Guidelines for the management of acne vulgaris in adolescents

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.

Tetracycline and viruses: a possible treatment for COVID-19?

Tetracyclines have been used to treat many bacterial infections. The use of these antibiotics for the treatment of viral diseases dates to the 1960s to 1970s. Over the decades, the effect of tetracyclines on the pathogenesis of viral infections has been demonstrated both clinically and experimentally. Tetracyclines can act on viral infections either through their antibacterial properties or through direct antiviral action. This review focuses on clinical and experimental data that support the use of tetracycline in treating viral infections and highlights an important approach to slowing disease progression during viral infections. Tetracycline treatment might represent a strategy for eliminating the infection or inhibiting the progression of COVID-19.

Non-antibiotic Isotretinoin Treatment Differentially Controls Propionibacterium acnes on Skin of Acne Patients

Emergence and potential transfer of antibiotic resistance in skin microorganisms is of current concern in medicine especially in dermatology contexts where long term treatment with antibiotics is common. Remarkably, non-antibiotic therapy in the form of isotretinoin – a non-antimicrobial retinoid is effective at reducing or eradicating the anaerobe Propionibacterium acnes which is causally involved in the complex pathogenesis of Acne vulgaris. This study measured the extent of colonization of P. acnes in patients with primary cystic or severe acne from three defined skin sites in ‘non-lesion’ areas before, during and after treatment with isotretinoin. Patients attending acne clinics were investigated using standardized skin sampling techniques and the recovery of anaerobic P. acnes from 56 patients comprising 24 females and 32 males (mean age 22 years, age range 15–46 years) who were given a standard course of isotretinoin (1 mg/kg/day) are reported. P. acnes cultured from the external cheek surface of patients following treatment showed a significant reduction (1–2 orders of magnitude) compared with their pre-treatment status. Interestingly, other distinct sites (nares and toe web) failed to show this reduction. In addition, high levels of antibiotic-resistant P. acnes were recorded in each patients’ skin microbiota before, during and after treatment. In this study, microbial composition of the skin appears substantially altered by isotretinoin treatment, which clearly has differential antimicrobial effects on each anatomically distinct site. Our study confirmed that orally administered isotretinoin shows good efficacy in the resolution of moderate to severe acne that correlates with reductions in the number of P. acnes on the skin, including resistant isolates potentially acquired from previous treatments with antibiotics. Our study suggests that the role of tetracycline’s and macrolides, which are currently first line treatments in dermatology, might be reserved for severe or life-threatening infections since current antibiotic stewardship guidelines from medical departments no longer prescribe these antibiotics for routine use.

Managing nonteratogenic adverse reactions to isotretinoin treatment for acne vulgaris

Isotretinoin is the strongest, most effective oral treatment for patients with severe acne vulgaris, with remission rates of 89% and higher. Because of its potency, isotretinoin causes many adverse reactions. This article reviews common and severe adverse reactions to isotretinoin and how providers can best manage these reactions. Because of inconclusive research on the correlation between isotretinoin and depression and irritable bowel syndrome, providers should ask patients about symptoms monthly. Prescribing micronized isotretinoin and starting at the lowest dose with gradual upward titration also can help reduce the incidence of adverse reactions.

Topical Ivermectin 10 mg/g and Oral Doxycycline 40 mg Modified-Release: Current Evidence on the Complementary Use of Anti-Inflammatory Rosacea Treatments

Rosacea is a common, chronic inflammatory skin disease that can present with a variety of signs and symptoms. The potentially simultaneous occurrence of different signs and symptoms is due to different underlying inflammatory pathways, emphasizing the need for complementary treatment approaches. Topical ivermectin cream (10 mg/g) and systemic, oral anti-inflammatory doxycycline (40 mg modified-release) are both approved for the treatment of papulopustular rosacea (PPR). Whether or not a combined therapeutic approach may be more beneficial than monotherapy for patients with PPR remains to be tested. Here, we summarize underlying inflammatory pathways implicated in rosacea and clarify the impact of these two agents on selective pathways during inflammation, due to specific characteristics of their individual mechanisms of action (MoA). Based on the complementary MoA of doxycycline modified-release and ivermectin, a scientific rationale for a combined therapy targeting inflammatory lesions in rosacea is given. We propose that topical ivermectin cream is a promising new candidate as first-line treatment to target the inflammatory lesions of rosacea, which can be used in combination with systemic doxycycline modified-release to provide an optimal treatment approach considering all inflammatory pathways involved in PPR.

Funding Galderma.

Adherence to drug treatments and adjuvant barrier repair therapies are key factors for clinical improvement in mild to moderate acne: the ACTUO observational prospective multicenter cohort trial in 643 patients

Background

In acne, several studies report a poor adherence to treatments. We evaluate, in a real-life setting conditions, the impact of compliance to physician’s instructions, recommendations and adherence to the treatments on clinical outcome in patients with mild to moderate acne in an observational, non-interventional prospective study carried out in 72 Dermatologic Services in Spain (ACTUO Trial).

Methods

Six-hundred-forty-three subjects were enrolled and 566 patients (88 %) completed the 3 study visits. Study aimed to evaluate the impact of adherence (assessed with ECOB scale) on clinical outcome, as well as how the use of specific adjuvant treatments (facial cleansing, emollient, moisturizing and lenitive specific topical products) influences treatment’s adherence and acne severity (0–5 points score). Recommendation of specific adjuvant skin barrier repair products was made in 85.2 %.

Results

Overall, clinical improvement was observed throughout follow-up visits with an increased proportion of patients who reported reductions of ≥50 % on the total number of lesions (2 months: 25.2 %; 3 months: 57.6 %) and reductions of severity scores (2.5, 2.0 and 1.3 at 1, 2 and 3 months after treatment, respectively). Adherence to treatment was associated with a significant reduction on severity grading, a lower number of lesions and a higher proportion of patients with ≥50 % improvement.

Conclusions

Good adherence to medication plus adherence to adjuvants was significantly associated with a higher clinical improvement unlike those that despite adherence with medication had a low adherence to adjuvants. A good adherence to adjuvant treatment was associated with improved adherence and better treatment outcomes in mild to moderate acne patients. (ISRCTN Registry: ISRCTN14257026).

Acne in patients with skin of color: practical management

Acne vulgaris is a prevalent and non-discriminatory condition affecting individuals of all races and ethnicities. As people with skin of color make up a rapidly expanding segment of the US population, dermatologic care must evolve accordingly to address their distinct concerns. Patients with skin of color with acne can be particularly challenging, given their potential for cosmetically disturbing complications, including post-inflammatory hyperpigmentation and keloid development. A variety of treatments have been shown to be effective in preventing or treating these complications. Topical retinoids are considered first-line therapy for acne in patients of color; topical alternatives include azelaic acid, dapsone, and antimicrobials. Hydroquinone may be used in combating post-inflammatory hyperpigmentation, specifically. For more severe acne, oral agents, including oral antibiotics or isotretinoin, may be used. Most recently, various lasers and phototherapies have been suggested for their safety and efficacy in patients with skin of color with acne. Ultimately, recognizing the clinical and histologic differences, as well as the variations in treatment regimens for darker skin types will allow for better care and patient satisfaction.

Principles of a combination therapy of acne

The authors discuss problems of selection of an adequate therapy for treatment of patients suffering from acne taking into account the clinical picture, course of the pathological process, efficiency of previous treatment, presence or absence of endocrinopathies.

Effective monitoring of isotretinoin safety in a pediatric dermatology population: a novel "patient symptom survey" approach

BACKGROUND

Assessment of adverse effects in pediatric patients on oral isotretinoin has not been standardized and the exact incidence is unknown.

OBJECTIVE

Our goal was to determine the usefulness of an isotretinoin symptom survey as a screening tool for assessment and quantification of adverse effects, including psychiatric symptoms, during isotretinoin treatment in a pediatric population of different age groups.

METHODS

We performed a retrospective chart review on a random sample of patients treated with isotretinoin at a tertiary pediatric dermatology clinic where patients completed an isotretinoin symptom survey at each visit. Responses were stratified by age group and psychiatric history.

RESULTS

The charts of 102 patients, representing 123 courses of isotretinoin and 760 treatment-months, were reviewed. A total of 722 (95.0%) symptom surveys were complete and 38 (5.0%) were incomplete/missing. Recorded side effects were similar to published adult data; dry lips/dry skin were reported in 94.25% and 72.13% of treatment-months of isotretinoin, respectively. Psychiatric symptoms were reported in 1.65%, with no statistical difference between patients with or without a mental health history. Patients aged 11 to 15 years had similar side-effect profiles to those aged 16 to 21 years. Impaired night vision, nosebleeds, and dry/bloodshot eyes were more common in the older age group.

LIMITATIONS

This was a retrospective chart review, with known limitations. The study was performed at a tertiary referral center for pediatric dermatology, possibly allowing patient selection bias.

CONCLUSIONS

The isotretinoin symptom survey appears to be an effective screening tool to standardize monitoring of isotretinoin side effects in the pediatric population.

Acne through the ages: case-based observations through childhood and adolescence

Acne vulgaris is a common disorder that affects more than 17 million individuals in the United States. Knowledge of the disease is an important part of clinical practice, particularly for the pediatric practitioner. Contrary to common belief, acne is not a disease limited to adolescents and young adults but can occur at any stage of life. This article is a case-based review of acne during childhood and adolescence. Workup is based on age and concurrent physical findings, whereas therapy depends on the type of skin lesions along with patient characteristics and preferences.

Practical considerations in acne treatment and the clinical impact of topical combination therapy

Acne vulgaris is a highly prevalent, multifactorial disease process affecting the pilosebaceous units of the dermis. The effects of acne are profound both physically and psychosocially across all age groups and ethnicities; therefore, prompt recognition and appropriate treatment are critical. Pharmacotherapeutic approaches range from simple monotherapy to multimodal treatments with a variety of topical and systemic agents. Optimal patient outcomes in acne management, however, are based both on treatment efficacy as well as overall patient satisfaction. In an effort to comprehensively address these key clinical considerations in acne management, we examine the diverse nature of acne patients, the factors in optimizing treatment outcomes, and the clinical impact of current medications, particularly topical combination therapy.

Reduced Salivary Flow Induced by Systemic Isotretinoin May Lead to Dental Decay. A Prospective Clinical Study

BACKGROUND

The adverse effects of isotretinoin have been well documented, but dental side effects over the course of treatment have never been studied.

OBJECTIVES

To prospectively document the oral side effects experienced by a group of patients taking isotretinoin and to compare the changes in oral health and salivary parameters with a control group.

METHODS

A cohort study was conducted within the dermatology department at the University Hospital in collaboration with two private dermatology practices in Nice, France. Patients were treated at a dose of 0.5 mg/kg/day. The control group was made up of students from the University of Nice-Sophia-Antipolis. The salivary flow, the buffer capacity of saliva, the number of pathogen bacteria and the DMFT index (number of decayed, missing and filled teeth) were assessed at each visit.

RESULTS

Eighteen patients and 99 controls were available for evaluation. None of the oral parameters varied with time in the control group, whereas the DMFT significantly increased in the treated group (3.07 +/- 3.85 vs. 3.41 +/- 4.36; p<0.036). The salivary flow gradually decreased with time (p<0.004), but the patients recovered their baseline salivary flow 2 months after the end of the treatment.

CONCLUSIONS

This study clearly showed that patients treated with isotretinoin experienced oral side effects.

Minocycline-induced lupus in adolescents: clinical implications for physical therapists

STUDY DESIGN

Resident's case problem.

BACKGROUND

In the United States, minocycline is a frequently prescribed medication for the treatment of moderate to severe acne, a common condition in adolescents. The use of minocycline has been associated with severe adverse effects that frequently comprise a musculoskeletal component, including drug-induced lupus. Physical therapists have the responsibility to identify drug reactions that mimic musculoskeletal symptoms. The patient described herein was a 15-year-old adolescent boy who had taken minocycline for 14 days. He was initially treated by his primary physician on the 15th day of minocycline therapy for symptoms of fever, joint swelling, and a rash. The patient presented to a physical therapist on the 22nd day with complaints of severe myalgia, arthralgia, and severely limited mobility secondary to pain. The patient was referred to a pediatric rheumatologist because of the systemic nature and severity of the symptoms.

DIAGNOSIS

The patient was subsequently diagnosed as having drug-induced lupus by a pediatric rheumatologist. The patient's myalgia and arthralgia subsided within 6 weeks, but his strength, coordination, and endurance did not reach their prior levels for 3 to 4 months.

DISCUSSION

Physical therapists who include a comprehensive pharmacovigilance component in their patient examination may recognize musculoskeletal symptoms that arise from a nonmusculoskeletal origin. Minocycline is commonly prescribed in the United States as an antibiotic and for treatment of acne and rheumatoid arthritis. Therefore, physical therapists should screen for minocycline use when an adolescent patient or a patient with rheumatoid arthritis presents with diffuse musculoskeletal symptoms. An automated medication monitoring system would provide physical therapists with a means of accessing current information on medication use.

Topical methyl aminolaevulinate photodynamic therapy for treatment of facial acne vulgaris: results of a randomized, controlled study

BACKGROUND

There is a need for alternative treatments for moderate to severe acne vulgaris. Preliminary experience suggests that topical methyl aminolaevulinate photodynamic therapy (MAL-PDT) may have potential.

OBJECTIVES

To investigate the efficacy and tolerability of MAL-PDT for treatment of moderate inflammatory facial acne.

PATIENTS/METHODS

Thirty patients aged 15-28 years with moderate to severe acne were included in a blinded, prospective, randomized, placebo-controlled multicentre study. Each side of each patient's face was randomly assigned to treatment with MAL (160 mg g1) or placebo cream, applied for 3 h prior to illumination. A second treatment was given 2 weeks later. On each occasion, patients assessed the intensity of pain using a 10-cm visual analogue scale. Inflammatory and noninflammatory acne lesions were counted at baseline and 4 and 10 weeks after the last PDT treatment. The investigator assessed the global severity of acne at baseline (seven patients had severe acne on at least one side of the face) and each study visit using a six-point rating scale. Data were analysed on an intention-to-treat basis, including all 30 patients.

RESULTS

There was a statistically significant greater reduction in the total inflammatory lesion count with MAL-PDT compared with placebo PDT at week 12; median reduction 54% [95% confidence interval (CI) 35-64%] vs. 20% (95% CI 8-50%), P = 0.0006. MAL-PDT was associated with more pain than placebo PDT, although intensity varied across centres and was reduced with repeated treatment. Local adverse events were consistent with this treatment modality.

CONCLUSIONS

MAL-PDT is effective in the treatment of moderate to severe inflammatory facial acne. Further studies are warranted to optimize this promising procedure.

Comparison of topical retinoids in the treatment of acne

Topical retinoids are been used to successfully treat acne for almost 3 decades. At the beginning, a retinoid was a compound of similar structure and action to retinol (vitamin A).(1) Changes at the carboxylic end group, the polyene chain, and the aromatic ring can result in the modification of the original molecule. To date, three generations of retinoids have been developed: the nonaromatics (retinol, tretinoin, and isotretinoin), the monoaromatics (etretinate and acitretin), and the polyaromatics (arotinoid, adapalene, and tazarotene). The new synthetic retinoid molecules have little resemblance with retinol but nonetheless are included in this family because they have the ability to bind with or activate retinoid receptors. Therefore, retinoids are vitamins and also hormones.(3)

Benzoyl peroxide-based combination therapies for acne vulgaris: a comparative review

Benzoyl peroxide, with its broad-spectrum antimicrobial activity, is among the most widely used topical agents in the treatment of inflammatory acne vulgaris. Benzoyl peroxide is marketed either alone or in combination with other topical antibiotics; namely, erythromycin and clindamycin. The combination products confer specific advantages over benzoyl peroxide alone, particularly in decreasing the in vivo follicular counts of Propionibacterium acnes, the anaerobic bacterium implicated in the pathogenesis of acne. In addition, the topical treatment of inflammatory acne has been complicated by the development of P acnes resistance to topical erythromycin and clindamycin. Combination products containing benzoyl peroxide and the topical antibiotics have been shown to both: (i) prevent the development of antibiotic resistance in acne patients; and (ii) confer significant clinical improvement to patients who have already developed antibiotic resistance.

Tetraciclinas, sulfamidas y metronidazol

Tetracyclines form a group of natural and semisynthetic products that acts inhibiting the bacterial protein synthesis. They are bacteriostatic agents, exhibiting activity against a wide range of organisms, but they are at the present of limited use because of their acquired resistance. Doxycycline is currently the most frequently used tetracycline in human medicine and it is included in the List of Essential Medicines of the World Health Organization. Sulfonamides are synthetic, broad-spectrum bacteriostatic antibiotics. They were the first effective systemic antimicrobial agents. Their mode of action is based on the inhibition of DNA synthesis. Due to their toxicity and high adquired resistance their use is currently very low. Metronidazole is the main compound of 5-nitroimidazole family. It is a very active bactericidal antibiotic against anaerobic and some microaerophilic bacteria and it is still very useful in the treatment of bacterian and parasitic infections.