Guidelines of care for the management of acne vulgaris

BACKGROUND

Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9 years or older.

OBJECTIVE

The objective of this study was to provide evidence-based recommendations for the management of acne.

METHODS

A work group conducted a systematic review and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of evidence and formulating and grading recommendations.

RESULTS

This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements.

LIMITATIONS

Analysis is based on the best available evidence at the time of the systematic review.

CONCLUSIONS

These guidelines provide evidence-based recommendations for the management of acne vulgaris.

Treatments for Moderate-to-Severe Acne Vulgaris: A Systematic Review and Network Meta-analysis

BACKGROUND

Multiple treatment options exist for the management of moderate-to-severe acne. However, the comparative effectiveness (efficacy/safety) of moderate-to-severe acne treatments has not been systematically examined.

METHODS

A systematic literature review (SLR) was conducted to identify randomized controlled trials of ≥4 weeks of treatment (topical, oral, physical, or combinations) for moderate-to-severe facial acne in patients aged ≥9 years. Efficacy outcomes included: percentage of patients achieving ≥2-grade reduction from baseline and “clear” or “almost clear” for global severity score (treatment success); absolute change in inflammatory (ILs reduction); and noninflammatory lesion counts (NILs reduction). A random-effects network meta-analysis (NMA) was conducted for the efficacy outcomes. Treatments were ranked with posterior rank plots and surface under cumulative ranking values.  Results: Eighty-five studies were included in the SLR/NMA. Topical triple-agent fixed-dose combination (FDC) gel (clindamycin phosphate 1.2%/adapalene 0.15%/benzoyl peroxide 3.1%) and combinations of double-agent fixed-dose topical treatments with oral antibiotics (TOA3) consistently ranked in the top 3 treatments. Topical triple-agent FDC gel was numerically superior to TOA3 for treatment success (log-odds ratios: 1.84 [95% credible interval (CrI) 1.36 to 2.29]) and 1.69 (95% CrI: 1.01 to 2.32) vs placebo/vehicle). TOA3 was numerically superior to topical triple-agent FDC gel for reduction of ILs (mean difference: -8.21 [-10.33 to -6.13]) and -10.40 [-13.44 to -7.14] vs placebo/vehicle) and NILs (mean difference: -13.41 [-16.69 to -10.32] and -17.74 [-22.56 to -12.85] vs placebo/vehicle).

CONCLUSIONS

Based on this SLR/NMA, topical triple-agent FDC gel was the most efficacious and safe treatment for moderate-to-severe acne. J Drugs Dermatol. 2024;23(4):     doi:10.36849/JDD.8148.

IGAxBSA composite for assessing disease severity and response in patients with atopic dermatitis

BACKGROUND

Accurate assessment of atopic dermatitis (AD) severity is critical when initiating and monitoring therapy. Use of existing research tools such as the Eczema Area and Severity Index (EASI) and the SCORing Atopic Dermatitis (SCORAD) is complex and time-consuming in clinical practice. A previous analysis found the product of validated Investigator Global Assessment (vIGA) and affected body surface area (BSA) to be an accurate and practical tool for routine assessment of paediatric AD.

OBJECTIVE

To evaluate IGAxBSA composite as an alternative to EASI or SCORAD for assessment of AD disease severity and disease responsiveness.

METHODS

The relationship between IGAxBSA, EASI, and SCORAD was assessed in a post-hoc analysis of pooled data from the dupilumab clinical trial programme in adult and paediatric patients with moderate-to-severe AD who had received dupilumab or placebo (with/without topical corticosteroids [TCS]).

RESULTS

Using datapoints from pooled dupilumab randomized controlled trials (n = 3473) and open-label extension (OLE) trials (n = 3045), we found that IGAxBSA correlated well with EASI and SCORAD, irrespective of treatment group and race (White/Asian/Black). IGAxBSA correlated better with objective measures (EASI, SCORAD) than with patient/caregiver-reported subjective measures. IGAxBSA correlated strongly with EASI and SCORAD in assessing disease change over time (r = 0.8973; r = 0.7649, respectively; P < 0.0001) and concordance between IGAxBSA-50/75/90 and EASI-50/75/90 was excellent (88-94%).

CONCLUSIONS

IGAxBSA is a valid alternative for assessment of AD disease severity and response over time, compared with EASI or SCORAD in patients with AD, irrespective of race.

International Dermatology Outcome Measures (IDEOM): Report from the 2020 Annual Meeting

BACKGROUND

The International Dermatology Outcome Measures (IDEOM) initiative is a non-profit organization that aims to develop evidence-based outcome measurements to evaluate the impact of treatments for patients with dermatological disease. IDEOM includes all key stakeholders in dermatology (patient, physician, industry, insurer, and government) during the process of developing such outcome measurements.

SUMMARY

Here, we provide an update of IDEOM activities that were presented at the 2020 IDEOM Virtual Annual Meeting (October 23-24, 2020). During the meeting, multiple IDEOM workgroups (psoriasis, psoriatic arthritis, hidradenitis suppurativa, acne, pyoderma gangrenosum, and actinic keratosis) shared their progress to date, as well as future directions in developing and validating Patient-Reported Outcome Measures. Updates on demonstrating efficacy in clinicals trials by the US Food and Drug Administration are also summarized. Key Messages: In this report, we summarize the work presented by each IDEOM workgroup (psoriasis, psoriatic arthritis, hidradenitis suppurativa, acne, pyoderma gangrenosum, and actinic keratosis) at the 2020 IDEOM Virtual Annual Meeting.

Current Concepts in Acne Pathogenesis: Pathways to Inflammation

Acne is a disease of pilosebaceous inflammation. Pivotal in pathogenesis are the roles of hormones (insulin, insulin-like growth factor-1, androgens), Propionibacterium acnes, lipogenesis, and a proinflammatory lipid profile. Innate immune responses are induced through interaction with toll-like receptors and inflammasome activation initially and subsequently through adaptive immune activation. These insights into pathogenic inflammatory pathways can translate into novel therapeutic approaches for acne. Semin Cutan Med Surg 37(supp3):S60-S62 ©2018 published by Frontline Medical Communication.

Treating Acne in Patients With Skin of Color

Patients with skin of color are more likely to develop acne and postinflammatory hyperpigmentation (PIH). Many therapies for acne have demonstrated efficacy in darker skin types and in the treatment of PIH. Semin Cutan Med Surg 37(supp3):S71-S73 © 2018 published by Frontline Medical Communications.

Advances in Acne and Rosacea Therapy

New topical therapies have demonstrated efficacy in patients with moderate or severe acne who might otherwise have required therapy with systemic antibiotics or isotretinoin. Increasing knowledge about the pathogenesis of acne has facilitated the development of therapies with novel modes of action. New and investigational therapies also are available or in development for the treatment of both the papulopustular and erythematous manifestations of rosacea. Semin Cutan Med Surg 37(supp3):S63-S66 © 2018 published by Frontline Medical Communications.

Use of an alternative method to evaluate erythema severity in a clinical trial: difference in vehicle response with evaluation of baseline and postdose photographs for effect of oxymetazoline cream 1·0% for persistent erythema of rosacea in a phase IV study

Background

Once‐daily topical oxymetazoline cream 1·0% significantly reduced persistent facial erythema of rosacea in trials requiring live, static patient assessments.

Objectives

To evaluate critically the methodology of clinical trials that require live, static patient assessments by determining whether assessment of erythema is different when reference to the baseline photograph is allowed.

Methods

In two identically designed, randomized, phase III trials, adults with persistent facial erythema of rosacea applied oxymetazoline or vehicle once daily. This phase IV study evaluated standardized digital facial photographs from the phase III trials to record ≥ 1‐grade Clinician Erythema Assessment (CEA) improvement at 1, 3, 6, 9 and 12 h postdose.

Results

Among 835 patients (oxymetazoline n = 415, vehicle n = 420), significantly greater proportions of patients treated with oxymetazoline vs. vehicle achieved ≥ 1‐grade CEA improvement. For the comparison between phase IV study results and the original phase III analysis, when reference to baseline photographs was allowed while evaluating post‐treatment photographs, the results for oxymetazoline were similar to results of the phase III trials (up to 85.7%), but a significantly lower proportion of vehicle recipients achieved ≥ 1‐grade CEA improvement (up to 29.7% [phase 4] vs. 52.3% [phase 3]; P<0.001). In the phase IV study, up to 80·2% of patients treated with oxymetazoline achieved at least moderate erythema improvement vs. up to 22·9% of patients treated with vehicle. The association between patients’ satisfaction with facial skin redness and percentage of erythema improvement was statistically significant.

Conclusions

Assessment of study photographs, with comparison to baseline, confirmed significant erythema reduction with oxymetazoline on the first day of application. Compared with the phase III trial results, significantly fewer vehicle recipients attained ≥ 1‐grade CEA improvement, suggesting a mitigated vehicle effect. This methodology may improve the accuracy of clinical trials evaluating erythema severity.

What's already known about this topic?

Phase III studies that evaluate the effects of medications on persistent facial erythema associated with rosacea require investigator assessments without allowing comparison with baseline images.

What does this study add?

Grading of facial erythema of rosacea that utilized baseline photographs compared with post‐treatment photographs enhanced the accuracy of persistent facial erythema assessments.

Furthermore, this method more accurately differentiated active treatment with oxymetazoline cream 1·0% from vehicle compared with live, static assessments.

Methodology that allows for comparison to baseline photographs may improve the accuracy of clinical trials that evaluate erythema severity.

Linked Comment: https://doi.org/10.1111/bjd.17725.

https://www.bjdonline.com/article/

Treating Acne in Adult Women

Acne can persist into adulthood or erupt de novo at any point after adolescence. Adult acne is more common in women than in men. Considerations for treating acne in adult women include childbearing potential, pregnancy, lactation, and concomitant skin conditions. Semin Cutan Med Surg 37(supp3):S67-S70 © 2018 published by Frontline Medical Communications.

Attitudes of Female Patients regarding Oral Contraceptives for Treatment of Acne

Background:

Two hormonal agents with contraceptive properties are currently indicated in Canada for treatment of acne.

Objective:

The purpose of this study was to determine the attitudes and concerns of female patients regarding the use of hormonal agents and oral contraceptives in treatment of acne.

Methods:

A self-completed questionnaire was administered to all female acne patients of a community-based dermatologist over a 10-week period between June and August 1999. Statistical analysis was performed by chi-square testing at the 5% significance level.

Results:

Eighty-six percent recognized that oral contraceptives (“birth control pills”) were also used as a treatment for acne and 60% were willing to use this form of treatment. The most common concern regarding the use of oral contraceptives were side effects (80%). Younger patients were seven times more likely to be concerned about potential disapproval or misunderstanding on the part of others regarding the use of these medications ( p ∼ 0.01).

Conclusion:

Female acne patients recognize that oral contraceptives are useful in treatment of acne. Although side effects of these medications are of general concern, social disapproval is of particular concern to younger patients.

Reliability of Dermatologists in Acne Lesion Counts and Global Assessments

Background:

There is a paucity of data on the reliability of dermatologists in acne lesion counting and global severity assessments. The effects of training and practice on reliability are also uncertain. The objective of this study was to determine the reliability of these outcome measurements when performed by trained dermatologists.

Methods:

Eleven dermatologists were divided into two groups that evaluated the same six acne subjects twice on the same day. A training session was provided either after (group A) or before (group B) the first patient evaluation sessions. Reliability of raters in lesion counting and global severity assessment was determined by calculation of intraclass correlation coefficients (ICCs). ICC values close to 1.0 indicate excellent reliability, whereas values less than 0.75 are considered unacceptable.

Results:

Intrarater ICCs ranged from 0.37 to 0.99 for noninflammatory lesions, 0.26 to 0.97 for inflammatory lesions, and 0.56 to 0.83 for global assessments for group A (trained after); corresponding values for group B (trained before) were 0.84 to 0.98, 0.61 to 0.95, and 0.43 to 0.91. ICC values ≥ 0.75 for all three outcome parameters were observed in one of six group A and three of five group B raters. Interrater ICCs for groups A and B after the first evaluation session were 0.17 versus 0.68 for noninflammatory counts, 0.84 versus 0.72 for inflammatory counts, and 0.71 versus 0.65 for global assessments, respectively. Corresponding values after session 2 were 0.79 and 0.77 for noninflammatory, 0.81 and 0.90 for inflammatory, and 0.61 and 0.77 for global assessments.

Conclusion:

Dermatologists tended to be reliable in acne lesion counting but somewhat less so in global assessments. Training tended to improve group reliability in noninflammatory lesion counts and increased the proportion of raters with good reliability in all three outcome measures. Practice enhanced reliability in all outcome measurements.

A global perspective on the epidemiology of acne

Acne is estimated to affect 9.4% of the global population, making it the eighth most prevalent disease worldwide. Epidemiological studies have demonstrated that acne is most common in postpubescent teens, with boys most frequently affected, particularly with more severe forms of the disease. This paper aims to provide an update on the epidemiology of acne worldwide. Recent general and institutional studies from around the world have shown that the prevalence of acne is broadly consistent globally (with the exception of specific populations, which are discussed). However, this review highlights that there is a wide range of disparate outcome measures being applied in epidemiology studies, and we emphasize the need to develop a widely accepted, credible, standard assessment scale to address this in the future. In addition we discuss special populations, such as those devoid of acne, as well as the impact of potential determinants of acne on disease epidemiology.

Critical appraisal of quality of clinical practice guidelines for treatment of psoriasis vulgaris, 2006-2009

Numerous international clinical guidelines for management of psoriasis have recently been published. We evaluated the quality of guidelines published between 2006 and December 2009 using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. Eight guidelines from five separate working groups fulfilled inclusion criteria and were evaluated. Four used the standards established by the AGREE instrument in the process of development of their guidelines. Each of the guidelines uniformly received high domain scores (i.e., > 90%) for scope and purpose (range of 94-100%), and clarity and presentation (range of 92-100%). Nevertheless, each of the eight guidelines had important shortcomings (item scores < or = 2/4, in which 4 indicates strongly agree and 1 indicates strongly disagree that specific items have been adequately addressed) in at least one item including: stakeholder involvement (by lack of piloting and inadequate determination of patient views), development rigor (inadequate procedure for updating), applicability (by lack of discussion on organizational barriers), and editorial independence (from funding body). Despite the use of predefined standards in their development, important deficiencies exist in the most recent clinical treatment guidelines for psoriasis.

Three-dimensional, Full-sized, Silicone-based, Facial Replicas for Teaching Outcome Measures in Acne

BACKGROUND

The scientific integrity of outcome measurements is dependent upon reproducibility and accuracy. In acne assessments, there is no current gold standard for accuracy in lesion counting and global grading.

PURPOSE

The purpose of this study was to create facial acne replicas for use in acne training and for evaluation of rater accuracy.

METHODS

Two full-sized, three-dimensional, silicone-based, facial replicas with predetermined acne lesion type and number were created. Their teaching value was evaluated by dermatologists and clinical coordinators undergoing training in acne evaluations. A questionnaire after the training session addressed realism, preferences, and ease of assessments with the facial replicas compared to live subjects.

RESULTS

Of 55 potential respondents, 32 questionnaires were completed and analyzable. Of these, 23 were from dermatologists and nine were from clinical research coordinators performing acne assessments. The facial replicas were considered sufficiently realistic for acne lesion counting by 91 percent (29/32) and for global grading by 94 percent (30/32). Of these, 66 percent preferred to have both real subjects and replicas for training (21/32), 31 percent preferred real subjects only (9/32), and one preferred replicas only. Replicas were considered easier to evaluate for noninflammatory and inflammatory lesions (p=0.002 and p=0.013, respectively) and equivalent to live models for global grading (p=0.001).

LIMITATIONS

Shortcomings include the limited spectrum of acne that could be represented due to production of only two prototypes, the relative paucity of secondary lesions, and production time and cost.

CONCLUSION

These facial replicas provide a realistic and practical method for teaching and evaluating raters in acne outcome measures as they provide a gold standard for acne lesion counts. Furthermore, their use may obviate some of the shortcomings inherent in recruitment of human acne volunteers for acne training sessions.

The safety profile and sustained remission associated with response to multiple courses of intramuscular alefacept for treatment of chronic plaque psoriasis

BACKGROUND

Safety and efficacy of up to 3 courses of alefacept intramuscular (IM) in the treatment of chronic plaque psoriasis have been demonstrated in earlier trials.

OBJECTIVE

We sought to determine the safety and efficacy of up to 5 courses of alefacept IM in treating plaque psoriasis.

METHODS

A standard treatment course was defined as 15 mg of alefacept IM once weekly for 12 weeks, followed by 12 weeks of treatment-free observation. Patients with chronic plaque psoriasis, who had previously received alefacept IM, received up to 3 additional courses (A, B, and C). Efficacy was evaluated by Physician Global Assessment.

RESULTS

Safety profiles were similar to those for a single course of treatment. There were no cumulative adverse effects. At 2 weeks postdosing, 16%, 22%, and 19% of patients were rated clear or almost clear by Physician Global Assessment in courses A, B, and C, respectively, with 35%, 42%, and 42% achieving this response at any time during these courses. Patients who achieved clear or almost clear at 2 weeks postdosing remained so for a median duration of 214 and 126 days after courses A and B, respectively.

LIMITATIONS

This was an extension study and therefore contained no control group.

CONCLUSIONS

Up to 5 courses of alefacept IM may provide extended treatment-free, symptom-free periods in responders while maintaining the safety profile.

Adapalene 0.1% and benzoyl peroxide 2.5%: a novel combination for treatment of acne vulgaris

Topical products commonly used to treat acne include retinoids and antimicrobials, due to their effects on different components of pathogenesis. Accordingly, a fixed combination of adapalene 0.1% and benzoyl peroxide (BPO) 2.5% was developed (Epiduo, Galderma) and was approved by the US FDA in December 2008 for the treatment of acne. The superior efficacy of this combination was demonstrated in 2 large randomized controlled trials. This paper reviews the evidence for efficacy and tolerability of the combination of the retinoid adapalene 0.1% and BPO 2.5%, a once-daily gel formulation for the treatment of acne.

Prevalence and severity of facial and truncal acne in a referral cohort

BACKGROUND

There is a paucity of information on the prevalence and severity of acne of the face, chest, and back.

PURPOSE

This study was designed to examine the prevalence and severity of acne on the face, chest, and back in a referral cohort of patients with acne using a validated global acne severity scale.

METHODS

Acne patients referred to dermatologists were evaluated at the face, chest, and back. Chi-square testing was performed to assess consistency between patient and physician assessments of each region. The correlation of acne severity between regions was evaluated by Spearman's rank correlation.

RESULTS

In 965 patients, the prevalence of acne on the face, chest, and back was 92%, 45%, and 61%, respectively. Acne severity was significantly correlated for all regional pairs (P<.001): face and back (r=0.11); face and chest (r=0.12); and chest and back (r=0.67). The consistency of patient reporting and clinical evaluation for the presence of acne varied by region: face=92%, chest=69%, and back=74%. The proportions of patients reporting no occurrence of acne when clinical acne was indeed absent (negative predictive value) were 67% and 65% for the chest and back, respectively.

LIMITATIONS

The operational threshold for clinical acne (>mild) may underestimate the total proportion of affected patients. These patients were referred to dermatologists for care and may represent a more severe cohort.

CONCLUSION

Acne affected the face in 92% and the trunk in just over 60% (with the back more frequently and severely affected than the chest). Acne severity was observed to have a much higher correlation between chest and back than face and back or face and chest. Patient-reporting evaluations of absence of acne on the chest and back are frequently erroneous, mandating clinical evaluations of these sites for assessment of overall extent.

New developments in hormonal therapy for acne

Oral contraceptives (OCs) are a valuable option for the treatment of women with acne. The use of OCs can be considered across the spectrum of acne disease severity in women. In Canada, three preparations are approved for mild-to-moderate acne, and a fourth is indicated for severe acne. These formulations contain estrogen in the form of ethinyl estradiol and a progestin. In Canada, the most recently approved OC is ethinyl estradiol 0.03 mg and drospirenone 3mg (Yasmin, Bayer). With the accumulating evidence on the efficacy and safety of drospirenone-containing hormonal preparations, this formulation provides dermatologists with a new treatment option for acne and other hyperandrogenic disorders.

Psychosocial impact of acne vulgaris: evaluating the evidence

This paper reviews current evidence presented by recent studies on the impact of acne on psychosocial health. Study methodologies, including case-control and cross-sectional surveys, have demonstrated psychological abnormalities including depression, suicidal ideation, anxiety, psychosomatic symptoms, including pain and discomfort, embarrassment and social inhibition. Effective treatment of acne was accompanied by improvement in self-esteem, affect, obsessive-compulsiveness, shame, embarrassment, body image, social assertiveness and self-confidence. Acne is associated with a greater psychological burden than a variety of other disparate chronic disorders. Future studies with a longitudinal cohort design may provide further validation of the causal inference between acne and psychosocial disability provided by the current literature.

Randomized placebo-controlled trial of metronidazole 1% cream with sunscreen SPF 15 in treatment of rosacea

BACKGROUND

Rosacea is a photoaggravated dermatosis responsive to treatment with topical and oral antibiotics. A formulation combining metronidazole 1% cream with sunscreen SPF 15 was developed for the treatment of rosacea.

OBJECTIVE

The objective of this study was to determine the safety and efficacy of a formulation combining metronidazole 1% cream with sunscreen SPF 15 in the treatment of moderate to severe rosacea.

METHODS

One hundred and twenty patients with moderate to severe rosacea were enrolled for a randomized, placebo-controlled (vehicle containing sunscreen with SPF 15), double-blind study. Study cream was applied twice daily to the entire face over a 12-week period.

RESULTS

Treatment with metronidazole 1% cream with sunscreen SPF 15 resulted in significant improvement (p <0.05) in inflammatory lesion count, erythema and telangiectasiae scores, and investigator and patient global assessment scores compared with baseline and placebo. Adverse reactions related to study medication were typically mild, occurred at the site of application, and were reversible. There was no difference between the safety profiles of metronidazole 1% cream with sunscreen SPF 15 and placebo.

CONCLUSIONS

The combined topical formulation of metronidazole 1% cream with sunscreen SPF 15 was an effective, well-tolerated topical agent for the treatment of moderate to severe rosacea.

Clindoxyl gel for the treatment of acne vulgaris

Clindoxyl Gel (Stiefel) is a combination of 1% clindamycin phosphate and 5% benzoyl peroxide in a gel vehicle that is well tolerated and more efficacious than either active agent alone or the vehicle in reducing lesion counts and improving global scores in patients with moderate acne. It was approved for once daily use in Canada in November 2001.