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Schleicher S, Moore A, Rafal E, Gagne-Henley A, Johnson SM, Dhawan S, Chavda R, York JP, Sforzolini B, Holcomb K, Ablon G, Del Rosso J, Dreno B. Trifarotene Reduces Risk for Atrophic Acne Scars: Results from A Phase 4 Controlled Study. Dermatol Ther (Heidelb) 2023; 13:3085-3096. [PMID: 37838987 PMCID: PMC10689318 DOI: 10.1007/s13555-023-01042-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
BACKGROUND Atrophic acne scarring often accompanies acne vulgaris. The efficacy of topical retinoids for treatment of acne is well documented; however, evidence for use in atrophic acne scars is limited. METHODS In this randomized, split-face, double-blind study, subjects (age: 17-34 years, N = 121) with moderate-to-severe facial acne, with acne scars present, were treated with either trifarotene 50 μg/g or vehicle once daily for 24 weeks. Efficacy was assessed by absolute and percent change from baseline in atrophic acne scar counts, Scar Global assessment (SGA), and IGA success rates as well as acne lesion counts. RESULTS At week 24, a statistically significantly greater reduction in the mean absolute change from baseline in the total atrophic scar count was noted in the trifarotene- vs vehicle-treated area (- 5.9 vs - 2.7; p < 0.0001) with differences between sides noted as early as week 2 (- 1.5 vs - 0.7; p = 0.0072). The SGA success rate was higher in the trifarotene side at week 12 (14.9% vs 5.0%, P < 0.05) and improved through week 24 (31.3% vs 8.1%, P < 0.001). Similarly, at week 24, the IGA success rate was higher with trifarotene (63.6% vs 31.3%, P < 0.0001) along with reductions in total (70% vs 45%) and inflammatory (76% vs 48%) lesion counts. The incidence of treatment-emergent adverse events was 5.8% (trifarotene) and 2.5% (vehicle); most common (> 1%) was skin tightness (1.7% vs 0.8%), and all events were mild to moderate in severity. CONCLUSIONS Trifarotene was effective and well tolerated in treating moderate-to-severe facial acne and reducing atrophic acne scars, with reduction of total atrophic scar count as early as week 2. TRIAL REGISTRATION Clinicaltrials.gov NCT04856904.
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Affiliation(s)
| | - Angela Moore
- Arlington Research Center, Inc, Arlington, TX, USA
- Baylor University Medical Center, Dallas, TX, USA
| | - Elyse Rafal
- DermResearchCenter of New York, Inc, Stony Brook, NY, USA
| | | | | | - Sunil Dhawan
- Center for Dermatology Clinical Research, Inc, Fremont, CA, USA
| | | | - J P York
- Galderma Laboratories, Dallas, TX, USA
| | | | | | - Glynis Ablon
- Ablon Skin Institute & Research Center, University of California, Los Angeles, CA, USA
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2
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Wei J, Ma X, Chen M, Pan S, Pang Y. In vitro and in vivo study of the efficacy of a new sebum control essence. J Cosmet Dermatol 2023; 22:2605-2611. [PMID: 37114429 DOI: 10.1111/jocd.15764] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/06/2023] [Accepted: 03/27/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND People with oily skin often suffer from skin problems such as oily face, blackheads, acne, and enlarged pores. It is necessary to regulate oily skin with skin care products. AIMS To develop an effective sebum control essence to reduce oiliness of skin. METHODS The composition of the essence was designed in consideration of different oil control mechanism targets. The skin irritation was assessed in 30 volunteers by a single application close patch test. The efficacy of the essence was evaluated by in vitro experiment, short- and long-term clinical trials with over 60 volunteers. RESULTS The results of both in vitro and clinical trials showed that the essence had significant oil control and moisturizing effect, the skin oil content decreased by 21.8% within 8 h and 30.05% after 28 days, which indicated that the essence could achieve rapid and persistent sebum control efficacy. In addition, the essence could relieve the problems of enlarged pores, blackheads and whiteheads in long-term use. CONCLUSIONS The essence developed in this study can alleviate the problems of oily skin from many aspects, and achieve an excellent effect in oily skin regulation. It is suitable for a daily application in oily skin regulation.
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Affiliation(s)
- Juan Wei
- Hangzhou CNFormulator Technology Co., Ltd, Hangzhou, China
| | - Xuemei Ma
- Hangzhou CNFormulator Technology Co., Ltd, Hangzhou, China
| | - Min Chen
- Hangzhou CNFormulator Technology Co., Ltd, Hangzhou, China
| | - Sha Pan
- Hangzhou CNFormulator Technology Co., Ltd, Hangzhou, China
| | - Ying Pang
- Hangzhou CNFormulator Technology Co., Ltd, Hangzhou, China
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3
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Al-Quran L, Li G, Liu Z, Xiong D, Cao X, Xie T. Comparative Efficacy Between Intense Pulsed Light Narrow Spectrum and Broad Spectrum in the Treatment of Post-Acne Erythema (PAE). Clin Cosmet Investig Dermatol 2023; 16:1983-1996. [PMID: 37547541 PMCID: PMC10404044 DOI: 10.2147/ccid.s419743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/21/2023] [Indexed: 08/08/2023]
Abstract
Purpose Post-acne erythema (PAE) is one of the most common physical sequelae of acne regression, PAE can resolve spontaneously, but in some patients it may last for years. This study aimed to evaluate the efficacy and safety of narrow and broad spectrum filters of intense pulsed light (IPL) for the treatment of PAE. Patients and Methods This prospective study evaluated 60 patients with PAE for at least 6 months, assigned equally to three groups: 1st group received narrow-spectrum with vascular filter (530-650 nm and 900-1200 nm), 2nd group received broad-spectrum with (560/590-1200 nm) filters, the appropriate adjustments were made according to patient's skin colour. Every patient received four sessions one month apart. 3rd group is blank control group did not receive any treatment. CAT (CEA (Clinical Erythema Assessment), Area, and Telangiectasia) used to grade clearance of PAE before and after treatment, Investigators Global Assessment (IGA) used to assess the improvement score after the treatment, and Cardiff Acne Disability Index (CADI) used to evaluate the impact of PAE on patients' Quality of Life (QoL). Self-satisfaction scale completed at the follow-up. Adverse events and acne relapse were recorded. Results A significant decrease of CAT score in vascular group (P<0.05). IGA scale showed significant improvement after vascular treatment. A significant decrease in CADI (P<0.05) after vascular treatment. Patient satisfaction was higher in vascular group than control and blank control groups. Acne relapse observed in control and blank control groups (40% and 15%, respectively).10% of patients showed pigmentation, 15% had blisters after 590 nm treatment. Conclusion IPL vascular filter (530-650 nm and 900-1200 nm) have efficacy in the treatment of PAE. CADI score, patient satisfaction, and acne relapse were significantly better after vascular narrow spectrum treatment than broad-spectrum treatment.
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Affiliation(s)
- Lina Al-Quran
- Department of Dermatology, The First Affiliated Hospital of Nanchang University, Nanchang City, People’s Republic of China
| | - Guang Li
- Department of Dermatology, Dermatology Hospital of Jiangxi Province, Nanchang City, People’s Republic of China
| | - Zhezhang Liu
- Department of Dermatology, The First Affiliated Hospital of Nanchang University, Nanchang City, People’s Republic of China
| | - Dan Xiong
- Department of Dermatology, The First Affiliated Hospital of Nanchang University, Nanchang City, People’s Republic of China
| | - Xianwei Cao
- Department of Dermatology, The First Affiliated Hospital of Nanchang University, Nanchang City, People’s Republic of China
| | - Ting Xie
- Department of Dermatology, The First Affiliated Hospital of Nanchang University, Nanchang City, People’s Republic of China
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4
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Drozhdina MB, Bobro VA. Mechanisms of rosacea pathogenesis. A phenotypic approach to therapeutic tactics. VESTNIK DERMATOLOGII I VENEROLOGII 2022. [DOI: 10.25208/vdv1310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Rosacea is a widespread disease worldwide, affecting 5.5% of the human population and accompanied by a significant deterioration in the patient's quality of life. Currently, there are two classifications of rosacea, the first of which is based on a subtype approach (erythematous-telangiectatic, papulo-pustular, phimatous and ophthalmological subtypes), or on an individual analysis of the presented phenotype of rosacea. New data on the pathophysiology of rosacea have emerged, which show that genetic factors and environmental components can cause the initiation and exacerbation of rosacea due to a violation of the regulation of the innate and adaptive immune system. In addition, trigger factors can directly interact with the cutaneous nervous system and, with the help of neurovascular and neuroimmune active neuropeptides, lead to the manifestation of rosacea foci. The main mechanisms of rosacea pathogenesis are currently: activation of the immune system, disorders of neuro-immune regulation, genetic predisposition. New pathogenetic mechanisms of rosacea make it possible to continue the diagnostic search and therapeutic approaches with the personalization of management tactics for each patient, depending on the prevalence of clinical features of the course of the disease. It is necessary to evaluate the advantages and disadvantages of subtypical and phenotypic approaches to rosacea classification and choose the most optimal one. The article presents arguments on this issue, and also suggests assessing the need to switch to a new classification in order to improve the effectiveness of therapy and improve the quality of life of patients.
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5
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Hu S, Laughter MR, Anderson JB, Sadeghpour M. Emerging topical therapies to treat pigmentary disorders: an evidence-based approach. J DERMATOL TREAT 2021; 33:1931-1937. [PMID: 34114938 DOI: 10.1080/09546634.2021.1940811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hyperpigmentation disorders are commonly encountered in dermatology clinics. The use of prescription-grade and over-the-counter topical lightening agents has increased in popularity, leading to a substantial growth of research over the past decade. OBJECTIVE We seek to review clinical studies evaluating the use of different Rx-grade and OTC ingredients in treating hyperpigmentation. METHODS AND MATERIALS A comprehensive search on PubMed was conducted to identify patient-based evidence on the most common ingredients used as topical lightening agents: arbutin, ascorbic acid, cysteamine, hydroquinone, kojic acid, niacinamide, retinoids, and triple-combination therapy. The topicals were classified as either prescription-grade or over-the-counter. RESULTS Varying levels of evidence support the use of topicals in treating hyperpigmentation. There were more clinical trials examining Rx-grade products than OTC products. Mild but tolerated side effects are noted in many of these agents. CONCLUSION Careful monitoring and adjustment of doses will be needed to maximize skin lightening benefits and minimize side effects.
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Affiliation(s)
- Sophia Hu
- Department of Dermatology, University of Colorado School of Medicine, Aurora, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Melissa R Laughter
- Department of Dermatology, University of Colorado School of Medicine, Aurora, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Jaclyn B Anderson
- Department of Dermatology, University of Colorado School of Medicine, Aurora, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
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Salicylic Acid Peel and Fusion Peel with Salicylic & Mandelic Acid Peel for Treatment of Acne Scars - A Comparative Study. SERBIAN JOURNAL OF DERMATOLOGY AND VENEREOLOGY 2021. [DOI: 10.2478/sjdv-2020-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction. Acne vulgaris is one of the most common skin diseases affecting more than 85% of individuals worldwide. The study aimed to compare the therapeutic efficacy of Salicylic acid peel and Salicylic acid - mandelic acid peel for treatment of acne scars.
Material and Methods. A comparative study was conducted on 41 patients, divided into two groups based on treatment choice by the subjects. Group A (23) were treated with 30% salycilic acid peels, and group B (18) were treated with 20% salycilic acid and 10% mandelic acid peels at an interval of 2 weeks for three sessions. The physician’s global assessment scale and clinical photographs were used at the end of three sessions. All the data were analysed using SPSS considering P<0.05 as significant.
Results. Of the total 41 patients analyzed, the mean age in both the groups were comparable. (Group A: 20.4 years; Group B: 20.5 years). Duration of acne was >12 months in both the groups 13 (56.52%) & 10 (55.56%)). Thirteen patients (56.52%) in group A and 1 (5.56%) in group B had no side effects which was statistically significant (p=0.01). Using the physician’s global assessment scale 51-75% (Good) an improvement was seen in grade I 4 (17%) and 18 (78%) in grade II in group A and 2 (11%) in grade I and 12 (67%) in grade II in group B, respectively which was statistically significant (p=0.001).
Conclusion. Both agents showed almost equal efficacy in improving mild-to-moderate acne scars. Adverse effects were less with Salicylic acid peel compared with mandelic acid peel..
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Chauhan AK, Li P, Sun Y, Wani G, Zhu Q, Wani AA. Spironolactone-induced XPB degradation requires TFIIH integrity and ubiquitin-selective segregase VCP/p97. Cell Cycle 2020; 20:81-95. [PMID: 33381997 PMCID: PMC7849777 DOI: 10.1080/15384101.2020.1860559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Mineralocorticoid and androgen receptor antagonist, spironolactone, was recently identified as an inhibitor of nucleotide excision repair (NER), acting via induction of proteolysis of TFIIH component Xeroderma Pigmentosum B protein (XPB). This activity provides a strong rationale for repurposing spironolactone for cancer therapy. Here, we report that the spironolactone-induced XPB proteolysis is mediated through ubiquitin-selective segregase, valosin-containing protein (VCP)/p97. We show that spironolactone induces a dose- and time-dependent degradation of XPB but not XPD, and that the XPB degradation is blocked by VCP/p97 inhibitors DBeQ, NMS-873, and neddylation inhibitor MLN4924. Moreover, the cellular treatment by VCP/p97 inhibitors leads to the accumulation of ubiquitin conjugates of XPB but not XPD. VCP/p97 knockdown by inducible shRNA does not affect XPB level but compromises the spironolactone-induced XPB degradation. Also, VCP/p97 interacts with XPB upon treatment of spironolactone and proteasome inhibitor MG132, while the VCP/p97 adaptor UBXD7 binds XPB and its ubiquitin conjugates. Additionally, ATP analog-mediated inhibition of Cdk7 significantly decelerates spironolactone-induced XPB degradation. Likewise, engaging TFIIH to NER by UV irradiation slows down spironolactone-induced XPB degradation. These results indicate that the spironolactone-induced XPB proteolysis requires VCP/p97 function and that XPB within holo-TFIIH rather than core-TFIIH is more vulnerable to spironolactone-induced proteolysis. Abbreviations
NER: nucleotide excision repair; TFIIH: transcription factor II H; CAK: Cdk-activating kinase (CAK) complex; XPB: Xeroderma Pigmentosum type B; VCP/p97: valosin-containing protein/p97; Cdk7: cyclin-dependent kinase 7; NAE: NEDD8-activating enzyme; IP: immunoprecipitation
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Affiliation(s)
- Anil K Chauhan
- Department of Radiology, The Ohio State University , Columbus, OH, USA
| | - Ping Li
- Department of Radiology, The Ohio State University , Columbus, OH, USA
| | - Yingming Sun
- Department of Radiology, The Ohio State University , Columbus, OH, USA
| | - Gulzar Wani
- Department of Radiology, The Ohio State University , Columbus, OH, USA
| | - Qianzheng Zhu
- Department of Radiology, The Ohio State University , Columbus, OH, USA
| | - Altaf A Wani
- Department of Radiology, The Ohio State University , Columbus, OH, USA.,Department of Molecular and Cellular Biochemistry, The Ohio State University , Columbus, OH, USA.,James Cancer Hospital and Solove Research Institute, The Ohio State University , Columbus, OH, USA
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8
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Aslan Kayıran M, Karadağ AS, Mutlu HH, Goldust M, Sarıcaoğlu H. Comparison of dermatologists and family physicians in terms of prescribing antibiotics for the treatment of acne vulgaris. Dermatol Ther 2020; 33:e13973. [PMID: 32621767 DOI: 10.1111/dth.13973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 11/28/2022]
Abstract
Acne vulgaris (AV) is a common skin disease that is treated both with dermatologists and family physicians (FPs) with different strategies. To assess the antibiotics that are frequently preferred in AV treatment, and the differences between the FPs and dermatologists in treatment were investigated. The physicians were informed about the study, and sent over the internet a multiple-choice questionnaire that consists of 29 questions in total. Afterwards, the answers provided were compared. 201 dermatologists and 147 FPs participated in the study. Dermatologists were found to have preferred topical erythromycin, nadifloxacin, clindamycin, and tetracycline, and systematically doxycycline and azithromycin in adult patients, whereas the FPs were found to have preferred mupirocin, fusidic acid (FA), and oxytetracycline, and systematically tetracycline. Dermatologists were found to have recommended topical clindamycin and erythromycin in pregnant/breastfeeding AV patients, whereas the FPs were found to have recommended FA. Dermatologists were found to have continued the antibiotics for 8 to 12 weeks, whereas the FPs were found to have continued for 1 to 4 weeks. The dermatologists preferred systemic antibiotics in cases with back involvement, moderate to severe AV, and that the FPs preferred them in severe AV. The dermatologists considered that the use of antibiotics alone or long-term were important factors causing antibiotic resistance. There were significant differences between the approaches of dermatologists and FPs to AV treatment. FPs were found to have insufficient information about prevention of antibiotic resistance. Therefore, we think that the continuous training of FPs on dermatology will be beneficial.
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Affiliation(s)
- Melek Aslan Kayıran
- Department of Dermatology and Venereology, Istanbul Medeniyet University, School of Medicine, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Ayşe Serap Karadağ
- Department of Dermatology and Venereology, Istanbul Medeniyet University, School of Medicine, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Hacer Hicran Mutlu
- Department of Family Medicine, Istanbul Medeniyet University, School of Medicine, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Mohamad Goldust
- Department of Dermatology, University of Rome G. Marconi, Rome, Italy.,Department of Dermatology, University Hospital Basel, Switzerland
| | - Hayriye Sarıcaoğlu
- Department of Dermatology and Venereology, Uludag University, School of Medicine, Bursa, Turkey
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Khunger N, Mehrotra K. Menopausal Acne - Challenges And Solutions. Int J Womens Health 2019; 11:555-567. [PMID: 31754313 PMCID: PMC6825478 DOI: 10.2147/ijwh.s174292] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/22/2019] [Indexed: 12/12/2022] Open
Abstract
Although acne is a disease predominant in adolescence, it is being increasingly observed in adult life, including the menopausal period. The etiology of menopausal acne is multifactorial, with hormonal imbalance being the major culprit. There is a relative increase of androgens in the menopausal female that leads to clinical hyperandrogenism manifesting as acne, hirsutism and androgenetic alopecia. Other endocrine disorders including thyroid abnormalities, hyperprolactinemia and insulin resistance also play a role. Genetics, stress, dietary changes, lack of sleep and exercise and other lifestyle changes are implicated as trigger factors. Most menopausal women with isolated few acne lesions have normoandrogenic serum levels and do not require extensive investigations. However, baseline investigations including total testosterone are useful. Patients must also be evaluated for associated comorbidities such as obesity, diabetes, hypertension and dyslipidemia. A detailed history can help to exclude polycystic ovarian syndrome, late-onset congenital adrenal hyperplasia or medications as a cause of acne. The evaluation of menopausal acne and the approach to treatment depend on the severity of acne and associated features. In patients with mild acne without virilization, prolonged topical therapy is the mainstay of treatment. Though combined oral contraceptives are effective, they are relatively contraindicated in the postmenopausal period. Spironolactone is the first choice of therapy in the subset of patients that require oral anti-androgen therapy. Procedural treatment can be useful as it can also help in the treatment of associated acne scars and concomitant skin aging. It is also important to focus on lifestyle changes such as reducing stress, controlling obesity, having a healthy diet, exercise and proper skin care routine to reduce acne. The focus of this article is on the clinical presentation and management challenges of menopausal acne, which represents a special subtype of acne.
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Affiliation(s)
- Niti Khunger
- Department of Dermatology and STD, Vardhman Mahavir Medical College, Safdarjang Hospital, New Delhi, India
| | - Krati Mehrotra
- Department of Dermatology and STD, Vardhman Mahavir Medical College, Safdarjang Hospital, New Delhi, India
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10
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Bauhammer I, Sacha M, Haltner E. Establishment of an in vitro model of cultured viable human, porcine and canine skin and comparison of different media supplements. PeerJ 2019; 7:e7811. [PMID: 31592353 PMCID: PMC6778665 DOI: 10.7717/peerj.7811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/01/2019] [Indexed: 12/31/2022] Open
Abstract
Transdermal drug delivery provides several advantages over conventional drug administration, such as the avoidance of first-pass metabolism and better patient compliance. In vitro research can abbreviate and facilitate the pharmaceutical development considerably compared to in vivo research as drug screening and clinical studies can be reduced. These advantages led to the development of corresponding skin models. Viable skin models are more useful than non-viable ones, due to the influence of skin metabolism on the results. While most in vitro studies concentrate on evaluating human-based models, the current study is designed for the investigation of both human and animal diseases. So far, there is little information available in the literature about viable animal skin cultures which are in fact intended for application in the veterinary and not the human field. Hence, the current study aims to fill the gap. For the in vitro viable skin model, specimens of human, porcine and canine skin were cultured over two weeks under serum-free conditions. To evaluate the influence of medium supplementation on skin viability, two different supplement mixtures were compared with basic medium. The skin specimens were maintained at a viability-level >50% until the end of the study. From the tested supplements, the addition of bovine pituitary extract and epidermal growth factor increased skin viability whereas hydrocortisone and insulin induced a decrease. This in vitro viable skin model may be a useful tool for the investigation of skin diseases, especially for the veterinary field.
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Reserva J, Adams W, Perlman D, Vasicek B, Joyce C, Tung R, Swan J. Coprescription of Isotretinoin and Tetracyclines for Acne is Rare: An Analysis of the National Ambulatory Medical Care Survey. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2019; 12:45-48. [PMID: 32038749 PMCID: PMC6937145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Introduction: Systemic therapy for acne can include tetracyclines or, for severe cases, isotretinoin. Concurrent use of tetracyclines and isotretinoin is known to increase the risk of development of pseudotumor cerebri (PTC). Objectives: Given their association with PTC when used concomitantly, this study sought to quantify the estimated frequency of the coprescription of isotretinoin and tetracyclines and to assess for trends in the use of isotretinoin and tetracycline for acne as it relates to age, sex, race, insurance, and provider specialty. Methods: Data from the National Ambulatory Medical Care Survey were analyzed over the years 2003 to 2013 regarding acne visits with isotretinoin and/or tetracycline prescriptions. Complex-samples logistic regression was used to estimate the effect of demographic variables on prescribing behavior. Results: Isotretinoin and tetracyclines were coprescribed in 0.35 percent of visits for acne. Dermatologists prescribed isotretinoin more frequently than nondermatologists. Patients younger than 36 years of age and men were more likely to receive treatment with isotretinoin or a tetracycline. No differences in prescribing patterns were found based on race or survey year. Conclusions: Concomitant exposure to tetracyclines and isotretinoin is exceedingly rare. The increased PTC risk associated with their concomitant use is well-known among dermatologists.
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Affiliation(s)
- Jeave Reserva
- Drs. Reserva, Vasicek, Tung, and Swan are with the Division of Dermatology at Loyola University Chicago in Chicago, Illinois
- Mr. Perlman is with the Stritch School of Medicine at Loyola University Chicago in Chicago, Illinois
- Drs. Adams and Joyce are with the Biostatistics Core-Clinical Research Office at Loyola University Chicago in Chicago, Illinois
| | - William Adams
- Drs. Reserva, Vasicek, Tung, and Swan are with the Division of Dermatology at Loyola University Chicago in Chicago, Illinois
- Mr. Perlman is with the Stritch School of Medicine at Loyola University Chicago in Chicago, Illinois
- Drs. Adams and Joyce are with the Biostatistics Core-Clinical Research Office at Loyola University Chicago in Chicago, Illinois
| | - David Perlman
- Drs. Reserva, Vasicek, Tung, and Swan are with the Division of Dermatology at Loyola University Chicago in Chicago, Illinois
- Mr. Perlman is with the Stritch School of Medicine at Loyola University Chicago in Chicago, Illinois
- Drs. Adams and Joyce are with the Biostatistics Core-Clinical Research Office at Loyola University Chicago in Chicago, Illinois
| | - Brooke Vasicek
- Drs. Reserva, Vasicek, Tung, and Swan are with the Division of Dermatology at Loyola University Chicago in Chicago, Illinois
- Mr. Perlman is with the Stritch School of Medicine at Loyola University Chicago in Chicago, Illinois
- Drs. Adams and Joyce are with the Biostatistics Core-Clinical Research Office at Loyola University Chicago in Chicago, Illinois
| | - Cara Joyce
- Drs. Reserva, Vasicek, Tung, and Swan are with the Division of Dermatology at Loyola University Chicago in Chicago, Illinois
- Mr. Perlman is with the Stritch School of Medicine at Loyola University Chicago in Chicago, Illinois
- Drs. Adams and Joyce are with the Biostatistics Core-Clinical Research Office at Loyola University Chicago in Chicago, Illinois
| | - Rebecca Tung
- Drs. Reserva, Vasicek, Tung, and Swan are with the Division of Dermatology at Loyola University Chicago in Chicago, Illinois
- Mr. Perlman is with the Stritch School of Medicine at Loyola University Chicago in Chicago, Illinois
- Drs. Adams and Joyce are with the Biostatistics Core-Clinical Research Office at Loyola University Chicago in Chicago, Illinois
| | - James Swan
- Drs. Reserva, Vasicek, Tung, and Swan are with the Division of Dermatology at Loyola University Chicago in Chicago, Illinois
- Mr. Perlman is with the Stritch School of Medicine at Loyola University Chicago in Chicago, Illinois
- Drs. Adams and Joyce are with the Biostatistics Core-Clinical Research Office at Loyola University Chicago in Chicago, Illinois
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Abstract
BACKGROUND Historically, garlic containing compounds have been used on wounds to improve healing and ward off infection. Researchers have tested many of these ancient ointments, discovering that garlic is a common ingredient in those that are effective. OBJECTIVE To determine the efficacy of topical garlic on surgical wounds compared with Vaseline by analysis of visual analog scales and digital photograph analysis. MATERIALS AND METHODS Seventeen patients with 2 skin excisions applied a 30% garlic ointment to one surgical wound and Vaseline to the other surgical wound twice daily. They were followed up at 2 weeks and 4 weeks post-op. Digital photographs were taken of the sites, and wound visual analog scales were filled out by the patient and the physician. RESULTS Patients and the onsite physician stated the garlic site healed better in 59% and 65% of the wounds, respectively, at 2 weeks. At 4 weeks, the patients and the onsite physician stated the garlic site healed better in 76% and 88% of wounds, respectively. Digital photograph analysis revealed less erythema at the garlic sites (p-value = .02). CONCLUSION Surgical wounds treated with 30% garlic ointment healed with more cosmetically appealing scars than the Vaseline-treated sites.
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Szymańska A, Budzisz E, Erkiert-Polguj A. Efficacy of 30% azelaic acid peel in the nonpharmacological treatment of facial acne. J DERMATOL TREAT 2019; 32:291-296. [DOI: 10.1080/09546634.2019.1657222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Anna Szymańska
- Department of Cosmetic Raw Materials Chemistry, Medical University of Lodz, Lodz, Poland
| | - Elzbieta Budzisz
- Department of Cosmetic Raw Materials Chemistry, Medical University of Lodz, Lodz, Poland
| | - Anna Erkiert-Polguj
- Department of Cosmetology and Aesthetic Dermatology, Medical University of Lodz, Lodz, Poland
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14
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Establishment of a novel in vitro viable human skin model as a basis for the treatment of human and veterinary chronic skin diseases. J Drug Deliv Sci Technol 2019. [DOI: 10.1016/j.jddst.2019.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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15
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Frew JW, Hawkes JE, Krueger JG. Topical, systemic and biologic therapies in hidradenitis suppurativa: pathogenic insights by examining therapeutic mechanisms. Ther Adv Chronic Dis 2019; 10:2040622319830646. [PMID: 30854183 PMCID: PMC6399757 DOI: 10.1177/2040622319830646] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/16/2019] [Indexed: 12/13/2022] Open
Abstract
Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the skin, manifesting in chronic, recurrent painful pustules, nodules, boils and purulent draining abscesses. Our current understanding of the pathogenesis of the disease is incomplete. This review aims to identify available treatment options in HS and discuss the pharmacological mechanisms through which such agents function. Identifying common pathways may inform our understanding of the pathogenesis of HS as well as identify future therapeutic targets. The pharmacological mechanisms implicated in topical therapies, antibiotic, hormonal, systemic immunomodulatory and biologic therapies for HS are discussed. Significant differences exist between agents and implicated pathways in therapy for mild and severe disease. This is an expression of the possible dichotomy in inflammatory pathways (and treatment responses) in HS. Studies involving monoclonal antibodies provide the greatest insight into what these specific mechanisms may be. Their variable levels of clinical efficacy compared with placebo bolsters the suggestion that differential inflammatory pathways may be involved in different presentations and severity of disease. Nuclear factor kappa B (NF-κB), tumor necrosis factor (TNF)-α and other innate immune mechanisms are strongly represented in treatments which are effective in mild to moderate disease in the absence of scarring or draining fistulae, however complex feed-forward mechanisms in severe disease respond to interleukin (IL)-1 inhibition but are less likely to respond to innate immune inhibition (through NF-κB or TNF-α) alone. It is unclear whether IL-17 inhibition will parallel TNF-α or IL-1 inhibition in effect, however it is plausible that small molecule targets (Janus kinase1 and phosphodiesterase 4) may provide effective new strategies for treatment of HS.
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Affiliation(s)
- John W. Frew
- Laboratory of Investigative Dermatology, The Rockefeller University, 1230 York Avenue, New York, NY 10065, USA
| | - Jason E. Hawkes
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, NY, USA
| | - James G. Krueger
- Laboratory of Investigative Dermatology, The Rockefeller University, New York, NY, USA
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16
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Spironolactone Depletes the XPB Protein and Inhibits DNA Damage Responses in UVB-Irradiated Human Skin. J Invest Dermatol 2019; 139:448-454. [PMID: 30227140 PMCID: PMC6342635 DOI: 10.1016/j.jid.2018.07.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/17/2018] [Accepted: 07/30/2018] [Indexed: 12/14/2022]
Abstract
UVB wavelengths of light induce the formation of photoproducts in genomic DNA that are potentially mutagenic and detrimental to epidermal cell function. The mineralocorticoid and androgen receptor antagonist spironolactone (SP) was recently identified as an inhibitor of UV photoproduct removal in human cancer cells in vitro via its ability to promote the rapid proteolytic degradation of the DNA repair protein XPB. Using normal human keratinocytes in vitro and skin explants ex vivo, we found that SP rapidly depleted XPB protein in both systems and abrogated two major responses to UVB-induced DNA damage, including the removal of UV photoproducts from genomic DNA and the activation of ATR/ATM DNA damage kinase signaling. These effects were also correlated with both mutagenesis and a predisposition to UVB-induced cell death but were unique to SP, because neither the SP metabolites canrenone and 7α-thiomethylspironolactone nor the more specific mineralocorticoid receptor antagonist eplerenone affected XPB protein levels or the UVB response. Our findings provide an approach for studying XPB and its roles in the UVB DNA damage response in human skin ex vivo and indicate that SP may increase UVB mutagenesis and skin cancer risk in certain individuals.
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17
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Najafi-Taher R, Ghaemi B, Amani A. Delivery of adapalene using a novel topical gel based on tea tree oil nano-emulsion: Permeation, antibacterial and safety assessments. Eur J Pharm Sci 2018; 120:142-151. [DOI: 10.1016/j.ejps.2018.04.029] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 04/17/2018] [Accepted: 04/19/2018] [Indexed: 11/30/2022]
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18
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de Vries FMC, Meulendijks AM, Driessen RJB, van Dooren AA, Tjin EPM, van de Kerkhof PCM. The efficacy and safety of non-pharmacological therapies for the treatment of acne vulgaris: A systematic review and best-evidence synthesis. J Eur Acad Dermatol Venereol 2018; 32:1195-1203. [PMID: 29444375 DOI: 10.1111/jdv.14881] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/02/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acne vulgaris is a multifaceted skin disorder, affecting more than 85% of young individuals worldwide. Pharmacological therapy is not always desirable because of the development of antibiotic resistance or the potential risk of adverse effects. Non-pharmacological therapies can be viable alternatives for conventional therapies. However, sufficient evidence-based support in the efficacy and safety of non-pharmacological therapies is lacking. OBJECTIVE To assess the efficacy and safety of several non-pharmacological therapies in the treatment of acne vulgaris. METHODS A systematic literature review, including a best-evidence synthesis, was performed to identify literature. Three electronic databases were accessed and searched for studies published between January 2000 and May 2017. RESULTS Thirty-three eligible studies were included in our systematic review. Three main types of non-pharmacological therapies were identified laser- and light-based therapies, chemical peels and fractional microneedling radiofrequency. The majority of the included studies demonstrated a significant reduction in acne lesions. However, only seven studies had a high methodologic quality. Based on these seven trials, a best-evidence synthesis was conducted. Strong evidence was found for glycolic acid (10-40%). Moderate evidence was found for amino fruit acid (20-60%), intense pulsed light (400-700 and 870-1200 nm) and the diode laser (1450 nm). Initially, conflicting evidence was found for pulsed dye laser (585-595 nm). The most frequently reported side-effects for non-pharmacological therapies included erythema, tolerable pain, purpura, oedema and a few cases of hyperpigmentation, which were in most cases mild and transient. CONCLUSION Circumstantial evidence was found for non-pharmacological therapies in the treatment of acne vulgaris. However, the lack of high methodological quality among included studies prevented us to draw clear conclusions, regarding a stepwise approach. Nevertheless, our systematic review including a best-evidence synthesis did create order and structure in resulting outcomes in which a first step towards future research is generated.
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Affiliation(s)
- F M C de Vries
- Research Group Innovation in Healthcare Processes in Pharmacology, HU University of Applied Sciences Utrecht, Utrecht, The Netherlands
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A M Meulendijks
- Research Group Innovation in Healthcare Processes in Pharmacology, HU University of Applied Sciences Utrecht, Utrecht, The Netherlands
| | - R J B Driessen
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A A van Dooren
- Research Group Innovation in Healthcare Processes in Pharmacology, HU University of Applied Sciences Utrecht, Utrecht, The Netherlands
| | - E P M Tjin
- Research Group Innovation in Healthcare Processes in Pharmacology, HU University of Applied Sciences Utrecht, Utrecht, The Netherlands
| | - P C M van de Kerkhof
- Department of Dermatology, Radboud University Medical Center, Nijmegen, The Netherlands
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19
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Loss MJ, Leung S, Chien A, Kerrouche N, Fischer AH, Kang S. Adapalene 0.3% Gel Shows Efficacy for the Treatment of Atrophic Acne Scars. Dermatol Ther (Heidelb) 2018; 8:245-257. [PMID: 29549598 PMCID: PMC6002315 DOI: 10.1007/s13555-018-0231-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Indexed: 12/02/2022] Open
Abstract
Introduction Scarring is an unfortunate clinical outcome of acne. Current treatment options for atrophic acne scars are dominated by non-pharmacological, invasive procedures which may not be suitable or affordable to all patients. This phase II, single-center, open-label, exploratory study assessed the efficacy, safety and subject-reported outcomes of adapalene 0.3% gel in the treatment of atrophic acne scars. Methods The study included subjects aged 18–50 years with past history of acne and moderate to severe facial atrophic acne scars. Subjects received adapalene 0.3% gel once daily for the first 4 weeks and twice daily for the following 20 weeks. Assessments were performed at baseline, day 10 and weeks 4, 8, 16 and 24, and at post-treatment follow-ups (weeks 36 and 48–72). Results At week 24, investigator and subject assessments reported improvement in skin texture/atrophic scars in 50% and > 80% of subjects, respectively. Subjects were satisfied with the treatment and reported improvements in quality of life. Conclusion Daily use of adapalene 0.3% gel for the treatment of atrophic acne scars showed promising clinical efficacy, a favorable tolerability profile, and improvement in quality of life. Funding Nestlé Skin Health–Galderma R&D. Trial Registration ClinicalTrials.gov Identifier NCT01213199.
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Affiliation(s)
- Manisha J Loss
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Sherry Leung
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Anna Chien
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nabil Kerrouche
- Nestlé Skin Health-Galderma R&D, Sophia Antipolis, Biot, France
| | - Alexander H Fischer
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sewon Kang
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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20
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Frade ML, de Annunzio SR, Calixto GMF, Victorelli FD, Chorilli M, Fontana CR. Assessment of Chitosan-Based Hydrogel and Photodynamic Inactivation against Propionibacterium acnes. Molecules 2018; 23:E473. [PMID: 29470387 PMCID: PMC6017752 DOI: 10.3390/molecules23020473] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/17/2017] [Accepted: 11/23/2017] [Indexed: 01/02/2023] Open
Abstract
Chitosan (CH) is a biopolymer that exhibits a number of interesting properties such as anti-inflammatory and antibacterial activity and is also a promising platform for the incorporation of photosensitizing agents. This study aimed to evaluate the efficacy of antimicrobial activity of chitosan hydrogel formulation alone and in combination with the methylene blue (MB) associated with antimicrobial photodynamic therapy (aPDT) against planktonic and biofilm phase of Propionibacterium acnes. Suspensions were sensitized with 12.5, 25.0, 37.5, 50.0 μg/mL of MB for 10 min and biofilms to 75, 100 and 150 μg/mL for 30 min then exposed to red light (660 nm) at 90 J/cm² and 150 J/cm² respectively. After treatments, survival fractions were calculated by counting the number of colony-forming units. The lethal effect of aPDT associated with CH hydrogel in planktonic phase was achieved with 12.5 µg/mL MB and 1.9 log10 biofilm reduction using 75 µg/mL MB. Rheological studies showed that formulations exhibited pseudoplastic non-Newtonian behavior without thixotropy. Bioadhesion test evidenced that the formulations are highly adhesive to skin and the incorporation of MB did not influence the bioadhesive force of the formulations.
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Affiliation(s)
- Maria Lucia Frade
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), 14800-903 Araraquara, São Paulo, Brazil.
| | - Sarah Raquel de Annunzio
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), 14800-903 Araraquara, São Paulo, Brazil.
| | - Giovana Maria Fioramonti Calixto
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), 14800-903 Araraquara, São Paulo, Brazil.
| | - Francesca Damiani Victorelli
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), 14800-903 Araraquara, São Paulo, Brazil.
| | - Marlus Chorilli
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), 14800-903 Araraquara, São Paulo, Brazil.
| | - Carla Raquel Fontana
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University (UNESP), 14800-903 Araraquara, São Paulo, Brazil.
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21
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Gollnick H, Abanmi A, Al-Enezi M, Al Hammadi A, Galadari I, Kibbi AG, Zimmo S. Managing acne in the Middle East: consensus recommendations. J Eur Acad Dermatol Venereol 2017; 31 Suppl 7:4-35. [DOI: 10.1111/jdv.14491] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- H. Gollnick
- Universitätsklinik für Dermatologie und Venerologie; Otto-von-Guericke Universität; Magdeburg Germany
| | - A.A. Abanmi
- Dr Sulaiman Al Habib Hospital; Riyadh Saudi Arabia
| | | | | | - I. Galadari
- Faculty of Medicine; United Arab Emirates University; Dubai UAE
| | - A.-G. Kibbi
- American University of Beirut Medical Center; Beirut Lebanon
| | - S. Zimmo
- King Abdulaziz University; Jeddah Saudi Arabia
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22
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Gold MH, Goldberg DJ, Nestor MS. Current treatments of acne: Medications, lights, lasers, and a novel 650-μs 1064-nm Nd: YAG laser. J Cosmet Dermatol 2017; 16:303-318. [PMID: 28703382 DOI: 10.1111/jocd.12367] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2017] [Indexed: 12/21/2022]
Abstract
The treatment of acne, especially severe acne, remains a challenge to dermatologists. Therapies include retinoids, antibiotics, hormones, lights, lasers, and various combinations of these modalities. Acne is currently considered a chronic rather than an adolescent condition. The appropriate treatment depends on the patient and the severity of disease. The purpose of this study was to review current therapies for acne of all severities and to introduce the 650-μs 1064-nm laser for the treatment of acne.
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Affiliation(s)
| | - David J Goldberg
- Skin Laser and Surgery Specialists of NY and NJ, Hackensack, NJ, USA
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23
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Barbieri JS, James WD, Margolis DJ. Trends in prescribing behavior of systemic agents used in the treatment of acne among dermatologists and nondermatologists: A retrospective analysis, 2004-2013. J Am Acad Dermatol 2017; 77:456-463.e4. [PMID: 28676330 DOI: 10.1016/j.jaad.2017.04.016] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/11/2017] [Accepted: 04/14/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Despite recommendations to limit the use of oral antibiotics and increasing support for hormonal agents in the treatment of acne, it is unclear whether there have been any significant changes in practice patterns. OBJECTIVE To characterize changes in prescribing behavior for systemic agents in the treatment of acne in the United States between 2004 and 2013. METHODS We conducted a retrospective analysis using the OptumInsight Clinformatics DataMart (Optum, Eden Prairie, MN). RESULTS The number of courses of spironolactone prescribed per 100 female patients being managed for acne by dermatologists and nondermatologists increased from 2.08 to 8.13 and from 1.43 to 4.09, respectively. The median duration of therapy with oral antibiotics was 126 and 129 days among patients managed by dermatologists and nondermatologists, respectively, and did not change significantly over the study period. LIMITATIONS The OptumInsight Clinformatics DataMart lacks information on acne severity and clinical outcomes. CONCLUSIONS Additional work to identify patients who would benefit most from alternative therapies such as spironolactone, oral contraceptives, or isotretinoin represents a potential opportunity to improve the care of patients with acne.
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Affiliation(s)
- John S Barbieri
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - William D James
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David J Margolis
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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