Acne vulgaris

Acne is a chronic inflammatory disease of the pilosebaceous unit resulting from androgen-induced increased sebum production, altered keratinisation, inflammation, and bacterial colonisation of hair follicles on the face, neck, chest, and back by Propionibacterium acnes. Although early colonisation with P acnes and family history might have important roles in the disease, exactly what triggers acne and how treatment affects the course of the disease remain unclear. Other factors such as diet have been implicated, but not proven. Facial scarring due to acne affects up to 20% of teenagers. Acne can persist into adulthood, with detrimental effects on self-esteem. There is no ideal treatment for acne, although a suitable regimen for reducing lesions can be found for most patients. Good quality evidence on comparative effectiveness of common topical and systemic acne therapies is scarce. Topical therapies including benzoyl peroxide, retinoids, and antibiotics when used in combination usually improve control of mild to moderate acne. Treatment with combined oral contraceptives can help women with acne. Patients with more severe inflammatory acne usually need oral antibiotics combined with topical benzoyl peroxide to decrease antibiotic-resistant organisms. Oral isotretinoin is the most effective therapy and is used early in severe disease, although its use is limited by teratogenicity and other side-effects. Availability, adverse effects, and cost, limit the use of photodynamic therapy. New research is needed into the therapeutic comparative effectiveness and safety of the many products available, and to better understand the natural history, subtypes, and triggers of acne.

Antioxidant activity, lipid peroxidation and skin diseases. What's new

Due to its interface function between the body and the environment, the skin is chronically exposed to both endogenous and environmental pro-oxidant agents, leading to the harmful generation of reactive oxygen species (ROS). There is compelling evidence that oxidative stress is involved in the damage of cellular constituents, such as DNA, cell membrane lipids or proteins. To protect the skin against the over-load of oxidant species, it contains a well-organised system of both chemical and enzymatic antioxidant which are able to work in a synergistic manner. Skin antioxidant network protects cells against oxidative injury and prevent the production of oxidation products, such as 4-hydroxy-2-nonenal or malonaldehyde, which are able to induce protein damage, apoptosis or release of pro-inflammatory mediators, such as cytokines. When oxidative stress overwhelms the skin antioxidant capacity the subsequent modification of cellular redox apparatus leads to an alteration of cell homeostasis and a generation of degenerative processes. Topical application or oral administration of antioxidants has been recently suggested as preventive therapy for skin photoaging and UV-induced cancer. The recognition that ROS can act as second messengers in the induction of several biological responses, such as the activation of NF-kB or AP-1, the generation of cytokines, the modulation of signalling pathways, etc., has led many researchers to focus on the possible effects of antioxidants in many pathological processes. The recent demonstration that the peroxisome proliferators-activated receptors, whose natural ligands are polyunsaturated fatty acids and theirs oxidation products, have a central role in the induction of some skin diseases, such as psoriasis or acne, has indicated new links between free radicals and skin inflammation. Based on these findings, the review summarises the possible correlations between antioxidant imbalance, lipid oxidative breakage and skin diseases, from both a pathological and therapeutic points of view.

Topical ALA-photodynamic therapy for the treatment of acne vulgaris

Topical aminolevulinic acid is converted into a potent photosensitizer, protoporphyrin, in human hair follicles and sebaceous glands. Photodynamic therapy with topical aminolevulinic acid was tested for the treatment of acne vulgaris, in an open-label prospective human study. Each of 22 subjects with acne on the back was treated in four sites with aminolevulinic acid plus red light, aminolevulinic acid alone, light alone, and untreated control. Half of the subjects were treated once; half were treated four times. Twenty percent topical aminolevulinic acid was applied with 3 h occlusion, and 150 J per cm2 broad-band light (550-700 nm) was given. Sebum excretion rate and auto-fluorescence from follicular bacteria were measured before, and 2, 3, 10, and 20 wk after, treatment. Histologic changes and protoporphyrin synthesis in pilosebaceous units were observed from skin biopsies. Aminolevulinic acid plus red light caused a transient acne-like folliculitis. Sebum excretion was eliminated for several weeks, and decreased for 20 wk after photodynamic therapy; multiple treatments caused greater suppression of sebum. Bacterial porphyrin fluorescence was also suppressed by photodynamic therapy. On histology, sebaceous glands showed acute damage and were smaller 20 wk after photodynamic therapy. There was clinical and statistically significant clearance of inflammatory acne by aminolevulinic acid plus red light, for at least 20 wk after multiple treatments and 10 wk after a single treatment. Transient hyperpigmentation, superficial exfoliation, and crusting were observed, which cleared without scarring. Topical aminolevulinic acid plus red light is an effective treatment of acne vulgaris, associated with significant side-effects. Aminolevulinic acid plus red light causes phototoxicity to sebaceous follicles, prolonged suppression of sebaceous gland function, and apparent decrease in follicular bacteria after photodynamic therapy. Potentially, aminolevulinic acid plus red light may be useful for some patients with acne.

Inflammatory events are involved in acne lesion initiation

The earliest subclinical acne "lesion" is a microcomedone, of which hyperproliferation of the follicular epithelium is a characteristic feature. Inflammatory cells have been observed at the periphery of these "lesions". This study investigated whether inflammatory events occur pre or post hyperproliferative changes. Cellular, vascular, and proliferative markers were examined by immunohistochemical techniques on biopsies of clinically normal follicles from uninvolved skin and early inflamed lesions from acne patients. Control follicles were obtained from non-acne subjects. Follicles from uninvolved skin exhibited no microcomedonal features. Proliferation in the epithelium was comparable to controls and was significantly lower than in inflamed lesions. Numbers of CD3+, CD4+ T cells were elevated in the perifollicular and papillary dermis although levels were not equivalent to those in papules. The number of macrophages was also greatly increased and similar to those in papules. There were no changes in blood vessel numbers or vascular intercellular adhesion molecule 1 expression but E-selectin expression was increased to levels found in papules and vascular adhesion molecule 1 levels were upregulated. Levels of the pro-inflammatory cytokine interleukin-1 were also upregulated perifollicularly. Moreover, aberrant integrin expression was demonstrated in the epidermis around these uninvolved follicles and inflamed lesions whereas the basement membrane was still intact. These results provide novel evidence for vascular endothelial cell activation and involvement of inflammatory responses in the very earliest stages of acne lesion development.

The assessment of acne vulgaris--the Leeds technique

We describe two simple, reproducible scoring systems for assessing acne severity, and we emphasize the technical problems which could invalidate either technique. Constant baseline data is desirable for any clinical trial, and our data clearly show that acne patients should ideally be off all treatment for at least 2 months before the start of a therapeutic trial.

Induction of toll-like receptors by Propionibacterium acnes

BACKGROUND

The bacterium Propionibacterium acnes is involved in the induction and maintenance of the inflammatory phase of acne. Recent studies have found that keratinocytes express toll-like receptors (TLRs) implicated in immediate immunity. No studies have, to date, been carried out on the action of P. acnes upon TLR activation in keratinocytes.

OBJECTIVES

Focusing on the inflammatory phase of acne, to clarify the role of P. acnes in immediate immunity by inducing expression of TLR-2 and TLR-4 by keratinocytes. We also studied how the secretion and expression of matrix metalloproteinase (MMP)-9 is induced by P. acnes.

METHODS

The work was carried out on two levels: in vivo with the study of the expression of TLR-2 and TLR-4 proteins in biopsies of acne lesions and in vitro on cultured keratinocyte monolayers to study the modulating effects of P. acnes on the expression of TLR-2 and TLR-4 and also on the expression and secretion of MMP-9.

RESULTS

Our findings reveal that in vivo TLR-2 and TLR-4 expression is increased in the epidermis of acne lesions. In vitro, an increase in TLR-2 and TLR-4 expression by human keratinocytes occurred in the first hours of incubation with bacterial fractions as well as an increase of the expression and secretion by the keratinocytes of MMP-9, which plays a role in inflammation.

CONCLUSIONS

This work demonstrates that P. acnes induces TLR expression and that this mechanism could play an essential role in acne-linked inflammation. These receptors could be involved notably in acute acne.

A clinical evaluation of acne scarring and its incidence

Despite scarring being a recognized sequel of acne, the actual extent and incidence of residual scarring remains unknown. One hundred and eighty-five acne patients were included in this study (101 females, 84 males). Patients were selected from acne clinics and their acne scarring was examined. The scarring was quantified according to a lesion count and allocated a score. The type and extent of scarring was correlated to the age and sex of the patient, the site of the acne, the previous acne grade according to the Leeds Technique, acne type (noted in clinic at the original referral time) and duration of acne, before adequate therapeutic measures had been instituted. Results indicate that facial scarring affects both sexes equally and occurs to some degree in 95% of cases. Total scarring on the trunk was significantly greater in males, as was hypertrophic and keloid scarring in these sites (P < 0.05). There were significant correlations between the initial acne grade and the overall severity of scarring in all sites and in both sexes (P < 0.01). Superficial inflamed papular acne lesions as well as nodular lesions were capable of producing scars. A time delay up to 3 years between acne onset and adequate treatment related to the ultimate degree of scarring in both sexes and in all three sites. This emphasizes the need for earlier adequate therapy in an attempt to minimize the subsequent scarring caused by acne.

Recent findings in the epidemiologic evidence, classification, and subtypes of acne vulgaris

Acne affects between 40 to 50 million individuals in the United States. Recent findings regarding the multifactorial pathogenesis of acne have facilitated a reexamination of the classification of acne and acne-related disorders. Disorders without a microcomedo as the initial pathologic condition are no longer classified as "acne." Research has also identified that the clinical characteristics of acne vary with age, pubertal status, gender, and race. These findings may have implications for the clinical management of acne and acne-related disorders.

Photodynamic therapy of acne vulgaris with topical delta-aminolaevulinic acid and incoherent light in Japanese patients

BACKGROUND

Photodynamic therapy (PDT) is useful for treatment of epidermal neoplasia but may also have a role in the treatment of inflammatory dermatoses.

OBJECTIVES

To study the effect of PDT in patients with acne.

METHODS

Three men and 10 women who suffered from intractable acne vulgaris were treated using PDT with topical delta-aminolaevulinic acid (ALA) and polychromatic visible light. Twenty per cent ALA in an oil-in-water emulsion was applied to the lesions for 4 h with a light-shielding dressing. The lesions were then exposed to polychromatic visible light at 600-700 nm using a halogen light source of energy intensity 17 mW cm-2 and a total energy dose of 13 J cm-2.

RESULTS

All patients had apparent improvement of facial appearance and reduction of new acne lesions at 1, 3 and 6 months following PDT treatment. The adverse effects were discomfort, burning and stinging during irradiation, oedematous erythema for 3 days after PDT, epidermal exfoliation from the fourth to the 10th day, irritation and hypersensitivity to physical stimulation for 10 days after PDT, and pigmentation or erythema after epidermal exfoliation; the treated lesions returned to normal skin conditions within 1 month.

CONCLUSIONS

PDT was beneficial in the treatment of acne. As a photoactivating light source, polychromatic visible light was thought to be better for use with acne patients than laser light because of its cost-effectiveness, uniform illumination and time-efficiency in treating large areas.

Pathogenesis of acne

Acne vulgaris is a skin disorder of the sebaceous follicles that commonly occurs in adolescence and in young adulthood. The major pathogenic factors involved are hyperkeratinization, obstruction of sebaceous follicles resulting from abnormal keratinization of the infundibular epithelium, stimulation of sebaceous gland secretion by androgens, and microbial colonization of pilosebaceous units by Propionibacterium acnes, which promotes perifollicular inflammation. The clinical presentation of acne can range from a mild comedonal form to severe inflammatory cystic acne of the face, chest, and back. At the ultrastructural level, follicular keratinocytes in comedones can be seen to possess increased numbers of desmosomes and tonofilaments, which result in ductal hypercornification. The increased activity of sebaceous glands elicited by androgen causes proliferation of P. acnes, an anaerobe present within the retained sebum in the pilosebaceous ducts. The organism possesses a ribosome-rich cytoplasm and a relatively thick cell wall, and produces several biologically active mediators that may contribute to inflammation, for instance, by promoting leukocyte migration and follicular rupture. In inflamed lesions, numerous neutrophils and macrophages infiltrate around hair follicles and sometimes phagocytose P. acnes. To examine the participation of neurogenic factors in the pathogenesis of acne, we quantitatively assessed the effects of neuropeptides on the morphology of sebaceous glands in vitro using electron microscopy. Substance P, which can be elicited by stress, promoted the development of cytoplasmic organelles in sebaceous cells, stimulated sebaceous germinative cells, and induced significant increases in the area of sebaceous glands. It also increased the size of individual sebaceous cells and the number of sebum vacuoles for each differentiated sebaceous cell, all of which suggests that substance P promotes both the proliferation and the differentiation of sebaceous glands. In this review, we introduce the general concept of pathogenic factors involved in acne, including typical electron microscopic findings and recent evidence of stress-induced exacerbation of acne from a neurological point of view. An improved understanding of the pathogenesis of acne should lead to a rational therapy to successfully treat this skin disease.

The safety and efficacy of salicylic acid chemical peels in darker racial-ethnic groups

BACKGROUND

There is a dearth of published data regarding chemical peels in darker racial-ethnic groups.

OBJECTIVE

The purpose of the present investigation was to assess the clinical efficacy and safety of a new superficial salicylic acid peel in individuals of skin types V and VI.

METHODS

Twenty-five patients were included in this pilot investigation. Nine had acne vulgaris, 5 had post-inflammatory hyperpigmentation, 6 had melasma, and 5 had rough, oily skin with enlarged pores. The patients were pre-treated for 2 weeks with hydroquinone 4% prior to undergoing a series of five salicylic acid chemical peels. The concentrations of salicylic acid were 20% and 30%. The peels were performed at 2 week intervals. RESULTS. Moderate to significant improvement was observed in 88% of the patients. Minimal to mild side effects occurred in 16%.

CONCLUSION

The results of this study suggest that superficial salicylic acid peels are both safe and efficacious for treatment of acne vulgaris, oily skin, textural changes, melasma, and post-inflammatory hyperpigmentation in patients with skin types V and VI.

Acne treatment with a 1,450 nm wavelength laser and cryogen spray cooling

BACKGROUND AND OBJECTIVES

A laser with a wavelength in the mid-IR range targeting the depth in skin where sebaceous glands are located in combination with cryogen spray cooling was evaluated for treatment of acne. In this non-ablative treatment, the laser energy heats the dermal volume encompassing sebaceous glands whereas the cold cryogen spray preserves the epidermis from thermal damage.

STUDY DESIGN/MATERIALS AND METHODS

Monte Carlo simulations and heat transfer calculations were performed to optimize the heating and cooling parameters. A variety of heating and cooling parameters were tested in an in vivo rabbit ear study to evaluate the histological effect of the device on sebaceous glands and skin. Similar experiments were performed on ex vivo human skin. A clinical study for the treatment of acne on backs of human males was also conducted.

RESULTS

Monte Carlo simulations and heat transfer calculations resulted in a thermal damage profile that showed epidermal preservation and peak damage in the upper dermis where sebaceous glands are located. Ex vivo human skin histology confirmed the damage profile qualitatively. In vivo rabbit ear histology studies indicated short-term thermal alteration of sebaceous glands with epidermal preservation. In the human clinical study on the back, a statistically significant reduction in lesion count on the treated side compared to the control side was seen (p < 0.001). Side effects were transient and few.

CONCLUSIONS

The studies reported here demonstrate the feasibility of treating acne using a photothermal approach with a mid-IR laser and cryogen cooling.

Current concepts of the pathogenesis of acne: implications for drug treatment

The pathogenesis of acne is complex, with strong evidence supporting the involvement of sebaceous hyperplasia, follicular hyperkeratinisation, bacterial hypercolonisation, as well as immune reactions and inflammation. High sebum concentrations and follicular hyperkeratinisation lead to a change of the follicular milieu with consecutive proliferation of bacteria, chiefly Propionibacterium acnes. This leads to further increased production of the pro-inflammatory cytokines interleukin-1alpha and tumour necrosis factor alpha by T cells and keratinocytes, leading to proliferation of both cell types. Follicular keratinocytes fail to differentiate by apoptosis and produce hypergranulosis similar to the impermeable skin outer layer, resulting in the formation of microcomedones. Further inflammatory responses lead to the development of increasing degrees of severity in inflammatory forms of acne. Retinoids aid the differentiation and reduce the hyperproliferation of keratinocytes, and can inhibit the migration of leucocytes. Combination therapy using retinoids plus benzoyl peroxide or antibacterials can treat existing acne lesions faster than the individual agents alone and can also prevent the development of new lesions. The new retinoids (e.g. adapalene) have not only the typical potent comedolytic activity but also anti-inflammatory effects. When added to antibacterial therapy, topical retinoids demonstrate faster and significantly greater reduction of inflammatory acne lesions and comedones than antibacterials alone.

Management of Acne Vulgaris: A Review

IMPORTANCE

Acne vulgaris is an inflammatory disease of the pilosebaceous unit of the skin that primarily involves the face and trunk and affects approximately 9% of the population worldwide (approximately 85% of individuals aged 12-24 years, and approximately 50% of patients aged 20-29 years). Acne vulgaris can cause permanent physical scarring, negatively affect quality of life and self-image, and has been associated with increased rates of anxiety, depression, and suicidal ideation.

OBSERVATIONS

Acne vulgaris is classified based on patient age, lesion morphology (comedonal, inflammatory, mixed, nodulocystic), distribution (location on face, trunk, or both), and severity (extent, presence or absence of scarring, postinflammatory erythema, or hyperpigmentation). Although most acne does not require specific medical evaluation, medical workup is sometimes warranted. Topical therapies such as retinoids (eg, tretinoin, adapalene), benzoyl peroxide, azelaic acid, and/or combinations of topical agents are first-line treatments. When prescribed as a single therapy in a randomized trial of 207 patients, treatment with tretinoin 0.025% gel reduced acne lesion counts at 12 weeks by 63% compared with baseline. Combinations of topical agents with systemic agents (oral antibiotics such as doxycycline and minocycline, hormonal therapies such as combination oral contraception [COC] or spironolactone, or isotretinoin) are recommended for more severe disease. In a meta-analysis of 32 randomized clinical trials, COC was associated with reductions in inflammatory lesions by 62%, placebo was associated with a 26% reduction, and oral antibiotics were associated with a 58% reduction at 6-month follow-up. Isotretinoin is approved by the US Food and Drug Administration for treating severe recalcitrant nodular acne but is often used to treat resistant or persistent moderate to severe acne, as well as acne that produces scarring or significant psychosocial distress.

CONCLUSIONS AND RELEVANCE

Acne vulgaris affects approximately 9% of the population worldwide and approximately 85% of those aged 12 to 24 years. First-line therapies are topical retinoids, benzoyl peroxide, azelaic acid, or combinations of topicals. For more severe disease, oral antibiotics such as doxycycline or minocycline, hormonal therapies such as combination oral conceptive agents or spironolactone, or isotretinoin are most effective.

Propionibacterium acnes Induces an IL-17 Response in Acne Vulgaris that Is Regulated by Vitamin A and Vitamin D

Acne vulgaris is the most common skin disorder affecting millions of people worldwide and inflammation resulting from the immune response targeting Propionibacterium acnes has a significant role in its pathogenesis. In this study, we have demonstrated that P. acnes is a potent inducer of T helper 17 (Th17) and Th1, but not Th2 responses in human peripheral blood mononuclear cells (PBMCs). P. acnes stimulated expression of key Th17-related genes, including IL-17A, RORα, RORc, IL-17RA, and IL-17RC, and triggered IL-17 secretion from CD4(+), but not from CD8(+) T cells. Supernatants from P. acnes-stimulated PBMCs were sufficient to promote the differentiation of naive CD4(+)CD45RA T cells into Th17 cells. Furthermore, we found that the combination of IL-1β, IL-6, and transforming growth factor-β-neutralizing antibodies completely inhibited P. acnes-induced IL-17 production. Importantly, we showed that IL-17-expressing cells were present in skin biopsies from acne patients but not from normal donors. Finally, vitamin A (all-trans retinoic acid) and vitamin D (1,25-dihydroxyvitamin D3) inhibited P. acnes-induced Th17 differentiation. Together, our data demonstrate that IL-17 is induced by P. acnes and expressed in acne lesions and that both vitamin A and D could be effective tools to modulate Th17-mediated diseases such as acne.

Topical aminolaevulinic acid-photodynamic therapy for the treatment of acne vulgaris: a study of clinical efficacy and mechanism of action

BACKGROUND

Acne affects 83-95% of 16-year-olds of both sexes, and many seek help from a clinician. Emerging problems with conventional acne treatments, specifically antibiotic resistance of Propionibacterium acnes and fears over the safety and tolerance of oral isotretinoin, create a demand for novel treatment modalities in acne.

OBJECTIVES

To study the efficacy of aminolaevulinic acid-photodynamic therapy (ALA-PDT) in the treatment of acne and to identify the mode of action, looking specifically at the effects on surface numbers of P. acnes and on sebum excretion.

METHODS

Ten patients (nine men and one woman, age range 16-40 years) with mild to moderate acne on their backs were recruited. Each patient's back was marked with four 30-cm2 areas of equal acne severity. Each site was then randomly allocated to either ALA-PDT treatment, light alone, ALA alone or an untreated control site. At baseline, numbers of inflammatory and noninflammatory acne lesions were counted, sebum excretion measured by Sebutapes (CuDerm, Dallas, TX, U.S.A.) and surface P. acnes swabs performed. ALA cream (20% in Unguentum Merck) was applied under occlusion to the ALA-PDT and ALA alone sites for 3 h. Red light from a diode laser was then delivered to the ALA-PDT and light alone sites (635 nm, 25 mW cm(-2), 15 J cm(-2)). Each patient was treated weekly for 3 weeks. At each visit acne lesion counts were performed and 3 weeks following the last treatment sebum excretion rates and P. acnes swabs were repeated.

RESULTS

There was a statistically significant reduction in inflammatory acne lesion counts from baseline after the second treatment at the ALA-PDT site but not at any of the other sites. No statistically significant reduction in P. acnes numbers or sebum excretion was demonstrated at any sites including the ALA-PDT site.

CONCLUSIONS

ALA-PDT is capable of clinically improving acne. An alternative mode of action for ALA-PDT other than direct damage to sebaceous glands or photodynamic killing of P. acnes is suggested from the results of this study.

Effects of subantimicrobial-dose doxycycline in the treatment of moderate acne

OBJECTIVE

To determine if treatment with subantimicrobial-dose (SD) doxycycline hyclate (20-mg tablets taken twice daily) improved clinical outcome, had any detectable effect on skin flora, led to overgrowth or colonization of skin by opportunistic pathogens, or resulted in an increase in antibiotic resistance by the surface skin microflora in patients with moderate acne compared with placebo.

DESIGN

Multicenter, double-blind, randomized, placebo-controlled, parallel-group trial.

SETTING

Two university-based clinics.

SUBJECTS

Adults (N = 51) with moderate facial acne.

INTERVENTIONS

Patients were randomized to receive SD doxycycline (Periostat; CollaGenex Pharmaceuticals Inc, Newtown, Pa) or placebo twice daily for 6 months. MAIN EFFICACY OUTCOMES: Primary: changes from baseline in numbers of inflammatory, noninflammatory, and total lesions. Secondary: changes from baseline of individual counts of papules, pustules, and nodules and global assessments of clinical improvement by patient and physician.

RESULTS

Forty patients completed 6 months of treatment. At 6 months, the SD doxycycline group had a significantly greater percent reduction in the number of comedones (P<.01), inflammatory and noninflammatory lesions combined (P<.01), and total inflammatory lesions (P<.05) than did the placebo group. They also had significantly greater improvement according to the clinician's global assessment (P =.03). There were no significant differences in microbial counts between groups and no evidence of change in antibiotic susceptibility or colonization by potential pathogens. The treatment was well tolerated.

CONCLUSIONS

Twice-daily SD doxycycline treatment significantly reduced the number of inflammatory and noninflammatory lesions in patients with moderate facial acne, was well tolerated, had no detectable antimicrobial effect on the skin flora, and did not result in any increase in the number or severity of resistant organisms.

The effect of a high-protein, low glycemic–load diet versus a conventional, high glycemic–load diet on biochemical parameters associated with acne vulgaris: A randomized, investigator-masked, controlled trial

BACKGROUND

No previous study has sought to examine the influence of dietary composition on acne vulgaris.

OBJECTIVE

We sought to compare the effect of an experimental low glycemic-load diet with a conventional high glycemic-load diet on clinical and endocrine aspects of acne vulgaris.

METHODS

A total of 43 male patients with acne completed a 12-week, parallel, dietary intervention study with investigator-masked dermatology assessments. Primary outcomes measures were changes in lesion counts, sex hormone binding globulin, free androgen index, insulin-like growth factor-I, and insulin-like growth factor binding proteins.

RESULTS

At 12 weeks, total lesion counts had decreased more in the experimental group (-21.9 [95% confidence interval, -26.8 to -19.0]) compared with the control group (-13.8 [-19.1 to -8.5], P = .01). The experimental diet also reduced weight (P = .001), reduced the free androgen index (P = .04), and increased insulin-like growth factor binding protein-1 (P = .001) when compared with a high glycemic-load diet.

LIMITATIONS

We could not preclude the role of weight loss in the overall treatment effect.

CONCLUSION

This suggests nutrition-related lifestyle factors play a role in acne pathogenesis. However, these preliminary findings should be confirmed by similar studies.

Photodynamic therapy of acne vulgaris using 5-aminolevulinic acid versus methyl aminolevulinate

BACKGROUND

Recent studies have shown that photodynamic therapy (PDT) is effective in the treatment of acne vulgaris. No studies have compared the treatment effect of aminolevulinic acid-PDT (ALA-PDT) and methyl aminolevulinate-PDT (MAL-PDT).

OBJECTIVE

We sought to compare the treatment effect and tolerability of ALA-PDT versus MAL-PDT in the treatment of acne vulgaris in a controlled randomized investigator-blinded trial.

METHODS

Fifteen patients with at least 12 facial inflammatory acne lesions had one split-face PDT treatment with MAL and ALA.

RESULTS

Twelve weeks after treatment we found a 59% decrease in inflammatory lesions from baseline, with no significant differences in effectiveness between the two treatments. All patients experienced moderate to severe pain during illumination and developed erythema, pustular eruptions, and epithelial exfoliation after treatment, which were more severe and uniform in the ALA-PDT-treated area.

LIMITATIONS

The study is paired and controlled, but the results should be evaluated with consideration given for the number of participating patients.

CONCLUSION

PDT appeared to be an effective treatment for inflammatory acne vulgaris with no significant differences in the response rate between ALA-PDT and MAL-PDT. ALA-PDT resulted in more prolonged and severe adverse effects after treatment.

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.

Improvement of facial acne scars by the 585 nm flashlamp-pumped pulsed dye laser

BACKGROUND

Hypertrophic or erythematous scars (or both) have remained notoriously difficult to treat because of their persistence or recurrence after traditional therapies. Recently, the 585 nm flashlamp-pumped pulsed dye laser has been shown to be effective in treating similar traumatic and surgical scars.

OBJECTIVE

Our purpose was to determine the effectiveness of the 585 nm flashlamp-pumped pulsed dye laser in the specific treatment of facial acne scars.

METHODS

Twenty-two patients with erythematous or hypertrophic facial acne scars were included in this Investigational Review Board-approved study. The 585 nm flashlamp-pumped pulsed-dye laser was used to treat scars on half of each patient's face, with the contralateral side used as control. Baseline, 6-week, and 6-month posttreatment photographs, erythema measurements made with reflectance spectrometry, and skin texture analyses were obtained from laser-irradiated and untreated scars. Clinical analyses were performed independently by two "blinded" observers.

RESULTS

Significant clinical improvement was observed in laser-irradiated acne scars compared with the untreated (control) scars after one or two 585 nm pulsed-dye laser treatments. Erythema measurements and skin texture analyses of laser-treated scars approximated those obtained in the adjacent normal skin.

CONCLUSION

The 585 nm flashlamp-pumped pulsed-dye laser can significantly improve the clinical appearance of erythematous or hypertrophic facial acne scars.

Acne phototherapy with a high-intensity, enhanced, narrow-band, blue light source: an open study and in vitro investigation

The purpose of this study was to investigate the efficacy of phototherapy with a newly-developed high-intensity, enhanced, narrow-band, blue light source in patients with mild to moderate acne. An open study was performed in acne patients who were treated twice a week up to 5 weeks. Acne lesions were reduced by 64%. Two patients experienced dryness. No patient discontinued treatment due to adverse effects. In vitro investigation revealed that irradiation from this light source reduced the number of Propionibacterium acnes (P. acnes), but not Staphylococcus epidermidis that were isolated from the acne patients. Phototherapy using this blue light source was effective and well tolerated in acne patients and had an ability to decrease numbers of P. acnes in vitro, suggesting that this phototherapy may be a new modality for the treatment of acne.