Use of lasers and light-based therapies for treatment of acne vulgaris
Journal: Lasers Surg Med. 2005 Dec;37(5):333-42 .
Mariwalla K and Rohrer TE
Over the last two decades, lasers and light-based therapies have been developed to treat a wide variety of cutaneous maladies. Given the prevalence and number of patients who suffer from refractory acne, alternatives to existing care are constantly sought after. In this review, we discuss the evidence currently available to justify the use of laser and light-based modalities and conclude that in combination therapy, such approaches provide a safe and effective treatment for acne vulgaris. Lasers Surg. Med. 37:333-342, 2005. (c) 2005 Wiley-Liss, Inc.
Optical treatments for acne.
Journal: Dermatol Ther. 2005 May-Jun;18(3):253-66.
Light-based treatments for acne are becoming increasingly commonplace in dermatology. This article reviews various light approaches in acne therapy. Methods are discussed from an anatomical and a functional perspective. The emphasis is on the practicality of treatment as well as the pros and cons of various devices. Also, a review of the recent literature is presented. The article is intended to give the reader a panoramic view of this still-young and developing area. Most likely, light-based acne treatment will receive more popularity as dermatologists learn how to integrate this type of therapy within the context of more established drug agents.
Nonablative laser surgery for pigmented skin.
Journal: Dermatol Surg. 2005 Oct;31(10):1263-7.
BACKGROUND: Nonablative laser surgery has been proven to improve early photodamaged skin and acne scars. These techniques include treatments with lasers, light sources, and/or radiofrequency devices. OBJECTIVES: To review the history of nonablative technology and its applicability to darker skin types and to provide an objective look at the various published studies documenting the efficacy of nonablative technology. CONCLUSION: Nonablative laser surgery can improve skin quality and acne scars in all skin types. Complications are rare but can occur. Future studies are required to compare the efficacy of the
various nonablative technologies.
Combined nonablative rejuvenation techniques.
Journal: Dermatol Surg. 2005 Sep;31(9 Pt 2):1206-10; discussion 1210.
Shah GM and Kilmer SL.
BACKGROUND: Nonablative technologies have been used for fine lines and improvement of skin texture without significant downtime. Nonablative technologies may also be used in combination. OBJECTIVE: To present a brief review on nonablative technologies and discuss using nonablative procedures in combination and with other adjunctive therapies. MATERIALS AND METHODS: A review of the literature was done to identify combination nonablative studies. We also discuss our own experience in combining these procedures. RESULTS: Various nonablative technologies can be used together, often with better outcomes and fewer treatments. CONCLUSION: Nonablative and adjunctive treatments should be performed in combination to optimize the results. Much of the information in this publication is from personal experience and expresses the opinions of these authors while citing relevant literature and studies.
Considerations for treating acne in ethnic skin.
Journal: Cutis. 2005 Aug;76(2 Suppl):19-23.
Patients with ethnic skin are at an increased risk for developing postinflammatory hyperpigmentation (PIH) and keloid scarring subsequent to acne lesions. Treatment approaches for acne in darker skinned patients must balance early aggressive intervention with the selection of efficacious and nonirritating agents. Most patients with prominent or long-lasting PIH will require treatment with a topical retinoid and hydroquinone, the gold standard in the treatment of PIH. Keloids may be treated with surgical excision, but the rate of recurrence can be as high as 50%. Successful management of ethnic skin with acne can be achieved with the appropriate combination drug regimen and good patient compliance. For best results, clinicians should manage the entire
grooming regimen of the skin and hair of their ethnic patients.
Acne, depression, and suicide.
Journal: Dermatol Clin. 2005 Oct;23(4):665-74.
Hull PR and D'Arcy C.
Acne is a common disorder that may have a considerable psychologic impact including anxiety and depression. Depression and suicide occur frequently in adolescents and young adults. Although case reports suggest an association between isotretinoin and depression and suicide, more rigorous observational studies and epidemiologic studies, using different designs, have not shown any effect of isotretinoin use in increasing the occurrence of depression and suicide. It is prudent for the practitioner to continue to use isotretinoin to treat severe acne, while at the same time informing patients and their relatives that depressive symptoms should be actively assessed at each visit and, if necessary, referral to a psychiatrist and a discontinuation of isotretinoin should be considered.
Lasers and light therapy for acne vulgaris.
Journal: Semin Cutan Med Surg. 2005 Jun;24(2):107-12.
Bhardwaj et al.
Acne vulgaris remains an emotionally and debilitating dermatologic disease, and is conventionally treated with a variety of oral and topical therapies with a number of significant side effects. An evolving understanding of laser-tissue interactions involving Propionibacterium acnes-produced porphyrins, and the development of infrared nonablative lasers to target sebaceous glands, has lead to the development of an escalating number of laser, light and radiofrequency devices for acne. Used as monotherapy or in combination, these devices are showing promise as a method to clear acne in a convenient, non-invasive manner, though there remains a clear need for long-term data and randomized, blinded studies.
The role of inflammation in the pathogenesis of acne and acne scarring.
Journal: Semin Cutan Med Surg. 2005 Jun;24(2):79-83.
Holland DB and Jeremy AH.
The Skin Research Centre,
School of Biochemistry and Microbiology,
Leeds, United Kingdom.
Evidence now supports a pivotal role for cellular inflammatory events at all stages of acne lesion development, from preclinical initiation to clinical presentation of active lesions through to resolution. The emphasis has moved from acne as a primarily hyperproliferative disorder of the sebaceous follicle to that of an inflammatory skin disorder. However, although the sequence of events leading to lesion formation has become clearer, the triggers for initiation remain speculative. The development of noninvasive techniques to detect preclinical "acne-prone" follicles is essential before triggers for initiation can be defined. Finally, the differences highlighted in the inflammatory profiles of inflamed lesions from patients who scar, as compared with other nonscarring acne patients reinforces the view that acne is a disorder, which embraces a number of pathologies.
Cosmetics in the treatment of acne vulgaris.
Journal: Dermatol Clin. 2005 Jul;23(3):575-81, viii.
This article describes scenarios of patients who have acne vulgaris have tried over-the-counter products and cosmetics and are disheartened by the persistence of their disease and the resulting scars. They may have seen an aesthetician, plastic surgeon, or even a general practitioner before seeing a well-informed skin specialist. Patients perceive the dermatologist to be the skin care expert and seek guidance to obtain otherwise unobtainable results. Therefore, practicing dermatologists should take advantage of the available tools to treat patients aggressively and completely. Appropriately applied cosmetics can play a role in achieving this goal. This article describes scenarios that integrate cosmetics into an anti-acne treatment regimen that is effective and safe for all
ethnic groups and is well tolerated by both male and female patients.
The new age of acne therapy: light, lasers, and radiofrequency.
Journal: J Cosmet Laser Ther. 2004 Dec;6(4):191-200.
Rotunda AM et al.
BACKGROUND: Current treatments for acne vulgaris include topical and oral medications that counteract microcomedone formation, sebum production, Propionibacterium acnes, and inflammation. Concerns about the short- and long-term consequences of these medications, along with technological advancements, have to significant progress in the management of acne. These
developments include light, laser, and radio frequency, which may offer faster onset of action, equal or greater efficacy, and greater convenience than traditional approaches. CONCLUSION: Research emphasizing long-term follow-up and comparative, randomized trials is necessary to determine whether these emerging technologies will become a viable alternative to standard therapies such as antibiotics.
Cutaneous effects of smoking.
1 Journal: J Cutan Med Surg. 2004 Nov-Dec;8(6):415-23.
Freiman A et al.
BACKGROUND: Cigarette smoking is the single biggest preventable cause of death and disability in developed countries and is a significant public health concern. While known to be strongly associated with a number of cardiovascular and pulmonary diseases and cancers, smoking also leads to a variety of cutaneous manifestations. OBJECTIVE: This article reviews the effects of cigarette smoking on the skin and its appendages. METHODS: A literature review was based on a MEDLINE search (1966-2004) for English-language articles using the MeSH terms cutaneous, dermatology, tobacco, skin, and smoking. An additional search was subsequently undertaken for articles related to smoking and associated mucocutanous diseases, with the focus on pathogenesis and epidemiologic data. Articles presenting the highest level of evidence and latest reports were preferentially selected. RESULTS: Smoking is strongly associated with numerous dermatologic conditions including poor wound healing, wrinkling and premature skin aging, squamous cell carcinoma, psoriasis, hidradenitis suppurativa, hair loss, oral cancers, and other oral conditions. In addition, it has an impact on the skin lesions observed in diabetes, lupus, and AIDS. The evidence linking smoking and melanoma, eczema, and acne is inconclusive. Anecdotal data exist on the possible protective effects of smoking in oral/genital aphthosis of Behcet's disease, herpes labialis, pyoderma gangrenosum, acral melanoma, and Kaposi's sarcoma in AIDS patients. CONCLUSIONS: An appreciation of the adverse cutaneous consequences of smoking is important. Dermatologists can play an integral role in promoting smoking cessation by providing expert opinion and educating the public on the deleterious effects of smoking on the skin.
Non-acne dermatologic indications for systemic isotretinoin.
Journal: Am J Clin Dermatol. 2005;6(3):175-84.
Akyol M and Ozcelik S.
Systemic isotretinoin has been used to treat severe acne vulgaris for 20 years. However, isotretinoin also represents a potentially useful choice of drugs in many dermatologic diseases other than acne vulgaris. Diseases such as psoriasis, pityriasis rubra pilaris, condylomata acuminata, skin cancers, rosacea, hidradenitis suppurativa, granuloma annulare, lupus erythematosus and lichen planus have been shown to respond to the immunomodulatory, anti-inflammatory and antitumor activities of the drug. Isotretinoin also helps prevent skin cancers such as basal cell carcinoma or squamous cell carcinoma. A combination of systemic isotretinoin and interferon-alpha-2a may provide a more potent effect than isotretinoin alone in the prevention and treatment of skin cancers.Systemic isotretinoin may be considered as an alternative drug in some dermatologic diseases unresponsive to conventional treatment modalities. However, randomized clinical trials aimed at determining the role of systemic isotretinoin therapy
in dermatologic diseases other than acne vulgaris are required.
Dermatologic signs in patients with eating disorders.
Journal: Am J Clin Dermatol. 2005;6(3):165-73.
Eating disorders are significant causes of morbidity and mortality in adolescent females and young women. They are associated with severe medical and psychological consequences, including death, osteoporosis, growth delay and developmental delay. Dermatologic symptoms are almost always detectable in patients with severe anorexia nervosa (AN) and bulimia nervosa (BN), and awareness of these may help in the early diagnosis of hidden AN or BN. Cutaneous manifestations are the expression of the medical consequences of starvation, vomiting, abuse of drugs (such as laxatives and diuretics), and of psychiatric morbidity. These manifestations include xerosis, lanugo-like body hair, telogen effluvium, carotenoderma, acne, hyperpigmentation, seborrheic dermatitis, acrocyanosis, perniosis, petechiae, livedo reticularis, interdigital intertrigo, paronychia, generalized pruritus, acquired striae distensae, slower wound healing, prurigo pigmentosa, edema, linear erythema craquele, acral coldness, pellagra, scurvy, and acrodermatitis enteropathica. The most characteristic cutaneous sign of vomiting is Russell's sign (knuckle calluses). Symptoms arising from laxative or diuretic abuse include adverse reactions to drugs. Symptoms arising from psychiatric morbidity (artefacta) include the consequences of self-induced trauma.The role of the dermatologist in the management of eating disorders is to make an early diagnosis of the 'hidden' signs of these disorders in patients who tend to minimize or deny their disorder, and to avoid over-treatment of conditions which are overemphasized by patients' distorted perception of skin appearance. Even though skin signs of eating disorders improve with weight gain, the dermatologist will be asked to treat the dermatological conditions mentioned above. Xerosis improves with moisturizing ointments and humidification of the environment. Acne may be treated with topical benzoyl peroxide, antibacterials or azaleic acid; these agents may be administered as monotherapy or in combinations. Combination antibacterials, such as erythromycin with zinc, are also recommended because of the possibility of zinc deficiency in patients with eating disorders. The antiandrogen cyproterone acetate combined with 35 microg ethinyl estradiol may improve acne in women with AN and should be given for 2-4 months. Cheilitis, angular stomatitis, and nail fragility appear to respond to topical tocopherol (vitamin E). Russell's sign may decrease in size following applications of ointments that contain urea. Regular dental treatment is required to avoid tooth loss.
Clinical practice. Acne.
Journal: N Engl J Med. 2005 Apr 7;352(14):1463-72.
Acne vulgaris: a review of antibiotic therapy.
Journal: Expert Opin Pharmacother. 2005 Mar;6(3):409-18.
Tan AW and Tan HH.
Antibiotic therapy has been integral to the management of inflammatory acne vulgaris for many years. Systemic antibiotics work via antibacterial, anti-inflammatory and immunomodulatory modes of action, and have been found to be useful in managing moderate-to-severe acne. Commonly prescribed antibiotics include tetracyclines, erythromycin and trimethoprim, with or without
sulfamethoxazole. In selecting the appropriate antibiotic for patients needing to receive topical or systemic antibiotic therapy, the clinician should take into account the severity of the acne, cost-effectiveness, the safety profile of the drug and the potential for development of resistance. The widespread and long-term use of antibiotics over the years has unfortunately led to the
emergence of resistant bacteria. The global increase in the antibiotic resistance of Propionibacterium acnes may be a significant contributing factor in treatment failures. It is therefore essential that clinicians prescribing antibiotics for the treatment of acne adopt strategies to minimise further development of bacterial resistance. This includes addressing compliance issues, using combination therapies, avoiding prolonged antibiotic treatment, and avoiding concomitant topical and oral antibiotics with chemically dissimilar
Psychosocial effects of acne.
Journal: J Cutan Med Surg. 2004;8 Suppl 4:3-5.
This article discusses the psychological effect of acne vulgaris. It is shown that acne has significant effect on self-image and impacts quality of life. The impact of acne may be equivalent to that of asthma or epilepsy. Anxiety and depression and a reduction in social functioning are a consequence of this condition. Effective treatment results in improvement of quality-of-life measurement. Most of the data is gathered from case control studies. Further work, particularly prospective longitudinal cohort studies, needs to be performed to validate the impact of acne on quality of life. Acne severity grading should incorporate life quality scores to better establish the true impact of this condition on our patients in order to optimize therapy.
Practical approach to the hormonal treatment of acne.
Journal: J Cutan Med Surg. 2004;8 Suppl 4:16-21.
Acne is a disease of the pilosebaceous units and these are mainly under hormonal control. In female patients, hormonal therapy is a unique opportunity for the treatment of acne. Several combined oral contraceptives (COCs), cyproterone acetate, spironolactone, flutamide, and others, have been tried for the control of acne. An overview on the use of the most useful drugs in clinical practice
was conducted. COCs are thoroughly discussed, also taking into consideration their potential side effects. A practical approach with guidelines on the use of COC in acne is proposed.
The mechanism of action of topical retinoids.
Journal: Cutis. 2005 Feb;75(2 Suppl):10-3; discussion 13.
UV irradiation of human skin sets in motion a complex sequence of events that causes damage to the dermal matrix. When topical tretinoin is applied to human skin, any collagen deficiency existing in photoaged skin is remedied at least partially, and the skin is primed to prevent further matrix degradation induced by solar UV. Retinoids, therefore, have become essential in the treatment and prevention of photoaging. This article describes the mechanism of action of retinoids, including how they are mediated through retinoic acid receptors (RARs) and retinoid X receptors (RXRs), how they block inflammation mediators, and how production of procollagen is increased to augment the formation of types I and III collagen. Three naturally occurring retinoids are reviewed.
Topical tretinoin or adapalene in acne vulgaris: an overview.
Journal: J Dermatolog Treat. 2004 Jul;15(4):200-7.
Retinoids target several pathoetiologic events of acne vulgaris. The undisputed efficacy of tretinoin, and yet its underutilization, due to apprehension of retinoid dermatitis, triggered a search for newer, well-tolerated retinoids. The discovery of nuclear retinoic acid receptors has provided clues to a rational design of synthetic, receptor-selective retinoic acid agonists. Adapalene is an
addition to the arsenal of topical retinoids. It possesses the biological properties of tretinoin, but has a distinct physiochemical profile, including high lipophilicity and increased chemical and photostability. It exhibits selective affinity for nuclear retinoic acid receptors and does not bind to cytosolic retinoic acid binding proteins. It exemplifies the formulation of a novel retinoid with specific pharmacologic profile and clinical objectives. Accordingly, numerous clinical trials have compared adapalene and tretinoin in the management of acne vulgaris and concluded that tretinoin 0.05% gel exhibits a greater anti-acne efficacy than adapalene 0.1% gel, but has higher skin irritation potential. This article reviews the pharmacology of adapalene, including its retinoid receptor binding profile, antiproliferative effects, cell differentiation modulation, comedolytic and anti-inflammatory activity, and specifically focuses on the comparison of the efficacy and irritation profile of adapalene and tretinoin.
Isotretinoin, depression and suicide: a review of the evidence.
Journal: Br J Gen Pract. 2005 Feb;55(511):134-8.
Magin P et al.
There is currently considerable controversy regarding a proposed causal relationship between the use of isotretinoin and depression and suicide. A search was made of the MEDLINE, EMBASE and PsychINFO databases using the search terms 'isotretinoin', 'depression' and 'suicide'. Despite numerous case reports linking isotretinoin to depression, suicidal ideation and suicide, there is, as yet, no clear proof of an association. While isotretinoin, used to treat acne vulgaris, has not been demonstrated to be associated with depression or suicide, the possibility of a relatively rare idiosyncratic adverse effect remains. GPs have a role in the clinical application of these findings.
Retinoid therapy for acne. A comparative review.
Journal: Am J Clin Dermatol. 2005;6(1):13-9.
Retinoids play a vital role in the treatment of acne because they act on the primary lesion, the microcomedo. They are synthetic derivatives of vitamin A (retinol), and are selected for their effectiveness. Several compounds are used for acne, either in topical or systemic form.We describe and compare the different topical retinoids, tretinoin (all-trans-retinoic acid), isotretinoin (13-cis-retinoic acid), adapalene (derived from naphthoic acid), and tazarotene (acetylenic retinoid). They act mainly as comedolytics, but anti-inflammatory actions have also been discovered recently. The retinoids have great beneficial effects, but also some adverse effects, the main one being teratogenicity. It is preferable not to use them in topical form for pregnant women, although a pregnancy test is only compulsory for tazarotene.Only isotretinoin is used in systemic form. It acts on all the factors of acne and offers long remissions, and sometimes complete cures. Precautions must be taken for women of childbearing age due to its teratogenicity. It is also important to be aware of its other adverse effects, explain them to the patient and, if possible, deal
with them in advance.
Guidelines for treating acne.
Journal: Clin Dermatol. 2004 Sep-Oct;22(5):439-44.
Katsambas AD et al.
Acne, a chronic inflammatory disease of the pilosebaceous units of the face, neck, chest, and back, is the most common skin disorder occurring universally, with an estimated prevalence of 70-87%.(1) It is a pleomorphic disorder characterized by both inflammatory (papules, pustules, nodules) and noninflammatory (comedones, open and closed) lesions. Grading of acne is mandatory to determine the appropriate therapeutic strategy. Mild acne can be purely comedonal or mild papulopustular, with a few papulopustules present as well.(2) Moderate acne is characterized by numerous comedones, few to many pustules, and few small nodules, with no residual scarring.(2) In severe acne papulopustules are numerous, many nodules can be detected, inflammation is marked, and scarring is present.(2) Very severe acne can be recognized by sinus tracts, grouped comedones, many deeply located nodules, and severe inflammation and scarring.(2) Although acne does not affect health overall, its impact on emotional well-being and function can be critical and is often associated with depression, anxiety, and higher-than-average unemployment rates.(3) Effective treatment can dramatically improve a person's quality of life.
Acne: treatment of scars.
Journal: Clin Dermatol. 2004 Sep-Oct;22(5):434-8.
Jemec GB and Jemec B.
Acne is a common disease affecting a significant proportion of the population.(1-3) It causes considerable morbidity through soreness, disfigurement, and social handicap due to inflammatory lesions.(4,5) Modern therapy ensures that a considerable proportion of all patients can be offered effective treatment of their disease, but the morbidity is not restricted solely to the inflammatory lesions of acne.(6,7) Despite appropriate and effective primary prevention of scarring, scarring occurs in some degree in 95% of all patients irrespective of the severity of inflammatory acne (although severe acne causes more scarring than the milder forms). The scarring causes long-term morbidity that requires specific therapy.(7)
Acne: hormonal concepts and therapy.
Journal: Clin Dermatol. 2004 Sep-Oct;22(5):419-28.
Acne vulgaris is the most common skin condition observed in the medical community. Although we know that hormones are important in the development of acne, many questions remain unanswered regarding the mechanisms by which hormones exert their effects. Androgens such as dihydrotestosterone (DHT) and testosterone, the adrenal precursor dehydroepiandrosterone sulfate (DHEAS), estrogens such as estradiol, and other hormones, including growth hormone and insulin-like growth factors (IGFs), may be important in acne. It is not known whether these hormones are taken up from the serum by the sebaceous gland, whether they are produced locally within the gland, or whether a combination of these processes is involved. Finally, the cellular and molecular mechanisms by which these hormones exert their influence on the sebaceous gland have not been fully elucidated. Hormonal therapy is an option in women with acne not responding to conventional treatment or with signs of endocrine abnormalities.
Acne: systemic treatment.
Journal: Clin Dermatol. 2004 Sep-Oct;22(5):412-8.
Katsambas A and Papakonstantinou A.
Acne vulgaris is a disease affecting mostly adolescents and young adults that, when severe, has the potential to result in scarring and permanent disfigurement. Systemic treatment is necessary to prevent significant psychological and social impairment in these patients.(1) Significant inflammatory and nodulocystic acne is usually recalcitrant to topical treatment, whereas uncommon acne variants, such as acne fulminans, pyoderma faciale, and acne conglobata, need to be promptly and effectively controlled. In all of these circumstances, systemic agents are indispensable. The choices include oral antibiotics, isotretinoin, and hormonal treatment (Table 1).
Comparison of topical retinoids in the treatment of acne.
Journal: Clin Dermatol. 2004 Sep-Oct;22(5):408-11.
Rigopoulos D et al.
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
Acne: topical treatment.
Journal: Clin Dermatol. 2004 Sep-Oct;22(5):398-407.
Krautheim A and Gollnick HP.
Acne vulgaris is a common skin disease, affecting about 70-80% of adolescents and young adults. It is a multifactorial disease of the pilosebaceous unit.(1) The influence of androgens at the onset of adolescence leads to an enlargement of the sebaceous gland and a rise in sebum production. Additional increased proliferation and altered differentiation of the follicular epithelium
eventually blocks the pilosebaceous duct, leading to development of the microcomedo as the primary acne lesion. Concomitantly and subsequently, colonization with Propionibacterium acnes increases, followed by induction of inflammatory reactions from bacteria, ductal corneocytes, and sebaceous proinflammatory agents (Fig 1).(2-5)
Acne and diet.
Journal: Clin Dermatol. 2004 Sep-Oct;22(5):387-93.
Wolf R et al.
Forbidden foods? "The first law of dietetics seems to be: If it tastes good, it's bad for you" (Isaac Asimov, Russian-born biochemist and science fiction writer). This was essentially the Magna Carta for dermatologists of the 1950s: anything coveted by the teenage palate was suspect for morning after acne. Today, half a century later, although the slant has shifted away for this line
of thinking in our dermatologic textbooks, several articles on the beliefs and perceptions of acne patients showed that nothing much has changed and that they expect us to give them detailed instructions of what "acne-related" foods they should avoid. In one such study(1), diet was the third most frequently implicated factor (after hormones and genetics) as the cause of the disease,
with 32% of the respondents selecting diet as the main cause, and 44% thinking that foods aggravate acne. In another study that analyzed knowledge about causes of acne among English teenagers, 11% of the responders blamed greasy food as the
main cause of the disease(2), whereas in another study found that 41% of final-year medical students of the University of Melbourne chose diet as an important factor of acne exacerbation on a final examination.(3)
Journal: Clin Dermatol. 2004 Sep-Oct;22(5):380-4.
Farrar MD, Ingham E.
The inflammatory stage of acne vulgaris is usually of greatest concern to the patient. A number of morphologically different inflammatory lesions may form that can be painful and unsightly. In 30% of patients, such lesions lead to scarring(1). Inflammatory acne and acne scarring can have significant psychological effects on the patient, including depression, anxiety, and poor
self-image(2). Although inflammatory acne has been well characterized clinically, the mechanisms by which inflammatory lesions arise are still poorly understood. The human skin commensal bacterium, Propionibacterium acnes, has long been associated with inflammatory acne. This organism has been implicated over and above all of the other cutaneous microflora in contributing to the
inflammatory response characteristic of acne. However, its precise role in the disease and its interaction with the human immune system remain to be elucidated.
Acne and Propionibacterium acnes.
Journal: Clin Dermatol. 2004 Sep-Oct;22(5):375-9.
Bojar RA and Holland KT.
The involvement of microorganisms in the development of acne has a long and checkered history. Just over 100 years ago, Propionibacterium acnes (then known as Bacillus acnes) was isolated from acne lesions, and it was suggested that P. acnes was involved in the pathology of the disease. The 1960s saw the use of antibiotics to treat acne, and the consequent clinical success combined with reductions in P. acnes gave new impetus to the debate. Over the past two decades, the inevitable emergence of antibiotic-resistant strains of P. acnes as a consequence of acne therapy not only has reopened the debate as to the role of
P. acnes in acne, but also has created some serious health care implications.
Comedone formation: etiology, clinical presentation, and treatment.
Journal: Clin Dermatol. 2004 Sep-Oct;22(5):367-74.
Cunliffe WJ et al.
An important feature in the etiology of acne is the presence of pilosebaceous ductal hypercornification, which can be seen histologically as microcomedones (Fig 1) and clinically as blackheads, whiteheads, and other forms of comedones, such as macrocomedones. There is a significant correlation between the severity of acne and the number and size of microcomedones (follicular casts), the presence of which is a measure of comedogenesis. This correlation can be demonstrated by skin surface biopsy using cyanoacrylate gel. In this procedure, microcomedones are sampled by applying cyanoacrylate gel to the skin surface. A glass microscopic slide is then applied on top of the gel and pressed firmly onto the skin for 1 minute(1-3). The glass slide is gently removed, taking with it the upper part of the stratum corneum and microcomedones, which are then analyzed by low-power microscopy or digital image analysis.(1-3)
Acne and sebaceous gland function.
Journal: Clin Dermatol. 2004 Sep-Oct;22(5):360-6.
The embryologic development of the human sebaceous gland is closely related to the differentiation of the hair follicle and the epidermis. The number of sebaceous glands remains approximately the same throughout life, whereas their size tends to increase with age. The development and function of the sebaceous gland in the fetal and neonatal periods appear to be regulated by maternal androgens and by endogenous steroid synthesis, as well as by other morphogens. The most apparent function of the glands is to excrete sebum. A strong increase in sebum excretion occurs a few hours after birth; this peaks during the first
week and slowly subsides thereafter. A new rise takes place at about age 9 years with adrenarche and continues up to age 17 years, when the adult level is reached. The sebaceous gland is an important formation site of active androgens. Androgens are well known for their effects on sebum excretion, whereas terminal sebocyte differentiation is assisted by peroxisome proliferator-activated receptor ligands. Estrogens, glucocorticoids, and prolactin also influence sebaceous gland function. In addition, stress-sensing cutaneous signals lead to the production and release of corticotrophin-releasing hormone from dermal nerves and sebocytes with subsequent dose-dependent regulation of sebaceous nonpolar lipids. Among other lipid fractions, sebaceous glands have been shown to synthesize considerable amounts of free fatty acids without exogenous influence. Sebaceous lipids are responsible for the three-dimensional skin surface lipid organization. Contributing to the integrity of the skin barrier. They also exhibit strong innate antimicrobial activity, transport antioxidants to the skin surface, and express proinflammatory and anti-inflammatory properties. Acne in childhood has been suggested to be strongly associated with the development of severe acne during adolescence. Increased sebum excretion is a major factor in the pathophysiology of acne vulgaris. Other sebaceous gland functions are also associated with the development of acne, including sebaceous proinflammatory lipids; different cytokines produced locally; periglandular peptides and neuropeptides, such as corticotrophin-releasing hormone, which is produced by sebocytes; and substance P, which is expressed in the nerve endings at the vicinity of healthy-looking glands of acne patients. Current data indicate that acne vulgaris may be a primary inflammatory disease. Future drugs developed to treat acne not only should reduce sebum production and Propionibacterium acnes populations, but also should be targeted to reduce proinflammatory lipids in sebum, down-regulate proinflammatory signals in the pilosebaceous unit, and inhibit leukotriene B(4)-induced accumulation of inflammatory cells. They should also influence peroxisome proliferator-activated receptor regulation. Isotretinoin is still the most active available drug for the treatment of severe acne.
Advances in the topical treatment of acne and rosacea.
Journal: J Drugs Dermatol. 2004 Sep-Oct;3(5 Suppl):S12-22.
Acne and rosacea are common skin diseases which may present similarly and both involve inflammation. Both can result in significant cosmetic impairment and lead to quality of life decrements if not optimally treated. The conventional approach for both diseases involves the use of topical therapy to treat inflammatory lesions in combination, when needed, with a systemic or topical antibiotic. An important issue in the management of both diseases at present is the need to reduce antibiotic usage due to the increasing problem of bacterial resistance. One of the emerging treatment paradigms that is becoming increasingly useful as an antibiotic-sparing strategy is the use of procedural therapies in combination with medical management. Such procedural modalities include lasers, intense pulsed light (IPL), and photodynamic therapies (PDT). Topical regimens are used pre-treatment and following physical modalities for maintenance of remission.
Topical antibacterial therapy for acne vulgaris.
Journal: Drugs. 2004;64(21):2389-97.
Topical antibiotics and benzoyl peroxide, are the two main topical antibacterial treatments indicated for mild-to-moderate acne vulgaris. Topical antibiotics act both as antibacterial agents suppressing Propionibacterium acnes in the sebaceous follicle and as anti-inflammatory agents. Benzoyl peroxide is a powerful antimicrobial agent that rapidly destroys both bacterial organisms and
yeasts. Topical clindamycin and erythromycin have been proven to be effective against inflammatory acne vulgaris in concentrations of 1-4% with or without the addition of zinc. However, none of the antibacterials tested was more effective than benzoyl peroxide, which also has the advantage of not being associated with antimicrobial resistance.Topical antibacterial therapy should be discontinued once improvement is observed. If no improvement is observed within 6-8 weeks, the agent should be discontinued and a therapeutic switch considered. The primary limitation of benzoyl peroxide for some acne vulgaris patients is cutaneous irritation or dryness.Antibacterial therapy can be used in combination with other agents. Combining topical antibiotics and topical retinoids may enhance the efficacy, since the retinoid will improve the penetration of the antibiotic. Combining a topical antibiotic with benzoyl peroxide may increase the bactericidal effect of the antibiotic and reduce the potential for bacterial resistance. Topical and oral antibacterials should not be used in combination for the treatment of acne vulgaris, since this association may increase the risk of bacterial resistance.
Psychosocial impact of acne vulgaris: evaluating the evidence.
Journal: Skin Therapy Lett. 2004 Aug-Sep;9(7):1-3, 9.
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.
Treatment of acne vulgaris.
Journal: JAMA. 2004 Aug 11;292(6):726-35.
Haider A and Shaw JC.
CONTEXT: Management of acne vulgaris by nondermatologists is increasing. Current understanding of the different presentations of acne allows for individualized treatments and improved outcomes. OBJECTIVE: To review the best evidence available for individualized treatment of acne. DATA SOURCES: Search of MEDLINE, EMBASE, and the Cochrane database to search for all English-language articles on acne treatment from 1966 to 2004. STUDY SELECTION: Well-designed randomized controlled trials, meta-analyses, and other systematic reviews are the focus of this article. DATA EXTRACTION: Acne literature is characterized by a lack of standardization with respect to outcome measures and methods used to grade disease severity. DATA SYNTHESIS: Main outcome measures of 29 randomized double-blind trials that were evaluated included reductions in inflammatory, noninflammatory, and total acne lesion counts. Topical retinoids reduce the number of comedones and inflammatory lesions in the range of 40% to 70%. These agents are the mainstay of therapy in patients with comedones only. Other agents, including topical antimicrobials, oral antibiotics, hormonal therapy (in women), and isotretinoin all yield high response rates. Patients with mild to moderate severity inflammatory acne with papules and pustules should be treated with topical antibiotics combined with retinoids. Oral antibiotics are first-line therapy in patients with moderate to severe inflammatory acne while oral isotretinoin is indicated for severe nodular acne, treatment failures, scarring, frequent relapses, or in cases of severe psychological distress. Long-term topical or oral antibiotic therapy should be avoided when feasible to minimize occurrence of bacterial resistance. Isotretinoin is a powerful teratogen mandating strict precautions for use among women of childbearing age. CONCLUSIONS: Acne responses to treatment vary considerably. Frequently more than 1 treatment modality is used concomitantly. Best results are seen when treatments are individualized on the basis of clinical presentation.
Phototherapy in the treatment of acne vulgaris: what is its role?
Journal: Am J Clin Dermatol. 2004;5(4):211-6.
Charakida A et al.
Acne vulgaris is a common dermatosis affecting 80% of the population. To date, different treatments have been used to manage this condition. Antibacterials and retinoids are currently the mainstay of treatment for acne, but their success rate varies. Phototherapy is emerging as an alternative option to treat acne vulgaris.Studies examining the role of different wavelengths and methods of light treatment have shown that phototherapy with visible light, specifically blue light, has a marked effect on inflammatory acne lesions and seems sufficient for the treatment of acne. In addition, the combination of blue-red light radiation seems to be superior to blue light alone, with minimal adverse effects. Photodynamic therapy has also been used, even in nodular and cystic acne, and had excellent therapeutic outcomes, although with significant adverse effects. Recently, low energy pulsed dye laser therapy has been used, and seems to be a promising alternative that would allow the simultaneous treatment of active acne and acne scarring.Further studies are needed to clarify the role of phototherapy as a monotherapy or an adjuvant treatment in the current management of acne vulgaris.
Journal: Facial Plast Surg Clin North Am. 2004 Aug;12(3):347-55, vi.
Acne vulgaris is a common inflammatory skin condition that presents management difficulties to cosmetic surgeons. Acute management and treatment focuses on early diagnosis as well as treatment with topical agents, oral antibiotics, hormonal therapy,and nonablative chemical peel and laser applications. The treatment of postinflammatory scarring must be individualized to address potential macular dyschromia, cystic lesions,epithelial bridges, or deep pitted scars. A review of interventional options is presented to apply to the spectrum of acne scarring as well as a review of the literature to address objectively published reports on efficacy.
Chemical peeling in ethnic/dark skin.
Journal: Dermatol Ther. 2004;17(2):196-205.
Chemical peeling for skin of color arose in ancient Egypt, Mesopotamia, and other ancient cultures in and around Africa. Our current fund of medical knowledge regarding chemical peeling is a result of centuries of experience and research. The list of agents for chemical peeling is extensive. In ethnic skin, our efforts are focused on superficial and medium-depth peeling agents and
techniques. Indications for chemical peeling in darker skin include acne vulgaris, postinflammatory hyperpigmentation, melasma, scarring, photodamage, and pseudofolliculitis barbae. Careful selection of patients for chemical peeling should involve not only identification of Fitzpatrick skin type, but also determining ethnicity. Different ethnicities may respond unpredictably to
chemical peeling regardless of skin phenotype. Familiarity with the properties each peeling agent used is critical. New techniques discussed for chemical peeling include spot peeling for postinflammatory hyperpigmentation and combination peels for acne and photodamage. Single- or combination-agent chemical peels are shown to be efficacious and safe. In conclusion, chemical
peeling is a treatment of choice for numerous pigmentary and scarring disorders arising in dark skin tones. Familiarity with new peeling agents and techniques will lead to successful outcomes.
Acne in ethnic skin: special considerations for therapy.
Journal: Dermatol Ther. 2004;17(2):184-95.
Acne vulgaris occurs in people of all ethnicities and races. Although the pathophysiology and treatment options are similar in all skin phototypes, darker-skinned patients have higher incidence rates of two sequelae of acne: postinflammatory hyperpigmentation and keloidal scarring. Postinflammatory hyperpigmentation may also be triggered by skin irritation. In choosing therapies for patients of color, therefore, clinicians must find a balance between aggressive early intervention to target inflammatory acne lesions, and gentle treatments to increase tolerability and avoid skin irritation. For most patients, a combination of topical retinoids, and topical or oral antibiotics with hydroquinone (as needed) to control hyperpigmentation will be successful. For patients with sensitive skin, topical agents in lower concentrations and cream vehicles are preferred. If tolerated, the retinoid strength can be titrated upward after four to six weeks. Ethnic patients also need to be counseled on use of noncomedogenic and nonirritating skin and hair-care products. Individualized care and close monitoring is required.
Topical retinoid and antibiotic combination therapy for acne management.
Journal: J Drugs Dermatol. 2004 Mar-Apr;3(2):146-54.
Weiss JS and Shavin JS.
The agents most commonly used in combination for the management of acne include topical retinoids and antibiotics. Topical retinoids normalize desquamation of the follicular epithelium, whereas antibiotics inhibit the growth of P. acnes and the production of free fatty acids. This therapeutic combination decreases comedogenesis, bacterial growth, and inflammation, thus targeting three of the four pathogenic factors associated with acne. Efficacy and tolerance are maximized with combination therapy, and the degree of skin irritation is minimized. Furthermore, adjunctive therapy with topical retinoids and antibiotics tends to produce results more quickly than single-agent therapy. This article will examine the individual agents used in combination for acne management, and discuss the mechanisms by which they achieve efficacy. The rationale of utilizing topical retinoids with antibiotics will be highlighted, particularly in relation to improved tolerance and reduced irritation.
Dermatologists and office-based care of dermatologic disease in the 21st century.
Journal: J Investig Dermatol Symp Proc. 2004 Mar;9(2):126-30.
Most professional care of skin diseases is provided in physicians' offices. In the past 25 y, medical practice has changed substantially. Since 1973, the National Ambulatory Medical Care Survey has provided data about patients seen in physicians' offices. Using 1974, 1980, and 1989 data, we have previously analyzed these data as they pertain to skin diseases. To provide a more current assessment of dermatologists' practices and the care of skin diseases in office-based practice, we analyzed National Ambulatory Medical Care Survey data for 1999 to 2000. We used statistical methods for survey data to estimate the number and characteristics of visits to dermatologists and others for skin diseases. We compared the characteristics of dermatologists' office-based practices with those of other physicians. In 1999 to 2000, there were approximately 35 million visits annually to office-based dermatologists, double the number for 1974. Eight diagnostic groups account for 65% of all visits to dermatologists. Acne is still the most frequent primary diagnosis at visits to dermatologists, but since 1974 the proportion of all visits that were for acne
has decreased by half. Compared to other office-based physicians, dermatologists are significantly more likely to own their practices (OR, 2.78; 95% CI, 1.52-5.02) and much less likely to see capitated patients (OR, 0.30; 95% CI, 0.17-0.53). Over 26 y, utilization of dermatologists' services has grown in proportion to the increase in the number of office-based dermatologists. The
organization of their practices has changed little. Dermatologists dominate the care of many of the same diagnoses as they did 20 years ago.
Systemic therapy for acne vulgaris.
Journal: Hosp Med. 2004 Feb;65(2):80-5.
There are three main groups of systemic therapies available for the treatment of acne vulgaris: systemic antibiotics, hormonal therapy (for females) and oral isotretinoin. This article outlines when these treatments should be prescribed for the treatment of acne, considers the impact of therapy on aetiology, and advises on dosage regimens, potential adverse effects and expected efficacy.
Light therapy in the treatment of acne vulgaris.
Journal: Dermatol Surg. 2004 Feb;30(2 Pt 1):139-46.
Elman M and Lebzelter J.
BACKGROUND: Over the past decade, lasers and light-based systems have become a common modality to treat a wide variety of skin-related conditions, including acne vulgaris. In spite of the various oral and topical treatments available for the treatment of acne, many patients fail to respond adequately or may develop side effects. Therefore, there is a growing demand by patients for a fast, safe, and side-effect-free novel therapy. OBJECTIVES: To address the role of light therapy in the armamentarium of treatments for acne vulgaris, to discuss photobiology aspects and biomedical optics, to review current technologies of laser/light-based devices, to review the clinical experience and results, and to outline clinical guidelines and treatment considerations. RESULTS: Clinical trials show that 85% of the patients demonstrate a significant quantitative reduction in at least 50% of the lesions after four biweekly treatments. In approximately 20% of the cases, acne eradication may reach 90%. At 3 months after the last treatment, clearance is approximately 70% to 80%. The nonrespondent rate is 15% to 20%. CONCLUSIONS: Laser and light-based therapy is a safe and effective modality for the treatment of mild to moderate inflammatory acne vulgaris. Amelioration of acne by light therapy, although comparable to the effects of oral antibiotics, offers faster resolution and fewer side effects and leads to patient satisfaction.
Laser surgery: an approach to the pediatric patient.
Journal: J Am Acad Dermatol. 2004 Feb;50(2):165-84; quiz 185-8.
Cantatore JL and Kriegel DA.
Revolutionary advances in laser research and technology have led to expanded dermatologic laser applications. With the wide range of lasers now available, a large spectrum of skin conditions in the pediatric population can be successfully treated or, in some cases, completely eradicated. Laser treatment of the pediatric population poses a unique challenge for the clinician on a variety of levels. Physically, the composition of many vascular and pigmented lesions changes as children age making them more resistant to laser therapy. Thus, in many cases, treating lesions at an early age has resulted in clearing in fewer sessions and with decreased complications. Mechanically, lasers and laser settings used for the treatment of adult lesions may have to be adjusted for the smaller vessels and the unpredictable nature of scarring with children's skin. For vascular lesions, the pulsed dye laser is considered the laser of choice for its efficacy and low-risk profile, whereas the Q-switched, pigment-specific lasers are ideal for most childhood pigmented lesions, allowing for single pigment cell destruction. Other conditions such as acne and acne scars, psoriasis, keloids, warts and hypertrichosis that traditionally have been treated with a variety of modalities are now being managed safely with laser surgery. Other issues specific to the pediatric population include the determination of suitable anesthesia, the provision of size-appropriate safety equipment, and the assessment and management of patient and parent anxiety. The use of lasers specifically designed for structural differences in pediatric lesions and the recognition of emotional issues surrounding a young patient during laser surgery are critical components of successful treatment. Learning objective: At the conclusion of this learning activity, participants should be familiar with the mechanism of laser technology, current trends in the use of lasers for skin lesions in the pediatric population, and the issues specific to treating a patient with laser surgery.
Acne in ethnic skin.
Journal: Dermatol Clin. 2003 Oct;21(4):609-15, vii.
Halder RM et al.
Acne is the most common disorder observed in ethnic skin. Clinical presentation is different than in white skin. Postinflammatory hyperpigmentation is a common sequelae of acne in darker skin. The management of acne in ethnic skin is based largely on the prevention and treatment of hyperpigmentation.