Re-evaluating Treatment Targets in Acne Vulgaris: Adapting to a New Understanding of Pathophysiology

June 2014 | Volume 13 | Issue 6 | Supplement Individual Articles | 57 | Copyright © June 2014


Leon H. Kircik MD

Indiana University School of Medicine, Indianapolis, IN
Icahn School of Medicine at Mount Sinai, New York, NY
Physicians Skin Care, PLLC, Louisville, KY

vehicle once daily for 12 weeks. As early as week 2, total, inflammatory, and noninflammatory lesion counts were reduced in the topical combination arm compared with the vehicle arm. At week 12, topical combination therapy plus doxycycline was statistically significantly superior to vehicle plus doxycycline in reducing total, inflammatory, and non-inflammatory lesion counts. A rapid reduction in P. acnes in the adapalene/BPO plus doxycycline group vs the doxycycline alone group—particularly within the first 4 weeks—was demonstrated through the use of digital UV fluorescence photography.28
The second portion of this study, which was also double-blind, randomized, and controlled, enrolled the subjects who had achieved at least 50% global improvement in the previous 12-week treatment. Subjects were randomized to receive adapalene/BPO gel or its vehicle once daily for 24 weeks. At week 24, subjects using adapalene/ BPO had a significantly higher rate of lesion maintenance success (at least 50% improvement in lesion counts achieved in initial treatment) for all types of lesions. Fifty-seven percent of subjects receiving adapalene/BPO had maintained 100% of the effect at week 24 following discontinuation of oral antibiotics. That number of subjects was 74% for the 70% of the effect at week 24.
Another open label study by Leyden has demonstrated that adaplene 0.1%/BPO 2.5% gel was able to reduce effectively skin colonization by antibiotic sensitive and antibiotic resistant P. acnes over 4 weeks in healthy volunteers.29

New Perspectives

Acne vulgaris has long been known to be an inflammatory disease rather than an infective one. However, the emerging concept of subclinical inflammation and its effect on development and progression of acne lesions correlating with the sequence of the underlying inflammation process has been a major change in our understanding of acne pathogenesis. Thus, inflammation has become the major feature of the disease process from onset to resolution, including postinflammatory erythema, postinflammatory hyperpigmentation, and scarring. Therefore, this new paradigm may even necessitate change of nomenclature, such as from postinflammatory hyperpigmentation and postinflammatory erythema to persistent hyperpigmentation and persistent erythema, since there is no end of inflammation in this disease process. Additionally, the term “noninflammatory” lesions should be eliminated, since we now know that all lesions are of an inflammatory nature, albeit subclinically.
Therefore, our treatment targets may also need to be reconsidered, with more emphasis on anti-inflammatory treatments.

DISCLOSURES

Dr. Kircik has served as an advisor, investigator, consultant, and speaker for Galderma, Allergan, Bayer, Promius Pharma, Quinnova, Stiefel/GSK, LeoPharma, Taro, Valeant, and Warner Chilcott.

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