Responsiveness of the Acne-Specific Quality of Life Questionnaire (Acne-QoL) to treatment for acne vulgaris in placebo-controlled clinical trials

Assessment of the Effect of Rehmannia glutinosa Leaf Extract in Maintaining Skin Health: A Proof-of-Concept, Double-Blind, Randomized, Placebo-Controlled Clinical Trial

Purpose

A double-blind, placebo-controlled, randomized, proof-of-concept trial aimed to evaluate the efficacy and safety of VerbasnolTM [Rehmannia glutinosa Libosch leaf-based extract (RGLE)] in females, with moderate to severe acne vulgaris.

Participants and Methods

Twenty-two females aged 18 to 35 years having moderate to severe acne with Global Acne Grading System (GAGS) scores of 19 to 38 were included in the study and were randomized in a 1:1 ratio to receive either one capsule (100 mg/day) of RGLE or placebo orally after breakfast for 56 days. The primary outcome was a change in acne severity measured by the GAGS compared to the placebo on day 56. The secondary outcomes were changes in the number of inflammatory acne lesions, facial sebum secretion, quality of life, local pain and itching, skin wrinkle severity, and other skin characteristics, including radiance, luminosity, smoothness, texture, firmness, and hydration. Additionally, the percentage of responders and global tolerability and efficacy were evaluated.

Results

The mean GAGS score was reduced by 21.72% and 14.20% on day 28 in RGLE (n=10) and placebo groups (n=12), respectively, which further reduced in both groups on day 56. The RGLE group reported better improvement in other skin characteristics on day 56. No safety or tolerability concerns were reported for the extract. RGLE reduced acne and improved the skin quality in females compared to placebo as early as 28 days of supplementation.

Conclusion

RGLE supplementation at a dose of 100 mg/day has provided a clinically relevant decrease in acne severity and improved the skin hydration and quality of life of the participants with acne after 56 days of dose administration.

Cost-effectiveness of Spironolactone for Adult Female Acne (SAFA): economic evaluation alongside a randomised controlled trial

OBJECTIVE

This study aims to estimate the cost-effectiveness of oral spironolactone plus routine topical treatment compared with routine topical treatment alone for persistent acne in adult women from a British NHS perspective over 24 weeks.

DESIGN

Economic evaluation undertaken alongside a pragmatic, parallel, double-blind, randomised trial.

SETTING

Primary and secondary healthcare, community and social media advertising.

PARTICIPANTS

Women ≥18 years with persistent facial acne judged to warrant oral antibiotic treatment.

INTERVENTIONS

Participants were randomised 1:1 to 50 mg/day spironolactone (increasing to 100 mg/day after 6 weeks) or matched placebo until week 24. Participants in both groups could continue topical treatment.

MAIN OUTCOME MEASURES

Cost-utility analysis assessed incremental cost per quality-adjusted life year (QALY) using the EQ-5D-5L. Cost-effectiveness analysis estimated incremental cost per unit change on the Acne-QoL symptom subscale. Adjusted analysis included randomisation stratification variables (centre, baseline severity (investigator's global assessment, IGA <3 vs ≥3)) and baseline variables (Acne-QoL symptom subscale score, resource use costs, EQ-5D score and use of topical treatments).

RESULTS

Spironolactone did not appear cost-effective in the complete case analysis (n=126 spironolactone, n=109 control), compared with no active systemic treatment (adjusted incremental cost per QALY £67 191; unadjusted £34 770). Incremental cost per QALY was £27 879 (adjusted), just below the upper National Institute for Health and Care Excellence's threshold value of £30 000, where multiple imputation took account of missing data. Incremental cost per QALY for other sensitivity analyses varied around the base-case, highlighting the degree of uncertainty. The adjusted incremental cost per point change on the Acne-QoL symptom subscale for spironolactone compared with no active systemic treatment was £38.21 (complete case analysis).

CONCLUSIONS

The results demonstrate a high level of uncertainty, particularly with respect to estimates of incremental QALYs. Compared with no active systemic treatment, spironolactone was estimated to be marginally cost-effective where multiple imputation was performed but was not cost-effective in complete case analysis.

TRIAL REGISTRATION NUMBER

ISRCTN registry (ISRCTN12892056).

Effectiveness of spironolactone for women with acne vulgaris (SAFA) in England and Wales: pragmatic, multicentre, phase 3, double blind, randomised controlled trial

OBJECTIVE

To assess the effectiveness of oral spironolactone for acne vulgaris in adult women.

DESIGN

Pragmatic, multicentre, phase 3, double blind, randomised controlled trial.

SETTING

Primary and secondary healthcare, and advertising in the community and on social media in England and Wales.

PARTICIPANTS

Women (≥18 years) with facial acne for at least six months, judged to warrant oral antibiotics.

INTERVENTIONS

Participants were randomly assigned (1:1) to either 50 mg/day spironolactone or matched placebo until week six, increasing to 100 mg/day spironolactone or placebo until week 24. Participants could continue using topical treatment.

MAIN OUTCOME MEASURES

Primary outcome was Acne-Specific Quality of Life (Acne-QoL) symptom subscale score at week 12 (range 0-30, where higher scores reflect improved QoL). Secondary outcomes were Acne-QoL at week 24, participant self-assessed improvement; investigator's global assessment (IGA) for treatment success; and adverse reactions.

RESULTS

From 5 June 2019 to 31 August 2021, 1267 women were assessed for eligibility, 410 were randomly assigned to the intervention (n=201) or control group (n=209) and 342 were included in the primary analysis (n=176 in the intervention group and n=166 in the control group). Baseline mean age was 29.2 years (standard deviation 7.2), 28 (7%) of 389 were from ethnicities other than white, with 46% mild, 40% moderate, and 13% severe acne. Mean Acne-QoL symptom scores at baseline were 13.2 (standard deviation 4.9) and at week 12 were 19.2 (6.1) for spironolactone and 12.9 (4.5) and 17.8 (5.6) for placebo (difference favouring spironolactone 1.27 (95% confidence interval 0.07 to 2.46), adjusted for baseline variables). Scores at week 24 were 21.2 (5.9) for spironolactone and 17.4 (5.8) for placebo (difference 3.45 (95% confidence interval 2.16 to 4.75), adjusted). More participants in the spironolactone group reported acne improvement than in the placebo group: no significant difference was reported at week 12 (72% v 68%, odds ratio 1.16 (95% confidence interval 0.70 to 1.91)) but significant difference was noted at week 24 (82% v 63%, 2.72 (1.50 to 4.93)). Treatment success (IGA classified) at week 12 was 31 (19%) of 168 given spironolactone and nine (6%) of 160 given placebo (5.18 (2.18 to 12.28)). Adverse reactions were slightly more common in the spironolactone group with more headaches reported (20% v 12%; p=0.02). No serious adverse reactions were reported.

CONCLUSIONS

Spironolactone improved outcomes compared with placebo, with greater differences at week 24 than week 12. Spironolactone is a useful alternative to oral antibiotics for women with acne.

TRIAL REGISTRATION

ISRCTN12892056.

Patient-Reported Outcome Measures for Health-Related Quality of Life in Patients With Acne Vulgaris: A Systematic Review of Measure Development and Measurement Properties

Importance

Multiple patient-reported outcome measures (PROMs) for health-related quality of life (HRQoL) exist for patients with acne. However, little is known about the content validity and other measurement properties of these PROMs.

Objective

To systematically review PROMs for HRQoL in adults or adolescents with acne.

Data Sources

Eligible studies were extracted from PubMed and Embase (OVID).

Study Selection

Full-text articles published in English or Spanish on development, pilot, or validation studies for acne-specific, dermatology-specific, or generic HRQoL PROMs were included. Development studies included original development studies, even if not studied in acne patients per Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) recommendations. If a study included several diagnoses, the majority (ie, over 50%) of patients must have acne or acne-specific subgroup analyses must be available. Abstract and full-text screening was performed by 2 independent reviewers.

Data Extraction and Synthesis

Two independent reviewers assessed study quality applying the COSMIN checklist and extracted and analyzed the data. For each distinctive PROM, quality of evidence was graded by measurement property.

Main Outcomes and Measures

PROM properties (target population, domains, recall period, development language), PROM development and pilot studies, content validity (relevance, comprehensiveness, comprehensibility), and remaining measurement properties (structural validity, internal consistency, cross-cultural validity, reliability, measurement error, criterion validity, construct validity, and responsiveness). Quality of evidence was assigned for each measurement property of included PROMs. An overall recommendation level was assigned based on content validity and quality of the evidence of measurement properties.

Results

We identified 54 acne PROM development or validation studies for 10 acne-specific PROMs, 6 dermatology-specific PROMs, and 5 generic PROMs. Few PROMs had studies for responsiveness. The only acne-specific PROMs with sufficient evidence for content validity were the CompAQ and Acne-Q. Based on available evidence, the Acne-Q and CompAQ can be recommended for use in acne clinical studies.

Conclusions and Relevance

Two PROMs can currently be recommended for use in acne clinical studies: the Acne-Q and CompAQ. Evidence on content validity and other measurement properties were lacking for all PROMs; further research investigating the quality of remaining acne-specific, dermatology-specific, and generic HRQoL PROMs is required to recommend their use.

Spironolactone for adult female acne (SAFA): protocol for a double-blind, placebo-controlled, phase III randomised study of spironolactone as systemic therapy for acne in adult women

INTRODUCTION

Acne is one of the most common inflammatory skin diseases worldwide and can have significant psychosocial impact and cause permanent scarring. Spironolactone, a potassium-sparing diuretic, has antiandrogenic properties, potentially reducing sebum production and hyperkeratinisation in acne-prone follicles. Dermatologists have prescribed spironolactone for acne in women for over 30 years, but robust clinical study data are lacking. This study seeks to evaluate whether spironolactone is clinically effective and cost-effective in treating acne in women.

METHODS AND ANALYSIS

Women (≥18 years) with persistent facial acne requiring systemic therapy are randomised to receive one tablet per day of 50 mg spironolactone or a matched placebo until week 6, increasing to up to two tablets per day (total of 100 mg spironolactone or matched placebo) until week 24, along with usual topical therapy if desired. Study treatment stops at week 24; participants are informed of their treatment allocation and enter an unblinded observational follow-up period for up to 6 months (up to week 52 after baseline). Primary outcome is the Acne-specific Quality of Life (Acne-QoL) symptom subscale score at week 12. Secondary outcomes include Acne-QoL total and subscales; participant acne self-assessment recorded on a 6-point Likert scale at 6, 12, 24 weeks and up to 52 weeks; Investigator's Global Assessment at weeks 6 and 12; cost and cost effectiveness are assessed over 24 weeks. Aiming to detect a group difference of 2 points on the Acne-QoL symptom subscale (SD 5.8, effect size 0.35), allowing for 20% loss to follow-up, gives a sample size of 398 participants.

ETHICS AND DISSEMINATION

This protocol was approved by Wales Research Ethics Committee (18/WA/0420). Follow-up to be completed in early 2022. Findings will be disseminated to participants, peer-reviewed journals, networks and patient groups, on social media, on the study website and the Southampton Clinical Trials Unit website to maximise impact.

TRIAL REGISTRATION NUMBER

ISRCTN12892056;Pre-results.

Treatment challenges in adult female acne and future directions

Introduction: Acne is a chronic, inflammatory, and immune-mediated disease of the pilosebaceous unit, highly prevalent in adolescents. However, an increasing number of adults over 25 years old with facial acne, particularly women, have been observed. It is considered a different disease when compared to acne vulgaris. Face is the mainly involved area with inflammatory lesions and more sensitive skin, pointing out the need of a holistic approach.Areas covered: We performed a comprehensive literature search on PubMed database, up to January 2021, regarding adult female acne. We synthesized data about pathogenesis; differences compared to acne vulgaris; and treatment, with focus in the management challenges and perspectives.Expert opinion: It is essential to value the negative impact on quality of life of adult female acne, independently of severity. The disease has prolonged evolution, and patient might be resilient once the improvement, regardless of the treatment option, will just be noticeable after 3 months. Aggravating factors should be clearly discussed, such as the need of changing many habits, especially lesions manipulation. The therapeutic regimen includes make-up and tailored skin care (considering proneness to sensitivity), while anti-acne drugs should be chosen in accordance with desire to be pregnant, presence of pregnancy or breastfeeding.

Patient-reported outcome measures for acne: a mixed-methods validation study (acne PROMs)

OBJECTIVES

To examine the acceptability and validity of two patient-reported outcome measures (PROMs) for adult acne, comparing them to the validated Acne-specific Quality of Life (Acne-QoL) measure.

DESIGN

Mixed-methods validation study.

SETTING

Participants were recruited by (1) mail-out through primary care if they had ever consulted for acne and received a prescription for acne treatment within the last 6 months, (2) opportunistically in secondary care and (3) poster advertisement in community venues.

PARTICIPANTS

221 (204 quantitative and 17 qualitative) participants with acne, aged 18-50 years.

OUTCOME MEASURES

Quantitative sub-study participants completed Acne-QoL, Skindex-16 and Comprehensive Acne Quality of Life Scale (CompAQ) at baseline, 24 hours and 6 weeks. Qualitative sub-study participants took part in cognitive think-aloud interviews, while completing the same measures. Transcribed audio recordings were analysed using inductive thematic analysis.

RESULTS

Quantitative analyses suggested high internal consistency (Cronbach's alpha 0.74-0.96) and reliability (intraclass correlation coefficient values 0.88-0.97) for both questionnaires. Both scales showed floor effects on some subdomains. Skindex-16 and CompAQ showed good evidence of construct validity when compared with Acne-QoL with Spearman's correlation coefficients 0.54-0.81, and good repeatability over 24 hours.Qualitative data uncovered wide-ranging views regarding usability and acceptability. Interviewees held strong but differing views about layout, question/response wording, redundant/similar questions and guidance notes. Similarly, interviewees differed in perceptions of acceptability of the different scales, particularly on relatability of questions and emotive reactions to scales.

CONCLUSIONS

All PROMs performed well in statistical analyses. No PROM showed superior usability and acceptability in the qualitative study. Any PROM should be acceptable for further research in adult acne but researchers should consider the different domains and whether they will measure only facial or facial and trunk acne before making a selection. A new PROM or further evaluation of novel PROMs may be beneficial.

Identifying the Impacts of Acne: A Delphi Survey of Patients and Clinicians

BACKGROUND

Acne can adversely impact those affected in multiple dimensions. The purpose of this study was to determine the most prominent impacts identified by acne patients and by clinicians.

METHODS

Independent Delphi surveys for acne patients and clinicians were conducted to achieve consensus regarding acne impacts within each group. Acne patients were recruited from outpatient clinics of authors (AL, JT, and DT). The first phase involved qualitative responses, where emergent themes were identified and used to generate items for 2 subsequent phases.

RESULTS

The qualitative phase generated 64 items in 3 themes: psychological, sociological, and treatment related. These items were independently ranked in importance by patients and by clinicians. Consensus for importance was achieved for 34 items by patients and 43 by clinicians. Patient-identified highest ranked items were being self-conscious, feeling unattractive, feeling uncomfortable in own skin, unattractive to others, would not want pictures taken, envious of people with clear skin, and time/effort spent concealing scarring; while clinicians identified feeling unattractive.

CONCLUSIONS

We identify acne impacts within psychological, sociological, and treatment-related domains by acne patients and clinicians. Further, we establish discrepancies between patients and clinicians regarding the impact of acne. This provides evidence for the importance of establishing patient-reported outcomes.

The effect on acne quality of life of topical azelaic acid 15% gel versus a combined oral contraceptive in adult female acne: A randomized trial

Acne vulgaris is a chronic inflammatory disease that affects the pilosebaceous unit. Recent studies have shown an increasing number of cases of acne in adult women. These cases are predominantly normoandrogenic and have show some clinical differences compared to adolescent acne. In addition to the physical aspects, acne has a strong psychosocial impact and can lead to the onset of signs and symptoms of depression, such as anger. Our objective was to evaluate the effect on acne-specific quality of life in adult women treated with topical azelaic acid versus a combined oral contraceptive. The study population consisted of 38 adult women with acne and without any features of hyperandrogenism recruited from the clinic of Dermatology Hospital Division of São Paulo, Federal University of São Paulo from January 2012 to September 2014. Patients were randomized into two different groups: one receiving containing 20 ug of ethinylestradiol and 3 mg drospirenone in a regimen of 24 days of medication, a combined oral contraceptive (COC), and the other group topical 15% azelaic acid (AA) gel, twice daily, both for six months. The quality of life was evaluated at baseline and end of treatment with an acne specific measure (Acne-QoL). Before treatment, our data revealed a significant impact of the presence of acne on quality of life. Both treatments resulted in improvement with significant statistical values in quality of life scores. Comparing the four domains of Acne-QoL, patients treated with an oral contraceptive showed greater improvement in two domains (self-perception and acne symptoms) than those treated with azelaic acid.

Quality of life measurement in acne. Position Paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa

Acne causes profound negative psychological and social effects on the quality of life (QoL) of patients. The European Dermatology Forum S3-Guideline for the Treatment of Acne recommended adopting a QoL measure as an integral part of acne management. Because of constantly growing interest in health-related QoL assessment in acne and because of the high impact of acne on patients' lives, the European Academy of Dermatology and Venereology Task Force on QoL and Patient Oriented Outcomes and the Task Force on Acne, Rosacea and Hidradenitis Suppurativa have documented the QoL instruments that have been used in acne patients, with information on validation, purposes of their usage, description of common limitations and mistakes in their usage and overall recommendations.

Translation, cross-cultural adaptation and validation of the Quality of Life Evaluation in Epidermolysis Bullosa instrument in Brazilian Portuguese

BACKGROUND

The Quality of Life Evaluation in Epidermolysis Bullosa (QoLEB) questionnaire was developed for use in English-speaking individuals.

OBJECTIVES

The aims of this study were to translate the QoLEB into Brazilian Portuguese, to culturally adapt it, and to verify its reliability and validity.

METHODS

The study followed the steps proposed by the World Health Organization, which include: translation; evaluation by a panel of experts and patients; back translation; and linguistic and cultural adaptation. All subjects were examined and assessed using the QoLEB and the Dermatology Life Quality Index (DLQI) or the Children's Dermatology Life Quality Index (CDLQI). Translation and cultural and linguistic adaptation were conducted by 10 patients, three translators, and the bilingual authors.

RESULTS

The population was composed of 40 children (mean age: 8,15 years) and 17 adults (mean age: 33 years). Among the children, eight had epidermolysis bullosa (EB) simplex (EBS), one had junctional EB (JEB), and 31 had dystrophic EB (DEB). In the adult group, four of the subjects had EBS, one had JEB, and 12 had DEB. Mean ± standard deviation (SD) scores on the QoLEB in children were 10.60 ± 7.13 in EBS subjects, 9.71 ± 7.87 in children with dominant DEB (DDEB), and 14.25 ± 9.67 in children with recessive DEB (RDEB). Mean ± SD scores in adults were 12.50 ± 9.95 in EBS subjects, 12.00 ± 5.83 in DDEB subjects, and 20.20 ± 9.21 in RDEB subjects. The QoLEB-BP (Brazilian Portuguese) showed high internal consistency (Cronbach's α = 0.88) and high test-retest reliability (intraclass correlation coefficient: 0.70), confirming the internal consistency and reproducibility of this Portuguese version. There were significant correlations between QoLEB scores and both CDLQI (Pearson's r = 0.688, P < 0.002) and DLQI (Pearson's r = 0.807, P < 0.001) scores.

CONCLUSIONS

Epidermolysis bullosa has marked impacts on the lives of EB patients and their families, which are strongly correlated with disease severity. The Brazilian Portuguese version of the QoLEB is validated and can be recommended for use in subsequent studies.

Translation, cross-cultural adaptation and validation of the vitiligo-specific health-related quality of life instrument (VitiQoL) into Brazilian Portuguese

BACKGROUND:

Vitiligo, although asymptomatic, highly compromises patients' quality of life (QoL). Therefore, an adequate evaluation of QoL is essential.

OBJECTIVES:

Translation, cultural adaptation and validation of VitiQol (Vitiligo-specific health-related quality of life instrument) into Brazilian Portuguese.

METHODS:

The study was conducted in two stages; the first stage was the translation and cultural/linguistic adaptation of the instrument; the second stage was the instrument's validation.

RESULTS:

The translated VitiQol showed high internal consistency (Cronbach alpha = 0.944) and high test-retest reliability and intraclass correlation coefficient=0.95 (CI 95% 0.86 - 0.98), p<0.001. There was no statistically significant difference between the means of the first completion of the VitiQoL questionnaire and the retest, p = 0.661. There was a significant correlation between VitiQoL and DLQI (r = 0.776, p <0.001) and also between VitiQoL-PB and subjects' assessment of the severity of their disease (r = 0.702, p <0.001).

CONCLUSIONS:

The impact of vitiligo on the QoL of Brazilian patients can be assessed by a specific questionnaire.

The Relationship Between Dermatologist- and Patient-Reported Acne Severity Measures and Treatment Recommendations

Background:

Acne treatment recommendations for individual patients may be derived from multiple factors including dermatologist- and patient-reported constructs.

Objectives:

To evaluate the effects of dermatologist- and patient-reported measures on acne treatment recommendations by dermatologists.

Methods:

An observational cross-sectional survey of acne patients was conducted with patient-reported quality of life and dermatologist-reported measures of primary and secondary (scar) acne severity using 3 assessment approaches: maximal regional grade, total grade, and facial grade.

Results:

The most highly associated factors with acne treatment recommendations were patient emotions, maximal regional acne severity, and total acne scar grade. Better acne-specific quality of life was negatively related to acne treatment recommendation intensity, while all 3 grading approaches were positively related to acne treatment recommendations.

Conclusions:

For dermatologists, overall acne severity is most highly associated with maximal regional acne grade, total scar grade, and patient’s emotional response to acne.

Acne-specific quality of life questionnaire (Acne-QoL): translation, cultural adaptation and validation into Brazilian-Portuguese language

BACKGROUND

many studies about the psychosocial impact of acne have been reported in international medical literature describing quality of life as a relevant clinical outcome. It is well known that the patient's perception about the disease may be different from the physician's evaluation. Therefore, it is important to use validated instruments that turn the patient's subjective opinion into objective information.

OBJECTIVES

to translate into Brazilian-Portuguese language and to culturally adapt a quality of life questionnaire, the Acne-Specific Quality of Life Questionnaire (Acne-QoL), as well as to evaluate its reliability and validity.

METHODS

measurement properties were assessed: 1) validity: comparison between severity and Acne-QoL domain scores, correlations between acne duration and Acne-QoL domain scores, and correlation between Acne-QoL domain scores and SF-36 components; 2) internal consistency: Cronbach's α coefficient; 3) test-retest reproducibility: intraclass correlation coefficient and Wilcoxon test.

RESULTS

Eighty subjects with a mean age of 20.5 ± 4.8 years presenting mild (33.8%), moderate (36.2%) and severe (30%) facial acne were enrolled. Acne-QoL domain scores were similar among the different acne severity groups except for role-social domain. Subjects with shorter acne duration presented significant higher scores. Acne-QoL domains showed significant correlations, both between themselves and with SF-36 role-social and mental health components. Internal consistency (0.925-0.952) and test-retest reproducibility were considered acceptable (0.768-0.836).

CONCLUSIONS

the Brazilian-Portuguese version of the Acne-QoL is a reliable and valid satisfactory outcome measure to be used in facial acne studies.

Acupoint Stimulation for Acne: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Acupoint stimulation-including acupuncture, moxibustion, cupping, acupoint injection, and acupoint catgut embedding-has shown a beneficial effect for treating acne. However, comprehensive evaluation of current clinical evidence is lacking.

OBJECTIVE

The aim of this review was to assess the effectiveness and safety of all acupoint stimulation techniques used to treat acne vulgaris.

DESIGN

A systematic review was conducted. It included only randomized controlled trials on acupoint stimulation for acne. Six electronic databases were searched for English and Chinese language studies. All searches ended in May 2012. Studies were selected for eligibility and assessed for quality. RevMan 5.1 software was used for data analysis with an effect estimate presented as risk ratios (RR) or mean difference (MD) with a 95% confidence interval (CI).

PATIENTS

Studies with subjects who were diagnosed with acne vulgaris, or papulopustular, inflammatory, adolescent, or polymorphic acne-regardless of gender, age, and ethnicity-were included.

INTERVENTION

Interventions included any acupoint stimulation technique-such as acupuncture, moxibustion, cupping, acupoint injection, and acupoint catgut embedding-compared with no treatment, placebo, or conventional pharmaceutical medication.

MAIN OUTCOME MEASURE

Reduction of signs and symptoms and presence of adverse effects were examined.

RESULTS

Forty-three trials involving 3453 patients with acne were included. The methodological quality of trials was generally poor in terms of randomization, blinding, and intention-to-treat analysis. Meta-analyses showed significant differences in increasing the number of cured patients between acupuncture plus herbal medicine and herbal medicine alone (RR: 1.60; 95% CI: 1.19-2.14; P=0.002), and between acupuncture plus herbal facial mask and herbal facial mask alone (RR: 2.14; 95% CI: 1.29-3.55; P=0.003). Cupping therapy was significantly better than pharmaceutical medications for increasing the number of cured patients (RR: 2.11; 95% CI: 1.45-3.07; P<0.0001). Serious adverse events were not reported in all included trials.

CONCLUSIONS

Acupoint stimulation therapies combined with other treatments appears to be effective for acne. However, further large, rigorously designed trials are needed to confirm these findings.

Which factors influence quality of life in acne patients?

BACKGROUND

The factors that impact quality of life in acne patient are not fully understood.

OBJECTIVE

The purpose of this study was to assess the relationship between quality of life with (i) acne severity; (ii) the duration of this cutaneous disease; and (iii) the gender.

METHODS

Leeds scale to quantify acne severity, and Assessment of the Psychological and Social Effects of Acne (APSEA) score to evaluate quality of life were used. An unselected consecutive group of 50 males and 50 females affected by facial acne filled in the APSEA questionnaire during the first visit and after 3 months of treatment.

RESULTS

(i) At the beginning of the treatment, APSEA score correlated with acne severity, but at the end of it, the reduction of APSEA score was less marked than the reduction of acne severity. (ii) Acne duration does not significantly influence APSEA score. (iii) Before treatment, acne severity was comparable between females and males, whereas APSEA score was significantly higher in females than in males.

CONCLUSION

The quality life of acne patients could be influenced by social and emotional factors. The discrepancy of the results reported in literature regarding the correlation of the quality of life with acne severity and duration probably depends on the sensitivity and specificity of the questionnaire used to assess the quality of life. Among the different available scores to measure quality of life in acne patients, in the authors' experience, APSEA score is a valuable one.

Cumulative response curves to enhance interpretation of treatment differences on the Self-Esteem And Relationship questionnaire for men with erectile dysfunction

What's known on the subject? and What does the study add? Studies on erectile dysfunction (ED) therapies rely heavily on patient-reported outcomes (PROs) to measure efficacy on treatment response. A challenge when using PROs is interpretation of the clinical meaning of changes in scores. A responder analysis provides a threshold score to indicate whether a change in score qualifies a patient as a responder. However, a major consideration with responder analysis is the sometimes arbitrary nature of defining the threshold for a response. By contrast, cumulative response curves (CRCs) display patient response rates over a continuum of possible thresholds, thus eliminating problems with a rigid threshold definition, allowing for a variety of response thresholds to be examined simultaneously, and encompassing all data. With respect to the psychosocial factors addressed in the Self-Esteem And Relationship questionnaire in ED, CRCs clearly, distinctly, and meaningfully highlighted the favourable profiles of responses to sildenafil compared with placebo. CRCs for PROs in urology can provide a clear, transparent and meaningful visual depiction of efficacy data that can supplement and complement other analyses.

OBJECTIVE

To use cumulative response curves (CRCs) to enrich meaning and enhance interpretation of scores on the Self-Esteem And Relationship (SEAR) questionnaire with respect to treatment differences for men with erectile dysfunction (ED).

PATIENTS AND METHODS

This post hoc analysis used data from all patients who took at least one dose of study drug and had at least one post-baseline efficacy evaluation in a previously published 12-week, multicentre, randomized, double-blind, placebo-controlled trial of flexible-dose (25, 50, or 100 mg) sildenafil citrate (Viagra) in adult men with ED who had scored ≤ 75 out of 100 on the Self-Esteem subscale of the SEAR questionnaire. CRCs were used on the numeric change in transformed SEAR scores from baseline to end-of-study for each SEAR component. The horizontal axis of the CRC represented change from baseline on the SEAR score, and the vertical axis represented the percentage of patients experiencing that change or greater. The differences between CRCs for the sildenafil group vs the placebo group were assessed using the Kolmogorov-Smirov test.

RESULTS

For each of the SEAR components, there was essentially no overlap in the CRCs between the sildenafil group (n = 113) and placebo group (n = 115 or 116, depending on the component), showing that a greater percentage of sildenafil recipients compared with placebo recipients had a more favourable change across the spectrum of response thresholds (P ≤ 0.01). Previous research showed that a 10-point score increase is the minimal clinically meaningful improvement for most SEAR components. In the sildenafil vs placebo groups, a ≥10-point score increase occurred in 72 vs 37% of patients, respectively, on the Sexual Relationship Satisfaction domain, 71 vs 41% on the Confidence domain, 76 vs 49% on the Self-Esteem subscale, 60 vs 44% on the Overall Relationship Satisfaction subscale, and 75 vs 38% on the Overall score.

CONCLUSIONS

With respect to the psychosocial factors addressed in the SEAR questionnaire, CRCs clearly, distinctly, and meaningfully highlighted the favourable profiles of responses to sildenafil compared with placebo. CRCs for patient-reported outcomes in urology can provide a clear, transparent, and meaningful visual depiction of efficacy data that can supplement and complement other analyses.

In vivo assessment of the efficacy of an innovative face care system in subjects with mild acne vulgaris

The purpose of our studies was to verify efficacy and skin compatibility of a medical face care system containing 2% lactic acid (LA) as active ingredient in a specially designed vehicle (Follicle Targeting System) in adult subjects with mild acne vulgaris. The first study (46 patients) demonstrated superiority of 2% LA in comparison to 2% salicylic acid with respect to number of comedones and inflammatory lesions. The second study evaluated 90 patients receiving distinct combinations of face care products (Eucerin) Impure Skin, Hamburg, Germany), i.e. cleansing gel, facial tonic (2% LA) and cream gel (2% LA). All treatments were performed twice daily over a 12 weeks period. Lesion counts, cyanoacrylate biopsies and determination of quality of life by questionnaires were performed at different timepoints. A reduction of comedones by 56% corresponding to an 46% increase of quality of life index was demonstrated in patients applying cleansing gel, facial tonic and cream gel. For the first time we were able to show a significant improvement concerning the quality of life after using a new face care line. Especially adults with mild forms of acne may benefit from this effective skin care regimen.

Effect of Quality of Life Impact and Clinical Severity on Adherence to Topical Acne Treatment

Background:

Topical medications are the most commonly prescribed treatments for acne patients. However, adherence to these treatments and possible associations with clinical severity and quality of life (QoL) impact are unclear.

Purpose:

We evaluated the association between sociodemographic factors, clinical severity, and QoL impact and adherence to topical acne treatments.

Methods:

This was an observational study of acne patients referred for usual care to community-based dermatologists. Adherence was assessed with questionnaires after 2 months of acne therapy. The associations of adherence with factors of interest were evaluated by chi-square analysis and Spearman rank correlation.

Results:

In 152 acne patients treated with topical medications, low adherence was observed in 26%, medium in 49%, and high in 24%. Age, gender, duration of acne, education level, third-party drug plan coverage, smoking history, recreational drug use, ingestion of alcohol, and number of prescribed topical agents were not significantly associated with adherence. Adherence was significantly positively correlated with QoL impact ( r = .24, p = .003), with the role-emotional and self-perception domains having the highest correlations. In contrast, adherence was weakly negatively correlated with facial acne severity ( r = .16, p = .047).

Limitations:

This study focused on facial acne, and adherence was based on patient reporting.

Conclusions:

Adherence to topical acne therapy increases with impact on QoL but decreases with increasing acne severity.

Divergence of Demographic Factors Associated with Clinical Severity Compared with Quality of Life Impact in Acne

Background:

Previous smaller studies suggest that age, gender, and duration of acne may individually be associated with clinical acne severity and quality of life (QoL) impact.

Objective:

Our purpose was to concurrently evaluate the association of demographic factors with clinical acne severity and with QoL impact.

Methods:

Clinical acne severity was assessed using the Investigators Global Assessment, whereas QoL impact was evaluated by the patient-completed Acne-QoL. These outcomes were correlated with sociodemographic variables, including age, gender, and duration of acne.

Results:

In 862 acne patients, clinical severity was associated with younger age, male gender, and shorter acne duration (1–5 years). In contrast, greater impact on QoL was associated with older age, female gender, and longer acne duration (> 5 years).

Conclusions:

Clinical and QoL measures each differentiate between groups of patients most severely affected by acne. Our findings reinforce the imperative for clinicians to use both measures for comprehensive patient management.

Limitations:

Study limitations include referral population of acne patients and the restriction of outcome measures to facial acne.

Condensation and validation of a 4-item index of the Acne-QoL

BACKGROUND

The 19-item Acne-QoL is a validated psychometric instrument designed for use in clinical trials.

OBJECTIVE

The purpose of this study was to develop a condensed version of the Acne-QoL as an alternative measure of psychosocial impact for use in routine clinical practice.

METHODS

Four condensed versions of the Acne-QoL were evaluated by regression analysis in a subset of 434 patients. The version with four items most broadly representative of acne-specific quality of life combined with a high level of correlation to Acne-QoL total score was selected for further validation in two different patient samples.

RESULTS

The patient ranked condensation, representing items from each domain of greatest patient-perceived importance and relevance was selected for further analysis (Acne-Q(4)). The Acne-Q(4) explained 98.5% of the variation in total score of Acne-QoL. Validation of the Acne-Q(4) in a follow-up group and an independent subset of patients resulted in Pearson correlation coefficients of 0.967 (p<0.001). Construct validity of the Acne-Q(4) was confirmed by demonstrating a similar relationship as the Acne-QoL to acne severity.

LIMITATIONS

There is less breadth and detail of QoL information in the Acne-Q(4) than in the Acne-QoL. The analysis relied on a total score for Acne-QoL, which the original developers did not validate.

CONCLUSIONS

The Acne-Q(4) is accurately reflective of the parent instrument and may facilitate the psychometric evaluation of the impact of facial acne on patients in routine clinical practice by its practicality.

Assessing quality of life in patients with acne vulgaris: implications for treatment

Diagnosing acne is easy. However, treatment must be adapted to the type and severity of acne, and must also take into account the impact of acne on patients' quality of life. As there is not always a correlation between the severity of acne and its impact on quality of life, it can be helpful for the dermatologist to use a quality of life scale to determine the psychological impact of acne on patients. Either global scales or specific scales for acne can be used. This article reviews the different scales used for evaluation of quality of life in patients with acne.Consideration of specific scales suggests that the Acne Disability Index/Cardiff Acne Disability Index is the easiest scale to use in routine dermatology practice. The Acne Quality of Life scale is particularly useful for evaluating anxiety and depression. The Acne-Specific Quality of Life questionnaire has been mainly validated in adult acne. The Assessment of the Psychological and Social Effects of Acne scale has yet to be validated. Clinical trials indicate that use of global and specific scales together has complementary benefits. In the management of acne, evaluation of quality of life may help to detect depression in teenagers. It may also help to enhance adherence to treatment, which is a crucial factor for success. Finally, there are now validated quality of life scales that are easy to use during patient consultations (taking <2 minutes to complete) by clinicians wishing to evaluate quality of life in patients with acne.

The validity and utility of the BPI interference measures for evaluating the impact of osteoarthritic pain

The psychometric properties of the Brief Pain Inventory (BPI), a widely used measure of pain and its impact on functioning, were assessed using data from two clinical trials of controlled-release oxycodone in osteoarthritis (OA) patients. Specifically, the pain-related functional interference subscale and the sleep item from that subscale were examined. In Study 1 (n = 133), "night awakenings with pain" was positively correlated with the BPI interference score and sleep item and both correlated negatively with "quality of sleep." In Study 2 (n = 107), pain experienced "at night while in bed" correlated higher with sleep interference than with the BPI interference subscale. Intraclass correlations denoted adequate test-retest reliability; moderate-to-large Guyatt's statistics provided evidence of responsiveness. These analyses address a gap in the literature regarding the psychometric properties of the BPI interference measures in noncancer pain patients, confirming their reliability, validity, and responsiveness as potential endpoints in trials of pain medications involving patients with OA.

Update on pathogenesis and treatment of acne

Acne vulgaris is a common cutaneous disorder of the pilosebaceous follicle. More than 45 million people are affected with acne vulgaris. In addition, 80% of people in the United States report that they suffered from acne at one point in life. It is estimated that US consumers spend $1.2 billion each year for the treatment of acne. Typically, lesions are pleomorphic and range from open and closed comedones to inflammatory papules, pustules, cysts, and nodules, and scarring may result. The disease is important, with a significant effect on patients' self-esteem. The pathogenesis is only partially understood and is multifactorial. Successful management of acne requires an understanding of the pathophysiology of disease. The first half of this review discusses new discoveries in the pathogenesis of acne, and the second half introduces new and time-honored therapies.