Low-dose oral isotretinoin versus topical retinoic acid for photoaging: a randomized, comparative study

Photoaging and cosmeceutical solutions in sun-overexposed countries: The experience of Australia and Brazil

Skin aging is the result of physiological changes determined by genetically driven processes and intrinsic factors, and exacerbated by a combination of multiple environmental factors, the main one being sun exposure. The effects of photoaging are particularly apparent on the face, where the appearance of aging signs can have a significant impact on the emotions conveyed and well-being. Photoprotection and facial skin care for managing photoaging signs are thus of particular importance for both physical and mental health. Countries, like Australia and Brazil, where the level of sun exposure is high and the populations have predominantly outdoor lifestyles, are particularly aware of the harms of photoaging and have implemented several measures to help reduce the risk of skin cancer in their populations. However, sun-seeking behaviours are difficult to change, and it takes time before interventions provide perceptible results. Australia still has some of the highest skin cancer incidence and mortality rates in the world. Solutions that target individuals can also be used for minimizing the clinical signs of facial aging and for improving skin quality, with the ultimate aim being not only to improve the appearance of the skin but also to mitigate the occurrence of pre-malignant and malignant lesions. This review summarizes the features of facial skin photoaging in photo-exposed populations, based on evidence gained from studies of Australian individuals, and discusses the various available solutions for skin photoaging, in particular those that are most popular in Brazil, which is a country with many years of experience in managing photoaged skin.

A systematic review of 454 randomized controlled trials using the Dermatology Life Quality Index: experience in 69 diseases and 43 countries

BACKGROUND

Over 29 years of clinical application, the Dermatology Life Quality Index (DLQI) has remained the most used patient-reported outcome (PRO) in dermatology due to its robustness, simplicity and ease of use.

OBJECTIVES

To generate further evidence of the DLQI's utility in randomized controlled trials (RCTs) and to cover all diseases and interventions.

METHODS

The methodology followed PRISMA guidelines and included seven bibliographical databases, searching articles published from 1 January 1994 until 16 November 2021. Articles were reviewed independently by two assessors, and an adjudicator resolved any opinion differences.

RESULTS

Of 3220 screened publications, 454 articles meeting the eligibility criteria for inclusion, describing research on 198 190 patients, were analysed. DLQI scores were primary endpoints in 24 (5.3%) of studies. Most studies were of psoriasis (54.1%), although 69 different diseases were studied. Most study drugs were systemic (85.1%), with biologics comprising 55.9% of all pharmacological interventions. Topical treatments comprised 17.0% of total pharmacological interventions. Nonpharmacological interventions, mainly laser therapy and ultraviolet radiation treatment, comprised 12.2% of the total number of interventions. The majority of studies (63.7%) were multicentric, with trials conducted in at least 42 different countries; 40.2% were conducted in multiple countries. The minimal clinically importance difference (MCID) was reported in the analysis of 15.0% of studies, but only 1.3% considered full score meaning banding of the DLQI. Forty-seven (10.4%) of the studies investigated statistical correlation of the DLQI with clinical severity assessment or other PRO/quality of life tools; and 61-86% of studies had within-group scores differences greater than the MCID in 'active treatment arms'. The Jadad risk-of-bias scale showed that bias was generally low, as 91.8% of the studies had Jadad scores of ≥ 3; only 0.4% of studies showed a high risk of bias from randomization. Thirteen per cent had a high risk of bias from blinding and 10.1% had a high risk of bias from unknown outcomes of all participants in the studies. In 18.5% of the studies the authors declared that they followed an intention-to-treat protocol; imputation for missing DLQI data was used in 34.4% of studies.

CONCLUSIONS

This systematic review provides a wealth of evidence of the use of the DLQI in clinical trials to inform researchers' and -clinicians' decisions for its further use. Recommendations are also made for improving the reporting of data from future RCTs using the DLQI.

Durability of the improvement of collagen I and collagen III with the use of oral isotretinoin in the treatment of photoaging

BACKGROUND

Oral isotretinoin (ISO) is the drug of choice for the treatment of severe acne. For photoaging treatment, ISO has been proved to be effective in some controlled and noncontrolled trials and is an alternative to topical retinoic acid (RA) therapy, which causes an expected skin irritation.

OBJECTIVE

To evaluate and compare the skin remodeling in patients taking ISO 20 mg 3 times a week for 12 weeks and 12 weeks after the end of the treatment to quantify collagen I and collagen III augmentation.

MATERIAL AND METHODS

Immunohistochemical studies were performed to evaluate the expression of collagen I and collagen III, metalloproteinases (MMPs) -1, -3, -7, -9, -12, and the tissue inhibitor of MMP type-1 (TIMP-1) of the skin of 20 45 to 50-year-old women through morphometry in a semiquantitative method. The inclusion criteria were facial aging 2 and 3 of Glogau's classification, with phototypes between II and V who had not entered menopause. Biopsies of the skin of the left preauricular region were performed at three different times: pre-treatment (T0), end of 12-week treatment (T1), and 12 weeks posttreatment (T2).

RESULTS

Collagen fibers I and III increased with statistical significance in T1 (50.7%; P = 0.012) but not in T2 (49.7%), which in turn was higher than in T0 (47.2%) for collagen I and T1 (33.3%; P = 0.002) but not in T2 (32.7%), and also was higher than T0 (32.0%) for collagen III. MMP-9 presented a decreased activity with statistical significance in T1 (P = 0.047) and T2 (P = 0.058). MMP-1 showed a reduction in T2 only (P = 0.015). MMPs -3, -7, -12, and TIMP-1 did not present significant modification in their expressions during or after the treatment.

CONCLUSIONS

Low-dose ISO is effective in remodeling the extracellular matrix (ECM). This study found that the increase of collagen occurs through the augmentation of both collagen I and collagen III fibers. With originality, it was possible to verify the durability of these fibers for at least 12 weeks. This may be related to the decrease in MMP-9 expression verified at the end of the treatment and 12 weeks posttreatment.

Approaches in line with human physiology to prevent skin aging

Skin aging is a complex process that is influenced by intrinsic and extrinsic factors that impact the skin's protective functions and overall health. As the body's outermost layer, the skin plays a critical role in defending it against external threats, regulating body temperature, providing tactile sensation, and synthesizing vitamin D for bone health, immune function, and body homeostasis. However, as individuals age, the skin undergoes structural and functional changes, leading to impairments in these essential functions. In contemporary society, there is an increasing recognition of skin health as a significant indicator of overall wellbeing, resulting in a growing demand for anti-aging products and treatments. However, these products often have limitations in terms of safety, effective skin penetration, and potential systemic complications. To address these concerns, researchers are now focusing on approaches that are safer and better aligned with physiology of the skin. These approaches include adopting a proper diet and maintaining healthy lifestyle habits, the development of topical treatments that synchronize with the skin's circadian rhythm, utilizing endogenous antioxidant molecules, such as melatonin and natural products like polyphenols. Moreover, exploring alternative compounds for sun protection, such as natural ultraviolet (UV)-absorbing compounds, can offer safer options for shielding the skin from harmful radiation. Researchers are currently exploring the potential of adipose-derived stem cells, cell-free blood cell secretome (BCS) and other endogenous compounds for maintaining skin health. These approaches are more secure and more effective alternatives which are in line with human physiology to tackle skin aging. By emphasizing these innovative strategies, it is possible to develop effective treatments that not only slow down the skin aging process but also align better with the natural physiology of the skin. This review will focus on recent research in this field, highlighting the potential of these treatments as being safer and more in line with the skin's physiology in order to combat the signs of aging.

Oral Isotretinoin and Its Uses in Dermatology: A Review

In 1982, the Food and Drug Administration (FDA) of the United States of America approved isotretinoin (13-cis-retinoic acid), a retinoid derivative of vitamin A, to treat severe recalcitrant acne vulgaris. Apart from its prescribed use for severe acne, evidence suggests that isotretinoin is commonly used off-label to treat mild-to-moderate acne, inflammatory skin conditions, genodermatoses, skin cancer, and other skin disorders. This is due to its anti-inflammatory, immunomodulatory, and antineoplastic properties. Some "off-label" use is successful, while others are ineffective. Therefore, this information is essential to clinicians for deciding on the appropriate use of isotretinoin. In this article, we aim to review the most updated evidence-based data about the use of oral isotretinoin in dermatology.

Efficacy and safety of low-dose oral isotretinoin monotherapy versus combined therapy with picosecond laser for the treatment of acne scars in Asian population

PURPOSE

Acne scars are common in patients with moderate to severe acne. Isotretinoin is the first-line treatment for those patients, but whether oral isotretinoin can improve acne scar is not clear. Picosecond lasers (FxPico) has been reported to improve acne scars. In the present study, we evaluated the clinical efficacy of low-dose isotretinoin with or without FxPico treatment for acne scars.

MATERIALS AND METHODS

A total of 48 patients with acne scars were enrolled and were randomly assigned to receive low dose oral isotretinoin or not. For all the patients in both treatment groups, one side of face were randomly assigned to be treated with picosecond laser. Assessments, including photos, échelle d'évaluation clinique des cicatrices d'acné (ECCA) and Global Acne Grading System (GAGS) score, the number of lesions, melanin and erythema indexes, transepidermal water loss were assessed at 0, 1, 2, and 3 month. Side effects, Dermatology Life Quality Index (DLQI) and satisfaction were recorded before and after the study.

RESULTS

A total of 44 patients completed the study (24 received oral low dose isotretinoin and 20 did not). Low dose oral isotretinoin treated group showed significant improvement on ECCA (from 112.5 [50-180] to 105 [50-160]), GAGS score (from 12.6 ± 3.3 to 10.1 ± 3.0), the count of papules (from 4.3 ± 3.7 to 1.0 ± 1.5) than the blank group, and higher improvement were noticed after isotretinoin combined with FxPico. All the side effects were temporary and tolerable, no adverse effects were observed. Higher DLQI and patients' satisfaction were achieved by oral isotretinoin alone and isotretinoin combined with FxPico.

CONCLUSIONS

This is the first paper showing the improvement of scars by early low dose-isotretinoin intervention with or without the combination of picosecond laser. Early intervention with oral low-dose isotretinoin is effective for the treatment and prevention of acne scars, the combined therapy with FxPico can achieve better outcome.

Oral Supplementation and Systemic Drugs for Skin Aging: A Narrative Review

Skin aging is influenced by intrinsic and extrinsic factors and involves multiple pathogenic mechanisms. The most widely used treatments are topical products and minimally invasive procedures. Evidence on the benefits of systemic therapy is limited for several reasons: Reliance on mostly small and predominantly female samples, short study durations, methodologic heterogeneity, and a lack of consensus on which outcome measures are clinically relevant. Furthermore, systemic drugs and oral supplements are not without adverse effects. Oral hydrolyzed collagen and oral hyaluronic acid are well tolerated, and numerous clinical trials show they can mitigate some signs of skin aging. Low-dose oral isotretinoin is another option, but it has a higher risk of adverse effects. Evidence is lacking on the effects of the many dietary supplements on offer, such as vitamins, flavonoids, plant extracts, and trace elements. The future of skin aging management would appear to lie in the use of senolytic and senomorphic agents targeting senescent cells in the skin.

Photobiomodulation Reduces Periocular Wrinkle Volume by 30%: A Randomized Controlled Trial

Objective: This study aimed to evaluate red and amber light-emitting diode protocols for facial rejuvenation at the same light dose. Background: The demand for minimally invasive cosmetic procedures to address skin aging has grown throughout the world. In vitro red and amber photobiomodulation (PBM) has been shown to improve collagen synthesis. Meanwhile, red PBM has already been studied in clinical trials; however, a comparison of the use of different wavelengths at the same light dose to reduce periocular wrinkles has not yet been performed. Methods: This split-face, randomized clinical trial recruited 137 women (40-65 years old) presenting with skin phototypes II-IV and Glogau photoaging scale types II-IV. The individuals received 10 sessions for 4 weeks of red (660 nm) and amber (590 nm) PBM (3.8 J/cm²), one at each side of the face. The outcomes, measured before and after the treatments, were the periocular wrinkle volume measured by VisioFace^® RD equipment; hydration measured by the Corneometer CM 825; skin elasticity measured by the Cutometer Dual MPA 580; and quality of life determined by adapted versions of validated questionnaires [Melasma Quality of Life Scale-Brazilian Portuguese (MelasQoL-BP) and Skindex-29]. Results: There was a significant reduction in wrinkle volume after red (31.6%) and amber (29.9%) PBM. None of the treatments improved skin hydration and viscoelasticity. Both questionnaires showed improvements in participants' quality of life. Conclusions: PBM, both at red and amber wavelengths, is an effective tool for rejuvenation, producing a 30% wrinkle volume reduction. The technique has strong potential in patients with diabetes or those presenting with keloids, conditions for which highly inflammatory rejuvenating procedures are not indicated. Clinical trial registration number: REBEC-6YFCBM.

Efficacy and Safety of Topical or Oral Hydrolyzed Collagen in Women with Dermatoporosis: A Randomized, Double-Blind, Factorial Design Study

BACKGROUND

Dermatoporosis defines the progressive chronic cutaneous insufficiency syndrome. Stage I is characterized by cutaneous atrophy, senile purpura, and stellate pseudoscars.

OBJECTIVE

To assess clinical, histologic, quality of life, and biophysical effects of oral and/or topical hydrolyzed collagen (HC) on forearm skin of postmenopausal women with Dermatoporosis stage I.

METHODS

Double-blind randomized placebo-controlled factorial design study. Two groups of menopausal women with stage I dermatoporosis on forearms were randomized to oral HC 5 g/day or matching placebo, and also to topical serum 2.5% HC or matching placebo once a day, for 6 months.

RESULTS

A total of 56 women, age range 60-93 years (mean 69.5 ± 7.3 years) were included. Comparing data from baseline and after 6 months, no significant difference was observed for each intervention nor their comparison, for all efficacy parameters: clinical and quality of life scores, dermal elasticity, thickness and echogenicity, and histologic and immunohistochemical markers (p > 0.1).

LIMITATIONS

Larger studies to confirm our findings are warranted.

CONCLUSIONS

In menopausal women with stage I dermatoporosis, oral or topical collagen peptides used alone or in combination do not have benefits on forearm skin after 6 months of intervention, and therefore should not be used routinely in this population. CONSORT flow chart.

[Translated article] Oral Supplementation and Systemic Drugs for Skin Aging: A Narrative Review

Skin aging is influenced by intrinsic and extrinsic factors and involves multiple pathogenic mechanisms. The most widely used treatments are topical products and minimally invasive procedures. Evidence on the benefits of systemic therapy is limited for several reasons: reliance on mostly small and predominantly female samples, short study durations, methodologic heterogeneity, and a lack of consensus on which outcome measures are clinically relevant. Furthermore, systemic drugs and oral supplements are not without adverse effects. Oral hydrolyzed collagen and oral hyaluronic acid are well tolerated, and numerous clinical trials show they can mitigate some signs of skin aging. Low-dose oral isotretinoin is another option, but it has a higher risk of adverse effects. Evidence is lacking on the effects of the many dietary supplements on offer, such as vitamins, flavonoids, plant extracts, and trace elements. The future of skin aging management would appear to lie in the use of senolytic and senomorphic agents targeting senescent cells in the skin.

The role of local retinoids in eliminating signs of skin aging

Skin aging is a complex process involving both internal (chronological aging) and external (biological aging) factors. Slowing down the proliferative and immune processes in the epidermis, reducing the activity of fibroblasts and vascularization of the dermis during chronological aging lead to thinning, dryness, hypersensitivity, vulnerability and superficial wrinkles. Exposure to ultraviolet rays, pollutants, climate, and thermal factors cause keratinocyte disorganization, enhanced melanogenesis, collagen dystrophy, solar elastosis, and disorder of microcirculation. The main signs of external skin aging are deep wrinkles, sagging, pigmentation, telangiectasia, skin neoplasms. Among the local anti-aging agents, retinoids occupy a leading place, as they eliminate the main signs of skin aging. Of the entire group of retinoids, retinoic acids are the most active. However, the possibility of skin irritation limits their use. Therapeutic and cosmetic products with retinol esters (retinol palmitate) have a minimal irritating effect and can be used both for the prevention of skin aging and the elimination of its signs. Oral use of isotretinoin as an anti-aging agent is undesirable due to the many side effects and contraindications.

Periocular Dark Circles: Correlates of Severity

Background

Periocular dark circles (PDCs) are a common cosmetic complaint. Grading systems based on objective measures have been used but no standard system is in place.

Objective

To determine factors associated with subjective and objective PDC severity.

Methods

Enrolled patients (n=100) completed a questionnaire comprised of demographic variables, medical history, and self-perception of PDC. Those perceiving PDC graded dissatisfaction on a 10-point scale. Clinical severity (grades 0~4) and subtype (constitutional, post-inflammatory, vascular, shadow effects, or others) were determined. A Konica Minolta CR-400 chromameter was used to obtain colorimetry measurements (L^*a^*b^* values). The objective average difference in darkness (ΔL^*) between the periocular region and the cheek was determined. Comparisons were made using Spearman correlation coefficients (r).

Results

Patient dissatisfaction correlated with both clinical severity (r=0.46, p<0.001) and the ΔL^* by colorimetry (r=0.35, p=0.004). Factors associated with subjective dissatisfaction were female sex (r=0.38, p=0.002), higher Fitzpatrick skin type (r=0.42, p=0.001), fewer hours of sleep (r=-0.28, p=0.03), and use of concealer (r=0.35, p=0.004). Factors associated with objective measures were higher Fitzpatrick skin type (r=0.36, p=0.0007 and r=0.28, p=0.009, respectively), family history of PDC (r=0.34, p<0.001 and r=0.20, p=0.05), and history of eczema (r=0.45, p<0.001 and r=0.20, p=0.0504). Clinical severity grading correlated with colorimetric severity (r=0.36, p=0.0003).

Conclusion

Overall, subjective dissatisfaction was associated with clinical severity. However, factors associated with subjective severity did not necessarily overlap with factors associated with objective severity. These findings highlight the importance of patient-reported grading. There may be added value in incorporating a component of subjective grading into the traditionally objective PDC grading scales.

Dietary nutrients and their control of the redox bioenergetic networks as therapeutics in redox dysfunctions sustained pathologies

Electrons exchange amongst the chemical species in an organism is a pivotal concomitant activity carried out by individual cells for basic cellular processes and continuously contribute towards the maintenance of bioenergetic networks plus physiological attributes like cell growth, phenotypic differences and nutritional adaptations. Humans exchange matter and energy via complex connections of metabolic pathways (redox reactions) amongst cells being a thermodynamically open system. Usually, these reactions are the real lifeline and driving forces of health and disease in the living entity. Many shreds of evidence support the secondary role of reactive species in the cellular process of control apoptosis and proliferation. Disrupted redox mechanisms are seen in malaises, like degenerative and metabolic disorders, cancerous cells. This review targets the importance of redox reactions in the body's normal functioning and the effects of its alterations in cells to obtain a better understanding. Understanding the redox dynamics in a pathological state can provide an opportunity for cure or diagnosis at the earlier stage and serve as an essential biomarker to predict in advance to give personalized therapy. Understanding redox metabolism can also highlight the use of naturally available antioxidant in the form of diet.

Boosting the Photoaged Skin: The Potential Role of Dietary Components

Skin photoaging is mainly induced by ultraviolet (UV) irradiation and its manifestations include dry skin, coarse wrinkle, irregular pigmentation, and loss of skin elasticity. Dietary supplementation of nutraceuticals with therapeutic and preventive effects against skin photoaging has recently received increasing attention. This article aims to review the research progress in the cellular and molecular mechanisms of UV-induced skin photoaging. Subsequently, the beneficial effects of dietary components on skin photoaging are discussed. The photoaging process and the underlying mechanisms are complex. Matrix metalloproteinases, transforming growth factors, skin adipose tissue, inflammation, oxidative stress, nuclear and mitochondrial DNA, telomeres, microRNA, advanced glycation end products, the hypothalamic-pituitary-adrenal axis, and transient receptor potential cation channel V are key regulators that drive the photoaging-associated changes in skin. Meanwhile, mounting evidence from animal models and clinical trials suggests that various food-derived components attenuate the development and symptoms of skin photoaging. The major mechanisms of these dietary components to alleviate skin photoaging include the maintenance of skin moisture and extracellular matrix content, regulation of specific signaling pathways involved in the synthesis and degradation of the extracellular matrix, and antioxidant capacity. Taken together, the ingestion of food-derived functional components could be an attractive strategy to prevent skin photoaging damage.

In vivo β-carotene skin permeation modulated by Nanostructured Lipid Carriers

Nanostructured Lipid Carriers (NLC) were investigated with the purpose of promoting skin permeation of the highly lipophilic β-carotene (BC) across the stratum corneum (SC) barrier so that it may perform its antioxidant properties in photo-aging and epithelial skin cancer prevention. Two differently sized NLC samples were developed using stearic acid and squalene as lipid matrix and evaluated in comparison with Microstructured Lipid Carriers (MLC). The carriers were characterized for morphology, size, Z-potential, BC loading and release as well as physical state by means of DSC and XRPD analyses. In vivo penetration of the carriers was assessed on humans by determining BC concentrations within the SC stratum disjunctum and stratum compactum layers removed by means of the tape stripping test in comparison with pure BC. Unlike MLC and pure BC that were mostly retained within the outermost layers of the SC, the NLC sample having the smallest size (about 200 nm) has proved to penetrate more deeply into the SC barrier. Accordingly, the goal of providing β-carotene actions against oxidative damages within the looser skin viable tissues could be envisaged.

Development and cathodic iontophoretic permeation evaluation of liquid crystalline systems provided of retinoic acid microparticles

BACKGROUND

The intracellular form of action of retinoids requires these agents to reach deeper layers of the skin with viable cells to ensure therapeutic efficiency. However, studies on swine skin models show that some retinoids have low skin permeability. Thus, the association of innovative formulations with technological strategies involving physical permeation promoters can be employed to increase the permeability of this active, ensuring a targeting effect of the active.

AIMS

In this study, it was proposed the development and evaluation of the release and permeation profile of liquid crystalline systems with retinoic acid polymeric microparticles under passive or iontophoretic diffusional conditions.

METHODS

For this study, release, permeation, and diffusional characterization assays were employed using the Franz diffusion cell model, associating or not the cathodic iontophoresis.

RESULTS

Retinoic acid was considered stable in front of the electric current of 0.5mA/cm² , because it did not show significant degradation (with maintenance from 96.03% to 98.57%), indicating the viability of such agents to be applied with iontophoresis. Controlled release profile was evidenced for microencapsulated systems. Comparatively, formulations F1, F3, and F5 presented a significantly higher RA release profile when compared to formulations with retinoic acid microencapsulated. A significant increase was observed in the absolute amount of RA retained in the skin with cathodic iontophoresis in all proposed formulations (P < .01). The increase was up to two times in relation to the passive condition.

CONCLUSIONS

The combination of iontophoresis technique with application of retinoic acid and microencapsulated retinoic acid allows the penetration of the active ingredient to deeper layers of the skin.

Oral isotretinoin for the treatment of dermatologic conditions other than acne: a systematic review and discussion of future directions

While isotretinoin has been the gold-standard of therapy for severe acne since its approval in 1982, its anti-inflammatory properties makes it a potentially applicable and versatile therapy for a wide variety of dermatologic conditions yet to be explored. This systematic review comprehensively recounts the success of oral isotretinoin in non-acne cutaneous diseases and provide insight into future directions of isotretinoin utility. A systematic literature review was performed using PubMed. Search terms included "isotretinoin" OR "accutane" AND "skin" OR "dermatology" OR "hair" OR "nails" OR "rosacea" OR "psoriasis" OR "pityriasis rubra pilaris" OR "condyloma acuminata" OR "granuloma annulare" OR "darier's disease" OR "non-melanoma skin cancer" OR "frontal fibrosing alopecia" OR "cutaneous lupus erythematosus" OR "hidradenitis suppurativa" OR "photodamaged skin" OR "skin aging" OR "wart" OR "flat warts" OR "plane warts" OR "lichen planus" OR "dissecting cellulitis" OR "folliculitis decalvans" OR "sebaceous hyperplasia" OR "cutaneous t-cell lymphoma" OR "mycosis fungoides." A total of 169 studies discuss the use of oral isotretinoin for 16 non-acne dermatologic conditions, the most common being non-melanoma skin cancers (0.2-8.2 mg/kg/day), cutaneous T-cell lymphomas (0.5-2 mg/kg/day), and rosacea (0.22-1 mg/kg/day). Inflammatory conditions such as rosacea, granuloma annulare, and hidradenitis suppurativa benefit from lower oral isotretinoin dosage of 0.3-1 mg/kg/day, whereas, hyperkeratotic diseases such as psoriasis and pityriasis rubra pilaris, consistently respond better to higher dosages of up to 2-4 mg/kg/day for lesion clearance. Recurrence of disease following discontinuation of isotretinoin have been reported for rosacea, psoriasis, granuloma annulare, Darier's disease, dissecting cellulitis, and non-melanoma skin cancers. Disease exacerbation was reported in some patients with hidradenitis suppurativa. Off-label isotretinoin is an effective treatment choice for dermatological conditions beyond acne. Further prospective, randomized human trials are needed to clarify when and how to prescribe off-label isotretinoin for maximum efficacy and safety.

Consensus on the use of oral isotretinoin in dermatology - Brazilian Society of Dermatology

BACKGROUND

Isotretinoin is a synthetic retinoid, derived from vitamin A, with multiple mechanisms of action and highly effective in the treatment of acne, despite common adverse events, manageable and dose-dependent. Dose-independent teratogenicity is the most serious. Therefore, off-label prescriptions require strict criteria.

OBJECTIVE

To communicate the experience and recommendation of Brazilian dermatologists on oral use of the drug in dermatology.

METHODS

Eight experts from five universities were appointed by the Brazilian Society of Dermatology to develop a consensus on indications for this drug. Through the adapted DELPHI methodology, relevant elements were listed and an extensive analysis of the literature was carried out. The consensus was defined with the approval of at least 70% of the experts.

RESULTS

With 100% approval from the authors, there was no doubt about the efficacy of oral isotretinoin in the treatment of acne, including as an adjunct in the correction of scars. Common and manageable common adverse events are mucocutaneous in nature. Others, such as growth retardation, abnormal healing, depression, and inflammatory bowel disease have been thoroughly investigated, and there is no evidence of a causal association; they are rare, individual, and should not contraindicate the use of the drug. Regarding unapproved indications, it may represent an option in cases of refractory rosacea, severe seborrheic dermatitis, stabilization of field cancerization with advanced photoaging and, although incipient, frontal fibrosing alopecia. For keratinization disorders, acitretin performs better. In the opinion of the authors, indications for purely esthetic purposes or oil control are not recommended, particularly for women of childbearing age.

CONCLUSIONS

Approved and non-approved indications, efficacy and adverse effects of oral isotretinoin in dermatology were presented and critically evaluated.

Oral isotretinoin and photoaging: A review

INTRODUCTION

Over the past 20 years, evidence has emerged indicating oral isotretinoin could be considered a potential treatment for photoaged skin. In this review, we provide a succinct overview of the available evidence and provide commentary on the current and future directions for utilizing oral isotretinoin as a potential treatment for photoaging.

METHODS

We prepared a review protocol and searched the PubMed and Cochrane databases for relevant literature published between January 1982 and April 2020. Using a defined keyword search, a total of 23 papers were initially identified by the main author. Two authors independently reviewed each of the 23 articles, and 6 articles were deemed relevant to this study.

RESULTS

Of the six studies included in this review, three were randomized clinical trials, one was a nonrandomized clinical trial and two were prospective cohort studies. All studies were conducted between 2000 and 2015. Across all 6 studies, 251 patients were recruited, with a mean of 42 patients per study. Four studies were in favor of isotretinoin to improve photoaged skin, 1 study showed no benefit, and 1 study showed no benefit when compared to topical tretinoin treatment. Of the studies available, many were hampered by methodological challenges.

CONCLUSION

Oral isotretinoin may be useful for treating photoaging but there is currently insufficient evidence to support its use. In comparison with other established anti-photoaging treatments, it is not clear whether the potential benefits of oral isotretinoin outweigh the potential risks.

A randomized, open, controlled trial of tretinoin 0.05% cream vs. low-dose oral isotretinoin for the treatment of field cancerization

BACKGROUND

Sun exposure may lead to actinic keratoses (AKs), field cancerization, and skin cancer. Effective treatment of AKs and field cancerization is important. Oral and topical retinoids can be used for this purpose. To compare clinical, histological, and immunohistochemical effects of oral and topical retinoid for AKs and field cancerization on face and upper limbs of immunocompetent patients, as well as the impact on quality of life, safety, and tolerability.

METHODS

This study compared 10 mg/day oral isotretinoin (ISO) to 0.05% tretinoin cream (TRE) every other night, associated with sunscreen (SPF 60). Patients of both genders, aged 50-75 years, underwent cryotherapy with liquid nitrogen for AKs at baseline and after 120 days when they were randomized into two groups, TRE (n = 31) and ISO (n = 30), for 6 months. Outcome measures were: number of AKs, histological (thickness of stratum corneum and epithelium) and immunohistochemical parameters (p53, Bcl-2 and Bax), dermatology life quality index (DLQI), and adverse events.

RESULTS

Both treatments reduced the number of AKs (around 28%), the thickness of stratum corneum, and expression of p53 and Bax. By contrast, the epithelium thickness and Bcl-2 expression increased. There was no difference in the outcomes between TRE and ISO. Both treatments improved quality of life and were well tolerated with minimal side effects.

CONCLUSIONS

Retinoids are effective and safe for field cancerization. Classical treatments for field cancerization (imiquimod and ingenol mebutate) are used for a short period; retinoids may be a good choice to intercalate with them and can be used continuously.

Adult female acne: a guide to clinical practice

BACKGROUND

Acne in women is often associated with anxiety and depression, and may persist from adolescence as well as manifest for the first time in adulthood. Genetic and hormonal factors contribute to its etiopathogenesis, and maintenance treatment is required, usually for years, due to its clinical evolution.

OBJECTIVE

To develop a guide for the clinical practice of adult female acne.

METHODS

A team of five experts with extensive experience in acne conducted a literature review of the main scientific evidence and met to discuss the best practices and personal experiences to develop a guide containing recommendations for the clinical practice of adult female acne.

RESULTS

The group of specialists reached consensus on the main guidelines for clinical practice, providing detailed recommendations on clinical picture, etiopathogenesis, laboratory investigation and treatment of adult female acne.

CONCLUSION

Different from teenage acne, adult female acne presents some characteristics and multiple etiopathogenic factors that make its management more complex. This guide provides recommendations for best clinical practices and therapeutic decisions. However, the authors consider that additional studies are needed in order to provide more evidence for adult female acne to be better understood.

Dermatological indications for the use of isotretinoin beyond acne

While the use of isotretinoin has revolutionized the treatment of acne vulgaris, isotretinoin is increasingly recognized as a useful therapeutic option for many other cutaneous conditions. We review the evidence underlying the use of isotretinoin for a variety of dermatological indications including hidradenitis suppurativa, sebaceous gland pathology, rosacea, scarring alopecia, cosmetic dermatology, and non-melanoma skin cancer prophylaxis amongst other uses, and thus consider alternative uses within dermatology practice. The studies found benefit of isotretinoin, however most trials lacked statistical power and in many cases the use was limited to case series. Isotretinoin, if used within the correct cohort with appropriate pretreatment counseling regarding side-effects, is a well-tolerated medication with potential as either an adjunctive treatment or a second-line agent in those recalcitrant cases unresponsive to first-line therapy.

Insights on Localized and Systemic Delivery of Redox-Based Therapeutics

Reactive oxygen and nitrogen species are indispensable in cellular physiology and signaling. Overproduction of these reactive species or failure to maintain their levels within the physiological range results in cellular redox dysfunction, often termed cellular oxidative stress. Redox dysfunction in turn is at the molecular basis of disease etiology and progression. Accordingly, antioxidant intervention to restore redox homeostasis has been pursued as a therapeutic strategy for cardiovascular disease, cancer, and neurodegenerative disorders among many others. Despite preliminary success in cellular and animal models, redox-based interventions have virtually been ineffective in clinical trials. We propose the fundamental reason for their failure is a flawed delivery approach. Namely, systemic delivery for a geographically local disease limits the effectiveness of the antioxidant. We take a critical look at the literature and evaluate successful and unsuccessful approaches to translation of redox intervention to the clinical arena, including dose, patient selection, and delivery approach. We argue that when interpreting a failed antioxidant-based clinical trial, it is crucial to take into account these variables and importantly, whether the drug had an effect on the redox status. Finally, we propose that local and targeted delivery hold promise to translate redox-based therapies from the bench to the bedside.

Cutaneous fungal microbiome: Malassezia yeasts in seborrheic dermatitis scalp in a randomized, comparative and therapeutic trial

Malassezia spp in skin microbiome scalp has been implicated in seborrheic dermatitis pathogenesis. Thus, treatment based in antifungal combined to topical keratolitic agents have been indicated as well as oral isotretinoin as it reduces the sebum production, glandular's size and possesses anti-inflammatory properties. This randomized, comparative and therapeutic trial aimed toper form the genotypic identification of Malassezia species before and after low-dose oral isotretinoin or topical antifungal treatments for moderate to severe seborrhea and/or seborrheic dermatitis on scalp. Scales and sebum of the scalp were seeded in the middle of modified Dixon and incubated at 32°C. For genotypic identification polymerase chain reaction primers for the ITS and D1/D2 ribossomal DNA were used and followed by samples sequencing. The procedure was conducted before and after therapeutic and randomized intervention for moderate to severe seborrhea/seborrheic dermatitis on the scalp, including oral isotretinoin, 10 mg, every other day and anti-seborrheic shampoo (piroctone olamine), over six months. The M. globosa and M. restricta were the most frequent species isolated on the scalp before and after both treatments. Other non-Malassezia species were also identified. The Malassezia spp. were maintained in the scalp after both treatments that were equally effective for the control of seborrhea/seborrheic dermatitis clinical signs.

Retinoic acid ameliorates photoaged skin through RAR‑mediated pathway in mice

Retinoic acid (RA), the bioactive metabolite of vitamin A, has demonstrated efficacy in the treatment of photoaged skin; however, the mechanism of action of RA remains unclear. The aim of the present study was to examine whether the therapeutic effects of RA on photoaged skin are mediated by retinoic acid receptor (RAR) and/or retinoid X receptor (RXR) in mice, and to investigate the underlying mechanism. Photoaged skin in Imprinting Control Region mice was induced by repeated exposure to ultraviolet (UV) irradiation. Mice were randomly divided into nine groups: Normal; UV control; all‑trans retinoic acid (ATRA); ATRA + RAR antagonist; ATRA + RXR antagonist; RAR agonist; RAR agonist + RAR antagonist; RXR agonist; and RXR agonist + RXR antagonist. Masson's trichrome staining was used to examine skin collagen fibers. Hydroxyproline assays were used to determine collagen content. The protein expression of matrix metalloproteinase (MMP)‑3, MMP‑13, type I procollagen, c‑Jun and c‑Fos was detected using western blot analysis. The results demonstrated that ATRA and RAR agonist ameliorated the UV‑induced damage to skin collagen fibers, and increased the collagen content in photoaged skin through RAR. Furthermore, ATRA and RAR agonist stimulated type I procollagen protein expression, and inhibited MMP‑3, MMP‑13 and c‑Jun protein expression through RAR in photoaged skin. However, ATRA and RAR agonist exhibited no significant effect on the protein expression of c‑Fos in photoaged skin. These findings suggest that RA ameliorates photoaged skin through a RAR‑mediated signaling pathway in mice.

Tretinoin peel: a critical view

The tretinoin peel, also known as retinoic acid peel, is a superficial peeling often performed in dermatological clinics in Brazil. The first study on this was published in 2001, by Cuce et al., as a treatment option for melasma. Since then, other studies have reported its applicability with reasonable methodology, although without a consistent scientific background and consensus. Topical tretinoin is used for the treatment of various dermatoses such as acne, melasma, scars, skin aging and non-melanoma skin cancer. The identification of retinoids cellular receptors was reported in 1987, but a direct cause-effect relation has not been established. This article reviews studies evaluating the use of topical tretinoin as agent for superficial chemical peel. Most of them have shown benefits in the treatment of melasma and skin aging. A better quality methodology in the study design, considering indication and intervention is indispensable regarding concentration, vehicle and treatment regimen (interval and number of applications). Additionally, more controlled and randomized studies comparing the treatment with tretinoin cream versus its use as a peeling agent, mainly for melasma and photoaging, are necessary.

The Effectiveness of a 5% Retinoic Acid Peel Combined with Microdermabrasion for Facial Photoaging: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

Background. Tretinoin has been shown to improve photoaged skin. This study was designed to evaluate the efficacy and tolerability of a 5% retinoic acid peel combined with microdermabrasion for facial photoaging. Materials and Methods. Forty-five patients, aged 35–70, affected by moderate-to-severe photodamage were enrolled in this trial. All patients received 3 sessions of full facial microdermabrasion and 3 sessions of either 5% retinoic acid peel or placebo after the microdermabrasion. Efficacy was measured using the Glogau scale. Patients were assessed at 2 weeks and 1, 2, and 6 months after treatment initiation. Results. The mean ± SD age of participants was 49.55 ± 11.61 years, and the majorities (73.3%) were female. Between 1 month and 2 months, participants reported slight but statistically significant improvements for all parameters (P < 0.001). In terms of adverse effects, there were statistically significant differences reported between the 5% retinoic acid peel groups and the control group (P < 0.001). The majority of adverse effects reported in the study were described as mild and transient. Conclusion. This study demonstrated that 5% retinoic acid peel cream combined with microdermabrasion was safe and effective in the treatment of photoaging in the Iranian population. This trial is registered with IRCT2015121112782N8.

Topical Retinoids: Therapeutic Mechanisms in the Treatment of Photodamaged Skin

Retinoids are a group of substances comprising vitamin A and its natural and synthetic derivatives. Retinoids were first used in dermatology in 1943 by Straumfjord for acne vulgaris. Since that time, retinoids have been utilized in the management and treatment of various skin conditions, including photoaging. Photodamage of the skin occurs as a consequence of cumulative exposure to solar ultraviolet radiation (UVR) and is characterized by deep wrinkles, easy bruising, inelasticity, mottled pigmentation, roughness, and telangiectasias. The mechanism of UVR-induced photodamage is multifactorial. Retinoids have demonstrated efficacy in the treatment of photoaged skin. Indeed, understanding the pathophysiology of photoaging and the molecular mechanism of retinoids can not only provide insight into the effects retinoids can exert in treating photoaging but also provide the rationale for their use in the treatment of other dermatologic diseases.

Skin Care

Aging skin is among the most common patient concerns in a facial plastic surgery practice. Ultraviolet (UV)-induced damage expedites the pace of intrinsic aging, resulting in many of the visible signs of aging, such as rough skin texture, pigmentation irregularities, fine and deep wrinkling, and inelasticity. Primary prevention of UV and environmental damage with proper skin care and the use of sunscreen are critical. There is great interest in topically applied products to reverse or delay the visible signs of photoaging. We discuss the most common topically applied agents for photoaging, reviewing their mechanisms and supporting evidence.

Test of association: which one is the most appropriate for my study?

BACKGROUND

Hypothesis tests are statistical tools widely used for assessing whether or not there is an association between two or more variables. These tests provide a probability of the type 1 error (p-value), which is used to accept or reject the null study hypothesis.

OBJECTIVE

To provide a practical guide to help researchers carefully select the most appropriate procedure to answer the research question. We discuss the logic of hypothesis testing and present the prerequisites of each procedure based on practical examples.

Statistical reporting in randomized controlled trials from the dermatology literature: a review of 44 dermatology journals

BACKGROUND

The validity of randomized controlled trials (RCTs) is determined by several statistical factors.

OBJECTIVES

To determine the level of recent statistical reporting in RCTs from the dermatology literature.

METHODS

We searched MEDLINE for all RCTs published between 1 May 2013 and 1 May 2014 in 44 dermatology journals.

RESULTS

Two hundred and ten articles were screened, of which 181 RCTs from 27 journals were reviewed. Primary study outcomes were met in 122 (67.4%) studies. Sample size calculations and beta values were reported in 52 (28.7%) and 48 (26.5%) studies, respectively, and nonsignificant findings were supported in only 31 (17.1%). Alpha values were reported in 131 (72.4%) of studies with 45 (24.9%) having two-sided P-values, although adjustment for multiple statistical tests was performed in only 16 (9.9% of studies with ≥ two statistical tests performed). Sample size calculations were performed based on a single outcome in 44 (86.3%) and multiple outcomes in six (11.8%) studies. However, among studies that were powered for a single primary outcome, 20 (45.5%) made conclusions based on multiple primary outcomes. Twenty-one (41.2%) studies relied on secondary/unspecified outcomes. There were no differences for primary outcome being met (Chi-square, P = 0.29), sample size calculations (P ≥ 0.55), beta values (P = 0.89), alpha values (P = 0.65), correction for multiple statistical testing (P = 0.59), two-sided alpha (P = 0.64), support of nonsignificant findings (Fisher's exact, P = 0.23) based on the journal's impact factor.

CONCLUSIONS

Levels of statistical reporting are low in RCTs from the dermatology literature. Future work is needed to improve these levels of reporting.