Activity of the type 1 5 alpha-reductase exhibits regional differences in isolated sebaceous glands and whole skin

New Insights into the Role of PPARγ in Skin Physiopathology

Peroxisome proliferator-activated receptor gamma (PPARγ) is a transcription factor expressed in many tissues, including skin, where it is essential for maintaining skin barrier permeability, regulating cell proliferation/differentiation, and modulating antioxidant and inflammatory responses upon ligand binding. Therefore, PPARγ activation has important implications for skin homeostasis. Over the past 20 years, with increasing interest in the role of PPARs in skin physiopathology, considerable effort has been devoted to the development of PPARγ ligands as a therapeutic option for skin inflammatory disorders. In addition, PPARγ also regulates sebocyte differentiation and lipid production, making it a potential target for inflammatory sebaceous disorders such as acne. A large number of studies suggest that PPARγ also acts as a skin tumor suppressor in both melanoma and non-melanoma skin cancers, but its role in tumorigenesis remains controversial. In this review, we have summarized the current state of research into the role of PPARγ in skin health and disease and how this may provide a starting point for the development of more potent and selective PPARγ ligands with a low toxicity profile, thereby reducing unwanted side effects.

Role of Oral Retinoids in Treatment of Acne Vulgaris With a Bioinformatics-Based Perspective of Personalized Medicine

Acne vulgaris is a skin condition characterized by the inflammation or hyperactivity of sebaceous glands on the skin, which results in the creation of comedones, lesions, nodules, and perifollicular hyperkeratinization. Increased sebum production, follicular blockage, and bacterial colonization may contribute to the disease etiology. Environmental factors, hormonal imbalance, and genetic predisposition can alter the severity of the disease. Its mental and monetary effects can be problematic for the society. In this study, we examined the role of isotretinoin in the treatment of acne vulgaris based on evidence from prior research. This review literature study compiled publications on the treatment of acne vulgaris from 1985 to 2022 based on PubMed and Google Scholar publications. Additional bioinformatics analyses were accompanied by GeneCards, STRING model, and DrugBank databases. These complementary analyses were designed to obtain a better perspective of personalized medicine which is highly required for dose-precise administrations of acne vulgaris treatment. Isotretinoin has been recognized as an effective treatment for acne vulgaris, particularly in cases that have been resistant to previous medications or have resulted in scarring, according to gathered data. Oral isotretinoin inhibits the proliferation of Propionibacterium acne, a critical factor in the development of acne lesions; also, it has been shown to be effective in reducing the number of Propionibacterium-resistant patients and regulating sebum production and reducing sebaceous gland size more effectively than other treatment options resulting in general improvements in skin clarity and acne severity and reduce inflammatory in 90% of patients. In addition to its efficacy, the majority of patients have shown that oral isotretinoin is well tolerated. This review highlights the use of oral retinoids, particularly isotretinoin, as an effective and well-tolerated treatment option for acne vulgaris. It has been proven that oral isotretinoin is useful for achieving long-lasting remission in patients with severe or resistant instances. Despite the fact that oral isotretinoin is related to a number of potential harmful effects, skin dryness was the most common side effect reported by patients that can be managed with the aid of suitable monitoring and drug administration against specific genes identified by genotyping of the susceptible variants of genes involved in TGFβ signaling pathway.

Antiacne and Anti-Inflammatory Effects of Phenolic Compounds from Quercus acutissima Carruth. Leaves

Quercus plants are widely distributed in Korea and have been used for their antiallergic and anti-inflammatory properties to treat dermatitis. The phenolic compounds of Quercus acutissima Carruth (QA) are estimated to have antioxidant and anti-inflammatory activities, based on the results of previous studies with Quercus mongilica, Quercus stenophylla, Quercus gilva Blame., and Quercus acuta Thunb. We yield QA extract and the isolated phenolic compounds (hyperoside (1), astragalin (2), kaempferol 3-O-(6″- galloyl)-β-D-glucopyranoside (KGG) (3), quercetin 3-O-(6″-O-galloyl)-β-D-glucopyranoside (QGG) (4), pedunculagin (5), and casuarinin (6)) and were identified using NMR. Among them, KGG (3) and QGG (4) were isolated for the first time from QA. QA extract and the isolated phenolic compounds demonstrated antioxidative, anti-inflammatory, and antiacne activities in RAW 264.7 mouse macrophage cells in vitro. 3-6 demonstrated strong inhibitory activities in the DPPH scavenging and NO production assay and anti-inflammatory and antiacne activities through western blotting (NLRP3, IL-1β, and 5α-reductase). The most outstanding activity in all experiments was casuarinin (6). The study findings suggest potential therapeutic candidates for acne.

In silico screening of effective inhibitor of 5α-reductase type 1 for androgenic alopecia treatment

Androgenic alopecia is caused due to genetic disorders associated with the excess level of androgens. The progressive miniaturization of the hair follicles leads the terminal hair to vellus transformation. Dihydrotestosterone, an endogenous sex-linked hormone responsible for the growth of facial hair in males is derived from testosterone circulating in the blood by the action of 5α-reductase isoenzymes. The 5α-reductase1 is found in secretory regions of skin encompassing sebaceous glands and hair follicles. In silico screening of phytochemical inhibitors of 5α-reductase1 identified potential candidates for androgenic alopecia treatment. Further, the molecular docking simulation-based virtual screening of 110 phytochemicals was performed against human 5α-reductase1 to identify the potential lead molecules. The ADMET studies for the lead compounds were undertaken and the results showed that β-sitosterol, brassicasterol, and campesterol could be potential inhibitors of 5α-reductase1. Molecular dynamics simulations of protein-lead molecule complex revealed that, β-sitosterol and brassicasterol complex showed better stability with RMSD similar to raw protein. These compounds could be used as lead molecules in drug development for androgenic alopecia.

Effects of dutasteride on sex hormones and cerebrospinal steroids in patients treated for benign prostatic hyperplasia

PURPOSE

Neuroactive steroids may have a role in regulating sexual function. This case-control study assessed whether dutasteride, a 5α-reductase inhibitor used for treatment of patients with benign prostate hyperplasia (BPH), impacts on the levels of neuroactive steroids, leading to erectile dysfunction (ED) and/or hypoactive sexual desire (HSD).

METHODS

Forty patients with BPH and moderate-to-severe lower urinary tract symptoms (LUTS), pre-scheduled for prostate transurethral resection or open prostatectomy were enrolled. Twenty of these patients with prostate volume ≤40 mL were treated with α-blockers (Group A) and the remaining 20, with prostate volume >40 mL, with dutasteride plus α-blockers (Group B) for at least 6 months before surgery. Serum sex steroids and gonadotropin levels were measured the day before surgery, and the neuroactive steroid levels were assessed in the cerebrospinal fluid (CSF) collected during spinal anesthesia, at the day of surgery.

RESULTS

Before surgery, the International Index of Erectile Function 5-item score was higher in Group A that Group B (18.8 ± 4.8 vs. 15.1 ± 5.4, p < 0.01). Group A showed lower total testosterone (TT) (4.5 vs.6.4 ng/ml, p < 0.01) and 17β-estradiol (E₂) (24.3 vs.30.7 pg/ml, p < 0.05) serum levels than Group B. CSF levels of TT (1446.6 vs. 19.9 pg/ml, p < 0.05) and dihydrotestosterone (7.9 vs. 1.4 pg/ml, p < 0.05) were higher and CSF E₂ levels were lower (26.0 vs.36.0 pg/ml, p < 0.01) in Group A than Group B.

CONCLUSIONS

A decrease of neuroactive steroids in the CSF of patients treated with dutasteride occurs. This may be one of the mechanisms by which dutasteride may cause ED and HSD.

The effectiveness of botulinum toxin type A (BTX-A) in the treatment of facial skin oily seborrhea, enlarged pores, and symptom complex of post-acne

BACKGROUND

This study aimed to examine the effectiveness of botulinum toxin type A (BTX-A) in the treatment of acne.

METHODS

The study was conducted in 2018 on 12 patients, 10 females and two males, aged 35 years on average. The injections with BTX-A were given during 2 weeks into the face skin in a dosage of 0.125-0.250 units.

RESULTS

Skin moisture indexes increased during the therapy by 4% (P ≤ 0.05), and porosity decreased by 7% (P ≤ 0.01). Maximal changes were recorded for the sulci and pigmentation of the skin, namely, its values decreased by 10 and 9%, respectively (P ≤ 0.01). BTX-A is recommended for an application not only in plastic surgeries but also for local correction of acne on the patient's skin.

CONCLUSION

A positive correlation was revealed between the duration of treatment and reduction of skin oiliness (0.87), pigmentation (0.78), skin sulci (0.84), and skin porosity (0.88), and negative correlation was established with increased skin moisture (-0.64). The obtained dependencies apply for the therapy period of up to 2 weeks. Pharmacological properties of BTX-A allow recommending it as a drug used in post-acne therapy.

Efficacy of Intralesional and Oral Dutasteride in the Treatment of Androgenetic Alopecia: A Systematic Review

Androgenetic alopecia is the most common cause of hair loss [Br J Dermatol. 2011 Jan;164(1):5-15]. Finasteride and minoxidil are the only approved treatments [J Am Acad Dermatol. 2008 Oct;59(4):547-8 and J Eur Acad Dermatology Venereol. 2018 Jan;32(1):11-22]. Dutasteride is more potent than finasteride due to its ability to inhibit both 5-α-reductase type I and II [Our Dermatol Online. 2017 Sep;9(1):75-9] though its adverse effects and long half-life contribute to the reluctance on its oral use. Mesotherapy could be a feasible alternative to avoid systemic exposure and side effects [J Pan-Arab League Dermatologist. 2009 Feb;20(1):137-45]. We aim to perform a systematic review to analyze scientific literature with the purpose of comparing efficacy and adverse effects of both administration routes. Five clinical trials using oral route and 3 intralesional in comparison with placebo met criteria for inclusion. Regarding intralesional dutasteride, only one study [Clin Dermatol. 2001 Mar;19(2):149-54] reported the mean change in hair count. Although both interventions favor over placebo, there are not enough data to reliably compare outcomes obtained between both routes. Mean increase in hair count observed with oral dutasteride was higher (MD: 15.92 hairs [95% CI: 9.87-21.96]; p = <0.00001; I ² = 90%) compared to intralesional dutasteride in Abdallah's study (MD: 7.90 hairs [95% CI: 7.14-8.66]; p = <0.00001). Future studies are required to assess the therapeutic efficacy of both treatment routes, including head-to-head treatments before well-supported conclusions can be established.

Effect of Genetic Polymorphisms of Human SLC22A3 in the 5'-flanking Region on OCT3 Expression and Sebum Levels in Human Skin

BACKGROUND

Human organic cation transporter 3 (OCT3,SLC22A3) mediates the uptake of many important endogenous substances and basic drugs, and has been identified as one of the transporters that are highly expressed in human skin. However, the mechanisms responsible for variability in mRNA expression, and the role of SLC22A3 in human skin is not clear.

OBJECTIVE

We examined the effects of the single nucleotide polymorphisms ofSLC22A3 on the variability in SLC22A3 expression and sebum levels in humans.

METHODS

Immunostaining of OCT3 in human skin was performed. We analyzed the association of promoter variants with the SLC22A3 mRNA expression levels in human skins. Luciferase, knockdown, chromatin immunoprecipitation (ChIP), electrophoretic mobility shift assay were employed to investigate transcriptional regulation of SLC22A3 expression. Effects of the identified variant on sebum levels were evaluated in healthy volunteers.

RESULTS

Immunohistochemistry revealed marked expressions of OCT3 in the basal epidermis, sebaceous glands, hair follicles, and sweat glands of human skin. SLC22A3 mRNA levels were significantly lower in skin samples with homozygotes for -1603A/A than in those for -1603 G/G. The analysis of p53 binding to -1603 G > A in the promoter ofSLC22A3 suggested that -1603 G > A down-regulates SLC22A3 gene expression by decreased p53 binding in the vicinity of the -1603 site. In humans, squalene levels in samples from the back at the baseline were significantly lower in homozygotes for -1603A/A than in those for -1603 G/G.

CONCLUSION

These results suggest that the genetic variant contributes to the variability of expression and activities of OCT3 in human skin.

Rhinophyma: Combined Surgical Treatment and Quality of Life

Rhinophyma is a progressive and disfiguring thickening of the nasal skin. It is typically found in middle-aged or elderly Caucasian males. The exact cause of the disease is unknown. There is excessive formation of scar-like tissue and hyperplasia of the sebaceous glands. This article will demonstrate our experience of treating rhinophyma using a combined surgical approach and propose a novel classification system. This is a retrospective analysis of cases operated by a single surgeon over 9 years using the Glasgow Benefit Inventory (GBI) tool. Thirty-three patients were identified. Twenty-nine patients had three techniques used in one sitting, two patients had two techniques used, and two further patients had one technique used. Total GBI showed a +50.99 result following surgery. Rhinophyma treatments can benefit patients as demonstrated by the GBI outcome. This can improve the patients' quality of life. The use of more than one technique in the same sitting potentially improves the outcome. Our classification system helps categorize the disease better as well as choosing the treatment and comparing disease and treatment. The Level of Evidence for the study is 4.

Targeting 5α-reductase with 99mTc labeled dutasteride derivatives for prostate imaging

To assess the suitability of 99mTc labeled 5α-reductase (5α-Rds) inhibitors for non-invasive targeting of prostate cancer (PCa) using Male Sprague Dawely Rat (MSDR) model. In this work, dutasteride (Cpd-1) a 5α-Rds inhibitor was derivatized to its dithiocarbamate analogue (Cpd-2) for subsequent synthesis of 99mTc(CO)3-dutasteride dithiocarbamate (Cpd-3) using tricarbonyl technique. To determine the structure of Cpd-3, for the first time a reference Re(CO)3-dutasteride dithiocarbamate (Cpd-4) was synthesized and characterized with NMR, ESIMS, HPLC and elemental analysis. HPLC was used to establish the identity of Cpd-3 using Cpd-4 as a reference standard. The suitability of Cpd-3 as a new 5α-Rds targeting agent was investigated, both in vitro and vivo. The Cpd-3 has shown ≥98 % in vitro stability at room temperature and was remained ≥90 % stable up to 6 h. In serum Cpd-3 has revealed an analogous behavior with a small decrease in stability after 16 h. High uptake (26.25 ± 1.10 %, after 4 h of i.v.) of Cpd-3 was observed in the prostate (target tissue) of MSDR model with reasonably good target to non-target ratio. Blocking the target site with excess Cpd-2 considerably decreased the uptake of Cpd-3 to 4.10 ± 0.75 % in PCa. High in vitro stability in saline and serum and in vivo uptake in prostate of MSDR model plausibly attracts the opportunity of using Cpd-3 as a novel radiopharmaceutical for non invasive targeting of prostate.

Efficacy of two plant extracts against acne vulgaris: Initial results of microbiological tests and cell culture studies

BACKGROUND

Acne vulgaris is a common skin disease characterized by increased sebum production, inflammation, and colonization of Propionibacterium acnes (P. acnes) on pilosebaceous follicles.

AIMS

To determine the efficacy of two different plant extracts against P. acnes and to analyze the gene expression levels of IL-1α, SRD5A1, and TNFα in HaCaT cells treated with these plant extracts.

METHODS

Anti-acne extract 1 (AE1) consisted of Juglans regia (walnut husk), Myrtus communis (myrtle leaves), Matricaria chamomilla (chamomilla flowers), Urtica dioica (stinging nettle leaves), and Rosa damascena (rose flowers). Anti-acne extract 2 (AE2) contained Brassica oleracea var. botrytis (broccoli) and B. oleracea var. italica (cauliflower). The antimicrobial activities of the extracts were tested on two different P. acnes strains: the reference strain of P. acnes (ATCC 51277) and the clinical isolate from a patient. The minimum inhibitory concentration (MIC) of the extracts was determined using the broth dilution method. Human keratinocyte cells were used for in vitro tests. Gene expression analyses were performed with RT-qPCR.

RESULTS

The MIC values of the extracts were below 1/2048 µg/mL. In the gene expression analysis, AE1 increased the expression level of TNFα (1.1719, P < 0.0001), suppressed the expression level of IL-1α, SRD5A1 (0.0588, P = 0.0231; 0.3081, P = 0.0351), respectively. AE2 suppressed gene expression level of IL-1α, SRD5A1, TNFα (0.3815, P = 0.0254; 0.3418, P = 0.0271; 0.1997, P = 0.0623).

CONCLUSIONS

Both herbal extracts demonstrated strong antibacterial and anti-inflammatory activity in this preliminary trial. In conclusion, the topical application of these botanical extracts can be good candidates for local acne treatment.

Androgens in women: Androgen-mediated skin disease and patient evaluation

Androgens are produced throughout the body in steroid-producing organs, such as the adrenal glands and ovaries, and in other tissues, like the skin. Several androgens are found normally in women, including dehydroepiandrosterone, dehydroepiandrosterone-sulfate, testosterone, dihydrotestosterone, and androstenedione. These androgens are essential in the development of several common cutaneous conditions in women, including acne, hirsutism, and female pattern hair loss (FPHL)-androgen-mediated cutaneous disorders (AMCDs). However, the role of androgens in the pathophysiology of these diseases is complicated and incompletely understood. In the first article in this Continuing Medical Education series, we discuss the role of the skin in androgen production and the impact of androgens on the skin in women. Specifically, we review the necessary but insufficient role that androgens play in the development of acne, hirsutism, and FPHL in women. Dermatologists face the challenge of differentiating physiologic from pathologic presentations of AMCDs in women. There are currently no dermatology guidelines outlining the indications for endocrinologic evaluation in women presenting with acne, hirsutism, or FPHL. We review the available evidence regarding when to consider an endocrinologic workup in women presenting with AMCDs, including the appropriate type and timing of testing.

Longer TA repeat but not V89L polymorphisms in the SRD5A2 gene may confer acne risk in the Chinese population

Introduction

Several studies have reported that the V89L and TA repeat polymorphisms [(TA)n] of the SRD5A2 gene were associated with SRD5A2 activity. The activity of dihydrotestosterone, which is converted from testosterone by SRD5A2, is responsible for sebum secretion and the formation of acne. We hypothesized that abnormalities in SRD5A2 action could contribute to the formation of acne.

Aim

To study whether the structural change of the SRD5A2 gene may affect the risk of acne in patients with normal serum testosterone levels.

Material and methods

Genotyping of rs523349 and (TA)n of SRD5A2 was performed in 49 Chinese acne patients with significant improvements with SRD5A2 inhibitor-finasteride but normal serum testosterone levels, and in 50 healthy Chinese age-matched controls without acne.

Results

There was no significant difference between the two groups in the frequencies of V and L alleles and VV, VL, and LL genotypes of V89L (χ² test, p > 0.5). (TA)n polymorphic repeat sites are 5 alleles (TA0, TA3, TA6, TA9, TA12) in our population. The differences in S and L allele frequencies between the two groups were statistically significant (p < 0.005). People with a longer (n ≥ 6) allele of the (TA)n repeat polymorphism had a higher risk of having acne than those with a shorter (n < 6) allele (OR = 3.52, 95% CI: 1.73–7.16).

Conclusions

This study suggests that SRD5A2 polymorphisms might be associated with acne risk. This is the first report focusing on the Chinese population according to our knowledge. Further large sample studies may be required to confirm the association and to assess any interactions with environmental factors.

Adult-onset acne: prevalence, impact, and management challenges

Acne is a multifactorial and inflammatory disease of pilosebaceous follicles, which affects most adolescents. Recent epidemiological data revealed a difference in adults affected by this disease. Women have a high prevalence and incidence when compared with men, especially after 25 years of age. In contrast to what was initially thought, most of these patients do not present endocrinopathy capable of leading to the development of the lesions. When present, polycystic ovarian syndrome is the main cause. However, in these cases, acne is rarely the only dermatological manifestation; hirsutism and acanthosis nigricans are often present. The majority of the normoandrogenic acne patients present a history since adolescence, but in many cases the lesion distribution and intensity change with time. There is often a typical localization of the lesions in the lower third of the face and lateral region of the neck. Another interesting feature is related to the impact on quality of life (QoL), which is always intense. Often there are signs of depression, even when the lesions are mild. As most adult patients are women, in addition to the conventional options, there is also hormone treatment. Combined oral contraceptives and spironolactone are good options. Knowing more about the particularities in etiopathogenesis, impact on QoL, and specific treatment options is important to all dermatologists who face the challenge of treating acne in adults.

Acne in late adolescence and risk of prostate cancer

Accumulating evidence suggest that Propionibacterium acnes may play a role in prostate carcinogenesis, but data are so far limited and inconclusive. The aim of this population-based cohort study was therefore to test whether presence of acne vulgaris during late adolescence is associated with an increased risk of prostate cancer later in life. We identified a large cohort of young men born in Sweden between 1952 and 1956, who underwent mandatory assessment for military conscription around the age of 18 (n = 243,187). Test information along with health data including medical diagnoses at time of conscription was available through the Swedish Military Conscription Register and the National Patient Register. The cohort was followed through linkages to the Swedish Cancer Register to identify the occurrence of prostate cancer until December 31, 2009. We used Cox regression to calculate adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) for the association between acne in adolescence and prostate cancer risk. A total of 1,633 men were diagnosed with prostate cancer during a median follow-up of 36.7 years. A diagnosis of acne was associated with a statistically significant increased risk for prostate cancer (adjusted HR: 1.43 95%; CI: 1.06-1.92), particularly for advanced stage disease (HR: 2.37 95%; CI 1.19-4.73). A diagnosis of acne classified as severe conferred a sixfold increased risk of prostate cancer (HR: 5.70 95% CI 1.42-22.85). Data from this large prospective population-based cohort add new evidence supporting a role of P. acnes infection in prostate cancer.

ADT-G as a promising biomarker for peripheral hyperandrogenism in adult female acne

Acne vulgaris is a chronic inflammatory disease that affects the pilosebaceous unit. Recent studies have shown an increasing number of cases of acne in adult women. These cases are predominantly normoandrogenic and present some clinical differences compared to adolescent acne. Local glandular metabolism turns some weak hormonal precursors into more active substances that increase the production of sebum, leaving these areas more prone to an increasing the colonization by Propionibacterium acnes (P. acnes). Our objective was to evaluate the usefulness of an androgenic metabolite as an adult female acne biomarker. The study population consisted of 38 adult women with acne without any features of hyperandrogenism and a control group. They were recruited from the clinic of Dermatology Hospital Division of São Paulo, Federal University of São Paulo from January 2012 to September 2014. After the first hormonal dosages, patients with acne were randomized into two different groups: one receiving a combined oral contraceptive (COC) containing 0,02 mg of ethinylestradiol and 3 mg drospirenone in a regimen of 24 days of medication, and the other group was treated with a topical gel containing 15% azelaic acid (AA), twice daily, both for six months. With the end of treatment new dosages were performed. Regarding the hormones, total and free testosterone and dehydroepiandrosterone sultate were quantified. In addition, the detection and quantification of androsterone glucuronate (ADT-G), an androgenic metabolite, has been developed. Only ADT-G was sensitive in detecting differences between the control and acne groups, and presented reduction of their values with systemic treatment. Therefore, only ADT-G was able to analyze the peripheral hyperandrogenism in cases of adult female acne.

Effect of 5α-Reductase Inhibitors on Sexual Function: A Meta-Analysis and Systematic Review of Randomized Controlled Trials

INTRODUCTION

5α-Reductase inhibitors (5ARIs) are widely used for the treatment of benign prostatic hyperplasia (BPH) and androgenetic alopecia (AGA).

AIM

To review all the available data on the effect of 5ARIs on sexual function and assess whether 5ARIs increase the risk of sexual dysfunction.

METHODS

A systematic search of the literature was conducted using the Medline, Embase, and Cochrane databases. The search was limited to articles published in English and up to October 2015. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Data were analyzed using Stata 12.0. A fixed- or a random-effects model was used to calculate the overall combined risk estimates. Publication bias was assessed using Begg and Egger tests.

MAIN OUTCOME MEASURES

Sexual dysfunction, erectile dysfunction, and decreased libido.

RESULTS

After screening 493 articles, 17 randomized controlled trials with 17,494 patients were included. Nine studies evaluated the efficacy of 5ARIs in men with BPH. The other eight reported using 5ARIs in the treatment of men with AGA. The mean age of participants was 60.10 years across all studies. We included 10 trials (6,779 patients) on the efficacy and safety of finasteride, 4 trials (6,222 patients) on the safety and tolerability of dutasteride, and 3 trials (4,493 patients) using finasteride and dutasteride for AGA. The pooled relative risks for sexual dysfunction were 2.56 (95% CI = 1.48-4.42) in men with BPH and 1.21 (95% CI = 0.85-1.72) in men with AGA; those for erectile dysfunction were 1.55 (95% CI = 1.14-2.12) in men with BPH and 0.66 (95% CI = 0.20-2.25) in men with AGA; and those for decreased libido were 1.69 (95% CI = 1.03-2.79) in men with BPH and 1.16 (95% CI = 0.50-2.72) in men with AGA. Estimates of the total effects were generally consistent with the sensitivity analysis. No evidence of publication bias was observed.

CONCLUSION

Evidence from the randomized controlled trials suggested that 5ARIs were associated with increased adverse effects on sexual function in men with BPH compared with placebo. However, the association was not statistically significant in men with AGA. Well-designed randomized controlled trials are indicated to study further the mechanism and effects of 5ARIs on sexual function.

Safety and Tolerability of the Dual 5-Alpha Reductase Inhibitor Dutasteride in the Treatment of Androgenetic Alopecia

BACKGROUND

After the approval of dutastride for androgenic alopecia (AGA) in 2009, Korean authority required a post-marketing surveillance to obtain further data on its safety profile.

OBJECTIVE

The objective was to monitor adverse events (AEs) of dutasteride 0.5 mg in Korean AGA male patients in a clinical practice environment.

METHODS

Open label, multi-center, non-interventional observational study was done from July 2009 to July 2013. AGA subjects (18~41 years of age) with no experience of dutasteride were enrolled. Dosage regimen was recommended according to the prescribing information. The incidences of any AEs, serious adverse events (SAEs), and adverse drug reactions (ADRs) were evaluated. Multiple logistic regression method was used to identify risk factors related to ADRs. Effectiveness was generally evaluated by physicians.

RESULTS

During study period, 712 subjects were enrolled. The subjects of 29.3±6.0 years old exposed to dutasteride for 204.7±161.5 days. One hundred and ten (15.4%) of subjects reported 138 AEs. Four subjects (0.6%) reported 5 SAEs (right radius fracture, 2 events of chronic follicular tonsillitis, influenza infection, and acute appendicitis). Sixty-six subjects (9.3%) reported 80 ADRs. Most frequent ADRs were libido decreased (9 subjects, 1.3%), dyspepsia (8 subjects, 1.1%), impotence (7 subjects, 1.0%), and fatigue (5 subjects, 0.7%). Other interested ADRs were sexual function abnormality (4 subjects, 0.6%), gynecomastia (2 subjects, 0.3%), and ejaculation disorder (1 subject, 0.1%). Most subjects (78.6%) showed overall improvement after treatment of dutasteride in the effectiveness.

CONCLUSION

Dutasteride 0.5 mg is to be well-tolerated in 18 to 41 years old AGA patients in a clinical practice environment.

Sebum Production Alteration after Botulinum Toxin Type A Injections for the Treatment of Forehead Rhytides: A Prospective Randomized Double-Blind Dose-Comparative Clinical Investigation

BACKGROUND

Research has investigated the decrease in human skin sebum after the application of botulinum toxin. Few studies of the mechanism and objective assessments of this phenomenon have been conducted and the correlation between the sebum production and injection dosages or techniques remains unclear.

OBJECTIVES

We prospectively investigated the sebum regulation and its gradient around the injection site in patients who received intramuscular injections of botulinum toxin A (BTX-A) for forehead rhytides, comparing two injection doses.

METHODS

Forty-two female volunteers with rhytides on the forehead region were randomly assigned to receive 10 or 20 units of BTX-A, which was administered in five standard injection sites. The baseline and post-treatment sebum production was measured using a Sebumeter.

RESULTS

Treatment with BTX-A exhibited significant sebum alteration at the injection site of both groups, with a sebum gradient surrounding the injection point. The efficacy did not improve at higher injection doses, with the four-unit regimen generally not being more potent than the two-unit regimen. The sebum production recovered to normal levels at the 16 week follow-up for both treatment groups, indicating that a higher dosage (four units) did not result in a longer duration until relapse compared with the two-unit dose.

CONCLUSIONS

We determined that the sebum production has a positive correlation with the distance away from the injection point. Intramuscular injection of BTX-A significantly reduces sebum production at the injection site but increases the sebum production of the surrounding skin at a radius of 2.5 cm at the 2, 4, and 8 week follow-ups.

LEVEL OF EVIDENCE

2 Therapeutic.

Recent advances in acne pathogenesis: implications for therapy

Acne pathogenesis is a multifactorial process that occurs at the level of the pilosebaceous unit. While acne was previously perceived as an infectious disease, recent data have clarified it as an inflammatory process in which Propionibacterium acnes and innate immunity play critical roles in propagating abnormal hyperkeratinization and inflammation. Alterations in sebum composition, and increased sensitivity to androgens, also play roles in the inflammatory process. A stepwise approach to acne management utilizes topical agents for mild to moderate acne (topical retinoid as mainstay ± topical antibiotics) and escalation to oral agents for more resistant cases (oral antibiotics or hormonal agents in conjunction with a topical retinoid or oral isotretinoin alone for severe acne). Concerns over antibiotic resistance and the safety issues associated with isotretinoin have prompted further research into alternative medications and devices for the treatment of acne. Radiofrequency, laser, and light treatments have demonstrated modest improvement for inflammatory acne (with blue-light photodynamic therapy being the only US FDA-approved treatment). However, limitations in study design and patient follow-up render these modalities as adjuncts rather than standalone options. This review will update readers on the latest advancements in our understanding of acne pathogenesis and treatment, with emphasis on emerging treatment options that can help improve patient outcomes.

Identification of unknown impurity of azelaic acid in liposomal formulation assessed by HPLC-ELSD, GC-FID, and GC-MS

The identification of new contaminants is critical in the development of new medicinal products. Many impurities, such as pentanedioic acid, hexanedioic acid, heptanedioic acid, octanedioic acid, decanedioic acid, undecanedioic acid, dodecanedioic acid, tridecanedioic acid, and tetradecanedioic acid, have been identified in samples of azelaic acid. The aim of this study was to identify impurities observed during the stability tests of a new liposomal dosage form of azelaic acid that is composed of phosphatidylcholine and a mixture of ethyl alcohol and water, using high-performance liquid chromatography with evaporative light-scattering detector (HPLC-ELSD), gas chromatography–flame ionisation detection (GC-FID), and gas chromatography–mass spectrometry (GC-MS) methods. During the research and development of a new liposomal formulation of azelaic acid, we developed a method for determining the contamination of azelaic acid using HPLC-ELSD. During our analytical tests, we identified a previously unknown impurity of a liposomal preparation of azelaic acid that appeared in the liposomal formulation of azelaic acid during preliminary stability studies. The procedure led to the conclusion that the impurity was caused by the reaction of azelaic acid with one of the excipients that was applied in the product. The impurity was finally identified as an ethyl monoester of azelaic acid. The identification procedure of this compound was carried out in a series of experiments comparing the chromatograms that were obtained via the following chromatographic methods: HPLC-ELSD, GC-FID, and GC-MS. The final identification of the compound was carried out by GC with MS.

Fractionated ablative carbon dioxide laser for the treatment of rhinophyma

BACKGROUND

Rhinophyma is a progressive and disfiguring proliferative disorder of the nose, which is related to chronic rosacea. Many different treatment modalities have been utilized both alone and in combination including: loop cautery, CO2 laser, argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel. CO2 resurfacing has been considered first line therapy but is often associated with a shiny, scarred appearance, with patulous pores, and with loss of pigmentation. We report a technique using aggressive parameters with the fractionated ablative CO2 laser, resulting in improvement of appearance with very few complications.

MATERIALS AND METHODS

Five patients who presented with rhinophyma of varying degrees were treated with a series of fractional ablative CO2 laser treatments (Fraxel re:Pair, Solta Medical, Hayward, CA). These patients were treated with settings of up to 70 mJ, 70% density and 16-18 passes. All patients received HSV prophylaxis using either acyclovir 400 mg TID or valacyclovir 500 mg BID. Patients were rendered anesthetic by 1% lidocaine and epinephrine regional perinasal nerve block.

RESULTS

All of the patients tolerated the procedure well with reepithelialization at days 4-7 and self-limited edema and erythema. Patients with relatively early to moderate signs of rhinophyma proved optimal candidates for this treatment. There were no adverse events. Patients and physicians noted significant improvement and reduction in the rhinophyma without the typical scarring noted with most other treatments.

CONCLUSION

Rhinophyma treated with fractionated ablative CO2 laser using relatively aggressive parameters achieved good cosmetic outcomes in this group of early to moderate cases of rhinophyma, while still retaining the benefits of a fractionated treatment such as faster healing times and fewer adverse events.

The lack of association between idiopathic hirsutism and metabolic disturbances: Iranian PCOS Prevalence Study

BACKGROUND

Idiopathic hirsutism (IH) is a condition diagnosed after other hirsutism related is ruled out. Its definition diagnosis had a dynamic process along with improving the understanding of the various androgen excess disorders. There is uncertainty regarding its health impact and its long-term metabolic consequences. We aimed to compare metabolic syndrome (Mets) and insulin resistance (IR) of Iranian women with IH and a group of healthy controls in a large community-based study.

METHODS

Anthropometric measurements, biochemical parameters, Mets (using Joint Interim Statement criteria) and IR (estimated by the homeostasis model assessment), were compared between 101 women with IH and 423 healthy controls recruited from among 1126 reproductive aged women.

RESULTS

There was a statistically significant difference between the BMI of women with IH in comparison to normal control (27.7 versus 26.7 kg/m(2), p = 0.02); however, the prevalence of android adiposity was similar (26.7% and 24.3%, respectively). The age and BMI adjusted prevalence of Mets and IR are similar in women with IH and controls (30% versus 23.9 and 25.7 % versus 22.5%, respectively).

CONCLUSION

There will be no need for additional cardiometabolic evaluations for women with IH, later in life.

Application of HPLC with ELSD Detection for the Assessment of Azelaic Acid Impurities in Liposomal Formulation

In the course of research and development of a new pharmaceutical formulation of azelaic acid in the liposomal form, we developed a rapid and accurate method for the detection of impurities using high-performance liquid chromatography. A chromatographic column from Merck (Purospher Star RP C18, 250–4 mm (5 μm) was used in the assay, and the mobile phase gradient consisted of three phases: A—methanol : water (5 : 95) + 1.5% (v/v) acetic acid; B—water : methanol (5 : 95) + 1.5% (v/v) acetic acid; and C—chloroform. Detection of the impurities and the active substance was performed by an evaporative light-scattering detector. The method was validated for selectivity, system precision, method precision, limit of detection, and response rates. The proposed method can be used to detect impurities in the liposomal formulation of azelaic acid. The method enables separation of azelaic acid from the identified and unidentified impurities and from the excipients used in the drug form.

Role of hormones in acne vulgaris

OBJECTIVE

To elucidate the role of endogenous hormones like testosterone, progesterone, estrogen, insulin-like growth factor, insulin and glucocorticoids in a common skin condition acne vulgaris.

DESIGN AND METHODS

We conducted a systematic review of the literature and abstracted the data for every published cut point.

RESULTS

We screened more than 1000 studies and found that serum testosterone, progesterone, glucocorticoids, insulin and insulin-like growth factors are increased in patients with acne vulgaris and serum estrogen levels are low in patients.

CONCLUSIONS

Various endogenous hormones play important role in the pathogenesis of acne vulgaris. Thus, in the clinical practice it is important to evaluate serum levels of these hormones and patients must be treated accordingly to avoid serious endocrine disorders at an early age.

Pilot Study of 15 Patients Receiving a New Treatment Regimen for Androgenic Alopecia: The Effects of Atopy on AGA

Background. We examined the efficacy of a new regimen to treat AGA, with attention to male patients who are atopic. Objective. To assess the efficacy of a four-part regimen for the treatment of AGA in atopic and nonatopic patients. NuH Hair is a novel topical combination of finasteride, dutasteride, and minoxidil, which is blended in a hypoallergenic lotion. The other three components included Rogaine foam, Propecia, and ketoconazole shampoo. Methods. A prospective pilot study was conducted in 15 patients. All patients were assessed for the presence of atopy. Each patient served as their own control. All patients were treated specifically with NuH Hair and were given the option to add any of the other components of the protocol to their regimen. Photographs were taken of each patient's scalp at months 0, 1, 3, 6, and 9. Results. All 15 patients demonstrated significant growth of hair. In those patients who utilized all 4 components, significant growth was achieved in as little as 30 days. In those patients who choose only to utilize NuH Hair, significant growth was demonstrated after 3 months. Conclusion. Aggressively treating AGA achieves significant and rapid growth of new hair. This is effective in atopic and nonatopic male patients.

[Acne vulgaris. The role of hormones]

Peripherally active androgens control cellular functions by binding to androgen receptors. Follicular keratinocytes and sebocytes are target cells for androgens, which, directly or indirectly, stimulate keratinocyte proliferation and the volume of sebaceous glands as well as the sebum secretion rate. Acne often begins with the adrenarche, namely with the up- regulation of adrenal synthesis of dehydroepiandrosterone sulfate, a hormone that is upstream to testosterone. The majority of acne patients exhibit normal levels of circulating androgens, while sebaceous glands from acne regions exhibit a stronger sensitivity to androgens than the sebaceous glands from other parts of the body. Hormone-like active lipids, hormones in diet and neuropeptides may also play a role in the development of acne lesions. The target of antiandrogen treatment of the skin is mainly the sebaceous gland and the primary effect is sebostasis.

Role of FGFR2-signaling in the pathogenesis of acne

It is the purpose of this review to extend our understanding of the fibroblast growth factor (FGF) receptor-2b-signaling network in the pathogenesis of acne. A new concept of the role of FGFR2b-signaling in dermal-epithelial interaction for skin appendage formation, pilosebaceous follicle homeostasis, comedogenesis, sebaceous gland proliferation and lipogenesis is presented. The FGFR2-gain-of-function mutations in Apert syndrome and unilateral acneiform nevus are most helpful model diseases pointing the way to androgen-dependent dermalepithelial FGFR2-signaling in acne. Androgen-mediated upregulation of FGFR2b-signaling in acne-prone skin appears to be involved in the pathogenesis of acne vulgaris. In organotypic skin cultures, keratinocyte-derived interleukin-1alpha stimulated fibroblasts to secrete FGF7 which stimulated FGFR2b-mediated keratinocyte proliferation. Postnatal deletion of FGFR2b in mice resulted in severe sebaceous gland atrophy. The importance of FGFR2b in sebaceous gland physiology is further supported by the mode of action of anti-acne agents which have been proposed to attenuate FGFR2b-signaling. Downregulation of FGFR2b-signaling by isotretinoin explains its therapeutic effect in acne. Downregulation of FGFR2b-signaling during the first trimester of pregnancy disturbs branched morphogenesis and explains retinoid embryotoxicity. Insulin-like growth factor-1 (IGF-1), the mediator of growth hormone during puberty, intracts with androgen-dependent FGFR2b-signaling and links androgen- and FGF-mediated signal transduction important in sebaceous gland homeostasis. The search for a follicular defect in the dermalepithelial regulation of growth factor-signaling in acne-prone skin appears to be a most promising approach to clarify the pathogenesis of acne.

Androgen dependence of hirsutism, acne, and alopecia in women: retrospective analysis of 228 patients investigated for hyperandrogenism

Hirsutism, acne, alopecia, and oligo-amenorrhea are clinical expressions of hyperandrogenism, one of the most frequent endocrine disorders in women of reproductive age. Women referred to our endocrine clinics for skin symptoms of hyperandrogenism underwent a laboratory workup to evaluate hormone measurements and received antiandrogen therapy. We retrospectively analyzed the outcome of 228 consecutive patients investigated over 6 years.Patients with hirsutism had higher levels of androstenedione, dehydroepiandrosterone sulfate (DHEAS), and salivary testosterone; lower levels of sex hormone-binding globulin (SHBG); and a higher prevalence of oligo-amenorrhea than patients with alopecia, while patients with acne showed intermediate values. Hirsutism score correlated positively with androstenedione, DHEAS, and salivary testosterone, and correlated negatively with SHBG; salivary testosterone showed the highest correlation coefficient. Total testosterone was not significantly different among patients with hirsutism, alopecia, or acne, and did not significantly correlate with hirsutism score. Hirsutism and oligo-amenorrhea were the most sensitive symptoms of hyperandrogenism, and no androgenic parameter alone allowed us to identify all cases of hyperandrogenism.Patients of central European origin sought consultation with milder hirsutism scores than patients of southern European origin. There was, however, no difference in the clinical-biological correlation between these groups, arguing against differences in skin sensitivity to androgens.Polycystic ovary syndrome, defined as hyperandrogenism (hirsutism or elevated androgens) and oligo-amenorrhea, was diagnosed in 63 patients (27.6%), an underestimate compared with other reports that include systematic ovarian ultrasound studies. Neither pelvic ultrasound, used in a limited number of cases, nor the luteinizing hormone/follicle-stimulating hormone ratio helped to distinguish patients with polycystic ovary syndrome from the other diagnostic groups. These included hyperandrogenism (hirsutism or elevated androgens) and eumenorrhea (101 patients; 44.3%); normal androgens (acne or alopecia and eumenorrhea) (51 patients; 22.4%); isolated low SHBG (7 patients; 3.1%); nonclassical congenital adrenal hyperplasia (4 patients; 1.8% of total, 4.9% of patients undergoing cosyntropin stimulation tests); and ovarian tumor (2 patients; 0.9%).Ethinylestradiol and high-dose cyproterone acetate treatment lowered the hirsutism score to 53.5% of baseline at 1 year, and was also effective in treating acne and alopecia. The clinical benefit is ascribed to the peripheral antiandrogenic effect of cyproterone acetate as well as the hormone-suppressive effect of this combination. Salivary testosterone showed the most marked proportional decrease of all the androgens under treatment. Cost-effectiveness and tolerance of ethinylestradiol and high-dose cyproterone acetate compared well with other antiandrogenic drug therapies for hirsutism. The less potent therapy with spironolactone only, a peripheral antiandrogen without hormone-suppressive effect, was effective in treating isolated alopecia in patients with normal androgens.

Pharmacology of anabolic steroids

Athletes and bodybuilders have recognized for several decades that the use of anabolic steroids can promote muscle growth and strength but it is only relatively recently that these agents are being revisited for clinical purposes. Anabolic steroids are being considered for the treatment of cachexia associated with chronic disease states, and to address loss of muscle mass in the elderly, but nevertheless their efficacy still needs to be demonstrated in terms of improved physical function and quality of life. In sport, these agents are performance enhancers, this being particularly apparent in women, although there is a high risk of virilization despite the favourable myotrophic-androgenic dissociation that many xenobiotic steroids confer. Modulation of androgen receptor expression appears to be key to partial dissociation, with consideration of both intracellular steroid metabolism and the topology of the bound androgen receptor interacting with co-activators. An anticatabolic effect, by interfering with glucocorticoid receptor expression, remains an attractive hypothesis. Behavioural changes by non-genomic and genomic pathways probably help motivate training. Anabolic steroids continue to be the most common adverse finding in sport and, although apparently rare, designer steroids have been synthesized in an attempt to circumvent the dope test. Doping with anabolic steroids can result in damage to health, as recorded meticulously in the former German Democratic Republic. Even so, it is important not to exaggerate the medical risks associated with their administration for sporting or bodybuilding purposes but to emphasize to users that an attitude of personal invulnerability to their adverse effects is certainly misguided.