severity of lesions. Systemic (eg, antibiotics, hormone therapy) and topical (eg, isotretinoin gel, benzoyl peroxide, salicylic acid) prescription medications are available as monotherapies or combination treatments. The “Global Alliance to Improve Outcomes in Acne” recommends using combination agents to target most of the pathophysiological features of acne, not only as they can target multiple processes, but they can also provide faster and more complete lesion clearance compared to monotherapy.9 Unfortunately, topical treatments have been associated with side effects, including visible signs of intolerance such as skin dryness, erythema, and scaling, as well as subjective symptoms of irritation such as stinging, burning, and itching. Studies reveal that experiencing side effects can reduce adherence to acne treatment by up to 50%,10 with nonuse of moisturizing creams and cleansers also being linked to poor compliance.11
Acne: Non-Prescription Adjuvants
Over-the-counter (OTC) products play a primarily adjunctive role in acne treatment and maintenance. Relevant OTC products may include skin cleansers, moisturizers, and sunscreens, among others. These products may offer several benefits to acne-prone skin, such as reducing oiliness, redness, inflammation, pain/ discomfort, improving skin texture, time for lesions to heal, the extent of scarring, and potentially, the number and severity of acne breakouts.12 They may provide adjunctive benefits, such as helping to treat the signs and symptoms of acne, and/or they may play a role in acne maintenance by mitigating side effects of prescription medications, thereby improving treatment compliance and outcomes.13,14 Notably, the market for OTC acne products is an order of magnitude larger than that for prescription medications, and acne patients commonly use homeopathy.15 As many acne patients have been reported to try multiple OTC products prior to seeking medical attention and often continue using them while receiving prescription therapy; OTC products may impact treatment outcomes.
Acne in Asian-Pacific Skin
In the 21st century, there was an important demographic change, with half of the world's population identifying as “Asian”; a term generally referring to those from the Asian- Pacific (APAC) regions of East, South, and Southeast Asia, and can include Oceania and/or the Indian subcontinent. Partially due to this population growth, Asians also make up one of the fastest-growing ethnic groups desiring aesthetic treatments and procedures.16 Other factors contributing to this trend include increasing disposable income and shifts in social perceptions of acceptability regarding aesthetics.2,5,6 Given their differential skin characteristics (eg, melanin content), specific environmental/geographical factors (eg, pollution), and unique cultural (eg, diet) and psychosocial influences, Asians represent a distinct ethnic group. Among Chinese and Japanese subjects, Asian skin typically consists of Fitzpatrick A. Andriessen, X. Jiang, K. Kulthanan, et al doi:10.36849/JDD.6259 phenotypes III to IV (light to moderate brown), while types IV and V (dark brown) is more common among Indians and Pakistanis.17 Therefore, Asian skin tends to consist of more melanin than their Caucasian counterparts (Fitzpatrick types I to III), allowing for superior natural photoprotection while also increasing the risk of pigmentary disorders. Post-inflammatory hyperpigmentation is peculiar to this skin type, which can occur after cutaneous damage from acne lesions or following the use of laser therapy. The treatment-seeking behaviors and related epidemiological features in Asian acne patients have been found to vary from that of the rest of the world,18 and multiple studies on topical acne treatments have found that Asians display greater sensitivity and less tolerability than Caucasians.19 For example, approximately 80% of Japanese patients experienced mild adverse effects following the first month of adapalene use, compared to the 20–30% observed in trials involving Caucasians.15
Currently, there is limited data regarding the use of OTC adjuvants in acne treatment and maintenance, and trends in clinical practice are not consistent in this regard. Moreover, it is important to continue studying the unique challenges of treating acne in Asian skin, to optimize clinical outcomes in this population.2,5,6,17 The current manuscript aimed to evaluate the role of OTC products in the treatment of acne, particularly in Asian skin.
Acne: Non-Prescription Adjuvants
Over-the-counter (OTC) products play a primarily adjunctive role in acne treatment and maintenance. Relevant OTC products may include skin cleansers, moisturizers, and sunscreens, among others. These products may offer several benefits to acne-prone skin, such as reducing oiliness, redness, inflammation, pain/ discomfort, improving skin texture, time for lesions to heal, the extent of scarring, and potentially, the number and severity of acne breakouts.12 They may provide adjunctive benefits, such as helping to treat the signs and symptoms of acne, and/or they may play a role in acne maintenance by mitigating side effects of prescription medications, thereby improving treatment compliance and outcomes.13,14 Notably, the market for OTC acne products is an order of magnitude larger than that for prescription medications, and acne patients commonly use homeopathy.15 As many acne patients have been reported to try multiple OTC products prior to seeking medical attention and often continue using them while receiving prescription therapy; OTC products may impact treatment outcomes.
Acne in Asian-Pacific Skin
In the 21st century, there was an important demographic change, with half of the world's population identifying as “Asian”; a term generally referring to those from the Asian- Pacific (APAC) regions of East, South, and Southeast Asia, and can include Oceania and/or the Indian subcontinent. Partially due to this population growth, Asians also make up one of the fastest-growing ethnic groups desiring aesthetic treatments and procedures.16 Other factors contributing to this trend include increasing disposable income and shifts in social perceptions of acceptability regarding aesthetics.2,5,6 Given their differential skin characteristics (eg, melanin content), specific environmental/geographical factors (eg, pollution), and unique cultural (eg, diet) and psychosocial influences, Asians represent a distinct ethnic group. Among Chinese and Japanese subjects, Asian skin typically consists of Fitzpatrick A. Andriessen, X. Jiang, K. Kulthanan, et al doi:10.36849/JDD.6259 phenotypes III to IV (light to moderate brown), while types IV and V (dark brown) is more common among Indians and Pakistanis.17 Therefore, Asian skin tends to consist of more melanin than their Caucasian counterparts (Fitzpatrick types I to III), allowing for superior natural photoprotection while also increasing the risk of pigmentary disorders. Post-inflammatory hyperpigmentation is peculiar to this skin type, which can occur after cutaneous damage from acne lesions or following the use of laser therapy. The treatment-seeking behaviors and related epidemiological features in Asian acne patients have been found to vary from that of the rest of the world,18 and multiple studies on topical acne treatments have found that Asians display greater sensitivity and less tolerability than Caucasians.19 For example, approximately 80% of Japanese patients experienced mild adverse effects following the first month of adapalene use, compared to the 20–30% observed in trials involving Caucasians.15
Currently, there is limited data regarding the use of OTC adjuvants in acne treatment and maintenance, and trends in clinical practice are not consistent in this regard. Moreover, it is important to continue studying the unique challenges of treating acne in Asian skin, to optimize clinical outcomes in this population.2,5,6,17 The current manuscript aimed to evaluate the role of OTC products in the treatment of acne, particularly in Asian skin.
MATERIALS AND METHODS
An advisory panel consisting of key opinion leaders and
dermatologists with expertise in the treatment and maintenance
of acne in Asian skin was held in December 2020, via web
conference. Prior to the meeting, advisors participated in an
online survey that collected data regarding: which (if any) OTC
products they currently recommend for acne patients; for which
(if any) patient profiles do they recommend these products;
when they recommend OTC adjunctive therapies be used; how
they recommend OTC products be used; and why advisors
recommend specific OTC products as adjuncts to acne therapy.
The pre-meeting survey results, evidence from the literature
presented during a series of plenary lectures, and discussions
conducted during a stepwise program of sessions were used
to develop recommendations on the use of OTC products as an
adjunct for treating acne in Asians.
RESULTS
Survey
Acne subtypes observed in the clinics of advisors and the corresponding therapeutic option(s) used to treat these conditions are displayed in Figure 1. According to advisors, OTC products currently serve an adjunctive role under three main conditions: 1) used remedially prior to or in combination with prescription medications, 2) post-procedural use (eg, after a chemical peel, microdermabrasion, laser therapy), or 3) when used as part of a maintenance regimen. Advisors reported
Acne subtypes observed in the clinics of advisors and the corresponding therapeutic option(s) used to treat these conditions are displayed in Figure 1. According to advisors, OTC products currently serve an adjunctive role under three main conditions: 1) used remedially prior to or in combination with prescription medications, 2) post-procedural use (eg, after a chemical peel, microdermabrasion, laser therapy), or 3) when used as part of a maintenance regimen. Advisors reported
