The assessment of acne vulgaris--the Leeds technique

A Comprehensive Review of the Acne Grading Scale in 2023

Acne is a common skin inflammatory condition that can significantly affect the patient's quality of life. Therefore, accurate assessment scales are very important for treatment and management of acne vulgaris. This review article issues a comprehensive review of various acne severity assessment scales. In this text, the authors review the acne grading scales, such as the Pillsbury scale, Cook's acne grading scale, Leeds acne grading system, Global Acne Grading System, and investigator's global assessment, etc. And we delve into the characteristics, advantages, limitations, and applicability of these scales. The acne grading scale to be developed in the future should be objective, accurate, comprehensive, easy to use, and applicable in a variety of clinics and research settings. Current technologies, such as artificial intelligence, could potentially contribute to the development of ideal acne grading scales that meet unmet needs.

Novel 1726 nm laser demonstrates durable therapeutic outcomes and tolerability for moderate-to-severe acne across skin types

BACKGROUND

Traditional acne management with topical therapy, systemic antibiotics, hormonal agents, or oral isotretinoin requires compliance and may produce significant side effects. However, alternative treatments with lasers had failed to demonstrate durable clearance.

OBJECTIVE

To assess the tolerability and therapeutic outcomes of a novel 1726 nm laser treatment of moderate-to-severe acne across skin types.

METHODS

A prospective, open-label, single-arm, Investigational Device Exemption-approved, institutional review board-approved study of 104 subjects with moderate-to-severe facial acne and Fitzpatrick Skin Types ranging from II-to-VI was conducted. Subjects received 3 laser treatments at 3 (-1/+2)-week intervals.

RESULTS

Following final treatment, ≥50% reduction in active acne inflammatory lesions was 32.6% at 4-weeks follow-up, increasing further to 79.8% and 87.3% at 12 and 26-weeks, respectively. The percentage of subjects clear or almost clear increased from 0% at baseline to 9%, 36.0%, and 41.8% at 4-, 12-, and 26-weeks follow-up. No serious adverse events were observed related to device or protocol; treatments were well tolerated, requiring no anesthetic. Therapeutic outcomes and discomfort were similar across all skin types.

LIMITATIONS

Lack of control group.

CONCLUSIONS

The study findings demonstrate the novel 1726 nm laser is well tolerated with durable progressive posttreatment improvement to at least 26 weeks for moderate-to-severe acne across skin types.

Efficacy of metformin vs. doxycycline in treating acne vulgaris: An assessor-blinded, add-on, randomized, controlled clinical trial

INTRODUCTION

Insulin-like growth factor 1 (IGF-1) plays a role in the pathogenesis of acne vulgaris. Metformin can reduce IGF-1 levels and insulin resistance, so it may be useful in treating acne.

OBJECTIVE

This study compared the efficacy of metformin and doxycycline in treating patients with acne vulgaris.

METHODS

In this assessor-blind, add-on, randomized controlled clinical trial, we enrolled 40 patients with moderate acne vulgaris aged 15-40 and randomly divided them into two groups. For two months, the first group received doxycycline 100 mg capsules daily, and the second received metformin 500 mg tablets twice daily. The patients in both groups were adminitered to apply a fingertip (fourth finger) of 5% benzoyl peroxide gel (Pangel®) topically every night over the lesions, and to wash it off after 30 min. Patients were evaluated using the Global Acne Grading System (GAGS) score, Investigator Global Assessment for Acne (IGA) score, Cardiff Acne Disability Index (CADI), Total Acne Lesion Count (TLC), and the number of inflammatory and noninflammatory lesions.

RESULTS

By the end of the study, the GAGS, IGA, CADI, and TLC scores and the number of inflammatory and noninflammatory lesions decreased significantly in both groups (p < 0.001), with no significant difference between the two groups (p > 0.05).

CONCLUSION

This trial indicates equal efficacy of doxycycline and metformin in reducing acne vulgaris severity, with doxycycline performing better in reducing lesions of the inflammatory type. Confirmatory or equivalence clinical trials should be performed to confirm our results.

SPIOMET4HEALTH-efficacy, tolerability and safety of lifestyle intervention plus a fixed dose combination of spironolactone, pioglitazone and metformin (SPIOMET) for adolescent girls and young women with polycystic ovary syndrome: study protocol for a multicentre, randomised, double-blind, placebo-controlled, four-arm, parallel-group, phase II clinical trial

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most prevalent, chronic endocrine-metabolic disorder of adolescents and young women (AYAs), affecting 5-10% of AYAs worldwide. There is no approved pharmacological therapy for PCOS. Standard off-label treatment with oral contraceptives (OCs) reverts neither the underlying pathophysiology nor the associated co-morbidities. Pilot studies have generated new insights into the pathogenesis of PCOS, leading to the development of a new treatment consisting of a fixed, low-dose combination of two so-called insulin sensitisers [pioglitazone (PIO), metformin (MET)] and one mixed anti-androgen and anti-mineralocorticoid also acting as an activator of brown adipose tissue [spironolactone (SPI)], within a single tablet (SPIOMET). The present trial will evaluate the efficacy, tolerability and safety of SPIOMET, on top of lifestyle measures, for the treatment of PCOS in AYAs.

METHODS

In this multicentre, randomised, double-blind, placebo-controlled, four-arm, parallel-group, phase II clinical trial, AYAs with PCOS will be recruited from 7 clinical centres across Europe. Intention is to randomise a total of 364 eligible patients into four arms (1:1:1:1): Placebo, PIO, SPI + PIO (SPIO) and SPI + PIO + MET (SPIOMET). Active treatment over 12 months will consist of lifestyle guidance plus the ingestion of one tablet daily (at dinner time); post-treatment follow-up will span 6 months. Primary endpoint is on- and post-treatment ovulation rate. Secondary endpoints are clinical features (hirsutism, menstrual regularity); endocrine-metabolic variables (androgens, lipids, insulin, inflammatory markers); epigenetic markers; imaging data (carotid intima-media thickness, body composition, abdominal fat partitioning, hepatic fat); safety profile; adherence, tolerability and acceptability of the medication; and quality of life in the study participants. Superiority (in this order) of SPIOMET, SPIO and PIO will be tested over placebo, and if present, subsequently the superiority of SPIOMET versus PIO, and if still present, finally versus SPIO.

DISCUSSION

The present study will be the first to evaluate-in a randomised, double-blind, placebo-controlled way-the efficacy, tolerability and safety of SPIOMET treatment for early PCOS, on top of a lifestyle intervention.

TRIAL REGISTRATION

EudraCT 2021-003177-58. Registered on 22 December 2021. https://www.clinicaltrialsregister.eu/ctr-search/search?query=%092021-003177-58 .

Automated Facial Acne Lesion Detecting and Counting Algorithm for Acne Severity Evaluation and Its Utility in Assisting Dermatologists

BACKGROUND

Although lesion counting is an evaluation method that effectively analyzes facial acne severity, its usage is limited because of difficult implementation.

OBJECTIVES

We aimed to develop and validate an automated algorithm that detects and counts acne lesions by type, and to evaluate its clinical applicability as an assistance tool through a reader test.

METHODS

A total of 20,699 lesions (closed and open comedones, papules, nodules/cysts, and pustules) were manually labeled on 1213 facial images of 398 facial acne photography sets (frontal and both lateral views) acquired from 258 patients and used for training and validating algorithms based on a convolutional neural network for classifying five classes of acne lesions or for binary classification into noninflammatory and inflammatory lesions.

RESULTS

In the validation dataset, the highest mean average precision was 28.48 for the binary classification algorithm. Pearson's correlation of lesion counts between algorithm and ground-truth was 0.72 (noninflammatory) and 0.90 (inflammatory), respectively. In the reader test, eight readers (100.0%) detected and counted lesions more accurately using the algorithm compared with the reader-alone evaluation.

CONCLUSIONS

Overall, our algorithm demonstrated clinically applicable performance in detecting and counting facial acne lesions by type and its utility as an assistance tool for evaluating acne severity.

Metabolic and Dietary Factors in Acne Vulgaris and Evaluation of the Acne Vulgaris Treatment with Oral Contraceptive-Based Therapies in Young Adult Women

The etiopathogenesis of acne is complex, as several endo- and exogenous factors that affect the sebaceous-hair unit are involved in the development of acne lesions. The main aim of the study was to evaluate selected metabolic parameters before treatment. Another goal of the study was to determine the correlation between selected metabolic and dietary parameters and the severity of acne before treatment. The third objective was to assess the severity of acne before and after treatment, considering the type of treatment used. The final objective was to assess the relationship between the difference in acne severity before and after treatment, considering the type of treatment used and factors of dairy or sweets intake. 168 women participated in the study. The patients belonged to two groups: the study group (99 patients with acne vulgaris) and the control group (69 patients without skin lesions). The study group was divided into subgroups according to the treatment used: contraceptive preparation, contraceptive preparation and cyproterone acetate, and contraceptive preparation and isotretinoin preparation. We found that LDL levels and consumption of sweets correlated with acne severity. The mainstay of acne treatment is contraceptive treatment (ethinylestradiol and drospirenone). The effectiveness of the three contraceptive-based treatments was confirmed by observing the severity of acne. There were no significant correlations between the difference in acne severity before and after treatment with the three treatments and factors of dairy or sweet consumption.

Truncal Acne and Scarring: A Comprehensive Review of Current Medical and Cosmetic Approaches to Treatment and Patient Management

Acne vulgaris is one of the most common skin disorders worldwide. It typically affects skin areas with a high density of sebaceous glands such as the face, upper arms, chest, and/or back. Historically, the majority of research efforts have focused on facial acne vulgaris, even though approximately half of patients with facial lesions demonstrate truncal involvement. Truncal acne vulgaris is challenging to treat and poses a significant psychosocial burden on patients. Despite these characteristics, studies specifically examining truncal acne vulgaris are limited, with treatment guidelines largely derived from facial protocols. Therefore, truncal acne remains an understudied clinical problem. Here, we provide a clinically focused review on the epidemiology, evaluation, and available treatment options for truncal acne vulgaris. In doing so, we highlight knowledge gaps with the goal of spurring further investigation into the management of truncal acne vulgaris.

Evaluation of Hormonal Factors in Acne Vulgaris and the Course of Acne Vulgaris Treatment with Contraceptive-Based Therapies in Young Adult Women

Acne vulgaris is a common chronic inflammatory skin disease, which is considered one of the diseases of civilization due to the significant influence of environmental factors on the severity and frequency of these lesions. The aim of this study was to evaluate the hormonal profile of patients before treatment and to assess selected hormonal parameters after treatment. Our first objective was to examine the correlation between the selected hormonal parameters and the severity of acne before treatment. Our second objective was to evaluate the impact of treatment with three therapies, as measured by the selected hormonal parameters and acne severity. Statistical calculations were performed using the R v.4.1.1 statistical calculation environment (IDE RStudio v. 1.4.1717) with a significance level for the statistical tests set at α = 0.05. The results showed that the women in the pre-treatment (T1) and control (C) groups had significant differences in testosterone, androstendione, FAI, SHBG, prolactin, ACTH, and cortisol concentrations. After treatment, there were still significant differences in testosterone, androstendione, FAI, and SHBG concentrations between the post-treatment (T2) and control groups. We concluded that testosterone, androstendione, and cortisol concentrations correlate with acne severity. Acne in adult women may be an important clinical marker of androgen excess syndrome and cannot be considered a transient symptom of puberty. The mainstay of acne treatment is contraceptive therapy (ethonylestradiol and drospirenone). In this study, we confirmed the effectiveness of three contraceptive-based treatments using hormonal parameters and acne severity.

Picture-based acne lesion counts: A validation study to assess accuracy and reliability of acne lesion counts via photography

BACKGROUND

Acne lesion counting (ALC) is widely used to evaluate efficacy of new acne treatments. Although such evaluations are precise and highly discriminative, if assessed live, it can be a time-consuming and intrusive measurement. Photographic assessment is a viable mode for ALCs and for training and/or qualifying evaluators.

AIMS

The purpose of this study was to validate photographic methods for performing ALCs and to provide an objective measurement tool to train and/or qualify lesion count evaluators for deployment in both small- and large-scale studies.

PATIENTS/METHODS

Assess accuracy and reliability of acne lesion counting via photographic methods in 8 subjects aged 16 to 40 years, with Fitzpatrick Skin Types I to VI. Frontal and 45°angle images taken at the single in-clinic visit. Each subject underwent 3 counts per 4 evaluators: 1 set of live counts and 2 sets of photo counts. Intra-evaluator and inter-evaluator reliability measures for photo counts were evaluated using calculations of intraclass correlation coefficients (ICCs).

RESULTS

Eight subjects (2 males and 6 females) age between 16 and 40 (min 16 years, max 25 years) diagnosed with facial acne vulgaris participated in the study. Fitzpatrick Skin Types ranged from III to V (three Type-III, four Type-IV, and one Type-V). ICC values for intra-evaluator reliability were found to be >0.95 for each evaluator, and ICC for inter-evaluator reliability was found to be 0.98.

CONCLUSIONS

Photographic lesion count methodology is a reliable and accurate tool for objective measurement of ALCs and additionally, for training and/or qualifying evaluators.

Treatment of Resistant Acne Vulgaris in Adolescents Using Dietary Supplementation with Magnesium, Phosphate and Fatty Acids (Omega 6 and 7): Comparison with 13-Cis-Retinoic Acid

The burden of disease associated with acne vulgaris has continued to increase over time in the world population. This continued growth suggests that there is an unmet dermatologic need for this condition worldwide. Potential sequelae of acne, such as scarring, depigmentation, and marked emotional and psychological problems (e.g., low self-esteem), can lead to significant morbidity. The purpose of this study was to investigate whether dietary supplementation with magnesium, phosphate, omega 6 (linoleic acid calcium salt - C18:2 fatty acid Ca salt), and omega 7 (palmitoleic acid calcium salt - C16:1 fatty acid Ca salt) would help patients with acne vulgaris, and to compare with isotretinoin (13-cis retinoic acid). Magnesium has anti-inflammatory properties. Linoleic and palmitoleic acids have bactericidal activity against Staphylococcus aureus and Cutibacterium acnes (formerly known as Propionibacterium acnes). A single-blind randomized study was conducted in which 257 patients were treated with the above dietary supplementation (group A) and 275 patients with isotretinoin (group B) for 6 months. All patients in group A (100%) reported complete regression of symptoms after 6 months of treatment. On the other hand, 187 subjects (68%) in group B reported complete resolution of symptoms during the same period. The difference between the groups (p < 0.05) was statistically significant. The study was approved by the CEP/CONEP. This natural formulation promotes regression and/or cure of acne vulgaris symptoms and has better results than drugs (such as isotretinoin), without significant side effects.

Truncal Acne: An Overview

Acne is a relatively common disease of the pilosebaceous units. Many aspects of facial acne have been studied. However, there is limited evidence regarding truncal acne. Truncal acne is also observed in a significant number of patients, but it is often ignored by patients and clinicians. Although the pathogenesis of facial and trunk acne is considered to be similar, the characteristics of the skin on the trunk and face are thought to be different. As truncal acne can cause scars on large areas of the body and adversely affect the quality of life of patients, more attention should be given to patients with truncal acne. Although only a few studies have been published to date, the epidemiology, etiology, severity assessment tool, assessments of the quality of life, and new treatments targeting truncal acne are currently being studied. Therefore, in this review, the latest knowledge on truncal acne will be discussed.

Female Adult Acne and Androgen Excess: A Report From the Multidisciplinary Androgen Excess and PCOS Committee

In endocrine and reproductive endocrine literature, adult female acne is considered as a possible clinical expression of hyperandrogenism, with most polycystic ovary syndrome (PCOS) guidelines considering acne as a condition of androgen excess. Adult female acne, however, in the dermatological literature is considered as an inflammatory skin disease and new guidelines on adult female acne have been produced by dermatological societies, with little perspective from any endocrine or reproductive endocrine points of view. An expert task force was appointed by the AE-PCOS society to determine the current state of knowledge and provide evidence-based recommendations that could be valid for all specialists taking care of female adult acne. The following are the recommendations (level of evidence A or B): (1) diagnosis of female adult acne is mainly clinical, but a grading tool is needed for optimizing the treatment; (2) measurement of serum androgen values (total testosterone, free testosterone, and dehydroepiandrosterone sulfate) by high-quality assays is recommended in all women with adult acne; (3) in women with adult acne and proven hyperandrogenism, oral combined estroprogestins should be added to the topical or systemic treatment of acne, independently of severity of acne; (4) all second- and third-generation estroprogestins may be used, independently of the estrogen dose and progestin component; (5) spironolactone may be added to estroprogestins in women with moderate or severe hyperandrogenic adult acne, not responding to usual treatments; (6) estroprogestins may be used in nonhyperandrogenic patients with adult acne as second-line therapy.

Attention Mechanism Guided Deep Regression Model for Acne Severity Grading

Acne vulgaris is the common form of acne that primarily affects adolescents, characterised by an eruption of inflammatory and/or non-inflammatory skin lesions. Accurate evaluation and severity grading of acne play a significant role in precise treatment for patients. Manual acne examination is typically conducted by dermatologists through visual inspection of the patient skin and counting the number of acne lesions. However, this task costs time and requires excessive effort by dermatologists. This paper presents automated acne counting and severity grading method from facial images. To this end, we develop a multi-scale dilated fully convolutional regressor for density map generation integrated with an attention mechanism. The proposed fully convolutional regressor module adapts UNet with dilated convolution filters to systematically aggregate multi-scale contextual information for density maps generation. We incorporate an attention mechanism represented by prior knowledge of bounding boxes generated by Faster R-CNN into the regressor model. This attention mechanism guides the regressor model on where to look for the acne lesions by locating the most salient features related to the understudied acne lesions, therefore improving its robustness to diverse facial acne lesion distributions in sparse and dense regions. Finally, integrating over the generated density maps yields the count of acne lesions within an image, and subsequently the acne count indicates the level of acne severity. The obtained results demonstrate improved performance compared to the state-of-the-art methods in terms of regression and classification metrics. The developed computer-based diagnosis tool would greatly benefit and support automated acne lesion severity grading, significantly reducing the manual assessment and evaluation workload.

TRASS: a global approach to assess the severity of truncal acne

INTRODUCTION

Only a small amount of published data regarding truncal acne is available and no proper tool to assess its severity exists.

AIM

to provide dermatologists with an easy-to-use tool to assess truncal acne (TRASS, truncal acne severity scale) using a global approach.

METHODS

A scoring tool that assesses the severity of acne (based on GEA and ECLA scales) on the trunk using a global approach was built, including three subscores: family history, clinical signs and quality of life (QoL). In order to test TRASS, the experts used photos of 47 patients attending their clinics with truncal acne. The ROP (Regression OPtimized) model was applied to assess the diagnosis performance of TRASS and to identify items contributing to the classification of the patients. Internal testing was made to demonstrate the robustness of the model. Correlation analyses between the different items were performed to evaluate the interaction between the different items and their impact on the severity grading of truncal acne.

RESULTS

Patients with the most severe acne were identified by TRASS. The error level was 6.6% after internal validation and 10.4% when using the median value or the centile 75^th (6.6% and 10.4%). Correlation was significant between systemic treatment and scars (p=0.0025) and nodules (p=0.01988) and between location and QoL (p=0.0095).

CONCLUSION

TRASS is the first global, patient-centred approach to evaluate truncal acne by scoring the importance of each factor independently from its clinical severity. TRASS may allow the practitioner to choose and validate the most suitable therapy together with the patient in order to treat his or her truncal acne successfully and to limit treatment failure.

Guidance for the pharmacological management of acne vulgaris

INTRODUCTION

Many international guidelines and expert consensuses are available to help the clinician diagnose and treat acne vulgaris; however, a simplified practical guidance that integrates current existing published recommendations is still lacking. This article aims to give practical and simplified insight into the treatment of acne.

AREAS COVERED

Herein, the author discusses the treatment of comedonal, papulopustular, and nodular/cystic/conglobate acne. The author also proposes a simplified treatment escalation strategy that is based on disease severity and extension, starting with topical treatments for mild cases and progressing over to systemic therapies in more severe cases.

EXPERT OPINION

The ideal acne treatment would simultaneously and safely target all the pathogenic factors implicated in the appearance of acne lesions with minimal side effects. Since no such treatment currently exists, combination therapies are usually recommended for most types of acne. A major limitation in choosing an appropriate treatment plan is the discrepant use of classification systems across the published literature making it difficult to draw clear and succinct conclusions about the recommendations given. Acne is not a traditional infectious disease and so while antibiotics may improve symptoms, they do not reliably resolve the condition. Thus, there is currently a tendency to opt for antibiotic-sparing treatment strategies whenever possible.

Unexpected Effects of Oral Isotretinoin in Adolescents With Acne Vulgaris

Background This study aimed to assess the effects of isotretinoin treatment on hirsutism, menstrual cycle and hormonal response in adolescents with acne vulgaris (AV). Methods In the study, 76 participants with nodulocystic acne were included. Free testosterone (fT), total testosterone (tT), dehydroepiandrosterone sulfate (DHEAS), luteinizing hormone (LH), follicle-stimulating hormone (FSH), 17-OH progesterone (17-OH PG), and sex hormone-binding globulin (SHBG) levels of the participants were measured before and at the third and sixth months of treatment. Furthermore, the patients were evaluated for hirsutism and menstrual irregularity. Results The rates of menstrual irregularity and hirsutism at the beginning and at the third and sixth months of treatment were found to be different (p < 0.05). fT, tT and DHEAS levels at the third and sixth months of treatment were higher than those at the beginning of treatment, and the SHBG level at the sixth month was found to be lower than that at the beginning and third month of treatment (p < 0.05). The tT levels were found to be lower and DHEAS levels were higher than those at the beginning of treatment in patients who presented with menstrual irregularity at the third month of treatment (p < 0.05). The LH and 17-OH PG levels were noted to be lower and DHEAS levels were higher than those at the beginning of treatment in patients who developed hirsutism at the third month of treatment (p < 0.05). The SHBG levels were observed to be lower and DHEAS levels were higher than those before treatment in patients who developed menstrual irregularity at the sixth month of treatment (p < 0.05). SHBG levels were discerned to be lower and DHEAS levels were higher compared to those at the beginning of treatment in patients who developed hirsutism at the sixth month of the treatment (p < 0.05). Conclusions Isotretinoin can cause alterations in the adrenal hormone levels. Hirsutism and menstrual irregularity can be observed during treatment follow-ups.

Clascoterone cream (1%) topical androgen receptor inhibitor for the treatment of acne in patients 12 years and older

INTRODUCTION

The efficacy of clascoterone cream was demonstrated in two phase three vehicle-controlled clinical trials that enrolled over 1,400 subjects. Its safety profile allowed it to be approved for treating patients as young as 12 years old. During clinical trials, the occurrence of local skin reactions (edema, erythema, pruritus, dryness) was similar to treatment with vehicle alone.

AREAS COVERED

All publications describing the clinical development of clascoterone cream (cortexolone 17α-propionate) are reviewed and discussed in relation to with existing topical and systemic therapies for acne vulgaris.

EXPERT OPINION

Clascoterone 1% cream is a novel first-in-class topical androgen receptor inhibitor for the treatment of acne vulgaris. Topical clascoterone 1% cream represents the first new type of therapy for acne treatment in almost 40 years and may become first-line therapy.

The interplay of vitamin D and body mass index in acne patients vs. controls

BACKGROUND

Acne vulgaris is a disease of pilosebaceous units and manifests with polymorphic lesions. Vitamin D acts at various stages in its pathogenesis. Recently, vitamin D and metabolic syndrome have shown to be associated with acne vulgaris and its severity.

AIMS

To see the effects of serum 25(OH)D3 levels and body mass index on acne vulgaris and their correlation with the severity of acne.

PATIENTS/METHODS

Fifty patients of acne vulgaris and thirty age- and sex-matched healthy volunteers were recruited. Global Acne Grading System was used to grade the acne severity. Body mass index of all patients and control group was calculated, and serum levels of 25(OH)D3 were measured using chemiluminescence immunoassay.

RESULTS

Vitamin D deficiency was detected in 28% of patients with acne but only in 6.7% of the healthy controls (p value 0.022). However, there was no significant difference in mean serum 25(OH)D levels in acne patients and controls. Vitamin D deficiency was seen in 60% of the very severe and 33% of the severe acne cases. Eighty percent of patients with very severe acne and 73.33% of severe acne patients had high body mass index. The relationship between severity of acne and body mass index was statistically significant.

CONCLUSION

Vitamin D deficiency was more prevalent in acne, and with the increase in severity of acne, an inverse relation between serum levels of vitamin D and body mass index was seen, but statistically significant relation was found only in the very severe cases of acne vulgaris.

Correlation study between clinical classification and disability index in a holistic evaluation of acne severity and impact in Turkey

BACKGROUND

This study provides a comparison between disease severity observed by inspectors and the disease burden assessed by patients is scanty in acne study.

METHODS

In a multicenter prospective hospital-based study, modified Comprehensive Acne Severity Scale (mCASS) and Cardiff Acne Disability Index (CADI) were employed to grade disease severity and to determine the quality of life, respectively. The average of the mCASS and CADI scores, with range at 0-25, was termed as Acne Severity and Impact Grading System (ASIG).

RESULTS

In 1331 evaluated patients (mean: 21,51±4,93 years), including 306 men and 1025 women, an overall significant, positive correlation was found between ASIG and mCASS (r=0.862), or CADI (r=0.686), respectively (P=0.001 each). Adult women with back acne and adolescent with décolleté expressed greater concern (higher CADI) than the clinical severity (lower mCASS). The overall prevalence of acne in décolleté area, including neck, was 32.3%.

CONCLUSIONS

Discrepancies in the acne severity between self-perception and objective evaluation exist in certain subgroups of patients. Décolleté acne deserves special attention in clinical assessment.

Analysis of trends and status of physician-based evaluation methods in acne vulgaris from 2000 to 2019

Various evaluation methods for acne severity have been used without standardization, and the diversity of acne outcome measures is an obstacle to the integrated analysis of various acne studies. In this study, we sought to investigate physician-based evaluation methods used in clinical studies of acne vulgaris and to determine differences according to time, region and study design. PubMed was searched for articles on acne published from January 2000 to June 2019 in five dermatology journals: Journal of the American Academy of Dermatology, JAMA Dermatology, British Journal of Dermatology, Journal of the European Academy of Dermatology and Venereology and Acta Dermato-Venereologica. A total of 186 articles with acne evaluation methods were selected. Among the selected studies, region, study design, type of intervention and the number of subjects were identified and analyzed. Articles from 2010 to 2019 used Investigator Global Assessment (IGA; odds ratio [OR], 5.808; 95% CI, 1.894-17.811) more often and the Leeds technique (OR, 0.282; 95% CI, 0.098-0.812) less often compared with articles from 2000 to 2009. Controlled experimental studies preferred lesion counting (OR, 238.637; 95% CI, 46.795-1216.954), IGA (OR, 9.177; 95% CI, 3.053-27.586) and Leeds Revised Acne Grading System (LRAGS; OR, 10.844; 95% CI, 3.050-38.559) compared with observational studies. North American studies applied lesion counting (OR, 4.573; 95% CI, 1.173-17.836) and IGA (OR, 11.330; 95% CI, 3.487-36.818) more often and LRAGS (OR, 0.171; 95% CI, 0.039-0.758) less often compared with European studies. This study demonstrated the diversity and heterogeneity of acne outcome measures even in highly influential dermatology journals. This is due to the limitations of current methods and suggests the importance of developing a core outcome measure.

Steroid biomarkers for identifying non-classic adrenal hyperplasia due to 21-hydroxylase deficiency in a population of PCOS with suspicious levels of 17OH-progesterone

OBJECTIVE

We aimed at defining the most effective routine immunoassay- or liquid chromatography-tandem mass spectrometry (LC-MS/MS)-determined steroid biomarkers for identifying non-classic adrenal hyperplasia due to 21-hydroxylase deficiency (21-NCAH) in a PCOS-like population before genotyping.

METHODS

Seventy PCOS-like patients in reproductive age with immunoassay-determined follicular 17OH-progesterone (17OHP) ≥ 2.00 ng/mL underwent CYP21A2 gene analysis and _1-24ACTH test. Serum steroids were measured by immunoassays at baseline and 60 min after ACTH stimulation; basal steroid profile was measured by LC-MS/MS.

RESULTS

Genotyping revealed 23 21-NCAH, 15 single allele heterozygous CYP21A2 mutations (21-HTZ) and 32 PCOS patients displaying similar clinical and metabolic features. Immunoassays revealed higher baseline 17OHP and testosterone, and after ACTH stimulation, higher 17OHP (17OHP₆₀) and lower cortisol, whereas LC-MS/MS revealed higher 17OHP (17OHP_LC-MS/MS), progesterone and 21-deoxycortisol and lower corticosterone in 21-NCAH compared with both 21-HTZ and PCOS patients. Steroid thresholds best discriminating 21-NCAH from 21-HTZ and PCOS were estimated, and their diagnostic accuracy in identifying 21-NCAH from PCOS was established by ROC analysis. The highest accuracy was observed for 21-deoxycortisol ≥ 0.087 ng/mL, showing 100% sensitivity, while the combination of 17OHP_LC-MS/MS ≥ 1.79 ng/mL and corticosterone ≤ 8.76 ng/mL, as well as the combination of ACTH-stimulated 17OHP ≥ 6.77 ng/mL and cortisol ≤ 240 ng/mL by immunoassay, showed 100% specificity.

CONCLUSIONS

LC-MS/MS measurement of basal follicular 21-deoxycortisol, 17OHP and corticosterone seems the most convenient method for diagnosing 21-NCAH in a population of PCOS with a positive first level screening, providing high accuracy and reducing the need for ACTH stimulation test.

Development of an Illustrated Scale for Acute Radiation Dermatitis in Breast Cancer Patients

PURPOSE

Scales for rating acute radiation dermatitis (ARD) have not been validated despite decades of clinical use, and little is known regarding the relationship between toxicity scores and patient-reported symptoms. Skin tone also complicates assessment of ARD, and as such we sought to design an illustrated scale to consistently describe ARD across several skin tone types in breast cancer patients undergoing radiation (RT).

METHODS AND MATERIALS

Patients undergoing RT for breast cancer were enrolled on a prospective study with photographs obtained at 2-week intervals. Photographs were clustered according to the apparent severity of acute radiation dermatitis and a descriptive photonumeric scale was developed. Four clinically experienced raters used both the illustrated photonumeric scale and the Common Terminology Criteria for Adverse Events to independently score the collection of photographs in 2 independent sessions.

RESULTS

Among 80 unique patients with 192 photographs, 47 patients (59%) completed questionnaires about their symptoms during RT. Physicians completed toxicity forms at the point-of-care for 52 patients (65%). Photonumeric ratings compared against patient reports of dry and moist desquamation demonstrated high specificity (95% and 93%, respectively) and negative predictive value (84% and 92%), indicating correct identification of patients who did not report dry or moist desquamation. The sensitivity and positive predictive value for separate measures of dry and moist desquamation were considerably lower. A combined measure of any desquamation (dry or moist) portrayed higher diagnostic accuracy, resulting in 72% sensitivity, 93% specificity, 75% positive predictive value, and 92% negative predictive value. Photonumeric ratings of dry or moist desquamation were significantly associated with patient reports of itching, burning or stinging, hurting, and swelling.

CONCLUSIONS

The Michigan scale for acute radiation dermatitis is a simple grading rubric that is distinguished by characterization of its intra- and interrater reliability and diagnostic accuracy, correlation with patient-reported symptoms of bother and pain, and applicability across the spectrum of skin pigmentation.

Truncal acne, what do we know?

Truncal acne is frequently overlooked in dermatological practice, even though it may result in scars and impact on self-esteem and body image. Therefore, it is important to identify the disease early in order to initiate treatment in time and, thus, to prevent it from worsening and resulting in physical and psychological sequelae. The aim of this review is to provide an overview of what is currently known about truncal acne, its prevalence, aetiology and physiopathology, how its severity is currently evaluated, how to differentiate it from other skin afflictions and current treatment options. A review of literature considering the issue of truncal acne published up to 2019 and available from PubMed was conducted, and in total, 76 articles were selected from PubMed. Currently, only little information about truncal acne is available. Considered as having the same pathophysiology as facial acne, the clinical picture and treatment response seem to differ. Specific acne severity grading systems and quality of life questionnaires as well as a specific treatment algorithm are still lacking. Filling this gap should allow clinicians to assess truncal acne in the best possible way, choosing suitable treatment options, helping patients to improve treatment adherence and quality of life and finally allowing a better management of truncal acne. In conclusion, more knowledge is required to treat more efficiently truncal acne.

Efficacy and Safety of VB-1953 Topical Gel in Non-Responder Acne Patients with Clindamycin-Resistant Cutibacterium acnes

BACKGROUND AND OBJECTIVES

The emergence of resistant strains of Cutibacterium acnes can limit the efficacy of currently approved antibiotics for acne. VB-1953 is a next-generation antibiotic that exerts a bactericidal effect on resistant C. acnes. In this study, we investigated the safety, tolerability, and efficacy of VB-1953 topical gel in patients with moderate to severe acne having clindamycin-resistant C. acnes.

METHODS

An investigator-initiated, open label, single-arm clinical study was conducted in patients with moderate to severe facial acne vulgaris showing poor or no response to previous clindamycin treatment. Nineteen subjects were enrolled in the study based on laboratory screening for the presence of clindamycin-resistant C. acnes in acne swab samples collected from patients. VB-1953 2% gel was applied on the entire face twice daily over 12 weeks. The primary efficacy endpoints were absolute changes in inflammatory and noninflammatory lesion counts from baseline at week 12, while the secondary efficacy endpoint was the proportion of subjects achieving Investigator Global Assessment success (score of 0 or 1) or a grade 2 or higher improvement from baseline at week 12. The presence and severity of local skin reactions (erythema, edema, scaling/dryness, burning/stinging, pruritus) were evaluated for safety. Additionally, the detection and quantification of drug-resistant C. acnes strains were performed in the laboratory using acne swab samples collected from patients.

RESULTS

The occurrence of treatment-emergent adverse events or changes in vital signs, physical examinations, and urinalysis for any of the patients during the course of the entire study were clinically insignificant. Topical application of 2% VB-1953 topical gel resulted in a significant reduction of mean absolute inflammatory and noninflammatory lesion counts by 53.1% and 52.2%, respectively (p < 0.0001 for both), with an Investigator Global Assessment success of 26.3% at week 12 compared with baseline. Resistant bacteria were reduced by (94.3 ± 1%; p < 0.05) within 12 weeks of treatment with VB-1953.

CONCLUSION

These results indicate that VB-1953 topical gel can be a safe and effective therapy for moderate to severe acne with underlying resistant C. acnes in subjects who had not responded to previous antibiotic treatments.

Acne and the Lesbian, Gay, Bisexual, or Transgender Teenager

Although most teenagers experience acne, for sexual and gender minority teenagers, acne could be more challenging and require specific psychosocial considerations. Acne may be more strongly associated with mental health issues in sexual and gender minority adolescents. Acne development during puberty may trigger gender dysphoria in transgender patients. Transgender and gender nonbinary patients receiving testosterone therapy may experience new or worsening acne. Comprehensive care for moderate to severe acne in sexual and gender minority adolescents should include culturally competent discussions about sexual behaviors, contraception, and/or gender-affirmation treatment plans.

Relationship between Hand Eczema Severity and Occupational Stress: A Cross-Sectional Study

Background

Stress has been recently implicated as a contributing factor of hand eczema (HE) severity. However, published data are both rare and contradictory justifying the need of further research. The purpose of this study was to evaluate the relation between stress and HE severity.

Methods

This is a cross-sectional study enrolling all patients who have been attending the Dermato-allergology unit of Farhat Hached University Hospital of Sousse over a period of one year. The HE severity was assessed by the Osnabrück Hand Eczema Severity Index (OHSI). The stress level was assessed by the Perceived Stress Scale-10 (PSS-10) in its validated Arabic version.

Results

During the study period, 109 participants meeting the inclusion criteria were identified. The mean age was 40 ± 9.9 years with a sex-ratio of 0.8. Severe eczema was found in 76 participants (69.7%). A high level of perceived stress was found in 18.3% of cases. A statistically significant association was noted between HE severity and the high level of perceived stress (p=0.039, OR = 4.46, 95% CI [0.96–20.59]) and the number of dependent children ≥3 (p=0.0039, OR = 1.92, 95% CI [0.51–7.22]). Leisure activity was found to be a protective factor against HE severity (p=0.031, OR = 0.27, 95% CI [0.09–0.80]).

Conclusion

Although the link between the severity of eczema and atopy, wet work, and contact with irritants and allergens is well known, the relation remains questionable for other factors including stress.

Occasional acne; an acne variant

This article is about a common skin eruption that dermatologists face regularly in their clinics. It is a form of acne that patients frequently refer to as nightshifts acne, stress acne or airplane acne (after experiencing a prior occasion that might aggravate it). Physical or psychological stress is not the only causative factor, therefore we took into consideration of naming it based on its presentation irrespectively of the skin proneness to acne and self-limiting tendency, we name the entity as "occasional acne". This article will discuss the similarities and differences between this entity and other forms of acne, as well as different causative factors that are involved in the eruption. These factors vary individually whether single or multiple factors might provoke it; maladaptation driven by mental and/or physical stress, temporary imbalance of sebum lipids and nicotine effect, etc.

Oral isotretinoin for acne

BACKGROUND

Acne vulgaris, a chronic inflammatory disease of the pilosebaceous unit associated with socialisation and mental health problems, may affect more than 80% of teenagers. Isotretinoin is the only drug that targets all primary causal factors of acne; however, it may cause adverse effects.

OBJECTIVES

To assess efficacy and safety of oral isotretinoin for acne vulgaris.

SEARCH METHODS

We searched the following databases up to July 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO and LILACS. We updated this search in March 2018, but these results have not yet been incorporated in the review. We also searched five trial registries, checked the reference lists of retrieved studies for further references to relevant trials, and handsearched dermatology conference proceedings. A separate search for adverse effects of oral isotretinoin was undertaken in MEDLINE and Embase up to September 2013.

SELECTION CRITERIA

Randomised clinical trials (RCTs) of oral isotretinoin in participants with clinically diagnosed acne compared against placebo, any other systemic or topical active therapy, and itself in different formulation, doses, regimens, or course duration.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 31 RCTs, involving 3836 participants (12 to 55 years) with mild to severe acne. There were twice as many male participants as females.Most studies were undertaken in Asia, Europe, and North America. Outcomes were generally measured between eight to 32 weeks (mean 19.7 weeks) of therapy.Assessed comparisons included oral isotretinoin versus placebo or other treatments such as antibiotics. In addition, different doses, regimens, or formulations of oral isotretinoin were assessed, as well as oral isotretinoin with the addition of topical agents.Pharmaceutical companies funded 12 included trials. All, except three studies, had high risk of bias in at least one domain.Oral isotretinoin compared with oral antibiotics plus topical agentsThese studies included participants with moderate or severe acne and assessed outcomes immediately after 20 to 24 weeks of treatment (short-term). Three studies (400 participants) showed isotretinoin makes no difference in terms of decreasing trial investigator-assessed inflammatory lesion count (RR 1.01 95% CI 0.96 to 1.06), with only one serious adverse effect found, which was Stevens-Johnson syndrome in the isotretinoin group (RR 3.00, 95% CI 0.12 to 72.98). However, we are uncertain about these results as they were based on very low-quality evidence.Isotretinoin may slightly improve (by 15%) acne severity, assessed by physician's global evaluation (RR 1.15, 95% CI 1.00 to 1.32; 351 participants; 2 studies), but resulted in more less serious adverse effects (67% higher risk) (RR 1.67, 95% CI 1.42 to 1.98; 351 participants; 2 studies), such as dry lips/skin, cheilitis, vomiting, nausea (both outcomes, low-quality evidence).Different doses/therapeutic regimens of oral isotretinoinFor our primary efficacy outcome, we found three RCTs, but heterogeneity precluded meta-analysis. One study (154 participants) reported 79%, 80% and 84% decrease in total inflammatory lesion count after 20 weeks of 0.05, 0.1, or 0.2 mg/kg/d of oral isotretinoin for severe acne (low-quality evidence). Another trial (150 participants, severe acne) compared 0.1, 0.5, and 1 mg/kg/d oral isotretinoin for 20 weeks and, respectively, 58%, 80% and 90% of participants achieved 95% decrease in total inflammatory lesion count. One RCT, of participants with moderate acne, compared isotretinoin for 24 weeks at (a) continuous low dose (0.25 to 0.4 mg/kg/day), (b) continuous conventional dose (0.5 to 0.7 mg/kg/day), and (c) intermittent regimen (0.5 to 0.7 mg/kg/day, for one week in a month). Continuous low dose (MD 3.72 lesions; 95% CI 2.13 to 5.31; 40 participants; one study) and conventional dose (MD 3.87 lesions; 95% CI 2.31 to 5.43; 40 participants; one study) had a greater decrease in inflammatory lesion counts compared to intermittent treatment (all outcomes, low-quality evidence).Fourteen RCTs (906 participants, severe and moderate acne) reported that no serious adverse events were observed when comparing different doses/therapeutic regimens of oral isotretinoin during treatment (from 12 to 32 weeks) or follow-up after end of treatment (up to 48 weeks). Thirteen RCTs (858 participants) analysed frequency of less serious adverse effects, which included skin dryness, hair loss, and itching, but heterogeneity regarding the assessment of the outcome precluded data pooling; hence, there is uncertainty about the results (low- to very-low quality evidence, where assessed).Improvement in acne severity, assessed by physician's global evaluation, was not measured for this comparison.None of the included RCTs reported birth defects.

AUTHORS' CONCLUSIONS

Evidence was low-quality for most assessed outcomes.We are unsure if isotretinoin improves acne severity compared with standard oral antibiotic and topical treatment when assessed by a decrease in total inflammatory lesion count, but it may slightly improve physician-assessed acne severity. Only one serious adverse event was reported in the isotretinoin group, which means we are uncertain of the risk of serious adverse effects; however, isotretinoin may result in more minor adverse effects.Heterogeneity in the studies comparing different regimens, doses, or formulations of oral isotretinoin meant we were unable to undertake meta-analysis. Daily treatment may be more effective than treatment for one week each month. None of the studies in this comparison reported serious adverse effects, or measured improvement in acne severity assessed by physician's global evaluation. We are uncertain if there is a difference in number of minor adverse effects, such as skin dryness, between doses/regimens.Evidence quality was lessened due to imprecision and attrition bias. Further studies should ensure clearly reported long- and short-term standardised assessment of improvement in total inflammatory lesion counts, participant-reported outcomes, and full safety accounts. Oral isotretinoin for acne that has not responded to oral antibiotics plus topical agents needs further assessment, as well as different dose/regimens of oral isotretinoin in acne of all severities.

Acne: a side-effect of masculinizing hormonal therapy in transgender patients

BACKGROUND

Masculinizing hormonal treatment in transgender men has the potential to increase the level of androgens at end organs, including the pilosebaceous unit. Androgen-induced sebocyte growth and differentiation, sebum production and infundibular keratinization may underlie the development of acne vulgaris among patients receiving this therapy.

OBJECTIVES

The aim of this article is to familiarize dermatologists with the sensitivities and challenges of treating acne in transgender male individuals.

METHODS

This review article discusses the pathogenesis and treatment of acne in transgender men on testosterone therapy and highlights the unique considerations in treating this underserved patient population.

RESULTS

Despite the incidence of treatment-related acne and the unique considerations in treating transgender men, studies addressing this topic among this patient population are limited.

CONCLUSIONS

Generally, the standard guidelines for the treatment of acne can be followed in treating these patients; however, several medical, social and psychological factors should be considered.

Comparison of the Efficacy of Azithromycin Versus Doxycycline in Acne Vulgaris: A Meta-Analysis of Randomized Controlled Trials

Background

Acne vulgaris is one of the most common disorders of the pilosebaceous unit. Although doxycycline is considered to be a first-line anti-acne antibiotic, various other antibiotics have been tried due to its adverse effects and contraindications. We performed a meta-analysis of randomized controlled trials (RCTs) that compared the efficacy of oral azithromycin pulse therapy with that of oral daily doxycycline in the management of moderate to severe acne vulgaris.

Methods

Five scientific databases (MEDLINE, EMBASE, Cochrane Library, SCOPUS, and Web of Science) were searched to identify relevant studies. A review of 1,341 publications produced six RCTs that met our predefined inclusion criteria. The clinical outcome measures were remaining acne lesion counts, patients' self-assessment of treatment, and the investigators' assessment of treatment after 12 weeks.

Results

We included six studies assessing 906 patients with moderate to severe acne vulgaris. Meta-analyses of clinical outcome measures revealed no significant difference between the two groups regarding remaining acne lesion counts (p=0.27), patients' self-assessment of treatment (p=0.67), and the investigators' assessment of treatment (p=0.32). The incidence of severe adverse events leading to the discontinuation of therapy was higher in the doxycycline daily therapy group when compared with the azithromycin pulse therapy group.

Conclusion

This study indicates that azithromycin pulse therapy is equivalent to doxycycline at 12 weeks in the efficacy of the treatment for moderate to severe acne vulgaris Therefore, oral azithromycin pulse therapy may be a good alternative to doxycycline in the management of acne for those unable to tolerate doxycycline.

Salivary cortisol and cortisone responses to short-term psychological stress challenge in late adolescent and young women with different hyperandrogenic states

Hyperandrogenic disorders have been associated with psychological distress, reduced quality of life, anxiety and depression. The hypothalamic-pituitary-adrenal (HPA) axis plays a pivotal role in the adaptive response to stressor events. Salivary cortisol (SalF) and cortisone (SalE) testing have been proven to be useful in the evaluation of HPA-axis activity. This study investigated whether SalF and SalE responses to two putative stressor levels differed between the hyperandrogenic states in late adolescent and young women, thus measuring the HPA-axis adaptive response to acute stress events. We selected 161 drug-free females aged 16-19 years from a large population previously enrolled in a cross-sectional epidemiological study. Saliva was collected in the morning before and after two putative stressor events consisting in a self-filled questionnaire (weaker stressor) and in a structured interview plus physical examination by an endocrinologist (stronger stressor). SalF and SalE, as well as blood steroids, were assessed by liquid chromatography-tandem mass spectrometry. Subjects were subdivided into different groups according to the presence of: isolated menstrual irregularities (MI, oligo-amenorrhea; n = 22), isolated hirsutism (HIR, modified Ferriman-Gallwey score ≥ 8; n = 26), isolated hyperandrogenaemia (HT, testosterone >0.438 ng/mL; n = 14), and polycystic ovary syndrome (PCOS, MI with HIR and/or HT, n = 16). The remaining 83 apparently healthy subjects were used as controls. SalF and SalE significantly decreased after the weaker stressor, following the physiologic diurnal loss, in all the groups except for isolated HIR, where they remained unchanged (P = 0.091 and P = 0.118, respectively). In contrast, SalF and SalE remained unchanged after the stronger stressor in isolated MI, isolated HT and controls, whereas SalF increased significantly in isolated HIR (P = 0.011), and SalE increased significantly both in isolated HIR (P = 0.005) and in PCOS (P = 0.011) groups. SalF percentage variation in response to the stronger stressor was positively associated with systolic blood pressure in PCOS (P = 0.018), and both SalF and SalE percentage variations were positively associated with diastolic blood pressure in the isolated HIR group (P = 0.010 and P = 0.006, respectively). In addition, in the isolated HIR group, the SalF percentage variation was negatively associated with HDL cholesterol levels (P = 0.005). Finally, SalF and SalE percentage variations were positively associated with circulating androstenedione (P = 0.031 and P = 0.011, respectively) and DHEA (P = 0.020 and P = 0.003, respectively) in the isolated HIR group. In conclusion, this study demonstrates that hirsute and PCOS adolescent and young women are characterized by HPA-axis overactivity in response to stressful stimuli, as detectable by salivary glucocorticoid measurements. These data also indicate that the higher the HPA-axis activity, the higher the adrenal androgen output and the worse the metabolic profile.

A review of diagnosis and treatment of acne in adult female patients

This review focuses on the treatment options for adult female patients with acne. Acne in adult female patients may start during adolescence and persist or have an onset in adulthood. Acne has various psychosocial effects that impact patients’ quality of life. Treatment of acne in adult women specifically has its challenges due to the considerations of patient preferences, pregnancy, and lactation. Treatments vary widely and treatment should be tailored specifically for each individual woman. We review conventional therapies with high levels of evidence, additional treatments with support from cohort studies and case reports, complementary and/or alternative therapies, and new agents under development for the treatment of patients with acne.

Laser treatments of active acne

The utility of laser therapy is increasingly being recognized in the treatment of active acne vulgaris. We aimed to perform a narrative review of the medical literature on the use of laser therapy for the treatment of active acne vulgaris. We performed a PubMed literature search on September 1, 2016 using the search terms "active acne," "acne," "laser therapy," and "laser surgery." Case reports, case series, cohort, and controlled trials were included. Studies of lasers in the treatment of acne, including erbium glass, Nd:YAG, pulse dye laser (PDL), potassium titanyl phosphate (KTP) laser, and laser-based photodynamic therapy, have been published. While treatment of active acne with lasers has been successful, many studies are limited by small patient number and lack of control populations and comparison to standard therapies for active acne. Laser therapies are increasingly becoming part of or an adjunct to the medical treatment of active acne and are a useful treatment modality.

A comparative study of Cutibacterium (Propionibacterium) acnes clones from acne patients and healthy controls

BACKGROUND

Cutibacterium (Propionibacterium) acnes is assumed to play an important role in the pathogenesis of acne.

OBJECTIVES

To examine if clones with distinct virulence properties are associated with acne.

METHODS

Multiple C. acnes isolates from follicles and surface skin of patients with moderate to severe acne and healthy controls were characterized by multilocus sequence typing. To determine if CC18 isolates from acne patients differ from those of controls in the possession of virulence genes or lack of genes conducive to a harmonious coexistence the full genomes of dominating CC18 follicular clones from six patients and five controls were sequenced.

RESULTS

Individuals carried one to ten clones simultaneously. The dominating C. acnes clones in follicles from acne patients were exclusively from the phylogenetic clade I-1a and all belonged to clonal complex CC18 with the exception of one patient dominated by the worldwide-disseminated and often antibiotic resistant clone ST3. The clonal composition of healthy follicles showed a more heterogeneous pattern with follicles dominated by clones representing the phylogenetic clades I-1a, I-1b, I-2 and II. Comparison of follicular CC18 gene contents, allelic versions of putative virulence genes and their promoter regions, and 54 variable-length intragenic and inter-genic homopolymeric tracts showed extensive conservation and no difference associated with the clinical origin of isolates.

CONCLUSIONS

The study supports that C. acnes strains from clonal complex CC18 and the often antibiotic resistant clone ST3 are associated with acne and suggests that susceptibility of the host rather than differences within these clones may determine the clinical outcome of colonization.

Oral Spironolactone for Acne Vulgaris in Adult Females: A Hybrid Systematic Review

BACKGROUND

The management of acne in adult females is problematic, with many having a history of treatment failure and some having a predisposition to androgen excess. Alternatives to oral antibiotics and combined oral contraceptives (COCs) are required.

OBJECTIVE

Our aim was to conduct a hybrid systematic review of the evidence for benefits and potential harms of oral spironolactone in the management of acne in adult females.

METHODS

The review was conducted according to a previously published protocol. Three reviewers independently selected relevant studies from the search results, extracted data, assessed the risk of bias, and rated the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Ten randomized controlled trials (RCTs) and 21 case series were retrieved. All trials were assessed as being at a 'high risk' of bias, and the quality of evidence was rated as low or very low for all outcomes. Apart from one crossover trial that demonstrated statistical superiority of a 200 mg daily dose versus inflamed lesions compared with placebo, data from the remaining trials were unhelpful in establishing the degree of efficacy of lower doses versus active comparators or placebo. Menstrual side effects were significantly more common with the 200 mg dose; frequency could be significantly reduced by concomitant use of a COC. Pooling of results for serum potassium supported the recent recommendation that routine monitoring is not required in this patient population.

CONCLUSION

This systematic review of RCTs and case series identified evidence of limited quality to underpin the expert endorsement of spironolactone at the doses typically used (≤100 mg/day) in everyday clinical practice.

Reliability of Dermatologists in Acne Lesion Counts and Global Assessments

Background:

There is a paucity of data on the reliability of dermatologists in acne lesion counting and global severity assessments. The effects of training and practice on reliability are also uncertain. The objective of this study was to determine the reliability of these outcome measurements when performed by trained dermatologists.

Methods:

Eleven dermatologists were divided into two groups that evaluated the same six acne subjects twice on the same day. A training session was provided either after (group A) or before (group B) the first patient evaluation sessions. Reliability of raters in lesion counting and global severity assessment was determined by calculation of intraclass correlation coefficients (ICCs). ICC values close to 1.0 indicate excellent reliability, whereas values less than 0.75 are considered unacceptable.

Results:

Intrarater ICCs ranged from 0.37 to 0.99 for noninflammatory lesions, 0.26 to 0.97 for inflammatory lesions, and 0.56 to 0.83 for global assessments for group A (trained after); corresponding values for group B (trained before) were 0.84 to 0.98, 0.61 to 0.95, and 0.43 to 0.91. ICC values ≥ 0.75 for all three outcome parameters were observed in one of six group A and three of five group B raters. Interrater ICCs for groups A and B after the first evaluation session were 0.17 versus 0.68 for noninflammatory counts, 0.84 versus 0.72 for inflammatory counts, and 0.71 versus 0.65 for global assessments, respectively. Corresponding values after session 2 were 0.79 and 0.77 for noninflammatory, 0.81 and 0.90 for inflammatory, and 0.61 and 0.77 for global assessments.

Conclusion:

Dermatologists tended to be reliable in acne lesion counting but somewhat less so in global assessments. Training tended to improve group reliability in noninflammatory lesion counts and increased the proportion of raters with good reliability in all three outcome measures. Practice enhanced reliability in all outcome measurements.

WITHDRAWN: Laser resurfacing for facial acne scars

This review has been withdrawn as it has been updated by way of a new protocol and then a review, as the scope of the review has substantially expanded. The citation for the new updated review is as follows: Abdel Hay R, Shalaby K, Zaher H, Hafez V, Chi CC, Dimitri S, Nabhan AF, Layton AM. Interventions for acne scars. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD011946. DOI: 10.1002/14651858.CD011946.pub2.

The editorial group responsible for this previously published document have withdrawn it from publication.

Quality of life, self-esteem and psychosocial factors in adolescents with acne vulgaris

Background

Dermatological diseases, among which acne vulgaris, have psychological impact on the affected generating feelings of guilt, shame and social isolation.

Objectives

To compare quality of life, self-esteem and other psychosocial variables amongst adolescents with and without acne vulgaris, and between levels of severity.

Methods

Cross-sectional observational study in a sample of 355 high school students from the city of João Pessoa. Data collection was performed with questionnaires and clinical-dermatological evaluation. The primary variables were the incidence of AV; quality of life, set by the Children's Dermatology Quality of Life Index and Dermatology Quality of Life Index; and self-esteem, measured by the Rosenberg Self-Esteem Scale. For calculation of statistical tests, we used the SPSS 20.0 software, considering p=0.05.

Results

The sample, with an average age of 16, showed 89.3% prevalence of acne vulgaris. The most prevalent psychosocial issue was "afraid that acne will never cease", present in 58% of affected youth. The median score of Quality of Life in Children's Dermatology Index was different amongst students with and without acne vulgaris (p=0.003), as well as the Quality of Life in Dermatology (p=0.038) scores, so that students with acne vulgaris have worse QoL. There was a correlation between the severity of acne vulgaris and worse quality of life. Self-esteem was not significantly associated with the occurrence or severity of acne vulgaris.

Conclusions

acne vulgaris assumes significance in view of its high prevalence and the effect on quality of life of adolescents, more severe at the more pronounced stages of disease (p<0.001). The psychosocial impact of acne vulgaris should be valued in the management of patients with this condition.

Guidelines of care for the management of acne vulgaris

Acne is one of the most common disorders treated by dermatologists and other health care providers. While it most often affects adolescents, it is not uncommon in adults and can also be seen in children. This evidence-based guideline addresses important clinical questions that arise in its management. Issues from grading of acne to the topical and systemic management of the disease are reviewed. Suggestions on use are provided based on available evidence.

Acne vulgaris

Acne vulgaris is a chronic inflammatory disease - rather than a natural part of the life cycle as colloquially viewed - of the pilosebaceous unit (comprising the hair follicle, hair shaft and sebaceous gland) and is among the most common dermatological conditions worldwide. Some of the key mechanisms involved in the development of acne include disturbed sebaceous gland activity associated with hyperseborrhoea (that is, increased sebum production) and alterations in sebum fatty acid composition, dysregulation of the hormone microenvironment, interaction with neuropeptides, follicular hyperkeratinization, induction of inflammation and dysfunction of the innate and adaptive immunity. Grading of acne involves lesion counting and photographic methods. However, there is a lack of consensus on the exact grading criteria, which hampers the conduction and comparison of randomized controlled clinical trials evaluating treatments. Prevention of acne relies on the successful management of modifiable risk factors, such as underlying systemic diseases and lifestyle factors. Several treatments are available, but guidelines suffer from a lack of data to make evidence-based recommendations. In addition, the complex combination treatment regimens required to target different aspects of acne pathophysiology lead to poor adherence, which undermines treatment success. Acne commonly causes scarring and reduces the quality of life of patients. New treatment options with a shift towards targeting the early processes involved in acne development instead of suppressing the effects of end products will enhance our ability to improve the outcomes for patients with acne.

A randomized controlled study for the treatment of acne vulgaris using high-intensity 414 nm solid state diode arrays

The treatment of acne vulgaris poses a challenge to the dermatologist, and the disease causes emotional anxiety for the patient. The treatment of acne vulgaris may be well-suited to home-use applications, where sufferers may be too embarrassed to seek medical treatment. This randomized controlled study is designed to quantify the effectiveness of using a blue light device in a therapy combined with proprietary creams, in the investigation of a self-treatment regimen. A total of 41 adults with mild-to-moderate facial inflammatory acne were recruited. The subjects were randomly assigned to combination blue light therapy (n = 26) or control (n = 15). Photography was used for qualitative assessment of lesion counts, at weeks 1, 2, 4, 8, and 12. All subjects in the treatment cohort achieved a reduction in their inflammatory lesion counts after 12 weeks. The mean inflammatory lesion counts reduced by 50.02% in the treatment cohort, and increased by 2.45% in the control cohort. The reduction in inflammatory lesions was typically observable at week-3, and maximal between weeks 8 and 12. The treatment is free of pain and side-effects. The blue light device offers a valuable alternative to antibiotics and potentially irritating topical treatments. Blue light phototherapy, using a narrow-band LED light source, appears to be a safe and effective additional therapy for mild to moderate acne.

Comparative study of the effect of 50% pyruvic and 30% salicylic peels on the skin lipid film in patients with acne vulgaris

Pyruvic (alfa-keto acid) and salicylic (beta-hydroxy acid) acids are superficial peels frequently used in patients with acne vulgaris.

AIM

The aim of the study was to compare the effect of 50% pyruvic and 30% salicylic peels on facial sebum secretion in patients with acne vulgaris, aged 13-30.

MATERIAL AND METHODS

The level of secreted sebum was determined in 20 men and women. Ten patients were treated with 50% pyruvic acid and the remaining 10 with 30% salicylic acid. Each peel was applied five times at 2-week intervals. The sebum measurements were taken in the T- and U-zones using a Sebumeter SM 815 (Courage & Khazaka, Germany). The last, sixth measurement was taken 2 weeks after the treatment.

RESULTS

A statistically significant decrease in the level of secreted sebum in both U- and T- zones was observed in the patients studied after the third application of 50% pyruvic peel and the second application of 30% salicylic peel. Two weeks following the completion of therapy, sebumetric measurements demonstrated a greater reduction in the facial skin lipid film among the patients treated with salicylic peel.

CONCLUSIONS

Peels with 50% pyruvic acid and 30% salicylic acid are the procedures that significantly contributed to a decrease in the level of secreted sebum on the facial skin surface in the group of patients studied. A greater therapeutic effect was observed following 30% salicylic peel, which might be associated with its high lipophilic properties and easier penetration through the lipid barriers of the epidermis.

Clinical Evaluation of Behçet's Disease: A Five Year Follow-Up Study

The frequencies of clinical features of Behçet's disease vary in different studies according to the diagnostic criteria used in the study, the department where the study is done, and the ethnic origin of patients included in the study. In this study, we aimed to evaluate the influence of the length of the follow-up period of patients on the frequencies of clinical features of Behçet's disease. Out of 231 patients who applied to our dermatology clinic from June of 1991 to October of 1996, only 52 patients that were followed up for at least five years were included in this retrospective study. The baseline characteristics of these 52 patients were almost the same as those of the 179 patients who dropped out. Almost all of the frequencies of clinical features at the end of the follow-up period of five years were higher than those at the time of presentation. The most prominent increases were observed for erythema nodosum (59.6% to 75.0%), papulopustular lesions (84.6% to 94.2%), and large vessel involvement (23.1% to 30.8%). According to our results, it is most likely that studies mainly including mostly patients with long-standing disease will report higher figures for the frequencies of these clinical features of Behçet's disease.