Acne vulgaris: a treatment update

Though acne is not generally cured, treatment can reduce the severity and frequency of outbreaks, lessen discomfort from inflamed lesions, improve appearance, and prevent or minimize scarring, thereby averting or ameliorating potentially serious adverse psychosocial effects. A number of new agents are available; combination therapies that achieve synergism are described.     

Evaluation of antismoking advertising campaigns

BACKGROUND: Steroid acne is a folliculitis that can result from systemic or topical administration of steroid, and has been described as showing a similar clinical picture to Pityrosporum folliculitis, but there have been few reports about the incidence of Pityrosporum ovale and the effect of antimycotic drugs in steroid acne and other acneiform eruptions. Our purpose was to describe the association between steroid acne and P. ovale, and to confirm the superior efficacy of oral antifungal drugs over anti-acne drugs in the treatment of steroid acne. METHODS: The history, clinical features direct microscopy, histopathologic analysis, and therapeutic results of 125 cases with steroid acne or other acneiform eruptions were described and compared. RESULTS: Over 80% of patients with acneiform eruption receiving systemic steroid revealed significant numbers of P. ovale in the lesional follicle. Furthermore, oral antifungal drug (itraconazole) showed significantly better clinical and mycologic effects than any other group of medications used in this study. CONCLUSIONS: Steroid acne and other acneiform eruptions showing discrete follicular papules and/or pustules localized to the upper trunk and acneiform facial skin lesions associated with multiple acneiform lesions on the body in the summer period should be suspected as Pityrosporum folliculitis. In addition, oral antifungal drugs recommended for Pityrosporum folliculitis; however, it will require a larger case-control study to confirm the superiority of antifungal therapy over anti-acne treatment.     

Acne: physiopathology and clinical aspects

Acne is easy to diagnose, but its physiopathology is complex and not yet fully elucidated. However, the three factors that are necessary to the genesis of acne are well defined, being seborrhoea, obstruction of the hair follicle and the sebaceous gland, and inflammation of the follicle. To this must be added a genetic predisposition. While the skin lesions leave little doubt about the diagnosis, a thorough examination is needed to evaluate the part due to sebum retention (comedos, microcysts) and that due to inflammatory elements (papules, pustules, nodules), for the lesions are so polymorphous that it would be better to speak of acnes rather than acne. A good knowledge of clinical and physiopathological data leads to the appropriate treatment, since almost all therapeutic failures result from a misappreciation of acne.     

Treatment of acne with a combination clindamycin/benzoyl peroxide gel compared with clindamycin gel, benzoyl peroxide gel and vehicle gel: combined results of two double-blind investigations

BACKGROUND: It has previously been shown that a combination of erythromycin and benzoyl peroxide is superior to either ingredient when used alone in the treatment of acne. A clindamycin/benzoyl peroxide combination gel might have an advantage over erythromycin/benzoyl peroxide gel because the former does not require refrigeration after it is dispensed. OBJECTIVE: Our purpose was to determine the efficacy and safety of a combination clindamycin/benzoyl peroxide gel when compared with benzoyl peroxide, clindamycin, or vehicle gels. METHODS: In two double-blind, randomized, parallel, vehicle-controlled trials, patients were treated for 11 weeks with once-nightly application of one of the above preparations. Evaluations were performed at 2, 5, 8, and 11 weeks and included lesion counts and assessment of global responses and irritant effects. RESULTS: A total of 334 patients completed the study. All three active preparations were significantly superior to the vehicle in global improvement and in reducing inflammatory lesions and noninflammatory lesions. The combination gel was significantly superior to the two individual agents in global improvement and reduction of inflammatory lesions and also to the clindamycin gel in reducing noninflammatory lesions. There was no significant difference in tolerance to the active gels versus the vehicle gel. CONCLUSION: In the treatment of acne, topical clindamycin/benzoyl peroxide combination gel is well tolerated and superior to either individual ingredient.     

The impact of acne: a study of adolescents' attitudes, perception and knowledge

AIM: To assess adolescent students' attitudes to, perceptions and knowledge of acne and to assess the effect of acne on daily living. METHOD: Students from Auckland sixth and seventh form classes were selected from ten Auckland secondary schools using a randomisation process which ensured proportional representation by socioeconomic group and gender. Eight hundred and forty-seven students completed a written questionnaire on the subject of acne vulgaris and had their acne examined. Their acne was graded using a modification of the Leeds system which determines severity on the basis of number, extent and nature of the skin lesions. RESULTS: Acne was present in 91% of males and 79% of females. Students' perceptions of the severity of their acne were significantly related to objective clinical assessment (p=0.00001). Severity of acne determined the extent of embarrassment (p<0.00001) and the lack of enjoyment of and participation in social activities (p<0.00002). These analyses were significant for both males and females. Students had misconceptions regarding the causes of acne. Parental occupation and ethnic group were related to knowledge of treatment for acne. CONCLUSION: Acne causes personal and social difficulties for a large number of adolescent students. There is a need for all students to have access to appropriate information and health services so that the social and psychological consequences of acne are minimised.     

Pyogenic granuloma-like lesions in a patient using topical tretinoin

A 16-year-old male developed numerous pyogenic granuloma like-lesions across his neck, chest and back after 6 weeks isotretinoin therapy for cystic acne. The isotretinoin was ceased and he was commenced on oral steroids. After 6 weeks, the lesions were almost completely healed. However, due to worsening comedonal acne, the patient was commenced on topical tretinoin cream 0.05% twice daily to his chest. He was reviewed 2 weeks later and, surprisingly, 2 new pyogenic granuloma-like lesions had developed on his chest. These lesions persisted until the topical tretinoin was ceased 3 months later.     

Retinoid therapy for aging skin and acne

Primary care physicians should be familiar with the effects and appropriate uses of retinoids. Topical tretinoin (Retin-A) can reverse photoaging of the skin, although some transient, undesirable side effects usually occur. In patients with acne vulgaris, topical tretinoin and systemic isotretinoin (Accutane) are the only agents that act upon the apparent underlying causes. Recurrence is unlikely after successful results are achieved. Chronic hypervitaminosis A presents insidiously, and physicians must maintain a high index of suspicion. Complete history taking should always include questions about the patient's use of vitamin supplements.     

Current options for the topical treatment of acne vulgaris

The etiopathogenesis of acne vulgaris, a common disorder of youth and adolescence, includes four primary processes: hyperkeratinization (plugging) of the pilosebacous follicles, increased testosterone levels, bacterial colonization with Propionibacterium acnes, and inflammation. No single agent has yet been developed that addresses all of these factors. Combination regimens, therefore, which usually include an antibiotic and an agent to reduce follicular plugging, have become the mainstay of treatment. Despite a relative dearth of new treatments for almost a decade, recent research has produced a number of new significant oral and topical agents. Azelaic acid, a naturally occurring dicarboxylic acid analogue, has shown promise, and a group of retinoids that include adapalene, tazarotene, and reformulations of tretinoin represent new and forthcoming agents for topical treatment of acne vulgaris. Some studies indicate that several of these agents are associated with less skin irritation than previous formulations while they retain potent comedolytic activity. Adapalene also possesses significant anti-inflammatory activity.     

Propionibacterium acnes isolated from synovial tissue and fluid in a patient with oligoarthritis associated with acne and pustulosis

This report describes the case of a patient with a 14-month course of severe oligoarthritis associated with acne. Pure cultures of Propionibacterium acnes were isolated from synovial tissue and synovial fluid specimens collected from the same joint after a 4-month interval. After 2 months of treatment with roxithromycin 300 mg/day, rifampicin 1,200 mg/day, and a nonsteroidal antiinflammatory drug (NSAID), followed by 4 months of treatment with azithromycin 1 gm/week and an NSAID, the synovitis persisted. Cultures of skin lesions and synovial fluid at this time were negative. Although P acnes has previously been isolated from bone specimens obtained from patients with osteitis associated with acne, this is the first report of the isolation of this microorganism from the synovial tissue of a patient with arthritis associated with acne. Our findings raise the question of the role of P acnes in the pathogenesis of arthritis associated with acne.     

Visual diagnosis of hematologic and oncologic diseases

Cancer-related problems are seen frequently by the emergency physician. More difficult presentations are seen with premonitory symptoms, paraneoplastic syndromes, and nonspecific lesions. Dermatologic paraneoplastic syndromes are numerous, nonspecific, and consist of hamartomatous growths, texture changes, new hair growth, or changes in skin color. Alteration of skin color may be of practically any color, localized or diffuse, and of sudden or indolent onset. Hormone production by tumors may lead to acne, hirsutism, gynecomastia, or a cushingoid appearance. Pruritus may herald the onset of leukemia or lymphoma and be intolerable, as with erythroderma. All suspicious presentations require thorough investigation for underlying disease. Metastasis to skin is not common and implies a poor prognosis if seen. Most metastases are seen on the head and neck, anterior chest wall, and abdomen. Basal cell and squamous cell carcinomas commonly occur in sun-exposed areas. Basal cell is locally destructive, whereas squamous cell occasionally metastasizes to local lymph nodes. Malignant melanoma is the leading fatal illness originating in skin, with a dramatic rise in incidence. It is classically described as asymmetric with irregular borders, is elevated, and shows color variegation; however, melanoma may present atypically, particularly in non-whites. Kaposi's sarcoma lesions are well-demarcated, symmetric, smooth nodules that appear purplish-brown, particularly if below the knee (owing to venous stasis). The closely interrelated structures of the eye and orbit are easily disturbed, leading to the presenting symptoms of visual disturbances, exophthalmos, pain, and ocular motility disorders. Primary tumors are not unusual and may include retinoblastoma, rhabdomyosarcoma, and melanoma. Equally common are metastatic lesions, most commonly lung and breast carcinoma. An estimation of the malignancy of bony lesions can be made by assessing the zone of transition, periosteal reaction, and bone destruction. A malignant lesion will more likely have a broad zone of transition, irregular periosteal reaction, and moth-eaten or permeative destruction of trabeculae. Metastatic bone lesions primarily occur in sites of persistent red marrow: skull, ribs, vertebrae, pelvis, and proximal humerus and femur. Bony lesions can be blastic or lytic in nature. Solitary pulmonary nodules that have not grown for 2 years can be assumed to be benign. Calcification seen on plain films are a strong (but not absolute) indication of benignancy. Lesions that are greater than 3 to 4 cm in diameter, have irregular contours, are cavitated with thick walls, have multiple peripheral nodules, and have lack of calcification are more likely malignant.     

Recent advances in the treatment of type II diabetes mellitus

Diabetes mellitus needs to be managed early to prevent the onset and progression of complications. Diet and exercise may not be sufficient to achieve and maintain good glycemic control. Currently, no pharmacologic agent addresses all of the fundamental abnormalities in the pathogenesis of type II diabetes mellitus. However, the newer agents do not exacerbate the hyperinsulinemia that often occurs with type II diabetes, and they may help reduce the risk of cardiovascular disease that is associated with high insulin levels. Two of these agents, metformin and acarbose, have recently become available in the United States for the treatment of type II diabetes. With the availability of agents that differ in their mechanisms of action and side effect profiles, regimens can be individualized to address the variety of pathophysiologic abnormalities in type II diabetes. For this purpose, agents can be used alone or in combination.     

Serum 3 alpha-androstanediol-glucuronide is decreased in nonhirsute women with acne vulgaris

OBJECTIVE: To determine if acne vulgaris in women has a different pattern of androgen activity than hirsutism at the pilosebaceous unit. DESIGN: Prospective clinical study. SETTING: Outpatient clinic for gynecological endocrinology at a university hospital. PATIENT(S): Twenty women suffering from mild or moderate acne vulgaris compared with 38 controls. MAIN OUTCOME MEASURE(S): Serum androgens DHEAS, androstendione, T, including 3 alpha-androstanediol-glucuronide (3 alpha-diolG), the metabolite of 5 alpha-reductase activity. RESULT(S): Serum 3 alpha-diolG was decreased in the acne groups depending on the grade of severity. No statistically significant differences were observed between the other androgens measured in acne patients and controls. CONCLUSION(S): In contrast to hirsutism, acne is influenced directly by T and not by its 5 alpha-reduced metabolites. In female acne patients, 5 alpha-reductase activity appears to be reduced, which is reflected in decreased serum levels of 3 alpha-diolG. Consequently, 5 alpha-reductase inhibitors are most likely not promising candidates for acne therapy; a postulation that, however, requires further clinical investigation.     

Hidradenitis suppurativa

BACKGROUND: Hidradenitis suppurativa (HS) is a recurrent, suppurative disease manifested by abscesses, fistulas, and scarring. METHODS: We reviewed the literature to identify reliable information regarding epidemiology, pathogenesis, clinical manifestations, evaluation and differential diagnosis, treatment, complications, and prognosis. RESULTS: Hidradenitis suppurativa usually affects young women, with a prevalence of 0.3% to 4% in industrialized countries. Once considered to be "apocrine acne," HS is actually a defect of terminal follicular epithelium. Obesity, chemical irritants, or hyperandrogenism are not consistently associated; bacterial involvement is secondary. Hidradenitis suppurativa should be suspected in young adults with recurrent, deep furuncular lesions in flexural sites, especially when such lesions respond poorly to antibiotic therapy. Clindamycin and isotretinoin may be useful, though wide excision with healing by granulation is considered most efficacious. Anemia, arthropathy, and squamous cell carcinoma are potential complications. CONCLUSIONS: Since spontaneous resolution is rare and progressive disability the rule, early definitive surgical treatment of HS is advisable.     

The naturally transformable marine bacterium WJT-1C formally identified as "Vibrio" is a pseudomonad

A case of the SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome in a 35-year-old woman is presented. Ignorance of this entity on the part of the physicians treating the patient may have contributed to her having repeated diagnostic procedures and treatment, some of which may have been unnecessary. Dentists are encouraged to suspect the SAPHO syndrome when they encounter a patient with mandibular osteomyelitis together with symptoms involving other bones and skin lesions such as pustulosis or psoriasis.     

Clinical models of chemoprevention for the esophagus

Esophageal SCC is a complex disease involving multiple etiologic factors. A number of preventive approaches could be taken to reduce the occurrence of the disease including changes in lifestyle and improved nutrition, for example, the inclusion of higher quantities of fruits and vegetables in the diet. Unfortunately, these primary prevention approaches are not easily implemented and often fall short in achieving marked reductions in disease occurrence. Chemoprevention offers another approach to reducing the risk of esophageal SCC that is likely to be useful, even though the clinical trials to date have not resulted in the identification of agents that produce marked inhibitory effects on the development of the disease. Given esophageal SCC's complex etiology, it would appear that the most effective chemoprevention strategy would be to employ agents that reduce mutational events associated with exposure to esophageal carcinogens in combination with agents that inhibit the progression of epithelial dysplasia to esophageal SCC. The feasibility of addressing carcinogen-induced mutational events is underscored by the fact that many of the suspected esophageal carcinogens are known, and inhibitors of these carcinogens have been identified in animal model systems. In addition, biomarkers to assess the efficacy of anti-initiation agents, such as levels of phase I and II enzyme activities and of carcinogen: DNA adducts, can be measured. The identification of agents that inhibit the progression of dysplastic lesions to esophageal SCC has proven difficult; however, the results of the trial with ATB and retinamide are encouraging. Clearly, it seems important to identify the active chemopreventives in the antitumor-B herbal mixture. Further studies to identify strong inhibitors of tumor progression in the rat model for esophageal SCC are also needed. Biomarkers of cell proliferation (e.g., PCNA, Ki67), cell differentiation (keratins), apoptosis, gene expression (EGFR, cyclin D1, p53), and nuclear/nucleolar morphometry can be used in studies to assess the efficacy of chemopreventives to either reverse esophageal dysplastic lesions or slow their rate of progression. The development of viable approaches toward the chemoprevention. of esophageal SCC is truly an important goal in view of the poor prognosis of this disease.     

Parenting and the best interests of minors

Magnetic resonance techniques can be employed to depict valvular abnormalities but are especially helpful in quantifying regurgitant or stenotic lesions which cannot be quantitatively assessed by other noninvasive techniques. Gradient echo techniques and phase velocity mapping are the most important magnetic resonance pulse sequences employed for these purposes. Valvular regurgitation can be quantitated by measuring the area of signal void on conventional gradient-echo images, by calculating stroke volume differences from k-space segmented gradient echo images, by measuring the proximal convergence zone from velocity encoded images or by comparing stroke volumes of the ventricles from velocity measurements. In contrast to this variety of possibilities in regurgitant lesions, stenotic lesions can only be quantitated by using velocity mapping techniques. Magnetic resonance spectroscopy can be used to assess myocardial metabolism in chronic valvular lesions. However, this tool needs further development and more clinical data before its use can be recommended to assess the necessity and optimal timing of surgical intervention.     

Oral and systemic effects of prolonged minocycline therapy

The following case report shows the unfortunate side effects of minocycline therapy used in the management of facial acne. All three features of discoloration affecting the skin, bone and dentition were found. A 46-year-old patient presented with adult onset discoloration of the dentition following prolonged minocycline therapy. In addition, oral and cutaneous pigmentation were noted. Unfortunately, the undesirable cosmetic appearance of facial acne was exchanged for permanent discoloration of the dentition. When considering prolonged minocycline therapy, patients would benefit from dialogue between the medical and dental practitioners, so that the risk of this potential side effect can be assessed in a more informed way.     

Effect of antisense oligodeoxynucleotides directed to individual calmodulin gene transcripts on the proliferation and differentiation of PC12 cells

Myocarditis has been shown to be a common cause of cardiomyopathy and is believed to account for 25% of all cases in human beings. Unfortunately, the disease is difficult to detect before a myopathic process ensues. Treatment of myocarditis-induced heart failure includes the standard regimen of diuretics, digoxin, angiotensin-converting enzyme inhibitors, and currently, beta-adrenergic blockers. Treatment of myocarditis itself is dependent on the etiology of the illness. Treatments under investigation include immunosuppressants, nonsteroidal antiinflammatory agents, immunoglobulins, immunomodulation, antiadrenergics, calcium-channel blockers, angiotensin-converting enzyme inhibitors, nitric oxide inhibition (e.g., aminoguanidine), and antiviral agents. Despite advances in treatment, more work needs to be done in the early detection of myocarditis. Additionally, better means need to be established for distinguishing between viral and autoimmune forms of the disease, so that appropriate treatment can be instituted.     

Antecedents of dental anxiety: learned responses versus personality traits

Patients recovering from alcohol and other drug addiction have unique medical and pharmacological needs. Careful selection of medications call decrease the risk of relapse. Angiotensin-converting enzyme inhibitors and calcium channel-blocking medications are excellent choices to treat hypertension. Most gastrointestinal problems resolve with abstinence and can be treated nonpharmacologically. In managing pain, physicians should avoid narcotics and use nonpharmacological treatment whenever possible. Treating recovering patients with HIV can be challenging because of the side effects of many of the antiviral medications. The newer antiviral agents have fewer side effects and contraindications. Commonly used remedies for colds and cough can cause a relapse to drug use. Patients with diabetes mellitus need to be monitored very closely in early recovery to prevent hypoglycemia. Frequently a team approach is helpful in managing the medication needs of patients in recovery.     

Body dysmorphic disorder in patients with acne

There is growing evidence that the prevalence of body dysmorphic disorder (BDD) is significantly higher in specially selected populations as compared to the general population. The goal of the current study was to evaluate prevalence of BDD in Turkish patients with mild acne presenting to a dermatologist for treatment. This study was the first empirical investigation of BDD in acne patients in Turkey. One hundred fifty-nine outpatients diagnosed with acne who consulted to the dermatology clinic were included in the study. The diagnosis of BDD was based on DSM-IV criteria and the Structured Clinical Interview for DSM-IV (SCID-I). A study-specific questionnaire was administered to document and investigate the demographic and clinical characteristics of the cases. Fourteen (8.8%) patients were diagnosed with BDD. Three (21.4%) patients with acne and BDD also had concomitant psychiatric diagnoses. All of the patients were psychiatric management-naive, never received any psychological or physical treatments. BDD was a common psychiatric condition in acne cases. We suggest that dermatologists should routinely explore symptoms and screen such patients for BDD.