Meeting the Challenges of Acne Treatment in Asian Patients: A Review of the Role of Dermocosmetics as Adjunctive Therapy

A review of the topical management of acne and its associated sequelae in the Asia-Pacific region with a spotlight on trifarotene

Acne, a highly prevalent skin disease, can be particularly bothersome for patients of Asian background because of its impact on self-confidence and social interactions. In addition to active acne lesions, some patients may develop sequelae such as scarring, macular/postinflammatory hyperpigmentation, or erythema. The tendency of Asian skin to develop sequelae because of its increased susceptibility to irritation, cultural preferences for lighter skin phototypes, and differences in skincare regimens may all contribute to the increased burden of acne. Moreover, many Asia-Pacific countries do not have their own guidelines for acne management, and those that do often have no schedule in place for regular updates. In this article, we provide a critical review of the published guidance for the management of acne and its sequelae in the Asia-Pacific region, identifying gaps in current recommendations that could be addressed to enhance standards of acne care in Asia-Pacific countries. Along with highlighting the importance of a comprehensive skincare regimen to increase treatment efficacy and adherence, we discuss topical retinoids and retinoid combination options in the acne armamentarium that may be beneficial for sequelae prevention and management, such as adapalene 0.3% ± benzoyl peroxide 2.5%, tretinoin 0.05%, tazarotene 0.1%, and trifarotene 0.005%. In particular, trifarotene 0.005% has been observed to significantly reduce acne scar counts in a Phase 4 study. The recent data highlight the need to establish up-to-date guidance for acne and acne sequelae management in Asia-Pacific countries to provide optimal care to Asian patients.

Expert consensus on holistic skin care routine: Focus on acne, rosacea, atopic dermatitis, and sensitive skin syndrome

BACKGROUND

Treatment, cleansing, moisturizing, and photoprotection are four major components of holistic skin care for dermatological conditions. While treatment (T) is recognized as a key component in the management of dermatological conditions, there is a lack of practical guidance on the adjunctive role of cleansing, moisturizing, and photoprotection ("CMP"). Limited patient knowledge, confusion over product selection, and lack of guidance on how to choose and use CMP skin care products (in conjunction with pharmacological therapy) are the main barriers to establishing a holistic skin care routine for dermatological conditions.

AIMS

This study aimed to review current clinical evidence, identify gaps, and provide practical guidance on conceptualization and implementation of CMP routine in the management of sensitive skin due to underlying acne, atopic dermatitis, or rosacea, including conditions with idiopathic causes referred to as idiopathic sensitive skin syndrome.

METHODS

An expert panel comprising of 10 dermatologists from Australia, China, Hong Kong, Taiwan, India, Indonesia, Philippines, Singapore, South Korea, and Thailand convened to develop consensus statements on holistic skin care in acne, rosacea, atopic dermatitis, and idiopathic sensitive skin syndrome using the Delphi approach.

RESULTS

Consensus was defined as ≥80% of panel rating statement as ≥8 or median rating of ≥8. The final statements were collated to develop consensus recommendations on holistic skin care.

CONCLUSION

A dermatologist-guided holistic skin care routine is essential to improve patient confidence and reduce confusion over product selection. The consensus recommendations presented here highlight the importance of cleansing, moisturization, and photoprotection in holistic skin care and how it can be utilized as a communication tool for physicians and patients to achieve overall better patient compliance, satisfaction, and treatment outcomes.

The influence of cosmetics dedicated to oily and acne-prone skin on skin parameters

INTRODUCTION

Patient compliance with care recommendations is closely related to the role of cosmetics in delaying or preventing the side effects of medications used to treat acne.

METHODS

A total of 33 volunteers with symptoms of acne vulgaris were qualified for the study. The skin parameters were measured before the experiment, after the 4 and at the 8 weeks of use. The measurements were subject to moisturizing the skin and secretion of sebum and skin color. A skin acoustic parameters using high-frequency ultrasound (33 MHz) was also performed. The recorded images were used to determine the epidermal entrance echo thickness and echo density of dermis.

RESULTS

The results show a change in the value of skin parameters during the 8-week application of a specific skin care procedure. The secretion of sebum did not change significantly, there was a decrease in hydration, and the level of melanin and hemoglobin remained at the same level. The thickness of the epidermis entrance echo in the ultrasound image was thinned.

CONCLUSION

For many mild/moderate acne patients, cosmetics proven to be effective and well tested in clinical trials can offer a real benefit in reducing both inflammation, sebum production, melanin, and irritation, but should also be moisturizing.

Evaluation of Personalized Skincare Through in-silico Gene Interactive Networks and Cellular Responses to UVR and Oxidative Stress

Purpose

Personalized approaches in dermatology are designed to match the specific requirements based on the individual genetic makeup. One major factor accounting for the differences in skin phenotypes is single nucleotide polymorphism (SNP) within several genes with diverse roles that extend beyond skin tone and pigmentation. Therefore, the cellular sensitivities to the environmental stress and damage linked to extrinsic aging could also underlie the individual characteristics of the skin and dictate the unique skin care requirements. This study aimed to identify the likely biomarkers and molecular signatures expressed in skin cells of different ethnic backgrounds, which could aid further the design of personalized skin products based on specific demands.

Methods

Using data mining and in-silico modeling, the association of SNP-affected genes with three major skin types of European, Asian and African origin was analyzed and compared within the structure-function gene interaction networks. Cultured dermal fibroblasts were subsequently subjected to ultraviolet radiation and oxidative stress and analyzed for DNA damage and senescent markers. The protective applications of two cosmetic ingredients, Resveratrol and Quercetin, were validated in both cellular and in-silico models.

Results

Each skin type was characterized by the presence of SNPs in the genes controlling facultative and constitutive pigmentation, which could also underlie the major differences in responses to photodamage, such as oxidative stress, inflammation, and barrier homeostasis. Skin-type-specific dermal fibroblasts cultured in-vitro demonstrated distinctive sensitivities to ultraviolet radiation and oxidative stress, which could be modulated further by the bioactive compounds with the predicted capacities to interact with some of the genes in the in-silico models.

Conclusion

Evaluation of the SNP-affected gene networks and likely sensitivities of skin cells, defined as low threshold levels to extrinsic stress factors, can provide a valuable tool for the design and formulation of personalized skin products that match more accurately diverse ethnic backgrounds.

The Synergy between Pharmacological Regimens and Dermocosmetics and Its Impact on Adherence in Acne Treatment

Background

Acne is the most common inflammatory skin disease in adolescence. It is also prevalent in adults, especially females. The disease has a considerable impact on health-related quality of life. Many studies have reported the negative impact of acne on patients due to skin disfigurement, ineffective treatment, and adverse effects of the treatment. Numerous factors contribute towards nonadherence to therapy. Summary. This review discusses the various factors that are related to treatment nonadherence such as ineffective therapy, adverse effects with topical pharmacotherapy such as skin irritation and erythema as well as patient-related factors such as lack of knowledge of disease and a poor patient-physician relationship. Various methods are being adopted to increase adherence to treatments. Increased adherence to acne therapy has been associated with the use of dermocosmetics, such as moisturizers and cleansers. Encouraging the use of dermocosmetics in synergy with pharmacological regimens could support improved treatment adherence resulting in better clinical outcomes for acne patients.

Conclusion

Dermocosmetics as an adjunct to pharmacological regimens has the potential to improve clinical outcomes by increasing treatment adherence in patients with acne.

Photoprotection according to skin phototype and dermatoses: practical recommendations from an expert panel

Increasing evidence on the impact of the different wavelengths of sunlight on the skin demonstrates the need for tailored recommendations of sunscreen according to skin phototype and dermatoses, which is now possible due to advances in the filters and formulations of sunscreens. A selective literature search was performed by an international expert panel, focusing on the type of sunscreen to recommend for photoaging, skin cancers, photodermatoses, pigmentary disorders and skin inflammatory disorders. Protection against ultraviolet (UV)B is especially important for light skin as there is a high risk of sunburn, DNA damage and skin cancers. Darker skin may be naturally better protected against UVB but is more prone to hyperpigmentation induced by visible light (VL) and UVA. Protection against UVA, VL and infrared A can be helpful for all skin phototypes as they penetrate deeply and cause photoaging. Long‐wave UVA1 plays a critical role in pigmentation, photoaging, skin cancer, DNA damage and photodermatoses. Adapting the formulation and texture of the sunscreen to the type of skin and dermatoses is also essential. Practical recommendations on the type of sunscreen to prescribe are provided to support the clinician in daily practice.

Treatment of acne and acne-related scarring with fixed combination clindamycin phosphate and benzoyl peroxide gel (1.2%/3.75%) and tretinoin gel microsphere 0.06% in an Asian American transgender female

Acne vulgaris is one of the most common skin diseases in the United States and can affect any gender or ethnic group. Post-inflammatory hyperpigmentation (PIH) and scarring from acne can have a negative psychosocial impact on patients. Skin of color patients are particularly prone to PIH, as the dark marks left from acne may take several months to resolve, far after the acne has cleared. Here, we report a case of moderate acne with associated scarring in a transgender, Asian American female who was successfully treated with fixed combination topical therapy with clindamycin phosphate and benzoyl peroxide gel 1.2%/3.75% and tretinoin gel microsphere 0.06%.

The application of skin care product in acne treatment

Acne is a kind of chronic inflammatory skin disease, which is common in the hair follicle and sebaceous gland of teenagers. It often recurs and affects the quality of life of patients. Acne itself can cause the damage of skin barrier function. On the other hand, common acne treatment methods, such as external drugs, systemic drugs, physical, and chemical treatment, can also lead to the damage of skin barrier function and affect the treatment effect. The application of skin care in the adjuvant treatment of acne has been widely concerned. Due to their high safety, good tolerance, and the effect of improving the damaged skin barrier, medical skin care products are a hot spot in the treatment of cosmetic skin diseases in recent years. It can not only increase the curative effect, reduce the side effects, but also increase the compliance of patients when combined with conventional acne treatment. In this article, skin care products and their application in acne treatment were reviewed.

Efficacy and Tolerability of Topical Nicotinamide Plus Antibacterial Adhesive Agents and Zinc-Pyrrolidone Carboxylic Acid Versus Placebo as an Adjuvant Treatment for Moderate Acne Vulgaris in Indonesia: A Multicenter, Double-blind, Randomized, Controlled Trial

OBJECTIVE: We investigated the efficacy and tolerability of nicotinamide cream plus an antibacterial adhesive agent and zinc-pyrrolidone carboxylic acid compared to placebo in patients with moderate acne vulgaris (MAV) in Indonesia. METHODS: This was a multicenter, double-blind, randomized, placebo-controlled, parallel-group study conducted in five teaching hospitals in Indonesia from August 2016 to January 2017. Eligible participants included 140 patients with MAV, aged 12 to 50 years, who were enrolled and randomly divided into two groups to receive either adapalene and the study formulation or adapalene and a placebo cream twice daily for six weeks. Clinical response and treatment efficacy were assessed through acne lesion counts, presence of side effects, and patient satisfaction at the second, fourth, and sixth weeks after the first visit. RESULTS: A total of 140 subjects from five different centers (28 subjects in each center) were enrolled. One hundred twenty-seven subjects completed the study, including 63 subjects in the study group and 64 subjects in the placebo group. A significant decrease in the number of noninflammatory lesions in the second week was noted in the study group compared to in the placebo group. There were no significant differences in adverse effects between the two groups in the second and fourth weeks. CONCLUSION: Treatment using nicotinamide plus an antibacterial adhesive agent and zinc-pyrrolidone carboxylic acid was effective in reducing noninflammatory lesions by the second week of therapy. ClinicalTrials.gov registration no. NCT0326298.

Challenges and Solutions in Oral Isotretinoin in Acne: Reflections on 35 Years of Experience

Acne vulgaris affects more than 80% of adolescents and young adults and forms a substantial proportion of the dermatologist's and general practitioner's caseload. Severity of symptoms varies but may result in facial scarring and psychological repercussions. Oral isotretinoin is highly effective but can only be prescribed by specialists. Side effects are recognized and mostly predictable, ranging from cosmetic effects to teratogenicity. These can affect patients' quality of life and treatment adherence. This article provides a commentary on 4 key areas: the use of oral isotretinoin vs oral antibiotics, including the importance of early recognition of nonresponse to treatment, the psychological effects of acne and isotretinoin treatment, the side effects of isotretinoin therapy, and cosmetic treatment options that can help alleviate predictable side effects. The authors, who have all participated in various international expert groups, draw on relevant literature and their extensive professional experience with oral isotretinoin in the treatment of acne. The aim of this article is to provide an informative and practical approach to managing oral isotretinoin treatment in patients with acne, to help optimize treatment of this skin disease.

Menopausal Acne - Challenges And Solutions

Although acne is a disease predominant in adolescence, it is being increasingly observed in adult life, including the menopausal period. The etiology of menopausal acne is multifactorial, with hormonal imbalance being the major culprit. There is a relative increase of androgens in the menopausal female that leads to clinical hyperandrogenism manifesting as acne, hirsutism and androgenetic alopecia. Other endocrine disorders including thyroid abnormalities, hyperprolactinemia and insulin resistance also play a role. Genetics, stress, dietary changes, lack of sleep and exercise and other lifestyle changes are implicated as trigger factors. Most menopausal women with isolated few acne lesions have normoandrogenic serum levels and do not require extensive investigations. However, baseline investigations including total testosterone are useful. Patients must also be evaluated for associated comorbidities such as obesity, diabetes, hypertension and dyslipidemia. A detailed history can help to exclude polycystic ovarian syndrome, late-onset congenital adrenal hyperplasia or medications as a cause of acne. The evaluation of menopausal acne and the approach to treatment depend on the severity of acne and associated features. In patients with mild acne without virilization, prolonged topical therapy is the mainstay of treatment. Though combined oral contraceptives are effective, they are relatively contraindicated in the postmenopausal period. Spironolactone is the first choice of therapy in the subset of patients that require oral anti-androgen therapy. Procedural treatment can be useful as it can also help in the treatment of associated acne scars and concomitant skin aging. It is also important to focus on lifestyle changes such as reducing stress, controlling obesity, having a healthy diet, exercise and proper skin care routine to reduce acne. The focus of this article is on the clinical presentation and management challenges of menopausal acne, which represents a special subtype of acne.

A Real-Life, International, Observational Study Demonstrating The Efficacy Of A Cosmetic Emulsion In The Supportive Care Of Mild-To-Moderate Facial Acne

Purpose

Cosmetic emulsions are increasingly being used as supportive care products to alleviate the severe side effects and improve the clinical outcomes associated with conventional acne treatments. The objectives of this study were to determine, in a real-life setting, the global effectiveness of an emulsion with antiseborrheic, keratolytic and anti-Propionibacterium acnes activities as an adjunct to anti-acne therapy, and to evaluate the effect of the product on acne severity, noninflammatory and inflammatory lesions, hyperseborrhea, skin irritation and patient quality of life (QoL). Tolerance of the product was also assessed.

Patients and methods

This international observational study involved 3960 patients aged 12 years and over with mild-to-moderate acne. The conventional acne prescriptions for these patients were either initiated at inclusion or were reviewed. Reviewed prescriptions may have been left unchanged, switched, or an addition made to ongoing treatment. At inclusion, participants were instructed to apply the cosmetic product daily for 2–3 months in combination with their medical acne treatment.

Results

After 2 to 3 months of use, the combined therapy resulted in moderate-to-large improvements in acne in over 75% of the patients whose acne prescriptions were left unchanged (n=859). The combination treatment led to an improvement in acne severity (−38.3% change in the mean investigator’s global assessment score; p<0.0001) and QoL (−38.3% change in the mean Cardiff acne disability index score; p<0.0001), and reduced noninflammatory and superficial inflammatory lesions (−35.3% and −47.0%, respectively; p<0.0001), hyperseborrhoea (−40.6%; p<0.0001) and skin irritation (−37.2%; p<0.0001). Tolerance was very good.

Conclusion

Use of the cosmetic emulsion combined with conventional acne therapy significantly improved clinical outcomes and patient QoL, and was very well tolerated. The combined therapy may have improved patient satisfaction, leading to improved patient adherence and higher rates of therapeutic success.

Acne Management Guidelines by the Dermatological Society of Singapore

Due to the multiethnic patient population with varying skin types in Singapore, clinicians often find the management of acne in their patients to be challenging. The authors developed these guidelines to provide comprehensive advice on individualized acne treatment and to provide a reference guide for all doctors who treat patients of Asian descent. Unique features of acne in Singapore are highlighted. We address concerns such as diet, special population needs, and the benefits, side effects, risks, and cost-effectiveness of currently available acne treatments. These treatment guidelines outline recommendations for the diagnosis, grading, and treatment of children, adolescents, and adults with acne of varying severity, and include advice pertaining to the use of cosmeceuticals and management of scars.

Optimizing the use of topical retinoids in Asian acne patients

Acne vulgaris is a common disease among people in Asia. International guidelines and treatment recommendations emphasize the central role of topical retinoids in the management of acne. However, topical retinoids remain underutilized in clinical practise, which may be in part due to fear of retinoid‐associated dermatitis/lack of experience, particularly in Asian patients. There is a perception that Asian skin has a greater tendency toward sensitivity compared with Caucasian skin. In our clinical experience, topical retinoid therapy can be used with excellent effect to treat Asians with acne. This article discusses available published work regarding the use of topical retinoids in Asian populations, and presents tips for utilizing these important agents in daily practise. Optimizing use of topical retinoids may improve adherence and, in turn, therapeutic outcomes and patient satisfaction.

The Use of Cosmeceuticals in Acne: Help or Hoax?

The use of cosmeceuticals by patients with acne is common; however, their role is unclear and confusing, with many asking, "Do they really help acne?" Cosmeceuticals are intermediate products between prescription medications and cosmetics, available to consumers over the counter. These products are popular and may be used without the direct supervision of a dermatologist, creating a practice gap in educating patients. Herein, a variety of cosmeceuticals are discussed, including retinoids, niacinamide, and glycolic acid. The evidence for and against cosmeceutical use in patients with acne is reviewed.