Acne vulgaris in women: prevalence across the life span

Society for Endocrinology Clinical Practice Guideline for the Evaluation of Androgen Excess in Women

CONTEXT

Androgen excess is common in women and refers to clinical or biochemical evidence of elevated androgenic steroids such as testosterone. It is associated with underlying polycystic ovary syndrome in the majority of cases. However severe androgen excess is less common and may indicate the presence of underlying adrenal or ovarian neoplasms, genetic disorders or severe insulin resistance syndromes. Currently there are few consensus guidelines to assist clinicians with a standardised management approach to the patient with severe androgen excess.

DESIGN

Clinical practice guideline.

METHODS

This guideline has been developed with expertise from colleagues in endocrinology, gynaecology, clinical biochemistry and nursing, and furthermore provides a unique patient perspective to guide clinicians.

RESULTS

The Society for Endocrinology commissioned this new guideline to collate multi-disciplinary guidance for clinical practitioners in the investigation of severe androgen excess. Recommendations have been made in the areas of clinical assessment, biochemical work up, dynamic testing and imaging, informed where possible by the best available evidence.

CONCLUSION

This guideline will provide guidance for clinicians in their approach to patients with severe androgen excess.

Evaluating the Effectiveness of Probiotic Supplementation in Combination With Doxycycline for the Treatment of Moderate Acne: A Randomized Double-Blind Controlled Clinical Trial

BACKGROUND

Acne is a chronic inflammatory skin disease that negatively affects patients' quality of life. Increasing antibiotic resistance is making acne less responsive to treatment. Probiotics are live microorganisms that can provide health benefits by fighting pathogens and maintaining intestinal homeostasis and skin microbiome balance. This study investigates the effects of probiotics in the treatment of acne vulgaris.

METHODS

In this randomized controlled clinical trial, 80 patients with moderate acne were divided into two groups of 40. All patients received the same topical treatment, which consisted of a daily antibacterial face wash and Adapalene gel every other night. The control group received one capsule of doxycycline (100 mg) daily, whereas the intervention group received one probiotic capsule daily in addition to doxycycline. Patients underwent photography of facial acne lesions, and treatment response was assessed using the global acne grading system (GAGS) and acne grading method at baseline, as well as during follow-up visits at 1, 2, and 3 months.

RESULTS

The global acne grading system indicated that both groups showed improvement. However, analyses revealed that outcomes were significantly better in the doxycycline plus probiotics group for the forehead (p = 0.018), chin (p = 0.021), and nose (p = 0.021). No significant differences were observed for the left and right cheeks, back, and chest areas, with the mean GAGS score reduction between the two groups differing by only 2%. Treatment with probiotics significantly reduced the severity of lesions compared to the control group (p < 0.001). The acne grading method also indicated that the intervention group had a significantly better treatment response than the control group (p < 0.001). Furthermore, treatment with probiotics did not result in any side effects.

CONCLUSION

Probiotics can serve as an effective and safe treatment option, enhancing the outcomes of routine acne treatments, particularly for patients with acne on the forehead, chin, and nose.

A Prospective Randomized Trial Comparing Quality of Life in Adult Female Acne Treated with Azelaic Acid 15% Gel versus Oral Spironolactone

Introduction

In several countries, recent research has shown an increase in the prevalence of adult female acne (AFA), defined as the acne that appears in women aged over 25. This disease brings some particularities and challenges, such as a greater impact on quality of life (QoL) and chronicity. A negative impact on QoL has been observed, as well as anxiety, depression, anger, low self-esteem, and feelings of embarrassment and frustration.

Purpose

To quantify AFA's impact on QoL and the influence of two dermatological treatments.

Material and Methods

A prospective study including 40 women, aging from 25 to 44 years old, with mild-to-moderate acne was conducted. Participants underwent clinical, laboratory, and photographic evaluations. They were randomized into two treatment groups: group 1 - azelaic acid (AZA) 15% gel twice daily; group 2 - spironolactone (SPIRO) 100 mg/day and treated for 6 months. At baseline and at the end of treatments, a specific QoL questionnaire for acne, already translated and validated for Brazilian Portuguese (Acne-QoL-BR), was applied. It contains 19 questions allotted in four domains. Each item within a domain is scored from 0 to 6. The total score ranges from 0 to 114 and domains are distributed as follows: 0-30 (self-perception), 0-30 (role-emotional), 0-24 (role-social), 0-30 (acne-symptoms). Higher scores reflect better QoL.

Results

The mean age was 32.7 (SD: 5.42); 85% presented persistent acne. After treatment regardless of group, there was a significant improvement in total score and all domains' scores of acne QoL-BR (p < 0.001), with no difference between groups, despite one treatment being topical and the other systemic (p=0.918).

Conclusion

Acne-QoL-BR is a useful tool for quantifying the impact of acne and should be used as an efficacy parameter in clinical trials.

Clinical and cost-effectiveness of spironolactone in treating persistent facial acne in women: SAFA double-blinded RCT

Background

Acne is common, can cause significant impact on quality of life and is a frequent reason for long-term antibiotic use. Spironolactone has been prescribed for acne in women for many years, but robust evidence is lacking.

Objective

To evaluate whether spironolactone is clinically effective and cost-effective in treating acne in women.

Design

Pragmatic, parallel, double-blind, randomised superiority trial.

Setting

Primary and secondary healthcare and community settings (community and social media advertising).

Participants

Women aged 18 years and older with facial acne persisting for at least 6 months, judged to potentially warrant oral antibiotic treatment.

Interventions

Participants were randomised 1 : 1, using an independent web-based procedure, to either 50 mg/day spironolactone or matched placebo until week 6, increasing to 100 mg/day spironolactone or matched placebo until week 24. Participants continued usual topical treatment.

Main outcome measures

Primary outcome was the adjusted mean difference in Acne-Specific Quality of Life symptom subscale score at 12 weeks. Secondary outcomes included Acne-Specific Quality of Life total and subscales; participant self-assessed improvement; Investigator's Global Assessment; Participant's Global Assessment; satisfaction; adverse effects and cost-effectiveness.

Results

Of 1267 women assessed for eligibility, 410 were randomised (201 intervention, 209 control), 342 in the primary analysis (176 intervention, 166 control). Mean age was 29.2 years (standard deviation 7.2) and 7.9% (28/356) were from non-white backgrounds. At baseline, Investigator's Global Assessment classified acne as mild in 46%, moderate in 40% and severe in 13%. At baseline, 82.9% were using topical treatments. Over 95% of participants in both groups tolerated the treatment and increased their dose. Mean baseline Acne-Specific Quality of Life symptom subscale was 13.0 (standard deviation 4.7) across both groups. Mean scores at week 12 were 19.2 (standard deviation 6.1) for spironolactone and 17.8 (standard deviation 5.6) for placebo [difference favouring spironolactone 1.27 (95% confidence interval 0.07 to 2.46) adjusting for baseline variables]. Mean scores at week 24 were 21.2 (standard deviation 5.9) in spironolactone group and 17.4 (standard deviation 5.8) in placebo group [adjusted difference 3.77 (95% confidence interval 2.50 to 5.03) adjusted]. Secondary outcomes also favoured spironolactone at 12 weeks with greater differences at 24 weeks. Participants taking spironolactone were more likely than those taking placebo to report overall acne improvement at 12 weeks {72.2% vs. 67.9% [adjusted odds ratio 1.16 (95% confidence interval 0.70 to 1.91)]} and at 24 weeks {81.9% vs. 63.3% [adjusted odds ratio 2.72 (95% confidence interval 1.50 to 4.93)]}. Investigator's Global Assessment was judged successful at week 12 for 31/201 (18.5%) taking spironolactone and 9/209 (5.6%) taking placebo [adjusted odds ratio 5.18 (95% confidence interval 2.18 to 12.28)]. Satisfaction with treatment improved in 70.6% of participants taking spironolactone compared with 43.1% taking placebo [adjusted odds ratio 3.12 (95% confidence interval 1.80 to 5.41)]. Adverse reactions were similar between groups, but headaches were reported more commonly on spironolactone (20.4% vs. 12.0%). No serious adverse reactions were reported. Taking account for missing data through multiple imputation gave an incremental cost per quality-adjusted life-year of £27,879 (adjusted) compared to placebo or £2683 per quality-adjusted life-year compared to oral antibiotics.

Conclusions

Spironolactone resulted in better participant-reported and investigator-reported outcomes than placebo, with greater differences at week 24 than week 12.

Trial registration

This trial is registered as ISRCTN12892056 and EudraCT (2018-003630-33).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/13/02) and is published in full in Health Technology Assessment; Vol. 28, No. 56. See the NIHR Funding and Awards website for further award information.

Influence of Social Media and Internet on Treatment Decisions in Adult Female Acne Patients: A Cross-Sectional Survey Study

INTRODUCTION

Adult female acne is a chronic condition that significantly impacts quality of life. The content on social media can influence patients perception of their disease and serve as a channel through which they may seek or obtain treatment options.

OBJECTIVES

This study aims to evaluate the impact of social media usage habits on treatment decisions among adult female acne patients.

METHODS

A cross-sectional, multicenter survey study involved 358 females aged 25 or above, diagnosed with acne. Sociodemographic data were collected, and social media behavior, treatment choices, outcomes, and motivation were explored.

RESULTS

Among 358 participants, 95.3% used at least 1 social media platform; 72.1% sought acne information online. Top platforms used to seek acne information were Google (75.6%), Instagram (72.3%), YouTube (60%), and TikTok (29.4%). For advice, 67.4% consulted doctor accounts, 53.5% non-medical influencers, 53.5% patient accounts, and 36.1% product promotion accounts. Commonly followed advice included skincare products (88%), dietary changes (42.3%), home remedies (38.8%), exercise (30.3%), topical medications (25.2%), and dietary supplements (17.4%). Notably, 20.9% were willing to alter prescribed treatment by their physician for acne based on social media advice. Patient motivations included quick information access (84.1%) and difficulty in securing dermatologist appointments (54.3%).

CONCLUSIONS

The study reveals widespread social media use among adult female acne patients, highlighting concerns about potentially misleading information. Dermatologists can enhance the impact of social media by providing reliable sources for patients.

Unveiling the Nuances of Adult Female Acne: A Comprehensive Exploration of Epidemiology, Treatment Modalities, Dermocosmetics, and the Menopausal Influence

Previously considered a skin disease exclusively affecting adolescents, characterized by inflammatory and non-inflammatory skin lesions, acne vulgaris is now increasingly observed in adult life, including post-menopause. Today, adult female acne (AFA) is a common chronic inflammatory disease of the pilosebaceous unit, with polymorphic lesions presenting as open or closed comedones, papules, pustules, and even nodules or cysts, often with the presence of sequelae. AFA may persist from adolescence or manifest de novo in adulthood. Its etiology is multifactorial, involving genetic, hormonal, dietary, and environmental factors, yet still incompletely understood. Increased sebum production, keratinocyte hyper-proliferation, inflammation, and reduced diversity of Cutibacterium acnes strains are the underlying disease mechanisms. During menopausal transition, a relative increase in androgen levels occurs, just as estrogens begin to decline, which can manifest itself as acne. Whereas most AFA exhibit few acne lesions with normo-androgenic serum levels, baseline investigations including androgen testing panel enable associated comorbidities to be eliminated, such as polycystic ovarian syndrome, congenital adrenal hyperplasia, or tumors. Another interesting feature is AFA's impact on quality of life, which is greater than in adolescents, being similar to other chronic diseases like asthma. The therapeutic approach to AFA depends on its severity and associated features. This review investigates the intricate facets of AFA, with a specific focus on incidence rates, treatment modalities, and the curious impact of menopause. Utilizing insights from contemporary literature and scientific discussions, this article seeks to advance our understanding of AFA, offering new perspectives to shape clinical practices and improve patient outcomes.

Recent advances in understanding inflammatory acne: Deciphering the relationship between Cutibacterium acnes and Th17 inflammatory pathway

Acne vulgaris is a common chronic inflammatory skin disease of the pilosebaceous units. Four factors contribute to acne: hyperseborrhea and dysseborrhea, follicular hyperkeratinisation, skin microbiome dysbiosis and local immuno-inflammation. Recent key studies have highlighted a better understanding of the important role of Cutibacterium acnes (C. acnes) in the development of acne. Three major findings in the last decade include: (1) the ability of C. acnes to self-organize in a biofilm associated with a more virulent activity, (2) the loss of the C. acnes phylotype diversity and (3) the central role of the Th17 pathway in acne inflammation. Indeed, there is a close link between C. acnes and the activation of the Th17 immuno-inflammatory pathway at the initiation of acne development. These mechanisms are directly linked to the loss of C. acnes phylotype diversity during acne, with a predominance of the pro-pathogenic phylotype IA1. This specifically contributes to the induction of the Th17-mediated immuno-inflammatory response involving skin cells, such as keratinocytes, monocytes and sebocytes. These advancements have led to new insights into the underlying mechanisms which can be harnessed to develop novel treatments and diagnostic biomarkers. A major disadvantage of traditional treatment with topical antibiotics is that they induce cutaneous dysbiosis and antimicrobial resistance. Thus, future treatments would no longer aim to 'kill' C. acnes, but to maintain the skin microbiota balance allowing for tissue homeostasis, specifically, the restoration of C. acnes phylotype diversity. Here, we provide an overview of some of the key processes involved in the pathogenesis of acne, with a focus on the prominent role of C. acnes and the Th17-inflammatory pathways involved.

The usefulness of a dermocosmetic containing Myrtus communis extract and azelaic acid for maintenance phase of adult female acne: Results from a randomized exploratory investigator-blinded comparative study

BACKGROUND

Acne is a very common condition. Currently, there are relatively few studies available to help guidance-based decisions for its long-term management, especially studies with cosmetic care products. We have developed a skin care product dedicated to adult female acne.

OBJECTIVES

Evaluate the efficacy and tolerance of the test product containing Myrtus communis extract and azelaic acid compared with a light moisturizing cream (LCM) in adult females in the acne maintenance phase.

METHODS

A clinical study was conducted as a Brazilian, multicentre, randomized, investigator-blinded trial in adult females with clear or almost clear facial acne after anti-acne treatment. The test group (26 subjects) applied the test product and the comparative product group (27 subjects) applied LCM. Both groups applied the products twice daily on the whole face. Subjects were evaluated every 4 weeks over 16 weeks. Efficacy was evaluated according to acne relapse; Investigator's Global Assessment (IGA); acne lesions counting; AcneQoL questionnaire; Subject Global change Assessment (SGA) of acne severity; and the number of Post-Inflammatory Hyperpigmentation (PIH) and Post-Inflammatory Erythema (PIE) lesions. Tolerance was assessed according to a 5-point scale.

RESULTS

Over 16 weeks, the number of acne relapse was more than double in the comparator compared to the test product group (eight subjects vs. three subjects respectively). There was no statistical difference in the evolution of the mean IGA from baseline between the two groups; however, 85% of subjects were assessed as clear or almost clear in the test product group and 67% in the comparative group.

CONCLUSIONS

This study demonstrated the effectiveness topical application of the test product compared to LCM on acne severity in the maintenance phase of adult female acne. Efficacy results after 16 weeks suggested a trend to limit acne relapses and a benefit of the test product in maintaining long-term remission.

The relationship between short-term PM2.5 exposure and outpatient visits for acne vulgaris in Chongqing, China: a time-series study

Many researches have reported the air pollution impacts, either long term or short term, on inflammatory skin diseases, but there are few studies on the relation between PM_2.5 and acne vulgaris. To determine the correlation between short-term PM_2.5 exposure and acne outpatient visits, data for 120,842 acne vulgaris outpatient visits between December 2013 and December 2019 were obtained from three large hospitals in Chongqing, China. Both single-pollutant models and two-pollutant models were established to explore the relationship between PM_2.5 exposure and acne outpatient visits. The stratified analyses were conducted through two-sample z-tests to investigate the possible gender (male or female) and age (< 25 years or ≥ 25 years) differences in PM_2.5 effects. The results demonstrated positive correlations between PM_2.5 concentrations and acne outpatient visits. A 10 μg/m³ increase in PM_2.5 concentration was associated with a 1.71% (95% CI: 1.06-2.36%) increase in acne outpatient visits at lag 0-7 day. Stratified analyses showed that PM_2.5 effects were greater in individuals aged ≥ 25 years than those aged < 25 years, but no gender difference was found. In conclusion, short-term PM_2.5 exposure was positively associated with the risk of acne outpatient visits, especially for people ≥ 25 years old.

Acne Vulgaris and Metabolic Syndrome: A Possible Association

Introduction

Acne vulgaris is an androgen-dependent disorder with excessive sebum production and proliferation of Propionibacterium acnes. Metabolic syndrome (MetS) is a multisystem disorder that increases the risk of diabetes mellitus, stroke, and cardiovascular diseases. ​This study aims to analyze the association of MetS with acne vulgaris.

Methods

A cross-sectional study was conducted with 65 cases of acne vulgaris and 65 age and sex-matched controls. We used the system provided by the Indian authors for grading acne according to the clinical severity. In addition, the criteria updated according to the joint consensus of 2009 were employed for the diagnosis of MetS.

Results

On clinical examination, grade 2 was the most prevalent grade of acne. We observed an increased incidence of abnormal waist circumference, triglyceride, HDL, and fasting blood glucose among the cases (p<0.05). Consequently, an increased occurrence of MetS was observed in the case group (p=0.011). While comparing the mean values of the parameters, we noted a significant difference in terms of waist circumference and HDL values. An increased mean value of waist circumference was noted in the case group while an increased mean value of HDL was reported from the control group (p<0.05). 

Conclusion

Patients with acne vulgaris have a greater chance of developing MetS. Hence, an in-depth examination of clinical, anthropometric, and biochemical parameters that may lead to the development of MetS is necessary.

Adult female acne: Clinical and therapeutic particularities (Review)

Acne is a chronic inflammatory condition affecting the pilosebaceous unit that was traditionally viewed as a disease of the adolescence. However, over the past several years, an increasing number of adult women have been reported to suffer from this condition. The prevalence of adult female acne ranges between 12 and 54%. Two clinical types can be distinguished in this population, a 'retentional' and an 'inflammatory' type, which usually tend to overlap. In terms of evolution, three main subtypes can be identified: Persistent acne, which is the most frequent subtype, late-onset acne and recurrent acne. This type of acne is mainly mild-to-moderate in severity and may be refractory to conventional treatment. The etiopathogenesis is complex and has yet to be fully elucidated. It appears to involve an interaction among genetic predisposition, hormonal factors, and chronic activation of the innate immune system overlapping with external factors, such as daily stress, Western-type diet, use of tobacco and cosmetics. The treatment may be challenging and a holistic approach is required, with special attention to the individual needs and particularities of adult women. Both topical and systemic treatments are available, with hormonal therapies being of special value in this population. The aim of the present article was to provide up-to-date, evidence-based information on the clinical presentation, etiopathogenesis and treatment of adult female acne.

Facial Acne: A Randomized, Double-Blind, Placebo-Controlled Study on the Clinical Efficacy of a Symbiotic Dietary Supplement

Introduction

Treatments other than topical and systemic antibiotics are needed to restore the dysbiosis correlated with acne onset and evolution. In this view, probiotics and botanical extracts could represent a valid adjunctive therapeutic approach. The purpose of this study was to test the efficacy of a dietary supplement containing probiotics (Bifidobacterium breve BR03 DSM 16604, Lacticaseibacillus casei LC03 DSM 27537, and Ligilactobacillus salivarius LS03 DSM 22776) and botanical extract (lupeol from Solanum melongena L. and Echinacea extract) in subjects with mild to moderate acne over an 8-week study period.

Methods

Monocentric, randomized, double-blind, four-arm, placebo-controlled clinical study involving 114 subjects.

Results

A significant (p < 0.05) effect on the number of superficial inflammatory lesions was reported over the study period in the subjects taking the study agent (group II) (−56.67%), the botanical extracts (group III) (−40.00%), and the probiotics (group IV) (−38.89%) versus placebo (−10.00%). A significant (p < 0.05) decrease in mean desquamation score, sebum secretion rate, and porphyrin mean count versus baseline was also reported, and the effect was most evident for group II. The analysis of log relative abundance after 4 and 8 weeks of treatment compared with baseline showed a significant (p < 0.01) decrease in Cutibacterium acnes and S. aureus, along with a contextually and significant (p < 0.05) increase in Staphylococcus epidermidis, especially in group II. No significant changes were reported for group I.

Conclusion

The results from this study suggest that the administration of the dietary supplement under study was effective, safe, and well tolerated in subjects with mild to moderate acne and could represent a promising optional complement for the treatment of inflammatory acne as well as for control of acne-prone skin.

Prevalence of adult female acne in Colombia: A population-based study

Background

Acne is a common inflammatory skin disease with adolescents being the most affected by this condition; however, acne also occurs frequently in the adult population. Adult acne is defined as late-onset acne or acne that persists beyond age 25 years. In terms of epidemiologic data, reports of adult female acne prevalence range from 5.5% to 61.5% around the world.

Objective

The aim of this study was to estimate the prevalence and trace the trend of adult female acne in Colombia over the last 5 years.

Methods

Using nationwide data from the General System of Social Security and Health in Colombia through the Sistema Integrado de Información de la Protección Social database and International Classification of Diseases, 10th Revision, diagnostic codes, a cross-sectional study was conducted to estimate the prevalence of adult female acne in outpatients in Colombia from 2015 to 2019.

Results

For the 5-year study period, overall acne prevalence was 2.14 per 1000 population. The highest annual prevalence (2.94 per 1000 population) was in 2019 and the lowest prevalence (1.71 per 1000 population) was in 2015. Prevalence peaked in patients age 25 to 29 years, and decreased to <1 per 1000 population in those age <50 years.

Conclusion

This nationwide study of adult female acne in Colombia suggests an increasing trend in prevalence over the last 5 years. We recommend further studies to determine risk factors involved in this condition.

Post-acne hyperpigmentation: Evaluation of risk factors and the use of artificial neural network as a predictive classifier

Acne is common among young individuals. People with dark skin have a higher risk for developing pigmentary complications. Inflammation is an important factor in post-acne hyperpigmentation however other factors are also involved in developing this complication however these factors are not well studied. The aim of this study is to identify risk factors involved in post-acne hyperpigmentation. Clinical data related to acne, acne- related hyperpigmentation were collected. Data was analyzed for risk factors associated with acne pigmentation. Artificial neural network was used as predictive disease classifier for the outcome of pigmentation. Majority of patients in this study (339 patients) had dark skin phototypes (3 and 4). Post- acne hyperpigmentation was seen in more than 80% of patients. Females, darker skin color, severe acne, facial sites, and excessive sunlight exposure, squeezing or scratching lesions are important risk factors for post-acne hyperpigmentation. Post-acne hyperpigmentation is multifactorial. Several factors implicated in PAH are modifiable by adequate patient education (lesion trauma, excessive sunlight exposure). The use of ANN was helpful in predicting appearance of post-acne hyperpigmentation based on identified risk factors.

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.

Adult female acne: Clinical characteristics and factors significantly associated with polycystic ovary syndrome

BACKGROUND

Adult female acne (AFA) may be different from adolescent acne, and may be a sign of polycystic ovary syndrome (PCOS). The objective of the study was to investigate the clinical characteristics of AFA, and the factors significantly associated with PCOS in AFA.

METHODS

AFA patients aged 25 years or older were enrolled. History taking and dermatologic examinations were performed by dermatologists. PCOS was diagnosed by gynaecologists. Perimenopausal acne (aged 45 years or older) and the Dermatology Life Quality Index (DLQI) were also evaluated.

RESULTS

Among 208 patients, mean age was 31.8 ± 7.1 years and 47.1%, 26.9%, and 26% had persistent, late-onset, and recurrent acne, respectively. The common aggravating factors included pre-menstruation (72.6%) and stress (53.8%). Recurrent acne was significantly aggravated by cosmetic products. Higher body mass index (BMI) was positively correlated with acne severity. Acne lesions were predominately located on both cheeks (87.0%) and at the perioral area (81.7%). PCOS was identified in 48.1%. Younger age (≥25 to <33 years), premenstrual flare, and irregular menstruation, but not hirsutism or androgenetic alopecia, were associated with PCOS in univariate and multivariate analysis. Perimenopausal acne was identified in 6.7%. The total mean DLQI score was 8.0 ± 5.4 (range from 0 to 23).

CONCLUSIONS

Persistent acne with moderate severity was common in AFA patients and higher BMI was associated with acne severity. PCOS should be screened in AFA patients with younger age, premenstrual flare, and irregular menstruation.

The Association Between Short-Term Air Pollution Exposure and Post-Adolescent Acne: The Evidence from a Time Series Analysis in Xi'an, China

BACKGROUND

Post-adolescent acne is a common skin disease faced by adults. However, whether air pollution (AP) serves as a risk factor for post-adolescent acne remains elusive.

AIM

To determine the relationship between short-term AP exposure (within 7 days) and outpatient visits for post-adolescent acne.

METHODS

Daily outpatient visit data for post-adolescent acne and routinely AP data between 2010 and 2013 were collected from Xi'an, China. A generalized additive regression model was used to analyze the relationship between outpatient visits for post-adolescent acne and short-term ambient AP exposure. The gender-specific analyses were conducted as well.

RESULTS

Totally, 27,190 outpatient visits for post-adolescent acne were included. The results revealed that a 10 μg/m3 increase in PM10, SO2, and NO2 at lag 0-7 day was associated with the increase of outpatient visits for post-adolescent acne at 0.84% (95% CI: 0.53%, 1.16%), 1.61% (95% CI: 0.12%, 3.10%), and 3.50% (95% CI: 1.60%, 5.40%), respectively. The significant positive associations of PM10, SO2, and NO2 were found at both single-lag models and moving average models. The gender-specific analyses showed that the effect estimates of PM10 was stronger for females than for males, while there was no observed gender difference in the effects of SO2 and NO2.

CONCLUSION

Short-term exposure to AP was associated with increased outpatient visits for post-adolescent acne, especially for females in the effects of PM10.

Incidence and Clinical Implications of Autoimmune Thyroiditis in the Development of Acne in Young Patients

Autoimmune thyroiditis (AIT) is on the rise among the population, and is frequently associated with patients with acne vulgaris, especially females aged between 18–55 years old. The connection between the two is not fully elucidated. In this study, 236 patients diagnosed with acne in the dermatological office of the private Pelican Hospital and in few private dermatological offices from Oradea, Romania, during January 2018–December 2020, aged between 12 and 55 years old, were endocrinologically investigated to determine AIT and its influence on the severity of the acne. The values for the thyroid antibodies and thyroid-stimulating hormone (TSH) were determined for all of the subjects. The frequency of AIT in the study group was 72% and was associated with severe acne (p < 0.001). Patients with AIT with normal or hypofunction had more frequent severe acne than those with hyperfunction (p < 0.001, p = 0.002). The TSH and anti thyroidperoxidase (TPO) values did not influence the severity of the acne (p = 0.494; p = 0.111), while the anti-TG values were associated with severe acne (p = 0.007). The risk analysis indicated that raised values of anti-TPO (2.91 times greater) correlated with high anti-thyroglobulin (TG) values (4.36 times greater) doubled the risk of developing severe acne in patients. In acne evolution, the existence of AIT involves significant modifications.

Incidence and Clinical Implications of Autoimmune Thyroiditis in the Development of Acne in Young Patients

Autoimmune thyroiditis (AIT) is on the rise among the population, and is frequently associated with patients with acne vulgaris, especially females aged between 18–55 years old. The connection between the two is not fully elucidated. In this study, 236 patients diagnosed with acne in the dermatological office of the private Pelican Hospital and in few private dermatological offices from Oradea, Romania, during January 2018–December 2020, aged between 12 and 55 years old, were endocrinologically investigated to determine AIT and its influence on the severity of the acne. The values for the thyroid antibodies and thyroid-stimulating hormone (TSH) were determined for all of the subjects. The frequency of AIT in the study group was 72% and was associated with severe acne (p < 0.001). Patients with AIT with normal or hypofunction had more frequent severe acne than those with hyperfunction (p < 0.001, p = 0.002). The TSH and anti thyroidperoxidase (TPO) values did not influence the severity of the acne (p = 0.494; p = 0.111), while the anti-TG values were associated with severe acne (p = 0.007). The risk analysis indicated that raised values of anti-TPO (2.91 times greater) correlated with high anti-thyroglobulin (TG) values (4.36 times greater) doubled the risk of developing severe acne in patients. In acne evolution, the existence of AIT involves significant modifications.

Prevalence of acne vulgaris and its clinico-epidemiological pattern in adult patients: Results of a prospective, observational study

BACKGROUND

Acne is a common disorder in adolescents. The prevalence of acne in adults is also increasing. There are only a few Indian studies on the prevalence and clinical features of adult acne.

AIMS

To evaluate the prevalence and possible etiological and aggravating factors of acne in adult population.

METHODS

Adult patients more than 25 years with acne were enrolled, and detailed history and examination were recorded. Type of acne, age, gender, area of involvement, and associated factors were noted.

RESULTS

Out of 24,056 adult patients, 180 had acne, with the prevalence of 0.74%. Mean age of patients with acne was 30.1 years. A total of 81.7% patients with acne were female and 68.3% had persistent type of acne. Inflammatory papular acne (72.8%) was the most common type of acne in our study population. Cheek (85%) was the predominant site of involvement; 62.8% patients developed scarring. Underlying chronic stress was present in 23.9% and family history of acne in 60.6%. A total of 43.5% patients reported aggravation with cosmetics and 42.8% provided history of oily and high glycemic food conduction. Premenstrual flare and hirsutism were seen in 61.9% and 16.3% female patients, respectively.

CONCLUSION

Acne is more common in people with 25-35 years of age with female preponderance and a gradual decline in the prevalence is seen thereafter. Inflammatory nature is more common with cheeks being commonest site of affection. Facial scarring is more common that emphasizes the importance of early and adequate intervention.

The comparative study of efficacy between 1064-nm long-pulsed Nd:YAG laser and 595-nm pulsed dye laser for the treatment of acne vulgaris

BACKGROUND

The popularity of laser therapy in acne treatment has been increasing recently due to its safety, effectiveness, and convenience. Both 595-nm pulsed dye laser (PDL) and 1064-nm long-pulsed neodymium:yttrium-aluminum-garnet laser (Nd:YAG) have been successful in treating inflammatory acne lesions. However, clinical data from controlled comparative studies are still lacking.

AIMS

To compare the clinical efficacy of 1064-nm Nd:YAG with 595-nm PDL for the treatment of acne vulgaris.

METHODS

Thirty-four participants with mild to moderate facial acne were enrolled and then randomized to receive three, 2-week interval treatments with 1064-nm Nd:YAG on one side of the face and 595-nm PDL on the other side. Clinical assessments including acne lesion counts, acne erythema grading, and erythema index were performed at baseline, 2nd, 4th, and 8th week. Participants' satisfaction, preference, and adverse effects were recorded.

RESULTS

As compared with baseline, the significant reduction of mean inflammatory acne lesion counts, acne erythema grading, and erythema index was demonstrated on 595-nm PDL-treated sides and 1064-nm Nd:YAG-treated sides. However, there were no significant differences between both sides. The participants were satisfied with both laser treatments, but the participants preferred 1064-nm Nd:YAG over 595-nm PDL treatment. The adverse effects were less on 1064 nm Nd: YAG-treated sides.

CONCLUSIONS

1064-nm Nd:YAG and 595-nm PDL treatments are equally effective in reducing inflammatory acne lesions and acne erythema in mild to moderate facial acne vulgaris.

Nonprescription acne vulgaris treatments: Their role in our treatment armamentarium-An international panel discussion

BACKGROUND

Acne vulgaris (acne), a common inflammatory skin disorder, has its peak incidence between 14 and 19 years of age, with girls frequently developing acne earlier than boys. Over recent years, persistent acne is becoming more prevalent in adult women.

OBJECTIVES

This review and panel discussion addresses challenges in acne management, particularly in adult women. The role which nonprescription acne treatment can play is explored when used as monotherapy or as an adjunctive treatment for acne of all severity.

METHODS

The best available evidence on nonprescription acne treatment was coupled with the opinion of an international expert panel of dermatologists to adopt statements and recommendations discussed in this review.

RESULTS

All severity of acne has a significant burden on patients. Addressing environmental factors that are important for the individual with acne may help to educate, prevent, effectively manage, and maintain acne, as per the panel. They agreed that the adult female acne population has unique needs because of their aging skin and social environment. Nonprescription acne treatment products may help to balance the efficacy and tolerability of prescription acne treatment. Currently, there are no specific guidelines for how to use nonprescription acne treatment products in these patients.

CONCLUSION

The panel agreed that guidelines including nonprescription acne treatment either as monotherapy for mild acne or in combination with prescription treatments for more severe acne would address a significant unmet need.

The potential of probiotics for treating acne vulgaris: A review of literature on acne and microbiota

Acne is known as a chronic inflammatory skin disease with sever adverse effects on quality of life in the patients. The increasing resistance to antibiotics has decreased their effectiveness in treating acne. As viable microbial dietary supplements, probiotics provide health benefits through fighting pathogens and maintaining the homeostasis of the gut and skin microbiome. The present article reviewed the potential of probiotics as beneficial microorganisms for treating acne vulgaris. This review of literature was conducted through a bibliographic search of popular databases, including Science Direct, PubMed, Scielo and Medline, using keywords such as probiotics, prebiotics, synbiotics, microbiome, and acne vulgaris to determine potential applications of these beneficial microbiomes in treating acne vulgaris. Acne lesions are associated with increases in proportion of Propionibacterium acnes as a skin commensal bacterium. The environmental studies showed inhibitory effects of probiotics on P. acnes, mediating by antibacterial proteins and bacteriocin-like inhibitory substances, and their immunomodulatory effects onkeratinocytes and epithelial cells. Probiotics were also found to inhibit cytokine IL-8 in epithelial cells and keratinocytes, suggesting immunomodulatory activities. Moreover, glycerol fermentation by Staphylococcus epidermidis was found to be a natural skin defense against acne and an overgrowth inhibitor of P. acnes. As an antimicrobial agent in lotions and cosmetic formulations, Lactococcus sp. can decrease the inflammatory mediators that are produced by P. acnes and cause vasodilation, edema, mast cell degranulation and TNF-alpha release. Oral administration of probiotics was found to constitute an adjuvant therapy to conventional modalities for treating mild-to-moderate acne vulgaris.

Skin Cutibacterium acnes Mediates Fermentation to Suppress the Calcium Phosphate-Induced Itching: A Butyric Acid Derivative with Potential for Uremic Pruritus

Pruritus and inflammation associated with accumulation of calcium phosphate (CaP) under the skin are common problems among dialysis patients with chronic kidney disease (CKD). The role of skin commensal microbiota in the CaP-induced uremic pruritus remains uncharacterized. Skin Cutibacterium acnes (C. acnes) can solubilize CaP by the production of short-chain fatty acids (SCFAs), such as butyric acid, through glucose fermentation. Like butyric acid, the N-[2-(2-Butyrylamino-ethoxy)-ethyl]-butyramide (BA-NH-NH-BA), a butyric acid derivative, remarkably induced acetylation of histone H3 lysine 9 (AcH3K9) in keratinocytes. Topical application of fermenting C. acnes, butyric acid or BA-NH-NH-BA onto mouse skin effectively ameliorated CaP-induced skin itching, interleukin (IL)-6 up-regulation in keratinocytes, and extracellular signal-regulated kinase (ERK) 1/2 activation in dorsal root ganglia (DRG). Activation of ERK 1/2 by CaP was markedly reduced in IL-6 knockout mice. Genus Cutibacterium was detected in relatively low abundance in itchy skin of patients with CKD. Our results identify a role for the skin fermenting C. acnes in ameliorating CaP-induced activation of IL-6/p-ERK signaling and resulting skin inflammation. Furthermore, we provide evidence for the potential therapeutic efficacy of BA-NH-NH-BA as a postbiotic for the treatment of uremic pruritus.

Hidradenitis suppurativa and acne vulgaris and conglobata—systematic review and meta-analysis

Background

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder which involves painful nodules and draining abscesses in flexural areas. Acne vulgaris and its more severe variants including acne conglobata and acne fulminans are also disorders involving the follicular unit. Given that follicular obstruction, dilatation and inflammation feature in both HS and acne vulgaris/conglobata, it has been suggested that HS is associated with acne vulgaris/conglobata.

Methods

The present systematic review and meta-analysis was performed according to recommended PRISMA guidelines. All eligible case-control studies comparing patients with HS vs non-HS were included in the present review. All studies must have included either the proportion of patients with acne vulgaris/conglobata in each group, or the summary effect size for association between HS and acne vulgaris/conglobata. The odds ratio (OR) was used as a summary statistic.

Results

From pooled unadjusted meta-analysis, we found a significantly higher proportion of patients with acne vulgaris/conglobata in HS cases compared to controls (OR 3.44, 95% CI 1.95–6.07, P < 0.0001, I2 = 100%). Pooled meta-analysis was also performed with adjusted effect sizes. This demonstrated that HS was significantly associated with acne vulgaris/conglobata after adjustment for potential confounders (OR 3.44, 95% CI 2.43–4.87, P < 0.00001, I2 = 99%).

Conclusions

In summary, a significant association was found between HS and acne vulgaris/conglobata. This has implications in terms of understanding the burden of disease on patient quality of life as well as consideration of optimal management strategies to target both disorders. Physicians taking care of patients with HS should be aware of this association.

Spironolactone-Loaded LeciPlexes as Potential Topical Delivery Systems for Female Acne: In Vitro Appraisal and Ex Vivo Skin Permeability Studies

Spironolactone (SP), an aldosterone antagonist with anti-androgen properties, has shown promising results in the treatment of female acne. However, its systemic side effects limit its clinical benefits. This study aimed to prepare and evaluate LeciPlexes for SP topical delivery. LeciPlexes were prepared by a one-step procedure and characterized using various techniques. Optimum LeciPlex preparation was incorporated into 1% methylcellulose gel and SP permeability was tested ex vivo in Sprague-Dawley rat skin. The maximum drug encapsulation efficiency obtained was 93.6 ± 6.9% and was dependent on the drug/phospholipid and surfactant/phospholipid ratios. A zeta potential of +49.3 ± 3.5 to +57.7 ± 3.3 mV and a size of 108 ± 25.3 to 668.5 ± 120.3 nm were observed for the LeciPlexes. FT-IR and DSC studies confirmed the incorporation of SP into the LeciPlexes through hydrophobic and hydrogen bonding interactions. SP release from the LeciPlex formulations was significantly slower than from the drug suspension. Cumulative SP permeated through rat skin from LeciPlex gel was about 2-fold higher than SP control gel. Cumulative SP deposited in the stratum corneum and other skin layers from the LeciPlex gel was about 1.8- and 2.6-fold higher than SP control gel, respectively. This new SP LeciPlex formulation is a promising carrier for the treatment of female acne.

Use of a monofilament debridement pad in the treatment of acne vulgaris

OBJECTIVE

Acne vulgaris (acne) presents with increased oil-sebum secretion and subsequent formation of comedones, papules, pustules and nodules. Skin cleansing is part of the daily routine to improve skin condition. A monofilament debridement pad has shown to be effective when used for wound debridement and skin cleansing in dermatological conditions. The pad may offer benefits when used for acne affected skin.

METHODS

The in vitro cleansing capacity of the monofilament fibre pad was analysed and compared with commercially available cosmetic pads. For this purpose, a sebum model consisting of glass plates coated with an oil-red-stained layer of artificial sebum was used. To gain clinical experience a case series evaluated cleansing efficacy of the monofilament debridement pad in combination with polyhexanide and sodium-hypochlorite based solutions. Over a period of four months, seven individuals suffering from retentive moderate facial acne who visited the dermatology clinic for their acne used the pad as necessary, ranging from twice weekly to daily, dependent on the sensitivity of the patient's skin condition.

RESULTS

The in vitro study exhibited a significantly better cleansing efficacy of the monofilament debridement pad compared with the cosmetic pads. After single use of the pad subject scores on sebum reduction revealed excellent/very good in 42.9% and acceptable in 57.1% of cases. After repeated use of the monofilament pads scores on sebum reduction of excellent/very good were given in 85.7% and acceptable in 14.3% of cases. Subject scored handling of the pad and comfort during use also received favourable ratings.

CONCLUSION

These initial results show the potential of the monofilament debridement pad for cleansing of acne-prone and acne affected skin. More robust studies are needed to confirm these results.

Menopausal Acne - Challenges And Solutions

Although acne is a disease predominant in adolescence, it is being increasingly observed in adult life, including the menopausal period. The etiology of menopausal acne is multifactorial, with hormonal imbalance being the major culprit. There is a relative increase of androgens in the menopausal female that leads to clinical hyperandrogenism manifesting as acne, hirsutism and androgenetic alopecia. Other endocrine disorders including thyroid abnormalities, hyperprolactinemia and insulin resistance also play a role. Genetics, stress, dietary changes, lack of sleep and exercise and other lifestyle changes are implicated as trigger factors. Most menopausal women with isolated few acne lesions have normoandrogenic serum levels and do not require extensive investigations. However, baseline investigations including total testosterone are useful. Patients must also be evaluated for associated comorbidities such as obesity, diabetes, hypertension and dyslipidemia. A detailed history can help to exclude polycystic ovarian syndrome, late-onset congenital adrenal hyperplasia or medications as a cause of acne. The evaluation of menopausal acne and the approach to treatment depend on the severity of acne and associated features. In patients with mild acne without virilization, prolonged topical therapy is the mainstay of treatment. Though combined oral contraceptives are effective, they are relatively contraindicated in the postmenopausal period. Spironolactone is the first choice of therapy in the subset of patients that require oral anti-androgen therapy. Procedural treatment can be useful as it can also help in the treatment of associated acne scars and concomitant skin aging. It is also important to focus on lifestyle changes such as reducing stress, controlling obesity, having a healthy diet, exercise and proper skin care routine to reduce acne. The focus of this article is on the clinical presentation and management challenges of menopausal acne, which represents a special subtype of acne.

Cutibacterium acnes Type II strains are associated with acne in Chinese patients

Acne is a common inflammatory skin disease, especially in adolescents. Certain Cutibacterium acnes subtypes are associated with acne, although more than one subtype of C. acnes strains may simultaneously reside on the surface of the skin of an individual. To better understand the relationship between the genomic characteristics of C. acnes subtypes and acnes, we collected 50 C. acnes strains from the facial skin of 10 people (5 healthy individuals, 5 patients with acne) in Liaoning, China and performed whole genome sequencing of all strains. We demonstrated that the six potential pathogenic C. acnes strains were all Type II subtype, and discovered 90 unique genes of the six strains related to acne using pan-genome analysis. The distribution of 2 of the 90 genes was identified by PCR in bacterial cultures collected from the facial skin of 171 individuals (55 healthy individuals, 52 patients with mild acne and 64 patients with moderate to severe acne). Both the genes were significantly associated with acne (Chi square test, P < 0.01). We conclude that Type II strains are associated with acne in Chinese patients.

Long-term safety and efficacy of trifarotene 50 μg/g cream, a first-in-class RAR-γ selective topical retinoid, in patients with moderate facial and truncal acne

BACKGROUND

Treatment for both facial and truncal acne has not sufficiently been studied.

OBJECTIVES

To evaluate the long-term safety and efficacy of trifarotene in both facial and truncal acne.

METHODS

In a multicentre, open-label, 52-week study, patients with moderate facial and truncal acne received trifarotene 50 μg/g cream (trifarotene). Assessments included local tolerability, safety, investigator and physician's global assessments (IGA, PGA) and quality of life (QOL). A validated QOL questionnaire was completed by the patient at Baseline, Week 12, 26 and 52/ET.

RESULTS

Of 453 patients enrolled, 342 (75.5%) completed the study. Trifarotene-related treatment-emergent adverse events (TEAEs) were reported in 12.6% of patients, and none was serious. Most related TEAEs were cutaneous and occurred during the first 3 months. Signs and symptoms of local tolerability were mostly mild or moderate and severe signs, and symptoms were reported for 2.2% to 7.1% of patients for the face and 2.5% to 5.4% for the trunk. Local irritation increased during the first week of treatment on the face and up to Weeks 2 to 4 on the trunk with both decreasing thereafter. At Week 12, IGA and PGA success rates were 26.6% and 38.6%, respectively. Success rates increased to 65.1% and 66.9%, respectively at Week 52. Overall success (both IGA and PGA success in the same patient) was 57.9% at Week 52. At Week 52 visit, 92/171 (53.8%) patients who had completed their assessments had scores from 0 to 1 (i.e. no effect of acne on their QOL) vs. 47/208 (22.6%) patients at Baseline visit.

CONCLUSION

In this 52-week study, trifarotene was safe, well tolerated and effective in moderate facial and truncal acne.

Acne, the Skin Microbiome, and Antibiotic Treatment

Acne vulgaris is a chronic skin disorder involving hair follicles and sebaceous glands. Multiple factors contribute to the disease, including skin microbes. The skin microbiome in the follicle is composed of a diverse group of microorganisms. Among them, Propionibacterium acnes and Malassezia spp. have been linked to acne development through their influence on sebum secretion, comedone formation, and inflammatory response. Antibiotics targeting P. acnes have been the mainstay in acne treatment for the past four decades. Among them, macrolides, clindamycin, and tetracyclines are the most widely prescribed. As antibiotic resistance becomes an increasing concern in clinical practice, understanding the skin microbiome associated with acne and the effects of antibiotic use on the skin commensals is highly relevant and critical to clinicians. In this review, we summarize recent studies of the composition and dynamics of the skin microbiome in acne and the effects of antibiotic treatment on skin microbes.

Overall and subgroup prevalence of acne vulgaris among patients with hidradenitis suppurativa

BACKGROUND

Evidence establishing a link between acne vulgaris (AV) and hidradenitis suppurativa (HS) is limited, and the burden of AV in adults with HS is unknown.

OBJECTIVE

To determine the prevalence of AV among adults with HS and determine the strength of this association.

METHODS

Cross-sectional analysis identifying adults with AV among patients with and without HS by using electronic health record data from a population-based sample of more than 55 million patients.

RESULTS

The prevalence of AV among adults with HS was 15.2% (7315 of 48,085) compared with 2.9% (497,360 of 16,899,470) for adults without HS (P < .001). The prevalence was greatest among patients with HS who were female (5870 of 35,790 [16.4%]), were 18 to 44 years old (5260 of 28,870 [18.2%]), were nonwhite (3120 of 17,825 [17.5%]), were obese (5430 of 35,135 [15.5%]), and had polycystic ovarian syndrome (685 of 2385 [28.7%]). Patients with HS had 4.51 [95% confidence interval, 4.40-4.63] times the odds of having AV than did patients without HS, with the higher likelihood of having AV persisting across all subgroups of patients with HS. The association between HS and AV was generally stronger for patients who were male, and 65 years of age or older.

LIMITATIONS

Influence of disease severity in HS, or in acne, on the strength of the association could not be assessed.

CONCLUSION

Patients with HS may benefit from assessment of acne status and optimization of comanagement strategies.

Lactase Persistence, Milk Intake, and Adult Acne: A Mendelian Randomization Study of 20,416 Danish Adults

Whether there is a causal relationship between milk intake and acne is unknown. We tested the hypothesis that genetically determined milk intake is associated with acne in adults using a Mendelian randomization design. LCT-13910 C/T (rs4988235) is associated with lactase persistence (TT/TC) in Northern Europeans. We investigated the association between milk intake, LCT-13910 C/T (rs4988235), and acne in 20,416 adults (age-range: 20⁻96) from The Danish General Suburban Population Study (GESUS). The adjusted observational odds ratio for acne in any milk intake vs. no milk intake was 0.93(95% confidence interval: 0.48⁻1.78) in females and 0.49(0.22⁻1.08) in males aged 20⁻39 years, and 1.15(95% confidence interval: 0.66⁻1.99) in females and 1.02(0.61⁻1.72) in males above 40 years. The unadjusted odds ratio for acne in TT+TC vs. CC was 0.84(0.43⁻1.62) in the age group 20⁻39 years, and 0.99(0.52⁻1.88) above 40 years. We did not find any observational or genetic association between milk intake and acne in our population of adults.

Emerging Therapies for Acne Vulgaris

As we gain a greater understanding of acne pathogenesis, both new agents as well as new uses for established drugs are being considered for the treatment of acne vulgaris. Multiple clinical trials assessing new formulations or combinations of established acne treatments have been conducted, and novel uses of antimicrobials such as modified diallyl disulfide oxide and nitric oxide are being assessed in clinical trials. There are also a multitude of new therapies currently being studied that target the inflammatory cascade of acne pathogenesis, including sebosuppressive and anti-inflammatory phytochemicals, and  small molecule inhibitors targeting sebaceous glands and enzymes, among others. Laser and light therapy is also being modified for the treatment of acne through combination methods with metal nanoshells and vacuum assistance. Probiotics have gained popularity in medicine as greater knowledge of the microbiome and its effects on multiple organ systems is being elucidated. Studies describing the positive effects of certain ammonia-oxidizing bacterial strains in the regulation of the skin's inflammatory response are ongoing. Therapies for acne are constantly evolving and current gold-standard acne therapy may be supplemented with novel treatment modalities in the near future.

Adult-onset acne: prevalence, impact, and management challenges

Acne is a multifactorial and inflammatory disease of pilosebaceous follicles, which affects most adolescents. Recent epidemiological data revealed a difference in adults affected by this disease. Women have a high prevalence and incidence when compared with men, especially after 25 years of age. In contrast to what was initially thought, most of these patients do not present endocrinopathy capable of leading to the development of the lesions. When present, polycystic ovarian syndrome is the main cause. However, in these cases, acne is rarely the only dermatological manifestation; hirsutism and acanthosis nigricans are often present. The majority of the normoandrogenic acne patients present a history since adolescence, but in many cases the lesion distribution and intensity change with time. There is often a typical localization of the lesions in the lower third of the face and lateral region of the neck. Another interesting feature is related to the impact on quality of life (QoL), which is always intense. Often there are signs of depression, even when the lesions are mild. As most adult patients are women, in addition to the conventional options, there is also hormone treatment. Combined oral contraceptives and spironolactone are good options. Knowing more about the particularities in etiopathogenesis, impact on QoL, and specific treatment options is important to all dermatologists who face the challenge of treating acne in adults.

Oral Spironolactone for Acne Vulgaris in Adult Females: A Hybrid Systematic Review

BACKGROUND

The management of acne in adult females is problematic, with many having a history of treatment failure and some having a predisposition to androgen excess. Alternatives to oral antibiotics and combined oral contraceptives (COCs) are required.

OBJECTIVE

Our aim was to conduct a hybrid systematic review of the evidence for benefits and potential harms of oral spironolactone in the management of acne in adult females.

METHODS

The review was conducted according to a previously published protocol. Three reviewers independently selected relevant studies from the search results, extracted data, assessed the risk of bias, and rated the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Ten randomized controlled trials (RCTs) and 21 case series were retrieved. All trials were assessed as being at a 'high risk' of bias, and the quality of evidence was rated as low or very low for all outcomes. Apart from one crossover trial that demonstrated statistical superiority of a 200 mg daily dose versus inflamed lesions compared with placebo, data from the remaining trials were unhelpful in establishing the degree of efficacy of lower doses versus active comparators or placebo. Menstrual side effects were significantly more common with the 200 mg dose; frequency could be significantly reduced by concomitant use of a COC. Pooling of results for serum potassium supported the recent recommendation that routine monitoring is not required in this patient population.

CONCLUSION

This systematic review of RCTs and case series identified evidence of limited quality to underpin the expert endorsement of spironolactone at the doses typically used (≤100 mg/day) in everyday clinical practice.

The management of acne vulgaris in primary care: a cohort study of consulting and prescribing patterns using the Clinical Practice Research Datalink

BACKGROUND

Effective management of acne vulgaris in primary care involves support (usually provided over a number of consultations) and prescription of effective treatments. However, consulting and prescribing patterns for acne in primary care are not well described.

OBJECTIVES

To describe the rate of primary-care consultations and follow-up consultations; prescribing patterns, including overall use of acne-related medications (ARMs); and initial and follow-up prescription for acne vulgaris in the U.K.

METHODS

U.K. primary-care acne consultations and prescriptions for ARMs were identified in the Clinical Practice Research Datalink. Annual consultation rates (between 2004 and 2013) by age and sex, new consultations and consultations in the subsequent year were calculated, along with prescribing trends - during a new consultation and over the subsequent 90 days and year - using the number of registered patients as the denominator.

RESULTS

Two-thirds (66·1%) of patients who had a new acne consultation had no further acne consultations in the subsequent year. Overall 26·7%, 24·9%, and 23·6% and 2·8% of patients were prescribed no ARM, an oral antibiotic, a topical antibiotic or an oral plus topical antibiotic, respectively, during a new acne consultation. In total 60·1% and 38·6% of patients prescribed an ARM received no further ARM prescriptions in the following 90 days and 1 year, respectively, despite most prescriptions being for 2 months or less. Prescribing rates for lymecycline and topical combined clindamycin and benzoyl peroxide increased substantially between 2004 and 2013. There were no important changes in consultation rates between 2004 and 2013.

CONCLUSIONS

These data suggest that patients with acne are receiving a suboptimal initial choice of ARMs, longitudinal care and prescribing.

The balance of metagenomic elements shapes the skin microbiome in acne and health

Studies have emphasized the importance of disease-associated microorganisms in perturbed communities, however, the protective roles of commensals are largely under recognized and poorly understood. Using acne as a model disease, we investigated the determinants of the overall virulence property of the skin microbiota when disease- and health-associated organisms coexist in the community. By ultra-deep metagenomic shotgun sequencing, we revealed higher relative abundances of propionibacteria and Propionibacterium acnes phage in healthy skin. In acne patients, the microbiome composition at the species level and at P. acnes strain level was more diverse than in healthy individuals, with enriched virulence-associated factors and reduced abundance of metabolic synthesis genes. Based on the abundance profiles of the metagenomic elements, we constructed a quantitative prediction model, which classified the clinical states of the host skin with high accuracy in both our study cohort (85%) and an independent sample set (86%). Our results suggest that the balance between metagenomic elements, not the mere presence of disease-associated strains, shapes the overall virulence property of the skin microbiota. This study provides new insights into the microbial mechanism of acne pathogenesis and suggests probiotic and phage therapies as potential acne treatments to modulate the skin microbiota and to maintain skin health.

Azelainsäure 20 % Creme: Auswirkung auf Lebensqualität und Krankheitsaktivität bei erwachsenen Patientinnen mit Acne vulgaris

HINTERGRUND

Zur Wirksamkeit von Aknetherapien und deren Auswirkungen auf die Lebensqualität erwachsener Patienten liegen kaum Daten vor. ZIEL: Erhebung der Wirkung von Azelainsäure 20 % Creme (Skinoren^® ) auf Akne-Schweregrad und krankheitsbedingte Lebensqualität.

PATIENTEN UND METHODIK

Nichtinterventionelle Studie bei erwachsenen Patientinnen mit leichter bis mittelschwerer Akne. Wirksamkeitsparameter waren DLQI sowie Akne-Schweregrad im Gesicht, am Dekolleté sowie am Rücken im Gesamturteil des Prüfarztes (IGA-Skala: Grad 1 = annähernd reine Haut; 2 = leichte Akne; 3 = mittelschwere Akne). Visiten waren zu Studienbeginn sowie nach 4-8 und zwölf Wochen geplant.

ERGEBNISSE

Von den 251 eingeschlossenen Patientinnen lag zu Studienbeginn bei 59 %, 31 % bzw. 10 % ein IGA-Grad von 1, 2 bzw. 3 vor; die am häufigsten betroffene Hautpartie war das Gesicht (IGA-Grad 2 oder 3: 79 %). Nach zwölf Behandlungswochen war eine signifikante Besserung der Acne vulgaris im Gesicht (IGA-Grad 0 oder 1: 82 %) sowie auf Dekolleté und Rücken feststellbar. Der mediane DLQI-Wert sank von neun zu Studienbeginn auf fünf nach zwölf Behandlungswochen. Neunzig Prozent der behandelnden Ärzte und Patientinnen beurteilten die Verträglichkeit der Behandlung als sehr gut oder gut.

SCHLUSSFOLGERUNGEN

Die Anwendung von 20%iger Azelainsäure-Creme führt bei erwachsenen Frauen zu einer signifikanten Besserung der Acne vulgaris und der krankheitsbedingten Lebensqualität.

Azelaic acid 20 % cream: effects on quality of life and disease severity in adult female acne patients

BACKGROUND

Data on the efficacy of acne treatments and their impact on quality of life (QoL) in adult patients is sketchy.

OBJECTIVE

Assessment of the efficacy of azelaic acid 20 % cream (Skinoren^® ) on acne severity and disease-related QoL.

PATIENTS AND METHODS

Noninterventional study in adult female patients with mild to moderate acne. Efficacy variables included DLQI and acne severity on the face, chest, and back using the Investigator's Global Assessment (IGA) scale (grade 1 = nearly clear skin; 2 = mild acne; 3 = moderate acne). Visits were scheduled at baseline, at 4-8 weeks, and at twelve weeks.

RESULTS

Of the 251 women enrolled, 59 % had grade 1 acne at baseline; 31 %, grade 2; and 10 %, grade 3; the most commonly affected area of the body was the face (IGA grades 2 or 3: 79 %). After twelve weeks, there was significant improvement of acne on the face (IGA grades 0 or 1: 82 %), chest, and back. Median DLQI decreased from nine at baseline to five after twelve weeks. Ninety percent of physicians and patients rated the tolerability of the treatment as very good or good.

CONCLUSIONS

Treatment with azelaic acid 20 % cream significantly improves acne severity and disease-related QoL in adult women.

Treatment of adult female acne: a new challenge

Acne is affecting an increasing number of adult females and so can no longer be considered as a disease of adolescence. The disease has a greater negative impact on the quality of life of adult females than their younger counterparts. Adult female acne may persist from adolescence or may have its first occurrence once adulthood has been reached. The clinical presentation and pathogenesis of adult female acne may be somewhat different to that of adolescent acne and this may require a different treatment approach. Genetic and hormonal factors are thought to play key roles in the pathogenesis of adult female acne and the disease is characterized by a chronic evolution with frequent relapses requiring long-term maintenance therapy. Fixed-dose retinoid/antimicrobial combinations may be of interest for the treatment of adult female acne given that subgroup analysis of clinical trials has indicated that they are effective against both inflammatory and non-inflammatory lesions in these patients. These treatments may also be of interest, given the chronic course of the disease in adult females, the high likelihood of the presence of antibiotic-resistant P. acnes and the poor adherence of patients to other long-term therapies. Oral hormonal treatment or isotretinoin may be required in patients with severe acne or disease that is refractory to other treatments. Additional clinical studies of acne treatments specifically conducted in adult female patients are required to increase the evidence base on which future treatment recommendations can be based.

Beliefs, perceptions and psychosocial impact of acne amongst Singaporean students in tertiary institutions

BACKGROUND

Acne vulgaris is a common skin condition which can have a negative impact on a patient's quality of life.

PATIENTS AND METHODS

A survey was distributed among students at tertiary institutions. Data was collected on participants' own rating of acne grade and how acne affected their social life. A clinician on-site graded the participants' acne.

RESULTS

Of the 429 students who participated in the survey, 59.8 % felt embarrassed or self-conscious because of their acne. There was a low but statistically significant correlation (Spearman's Correlation Coefficient = 0.471, p < 0.001) between participants' and clinicians' grading of acne.

CONCLUSIONS

Acne vulgaris causes a considerable amount of psychosocial stress. There are unfounded beliefs surrounding acne and unawareness of treatment options available.

Study of lipid profile in adult women with acne

Objective

The aim of this study was to establish the lipid profile of female patients with acne in the Acne-in-Adult-Women Ambulatory Care Clinic in order to observe the prevalence of dyslipidemia in those patients.

Methods

This is a retrospective transversal study that evaluated the medical records of 416 patients who attended at the Acne-in-Adult-Women Ambulatory Care Clinic, at the Dermatology Department, Faculdade de Medicina do ABC, Santo André, São Paulo, Brazil, in the year 2012. Relevant data included age and clinical classification of acne. The lipid profile was analyzed according to the results of laboratory tests ordered during outpatient visits, which included total and fractionated cholesterol levels and triglycerides.

Results

The epidemiological study sample was of 219 patients, with ages ranging from 21 to 61 years (mean of 32.23 years). The predominant clinical grade was papule-pustule acne (grade II) with 156 patients (71%). Regarding the lipid profile of the patients, there was a high increase in total cholesterol levels in 17.35% of the cases. High-density lipoprotein levels were low in 11.42% of the patients, with normal prevalence in 194 subjects. Low-density lipoprotein levels were normal in most patients (60.27%). Very-low-density lipoprotein values were normal in almost all patients (94.06%) and increased in only 13 patients (5.94%). Only 18 patients presented high levels of triglycerides (8.22%).

Conclusion

The conclusion was that patients with grades II and III acne are more likely to have total cholesterol and low-density lipoprotein altered. A correct and early diagnosis can be an important measure for the prevention of the metabolic syndrome in these patients.