Acne vulgaris: pathogenesis and treatment

Polyphenol-rich apple extract inhibits dexamethasone-induced sebaceous lipids production by regulating SREBP1 expression

Sebum production and excretion is a primary function of the sebaceous glands, but abnormally increased sebum production is a major cause of acne vulgaris. To identify a new candidate that regulates sebum production, we investigated the possible inhibitory effects of apple polyphenols (APP) purified from unripe apples on primary cultured human sebocytes and in patients with acne vulgaris. Dexamethasone (Dex) increased lipid synthesis and expression of the sterol response element-binding protein 1 (SREBP 1) and its target enzymes, acetyl-CoA carboxylase (ACC) and fatty acid synthase (FAS), in the sebocytes. However, APP inhibited Dex-induced lipid production and expression of SREBP-1, ACC and FAS. APP also inhibited the increase in the expression and activation of glucocorticoid receptor in the sebocytes. Taken together, these results suggest that APP may be useful to regulate sebum production and may alleviate sebum-involved skin disease, such as acne vulgaris.

Decrease in "Hamilton Rating Scale for Depression" Following Isotretinoin Therapy in Acne: An Open-Label Prospective Study

Background:

Acne is a common disorder among adolescents and young adults causing a considerable psychological impact including anxiety and depression. Isotretinoin, a synthetic oral retinoid is very effective in the treatment of moderate to severe acne. But there have been many reports linking isotretinoin to depression and suicide though no clear proof of association has been established so far.

Objective:

To determine whether oral isotretinoin increases the risk of depression in patients with moderate to severe acne.

Materials and Methods:

One hundred and fifty patients with moderate to severe acne were treated with oral isotretinoin 0.5 mg/kg/day for a period of 3 months. Their acne and depression scoring was done at baseline and then every month for the first 3 months and then at 6 months.

Results:

We found that the acne scoring reduced from 3.11 ± 0.49 to 0.65 ± 0.62 (P = < 0.001) at the end of 3 months. Also, the depression scoring decreased significantly from 3.89 ± 4.9 at the beginning of study to 0.45 ± 1.12 (P < 0.001) at the end of 3 months. Both the acne and depression scores continued to remain low at the end of 6 months at 0.5 ± 0.52 (P = < 0.001) and 0.18 ± 0.51 (P = < 0.001), respectively.

Conclusions:

Our study proves that oral isotretinoin causes significant clearance of acne lesions. It causes significant reduction in depression scores and is not associated with an increased incidence of depression or suicidal tendencies.

Adherence to acne treatment guidelines in the military environment - a descriptive, serial cross-sectional study

BACKGROUND

Acne vulgaris, a common skin disease, affects up to 80 % of the population. Moderate to severe acne requires treatment with a combination of topical and oral drugs such as antibiotics, hormones and retinoids. Retinoids have many contraindications and adverse effects requiring close monitoring. The study's objectives were to describe prescribing trends in acne medication over time in a military setting, and assess physician adherence to guidelines for acne treatment, including drug precautions, clinical monitoring, and treatment progression.

METHODS

We conducted a descriptive, serial cross-sectional study of acne drugs prescribed in the Israel Defense Forces (IDF) in the years 2002-2007, analyzing the classes of drugs prescribed and patient characteristics. In addition, the clinical quality of the medical encounter was assessed by examining physician adherence to IDF guidelines.

RESULTS

Between 2002 and 2007, 64,281 patients were treated for acne. Treatment courses generally persisted for 1-2 months. Over 70 % of female patients receiving oral retinoids were not concomitantly receiving oral contraceptives.

CONCLUSION

This study provides a unique perspective of acne treatment in a military setting, overall displaying good adherence to general guidelines. The common prescription of oral retinoids to young females without concomitant contraception is alarming.

Clinical and sebumetric evaluation of topical emulsions in the treatment of acne vulgaris

Introduction

Numerous plant products described in the scientific literature show distinct activities on the skin, such as moisturizing, antioxidant, sunscreen, anti-acne and depigmentation.

Aim

The main objective of this study was to compare the effectiveness of emulsion formulations containing plant extracts (Hippophae rhamnoides and Cassia fistula) and placebo (without plant extracts) on acne patients.

Material and methods

A single-blind, randomized, placebo-controlled, split-face study was designed. Two groups of 25 patients each (aged 18–37 years) with grade I and grade II acne vulgaris received active formulations on the left side of their cheeks and placebo on the right side of their cheeks twice daily for 12 weeks. Prior to the study, signed consent was obtained from each patient. The anti-bacterial activity of the extracts and formulations was tested in vitro. The skin sebum contents of patients were evaluated by the sebumeter^® and subjectively using a clinical evaluation before and after treatment of 12 weeks. One way ANOVA and Kruskal-Wallis tests were used in the statistical analysis.

Results

A significant (p ≤ 0.05) decrease in the level of sebum contents was observed in both groups who used formulations (F1 and F2) containing the plant extract. The difference between pre- and post-treatment levels of sebum contents was statistically significant (p ≤ 0.05). Formulations containing plant extracts were found effective in the reduction of skin sebum contents (anti-acne effects) sebumetrically as well as clinically when compared to placebo (F3).

Conclusions

Formulations with 5% plant extracts could be effective, safe, and well-tolerated topical medications for grade I and grade II acne vulgaris.

A longitudinal study of adult-onset asthma incidence among HMO members

BACKGROUND

HMO databases offer an opportunity for community based epidemiologic studies of asthma incidence, etiology and treatment. The incidence of asthma in HMO populations and the utility of HMO data, including use of computerized algorithms and manual review of medical charts for determining etiologic factors has not been fully explored.

METHODS

We identified adult-onset asthma, using computerized record searches in a New England HMO. Monthly, our software applied exclusion and inclusion criteria to identify an "at-risk" population and "potential cases". Electronic and paper medical records from the past year were then reviewed for each potential case. Persons with other respiratory diseases or insignificant treatment for asthma were excluded. Confirmed adult-onset asthma (AOA) cases were defined as those potential cases with either new-onset asthma or reactivated mild intermittent asthma that had been quiescent for at least one year. We validated the methods by reviewing charts of selected subjects rejected by the algorithm.

RESULTS

The algorithm was 93 to 99.3% sensitive and 99.6% specific. Sixty-three percent (n = 469) of potential cases were confirmed as AOA. Two thirds of confirmed cases were women with an average age of 34.8 (SD 11.8), and 45% had no evidence of previous asthma diagnosis. The annualized monthly rate of AOA ranged from 4.1 to 11.4 per 1000 at-risk members. Physicians most commonly attribute asthma to infection (59%) and allergy (14%). New-onset cases were more likely attributed to infection, while reactivated cases were more associated with allergies. Medical charts included a discussion of work exposures in relation to asthma in only 32 (7%) cases. Twenty-three of these (72%) indicated there was an association between asthma and workplace exposures for an overall rate of work-related asthma of 4.9%.

CONCLUSION

Computerized HMO records can be successfully used to identify AOA. Manual review of these records is important to confirm case status and is useful in evaluation of provider consideration of etiologies. We demonstrated that clinicians attribute most AOA to infection and tend to ignore the contribution of environmental and occupational exposures.

Acne vulgaris. Topical and systemic therapies

Acne vulgaris is a condition commonly treated by primary care physicians. An understanding of the causes of the disease and methods of clinical evaluation allows selection of appropriate therapy. Effective treatment is available for all types of acne, including severe, nodulocystic forms. Regardless of the regimen chosen, patients should receive encouragement and instructions about the necessity of regular ongoing treatment for a successful outcome.

A comparative study of tea-tree oil versus benzoylperoxide in the treatment of acne

Tea-tree oil (an essential oil of the Australian native tree Melaleuca alternifolia) has long been regarded as a useful topical antiseptic agent in Australia and has been shown to have a variety of antimicrobial activities; however, only anecdotal evidence exists for its efficacy in the treatment of various skin conditions. We have performed a single-blind, randomised clinical trial on 124 patients to evaluate the efficacy and skin tolerance of 5% tea-tree oil gel in the treatment of mild to moderate acne when compared with 5% benzoyl peroxide lotion. The results of this study showed that both 5% tea-tree oil and 5% benzoyl peroxide had a significant effect in ameliorating the patients' acne by reducing the number of inflamed and non-inflamed lesions (open and closed comedones), although the onset of action in the case of tea-tree oil was slower. Encouragingly, fewer side effects were experienced by patients treated with tea-tree oil.

Current views on the aetiology, pathogenesis and treatment of acne vulgaris

Acne may vary from a relatively trivial condition to a severe disfiguring disease and management must be tailored to suit individuals. Pathogenetic factors that may be addressed by treatment include increased sebum secretion, abnormal follicular keratinisation, bacterial colonisation and local inflammation. Mild acne can be controlled with topical preparations alone but many patients with more severe disease require oral therapy with antibiotics, antiandrogens or retinoids. Combinations of topical and systemic treatments are often appropriate. The choice of drug requires knowledge of their efficacy, ease of use and possible adverse effects.

A 4% erythromycin and zinc combination (Zineryt) versus 2% erythromycin (Eryderm) in acne vulgaris: a randomized, double-blind comparative study

A double-blind, randomized multi-centre study was performed to evaluate the efficacy of a 4% erythromycin and zinc combination (Zineryt) versus 2% erythromycin (Eryderm). One-hundred and twenty-two patients suffering from acne vulgaris were treated with either Zineryt lotion or 2% erythromycin lotion. Acne grading and lesion counts for comedones, papules, pustules, nodules and macules were performed at each visit at 0, 1, 2, 4, 8 and 12 weeks. Treatment with Zineryt lotion was found to be more effective than with 2% erythromycin as regards the reduction in number of the acne lesions and the severity grade of the acne.

Contemporary therapy for acne. What, when, and how to prescribe

The use of topical tretinoin (Retin-A) for comedonal lesions, benzoyl peroxide for inflamed papules and pustules, and topical or oral antibiotics for more severe or widespread disease gives excellent results for the majority of patients with acne. At present, oral isotretinoin (13-cis-retinoic acid) (Accutane) should be reserved for patients with severe nodulocystic acne whose condition has not responded to an accepted therapeutic regimen. Good patient rapport and follow-up are essential in the management of this common disease.