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Del Rosso JQ, Kircik L. The cutaneous effects of androgens and androgen-mediated sebum production and their pathophysiologic and therapeutic importance in acne vulgaris. J DERMATOL TREAT 2024; 35:2298878. [PMID: 38192024 DOI: 10.1080/09546634.2023.2298878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024]
Abstract
Background: The recognition of an association between the development of acne vulgaris (AV) and pubertal hormonal changes during adolescence dates back almost 100 years. Since these formative observations, a significant role of circulating hormones in the pathophysiology of AV and other cutaneous disorders has been established.Aims: This review article aims to provide an overview of clinical and preclinical evidence supporting the influences of androgens on the skin and their therapeutic importance in AV pathophysiology.Results: The cutaneous effects of hormones are attributable, to a large extent, to the influence of steroid hormones, particularly androgens, on sebocyte development and sebum production in both sexes. Androgen-mediated excess sebum production is implicated as a necessary early step in AV pathophysiology and is therefore considered an important therapeutic target in AV treatment. Although the local production and/or activity of androgens within the skin is believed to be important in AV pathophysiology, it has received limited therapeutic attention.Conclusions: We have summarized the current evidence in support of the therapeutic benefits of targeted hormonal treatment to decrease androgen-stimulated sebum production for the effective and safe treatment of AV in both male and female patients.
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Affiliation(s)
- James Q Del Rosso
- Touro University Nevada, Henderson, NV, USA
- JDR Dermatology Research, Las Vegas, NV, USA
- Advanced Dermatology and Cosmetic Surgery, Maitland, FL, USA
| | - Leon Kircik
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Indiana University, School of Medicine, Indianapolis, IN, USA
- Physicians Skin Care, PLLC, Louisville, KY, USA
- DermResearch, PLLC, Louisville, KY, USA
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Ryguła I, Pikiewicz W, Kaminiów K. Impact of Diet and Nutrition in Patients with Acne Vulgaris. Nutrients 2024; 16:1476. [PMID: 38794714 PMCID: PMC11124289 DOI: 10.3390/nu16101476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/08/2024] [Accepted: 05/12/2024] [Indexed: 05/26/2024] Open
Abstract
Acne vulgaris is a widespread a chronic inflammatory dermatosis that affects millions of people around the world, which has a significant influence on patients' standard of living. The progression of this dermatosis results in the appearance of inflammatory and non-inflammatory changes, and, in severe cases, disfiguring scars and hyperpigmentation. The aetiopathogenesis of acne is complex. It involves a complex interaction of many different factors, both endo- and exogenous in their effect on the hair and sebaceous unit. Genetic predisposition, hormones, the skin and gut microbiome, psychological stress, air pollutants, aggressive facial products, and certain medications are cited as factors influencing acne formation. The link between nutrition and acne is extensively debated for many years and is still relatively controversial. Diet is commonly recognised to have a direct relationship with certain biochemical markers and the transcription of genes related to sebaceous gland function, and the proliferation of bacteria and inflammation that encourage the progression of the disease. In this review, the authors take a closer look at the existing scientific reports on the involvement of nutrition in the development of acne vulgaris.
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Affiliation(s)
- Izabella Ryguła
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland;
| | - Wojciech Pikiewicz
- Collegium Medicum—Faculty of Medicine, WSB University, 41-300 Dabrowa Gornicza, Poland;
| | - Konrad Kaminiów
- Collegium Medicum—Faculty of Medicine, WSB University, 41-300 Dabrowa Gornicza, Poland;
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Kim HJ, Kim YH. Exploring Acne Treatments: From Pathophysiological Mechanisms to Emerging Therapies. Int J Mol Sci 2024; 25:5302. [PMID: 38791344 PMCID: PMC11121268 DOI: 10.3390/ijms25105302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
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.
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Affiliation(s)
- Hyun Jee Kim
- Department of Dermatology, International St. Mary’s Hospital, College of Medicine, Catholic Kwandong University, Incheon 22711, Republic of Korea;
| | - Yeong Ho Kim
- Department of Dermatology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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Rudzińska J, Głąbska D. Influence of Selected Food Product Groups Consumption Frequency on Acne-Related Quality of Life in a National Sample of Polish Female Adolescents. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11670. [PMID: 36141942 PMCID: PMC9517132 DOI: 10.3390/ijerph191811670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 06/16/2023]
Abstract
Acne vulgaris affects over 80% of adolescents, mainly female ones, and may reduce their general quality of life, so its prevention and treatment are becoming necessary, while among the options for acne management, the potential influence of diet is indicated. The aim of the study was to assess the influence of selected food product groups consumption frequency on acne-related quality of life in a national sample of Polish female adolescents. The studied population of 1370 Polish female adolescents was gathered using random quota sampling of secondary schools representative of the whole country. The acne-related quality of life was assessed using the Acne Quality of Life (AQoL) Scale with the calculated Social Quality of Life (SOCQOL) Score, as well as the Acne Disability Questionnaire (ADQ) with the calculated Cardiff Acne Disability Index (CADI). The acne-related food product groups' consumption frequency was assessed using the Acne-specific Food Frequency Questionnaire (Acne-FFQ). There were no differences in food product consumption between subgroups stratified by the acne-related quality of life (p > 0.05), and there was no correlation between food product consumption and the results of the SOCQOL Score (p > 0.05). For the CADI, positive correlations were indicated for fast foods (p = 0.0450; R = 0.0688), salty snacks (p = 0.0342; R = 0.0727), and chocolate confectionary (p = 0.0147; R = 0.0837), while a negative correlation was indicated for dairy beverages other than milk (p = 0.0414; R = -0.0701). In the studied group of Polish female adolescents, fast foods, salty snacks, and chocolate confectionary were indicated as potential acne-promoting factors, while dairy beverages other than milk were indicated as a potential acne-protective factor.
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Association between Nutritional Behaviours and Acne-Related Quality of Life in a Population of Polish Male Adolescents. Nutrients 2022; 14:nu14132677. [PMID: 35807855 PMCID: PMC9268073 DOI: 10.3390/nu14132677] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/26/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023] Open
Abstract
Acne vulgaris is diagnosed in the majority of adolescents, decreasing their quality of life, while the diet may influence its aetiology in a gender-dependent manner. The aim of the study was to analyse associations between nutritional behaviours and acne-related quality of life in a population of Polish male adolescents. The study was conducted on a population of Polish secondary school adolescents (a studied sample of 925 adolescents), while the random quota sampling procedure of secondary schools was applied. To assess acne-related quality of life, the Acne Quality of Life (AQoL) Scale and Acne Disability Questionnaire (ADQ) were applied, while the Social Quality of Life (SOCQOL) Score and Cardiff Acne Disability Index (CADI) were calculated. To assess the diet, an Acne-specific Food Frequency Questionnaire (Acne-FFQ) was applied. Neither for the ADQ results, nor for the CADI calculated on the basis of ADQ, was there an association with dietary intake (p > 0.05). The results of the SOCQOL Score (calculated on the basis of AQoL) were positively correlated with the intake of fish (p = 0.0085; R = 0.1144), salty snacks (p = 0.0495; R = 0.0854), and non-chocolate confectionary (p = 0.0078; R = 0.1156). In a group of respondents declaring any acne-related quality of life problems in AQoL, while compared with those declaring no such problems, higher intakes of dairy beverages other than milk (p = 0.0063), white bread (p < 0.0001), other white cereal products (p < 0.0001), fast foods (p = 0.0006), salty snacks (p < 0.0001), chocolate confectionary (p < 0.0001), and other confectionary (p < 0.0001), but lower intake of wholegrain bread (p = 0.0084) were observed. It may be concluded that acne-related quality of life is associated with dietary intake in a population of Polish male adolescents. In the studied population, the most prominent influencing factors were salty snacks and non-chocolate confectionary, with both of them having a proacnegenic effect.
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Affiliation(s)
- James Meixiong
- Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cristina Ricco
- Robert Wood Johnson Medical School, Rutgers University, Piscataway, New Jersey
| | - Chirag Vasavda
- Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Byron K. Ho
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Correspondence to: Byron K. Ho, MD, Department of Dermatology, Johns Hopkins University School of Medicine, 601 N Caroline Street, JHOC 8072, Baltimore, MD 21287.
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Ah-Thiane L, Nguyen JM, Khammari A, Dréno B. Lifestyle habits and impact of the Mediterranean diet on facial acne severity in French women: a case-control study. Int J Womens Dermatol 2022; 8:e017. [PMID: 35795692 PMCID: PMC9249266 DOI: 10.1097/jw9.0000000000000017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 04/15/2022] [Indexed: 11/25/2022] Open
Abstract
Acne is a common benign inflammatory disease, but it has a significant psychosocial impact. The role of the diet in the development of acne is controversial. Some daily foods such as milk and fast-release sugars tend to promote acne. The Mediterranean Diet (MD) is based on virgin olive oil and nuts that are rich in polyphenols with anti-inflammatory properties. The aim of this study was to assess an association between the adherence to the MD and the severity of facial acne in French women. A case-control observational study was conducted in Nantes Hospital (France). Based on a validated PREvención con DIeta MEDiterránean questionnaire, the adherence to the MD was assessed. The Global Evaluation Acne severity score was assessed by a trained dermatologist. Forty women with mild-to-severe acne and 40 control subjects were included. A global linear model identified a significant negative correlation between the severity of acne and the adherence to the MD in acne patients (regression coefficient = -0.17; P = 0.017). This was the first study conducted in France to investigate the relationship between the adherence to the MD and the severity of facial acne in women. This study confirmed the importance of using a holistic approach for acne management. Further studies are needed to confirm our findings.
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Affiliation(s)
- Laurie Ah-Thiane
- Service de Dermatologie, Université de Nantes, CHU Nantes, CRCINA, Nantes, France
| | - Jean Michel Nguyen
- Service de Biostatistiques, PIMES Hôpital St Jacques, CHU Nantes, Nantes, France
| | - Amir Khammari
- Laboratoire Immunodermatologie, Université Nantes, CHU Nantes, CRCINA, Nantes, France
| | - Brigitte Dréno
- Service de Dermatologie, Université de Nantes, CHU Nantes, CRCINA, Nantes, France.,Laboratoire Immunodermatologie, Université Nantes, CHU Nantes, CRCINA, Nantes, France
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Dall'Oglio F, Nasca MR, Fiorentini F, Micali G. Diet and acne: review of the evidence from 2009 to 2020. Int J Dermatol 2021; 60:672-685. [PMID: 33462816 DOI: 10.1111/ijd.15390] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 11/17/2020] [Accepted: 12/02/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Dietary habits may play a non-negligible role in the development, duration, and severity of acne, as shown in past critical review articles on such association. METHODS The aim of this systematic review is to supplement data available on scientific literature spanning the last 10 years by inserting the keywords "acne" or "acne vulgaris" and "diet", "nutrition", "food", "chocolate", "dairy", "whey protein", "fatty acid", or "drink" in the timeframe "January 2009-April 2020" within the PubMed database. RESULTS Fifty-three reviewed articles met eligibility criteria. They included 11 interventional clinical trials (seven randomized controlled trials and four uncontrolled open label studies) and 42 observational studies (17 case-control and 22 cross-sectional studies, and three descriptive studies). CONCLUSIONS This review reinforces the notion of a rapidly growing exponential trend of interest in this subject by the scientific community. Acne-promoting factors include high GI/GL food, dairy products, fat food, and chocolate, whereas acne-protective factors include fatty acids, fruit, and vegetable intake. The role played by specific dietary components pertaining to different foods, as done for milk (full-fat/whole, reduced-fat, low-fat/skim milk), dairy products (milk cream, ice cream, yogurt, cheese, etc.), or chocolate (cocoa, dark/milk chocolate), remains an unsolved issue and objective of future research.
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Abstract
Our understanding of the pathogenesis of acne vulgaris is still evolving. It is known that multiple factors impact acne pathophysiology, including genetic, hormonal, inflammatory, and environmental influences. Because of its implications in many of these factors, diet has been a part of the acne discussion for decades. Several studies have evaluated the significance of the glycemic index of various foods and glycemic load in patients with acne, demonstrating individuals with acne who consume diets with a low glycemic load have reduced acne lesions compared with individuals on high glycemic load diets. Dairy has also been a focus of study regarding dietary influences on acne; whey proteins responsible for the insulinotropic effects of milk may contribute more to acne development than the actual fat or dairy content. Other studies have examined the effects of omega-3 fatty acid and γ-linoleic acid consumption in individuals with acne, showing individuals with acne benefit from diets consisting of fish and healthy oils, thereby increasing omega-3 and omega-6 fatty acid intake. Recent research into the effects of probiotic administration in individuals with acne present promising results; further study of the effects of probiotics on acne is needed to support the findings of these early studies. In this review, we discuss the current evidence regarding the diets of US patients with acne and how they may impact acne and acne treatment.
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Tsai TY, Liu HW, Chao YC, Huang YC. Wirkung von Isotretinoin auf den Glukosestoffwechsel bei Patienten mit Akne: eine systematische Übersicht und Metaanalyse. J Dtsch Dermatol Ges 2020; 18:539-546. [PMID: 32519482 DOI: 10.1111/ddg.14108_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 10/01/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Tsung-Yu Tsai
- Department of Dermatology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Han-Wen Liu
- Division of Endocrine and Metabolism, Wan Fang hospital, Taipei Medical University, Taipei, Taiwan
| | - Yuan-Chen Chao
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Chen Huang
- Department of Dermatology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Research center of big data and meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Tsai T, Liu H, Chao Y, Huang Y. Effects of isotretinoin on glucose metabolism in patients with acne: A systematic review and meta‐analysis. J Dtsch Dermatol Ges 2020; 18:539-545. [DOI: 10.1111/ddg.14108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 10/01/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Tsung‐Yu Tsai
- Department of Dermatology Wan Fang Hospital Taipei Medical University Taipei Taiwan
| | - Han‐Wen Liu
- Division of Endocrine and Metabolism Wan Fang hospital Taipei Medical University Taipei Taiwan
| | - Yuan‐Chen Chao
- School of Medicine College of Medicine Taipei Medical University Taipei Taiwan
| | - Yu‐Chen Huang
- Department of Dermatology Wan Fang Hospital Taipei Medical University Taipei Taiwan
- Department of Dermatology School of Medicine College of Medicine Taipei Medical University Taipei Taiwan
- Research center of big data and meta‐analysis Wan Fang Hospital Taipei Medical University Taipei Taiwan
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Espinosa NI, Cohen PR. Acne Vulgaris: A Patient and Physician's Experience. Dermatol Ther (Heidelb) 2020; 10:1-14. [PMID: 31701473 PMCID: PMC6994586 DOI: 10.1007/s13555-019-00335-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Indexed: 12/13/2022] Open
Abstract
In this article, the first coauthor, a young woman with acne vulgaris, shares her experience with the condition; she not only describes the clinical presentation and the eventual successful treatment of her acne, but also the emotional consequences that this skin disorder caused. The second coauthor, the patient's dermatologist, reviews some of the features of acne vulgaris: morphologic manifestations, pathogenesis, and treatment options. He also summarizes the patient's response to isotretinoin therapy. In addition, he reveals his subsequent enlightenment regarding the acne-related non-dermatologic effects that the patient experienced and the significant improvement of her self-image that occurred following the successful treatment of her acne.
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Affiliation(s)
| | - Philip R Cohen
- San Diego Family Dermatology, National City, CA, USA.
- Department of Dermatology, Touro University California College of Osteopathic Medicine, Vallejo, CA, USA.
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Markovic M, Soldatovic I, Bjekic M, Sipetic-Grujicic S. Adolescents' self perceived acne-related beliefs: from myth to science. An Bras Dermatol 2019; 94:684-690. [PMID: 31789254 PMCID: PMC6939091 DOI: 10.1016/j.abd.2019.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/19/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Acne vulgaris is recognized as the third most prevalent skin disease worldwide, with highest prevalence among adolescents. Beliefs and perceptions of adolescents about acne are incoherent in the literature. OBJECTIVES To assess the most frequently reported acne-related beliefs in adolescents in order to focus on misconceptions and develop proper recommendations. METHODS A cross-sectional community-based study on representative sample of 2516 schoolchildren was conducted in six randomly selected secondary schools in Belgrade, Serbia. Only schoolchildren with present or past acne history participated. Factors believed to aggravate or ameliorate acne were recorded and analyzed, and the comparisons between girls and boys were evaluated using Pearson's chi-squared test. RESULTS A total of 1452 schoolchildren with acne participated, aged 14-18 years, among them 801 (55.2%) girls and 651 (44.8%) boys. Boys significantly more frequently believed that sweating, exercise, and dairy foods aggravate acne, whereas girls significantly more frequently blamed emotional stress, sweets, fatty foods, sun, and lack of sleep. The top four amelioration factors were as follows: comedone extraction, healthy diet, sun exposure, and increased water consumption. Acne regression was more frequently perceived to be linked with cigarettes in boys, but with sun exposure and weight loss in girls. STUDY LIMITATIONS The narrow age span of adolescents (14-18 years) and exclusion of acne-free adolescents are limitations due to study design. CONCLUSION This survey is part of the first epidemiological study on a representative sample in the Western Balkan region. The significance of the most frequent acne-related beliefs is discussed and myths about acne are highlighted.
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Affiliation(s)
- Milica Markovic
- Department for Facial Dermatoses, City Institute for Skin and Venereal Diseases, Belgrade, Serbia.
| | - Ivan Soldatovic
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milan Bjekic
- Department of General Dermatovenereology, City Institute for Skin and Venereal Diseases, Belgrade, Serbia
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15
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Affiliation(s)
- Andrea L Zaenglein
- From the Departments of Dermatology and Pediatrics, Penn State Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey
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A Low Glycemic Index and Glycemic Load Diet Decreases Insulin-like Growth Factor-1 among Adults with Moderate and Severe Acne: A Short-Duration, 2-Week Randomized Controlled Trial. J Acad Nutr Diet 2018; 118:1874-1885. [DOI: 10.1016/j.jand.2018.02.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 02/06/2018] [Indexed: 12/17/2022]
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Abstract
PURPOSE OF REVIEW This review will update the pediatric provider on recent data on the pathogenesis and treatment of acne in adolescent patients. A special focus was made to summarize recent guidelines and fill in several identified practice gaps. RECENT FINDINGS Our understanding of the pathogenesis of acne is greatly expanding and data is emerging to tie diet, particularly the role of IGF-1 with inflammation in acne. Additionally, stronger recommendations to limit antibiotic usage in acne are being made worldwide. Although retinoids are considered the base of most effective acne treatment strategies, data suggests that all providers need to emphasize their importance in maintenance of acne. SUMMARY An effective acne management strategy targets multiple pathogenic factors in acne, using a retinoid as the foundation. Systemic antibiotics for moderate-to-severe acne should be used for acute management, then discontinued at 3-4 months, while maintaining on topical treatments. If therapy is ineffective, alternate treatments, such as combined oral contraceptives in females or isotretinoin, should be promptly employed to prevent prolonged psychological impact and cutaneous scarring.
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