Volume 10 | Issue 6
Why Are Dermatologists Still Talking About Acne? Because So Many People Have It... and We Are Always Seeking Better Ways to Manage It
James Q. Del Rosso, DO|No abstract details for the moment.
Perry Robins, MD|No abstract details for the moment.
Acne vulgaris is the most common skin disorder seen in dermatology and primary care offices today with significant associated morbidity. The pathogenesis of acne is complex and multifactorial, and there continues to be an influx of new information to increase our understanding of this chronic disease. Recent advances in acne pathogenesis will be discussed, including theories regarding the sequence of events in acne formation, the functions of P. acnes, TLR involvement and role of the sebaceous gland and factors influencing sebum production.
J Drugs Dermatol. 2011;10(6):582-585.
Efficacy and Safety of Azelaic Acid (AzA) Gel 15% in the Treatment of Post-Inflammatory Hyperpigmentation and Acne: A 16-Week, Baseline-Controlled Study
Leon H. Kircik, MD|Although there are few differences in the incidence and pathophysiology of acne across various races and ethnicities, there is some evidence that black patients may have larger sebaceous glands and increased sebum production. Of greater clinical relevance, patients with darker skin types are at increased risk for the development of post-inflammatory hyperpigmentation (PIH), which some find as or more troubling than acne itself. This common and bothersome sequelum of acne can be difficult to manage in this population. Topical azelaic acid gel is recognized to have anti-tyrosinase activity, suggesting it may be a suitable treatment option for mild-to-moderate acne with associated moderate-to-severe PIH. This pilot study demonstrates the efficacy of topical AzA gel 15% when applied twice daily for the reduction of both acne and PIH.
J Drugs Dermatol. 2011;10(6):586-590.
Introduction: This study evaluated the efficacy and tolerability of treating mild-to-moderate facial acne using a new, hand-held, light-emitting diode blue light device in conjunction with a foam cleanser containing 5% glycolic acid and 2% salicylic acid plus a skin rebuilding serum containing 1.25% salicylic acid, 0.5% niacinamide, 0.08% liposomal-based azelaic acid and superoxide dismutase.
Methods: Volunteers with mild-to-moderate facial inflammatory acne used the blue light device twice daily for eight weeks, plus the cleanser before treatments and the serum after each evening treatment.
Results: Among 33 subjects aged 25–45 years old, 28 completed. In a 3 cm x 5 cm target area receiving a daily dose of ~29 J/cm2, treatment was associated with significant reductions from baseline in the inflammatory lesion count from week 1 onward (P≤.01) and in the non-inflammatory lesion count from week 4 onward (P≤.05). The number of flares was significantly reduced from baseline from week 2 onward (P≤.05), and flare severity and flare redness were significantly reduced from baseline from week 4 onward (P≤.01 and P≤.05, respectively). At week 8, more than 90 percent of subjects reported improvements in their skin’s overall appearance, clarity, radiance, tone, texture and smoothness. In addition, 82 percent were satisfied, very satisfied, or extremely satisfied with the blue light treatment system and 86 percent agreed the treatment system was much gentler than traditional acne treatments.
Conclusion: The blue light treatment system offers effective, rapid, convenient and well tolerated treatment of inflammatory and non-inflammatory acne lesions. The majority of subjects consider it much gentler than traditional acne treatments and it facilitates effective treatment without the need for antibiotic exposure. The blue light treatment system and blue light therapy alone are attractive treatment options for acne vulgaris, both as alternatives to traditional acne treatments and as adjunctive treatments to complement existing therapies.
J Drugs Dermatol. 2011;10(6):596-602.
Steven R. Feldman MD PhDa and Diana M. Chen MDb|
Background: Products that may cause irritation are widely used to treat acne. Irritation has the potential to reduce treatment adherence. How patients manage irritation and dryness is not well characterized.
Objectives: To study self-reported irritation, its impact and coping mechanisms in patients who had been treated for acne with a clindamycin-5% benzoyl peroxide (BPO) product.
Methods: An Internet-based survey of 200 subjects, aged 15-40 years who had used a clindamycin-5% BPO fixed combination product in the last six months on at least 50 percent of their face, at least five days per week.
Results: The majority of subjects (57%) had moderate acne, 28 percent had severe acne. Bothersome side effects of the clindamycin- 5% BPO combination included dry skin (55%), flaky/peeling skin (45%), irritated skin (44%), itchy skin (39%) and redness (37%). As a result, subjects used the product only as a spot treatment (33%), only when breakouts seemed worse (28%), or less often than recommended (32%); stopped using from time to time (32%); switched to a different prescription medication and/or an over-thecounter acne product (28%); or stopped using altogether (10%). 41 percent of subjects reported using moisturizers to counteract dryness and redness.
Limitations: We queried patients concerning use of combination clindamycin/BPO products and not other products.
Discussion: Irritation to clindamycin-5% BPO is a common problem that reduces patients' use of the medication. Strategies to improve treatment include communication with patients on possible side effects, providing written instruction on how to manage irritation and dryness and consideration of alternative topical treatments and treatment regimens.
J Drugs Dermatol. 2011;10(6):605-608.
Alan B. Fleischer Jr MD|
Rosacea and acne are chronic inflammatory skin conditions that share an inflammatory pathogenesis, but clinically remain quite distinct. Although many have long assumed that these conditions are primarily infectious, emerging evidence suggests that inflammation plays a critical role in the pathogenesis of these disorders. Part of the innate immune system, the antimicrobial and proinflammatory cathelicidins, may be downregulated by both azelaic acid and subantimicrobial doxycycline. In acne, the creation of papules, pustules and nodules is clearly mediated through immune mechanisms, and the antiinflammatory effects of retinoids play a key role in management. Recent observations help us understand in greater detail the role that inflammation plays in these two diseases, and the mechanisms by which commonly used medications exert their effect by modulating inflammatory processes. This review will present and synthesize recently acquired information as it relates to inflammatory acne and rosacea pathogenesis and clinical management.
J Drugs Dermatol. 2011;10(6):614-620.
J. Mark Jackson MDa and Michelle Pelle MDb|
Many topical medications are available for the treatment of papulopustular rosacea. While treatments contain metronidazole, azelaic acid, or sodium sulfacetamide-sulfur as the active ingredient, the composition of the vehicle formulations varies widely. These vehicles come in gels, creams, lotions and foams; some ingredients are common to many vehicles, while some vehicles contain unique ingredients designed to optimize skin penetration and delivery of the active drug to its target. Vehicles can also influence tolerability, which is always a concern in patients with heightened skin sensitivity, and compliance, which is typically lower for topical treatments than oral treatments. Ideally, the vehicle of any rosacea treatment should enhance drug delivery, be nonirritating and be easy to use. Ingredients that help repair barrier function are also desirable. This review will focus on the key components of the vehicles from the most commonly used topical therapies for papulopustular rosacea and how vehicle formulations influence the delivery of active ingredient, skin barrier repair, tolerability and compliance.
J Drugs Dermatol. 2011;10(6):627-633.
Guy F. Webster MD PhD|Topical fixed-combination products and topical retinoid monotherapy are established first-line treatments for mild-to-moderate acne vulgaris, yet adequate comparative data are lacking. The following evidence-based review addresses the question: "In patients with mild-to-moderate acne, are topical fixed-combination products or topical retinoids a more efficacious choice in reducing noninflammatory, inflammatory and total lesions after 12 weeks of treatment?" To identify relevant studies, a PubMed search was performed using "acne" and search terms for adapalene, tretinoin, tazarotene, benzoyl peroxide, clindamycin, or erythromycin. Forty-two studies from January 1991 to November 2009 were included. The studies were evaluated using the Strength of Recommendation Taxonomy, and all but seven received the highest level of evidence grade. To evaluate efficacy, a side-by-side comparison was made using reduction in acne lesion counts at week 12 for study groups treated with fixed-combination therapy or retinoid monotherapy. Twenty-nine studies containing relevant efficacy data for fixed-combination therapy and retinoid monotherapy are summarized here. Nine studies compared fixed-combination therapy with retinoid monotherapy; in eight of these studies, fixed-combination therapy was significantly more efficacious in reducing acne lesion counts. This evidence-based review analyzes clinical evidence to date for these therapies to provide guidance in determining appropriate treatment for patients with mild-to-moderate acne.
J Drugs Dermatol. 2011;10(6):636-644.
Helen M Torok MDa and Radhakrishan Pillai PhDb|
Tretinoin is widely used in the treatment of acne. Despite significant advances in formulation development, irritation and dryness can be particularly bothersome, especially during the first 3-4 weeks, impacting adherence. Dose titration and adjunct use of moisturizers have been commonly employed. Co-prescribing with benzoyl peroxide (BPO) or a BPO/antibiotic combination is also common practice. The tretinoin molecule is unstable and can be degraded by BPO, further complicating treatment regimens.
Lately, formulation technology has focused on providing more efficient penetration of the tretinoin into the skin layers so that lower concentrations of tretinoin might afford better tolerability, but maintain good efficacy; incorporating moisturizing excipients to minimize irritation; and providing greater stability to the tretinoin molecule. This approach would be particularly relevant in a pediatric acne population where efficacy/tolerability balance is important and treatment regimens must take into account lifestyles, but little data exist on the use of tretinoin in this patient population.
A micronized formulation of tretinoin (0.05%) gel has been developed that provides a more efficient delivery of tretinoin, because of its optimal particle size, no degradation by BPO and better cutaneous tolerability than tretinoin microsphere (0.1%) gel without compromising efficacy in a pediatric population.
J Drugs Dermatol. 2011;10(6):647-652.
Candace Thornton Spann MD|During the 21st century, people with skin of color will account for a large portion of the US population. According to race projections from the US Census Bureau, persons of African American, Hispanic, Asian and Native American descent will make up nearly half of the total US population by the year 2050. Because of our changing demographics, it is important that all dermatologists become comfortable in treating skin of color. This article provides 10 practical pearls for management of acne vulgaris in patients with Fitzpatrick skin types IV-VI.
J Drugs Dermatol. 2011;10(6):654-657.
Taurine Chloramine Inhibits NO and TNF-α Production in Zymosan Plus Interferon-γ Activated RAW 264.7 Cells
Bo Sook Kim,a In Soo Cho,b Seung Yong Park,c Georgia Schuller-Levis,d William Levis,e Eunkyue Parkd|
Taurine is present abundantly in various tissues, especially in leukocytes embattled to foreign invaders such as microorganisms or oxidants. Taurine-chloramine (Tau-Cl) is produced from taurine at the site of inflammation via the myeoloperoxidase-halide pathway in leukocytes induced by oxidants and/or infectious materials. Previously, our data demonstrated that Tau-Cl inhibited nitric oxide (NO) production and TNF-α secretion induced by lipopolysaccharide (LPS), a Toll-like receptor 4 (TLR-4) ligand or lipoarabinomannan (LAM), a TLR-2 ligand plus interferon-γ (IFN-γ) in peritoneal macrophages or RAW 264.7 cells. Zymosan, a β-glucan of yeast cell wall, is a ligand for TLR-2 and dectin-1 and stimulates macrophages to produce proinflammatory mediators such as NO and TNF-α. Based on our previous data, we examined the effect of zymosan and IFN-γ induced production of NO and TNF-α in the absence or presence of Tau-Cl or taurine using RAW 264.7 cells. Production of NO and secretion of TNF-α is increased when zymosan is combined with IFN-γ. Tau-Cl inhibited production of NO and secretion of TNF-α in zymosan plus IFN-γ activated RAW 264.7 cells in a dose-dependent manner (99% vs. 48% using 0.8mM Tau-Cl). Taurine was without effect. Nitric oxide synthase protein (iNOS), induced by zymosan plus IFN-γ, was inhibited by Tau-Cl (0.8mM) as measured using western blot analysis. NOS mRNA was inhibited by Tau-Cl at four, eight and 16 hours post activation, but not at 24 hours. TNF-α mRNA was inhibited at four hours and eight hours, but not at 16 and 24 hours. These data suggest that expression of both iNOS and TNF-α mRNAs are inhibited by treatment with Tau-Cl within four and eight hours, but not at later time points. Transient suppression of activation of RAW 264.7 cells induced by zymosan may play a critical physiological role for taurine in protecting against tissue injury from initial overt inflammation. This study indicates that tropical treatment of taurine may ameliorate inflammatory dermatoses caused by an environmental yeast or abnormal immune function.
J Drugs Dermatol. 2011;10(6):659-665.
Bilateral Comparison Study of Pimecrolimus Cream 1% and a Ceramide-Hyaluronic Acid Emollient Foam in the Treatment of Patients With Atopic Dermatitis
Topical corticosteroids have been the mainstay of treatment for atopic dermatitis (AD) over the last decade, especially in the setting of acute flares. However, heavy and prolonged use of topical corticosteroid is undesirable as it is associated with side effects such as, skin atrophy, telangiectasia, striae, steroid-induced dermatoses, rosacea, acne exacerbation, and in some severe and rare cases, systemic effects such as hypothalamic-pituitary-adrenal axis suppression, growth retardation and ocular problems. Non-steroidal antinflammatory agents specific for the treatment of AD (topical calcineurin inhibitors, or TCIs) are now available and they are a viable alternative to topical corticosteroids in treating dermatitis of the face, neck, eyelids, and intertriginous areas where there is a greater risk of the steroid-induced side effects. More recently, medical device emollients have entered the marketplace. These medical devices provide, but are not limited to, anti-oxidant, anti-protease, anti-inflammatory activity, and aid in restoring the natural balance of lipids, which is one of the causes of the epidermal abnormalities seen with AD. The present study evaluated the short-term effectiveness and appeal of a non-steroidal medicated device foam as compared to pimecrolimus cream 1% in the treatment of AD within a wide age group of subjects with active disease at baseline. In this study, both pimecrolimus and the medical device foam exhibited efficacy in mild-to-moderate AD. Primary efficacy was measured by IGA. After four weeks of treatment with the medical device foam, 82% of target lesions were scored "clear" (0) or "almost clear" (1) compared to 71% of target lesions under the pimecrolimus arm. This study confirmed that pimecrolimus cream 1% and the medical device foam work well in the treatment of AD in both adults and children with no associated adverse effects.
J Drugs Dermatol. 2011;10(6):666-672.
Amir Moradi MD,a Azadeh Shirazi MD,b Veronica Pereza|
Loss of volume in the temple can result in a gaunt, wasted appearance. Dermal filler augmentation of the temples can counteract volume loss and achieve a more balanced and youthful appearance. Although the temporal fossa is a critical area for volume restoration of the aging face, published information is limited. The authors retrospectively describe the treatment of 20 female patients who sought facial rejuvenation and received small gel particle hylauronic acid (SPG-HA) injections for temporal fossa augmentation. The authors discuss a rationale for their choice of dermal filler and provide a detailed, illustrated injection technique guide for restoring volume in the temporal fossa region with SPG-HA. There is a need for prospective, controlled studies investigating safety, efficacy and persistency of hyaluronic acid fillers in this area of the face.
J Drugs Dermatol. 2011;10(6):673-676.
Clinical Trial Review is a JDD department designed to provide physicians with information on drugs and devices undergoing clinical testing. It is our goal to inform the reader of the status of select drug and device studies relevant to the practice of dermatology before this information is available through standard channels. To participate in or learn more about these and additional trials, visit www.clinicaltrials.gov.
Resident Rounds: Part I: Program Spotlight: The University of California, Irvine Department of Dermatology Residency Training Program
Nazanin Saedi MD, Amy Reinstadler MD, Sam Truong MD, Kristen Kelly MD|
Resident Rounds is a new section of the JDD dedicated to highlighting various dermatology departments with residency training programs. Resident Rounds will feature three sections: (1) a program spotlight, highlighting pertinent information about the department and residency training program; (2) a section presenting study materials used by residents at the program; and (3) a section designed to highlight recent interesting cases seen at the institution. This issue of Resident Rounds features the University of California, Irvine Department of Dermatology Residency Training Program. The editor of Resident Rounds is Omar A. Ibrahimi, MD, PhD. Dr. Ibrahimi is a recent graduate of the Harvard Combined Program in Dermatology and currently a fellow in Mohs, Laser and Cosmetic Surgery at the University of California Davis. If you are interested in highlighting your training program in a future issue, please contact Dr. Ibrahimi at firstname.lastname@example.org
Amy Reinstadler MD, Sam V. Truong MD, Nazanin Saedi MD|No abstract details for the moment.
Resident Rounds: Part III: Nephrogenic Systemic Fibrosis: A Case Report and Review of the Literature
Sam V. Truong MD, Jennifer K Chen MD, Amy Reinstadler MD, Nazanin Saedi MD|The authors report a case of a patient who presented with thick, indurated, hyperpigmented plaques of the bilateral upper and lower extremities, ultimately discovered to be attributed to nephrogenic systemic fibrosis. The case was written to highlight the clinical manifestations of nephrogenic systemic fibrosis, as well as to make dermatologists aware of this disease, their role in diagnosis and management, and review treatment options.
News, Views & Reviews. A Biopsy Diagnosis? Clinical Clues and Patterns to Help Distinguish Cutaneous Metastases: Part I of II
Karin Blecher BA and Adam Friedman MD|News, Views and Reviews provides focused updates, topic reviews and editorials concerning the latest developments in dermatologic therapy.
Pipeline Previews brings to you information on the newest drugs and medical products as they become available to the dermatologic community. This department may include additional information from the manufacturers, plus reports from physicians who wish to share their clinical experience with these new products. In addition, we will inform our readers about the latest drugs receiving Food and Drug Administration (FDA) approval. We trust you will find this information beneficial to your practice and research.
Diane Thiboutot MD, Andrew F. Alexis MD MPH, Leon H. Kircik MD|Despite the fact that acne is among the most common conditions treated by dermatologists, challenges in managing acne patients are encountered on a daily basis. The articles in this supplement help to address some of those challenges, namely choice of appropriate topical formulations, management of acne in patients with skin of color and appropriate use of oral antibiotics in an age of emerging antibiotic-resistant bacteria.
This is a CME supplement; visit the JDD Medical Education Library to participate in this activity and earn 1 category 1 CME Credit.