patients with a history of acne were recruited and treated with the 1,450-nm diode laser on the right side of the nose over a 6-week period, for a total of three treatments. Sebum production was quantified using the Sebutape method.

RESULTS

The number of sebum-producing follicles was reduced by 8.5 and 16.7% at weeks 4 and 6, respectively (P<0.05). A significant reduction in total collected sebum (-18%) was observed at week 6.

CONCLUSION

This data suggests that the clinical effectiveness of the 1,450-nm diode laser may be based, at least in part, on its effects on sebaceous glands, with subsequent reduction in sebum production.

Inhibitors of Dipeptidyl Peptidase IV and Aminopeptidase N Target Major Pathogenetic Steps in Acne Initiation

Acne is a chronic disease hallmarked by sebaceous hyperplasia, follicular hyperkeratosis, and inflammation. Parallel targeting of these factors is required to treat acne effectively. Inhibitors of dipeptidyl peptidase IV (DP IV) and aminopeptidase N (APN) show strong anti-inflammatory effects on immune cells and therapeutic efficacy in autoimmune disorders. Our investigation focused on the expression and functional relevance of these ectopeptidases in three cell types which exhibit an altered phenotype in early acne lesions. We showed for the first time expression of DP IV and APN on human sebocytes. In the SZ95 sebocyte cell line, the DP IV inhibitors Lys[Z(NO2)]-thiazolidide and Lys[Z(NO2)]-pyrrolidide and the APN inhibitors actinonin and bestatin suppressed proliferation, enhanced terminal differentiation, and slightly decreased total neutral lipid production. The anti-inflammatory and differentiation-restoring cytokine IL-1 receptor antagonist was significantly upregulated in SZ95 sebocytes and the HaCaT keratinocyte cell line in the presence of inhibitors. Furthermore, the inhibitors suppressed proliferation and IL-2 production of Propionibacterium acnes-stimulated T cells ex vivo and enhanced the expression of the immunosuppressive cytokine transforming growth factor-beta1. Our data provide first evidence for a functional role of DP IV and APN in the sebaceous gland apparatus and for their inhibitors, used alone or in combination, as completely new substances possibly affecting acne pathogenesis in a therapeutic manner.

Selective electrothermolysis of the sebaceous glands: treatment of facial seborrhea

BACKGROUND

There are few publications on facial seborrhea treatment. A focused therapy is needed.

OBJECTIVE

Our aim was to evaluate the efficacy of electrothermolysis of the sebaceous glands.

METHODS

In the preliminary studies, histologic changes in the cheek skin by electrothermolysis were examined by light microscopy. In the clinical studies, 15 adult women subjects with facial seborrhea were treated four times by the same procedure. A 1.50-mm-long needle with a 0.45-mm base insulation was inserted into pores in the forehead and cheeks, and a high-frequency electrical current was applied for 0.25 to 0.50 seconds with an output of 40 W. Each treatment took 60 to 90 minutes. The subjects returned for 6-months follow-up after their fourth treatment.

RESULTS

Histology 1 and 6 months later showed fewer sebaceous glands and the development of fibrosis. All 12 subjects who completed the 6-month follow-up gave a subjective assessment of continuous reduction of facial seborrhea. On a scale of 0.0 to 3.0, the mean improvement score was 1.67+/-0.75. The mean reduction rate of skin surface lipids was 31.5% by sebumeter (p< .01).

CONCLUSIONS

Even though this is a pilot, uncontrolled clinical assessment study, electrothermolysis of sebaceous glands may be an effective and safe approach for facial seborrhea treatment.

The use of photodynamic therapy for treatment of acne vulgaris

Current topical and most oral therapies for acne vulgaris have limited efficacy, especially in moderate to severe cases. Photodynamic therapy with 5-aminolevulinic acid and recently methyl aminolevulinate has been shown to be a safe and effective modality for the treatment of acne vulgaris. Consensus guidelines suggest that 30 to 60 minutes is sufficient 5-aminolevulinic acid contact time before photoactivation with blue light, red light, yellow light, broadband light, halogen, or pulsed dye laser devices. An average of three treatment can yield significant long-term improvement.

Acne is prevalent but use of its treatments is infrequent among adolescents from the general population

BACKGROUND

Little is known about the use of acne treatments among teenagers in the community.

OBJECTIVES

To assess the prevalence of use of acne treatments in a general population sample of adolescents and to investigate factors associated with its use.

METHODS

During official school examinations, 594 adolescents (14-18 years old) were examined for acne on the face and body using a validated scoring system. In addition, they were interviewed about current and prior treatment use by showing them packages of available (non-)prescription treatments of acne in Belgium.

RESULTS

Despite the high prevalence of acne, its treatments were used infrequently; 13% had used topicals and 5% systemic drugs. Among adolescents who used therapy, benzoylperoxide and oral antibiotics were most often used. Although the likelihood of having used treatment increased significantly for both number of retentional and inflammatory lesions (P < or = 0.03), only a quarter of those with 20 or more papules and/or pustules had used topical treatment, and 10% systemic therapy. Multivariate logistic regression models demonstrated that girls were about twice as likely to have used topical agents (adjusted OR = 2.30 [95%CI = 1.37, 3.87]). Those with more inflammatory lesions on the face and with more extensive acne on the chest and back were about three times more likely to have used topical and/or systemic acne therapy.

CONCLUSION

Acne is very common among teenagers but very few have actually used treatments. These findings suggest that it may be worthwhile to better inform the community about acne and its treatment options to reduce acne severity and its impact on those affected.

Abuse of anabolic-androgenic steroids and bodybuilding acne: an underestimated health problem

Abuse of anabolic-androgenic steroids (AAS) by members of fitness centers and others in Germany has reached alarming dimensions. The health care system provides the illegal AAS to 48.1 % of abusers. Physicians are involved in illegal prescription of AAS and monitoring of 32.1 % of AAS abusers. Besides health-threatening cardiovascular, hepatotoxic and psychiatric long-term side effects of AAS, acne occurs in about 50 % of AAS abusers and is an important clinical indicator of AAS abuse, especially in young men 18-26 years of age. Both acne conglobata and acne fulminans can be induced by AAS abuse. The dermatologist should recognize bodybuilding acne, address the AAS abuse, and warn the patient about other potential hazards.

Treatment of inflammatory facial acne vulgaris: comparison of the 1450-nm diode laser and conventional physical treatment

The efficacy of the 1450-nm diode laser in the treatment of inflammatory facial acne was evaluated by comparing it with conventional physical treatment. Seventeen patients received laser treatment on the right side of the face and conventional physical treatment on the other side. The two modalities were compared through photographs, inflammatory acne lesion counts, and a patient questionnaire. Clinical response was evaluated in 16 patients. Evaluation of baseline and follow-up photographs indicated that more improvement was obtained after laser treatment than by physical treatment in six patients. In two patients, physical treatment yielded better results than laser treatment. Equal effect was obtained in eight patients. All patients had a reduction in the inflammatory acne lesion count on the laser-treated side, which was statistically significantly greater on the laser-treated side compared with the side treated physically (p=0.039, Wilcoxon signed ranks test). By the assessment of patient satisfaction, seven patients preferred laser treatment, two patients preferred physical treatment and three patients found laser treatment equal to physical treatment. Questionnaire details could not be obtained in 4 patients. This study indicates that the 1450-nm diode laser is a new option for local treatment of acne.

The relationship between CYP17 -34T/C polymorphism and acne in Chinese subjects revealed by sequencing

BACKGROUND

Although many arguments have been raised on the role of heredity in the etiology of acne, the relevant genetic elements in the pathogenesis of the disease are not well established.

OBJECTIVE

The aim of our study was to evaluate the association between a genetic polymorphism in the promoter region of the CYP17 gene and the development of acne.

METHODS

206 acne patients and 200 controls were included in the study. A polymerase chain reaction (PCR) sequencing technique was used to reveal a CYP17 gene polymorphism in its promoter region. A chi2 test was used for data analysis.

RESULTS

CYP17 -34T/C polymorphism was found and the frequency distribution of the C/C homozygotes and C allele in the male patients with severe acne (33.3 and 60.9%, respectively) were statistically significantly different from those of the control samples (18.2 and 46.6%; p < 0.05). No significant difference was observed between the female patients, mild + moderate male patients and their controls, respectively.

CONCLUSION

The CYP17 -34C/C homozygote Chinese men are at a significantly increased risk of developing severe acne.

Systemic antibiotic therapy of acne vulgaris

BACKGROUND

Inflammatory, medium to severe acne vulgaris is treated with systemic antibiotics worldwide. The rationale is an effect on Propionibacterium acnes as well as the intrinsic anti-inflammatory properties of these antibiotics. Although there are no correlations between the number of P. acnes and the severity of the disease, associations between the degree of humoral and cellular immune responses towards P. acnes and the severity of acne have been reported. Exact data on practical use of these compounds, such as differential efficacy or side effects are unavailable. A summary of currently available studies is presented.

METHODS

The data of studies of systemic antibiotic therapy of acne vulgaris up to 1975, the summary of literature in English up to 1999, a systematic review of minocycline from 2002 as well as the data of randomized controlled studies published and listed in Medline thereafter were reviewed.

RESULTS

Tetracyclines [tetracycline 1,000 mg daily, doxycycline 100 (-200) mg daily, minocycline 100 (-200) mg daily, lymecycline 300 (-600) mg] and erythromycin 1 000 mg daily are significantly more effective than placebo in the systemic treatment of inflammatory acne. The data for tetracycline are best founded. Clindamycin is similarly effective. Co-trimoxazole and trimethoprim are likely to be effective. Clear differences between the tetracyclines or between tetracycline and erythromycin cannot be ascertained. The data for the combination with topical treatments [topical benzoyl peroxide (BPO) or retinoids] suggest synergistic effects. Therefore systemic antibiotics should not be used as monotherapy. In case of similar efficacy, other criteria, such as pharmacokinetics (doxycycline, minocycline, lymecycline have longer half-lives than tetracyclines), the rate of side-effects (tetracycline: side effect-rate approximately 4 % mild side effects; erythromycin: frequent gastrointestinal complaints; minocycline: rare, but potentially severe hypersensitivity reactions; doxycycline: dose-dependent phototoxic reactions), the resistance rate [percentage of resistant bacteria higher with erythromycin (approximately 50 %) than with tetracycline-therapy (approximately 20 %)], and the costs of therapy have to be taken into account.

CONCLUSIONS

The systemic antibiotic therapy of widespread papulo-pustular acne not amenable to a topical therapy is effective and well-tolerated. In general therapy can be carried out for 3 months and should be combined with BPO to prevent resistance.

Treatment of inflammatory facial acne vulgaris with intense pulsed light and short contact of topical 5-aminolevulinic acid: a pilot study

BACKGROUND

Photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA) and red light (550-700 nm) has been introduced for effective treatment of facial acne. Untoward side effects are common, however.

OBJECTIVE

To evaluate the efficacy and safety of the short contact of topical ALA and intense pulsed light (IPL) in treatment of inflammatory facial acne.

METHODS

Fourteen patients with inflammatory facial acne were treated with IPL on the left side and combination of IPL and topical ALA on the right side at 3- to 4-week intervals for three sessions. Clinical photographs and lesion counts were obtained for evaluation.

RESULTS

All patients revealed a reduction in number of acne lesions on both sides. On the ALA-pretreated side, lesion counts decreased 87.7% at 12 weeks after the last treatment (p < .01). Meanwhile, lesion counts on the nonpretreated side decreased 66.8% (p < .01). In addition, a number of lesion counts on the ALA-pretreated side decreased. Mild edema and minimal crust developed on the combined-treatment side.

CONCLUSION

Short contact of topical ALA and IPL or IPL alone showed some beneficial effect in treatment of inflammatory facial acne; however, degree of improvement was better and remained longer with the combined regimen. Side effects were mild and reversible.

Update in retinoid therapy of acne

The pathogenesis of acne, the most common skin disease, is complex and multifactorial. Clinical experience has demonstrated that parallel targeting of various pathogenetic factors, achieved either by mono- or combination therapy with appropriate drugs, represents the most effective approach to treating acne. Topical retinoids have been shown to expulse mature comedones, reduce microcomedone formation, and exert immunomodulatory effects. They have broad anti-acne activity without the risk of inducing bacterial resistance, which justifies their use as first-line treatment in most types of noninflammatory and inflammatory acne and makes them uniquely suitable as long-term medication to maintain remission after cessation of initial combination therapy. Systemic isotretinoin as a monotherapeutic agent strongly affects all four major pathogenetic factors and has been, in the hand of experienced dermatologists, a potent and safe agent for the treatment of severe and recalcitrant acne forms for more that 20 years. However, patient counseling, careful monitoring, and evaluation and management of adverse events are necessary. The use of isotretinoin has experienced a drawback now that its indication has been lowered from a first-line to a second-line medication.

Expert committee recommendations for acne management

In 2003, an international committee of physicians and researchers in the field of acne, working together as the Global Alliance to Improve Outcomes in Acne, developed consensus guidelines for the treatment of acne. These guidelines were evidence based when possible but also included the extensive clinical experience of this group of international dermatologists. As a result of the evaluation of available data and the experience, significant changes occurred in the management routines for acne. The greatest change arose on the basis of improved understanding of acne pathophysiology. The recommendation now is that acne treatments should be combined to target as many pathogenic factors as possible. A topical retinoid should be the foundation of treatment for most patients with acne, because retinoids target the microcomedo, the precursor to all acne lesions. Retinoids also are comedolytic and have intrinsic antiinflammatory effects, thus targeting 2 pathogenic factors in acne. Combining a topical retinoid with an antimicrobial agent targets 3 pathogenic factors, and clinical trials have shown that combination therapy results in significantly faster and greater clearing as opposed to antimicrobial therapy alone. Oral antibiotics should be used only in moderate-to-severe acne, should not be used as monotherapy, and should be discontinued as soon as possible (usually within 8-12 weeks). Because of their effect on the microcomedo, topical retinoids also are recommended as an important facet of maintenance therapy.

Cumulative irritancy comparison of topical retinoid and antimicrobial combination therapies

BACKGROUND

The use of multiple topical drugs for the treatment of acne may cause elevated irritation. Therefore, the selection of a combination regimen should include a careful consideration of the irritation potential of the individual acne medications.

OBJECTIVE AND METHODS

To compare the cumulative irritation potential of adapalene gel 0.1%, tazarotene cream 0.05%, and tretinoin microsphere 0.04% when applied in combination with two benzoyl peroxide/clindamycin topical gels in 35 healthy subjects in a 3-week, randomized, controlled study.

RESULTS

The mean cumulative irritancy index of adapalene combinations was significantly lower relative to tretinoin and tazarotene regimens (all P<.01). Test areas exposed to tretinoin or tazarotene were also more likely to be discontinued for severe irritation than those exposed to adapalene. There were no serious adverse events. No significant difference in the irritancy potentials of tazarotene and tretinoin combination regimens was observed.

CONCLUSIONS

Adapalene gel 0.1% has tolerability superior to both tazarotene cream 0.05% and tretinoin microsphere 0.04% when used in topical combination therapy. In view of the lower irritation potential observed in this study, along with its demonstrated efficacy, adapalene gel 0.1% in combination with antimicrobial agents may be used as part of an aggressive treatment regimen for the management of acne.

Acne: more than skin deep

Acne is one of the most prevalent skin conditions affecting teenagers. It is a disease of the pilosebaceous unit. Blockage of sebaceous glands and colonisation with Proionobacterium acnes leads to acne. Grading the severity of acne helps to determine the appropriate treatment. Treatment of acne should be started as early as possible to minimise the risk of scarring and adverse psychological effects. It should be tailored to the individual patient, the type of acne, its severity, the patient's ability to use the treatment, and the psychological state. Topical agents are the mainstay for treatment of mild acne. Moderate acne is treated with oral antibiotics. Resistance to antibiotics may be reduced by subsequent use of non-antibiotic topical medications. Severe acne is treated with isotretinoin, and this can lead to permanent remission. With better education and care given by medical profession, acne treatment could be significantly improved.

Topical methyl aminolaevulinate photodynamic therapy for treatment of facial acne vulgaris: results of a randomized, controlled study

BACKGROUND

There is a need for alternative treatments for moderate to severe acne vulgaris. Preliminary experience suggests that topical methyl aminolaevulinate photodynamic therapy (MAL-PDT) may have potential.

OBJECTIVES

To investigate the efficacy and tolerability of MAL-PDT for treatment of moderate inflammatory facial acne.

PATIENTS/METHODS

Thirty patients aged 15-28 years with moderate to severe acne were included in a blinded, prospective, randomized, placebo-controlled multicentre study. Each side of each patient's face was randomly assigned to treatment with MAL (160 mg g1) or placebo cream, applied for 3 h prior to illumination. A second treatment was given 2 weeks later. On each occasion, patients assessed the intensity of pain using a 10-cm visual analogue scale. Inflammatory and noninflammatory acne lesions were counted at baseline and 4 and 10 weeks after the last PDT treatment. The investigator assessed the global severity of acne at baseline (seven patients had severe acne on at least one side of the face) and each study visit using a six-point rating scale. Data were analysed on an intention-to-treat basis, including all 30 patients.

RESULTS

There was a statistically significant greater reduction in the total inflammatory lesion count with MAL-PDT compared with placebo PDT at week 12; median reduction 54% [95% confidence interval (CI) 35-64%] vs. 20% (95% CI 8-50%), P = 0.0006. MAL-PDT was associated with more pain than placebo PDT, although intensity varied across centres and was reduced with repeated treatment. Local adverse events were consistent with this treatment modality.

CONCLUSIONS

MAL-PDT is effective in the treatment of moderate to severe inflammatory facial acne. Further studies are warranted to optimize this promising procedure.

Adapalene gel 0.3% for the treatment of acne vulgaris: a multicenter, randomized, double-blind, controlled, phase III trial

BACKGROUND

A new 0.3% gel formulation of adapalene has been developed.

OBJECTIVE

We sought to provide evidence of the superiority of adapalene gel 0.3% over adapalene gel 0.1% and gel vehicle in the treatment of acne.

METHODS

A total of 653 patients were randomized to receive adapalene gel 0.3%, adapalene gel 0.1%, or vehicle once daily for 12 weeks (2:2:1 randomization). Analysis for efficacy was conducted on correlated repeated measurements at weeks 8 and 12 using Generalized Estimating Equation methodology.

RESULTS

Adapalene gel 0.3% was significantly superior to adapalene gel 0.1% and vehicle in success rate, total lesion count, and inflammatory lesion count. A consistent, dose-dependent effect was demonstrated for all efficacy measures. Signs and symptoms were mostly mild to moderate and transient in nature.

LIMITATIONS

Adjunctive topical or oral agents and their impact on acne were not studied in this trial.

CONCLUSIONS

Adapalene gel 0.3% was effective and well tolerated in the treatment of acne.

An open study to determine the efficacy of blue light in the treatment of mild to moderate acne

BACKGROUND

The effective management of acne remains a challenge; achieving an optimal response whilst minimizing adverse events is often difficult. The rise in antibiotic resistance threatens to reduce the future usefulness of the current mainstay of therapy. The need for alternative therapies remains important. Phototherapy has previously been shown to be effective in acne, with renewed interest as both endogenous and exogenous photodynamic therapies are demonstrated for this condition.

OBJECTIVES

To determine the effect of narrowband blue light in the reduction of inflammatory and non-inflammatory lesions in patients with mild to moderate acne and to evaluate patient tolerance of the therapy.

METHODS

We performed an open study utilizing a blue LED light source in 30 subjects with mild to moderate facial acne. Two weeks after screening, lesions were counted and recorded by lesion type. Over 4 weeks, patients received eight 10- or 20-minute light treatments, peak wavelength 409-419 nm at 40 mW/cm2. Assessments were taken at weeks 5, 8 and 12 and lesion counts were recorded. Repeated measures-ANOVA and Dunnett's tests, respectively, allowed assessment of the different scores over time and permitted comparison of mean counts.

RESULTS

An overall effect on inflammatory counts was observed at week 5, and a statistically significant decrease in inflamed counts was detected at the week 8 assessments, which continued to week 12. There was little effect on non-inflamed lesions. The treatment was well tolerated with adverse events experienced generally rated as being mild and usually self-limiting.

CONCLUSIONS

Eight 10- or 20-minute treatments over 4 weeks with a narrowband blue light was found to be effective in reducing the number of inflamed lesions in subjects with mild to moderate acne. The treatment had little effect on the number of comedones. The onset of the effect was observable at the first assessment, at week 5, and maximal between weeks 8 and 12. Blue light phototherapy using a narrowband LED light source appears to be a safe and effective additional therapy for mild to moderate acne.

Persistent acne in women : implications for the patient and for therapy

Acne is traditionally regarded as a skin disorder of the teenage years. However, recent epidemiologic studies have shown that a significant number of female patients aged >25 years experience acne. One recent community-based UK study estimated the prevalence of facial acne in adult women aged between 26 and 44 years to be 14%. It is not clear whether there is a true increase in acne in this age group or whether these patients are less tolerant of their acne and/or better informed of available therapies and so seek advice. The reasons for persistent acne are not fully understood. External factors such as use of certain cosmetics, ingestion of drugs, and endocrine abnormalities should all be considered when managing these patients. Post-adolescent acne in females can be divided into 'persistent acne', which represents a continuation of acne from adolescence into adult life, and 'late-onset' acne, which describes significant acne occurring sometimes for the first time after the age of 25 years. The clinical picture of each of these forms of acne in adult females can differ slightly from conventional adolescent disease. The course of each form is more indolent. Because of these variations, the approach to investigation and management of these cases may have subtle differences when compared with that for teenage disease. Acne treatment should aim to reduce sebum, comedogenesis, propionibacteria population, and inflammation. Treatment selection will depend on the acne grade and site as well as the patient's preference and ability to comply with therapy. Maintenance therapy plays an important role in managing this group of patients. As the response to treatment is inevitably slow, patients must be encouraged to adhere to the chosen treatment regimen. This article reviews the literature on persistent acne in women in terms of clinical presentation and possible etiologic factors, and outlines principles of therapy related to managing these cases.

Two randomized, double-blind, controlled trials of 2219 subjects to compare the combination clindamycin/tretinoin hydrogel with each agent alone and vehicle for the treatment of acne vulgaris

BACKGROUND

The development of a hydrogel to stabilize and solubilize clindamycin and tretinoin provides a single, once-daily treatment for acne vulgaris.

OBJECTIVE

Our aim was to compare the efficacy and safety of the combination of clindamycin (1%) and tretinoin (0.025%) with each agent alone and vehicle.

METHODS

Two randomized, double-blind, active drug- and vehicle-controlled 12-week studies evaluated inflammatory and noninflammatory lesion counts and the Investigator's Static Global Assessment in 2219 subjects with acne vulgaris.

RESULTS

The combination demonstrated superior efficacy to clindamycin, tretinoin, and vehicle. Combination hydrogel was significantly more effective in reducing inflammatory (P < .005), noninflammatory (P < or = .0004), and total (P < .0001) lesion counts than the other treatments and vehicle. The proportion of subjects with clear or almost clear skin on the Investigator's Static Global Assessment was greater with the combination (P < .0001).

LIMITATIONS

A majority of subjects (82.6%) had grade 2-3 acne vulgaris at baseline; therefore these overall results may not be representative of the response in the subjects (17.4%) with grade 4-5 acne.

CONCLUSION

The combination clindamycin/tretinoin hydrogel was well tolerated and significantly more effective than clindamycin, tretinoin, or vehicle for the treatment of acne vulgaris.

Novel Drug Delivery Systems: Potential in Improving Topical Delivery of Antiacne Agents

Acne is the most common cutaneous disorder of multifactorial origin with a prevalence of 70-85% in adolescents. The majority of the acne sufferers exhibit mild to moderate acne initially, which progresses to the severe form in certain cases. Topical therapy is employed as first-line treatment in mild acne, whereas for moderate and severe acne, systemic therapy is required in addition to topical therapy. Currently, several topical agents are available that affect at least one of the main pathogenetic factors responsible for the development of acne. Although topical therapy has an important position in acne treatment, side effects associated with various topical antiacne agents and the undesirable physicochemical characteristics of certain important agents like tretinoin and benzoyl peroxide affect their utility and patient compliance. Novel drug delivery strategies can play a pivotal role in improving the topical delivery of antiacne agents by enhancing their dermal localization with a concomitant reduction in their side effects. The current review emphasizes the potential of various novel drug delivery strategies like liposomes, niosomes, aspasomes, microsponges, microemulsions, hydrogels and solid lipid nanoparticles in optimizing and enhancing the topical delivery of antiacne agents.