European evidence-based (S3) guidelines for the treatment of acne

The adjuvant treatment role of ω-3 fatty acids by regulating gut microbiota positively in the acne vulgaris

Objectives:We aimed to explore the potential role of omega-3 (ω-3) fatty acids on acne vulgaris by modulating gut microbiota.Materials and Methods:We randomly divided the untreated acne patients into two groups with or without ω-3 fatty acids intervention for 12 weeks. The Sprague Dawley (SD) rats with acne model were given isotretinoin, ω-3 fatty acids or their combination respectively. Then the colonic contents samples of the drug intervention SD rats were transferred to the pseudo sterile rats with acne model. The severity of the disease was assessed by the Global Acne Grading System (GAGS) score of the patients, and the swelling rate of auricle and the pathological section of the rat with acne model. The 16S rDNA gene sequencing was performed to detect the alteration of the gut microbiota.Results:ω-3 fatty acids could increase the diversity of the gut microbiota and regulate the flora structure positively both in the patients and rats, increase the abundance of butyric acid producing bacteria and GAGS score in the patients, and alleviate the inflammation and comedones of rats.Conclusion:Supplementation of ω-3 fatty acids could alleviate the inflammation of acne vulgaris by increasing the abundance of butyric acid producing bacteria.

Challenges in designing a randomized, double-blind noninferiority trial for treatment of acne: The SD-ACNE trial

BACKGROUND/AIMS

Excessive use of antibiotics has led to development of antibiotic resistance and other antibiotic-associated complications. Dermatologists prescribe more antibiotics per clinician than any other major specialty, with much of this use for acne. Alternative acne treatments are available but are used much less often than antibiotics, at least partially because dermatologists feel that they are less effective. Spironolactone, a hormonal therapy with antiandrogen effects that can address the hormonal pathogenesis of acne, may represent a therapeutic alternative to oral antibiotics for women with acne. However, the comparative effects of spironolactone and oral antibiotics in the treatment of acne have not been definitively studied. The Spironolactone versus Doxycycline for Acne: A Comparative Effectiveness, Noninferiority Evaluation (SD-ACNE) trial aims to answer whether spironolactone, in addition to standard topical therapy, is noninferior to doxycycline (an oral antibiotic) for women with acne. Several interesting challenges arose in the development of this study, including determining acceptability of the comparative regimens to participating dermatologists, identifying data to support a noninferiority margin, and establishing a process for unblinding participants after they completed the study while maintaining the blind for study investigators.

METHODS

We present the scientific and clinical rationale for the decisions made in the design of the trial, including input from key stakeholders through a Delphi consensus process.

RESULTS

The Spironolactone versus Doxycycline for Acne: A Comparative Effectiveness, Noninferiority Evaluation trial (NCT04582383) is being conducted at a range of community and academic sites in the United States. To maximize external validity and inform clinical practice, the study is designed with broad eligibility criteria and no prohibition of use of topical medications. Participants in the trial will be randomized to receive either spironolactone 100 mg/day or doxycycline hyclate 100 mg/day for 16 weeks. The primary outcome is the absolute decrease in inflammatory lesion count, and we have established a noninferiority margin of four inflammatory lesions. Secondary outcomes include the percentage of participants achieving Investigator Global Assessment success, change in quality of life, and microbiome changes and diversity.

CONCLUSIONS

The Spironolactone versus Doxycycline for Acne: A Comparative Effectiveness, Noninferiority Evaluation trial will have substantial implications for the treatment of acne and antibiotic stewardship. In addition, this study will provide important information on the effect of these systemic agents on the development of changes to the microbiome and antibiotic resistance in a healthy population of patients.

Investigating Propionibacterium acnes antibiotic susceptibility and response to bacteriophage in vitro and in vivo

Introduction

A total of 94 Propionibacterium acnes (P. acnes) isolates were obtained from a hospital in Beijing to evaluate their susceptibility to erythromycin, clarithromycin, doxycycline, and minocycline. As well as the determination of the effectiveness of P. acnes phages in vitro and in P. acnes-induced lesions mouse model.

Methods

Patients with acne vulgaris (AV) were enrolled from August 2021 to October 2022. Standard methods were employed for specimen collection, culture, and identification of P. acnes. Susceptibility testing was conducted using E-strips for erythromycin, clarithromycin, minocycline, and doxycycline. Phage culture and identification followed standard procedures. A mouse model with P. acnes-induced skin lesions was established, and data was analyzed using χ 2 test.

Results

The results showed that all isolates were susceptible to minocycline and doxycycline, while 53 (56.4%) and 52 (55.3%) isolates were susceptible to erythromycin and clarithromycin, respectively. Interestingly, younger patients and those with lower acne severity exhibited reduced resistance. Phage cleavage rates ranged from 88.30 to 93.60%. Multilocus sequence typing (MLST) analysis was conducted on eight randomly selected P. acnes isolates, and the IA-2 subtype was used in experiments to address P. acnes-induced lesions in mice. Phage therapy proved effective in this model.

Discussion

This study highlights the high susceptibility of P. acnes to doxycycline and tetracycline, while erythromycin and clarithromycin exhibited elevated resistance. Additionally, P. acnes phages demonstrated high cleavage rates and potential effectiveness in treating P. acnes-induced lesions. These findings suggest promising avenues for further exploration of phage therapy in acne treatment.

Females May Have Less Severe Acne, but They Suffer More: A Prospective Cross-Sectional Study on Psychosocial Consequences in 104 Consecutive Polish Acne Patients

Acne is a common skin condition affecting both adolescents and adults, and it can profoundly impact patients' quality of life and mental well-being. This prospective cross-sectional study aims to explore the differences in psychosocial aspects between male and female acne patients in Poland. A total of 104 consecutive acne patients were included in this study. Clinical severity, patients' quality of life, stigmatization levels, and psychiatric disturbances were evaluated using the following instruments: Investigator Global Assessment (IGA), Dermatology Life Quality Index (DLQI), Cardiff Acne Disability Index (CADI), 6-Item Stigmatization Scale (6-ISS), and Hospital Anxiety and Depression Scale (HADS). This study found that female patients exhibited significantly less severe acne and experienced significantly decreased quality of life and increased levels of stigmatization. Furthermore, anxiety levels among female patients exceeded those observed in their male counterparts. Notably, no disparities in the severity of depression were observed between the two gender groups. Correlations were discerned among all psychosocial parameters in the entire study cohort and in the female subgroup, while such correlations were not uniformly observed among male participants. This study underscores the importance of considering psychosocial aspects and implementing routine measurements in the management of acne to improve patients' well-being.

A systematic review to evaluate the efficacy of azelaic acid in the management of acne, rosacea, melasma and skin aging

BACKGROUND

Topical azelaic acid (AA) is indicated for acne and rosacea, but there is some evidence for its use for other dermatological conditions.

AIMS

To assess the effectiveness and safety of topical AA for acne vulgaris, rosacea, hyperpigmentation/melasma, and skin aging.

METHODS

RCTs of at least 6 weeks' treatment duration were eligible for inclusion. Databases including MEDLINE, Embase, CINAHL, and ClinicalTrials.gov were searched up to December 2022. Two reviewers were involved in all stages of the systematic review process.

RESULTS

Forty-three RCTs met the inclusion criteria. Meta-analyses within 20 rosacea studies demonstrated that erythema severity, inflammatory lesion counts, overall improvement, and treatment success (achieving skin clarity) were significantly improved with AA compared with vehicle after 12 weeks. AA was more effective than metronidazole 0.75% for improved erythema severity, overall improvement, and inflammatory lesion counts. Sixteen acne studies suggest that AA is more effective than vehicle for improving global assessments and reducing acne severity. AA 20% also significantly reduced more lesions than erythromycin gel. Within seven melasma studies, AA 20% was significantly better than vehicle for both severity and global improvement. AA 20% demonstrated significantly better results compared with hydroquinone 2% for global improvement. Very few significant differences between AA and comparators were observed for commonly reported adverse events. No eligible RCTs were found that evaluated skin aging.

CONCLUSIONS

AA is more effective than vehicle for rosacea, acne and melasma. Comparisons between AA and other treatments were often equivalent. Where there is equivalence, AA may be a good option for some clinical situations. RCT evidence is needed to evaluate the effectiveness of AA on skin aging.

Treatment of Acne with Isotretinoin Should Be Avoided in Patients with Hidradenitis Suppurativa "Conglobata Phenotype"

BACKGROUND

Acne conglobata (AC) and nodulocystic acne have long been confused clinically, despite the presentation and the response to treatment being different. AC and hidradenitis suppurativa (HS) resemble each other; a subtype of HS called "conglobata phenotype" has recently been reported in a large Dutch cohort. Acne vulgaris and HS are often associated. Isotretinoin is typically ineffective in treating HS and may even aggravate it, but it is often indispensable in treating acne vulgaris.

OBJECTIVE

The aim of the study was to assess whether isotretinoin may be used safely in adults with both HS and acne vulgaris and when it might be contraindicated.

MATERIALS AND METHODS

Belgian HS patients from the European Registry for Hidradenitis Suppurativa Registry (ERHS) reporting a history of severe acne of the face and/or the back, and who have ever used isotretinoin for their acne, were all selected. Patients whose acne worsened on isotretinoin were compared to patients whose acne did not worsen (improvement or no change).

RESULTS

Among the 82 selected patients, 10 (12.2%) report that their acne was aggravated while taking isotretinoin, while 72 (87.8%) report that their acne was not aggravated on isotretinoin. Of the 10 HS patients whose acne worsened with isotretinoin, 9 (90%) were men (p = 0.04) and 8 (80%) were HS "conglobata phenotype" (p < 0.001). In contrast, 47 (65.3%) of the 72 patients whose acne did not worsen on isotretinoin belonged to the HS "regular phenotype" (p = 0.01). On multivariate analysis, the item most strongly associated with poor response to isotretinoin was the HS "conglobata phenotype," followed by body mass index (BMI) (worse response to isotretinoin if BMI >25 kg/m2). Additionally, of 26 patients who received isotretinoin while their HS had already started, only 6 (23.1%) reported isotretinoin effectiveness on their HS.

CONCLUSION

Subject to confirmation by larger studies, our study suggests that isotretinoin should be avoided in the treatment of acne in HS patients with the HS "conglobata phenotype," as it may worsen the acne, likewise being male or having a BMI above 25 seems to increase this risk of a bad therapeutic outcome. Patients with an HS "regular phenotype" appear to be at a reduced risk of isotretinoin treatment worsening their acne.

Efficacy of Carbon Peel Laser in Acne Vulgaris in Skin of Color: A Single Center Prospective Study

Background

Acne vulgaris is a chronic disease of pilosebaceous units that affects approximately 80% of adult population. Despite various treatment modalities being reported, treating acne with minimal side effects is difficult. Specifically, topical carbon suspension combined with QsNdYAG laser treatment (carbon peel laser technique) has gained popularity recently for effective treatment of acne vulgaris.

Objectives

To study the efficacy of carbon peel laser technique in the management of acne vulgaris (Grade II-IV) in skin of color.

Materials and Methods

A prospective observational study was done on 35 patients who presented with acne vulgaris Grade II-IV, who were poorly compliant to treatment with topical/systemic agents owing to side effects or failure of treatment, to meet patient's expectations. The patients were subjected to an initial topical application of carbon suspension (Cosderma Carbon gel) followed by treatment with quality switching neodymium yttrium aluminum garnet (Qs:NdYAG) laser in two modes (quasi long pulsed mode followed by Q switched mode 1064 nm). The treatment consisted of three sittings with intervals of 2 weeks. The patients were asked to avoid use of any topical/systemic medication for acne during this period.

Results

Significant reduction of erythematous and nodular acne lesions was noted after three sittings of "carbon peel laser technique". Among 35 patients, 28 (80%) showed >80% improvement and 7 (20%) showed 50%-80% improvement in skin lesions in the form of decrease in the number and size of lesions and extent of inflammation, with no patients nonresponsive to treatment. The postprocedure complications were minimal; 6 (20%) developed erythema, and 1 (3.3%) patient developed mild tolerable pain with no post inflammatory hyper/hypopigmentation. The postprocedure mean ISGA (Investigator Status Global Assessment) was 1.342 as compared with preprocedure mean ISGA of 3.657 with value of P <0.0001.

Conclusion

Carbon peel laser technique is an effective method for the management of acne vulgaris in skin of color with minimal side effects and significant results.

Tea Tree Oil: Properties and the Therapeutic Approach to Acne-A Review

Acne vulgaris is an inflammatory dermatological pathology that affects mostly young people. However, it can also appear in adulthood, mainly in women. It has a high psychosocial impact, not only at the time of active lesions but also due to the consequences of lesions such as scarring and hyperpigmentation. Several factors are involved in the physiopathology of acne and the constant search for active ingredients is a reality, namely phytotherapeutic ingredients. Tea tree oil is an essential oil extracted from Melaleuca alternifolia (Maiden & Betch) Cheel with known antibacterial, anti-inflammatory, and antioxidant properties, making it a candidate for the treatment of acne. This review aims to describe the various properties of tea tree oil that make it a possible ingredient to use in the treatment of acne and to present several human studies that have evaluated the efficacy and safety of using tea tree oil in the treatment of acne. It can be concluded that tea tree oil has good antibacterial, anti-inflammatory, and antioxidant properties that result in a decrease in the number of inflammatory lesions, mainly papules, and pustules. However, given the diversity of study designs, it is not possible to draw concrete conclusions on the efficacy and safety of this oil in the treatment of acne.

Anti-Inflammatory and Anti-Quorum Sensing Effect of Camellia sinensis Callus Lysate for Treatment of Acne

Cutibacterium acnes (C. acnes) is involved in the pathogenesis of acne by inducing inflammation and biofilm formation, along with other virulence factors. A Camellia sinensis (C. sinensis) callus lysate is proposed to reduce these effects. The aim of the present work is to study the anti-inflammatory properties of a callus extract from C. sinensis on C. acnes-stimulated human keratinocytes and the quorum-quenching activities. Keratinocytes were stimulated with thermo-inactivated pathogenic C. acnes and were treated with the herbal lysate (0.25% w/w) to evaluate its anti-inflammatory effect. C. acnes biofilm was developed in vitro and treated with 2.5 and 5% w/w of the lysate to evaluate quorum sensing and the lipase activity. The results showed that the lysate was able to reduce the production of interleukin-6 (IL-6), interleukin-8 (IL-8), tumor necrosis factor-α (TNF-α), and C-X-C motif chemokine ligand 1 (CXCL1), and decrease the nuclear translocation of nuclear factor kappa light chain enhancer of activated B cells (NF-κB). The lysate did not show bactericidal activity but showed diminished biofilm formation, the lipase activity, and the production of autoinducer 2 (AI-2), a member of a family of signaling molecules used in quorum sensing. Therefore, the proposed callus lysate could have the potential to reduce acne-related symptoms without the eradication of C. acnes, which is part of the natural skin microbiome.

Bibliometric Study of Adaptogens in Dermatology: Pharmacophylogeny, Phytochemistry, and Pharmacological Mechanisms

Background

Adaptogens are a class of medicinal plants that can nonspecifically enhance human resistance. Most of the plant adaptogens have relevant applications in dermatology, but there are still few studies related to their particular action and co-operative mechanisms in topical skin application.

Methods

Plant adaptogens related articles and reviews that published between 1999 and 2022 were obtained from the Web of Science Core Collection database. Various bibliographic elements were collected, including the annual number of publications, countries/regions, and keywords. CiteSpace, a scientometric software, was used to conduct bibliometric analyses. Also, the patsnap global patent database was used to analyze the patent situation of plant adaptogens in the field of cosmetics up to 2021.

Results

We found that the effects of plant adaptogens on skin diseases mainly involve atopic dermatitis, acne, allergic contact dermatitis, psoriasis, eczema, and androgenetic alopecia, etc. And the effects on skin health mainly involve anti-aging and anti-photoaging, anti-bacterial and anti-fungal, anti-inflammatory, whitening, and anti-hair loss, etc. Also, based on the results of patent analysis, it is found that the effects of plant adaptogens on skin mainly focus on aging retardation. The dermatological effects of plant adaptogens are mainly from Fabaceae Lindl., Araliaceae Juss. and Lamiaceae Martinov., and their mainly efficacy phytochemical components are terpenoids, phenolic compounds and flavonoids.

Conclusion

The plant adaptogens can repair the skin barrier and maintain skin homeostasis by regulating the skin HPA-like axis, influencing the oxidative stress pathway to inhibit inflammation, and regulating the extracellular matrix (ECM) components to maintain a dynamic equilibrium, ultimately achieving the treatment of skin diseases and the maintenance of a healthy state.

Assessment of the Benefit of a Deep Cleansing Gel Containing Salicylic Acid 2%, Zinc Gluconate 0.2% and Lipohydroxy Acids 0.05% in Patients with Mild to Moderate Truncal Acne: Results from an Exploratory Study

Purpose

Acne is a skin condition of the pilosebaceous unit that affects mainly the face, chest and trunk. Approximately 50% of subjects with facial acne also have acne of the trunk. This study investigated the clinical benefit of a cleansing gel containing salicylic acid 2%, zinc gluconate 0.2% and lipohydroxy acid 0.05% in truncal acne after 84 days of daily use.

Materials and Methods

A single center, open label, non-randomized study with 51 subjects with mild to moderate truncal acne was conducted. Thirty-five (35) subjects completed the study; mean age was 23 years. Inflammatory and non-inflammatory lesions, Transepidermal water loss (TEWL) and local tolerance were assessed at baseline, Day 42 and Day 84 and total lesion count was calculated.

Results

The total lesion count was significantly reduced (p<0.05) after 42 days (-21.5%) and 84 days (-56.3%). Non-inflammatory lesions were significantly decreased after 84 days (-64.0%) only, while inflammatory lesions were decreased at Day 42 (-29.2%), and Day 84 (-48.2%). A statistically significant skin barrier improvement was observed at Day 84 (-21.26%). No adverse events or relevant local intolerance were reported.

Conclusion

The use of the cleansing gel studied was effective in improving mild to moderate truncal acne and contributed to the skin barrier improvement. The product was well tolerated.

Clintrial Data Base Identifier

NCT05584150.

Real-World Case Studies Showing the Effective Use of Azelaic Acid in the Treatment, and During the Maintenance Phase, of Adult Female Acne Patients

Acne Vulgaris is a chronic inflammatory skin disease, and one of the most prevalent inflammatory dermatoses among teenagers, affecting more than >95% of boys and 85% of girls. Adult female acne (AFA) is a subtype of acne, pragmatically defined as affecting women over the age of 25. The clinical presentation of AFA may be distinguished from adolescent acne according to some key clinical and psychosocial characteristics. The etiopathogenic factors and the chronic clinical course that are implicated in AFA make management complex and challenging. A frequent tendency to relapse makes the requirement for maintenance therapy highly likely. Therefore, AFA typically requires a specific, tailored therapeutic approach. This paper presents six challenging case studies that demonstrate the efficacy of azelaic acid gel (AZA) in adult female acne. The six cases use AZA as monotherapy, as part of a combination regimen at treatment initiation, or as maintenance treatment (which is frequently required in this adult population). The positive outcomes achieved in this case series demonstrate that AZA can be efficacious, result in excellent patient satisfaction in mild to moderate adult female acne, and can be effective as a maintenance therapy.

Zinc and Zinc Transporters in Dermatology

Zinc is an important trace mineral in the human body and a daily intake of zinc is required to maintain a healthy status. Over the past decades, zinc has been used in formulating topical and systemic therapies for various skin disorders owing to its wound healing and antimicrobial properties. Zinc transporters play a major role in maintaining the integrity of the integumentary system by controlling zinc homeostasis within dermal layers. Mutations and abnormal function of zinc-transporting proteins can lead to disease development, such as spondylocheirodysplastic Ehlers-Danlos syndrome (SCD-EDS) and acrodermatitis enteropathica (AE) which can be fatal if left untreated. This review discusses the layers of the skin, the importance of zinc and zinc transporters in each layer, and the various skin disorders caused by zinc deficiency, in addition to zinc-containing compounds used for treating different skin disorders and skin protection.

Effect of systemic isotretinoin use on neutrophil/lymphocyte ratio in acne patients: A retrospective study

Objective: Acne vulgaris (AV) describes a chronic inflammatory condition that occurs in the pilosebaceous unit, which is common in the community. Increase in sebum production, abnormal follicular keratinization, Propionibacterium acnes (P.acnes) colonization and inflammation play a role in acne development. ISO, comedolytic, is the only agent that has an effect on all four conditions that determine the pathogenesis of acne, such as a large reduction in sebaceous gland size, suppression of sebum production and reduction in inflammation. In this study, it was aimed to compare the N/L ratio values at the beginning of the treatment and at the 4th month of the treatment in acne vulgaris patients receiving systemic ISO treatment. Material and Method 50 patients with acne vulgaris who applied to the dermatology outpatient clinics of Karaman Training and Research Hospital between October 2020 and February 2021, had moderate and severe acne vulgaris and were started on oral isotretinoin were included in the study. The medical records of the patients were reviewed retrospectively. The neutrophil/lymphocyte (N/L) ratio values of the patients at the beginning of Isotretinoin treatment and after four months were recorded. Results The mean age of the patients was 23.1±6.23, 52.0% (26 persons) were male. There was a significant decrease in the N/L ratio in total and in both genders with isotretinoin use (p

Feasibility of Reflectance Confocal Microscopy Monitoring in Oily, Acne-Prone Facial Skin Treated with a Topical Combination of Alpha and Beta-Hydroxy Acids, Anti-Inflammatory Molecules, and Herculane Thermal Water: A Blinded, One-Month Study

Oily, acne-prone skin is a common skin type which may be monitored in vivo using reflectance confocal microscopy (RCM). The aim of the study was to assess the feasibility of RCM in evaluating the effectiveness of a topical combination of alpha- and beta-hydroxy acids, anti-inflammatory and antibacterial molecules, and Herculane thermal water on acne-prone skin. Thirty-five subjects with oily, acne-prone skin were prescribed topical combination products and were evaluated by clinical, Wood's lamp, and RCM imaging at baseline and after 28 days. At 28 days, the RCM-evaluated number of dilated infundibula, infundibula filled with keratotic material, and infundibula with thickened bright borders, as well as the density of the inflammatory infiltrate, were significantly decreased. Wood's light images at 28 days showed a significantly reduced number of C. acnes-colonized infundibula, and both the median area and the intensity of the red-orange fluorescence were decreased. The reduction in the clinical score was concurrent with the improvement in the RCM parameters, suggesting that this non-invasive imaging technique is appropriate for efficiency evaluations of topical acne treatments.

The Screening and COnsensus Based on Practices and Evidence (SCOPE) Program Results of a Survey on Daily Practice Patterns for Patients with Metastatic Colorectal Cancer—A Swiss Perspective in the Context of an International Viewpoint

In Switzerland, physicians do not have national guidelines for metastatic colorectal cancer (mCRC) patient care and utilize international versions for management recommendations. Moreover, information about adherence to these guidelines and real-world practice patterns in Switzerland or other countries is lacking. The Screening and COnsensus based on Practices and Evidence (SCOPE) program were designed by an international expert panel of gastrointestinal oncologists to gather real-world insights in the current clinical setting to manage patients with mCRC who have received prior treatment. We sought to understand general practice patterns, the influence of molecular diagnostics (e.g., testing for KRAS, NRAS, BRAF, and MSI), tumor sidedness, and patient-centric factors on treatment selection utilizing in-person surveys and three hypothetical patient case scenarios. Here, we describe and evaluate the Swiss data from the SCOPE program within the context of an international viewpoint and discuss the findings of our analysis. In general, we find that the real-world clinical decisions of Swiss physicians (SWI) closely follow international (INT) recommendations and guidelines, largely paralleling their regional and international counterparts in using the two approved treatments in the third- and fourth-line settings, namely trifluridine-tipiracil and regorafenib. Finally, our data suggest a tendency toward the use of trifluridine-tipiracil (SWI: 79%; INT: 66%) over regorafenib (SWI: 18%; INT: 18%) as the preferred third-line treatment choice in mCRC patients regardless of KRAS status.

Evaluation of Psychological Wellbeing and Social Impact of Combined Facial and Truncal Acne: a Multi-national, Mixed-Methods Study

INTRODUCTION

Half of the individuals with facial acne develop truncal acne, but the impact of combined facial and truncal acne (CA) on patients' quality of life is poorly researched.

METHODS

A 60-min interview of 30 participants with CA was conducted that formed the basis for a cross-sectional survey of 694 adolescents and adults with CA.

RESULTS

The main themes identified from the qualitative interviews among CA subjects included acceptability to self and others, social functioning and emotional wellbeing. Feelings of embarrassment, self-consciousness and low confidence were experienced often or all the time by over 50% of participants, and were more frequent in those who perceived their acne to be out of control (P = 0.003). Half of patients reported feeling stigmatised because of their CA, and 65.4% believed that others associated their truncal acne with unhealthy or unhygienic habits. Perceived stigma was associated with more feelings of embarrassment (P = 0.005), self-consciousness (P = 0.034) and low self-confidence (P = 0.017). Overall, 64% participants reported that CA interfered with daily life, 46.4% often or always avoided social interaction, 48.6% were often concerned about talking to unfamiliar people and 47.4% were uncomfortable showing affection. Further, 32% and 24.4% participants ≥ 16 years old avoided dating or having romantic/intimate relationships because of their facial and truncal acne, respectively. Social and leisure activities were more frequently negatively impacted among those with perceived uncontrolled CA than among those with controlled CA. Avoiding undressing in front of spouse/partner/friends/relatives was more commonly reported by participants with perceived uncontrolled truncal acne than by those with controlled truncal acne (90.5% versus 80.6%, P = 0.031).

CONCLUSION

CA is associated with considerable psychological morbidity, with several exacerbating (e.g. perceived stigma) and attenuating factors (e.g. acne being perceived as being under control) that should be accounted for in CA management.

Effect of Evening Primrose Oil Supplementation on Biochemical Parameters and Nutrition of Patients Treated with Isotretinoin for Acne Vulgaris: A Randomized Double-Blind Trial

Background: Acne vulgaris is one of the most common skin diseases. One of the therapeutic options recommended for severe acne or acne that has not responded to previous therapies is isotretinoin. However, its use may lead to adverse changes in the serum lipid profile and increased levels of transaminases. In this study, we evaluated the effect of supplementation with evening primrose oil in acne vulgaris patients treated with isotretinoin on blood lipid parameters and transaminase activity. Methods: Study participants were randomly assigned to two treatments: conventional with isotretinoin (25 patients) and novel with isotretinoin combined with evening primrose oil (4 × 510 mg/day; 25 patients) for 9 months. Results: Compared to isotretinoin treatment, isotretinoin treatment combined with evening primrose oil had a positive effect on TCH concentrations (mean: 198 vs. 161, p < 0.001), LDL (95.9 vs. 60.2, p < 0.001), HDL (51.0 vs. 48.0, p < 0.001), TG (114 vs. 95.0, p < 0.001), ALT (24.0 vs. 22.0, p < 0.001), and AST (28.0 vs. 22.0, p < 0.001), but had no effect on the energy and ingredient content of the diets (p > 0.05) after treatment. Conclusion: Evening primrose oil was found to have beneficial effects on lipid profiles and transaminase activity during isotretinoin treatment. However, longer studies are needed to make more reliable decisions regarding the use of evening primrose oil and its safety in clinical practice. The evening primrose oil treatment group also showed a reduction in dietary energy due to a reduction in dietary protein and carbohydrates.

Isotretinoin Impairs the Secretory Function of Meibomian Gland Via the PPARγ Signaling Pathway

Purpose

To investigate the effects of isotretinoin on the ocular surface and to explore the possible mechanisms.

Methods

Rats were treated with isotretinoin 20 mg/kg/d for five months and tested monthly for tear secretion, fluorescein staining, and infrared photography. After five months of treatment, tissues were harvested for routine staining to evaluate the morphological changes; and real-time polymerase chain reaction, Western blot, and immunohistochemistry to study the expression of associated genes and their products such as forkhead box protein O1 (FoxO1), forkhead box protein O3, peroxisome proliferator–activated receptor γ (PPARγ), adipose differentiation–related protein, elongation of very long chain fatty acids protein 4, fatty acid binding protein 4, matrix metalloproteinase-9, and interleukin-6.

Results

Systemically, isotretinoin-treated rats have a significantly lower body weight that controls and apparent skin damage. Locally, although there was no alteration in tear secretion, a significant corneal involvement indicated by increased fluorescein staining scores, and also the contrast of meibomian gland was significantly reduced but no significant atrophy of the acinus was found. In addition, isotretinoin causes a decrease in conjunctival goblet cells. Furthermore, isotretinoin treatment did not cause the upregulation of FoxO1 and inflammation related genes but significantly suppressed the expression of PPARγ pathway.

Conclusions

Isotretinoin does not cause a significant atrophy of the acinus and a significant change of FoxO1 expression in the meibomian gland. Isotretinoin causes meibomian gland dysfunction, affecting meibocyte differentiation and qualitative and quantitative changes in the meibum, through PPARγ pathway.

Bacteria associated with acne use glycosaminoglycans as cell adhesion receptors and promote changes in the expression of the genes involved in their biosynthesis

Background

Cell surface glycosaminoglycans (GAGs) participate in many physiological and pathological processes, including infections and inflammatory response. Acne is a common chronic inflammatory skin disorder that affects the pilosebaceous unit and has a multifactorial etiology, including bacterial colonization of the hair follicle. This study aimed to investigate the participation of GAG in the adhesion of Propionibacterium acnes, Staphylococcus aureus and Staphylococcus epidermidis to keratinocytes and fibroblasts of the skin by competition experiments and cell surface removal using specific liases. The alteration in the transcription of the genes responsible for the synthesis of GAG induced by the adhesion of these bacteria was also analyzed by qRT-PCR.

Results

GAGs are involved in bacterial adherence to skin cells, especially fibroblasts, where chondroitin sulfate displayed the higher effect. Bacterial adherence produced different alterations in the transcription of the genes responsible for GAG structures. P. acnes induced mostly changes in keratinocytes, while S. epidermidis was the main cause of alterations in fibroblasts. These variations in gene expression affected all the stages in the biosynthesis of the main species of GAGs, heparan and chondroitin sulphate.

Conclusions

GAGs species are involved in the adhesion of acne-related bacteria to skin cells in a differential manner depending on each microorganism and cellular type, although other receptors seem to exist. Bacterial adherence led to variations on gene expression in skin cells affecting GAG chains structure what, consequently, should alter their interactions with different ligands, affecting the development of acne disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12866-022-02477-2.

Metagenomic Sequencing Analysis for Acne Using Machine Learning Methods Adapted to Single or Multiple Data

The human health status can be assessed by the means of research and analysis of the human microbiome. Acne is a common skin disease whose morbidity increases year by year. The lipids which influence acne to a large extent are studied by metagenomic methods in recent years. In this paper, machine learning methods are used to analyze metagenomic sequencing data of acne, i.e., all kinds of lipids in the face skin. Firstly, lipids data of the diseased skin (DS) samples and the healthy skin (HS) samples of acne patients and the normal control (NC) samples of healthy person are, respectively, analyzed by using principal component analysis (PCA) and kernel principal component analysis (KPCA). Then, the lipids which have main influence on each kind of sample are obtained. In addition, a multiset canonical correlation analysis (MCCA) is utilized to get lipids which can differentiate the face skins of the above three samples. The experimental results show the machine learning methods can effectively analyze metagenomic sequencing data of acne. According to the results, lipids which only influence one of the three samples or the lipids which simultaneously have different degree of influence on these three samples can be used as indicators to judge skin statuses.

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.

Real-world adherence to topical therapies in patients with moderate acne

Background

Real-life data on topical treatments in daily practice in patients with moderate acne are poorly characterized.

Objective

To investigate the drug survival of topical treatments administered to patients with moderate acne in a daily practice.

Methods

Survival analysis was performed on subjects (Belgian university hospital and private practice outpatient dermatology patients) with moderate acne who received topical therapies according to the current published guidelines.

Results

A total of 1160 treatment series (1029 patients) were included, including benzoyl peroxide (BPO, n = 93), azelaic acid (n = 246), adapalene (n = 254), a fixed combination of adapalene 0.1% and BPO 2.5% (A/BPO, n = 264), and a fixed combination of clindamycin 1.2% and tretinoin 0.025% gel (Clin-RA, n = 303). The calculated overall median treatment duration of all drugs was 2 months. The probability of treatment discontinuation after only 3 months was 50%. Overall, the drugs were discontinued for the following reasons: controlled acne (9%), side effects (9%), ineffectiveness (52%), combination of side effects and ineffectiveness (3%), and other reasons (1%). Overall, 27% patients were lost to follow-up.

Limitations

The post hoc study design and generalizability limit interpretation of the data.

Conclusion

Overall, the median treatment duration of topical anti-acne therapies was short (2 months). The main reason for discontinuation was ineffectiveness.

Efficacy of a combined chemical peel and topical salicylic acid-based gel combination in the treatment of active acne

BACKGROUND

Acne vulgaris is a common skin condition affecting the pilosebaceous unit of the skin characterized by the presence of comedones, papules, pustules, nodules, and cysts, which might result in permanent scars. It commonly affects adolescents, but it can occur in any age-group with the second group of incidence in young women in their 30s. Acne vulgaris can highly affect a person's quality of life. Therefore, it is necessary to act against it to prevent emotional impact and long-term complications.

AIM

This study aimed to demonstrate the efficacy of a chemical peel in combination with a home care-exfoliating and purifying product in improving mild and moderate acne.

METHODS

The study included 45 patients with mild-to-moderate acne. Patients were treated with a chemical peel containing a mix of salicylic acid, pyruvic acid, and retinoic acid once every 3 weeks for 4 times, plus a home care treatment after the healing process. Michaelson's acne severity score, Subject Global Aesthetic Improvement Scale, and Face Skin Q questionnaire were used to evaluate patients' skin improvement and patients' satisfaction.

RESULTS

All patients have shown improvement in skin lesions after 4 sessions of chemical peel according to Michaelson's acne severity score and Subject Global Aesthetic Improvement Score. Face Skin Q questionnaire demonstrated an improved quality of life in all treated patients.

CONCLUSION

The combination of salicylic acid-based chemical peel plus exfoliating home care treatment appears to be a very good strategy against acne. Therefore, the physician may use this combination as an effective treatment for patients dealing with acne vulgaris.

Exploring patient journeys through acne healthcare: a patient perspective

BACKGROUND

Despite the large availability of caregivers, there are no standardized care pathways for patients with acne. This increases the risk of ineffective care and unnecessary medicalizing. To better understand how to provide effective, efficient, and patient-satisfying care, it is necessary to gain insights into the patient journey through acne healthcare services.

OBJECTIVE

To explore the patient journeys, assessed by a series of consecutive steps through acne healthcare.

METHODS

A cross-sectional survey was conducted among Dutch individuals with acne.

RESULTS

A total of 371 respondents completed the questionnaire. Data revealed 58 different pathways through acne healthcare services. Patient with severe acne had a stronger tendency to seek professional care than those with mild acne (p< .05). The highest proportion of clinically relevant improvement was found in patients treated by dermatologists, compared to respondents treated by beauticians, p = .023 and dermal therapists, p = .018.

CONCLUSIONS

Mapping the patient journeys contributed to a better understanding of the gap between professional guidelines and the experiences of patients. Identifying these areas of care implies that there is potential to bring acne care services more in line with the patients' needs. Further research is recommended; for example by comparing the clinical treatment outcomes of multiple sequences of caregivers.

Structure, quality and accessibility of the Dutch acne healthcare; a care providers' perspective

Background: Despite the wide range of available treatment modalities a delay between the first outbreak of acne vulgaris and an effective treatment outcome is experienced by many patients. Considering the growing incentives to improve patient satisfaction and quality of care while reducing healthcare costs, insights into the structure, quality and accessibility of acne healthcare services beyond guidelines are therefore needed.Objective: To provide insights into the structure, quality and accessibility of acne healthcare services.Methods: A qualitative study was conducted according to the principles of 'situational analysis'. The Dutch acne healthcare system was taken as an illustrative example. Twenty-four semi-structured interviews were conducted among representatives of the 4 main Dutch professions providing acne care. All interviews were audiotaped, transcribed verbatim and analyzed.Results: Multiple facilitators and barriers emerged from the interviews. Identified facilitators were care providers delivering personalized patient care and having a positive attitude toward formalized multidisciplinary care delivery. A lack of streamlined referral pathways and standardization in acne severity-assessment, financial aspects and unfamiliarity with the content and added value of other acne care professionals were identified as barriers. Further research is recommended to investigate how de-medicalisation, the gatekeepers role, and the impact of location and work setting influence the quality of and accessibility to care.Conclusions: Identified facilitators and barriers and an overall positive attitude of care providers toward multidisciplinary care provision provides opportunities for the utilization of future guidelines involving streamlined referral pathways and good working arrangements between all acne care providing professions.

Increased prevalence of doxycycline low-susceptible Cutibacterium acnes isolated from acne patients in Japan caused by antimicrobial use and diversification of tetracycline resistance factors

The prevalence of antimicrobial-resistant Cutibacterium acnes is an important concern for the antimicrobial treatment of acne vulgaris. We hypothesized that antimicrobial treatment regimens for acne vulgaris would change following the revisions in the Japanese acne treatment guidelines, which added a statement regarding appropriate antimicrobial usage. Here, we studied the changes in antimicrobial use and antimicrobial-resistant C. acnes isolated from acne patients. A total of 127 C. acnes isolates collected from 212 patients with acne between 2013 and 2018 were used. Roxithromycin and clindamycin resistance rates were approximately 50% and 40%, respectively. In contrast, the prevalence of low doxycycline-susceptible strains (minimum inhibitory concentration [MIC] ≥8 μg/mL) in 2018 (17.4%) was 5.6-fold higher than that in 2013 (3.1%). Although the number of patients with severe and moderate acne did not change, the number of patients with a history of oral tetracycline use increased. The incidence of low doxycycline-susceptible strains was high in patients with a history of oral tetracycline use. The prevalence of strains with a 16S rRNA mutation, which confers reduced susceptibility to tetracyclines, increased by 8.6-fold (12.1%) from 2016 to 2018 in comparison with the previously revised guidelines (1.4%). Furthermore, the prevalence of low susceptibility strains with two resistance factors, 16S rRNA mutation and ribosomal S10 protein substitution, also increased. Approximately 10% of strains had the exogenous resistance gene, tet(W) (2013 to 2015, 10.1%; 2016 to 2018, 8.6%), and these strains showed different susceptibility to doxycycline dependent on the expression of tet(W) (MIC range 0.5-8 μg/mL). Our data show that the antimicrobial resistance pattern in C. acnes changes according to the trend of antimicrobial usage for acne treatment. Therefore, we should pay heed to the rapid dissemination of tetracycline resistance in C. acnes owing to acquisition of 16S rRNA mutation and tet(W).

50 Years of Topical Retinoids for Acne: Evolution of Treatment

Since the US Food and Drug Administration (FDA) approved tretinoin in 1971, retinoids alone or combined with other agents have become the mainstay of acne treatment. Retinoids act through binding to retinoic acid receptors, altering expression levels of hundreds of cellular proteins affecting multiple pathways involved in acne pathogenesis. Retinoids have evolved from first-generation agents, such as tretinoin, through chemical modifications resulting in a second generation (etretinate and acitretin for psoriasis), a third generation (adapalene and tazarotene) and, most recently, a fourth (trifarotene). For all topical retinoids, local irritation has been associated with poor tolerability and suboptimal adherence. Efforts to improve tolerability have utilized novel delivery systems and/or novel agents. This qualitative literature review summarizes the evolution of the four topical single-agent retinoids available for the treatment of acne in the US today and their various formulations, presenting the rationale behind their development and data from key studies.

Impact of facial and truncal acne on quality of life: A multi-country population-based survey

Background

Acne confers an increased risk of physical, psychiatric, and psychosocial sequelae, potentially affecting multiple dimensions of health-related quality of life (HRQoL). Morbidity associated with truncal acne is poorly understood.

Objective

To determine how severity and location of acne lesions impact the HRQoL of those who suffer from it.

Methods

A total of 694 subjects with combined facial and truncal acne (F+T) and 615 with facial acne only (F) participated in an online, international survey. Participants self-graded the severity of their acne at different anatomical locations and completed the dermatology life quality index (DLQI).

Results

The F+T participants were twice as likely to report “very large” to “extremely large” impact on HRQoL (ie, DLQI > 10 and children's DLQI [CDLQI] > 12) as compared with the F participants (DLQI: odds ratio [OR] 1.61 [95% confidence interval {CI} 1.02-2.54]; CDLQI: OR 1.86 [95% CI 1.10-3.14]). The impact of acne on HRQoL increased with increasing acne severity on the face (DLQI and CDLQI P values = .001 and .017, respectively), chest (P = .003; P = .008), and back (P = .001; P = .028).

Limitations

Temporal evaluation of acne impact was not estimated.

Conclusions

Facial and truncal acne was associated with a greater impact on HRQoL than facial acne alone. Increasing severity of truncal acne increases the adverse impact on HRQoL irrespective of the severity of facial acne.

Comparison of the psychosocial impact of acne in adolescents and adults; body satisfaction, self-esteem, and quality of life

BACKGROUND

Dermatological diseases, including acne vulgaris, have significant psychosocial effects on patients.

AIMS

To compare body satisfaction, self-esteem, and quality of life (QoL) in adolescents and adults with acne.

METHODS

A total of 192 acne patients (132 female, 60 male; aged 19.42 ± 3.50 years) were included in the study. Global Acne Grading System, Rosenberg Self-Esteem Scale (RSES), Turkish Acne Quality of Life Index (TAQoLI), and Body Cathexis Scale (BCS) were used. The patients were divided into two groups: under 20 years old (adolescents) and 20 years and above (adults).

RESULTS

The mean RSES score was found as 19.49 ± 5.11, the mean BCS score was 143.95 ± 20.92 and the mean TAQoLI score was 23.44 ± 10.02. There was no difference between adolescents and adults in terms of the mean value of the RSES score, TAQoLI score, and BCS score (p > 0.05). But, the proportion of those whose RSES score is below 15 is higher in patients under 20 years of age (28%) than patients aged 20 and over (14%) (p < 0.05). Linear regression analysis revealed that the most important determinant of body satisfaction was self-esteem (β = 0.287, p < 0.05), the most important determinants of self-esteem were body satisfaction (β = 0.208, p < 0.05), QoL (β = -0.398, p < 0.001), and education level (β = 0.245, p = 0.007) and, one of the most important determinant of QoL was self-esteem (β = -0.403, p < 0.001).

CONCLUSIONS

This study demonstrates that acne vulgaris negatively affects an individual's body satisfaction, self-esteem, and QoL. The psychosocial burden of acne is as significant for adults as for adolescents. Body satisfaction, self-esteem, and QoL are in interaction with each other.

Fluorescent light energy combined with systemic isotretinoin: A 52-week follow-up evaluating efficacy and safety in treatment of moderate-severe acne

Fluorescent light energy therapy combined with low-dose isotretinoin or tetracycline show remarkable clinical effect on 12 cases of moderate-to-severe acne. Treatment was considered safe, well-tolerated, and highly efficacious.

Patient-reported outcome measures for acne: a mixed-methods validation study (acne PROMs)

OBJECTIVES

To examine the acceptability and validity of two patient-reported outcome measures (PROMs) for adult acne, comparing them to the validated Acne-specific Quality of Life (Acne-QoL) measure.

DESIGN

Mixed-methods validation study.

SETTING

Participants were recruited by (1) mail-out through primary care if they had ever consulted for acne and received a prescription for acne treatment within the last 6 months, (2) opportunistically in secondary care and (3) poster advertisement in community venues.

PARTICIPANTS

221 (204 quantitative and 17 qualitative) participants with acne, aged 18-50 years.

OUTCOME MEASURES

Quantitative sub-study participants completed Acne-QoL, Skindex-16 and Comprehensive Acne Quality of Life Scale (CompAQ) at baseline, 24 hours and 6 weeks. Qualitative sub-study participants took part in cognitive think-aloud interviews, while completing the same measures. Transcribed audio recordings were analysed using inductive thematic analysis.

RESULTS

Quantitative analyses suggested high internal consistency (Cronbach's alpha 0.74-0.96) and reliability (intraclass correlation coefficient values 0.88-0.97) for both questionnaires. Both scales showed floor effects on some subdomains. Skindex-16 and CompAQ showed good evidence of construct validity when compared with Acne-QoL with Spearman's correlation coefficients 0.54-0.81, and good repeatability over 24 hours.Qualitative data uncovered wide-ranging views regarding usability and acceptability. Interviewees held strong but differing views about layout, question/response wording, redundant/similar questions and guidance notes. Similarly, interviewees differed in perceptions of acceptability of the different scales, particularly on relatability of questions and emotive reactions to scales.

CONCLUSIONS

All PROMs performed well in statistical analyses. No PROM showed superior usability and acceptability in the qualitative study. Any PROM should be acceptable for further research in adult acne but researchers should consider the different domains and whether they will measure only facial or facial and trunk acne before making a selection. A new PROM or further evaluation of novel PROMs may be beneficial.

Oral Antibiotics for Acne

Oral antibiotics are integral for treating inflammatory acne based on what is understood about the pathogenesis as well as the role of Cutibacterium acnes. However, rising concerns of antibiotic resistance and the perception of "antibiotic phobia" create potential limitations on their integration in an acne treatment regimen. When prescribing oral antibiotics, dermatologists need to consider dosage, duration, and frequency, and to avoid their use as monotherapy. These considerations are important, along with the use of newer strategies and compounds, to reduce adverse-event profiles, antibiotic resistance, and to optimize outcomes. Aside from concomitant medications, allergies, and disease severity, costs and patient demographics can influence variability in prescribing plans. There are multiple published guidelines and consensus statements for the USA and Europe to promote safe antibiotic use by dermatologists. However, there is a lack of head-to-head studies and evidence for comparative superiority of any individual antibiotic, as well as any evidence to support the use of agents other than tetracyclines. Although oral antibiotics are one of the main options for moderate to severe acne, non-antibiotic therapy such as isotretinoin and hormonal therapies should be considered. As newer therapies and more outcomes data emerge, so will improved management of antibiotic therapy to foster patient safety.

Trifarotene: A Current Review and Perspectives in Dermatology

Retinoids have numerous applications in inflammatory, dyskeratotic, and oncohematology diseases. Retinoids have now reached the fourth generation, progressively reducing toxicity whilst increasing their efficacy. Trifarotene is a new fourth-generation retinoid with a selective action on RAR-γ. In this review, we reported the trials—both concluded and in progress—including the use of trifarotene in dermatological diseases. Studies were identified by searching electronic databases (MEDLINE, EMBASE, PubMed, Cochrane, Trials.gov) from 2012 to today and reference lists of respective articles. Only articles published in English language were included. Randomized trials evaluating trifarotene tolerability, safety, and efficacy in congenital ichthyosis and acne have demonstrated great results and mild side effects, leading to the approval by the FDA of trifarotene for the treatment of lamellar ichthyosis in 2014, and of acne vulgaris in October 2019. No high-quality randomized clinical trials have evaluated the treatment of primary cutaneous lymphomas with trifarotene. Finally, we are hypothesizing future perspectives in the treatment of non-melanoma skin cancers, fungal infections, photoaging, and hand-foot skin reactions with trifarotene.

Combination of 5-Aminolevulinic acid photodynamic therapy and isotretinoin to treat moderate-to-severe acne

BACKGROUND

In China, photodynamic therapy(PDT) has been widely accepted in the treatment of acne. However, there are few studies on PDT combined with isotretinoin of moderate to severe acne.

AIMS

To evaluate the efficacy and safety of PDT combined with isotretinoin in the treatment of moderate to severe acne.

METHODS

70 cases of moderate and severe acne patients were randomly divided into PDT group and combination group. In combination group, patients were treated with PDT, once/2weeks, for 3 times; and oral isotretinoin, 10 mg twice a day for 3 months. The PDT group was treated with PDT alone. The skin lesions were counted before treatment and in the 4th, 6th, 8th, and 12th weeks to evaluate the clinical efficacy. Adverse reactions during the treatment were recorded. We monitored the liver function of the combination group once a month. The recurrence rate was recorded 6 months after treatment.

RESULTS

A total of 67 patients completed the study. The effective rates of combination group in the 4th, 6th, 8th, and 12th weeks of treatment were 28.6 %, 71.4 %, 91.4 %, and 94.1 %, respectively; the effective rates of PDT group in the 4th, 6th, 8th, and 12th weeks of treatment were 22.9 %, 54.3 %, 74.3 %, and 78.8 %, respectively; the effective rates of two groups were statistically significant in the 6th, 8th, and 12th weeks of treatment (P < 0.05). There was no significant difference in pain score between two groups during the photodynamic therapy(P＞0.05). Adverse reactions, such as erythema and pustule during photodynamic therapy in both groups were tolerable. The pigmentation subsided in about 3 months. The recurrence rate of combination group was significantly lower than that of PDT group(7% VS 24 %,P＜0.05).

CONCLUSION

PDT combined with isotretinoin has higher effective rate and lower recurrence rate than single PDT, and is a choice for the treatment of moderate to severe acne.

A Comparative Study Between Once-Weekly and Alternating Twice-Weekly Regimen Using Blue (470 nm) and Red (640 nm) Light Combination LED Phototherapy for Moderate-to-Severe Acne Vulgaris

BACKGROUND AND OBJECTIVE

Phototherapy for acne with a combination of blue and red light-emitting diodes (LEDs) appears to have excellent potential in treating inflammatory acne. However, a standard twice-weekly protocol administered 3 days apart may not be practical for patients. This study aims to seek the efficacy of LED treatment in moderate to severe acne, comparing between once and alternating twice-weekly regimens.

STUDY DESIGN/MATERIALS AND METHODS

Thirty subjects with moderate to severe acne, as defined by Burton's grading score, were recruited in the study. The subjects were randomly divided into two groups- one group received alternating blue (470 nm) and red (640 nm) light in two visits per week for 4 consecutive weeks, while the other group got blue and red light treatments consecutively on the same visit for 4 consecutive weeks. During the study period, conventional treatments were prohibited. Clinical assessments were performed by lesion counts and blinded comparative photographs before treatment and at 1, 4, and 8 weeks after the final treatment.

RESULTS

There was no statistically significant difference between once- and alternating twice-weekly regimens. Both regimens provided marked improvement only for inflammatory lesions. The median percentage of acne reduction was significantly demonstrated for 1 week after finishing the course of treatment and was sustained until the end of the study. There were no side effects noted throughout the study period.

CONCLUSION

LED therapy is safe and effective for treatment of inflammatory acne. The treatment outcomes of once and alternating twice-weekly regimens were comparable, hence, once-weekly treatment could be considered as an alternative choice for patient's convenience. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

Subclinical effects of adapalene-benzoyl peroxide: a prospective in vivo imaging study on acne micromorphology and transfollicular delivery

BACKGROUND

Adapalene-benzoyl peroxide (A-BPO) is a first-line topical treatment for acne vulgaris. In vivo reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) detect micromorphological changes over time and visualize transfollicular delivery.

OBJECTIVES

To visualize temporal, subclinical effects of A-BPO on acne micromorphology using RCM and OCT, and evaluate their impact on transfollicular delivery of microparticulate carrier systems.

METHODS

Fifteen patients with mild to moderate acne received a 6-week course of A-BPO. Micromorphological changes were evaluated at time 0, 3 and 6 weeks with RCM (n = 1190 images) and OCT (n = 210 scans). Transfollicular delivery of microparticles was assessed at baseline and week 6.

RESULTS

In vivo imaging visualized steady normalization of skin micromorphology in response to A-BPO over 6 weeks, including decreased hyperkeratinization of follicular borders (RCM median decrease -71.2%, P < 0.05), reduced intrafollicular keratinous content (RCM median decrease -47.7%, P < 0.05) and increased epidermal thickness (OCT median increase of 25.25%, P < 0.05). Imaging visualized microparticles in the follicular unit. Despite a visible reduction in keratin and sebum, transfollicular microparticle delivery appeared unaffected.

CONCLUSIONS

Reflectance confocal microscopy and OCT detect A-BPO-induced changes in micromorphology and visualize transfollicular microparticle delivery. Keratolysis and sebolysis did not have a measurable effect on transfollicular delivery of microparticles.

Efficacy and tolerability of short contact therapy with tretinoin, clindamycin, and glycolic acid gel in acne: A randomized, controlled, assessor-blinded two-center trial: The MASCOTTE study

Retinoids and antibiotics topical treatments are commonly used as first line therapy in mild to moderate acne. However, irritant contact dermatitis is a common side effect of topical retinoids. A strategy to increase local tolerability is the "short contact therapy" (SCT) approach, consisting in the application of the product with the complete removal after 30 to 60 minutes using a non-aggressive cleanser. A gel containing tretinoin 0.02%, clindamycin 0.8%, and glycolic acid 4% in polyvinyl alcohol (MP-gel) has shown to be effective as monotherapy in mild to moderate acne with a tolerability profile similar to other topical retinoids. So far, no trials have been performed with this gel comparing the tolerability profile of SCT with standard application therapy (SAT). We conducted a 2-center randomized parallel groups, controlled, assessor-blinded study, comparing MP-gel applied as SCT in comparison with MP-gel used as SAT (The "MASCOTTE" trial). Forty-six subjects (nine men and 37 women, mean age 23 ± 4 years, range 18-31 years) with mild-to-moderate acne were enrolled, after their written informed consent in a randomized, parallel groups controlled, assessor-blinded 8-week trial. Twenty-three were assigned to MP-gel once daily (evening application) using the SCT approach (ie, complete removal of product after 1 hour using a gentle cleanser), and 23 were randomized to the SAT approach with the same gel. The primary endpoint was the evolution of the tolerability score (TS) assessed evaluating four items: erythema, dryness, stinging, and burning, using a 4-point score scale (from 0: no symptom to 3: severe symptom). Secondary endpoints were the evolution of global acne grading system (GAGS) score (range: from 0 to >39) and the investigator global assessment (IGA of acne severity) score (range from 0 to 4). TS was evaluated at 2, 4, and 8 weeks. GAGS and IGA scores were evaluated at baseline and at week eight. At week eight, an efficacy global score (EGS) (from 1: no efficacy to 4: very good efficacy) and a tolerability global score (TGS) (from 1: very low tolerability to 3: very good tolerability) evaluation were also done. All the evaluations were performed by an investigator unaware of treatment groups allocation (SCT or SAT). Thirty-eight subjects (83%) completed the 8-week treatment period. Eight subjects (two in the SCT group and six in the SAT group) dropped out prematurely due to low skin tolerability. In the SCT the TS at week two was 1.3 ± 1.7, in the SAT group TS was significantly higher (3.1 ± 1.7) (P = .028). TS was significantly lower in SCT group vs SAT also at weeks four and eight (P = .01; ANOVA test). The GAGS score at baseline was 19 ± 7 in the SCT group and 23 ± 4 in the SAT group (NS). At week 8 the GAGS score in SCT was significantly reduced to 8.5 ± 2.8 (-55%) (P = .001 vs baseline) and was also significantly lower in comparison with SAT group (8.5 vs 15; P = .0054). The IGA scores at baseline were 1.9 ± 0.6 in SCT and 2.4 ± 0.7 in SAT group. At week eight, in comparison with baseline values IGA score was reduced significantly by 48% in SCT and by 30% in SAT. EGS and TGS were significantly higher (better clinical efficacy and better tolerability) in SCT in comparison with SAT (3.6 ± 0.5 and 2.9 ± 0.3 vs 2.7 ± 0.6 and 1.5 ± 0.7; respectively). This tretinoin, clindamycin, glycolic acid gel, applied as SCT, has shown a better skin tolerability and at least a comparable clinical efficacy in comparison with the standard application modality in the treatment of mild-to-moderate acne. The SCT therefore could be an effective treatment strategy which could improve subjects' compliance and adherence.

Antibiotic Resistance in Acne: Mechanisms, Complications and Management

Antibiotic resistance in acne was first observed in the 1970s, and since the 1980s has become a major concern in dermatologic daily practice. The mechanisms for this type of resistance include biofilm formation that promotes virulence and the transmission of resistant bacterial strains. Genetic mutations with modification of ribosomal RNA, alteration in efflux pumps, and enzymatic inactivation are able to create resistance to tetracyclines and macrolides. The state of art in acne treatment is no longer to use antimicrobials as monotherapy. There should be a time limit for its use plus the employment of non-antibiotic maintenance. Earlier initiation of oral isotretinoin therapy should be considered in patients with insufficient response to antimicrobials, severe acne, or a history of repeated antimicrobial use. A better understanding of acne pathogenesis, the subtypes of Propionibacterium (also known as Cutibacterium) acnes, homeostasis of the skin microbiota, and the mechanisms of antibiotic resistance would be useful in the selection of narrow-spectrum or species-specific antimicrobials, as well as the non-antimicrobial, anti-inflammatory treatment of acne. A number of novel treatments awaiting clinical proof may include the use of bacteriophages, natural or synthetic antimicrobial peptides, probiotics, and biofilm-targeting agents, as well as the reassessment of phototherapy.

Epiderm-Abrasion-Assisted Intensive Pulsed Light and Radiofrequency in Aesthetic Treatment Extensive Facial Freckles

BACKGROUND

Freckles are typical epidermal pigmented disorders that occur at sun-exposed areas, presenting with dark-brown or light-brown circular hyperpigmentation. A lot of treatment modalities have been used for treatment of freckles like chemicals, electrosurgery and cryotherapy. These treatments may cause undesirable side effects such as scaring (Sarkar et al. in Indian J Dermatol 62(6):578-584, 2017). Microdermabrasion has been used in treatment of freckles; however, the results are not satisfactory, as it removes the outermost layer of the epidermis only (El-Domyati et al. in J Cosmet Dermatol 15(4):503-513, 2016). Also ablative lasers and non-ablative lasers have been used but have not proved to be completely satisfactory and share a common risk of post-inflammatory hyperpigmentation (Jang et al. in Dermatol Surg 26:231-234, 2000). In our study, we have used epiderm-abrasion-assisted intensive pulsed light (IPL) and radiofrequency (RF) to study their effect in treatment of freckles.

PATIENTS AND METHODS

this prospective controlled clinical trial was carried out on 48 patients, who presented with extensive facial freckles, in the period between March 2015 and April 2018. The epiderm-abrasion procedure was performed first, and then, electro-photobiomodulation sessions were started two weeks later.

RESULTS

This study was carried out on 48 patients, 39 female and 9 males. Their age ranged between 12 and 58 years old. According to Fitzpatrick classification, four patients were type II, 30 patients were type III, and 14 patients were type IV. The results were excellent in 32 cases, good in 12 cases, fair in four cases, and we have no poor results. Side effects like hyperpigmentation were reported in three patients (6.3%), one case grade III and two cases grade IV Fitzpatrick skin type. No cases with hypopigmentation, or scars, were reported.

CONCLUSIONS

Epiderm-abrasion and electro-photobiomodulation (IPL&RF) are effective methods in treatment of facial freckles. Some complications may occur post-procedure such as hyperpigmentation, hypopigmentation and abnormal scarring.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Age correlations of acne vulgaris. Comparative study of microbiome and acne exposom at students of Kirov state medical university. Analysis of the results of therapy applicable to indicators of quality of life

A modern review of the pathogenetic factors underlying acne vulgaris, genetic determinism, and the influence of exposure factors on the formation of the disease are presented. The features of the microbiome and immunity indicators of this category of patients in the student population were studied. The clinic of various forms is described depending on the age gradation. The optimal therapeutic tactics, including those preventing the formation of antibiotic resistance, are substantiated. Clinical cases with a successful therapeutic outcome are presented.

Antibiotic resistant Cutibacterium acnes among acne patients in Jordan: a cross sectional study

BACKGROUND

Antibiotics have been used for decades against Cutibacterium acnes (previously known as Propionibacterium acnes; C. acnes). Alarmingly, antibiotic resistance to this bacterium has become a worldwide problem in recent years. No studies are available on the antibiotic susceptibility patterns of C. acnes among Jordanian acne patients and how that is influenced by antibiotic use. This study aims to assess antibiotic resistance patterns of C. acnes clinical isolates and neighboring Gram-positive normal flora of the skin obtained from acne patients attending dermatology clinics in Amman -Jordan appraising the role of antibiotic consumption.

METHODS

This is a cross-sectional study of acne patients presenting to selected dermatology outpatient clinics over a 6-month study period. Swabs obtained from inflamed lesions were cultured aerobically and anaerobically. Isolates were identified and screened for antibiotic susceptibility. In addition, all patients were asked to fill in a questionnaire that included questions about the history of antibiotic treatment.

RESULTS

C. acnes was isolated from lesions of 100 patients out of 115 participants included in this study. 73% of the isolates were resistant to erythromycin and 59% to clindamycin 37% to doxycycline, 36% to tetracycline, 31% to trimethoprim / sulfamethoxazole, 15% to levofloxacin, and 3% to minocycline. Multi drug resistance (MDR) in C. acnes isolates as well as Staphylococcus aureus (S. aureus) and Staphylococcus epidermidis (S. epidermidis) with a similar pattern of resistance were detected from the same patient in most cases. A pattern of higher resistance towards variable antibiotic was observed in patients previously treated with antibiotics for acne management.

CONCLUSIONS

The findings of this study demonstrate the distribution of antibiotic resistance of C. acnes towards used antibiotics and emphasizes the influence of antibiotic consumption on development of antibiotic resistance. The similar pattern of resistance between skin bacteria tested in this study highlights the genetic transfer of resistance between skin commensals including S. aureus and S. epidermidis hence promoting its circulation in the community.

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

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

Novel Topical Application of a Postbiotic, LactoSporin®, in Mild to Moderate Acne: A Randomized, Comparative Clinical Study to Evaluate its Efficacy, Tolerability and Safety

Acne vulgaris is a common skin disorder of pilosebaceous units. The therapy for mild-to-moderate acne includes topical antibiotics, benzoyl peroxide and retinoids. In this open-label, randomized monocentric study, we compared the efficacy of LactoSporin® 2% w/w cream with benzoyl peroxide in 64 male and female subjects with mild-to-moderate acne for three weeks. The efficacy parameters were evaluated based on the dermatologist visual assessment and instrumental measurements using Sebumeter® MPA580, Antera 3DTM and VISIA CR 2.2 and subject self-assessment questionnaires. Adverse events were recorded throughout the study period. In order to understand the mechanism of action and properties of LactoSporin, the pH stability, thermostability, antimicrobial activity and 5-alpha reductase activity were evaluated in vitro. A significant improvement was observed in the dermatological assessment of closed comedones (p < 0.0001), open comedones (p = 0.0069) and papules count (p < 0.0001) in comparison to the baseline in both LactoSporin and benzoyl peroxide groups. The antera analysis showed significant improvement in redness (p < 0.0001) and elevation (p < 0.0001) (small and medium) in both the treatment groups. The sebumeter analysis showed a significant decrease in sebaceous secretion (p < 0.0001) for LactoSporin, which resulted in reduced oiliness, pimples, acne spots and redness around the acne spot. The product was found to be safe without any irritancy. LactoSporin was stable at an acidic pH and temperature range of 70 to 90 °C, with antimicrobial activity against various pathogenic bacteria, including Cutibacterium acnes. It was also a potent inhibitor of 5-alpha reductase activity. Thus, it can be concluded that the efficacy of LactoSporin is equivalent to benzoyl peroxide in the treatment of mild-to-moderate acne lesions and better than benzoyl peroxide for reducing the sebaceous secretion and oily, greasy nature of the skin, implying its efficacy in other sebohorriec conditions.

An overview of sarecycline for the treatment of moderate-to-severe acne vulgaris

INTRODUCTION

Sarecycline is a novel, tetracycline-class antibiotic specifically designed to treat inflammatory acne. It offers a narrow spectrum of activity (mainly against Cutinebacterium acnes), and it shows less in vitro activity than other tetracyclines against enteric Gram-negative bacteria, offering advantages over older tetracyclines by decreasing the disruption of the gastrointestinal microbiome and the likelihood of developing bacterial resistance.

AREAS COVERED

The drug's pharmacology, safety profile, and clinical efficacy are discussed. Results of phase I, II and III clinical trials have shown that 1.5 mg/kg/day sarecycline is safe, well tolerated and more effective than placebo in treating inflammatory acne in patients 9 years old and older. Furthermore, sarecycline's narrow spectrum of activity leads to a lower incidence of undesirable off-target antibacterial effects and consequently less adverse events such as diarrhea, fungal overgrowth and vaginal candidiasis.

EXPERT OPINION

Sarecycline could become the first-line antibiotic therapy used in acne in the near future as it is an effective option for treating inflammatory acne lesions. Due to its narrow spectrum of activity, it could have a more adequate safety profile than older tetracyclines; however, head-to-head trials comparing the efficacy and safety profile of sarecycline with other tetracyclines are still needed to prove sarecycline's superiority.

GPs' practice and attitudes to initiating isotretinoin for acne vulgaris in Ireland: a cross-sectional questionnaire survey in primary care

BACKGROUND

Isotretinoin is prescribed in secondary care for severe acne vulgaris. Anecdotal reports suggest that GPs in Ireland currently initiate isotretinoin.

AIM

To ascertain the prevalence and management of isotretinoin in Irish general practice and to describe GPs' attitudes about the use of isotretinoin in Ireland.

DESIGN AND SETTING

A cross-sectional questionnaire survey of GPs in Ireland between October 2018 and February 2019.

METHOD

Two short questionnaires were developed: one for GPs who prescribe isotretinoin and one for GPs who do not prescribe isotretinoin. Questionnaires were distributed via email and online via GP Forum to GPs in Ireland.

RESULTS

Of a total 298 GPs who completed the questionnaire, 52 (17%) initiated isotretinoin. Older GPs (aged 35 years) and male GPs were more likely to prescribe isotretinoin. GPs cited prolonged dermatology waiting lists (n = 34, 65%) and a special interest in dermatology (n = 31, 60%) as two key drivers to initiating isotretinoin. However, this study found evidence of suboptimal blood monitoring, pregnancy testing, and contraceptive advice. Most GPs (n = 246, 83%) did not initiate isotretinoin and identified multiple barriers: medicolegal concerns (n = 150, 61%), being unaware that GPs may initiate isotretinoin (n = 135, 55%), and being unfamiliar with managing isotretinoin (n = 102, 41%). Important enablers to initiating isotretinoin cited by GPs include Irish College of General Practitioners guidelines (n = 118, 48%) and dermatologist support (n = 119, 48%). Two-thirds of the GPs questioned (n = 164, 67%) expressed an interest in initiating isotretinoin and most (n = 223, 91%) agreed that GPs can safely manage isotretinoin.

CONCLUSION

Few GPs in Ireland currently initiate treatment of acne with isotretinoin, and there is suboptimal adherence to recommended monitoring. Barriers to and enablers for GPs initiating isotretinoin were identified. Most GPs expressed an interest in initiating isotretinoin.