A New Class of Topical Acne Treatment Addressing the Hormonal Pathogenesis of Acne

Exploring Acne Treatments: From Pathophysiological Mechanisms to Emerging Therapies

Acne vulgaris is a common dermatological condition that can present across different ages but predominantly affects adolescents and young adults. Characterized by various lesion types, the pathogenesis of acne is complex, involving genetic, hormonal, microbial, and inflammatory factors. This review comprehensively addresses current and emerging acne management strategies, emphasizing both topical and systemic treatments, procedural therapies, and dietary modifications. Key topical agents include retinoids, benzoyl peroxide, antibiotics, and other specialized compounds. Systemic options like antibiotics, hormonal therapies, and retinoids offer significant therapeutic benefits, particularly for moderate to severe cases. Procedural treatments such as laser devices, photodynamic therapy, chemical peels, and intralesional injections present viable alternatives for reducing acne symptoms and scarring. Emerging therapies focus on novel biologics, bacteriophages, probiotics, and peptides, providing promising future options. This review underscores the importance of personalized approaches to treatment due to the multifaceted nature of acne, highlighting the potential of innovative therapies for improving patient outcomes.

The impact of current investigational drugs for acne on future treatment strategies

INTRODUCTION

Acne vulgaris is one of the most prevalent diseases worldwide with a considerably high cost and a burden on quality of life. There are currently many topical and systemic therapies for acne; however, many are limited by their local adverse event profile. This review provides an update on current, novel Phase I and II trials for acne vulgaris.

AREAS COVERED

This review searched the National Institutes of Health US National Library of Medicine online database of clinical trials (ClinicalTrials.gov) for ongoing Phase I and II trials. Only papers discussing novel therapies were discussed, and combinations of previously FDA-approved drugs were excluded.

EXPERT OPINION

The current investigational approaches to acne treatment reflect an attempt to mitigate the underlying cause of acne pathogenesis. By targeting key mechanisms involved, studies aim to show long-term improvement with less frequent treatment use. This provides potential for more tolerable treatments with better patient adherence, in turn leading to increased efficacy.

Targeting Inflammation in Acne: Current Treatments and Future Prospects

Acne is a common, chronic inflammatory condition affecting millions of people worldwide, with significant negative impact on quality of life and mental health. Acne is characterized by comedones, inflammatory papules, pustules, and nodulocystic lesions, with long-lasting sequelae including scarring and dyspigmentation, the latter of which is more common in skin of color. The four main pillars of acne pathophysiology include alteration of sebum production and concentration, hyperkeratinization of the follicular unit, Cutibacterium acnes strains, and an inflammatory immune response. Newer research has provided greater insight into these pathophysiologic categories. This greater understanding of acne pathogenesis has led to numerous new and emerging treatment modalities. These modalities include combinations of existing treatments, repurposing of existing agents historically used for other conditions, new topical treatments, novel antibiotics, topical and oral probiotics, and various procedural devices. This article will provide an overview of emerging treatments of acne and their link to our current and improved understanding of acne pathogenesis.

Treatment of Acne Vulgaris During Pregnancy and Lactation: A Narrative Review

Acne vulgaris frequently affects women during pregnancy and lactation. Hormonal and physiologic changes in pregnancy contribute to the pathogenesis of acne during the various phases of pregnancy. Several effective acne treatments commonly prescribed in the general population are contraindicated during pregnancy or lactation. There is a lack of guidelines and updated resources on acne management in these populations. In this narrative review, we summarize existing evidence on the safety and efficacy of acne treatments during pregnancy and breastfeeding. Acne management in pregnancy and lactation should follow a stepwise approach based on severity to minimize risk. Topical therapies, such as benzoyl peroxide, azelaic acid, or keratolytics, can be used to treat mild-to-moderate disease. Moderate-to-severe acne may require systemic treatments, including penicillin, amoxicillin, cephalexin, and erythromycin, with special consideration for trimester-specific teratogenicity of medications and relevant medical history of the mother and infant. For refractory cases, oral or intralesional corticosteroids as well as laser and light therapies may be considered. This review provides an updated reference to aid patient-physician decision-making on acne management in these special populations.

High-frequency devices effect in vitro: promissing approach in the treatment of acne vulgaris?

BACKGROUND

Acne vulgaris is an inflammatory skin disorder leading to an impairment of quality of life and is therefore not only a cosmetic issue. Its pathogenesis is multifactorial - of particular importance is the colonization with the bacterium Propionibacterium acnes. A wide range of different treatment options exists including topical and systemic treatments depending on severity. High Frequency (HF) therapy, historically developed in the 19^th century, claims antimicrobial effects on acne skin, but solid data on its efficacy and mechanism of action is lacking.

OBJECTIVES

The main objective of this study was to determine the efficacy of HF therapy on skin flora and P. acnes in vitro using a commercial device as well as to review studies on the mechanism of action.

METHODS

The plasma source was investigated regarding electrical settings, heat, and ozone development. Bacterial skin flora, fungal isolates, and P. acnes were exposed to HF in vitro and compared to unexposed controls by evaluating the number of colonies on agar plates. To further analyze bacterial species from normal skin flora, 16S-sequencing was performed. Statistical analyses were carried out using row analysis and unpaired t-test.

RESULTS

HF treatment led to a significant reduction of almost every bacterial and fungal species investigated in this study. Moreover, the number of colonies forming units was significantly decreased in P. acnes after HF treatment compared to controls in vitro.

STUDY LIMITATIONS

The experiments were performed in vitro only. To assess clinical effects further in vivo experiments are necessary.

CONCLUSIONS

The results collected in this study, although in vitro, provide a mechanistic basis for HF as a complementary treatment option for patients with acne. It might also have a beneficial effect on patients with superficial infectious skin of the skin.

Acne Treatment Review and Future Perspectives

Acne affects approximately 9% of people worldwide and is the most common skin condition in the United States. There are abundant topical and oral treatment options available for patients with acne. First-line agents include topical retinoids, azelaic acid, benzoyl peroxide, and combinations of these agents. For recalcitrant or more severe acne, oral medications, including oral antibiotics, isotretinoin, or hormonal therapy, may be considered. This review will also discuss the many advances being made in the treatment of acne vulgaris, from the development of microencapsulated medications to targeted treatments. This article is protected by copyright. All rights reserved.

New Developments in Topical Acne Therapy

Acne vulgaris is a common chronic inflammatory disease with a multifactorial pathogenesis. Although myriad acne treatments are available, current options may not be sufficient because of a lack of efficacy, limited tolerability, or burden of cost to patients. In this review, we highlight recently approved topical acne treatments, as well as those currently in clinical trials. Novel formulations of tretinoin, tazarotene, and minocycline provide modifications of and improvements to existing products. Trifarotene, a novel fourth-generation retinoid, has demonstrated improved tolerability compared with existing topical retinoids. Clascoterone is a novel first-in-class antiandrogen that topically addresses the hormonal etiology of acne. The late-phase clinical trials pipeline consists of agents with bactericidal and anti-sebum mechanisms. Although it is evident that acne treatments continue to evolve, it is important to recognize the need for further comparative studies among new and existing agents to define optimal treatment algorithms that address not only safety and efficacy but also cost-effective care.

The Use of Lasers and Light Devices in Acne Management: An Update

Acne vulgaris is a disease of the pilosebaceous unit and the most common inflammatory dermatosis worldwide. It is also associated with significant economic burden. Limitations of conventional topical and systemic treatments include long treatment course, intolerable adverse effects, antibiotic resistance, and patient compliance. Therefore, laser and light-based interventions present as alternative options over the past decade and have been used in combination with conventional pharmacological therapies and other physical modalities. An updated overview on the use of lasers and light-based devices in acne management is presented to help clinicians understand the safety and efficacy of these treatment options. The effectiveness of neodymium:yttrium aluminum garnet (Nd:YAG) for treating acne is supported by more high-level studies compared with other laser devices. There is limited evidence to support the use of CO₂ lasers, potassium titanyl phosphate lasers, and 1565-nm non-ablative fractional lasers for treating acne. Among light devices, photodynamic therapy is the most studied, showing higher efficacies than some of the conventional topical and oral acne therapies. Intense-pulsed light and blue light therapies also show favorable outcomes. A limitation is that most studies are non-randomized and lack a control group, and report on a variety of device settings, treatment regimens, and outcome measures, making it challenging to summarize and generalize findings. Although the use of laser and light devices to treat acne is promising, further work with randomized controlled study designs and larger sample sizes will provide improved guidance on the application of these modalities.

Dermatology: how to manage acne vulgaris

Background

Acne vulgaris is the most common skin disease that can lead to disfigurement and psychological distress. This article aims to provide a narrative updated review on the management of acne vulgaris.

Methods

A PubMed search was performed with Clinical Queries using the key term “acne”. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to articles published in English.

Results

Treatments of acne include proper skin care, topical medications, oral medications and procedural therapies. Topical agents are the first-line treatment for mild-to-moderate acne and can be used as combination therapy for more severe acne. Systemic therapies are usually prescribed for the initial treatment of moderate-to-severe acne as well as for acne that is refractory to topical therapies.

Conclusion

Topical retinoids are the drugs of choice for the treatment and maintenance therapy of patients with mild-to-moderate acne vulgaris. Depending on the severity of the acne, topical retinoids may be used alone or in combination with benzoyl peroxide and topical or oral antibiotics. Oral antibiotics are an important therapy for inflammatory acne unresponsive to topical therapy. Neither topical nor oral antibiotics should be used as monotherapy. Oral contraceptives and/or spironolactone are useful for many women with acne. Oral isotretinoin is the drug of choice for severe, extensive, nodular acne vulgaris but is also often used in moderate cases where scarring is evident, acne-related psychosocial distress is significant or other treatment modalities have failed.

Trends in utilization of non-first-line topical acne medications among children, adolescents, and adults in the United States, 2012-2016

BACKGROUND/OBJECTIVE

Current knowledge about usage of effective, but non-first-line topical acne medications in the United States is limited. We aimed to investigate utilization patterns and temporal trends for such acne medications in the US ambulatory care.

METHODS

Pediatric (≤18 years old) and adult (>18 years old) data from the 2012 to 2016 (inclusive) cycles of the US National Ambulatory Medical Care Survey were extracted. Utilization patterns of six non-first-line topical acne medications (ie, azelaic acid, salicylic acid, glycolic acid, sulfur, resorcinol, and zinc) were compared and followed over time.

RESULTS

Data from 218 410 US office-based sampled visits during 2012-2016 were included in the analysis. Across all acne visits (n = 1542), salicylic acid (1.58%), azelaic acid (1.22%), and glycolic acid (0.52%) were the most frequently used agents, while zinc and resorcinol were not used. Sulfur (0.52%) and salicylic acid (0.33%) were the only medications used in preadolescents, and none of these medications were used in the neonatal or infantile group. Temporal trends for using at least one of these medications were insignificant among both pediatric and adult age groups (P = .825 and .136, respectively).

CONCLUSIONS

Salicylic acid and azelaic acid are the most frequently used of the studied second-line medications to treat acne, although the use of these and the other non-first-line topical medications overall is uncommon, especially among younger groups of US pediatric patients.

Clascoterone: First Approval

Clascoterone (Winlevi^®) is an androgen receptor inhibitor being developed as a topical cream and solution by Cassiopea (a spin-out company of Cosmo Pharmaceuticals) for the treatment of androgen-dependent skin disorders, including androgenetic alopecia and acne vulgaris. Although the exact mechanism of action of clascoterone for the topical treatment of acne vulgaris is unknown, the drug is believed to compete with the androgen dihydrotestosterone for binding to androgen receptors in the sebaceous gland and hair follicles to attenuate signalling necessary for acne pathogenesis. In August 2020, clascoterone cream 1% received its first approval in the USA for the topical treatment of acne vulgaris in patients 12 years of age or older. Clinical studies of a different formulation of clascoterone (a solution containing a higher concentration of the drug) for the treatment of androgenetic alopecia are underway in Germany and the USA. This article summarizes the milestones in the development of clascoterone leading to this first approval for the topical treatment of acne vulgaris.

Treatment challenges in adult female acne and future directions

Introduction: Acne is a chronic, inflammatory, and immune-mediated disease of the pilosebaceous unit, highly prevalent in adolescents. However, an increasing number of adults over 25 years old with facial acne, particularly women, have been observed. It is considered a different disease when compared to acne vulgaris. Face is the mainly involved area with inflammatory lesions and more sensitive skin, pointing out the need of a holistic approach.Areas covered: We performed a comprehensive literature search on PubMed database, up to January 2021, regarding adult female acne. We synthesized data about pathogenesis; differences compared to acne vulgaris; and treatment, with focus in the management challenges and perspectives.Expert opinion: It is essential to value the negative impact on quality of life of adult female acne, independently of severity. The disease has prolonged evolution, and patient might be resilient once the improvement, regardless of the treatment option, will just be noticeable after 3 months. Aggravating factors should be clearly discussed, such as the need of changing many habits, especially lesions manipulation. The therapeutic regimen includes make-up and tailored skin care (considering proneness to sensitivity), while anti-acne drugs should be chosen in accordance with desire to be pregnant, presence of pregnancy or breastfeeding.

New Acne Therapies and Updates on Use of Spironolactone and Isotretinoin: A Narrative Review

Acne vulgaris is a chronic inflammatory skin disease with a multifactorial pathogenesis. Although a variety of acne treatments are available, limitations of current therapies include tolerability, antimicrobial resistance, and costs and patient burden associated with monitoring. This narrative review focuses on emerging treatments and updates on the management of acne. Clascoterone, sarecycline, trifarotene, and novel lotion formulations of tretinoin and tazarotene have been evaluated in clinical trials and provide new options for treatment. Emerging data on the safety and efficacy of spironolactone and isotretinoin challenge current conventions and suggest a need to reconsider drug monitoring guidelines and risk prevention systems. Additional head-to-head data are needed to confirm these novel treatments' utility in treating acne.