A comparative study on the effectiveness of herbal extracts vs 2.5% benzoyl peroxide in the treatment of mild to moderate acne vulgaris

International expert consensus recommendations for the use of dermocosmetics in acne

BACKGROUND

A wide variety of dermocosmetics (products with both active skincare and cosmetic activity) are available for the management of acne vulgaris. These products are important because they may be the first line of approach for patients desiring to self-treat and they can also have beneficial effects-reducing lesion counts and improving global acne severity. When used in conjunction with medical therapy, dermocosmetics can improve tolerability and enhance results. We reviewed available evidence and combined it with our clinical experience to help guide clinicians in selecting skincare products with acne-targeting ingredients.

METHODS

An international panel of dermatologists with an interest and expertise in managing acne performed a literature review, formulated clinical questions related to the role of dermocosmetics in the acne setting, used a modified GRADE approach to evaluate available evidence and then utilized an online iterative Delphi process to create consensus recommendations. It should be noted that due to the limited number of available studies, the category of dermocosmetics was evaluated rather than specific ingredients.

RESULTS

The quality of evidence was found to be low to moderate. Key recommendations were made based on available evidence for the use of dermocosmetics in acne to improve acne global assessment, reduce acne lesion counts, reduce superficial skin oiliness and serve as maintenance therapy after medical treatment, while providing a good tolerability. Recommendations were also made for using dermocosmetics as adjuncts to medical treatment.

CONCLUSIONS

While there is a need for better quality evidence, dermocosmetics have demonstrated some benefit for acne both when used alone in its milder clinical presentations or in maintenance post acne medication and as adjunct to acne treatments.

A systematic review of 454 randomized controlled trials using the Dermatology Life Quality Index: experience in 69 diseases and 43 countries

BACKGROUND

Over 29 years of clinical application, the Dermatology Life Quality Index (DLQI) has remained the most used patient-reported outcome (PRO) in dermatology due to its robustness, simplicity and ease of use.

OBJECTIVES

To generate further evidence of the DLQI's utility in randomized controlled trials (RCTs) and to cover all diseases and interventions.

METHODS

The methodology followed PRISMA guidelines and included seven bibliographical databases, searching articles published from 1 January 1994 until 16 November 2021. Articles were reviewed independently by two assessors, and an adjudicator resolved any opinion differences.

RESULTS

Of 3220 screened publications, 454 articles meeting the eligibility criteria for inclusion, describing research on 198 190 patients, were analysed. DLQI scores were primary endpoints in 24 (5.3%) of studies. Most studies were of psoriasis (54.1%), although 69 different diseases were studied. Most study drugs were systemic (85.1%), with biologics comprising 55.9% of all pharmacological interventions. Topical treatments comprised 17.0% of total pharmacological interventions. Nonpharmacological interventions, mainly laser therapy and ultraviolet radiation treatment, comprised 12.2% of the total number of interventions. The majority of studies (63.7%) were multicentric, with trials conducted in at least 42 different countries; 40.2% were conducted in multiple countries. The minimal clinically importance difference (MCID) was reported in the analysis of 15.0% of studies, but only 1.3% considered full score meaning banding of the DLQI. Forty-seven (10.4%) of the studies investigated statistical correlation of the DLQI with clinical severity assessment or other PRO/quality of life tools; and 61-86% of studies had within-group scores differences greater than the MCID in 'active treatment arms'. The Jadad risk-of-bias scale showed that bias was generally low, as 91.8% of the studies had Jadad scores of ≥ 3; only 0.4% of studies showed a high risk of bias from randomization. Thirteen per cent had a high risk of bias from blinding and 10.1% had a high risk of bias from unknown outcomes of all participants in the studies. In 18.5% of the studies the authors declared that they followed an intention-to-treat protocol; imputation for missing DLQI data was used in 34.4% of studies.

CONCLUSIONS

This systematic review provides a wealth of evidence of the use of the DLQI in clinical trials to inform researchers' and -clinicians' decisions for its further use. Recommendations are also made for improving the reporting of data from future RCTs using the DLQI.

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.

Antimicrobial Activity of Smilax china L. Root Extracts against the Acne-Causing Bacterium, Cutibacterium acnes, and Its Active Compounds

The root of Smilax china L. is used in traditional Korean medicine. We found that the Smilax china L. root extract has strong antimicrobial activity against two Cutibacterium acnes strains (KCTC 3314 and KCTC 3320). The aim of this study was to identify the beneficial properties of Smilax china L. extracts for their potential use as active ingredients in cosmetics for the treatment of human skin acne. The high-performance liquid chromatography (HPLC) and liquid chromatography-hybrid quadrupole time-of-flight mass spectrometry (LC/QTOF/MS) methods were used to obtain the profile of secondary metabolites from the ethyl acetate-soluble fraction of the crude extract. Agar diffusion and resazurin-based broth microdilution assays were used to evaluate antimicrobial activity and minimum inhibitory concentrations (MIC), respectively. Among the 24 metabolites, quercetin, resveratrol, and oxyresveratrol were the most potent compounds against Cutibacterium acnes. Minimum inhibitory concentrations of quercetin, resveratrol, and oxyresveratrol were 31.25, 125, and 250 μg/mL, respectively.

Acne Vulgaris, Atopic Dermatitis and Rosacea: The Role of the Skin Microbiota-A Review

The skin harbors a huge number of different microorganisms such as bacteria, fungi and viruses, and it acts as a protective shield to prevent the invasion of pathogens and to maintain the health of the commensal microbiota. Several studies, in fact, have shown the importance of the skin microbiota for healthy skin. However, this balance can be altered by intrinsic and extrinsic factors, leading to the development of skin disease, such as acne vulgaris (AV), atopic dermatitis (AD) and rosacea(RS). Although these diseases are widespread and affect both adolescents and adults, the scientific correlation between these disorders and the skin microbiota and physiological parameters (TEWL, hydration and lipid composition) is still unclear. This review aims to investigate the current literature regarding the correlation between the skin microbiota and its imbalance underlying microbiological aspects, how the skin microbiota changes over the course of the disease and the current possible treatments. The following reported studies show a general imbalance of the bacterial flora. For this reason, more in-depth studies are necessary to explore the different subspecies and strains involved in all three diseases.

Kaempferia parviflora Rhizome Extract as Potential Anti-Acne Ingredient

Kaempferia parviflora (Black ginger) is used widely in medical fields as an anti-microorganism and anti-inflammation. In this study, the aim was to evaluate the in vitro and in vivo anti-acne efficacy of black ginger extract. The results indicate that the methanol and ethanol extracts showed the highest total phenolic contents, without a significant difference, whereas the n-hexane extract showed the highest total flavonoid content. Nine flavones were detected using UPLC−QTOF−MS, and the ethyl acetate extract showed the highest amount of 5,7-dimethoxyflavone (DMF) according to HPLC. Antibacterial activity against Staphylococcus aureus, S. epidermidis, and Cutibacterium acnes was observed. All the extracts showed antimicrobial activity against C. acnes, revealing MICs in the range of 0.015 to 0.030 mg/mL, whereas the ethyl acetate extract inhibited the growth of S. epidermidis with a MIC of 3.84 mg/mL. In addition, the ethyl acetate extract showed the highest activity regarding nitric oxide inhibition (IC50 = 12.59 ± 0.35 µg/mL). The ethyl acetate extract was shown to be safe regarding cell viability at 0.1 mg/mL. The anti-acne efficacy was evaluated on volunteers. The volunteers were treated in two groups: one administered a 0.02% ethyl acetate extract gel-cream (n = 9) and one administered a placebo (n = 9) for 6 weeks. The group treated with the gel-cream containing the extract showed 36.52 and 52.20% decreases in acne severity index (ASI) after 4 and 6 weeks, respectively, and 18.19 and 18.54% decreases in erythema, respectively. The results suggest that K. parviflora could be a potent active ingredient in anti-inflammatory and anti-acne products.

The Role of Herbal Medicine in the Treatment of Acne Vulgaris: A Systematic Review of Clinical Trials

Over the past few decades, interest in medicinal plants and phytochemicals for the treatment of skin disorders, including acne vulgaris, has progressively increased. Acne vulgaris is a chronic inflammatory disease of the pilosebaceous unit, which mainly occurs in adolescents and young adults. The treatment focuses on the four main factors involved in its pathogenesis: increased sebum production, hyperkeratinization, overgrowth of Cutibacterium acnes, and inflammation. The treatment includes topical retinoids, benzoyl peroxide, antibiotics, and oral isotretinoin. In this regard, the use of herbal medicine as a complementary and alternative medicine is a promising strategy. The main objective of this study was to systematically evaluate the efficacy and safety of medicinal plants and phytochemicals in the treatment of acne vulgaris. Three scientific databases (PubMed, Web of Science, and Scopus) were searched from inception to January 2021. Clinical trials comparing herbal therapies with placebo or other medicines for the treatment of acne vulgaris were included and analyzed. Outcome measures of interest comprised acne lesions (inflammatory and noninflammatory), sebum production, acne severity, and quality of life. The risk of bias in the included randomized controlled trials (RCTs) was assessed using the Cochrane risk-of-bias tool. A total of 34 clinical trials involving 1753 participants met the inclusion criteria for this systematic review. Most trials showed that herbal medicine significantly reduces inflammatory and noninflammatory acne lesions and has a relevant effect on acne severity. Some medicinal plants revealed equal or higher efficacy to standard treatments. No significant difference between groups in sebum production and quality of life was observed and no severe adverse events were reported. This systematic review provides evidence that medicinal plants and phytochemicals are promising treatments for mild to moderate acne vulgaris. However, more quality of evidence and standardized methodologies are needed to support their effectiveness and safety claims.

Clinical study to assess efficacy and safety of Purifying Neem Face Wash in prevention and reduction of acne in healthy adults

BACKGROUND

Acne vulgaris is a chronic, inflammatory skin condition of pilosebaceous units. The standard treatment involves topical and oral antibiotics, retinoids, benzoyl peroxide, and other synthetic compounds, mostly associated with adverse effects. Hence, herbal skincare products are considered nowadays.

AIM

To evaluate the safety and efficacy of Purifying Neem Face Wash (PNFW), an herbal skincare product in the prevention and/or reduction of mild-to-moderate acne.

METHODS

An open-label, single-center, single-arm, four-week clinical study was conducted with subjects having either mild-to-moderate acne or oily skin and non-existent acne. The performance of PNFW in the reduction and/or prevention of acne was detected by counting cutaneous inflammatory and non-inflammatory acne lesions in each of the four visits. Sebum level and skin hydration of both cheeks were measured via sebumeter and corneometer, respectively. Self-assessment questionnaires were used to assess the subjects' responses toward PNFW.

RESULTS

Out of 120 study subjects, 79% and 72% showed either reduction or no new appearance of inflammatory and non-inflammatory acne lesions, respectively, from baseline to Visits 3 and 4. Skin sebum level and skin hydration showed a statistically significant decrease (p < 0.001) and increase (p < 0.001), respectively, in Visits 3 and 4. Self-assessment surveys showed the satisfaction of the subjects about the product in terms of condition improvement, ease in use, and fragrance.

CONCLUSION

The present study indicated the beneficial effect of the herbal ingredients (neem and turmeric) of Himalaya's PNFW in the prevention and reduction of mild-to-moderate acne with no side effects.

Complementary and alternative medicine treatments for common skin diseases: A systematic review and meta-analysis

Background

Complementary and alternative medicine (CAM) treatments are growing in popularity as alternative treatments for common skin conditions.

Objectives

To perform a systematic review and meta-analysis to determine the tolerability and treatment response to CAM treatments in acne, atopic dermatitis (AD), and psoriasis.

Methods

PubMed/Medline and Embase databases were searched to identify eligible studies measuring the effects of CAM in acne, AD, and psoriasis. Effect size with 95% confidence interval (CI) was estimated using the random-effect model.

Results

The search yielded 417 articles; 40 studies met the inclusion criteria. The quantitative results of CAM treatment showed a standard mean difference (SMD) of 3.78 (95% CI [−0.01, 7.57]) and 0.58 (95% CI [−6.99, 8.15]) in the acne total lesion count, a SMD of −0.70 (95% CI [−1.19, −0.21]) in the eczema area and severity index score and a SMD of 0.94 (95% CI [−0.83, 2.71]) in the scoring of atopic dermatitis score for AD, and a SMD of 3.04 (95% CI [−0.35, 6.43]) and 5.16 (95% CI [−0.52, 10.85]) in the Psoriasis Area Severity Index score for psoriasis.

Limitations

Differences between the study designs, sample sizes, outcome measures, and treatment durations limit the generalizability of data.

Conclusions

Based on our quantitative findings we conclude that there is insufficient evidence to support the efficacy and the recommendation of CAM for acne, AD, and psoriasis.

Development of a Novel Freeze-dried Mulberry Leaf Extract-based Transfersome Gel

Objectives

Nowadays, antioxidants are important for health-related concerns related to acne vulgaris. Acne vulgaris is interrelated with the development of free radicals that interact with cells. Mulberry leaves contain phenolic compounds, including antioxidants such as quercetin. An antioxidant is a scavenger of free radicals. The current study addresses the development of a mulberry leaf extract-based transfersome gel containing quercetin by a thin-layer hydration method for topical antioxidant delivery. The process was optimized by encapsulating the drug in a variety of transfersome formulations.

Materials and Methods

Batch optimization was carried out by particle size and zeta analysis, entrapment efficiency (%), polydispersity index, in vitro drug release, and drug content analysis.

Results

The optimized batch MF5 provided 86.23% entrapment efficiency of quercetin in the vesicles and 95.79% drug release. It furnished a spherical shaped vesicle with an average diameter of 118.7 nm and zeta potential of -45.11 mV. The MG1 formulation provided superior antioxidant activity, drug content, and entrapment efficiency, ex vivo drug release, spreadability, homogeneity, and stability to MG2. The presence of quercetin in the extract and gel formulation was confirmed by using high performance thin layer chromatography.

Conclusion

It is evident from this study that a mulberry leaf extract-based transfersome gel is a promising prolonged delivery system for quercetin and has reasonably good stability characteristics. This research recommends that mulberry leaf extract-based transfersome gel can potentially be used in the treatment of acne vulgaris through a transdermal drug delivery system.

Identifying and appraising patient-reported outcome measures on treatment satisfaction in acne: a systematic review

BACKGROUND

After dermatitis, acne is the next skin disease to contribute most to the burden of skin diseases worldwide. Recently, seven core outcome domains have been identified, which together form an Acne Core Outcome Set (ACORN). One of these was satisfaction with acne treatment.

OBJECTIVES

To identify studies that described the development of patient-reported outcome measures (PROMS), evaluated one or more measurement properties of a PROM, or evaluated the interpretability of a PROM in patients with acne regarding treatment satisfaction.

METHODS

The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) search strategy for identifying PROMS on acne treatment satisfaction was used. We searched PubMed, MEDLINE, Embase, LILACS, Web of Science, Cochrane Library, Emcare, PsycINFO and Academic Search premier (June 2020). Study selection, data extraction and assessment of methodological quality according to COSMIN guidance were carried out independently by two authors.

RESULTS

Only one study could be included, describing the development of a treatment satisfaction measure in patients with acne. The development was assessed as inadequate and data on measurement properties were lacking. Additionally, we found 188 studies reporting treatment satisfaction solely as an outcome, using a wide variety of methods, none of them standardized or validated.

CONCLUSIONS

We could not find a PROM on treatment satisfaction to recommend for a core outcome set in acne. There is an unmet need for a PROM on treatment satisfaction in acne that is robustly developed, designed and validated.