Treatment of acne vulgaris in pregnant patients

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

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

Tetracyclines and bone: Unclear actions with potentially lasting effects

Tetracyclines are a broad-spectrum class of antibiotics that have unclear actions with potentially lasting effects on bone metabolism. Initially isolated from Streptomyces, tetracycline proved to be an effective treatment for Gram +/- infections. The emergence of resistant bacterial strains commanded the development of later generation agents, including minocycline, doxycycline, tigecycline, sarecycline, omadacycline, and eravacycline. In 1957, it was realized that tetracyclines act as bone fluorochrome labels due to their high affinity for the bone mineral matrix. Over the course of the next decade, researchers discerned that these compounds are retained in the bone matrix at high levels after the termination of antibiotic therapy. Studies during this period provided evidence that tetracyclines could disrupt prenatal and early postnatal skeletal development. Currently, tetracyclines are most commonly prescribed as a long-term systemic therapy for the treatment of acne in healthy adolescents and young adults. Surprisingly, the impact of tetracyclines on physiologic bone modeling/remodeling is largely unknown. This article provides an overview of the pharmacology of tetracycline drugs, summarizes current knowledge about the impact of these agents on skeletal development and homeostasis, and reviews prior work targeting tetracyclines' effects on bone cell physiology. The need for future research to elucidate unclear effects of tetracyclines on the skeleton is addressed, including drug retention/release mechanisms from the bone matrix, signaling mechanisms at bone cells, the impact of newer third generation tetracycline antibiotics, and the role of the gut-bone axis.

The Effectiveness of Autologous Serum and Single-dose Oral Doxycycline in the Treatment of Acne Vulgaris: A Pilot Clinical Trial

Introduction: Acne vulgaris is a chronic inflammatory disease that occurs with various factors, both intrinsic and extrinsic. Treatment of choice can vary from topical, systemic or a combination of both depending on the degree of severity. Recently, treatment using products from human blood has been widely studied, including in the field of dermatology as it has a unique composition. Objective: to assess the effectiveness of autologous serum and single-dose oral doxycycline in the treatment of acne vulgaris Methods: this clinical trial compared two groups which received autologous serum only and autologous serum combined with single dose of oral 200 mg doxycycline, respectively. Photographic pictures and number of lesions (blackheads, papules, pustules) were compared before and after application using Wilcoxon test. Results: A total of 20 participants participated in this study. Both treatment groups showed significant decrease in lesion count (p <0.01). However, the group which received autologous serum and single dose of oral doxycycline showed superior improvement of inflammatory acne lesions. Conclusion: autologous serum and single dose of oral doxycycline was superior to autologous serum only in the treatment acne lesions. Keywords: Acne Vulgaris, Doxycycline, Autologous Serum

Acne in the first three decades of life: An update of a disorder with profound implications for all decades of life

Acne vulgaris is a chronic, inflammatory, skin condition that involves the pilosebaceous follicles and is influenced by a variety of factors including genetics, androgen-stimulation of sebaceous glands with abnormal keratinization, colonization with Cutibacterium acnes (previously called Propionibacterium acnes), and pathological immune response to inflammation. Acne can occur at all ages and this discussion focuses on the first three decades of life. Conditions that are part of the differential diagnosis and/or are co-morbid with acne vulgaris are also considered. Acne in the first year of life includes neonatal acne (acne neonatorum) that presents in the first four weeks of life and infantile acne that usually presents between 3 and 6 months of the first year of life with a range of 3 to 16 months after birth. Acne rosacea is a chronic, inflammatory, skin condition that is distinct from acne vulgaris, typically presents in adults, and has four main types: erythemato-telangiectatic, papulopustular, phymatous and ocular. Treatment options for acne vulgaris include topical retinoids, topical benzoyl peroxide, antibiotics (topical, oral), oral contraceptive pills, isotretinoin, and others. Management must consider the increasing impact of antibiotic resistance in the 21st century. Psychological impact of acne can be quite severe and treatment of acne includes awareness of the potential emotional toll this disease may bring to the person with acne as well as assiduous attention to known side effects of various anti-acne medications (topical and systemic). Efforts should be directed at preventing acne-caused scars and depigmentation on the skin as well as emotional scars within the person suffering from acne.

Successful pregnancy and delivery following selective use of photodynamic therapy in treatment of cervix and vulvar diseases

BACKGROUND

Photodynamic therapy has been gaining popularity, particularly among young women. Therefore it is crucial to evaluate PDT for safety and its impact on fertility and delivery of healthy newborns.

OBJECTIVE

The study analyzed the PDT treatment of 10 young women, who suffered from diseases of the vulva and cervix. The aim of the analysis was evaluating what impact PDT treatment had on their pregnancies and delivery.

METHODS

10 patients (22-32 years of age, 25.5 years of age on average) were treated with PDT in 2007-2014. 2 patients suffered from squamous cell hyperplasia, 2 patients from vulvar lichen sclerosus, 1 - genital warts, 1 - VIN I (current terminology: LSIL/Flat condyloma), 2 - CIN III (HSIL), 2 - CIN I (LSIL). The patients underwent photodynamic therapy (PDT). In the course of PDT the 5% 5- aminolevulinic acid was used in gel form three hours before irradiation. The affected areas were irradiated with a halogen lamp PhotoDyn 501 (590-760 nm) during a 10-min radiation treatment. The treatment was repeated weekly for 10 weeks.

RESULTS

The median observation time period between the end of therapy and delivery was 3.92 years (2-7 years). None of the patients suffered from infertility. All patients gave birth to healthy, full-term infants. In case of one pregnancy cervical cerclage was needed. Two patients were treated for hypothyroidism caused by the Hashimoto disease. One patient had gestational diabetes. Two patients had already given birth to 2 children. Five patients gave birth by caesarean section.

CONCLUSION

Topical PDT selectively used for treating the diseases of the female reproductive organs was applied in our group of patients and proved to be a safe method. It had no apparent negative impact on female fertility and allowed these women to give birth to healthy children.

The susceptibility of pathogens associated with acne vulgaris to antibiotics

BACKGROUND Acne vulgaris is a pilosebaceous disorder. Bacterial activity and inflammation both influence acne formation. Antibiotics suppress the bacterial activities and elicit anti-inflammatory effects. The overuse of antibiotics may lead to resistance in bacteria. This study was aimed to provide an overview of bacteria that may cause acne and determine their susceptibility to antibiotics.METHODS This was a cross-sectional study sampling from 93 patients with acne in Ciptomangunkusumo Hospital. Comedones were extracted and cultured on Brucella blood agar, under aerobic and anaerobic conditions at 35oC for 24–48 hours. Bacterial identification was performed using Vitek®, and susceptibility test using E-test. Data interpretation was based on the Clinical and Laboratory Standards Institute 2015.RESULTS Staphylococcus epidermidis (50.5%), Propionibacterium acnes (11.0%), and Staphylococcus aureus (7.7%) were identified. Bacteria were not found in 69.2% and 1.1% of samples in anaerobic and aerobic cultures, respectively. P. acnes was susceptible to doxycycline (100%) and minocycline (100%), while 10% was resistant to erythromycin, clindamycin, and tetracycline. S. epidermidis was susceptible to minocycline (100%); but resistant to erythromycin (65.2%), clindamycin (52.2%) and tetracycline (32.6%). The susceptibility of S. epidermidis to doxycycline was 89.1%, which was lower than that of P. acnes (100%). S. aureus was found to be sensitive to minocycline (100%), doxycycline (71.4%), clindamycin (71.4%), and tetracycline (71.4%); but it was resistant to erythromycin (42.9%).CONCLUSIONS Doxycycline and minocycline showed 100% effectiveness for P. acnes. The isolated bacteria were more susceptible to doxycycline compared to tetracycline. The use of clindamycin and erythromycin needs to be limited as most S. epidermidis isolates were resistant to both.

The effects of microduplication 1q21.1 and in-utero isotretinoin exposure

The impact of in-utero isotretinoin exposure has been widely reported, with many affected pregnancies failing to reach term.^{1 2} Due to the low numbers of in-utero isotretinoin exposed pregnancies, the interactions between this drug and rare genetic defects such as microduplication 1q21.1 are unclear, particularly how they might manifest phenotypically. We present this case of in-utero isotretinoin exposure occurring in a child with microduplication 1q21.1. The child was born with congenital abnormalities which did not fit into a single syndrome. Regrettably in-utero exposure to isotretinoin continues to occur. We hope this case will trigger further discussion on the dangers of dispensing Isotretinoin without ensuring stringent pregnancy testing and its potential interaction with genetic abnormalities, in particular with microduplication 1q21.1.

Management of severe acne during pregnancy: A case report and review of the literature

The treatment of acne during pregnancy is often limited by the potential toxicities that are posed to the fetus by the most common and effective acne therapies. As with all dermatoses during pregnancy, the treatment of acne vulgaris in this population requires a thorough understanding of the risks and benefits that are inherent to each treatment. We report on a case of a 30-year-old pregnant patient with severe acne conglobata who showed significant improvement with a combination treatment of topical modalities, oral metronidazole, and low dose prednisone during pregnancy. We also review the literature and present an approach for the care of these patients.

Dermatologic conditions in patients of color who are pregnant

Certain dermatoses that present during pregnancy have a predilection for populations with skin of color (SOC). Additionally, certain systemic diseases such as systemic lupus erythematosus tend to be more aggressive during pregnancy and confer worse prognoses in women with SOC. The purpose of this review is to highlight the unique implications of selected diseases during pregnancy as it relates to SOC. Dermatologists should be vigilant for the unique clinical variations of dermatological conditions in patients of color who are pregnant to ensure correct diagnoses and optimize treatment outcomes.

Consensus-Based Acne Classification System and Treatment Algorithm for Spain

Acne is a chronic inflammatory disease whose psychosocial effects can greatly impair quality of life. Various scales are used to classify the severity of acne, and several treatment algorithms are currently applied: no consensus on a common scale or treatment guidelines has been reached. A group of Spanish experts therefore met to identify a scale the majority could accept as the most appropriate for classifying severity and treating accordingly. The group chose the following classifications: comedonal acne, mild or moderate papulopustular acne, severe papulopustular acne, moderate nodular acne, and nodular-cystic acne (or acne tending to leave scars). Consensus was reached on first- and second-choice treatments for each type and on maintenance treatment. The experts also issued specific recommendations on antibiotic use (starting with mild or moderate papulopustular acne), always in combination with retinoids and/or benzoyl peroxide. The use of isotretinoin (starting at severe papulopustular or moderate nodular acne) was also covered.

Nuclear retinoid receptors and pregnancy: placental transfer, functions, and pharmacological aspects

Animal models of vitamin A (retinol) deficiency have highlighted its crucial role in reproduction and placentation, whereas an excess of retinoids (structurally or functionally related entities) can cause toxic and teratogenic effects in the embryo and foetus, especially in the first trimester of human pregnancy. Knock-out experimental strategies-targeting retinoid nuclear receptors RARs and RXRs have confirmed that the effects of vitamin A are mediated by retinoic acid (especially all-trans retinoic acid) and that this vitamin is essential for the developmental process. All these data show that the vitamin A pathway and metabolism are as important for the well-being of the foetus, as they are for that of the adult. Accordingly, during this last decade, extensive research on retinoid metabolism has yielded detailed knowledge on all the actors in this pathway, spurring the development of antagonists and agonists for therapeutic and research applications. Natural and synthetic retinoids are currently used in clinical practice, most often on the skin for the treatment of acne, and as anti-oncogenic agents in acute promyelocytic leukaemia. However, because of the toxicity and teratogenicity of retinoids during pregnancy, their pharmacological use needs a sound knowledge of their metabolism, molecular aspects, placental transfer, and action.

Systemic exposure of topical erythromycin in comparison to oral administration and the effect on cytochrome P450 3A4 activity

AIMS

Erythromycin is a macrolide antibiotic, which is frequently used as a topical formulation for the treatment of acne. It is also known as an inhibitor of the cytochrome P450 (CYP) isoenzyme 3A4. In this study, the systemic availability of topical erythromycin, hence the influence on the activity of CYP3A, is evaluated in comparison to orally administered erythromycin.

METHODS

Sixteen healthy volunteers received consecutively topical (two applications of 800 mg) and oral erythromycin (two dose groups, 250 and 1000 mg, with n = 8) to assess erythromycin pharmacokinetics. A microdose of midazolam (3 μg orally) was used to determine the effect on CYP3A activity.

RESULTS

After topical administration, erythromycin was detected in the plasma of every participant without causing a statistically significant alteration of CYP3A activity. After oral administration, the dose-normalized erythromycin exposure (AUC∞ ) was 1335 h ng ml(-1) after 250 mg and 3-fold higher after the 1000 mg dose (4051 h ng ml(-1); P < 0.01), suggesting nonlinear pharmacokinetics of erythromycin. Both oral doses inhibited CYP3A activity; midazolam clearance was decreased to 61% (250 mg) and 21% (1000 mg). The relationship between erythromycin exposure and CYP3A activity (Hill equation) revealed a 50% reduction of CYP3A activity by an erythromycin AUC∞ of 2106 h ng ml(-1).

CONCLUSIONS

Topical erythromycin did not cause clinically relevant CYP3A alterations, although low systemic availability of erythromycin was observed. This supports the assumption that treatment with topical erythromycin is not critical in terms of CYP3A inhibition. Furthermore, substantial nonlinearity of erythromycin pharmacokinetics after two different oral doses was observed, possibly due to autoinhibition.