Acne vulgaris--its aetiology and treatment. A review

Prevalence and risk factors for chalazion in an older veteran population

BACKGROUND

Chalazia are common inflammatory eyelid lesions, but their epidemiology remains understudied. This retrospective case-control study examined the prevalence, risk factors and geographic distribution of chalazia in a large veteran population.

METHODS

Data on all individuals seen at a Veterans Affairs (VA) clinic between October 2010 and October 2015 were extracted from the VA health database. Subjects were grouped based on International Classification of Diseases, Ninth Revision (ICD-9) code for chalazion. Univariable logistic regression modelling was used to identify clinical and demographic factors associated with chalazion presence, followed by multivariable modelling to examine which factors predicted risk concomitantly. All cases were mapped across the continental US using geographic information systems modelling to examine how prevalence rates varied geographically.

RESULTS

Overall, 208 720 of 3 453 944 (6.04%) subjects were diagnosed with chalazion during the study period. Prevalence was highest in coastal regions. The mean age of the population was 69.32±13.9 years and most patients were male (93.47%), white (77.13%) and non-Hispanic (93.72%). Factors associated with chalazion risk included smoking (OR=1.12, p<0.0005), conditions of the tear film (blepharitis (OR=4.84, p<0.0005), conjunctivitis (OR=2.78, p<0.0005), dry eye (OR=3.0, p<0.0005)), conditions affecting periocular skin (eyelid dermatitis (OR=2.95, p<0.0005), rosacea (OR=2.50, p<0.0005)), allergic conditions (history of allergies (OR=1.56, p<0.0005)) and systemic disorders (gastritis (OR=1.54, p<0.0005), irritable bowel syndrome (OR=1.45, p<0.0005), depression (OR=1.35, p<0.0005), anxiety (OR=1.31, p<0.0005)). These factors remained associated with chalazion risk when examined concomitantly.

CONCLUSION

Periocular skin, eyelid margin and tear film abnormalities were most strongly associated with risk for chalazion. The impact of environmental conditions on risk for chalazion represents an area in need of further study.

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.

Clinical Pharmacokinetics, Safety and Exploratory Efficacy Study of a Topical Bactericidal VB-1953: Analysis of Single and Multiple Doses in a Phase I Trial in Acne Vulgaris Subjects

BACKGROUND AND OBJECTIVE

Cutibacterium acnes is a key pathogenic factor in the development of acne vulgaris. Topical and oral antibiotics play a pivotal role in effective management of the disease. The emergence of resistance to the currently available antibiotics poses a serious set-back to this algorithm, and the reduced arsenal can diminish the efficacy of treatment. A novel formulation of VB-1953 (2%) topical gel has been developed with dual mechanism of action and bactericidal activity, unlike the currently approved antibiotics, which are bacteriostatic agents, targeting acne vulgaris. The objective was to check the clinical pharmacokinetics, safety and tolerability of single and multiple doses of VB-1953 in adult subjects with facial acne vulgaris, when applied twice daily (every 12 h) for about 15 days starting from Day 1, morning dose until Day 15, morning dose.

METHODS

This was a Phase 1 open-label study of VB-1953 for evaluation of pharmacokinetics, safety, tolerability and exploratory efficacy in otherwise healthy adult patients with moderate-to-severe facial acne vulgaris. The 12 subjects (aged 18-45 years) enrolled for the study applied VB-1953 (2%) gel twice daily for 15 days on the entire face every 12 h starting from Day 1 morning to Day 15 morning. Pharmacokinetic assessment was evaluated by sequential blood collection and safety was measured by assessments of local skin reactions (LSRs).

RESULTS

Plasma concentrations of VB-1953 indicate a low systemic exposure. By Day 2, steady-state was achieved and by Day 15 maximum plasma concentration (C_max) was 0.4640 ng/mL indicating about twofold increase upon multiple dosing. Changes in safety parameters (vital signs, electrocardiogram, physical examinations, hematology, chemistry, urinalysis) were clinically insignificant.

CONCLUSION

VB-1953 topical gel appears to be safe for use in adults with facial acne vulgaris and may offer new advances as a topical antibiotic agent for the disease.

A Rationally Designed Multifunctional Antibiotic for the Treatment of Drug-Resistant Acne

Acne is a multifactorial skin disease, underpinned by colonization of Propionibacterium acnes and inflammation. The emergence of resistant P. acnes strains has affected the current acne treatment algorithm. This setback served as an impetus for rationally designing a library of next-generation antibiotics that exhibit a bactericidal effect on resistant P. acnes and exert an immunomodulatory function to reduce inflammation. In silico screening showed that one of the molecules, VCD-004, exhibits improved mode of binding to bacterial DNA gyrase. VCD-004 shows high potency against clinical isolates of resistant P. acnes and excellent efficacy in vivo. Furthermore, VCD-004 exhibits a superior mutant prevention index, suggesting that it impedes the development of resistance better than clindamycin. Additionally, it shows optimal skin penetration and has a potent anti-inflammatory effect via reduction of proinflammatory cytokines (IL-6) independent of its antibacterial action. VCD-004 affects P. acnes-induced nuclear accumulation of NF-κB in THP-1 cells. The in vitro viability of human keratinocytes in the presence of VCD-004 indicates a desirable therapeutic window for topical use. Such rationally designed bactericidal and immunomodulatory dual pharmacophore-based lipophilic molecule(s) can emerge as the next-generation topical therapy for acne with underlying resistant P. acnes etiology.

A review on the treatment of acne vulgaris

The following article reviews treatment for acne vulgaris. Selection of therapy should be based on clinical appearance taking into account lesion type and severity, as well as identification of acne scarring and the psychosocial disability caused by the disease.

Guidelines for the management of acne vulgaris in adolescents

This article reviews the treatment of acne in adolescents. The choice of therapy should be principally based on the type of lesion and the severity of the acne, but psychosocial disability relating to the disease and the presence of scarring may also influence the approach to treatment.Mild acne generally requires topical treatment only. Benzoyl peroxide, azelaic acid, and antibacterials are generally used for inflammatory lesions. Topical retinoids are particularly effective for noninflamed lesions, and combination therapies are useful for mixed lesions. Moderately severe acne generally requires oral antibacterials. Tetracyclines/oxytetracycline and erythromycin are usually the first-line antibacterials. Second-generation tetracyclines, such as lymecycline, doxycycline, and minocycline, show improved absorption. Minocycline has the advantage of being rarely associated with Propionibacterium acnes antibacterial resistance, but can occasionally lead to potentially serious adverse effects. Trimethoprim is a useful third-line antibacterial therapy for patients resistant to other antibacterial therapies. Benzoyl peroxide should generally be used in combination with oral antibacterials as this has been shown to reduce the development of antibacterial resistance. For severe nodular acne, isotretinoin is the treatment of choice. In addition, over recent years dermatologists have increasingly used this drug to treat patients with moderate acne which has not responded to other systemic therapies, particularly when associated with scarring or significant psychological disability. However, this use is outside the current license of the drug. Isotretinoin is associated with a number of serious adverse effects and careful monitoring of patients during therapy is required.Physical therapies for the treatment of acne nodules and macrocomedones are also important adjuncts to drug therapies.

A clinical and therapeutic study of 29 patients with infantile acne

BACKGROUND

Infantile acne is a relatively uncommon condition; there are few data in the literature on the optimum treatment for this disorder.

OBJECTIVES

To review treatment results in infantile acne.

METHODS

We performed a retrospective review of 29 patients (24 boys and five girls) treated over a 25-year period.

RESULTS

The age at onset was 6-16 months (median 9). The acne was mild in 24%, moderate in 62% and severe in 14%. The type of acne was predominantly inflammatory (59%), but was comedonal in 17%, showed a mixed pattern in 17% and was nodular in 7%. No infants had any clinically obvious endocrinopathy. Patients with mild acne responded well to topical treatment (benzoyl peroxide, erythromycin and retinoids). All but two infants with moderate acne responded well to oral (paediatric) erythromycin 125 mg twice daily and topical therapy. Patients with erythromycin-resistant Propionibacterium acnes required trimethoprim 100 mg twice daily. Most patients were able to stop oral antibiotics within 18 months. In 38% of children, long-term oral antibiotics (> 24 months) were required. The time for clearance of the acne was 6-40 months (median 18). One patient required oral isotretinoin that cleared the acne in 4 months. Five patients (17%) were left with scarring.

CONCLUSIONS

This study confirms the male predominance of infantile acne. Treatment is similar to that of adult acne, with the exclusion of the use of tetracyclines. When necessary, oral isotretinoin can be used.

Azithromycin for the treatment of acne

BACKGROUND

Acne affects a large number of young adults, including women, who often present with facial as well as truncal involvement. Systemic antimicrobial agents currently used for the reduction of inflammatory papules and cysts require frequent administration and are sometimes associated with uncomfortable side-effects contributing to a decrease in compliance.

METHODS

Ninety-nine episodes of inflammatory acne in 79 patients treated with oral antimicrobial agents were studied retrospectively over a period of 46 weeks. Patients were treated with tetracycline, erythromycin, minocycline, and doxycycline, the most commonly prescribed oral antimicrobials used to treat acne. Individuals that were unable to tolerate this therapy or had failed conventional therapy were treated with the azalide antibiotic azithromycin, given in a single oral 250-mg dose three times a week. The other agents were administered daily in divided doses as is current practice. Patients were also on topical care.

RESULTS

The efficacy and reported side-effects were examined for all agents. Significant improvement was noted in 4 weeks. All agents were effective in reducing inflammatory lesions and improving acne. Azithromycin produced a slightly higher percentage of patients with a greater than 80% reduction in their inflammatory acne lesions (85.7%) vs. an average of 77.1% for all other agents. All differences observed were not statistically significant.

CONCLUSIONS

The results show that azithromycin is a safe and effective alternative in the treatment of inflammatory acne with few side-effects and good compliance, and suggest the need for further investigation with a clinical trial that will compare the long-term efficacy and tolerability.

The treatment of acne with topical retinoids: one man's opinions

Acne is a family of disorders that vary greatly in pathogenesis and clinical manifestation. Accordingly, no simple recipe for treatment can be given, and treatment options vary with the stage and intensity of the disease. Topical retinoids are the mainstay for treating common varieties of acne vulgaris. They also prevent development of comedones, halting progression to inflammatory lesions. Tretinoin was the first retinoid used in the topical treatment of acne more than 25 years ago. Isotretinoin, which has recently become available, is less irritating, but is probably somewhat less effective. Adapalene is a recently introduced topical retinoid used to treat acne. It enjoys therapeutic equivalence to tretinoin but is less irritating. Except for very mild acne cases, topical retinoids should be used concommitantly with other drugs. The operating principle is to choose drugs whose modes of action are different from topical retinoids, that is, antibiotics or benzoyl peroxide. Topical retinoids, however, constitute the core of nearly all therapeutic programs for acne.

Isotretinoin therapy in acne vulgaris: a 10-year retrospective study in Singapore

BACKGROUND

The use of isotretinoin, a first generation synthetic retinoid, in the treatment of patients with severe acne vulgaris was a major therapeutic advance in dermatology. This 10-year retrospective study reviews the effectiveness of isotretinoin in patients with acne vulgaris seen in a skin clinic in Singapore.

METHODS

The case records of 250 cases of severe inflammatory and nodulocystic acne treated with isotretinoin were analyzed with reference to the demographic data, response to isotretinoin, dosage and cost of isotretinoin used, adverse effects, clinical follow-up, and relapse.

RESULTS

Two hundred and fifty patients, 171 men (68.4%) and 79 women (31.6%), with different types and grades of acne vulgaris were studied. The dose of isotretinoin used ranged from 0.33 to 1.0 mg/kg/day (median 0.5 mg/kg/day) for a period ranging from 1 to 12 months (median 4 months). Response was excellent in 127 (50.8%) patients, good in 86 (34.4%), fair in 30 (12.0%) and poor in 7 (2.8%). Relapse occurred in 14 (5.6%) patients over a 6-month follow-up period. Adverse effects were noted in 140 (56.0%) patients and were mild in most cases. Eighteen (7.2%) patients had to discontinue the drug due to significant side effects.

CONCLUSION

This study confirms that isotretinoin is very effective for severe acne, and complete remission can be induced in more than 90% of cases even with lower dosage regimens. Significant clinical improvement can be achieved with the use of lower doses (mean 0.5 mg/kg/day) for an average of 4 months of treatment with lower risk of adverse effects.

The vellus hair follicle in acne: hair growth and sebum excretion

In this study we investigated the activity of the vellus hair follicle in acne. Hair growth and sebum excretion in vellus hair follicles were measured on the forehead and back of men, and on the forehead, cheek, and back of women with acne. Hair growth was assessed by computerized image analysis (phototrichogram), and sebum excretion by computer analysis using Sebutape. In patients with acne, marked differences were revealed when results were compared with recent data from healthy persons. In particular, the mean growth rate of vellus hairs was higher, whereas the percentage of anagen hairs was lower, and the duration of the anagen phase shorter in patients with acne than in healthy individuals. Hair growth and sebum excretion depended significantly (P < 0.01) on the anatomical site (forehead 414 hairs/cm2, 0.053 mm/day, 34%; back 93 hairs/cm2, 0.16 mm/day, 21%). In addition, analysis of hair growth revealed significantly higher values in females than in males for (i) percentage of anagen hairs (P > 0.01), (ii) for vellus hair length (P < 0.05), and (iii) for the duration of the anagen phase (P < 0.01). The present study demonstrates that the activity of the vellus hair follicle is influenced by acne, and vice versa, and therefore its role in the aetiopathogenesis of acne should be reconsidered.

Seborrhoea--an indicator for poor clinical response in acne patients treated with antibiotics

The relationship between sebum excretion rate (SER) and clinical improvement was investigated in 255 acne patients treated for 6 months with either oral erythromycin (1 g/day), minocycline (100 mg/day), oxytetracycline (1 g/day) or cotrimoxazole (400 mg/day); topical therapy was 5% benzoyl peroxide. In all but the cotrimoxazole treated group, there was a significant correlation between a high SER and reduced clinical response. This was particularly evident in those patients with an SER of greater than 2.5 micrograms/cm2/min. These patients showed only 17% improvement compared with 100% improvement in those subjects with an SER of 1.0 micrograms/cm2/min or less. The presence of obvious seborrhoea in a patient who has failed to respond to an adequate 6-month course of antimicrobial therapy, should indicate the earlier rather than later use of isotretinoin for their acne.

Clinical and bacteriologic evaluation of OPC-7251 in patients with acne: a double-blind group comparison study versus cream base

Twenty-eight patients with acne were assigned to 4 weeks of treatment with OPC-7251 (a new fluoroquinolone derivative) 1% cream or the cream base in a double-blind manner to evaluate the antibacterial effect of the drug on resident bacteria in the hair follicles and to evaluate clinical response. Propionibacterium acnes was isolated from 21 of the 28 acne patients. When the number of P. acnes was compared before and after treatment, the posttreatment P. acnes count in the OPC-7251 1% cream group was significantly (p = 0.000) reduced compared with that in the cream base group. OPC-7251 1% cream was also significantly (p = 0.019) superior to the cream base in terms of clinical response. P. acnes and Staphylococcus epidermidis isolated from the acne lesions were selected for their susceptibility to various antibacterial agents. The minimal inhibitory concentration of OPC-7251 against P. acnes and S. epidermidis was 0.10 to 0.20 and 0.024 to 0.10 micrograms/ml, respectively, which indicates that the drug has a potent antibacterial effect.

Acne as a risk factor for anorexia nervosa in Chinese

Acne is a highly visible and common skin disorder which is potentially disfiguring and associated with adverse emotional responses in adolescents, who are markedly sensitive to body image changes. Two psychologically vulnerable Chinese girls are reported, in whom traditional health concepts reinforced dieting behaviour, led to weight loss, regression of acne and eventually anorexia nervosa. The intricate interactions of acne, health beliefs, dieting behaviour and eating disorders are discussed.

Recalcitrant acne vulgaris. Clinical, biochemical and microbiological investigation of patients not responding to antibiotic treatment

A small, but clinically significant proportion of acne patients fail to respond adequately to antibiotic therapy. All non-responding acne patients attending the Leeds General Infirmary between September 1985 and April 1986 (49 out of a total of 610 patients; 8%) were investigated with respect to changes in their acne grade, microbial flora and sebum excretion rate. They were compared with 22 age and sex matched untreated control subjects. It was found that in 65% of non-responding patients there was no microbiological abnormality, in 16% there was evidence of Gram-negative folliculitis and 20% carried predominantly antibiotic resistant propionibacteria compared with only 5% of untreated controls. There was a significant association between erythromycin therapy and the isolation of erythromycin resistant propionibacteria (P less than 0.001). A causal link, however, has yet to be established between carriage of antibiotic resistant propionibacteria and failure to respond to antibiotic therapy. Our results show that for most patients with recalcitrant acne a non-microbiological explanation must be sought for the lack of therapeutic success. The mean sebum excretion rate (SER) of the non-responding patients was significantly higher than that of matched untreated acne patients (P less than 0.001). A majority of non-responders (69%) had an SER above the upper 95% confidence limit of the control mean. The SER may affect treatment efficacy by influencing the antibiotic concentration within the pilosebaceous ducts.

Evolution of a strategy for the treatment of acne

The management of skin disease may differ in different parts of the world, but in most countries, acne should be a most treatable disease. Acne therapy has not evolved in the most logical fashion, but this article reviews our demonstration of risk factors in the treatment of acne. Young patients, male patients, truncal acne, a marked seborrhea, and a low dose (500 mg/day or less) of tetracycline are factors associated with a poorer response and, when oral therapy is stopped, a greater relapse rate. One gram a day of tetracycline, given for 6 months, is the minimum course of oral therapy and should be given along with topical therapy. One of the most widely used topical treatments is benzoyl peroxide, and this presentation was given in honor of Dr. William Pace, who was possibly the first dermatologist to be aware of the benefit of benzoyl peroxide--a fact not adequately recorded in dermatologic history. A small number of patients do not respond well to conventional therapy, but alternative treatments should bring about a successful outcome. Alternative treatments include hormonal therapy (i.e., 2 mg cyproterone acetate plus 50 micrograms ethinyl estradiol; spironolactone, 100 mg twice daily; or isotretinoin, 1 mg/kg). The success of all these treatments bears some relationship to their effect in modulating the etiologic factors of acne: an enhanced sebum production, increased ductal cornification, abnormal bacterial colonization, and the production of inflammation. Isotretinoin is the most beneficial of all drug regimens, and this fact no doubt relates to its favorable effect on all etiologic factors.

Topical azelaic acid and the treatment of acne: a clinical and laboratory comparison with oral tetracycline

Topical azelaic acid and oral tetracycline were compared in a 6-month double-blind study for treatment of acne vulgaris in 45 male subjects with clinical acne. Their acne was graded, inflamed or non-inflamed, lesions were counted and the density of their skin microflora was measured. Both treatments were of benefit and produced only a few minor side-effects. Although oral tetracycline was more effective than azelaic acid, the differences were only just significant. The average reduction in numbers of cutaneous micrococcaceae and Propionibacterium sp. with azelaic acid treatment was 224 and 30-fold, respectively. In a separate group of 11 male subjects with physiological acne the effect of azelaic acid on sebum excretion rate was assessed, and little change was detected.

Evaluation of a therapeutic strategy for the treatment of acne vulgaris with conventional therapy

Four hundred and twenty patients with moderate to severe acne vulgaris were treated with oral erythromycin and topical benzoyl peroxide to determine the optimum dose regimes. Our results show that the response was significantly less in patients with a greater severity of acne, with truncal acne and in those with a higher sebum excretion rate. There was a significantly better clinical result in patients given Ig erythromycin daily than in those given 0.5 g daily (plus topical therapy in both groups). The relapse rate on stopping antibiotics is also significantly less in patients given I g daily and this dosage did not produce any increase in side effects. We suggest that any patient requiring oral antibiotics should initially be given I g daily of erythromycin (or tetracycline) for up to six months, plus topical therapy.

Acne and hyperandrogenism: impact of lowering androgen levels with glucocorticoid treatment

The impact of lowering androgen levels with glucocorticoid treatment in a group of consecutive female patients presenting to the Department of Reproductive Medicine and Biology, University of Texas, with a chief complaint of acne has been studied. One hundred fifty-eight patients, ages 16 to 40, who received prednisone at a maximum daily dose ranging from 7.5 to 15 mg for a period of at least 6 months were selected for the study. These patients were not taking other systemic medication affecting androgens or acne. Only thirty patients (19%) had pretreatment testosterone levels below the upper limits (40 ng/dl) of our normal range; while on treatment 146 patients (92.4%) had testosterone levels below 40 ng/dl. In sixty-three patients (39.9%) the acne completely cleared, in eighty patients (50.6%) it significantly improved, and in only fifteen patients (9.5%) was the acne not affected by the medication. There was a highly significant difference between the mean testosterone levels during treatment of those who cleared or improved, versus those who did not (p less than 0.05), the percentage drop in testosterone being greatest in those who cleared. Pretreatment testosterone levels were not significantly different in those who cleared, improved or did neither. It is concluded that glucocorticoid treatment frequently results in a lowering of androgen levels in hyperandrogenic women with acne and that this is associated with clearing or improvement of the acne.

Topical benzoyl peroxide increases the sebum excretion rate in patients with acne

Investigations on fifteen patients with acne showed that at the end of 1 and 2 months of treatment 5% benzoyl peroxide increased the sebum excretion rate by 22.5%. This rise in sebum excretion is probably due to the comedolytic activity of benzoyl peroxide which will influence the pooling of sebum in the upper reaches of the pilosebaceous duct.

A dose-response study of I3-cis-retinoic acid in acne vulgaris

13-cis-retinoic acid has been used as a single agent in the treatment of seventy-six patients with previously unresponsive cystonodular acne. The study was carried out in a double-blind fashion using three doses of the drug. Ninety per cent of the patients responded with a 70% improvement in the acne severity. Sixty-six per cent of the patients experienced no further problems with their acne during follow-up. Side-effects were frequent. The 0.5 mg/kg b.w. dose is recommended for the initial course of treatment.