Update on etiopathogenesis and treatment of Acne.

Acne, the most common skin disease, is a disorder of pilosebaceous units that affects adolescents mainly and adults occasionally. The pathogenesis is multifactorial. Besides genetic predisposition, other major factors include the action of androgens, pro-inflammatory lipids acting as ligands of peroxisome proliferator-activated receptors in the sebocytes, toll-like receptor-2 acting on keratinocytes, recognition of pathogen-associated molecular patterns, cytokines, chemokines, inflammasomes, neuroendocrine regulatory mechanisms, diet and other pro-inflammatory targets implicated in the activation of immune detection and response. Most of these factors converge on mammalian target of rapamycin complex1 (mTORC1) activation which is further enhanced by the nutrient signaling of Western diet. This multitude of pathogenic factors has led to a new armamentarium of drugs for the treatment of acne. Topical anti-androgens, insulin-like growth factor-1 inhibitors, peroxisome proliferator-activated receptor-modulators, acetylcholine inhibitors, topical retinoic acid metabolism-blocking agents, vitamin D analogues, antimicrobial peptides, interleukin-1α and interleukin-1ß blockers and immunotherapy are some of the novel treatment options.

A clinico-epidemiological study of adult acne: is it different from adolescent acne?

BACKGROUND: Although acne is usually recognized as an adolescent skin disorder, the prevalence of adults with acne is increasing. There is surprisingly a paucity of data on the prevalence and clinical features of postadolescent acne in the adult Indian population. AIMS: The clinical and epidemiological data of adult acne were evaluated with a view to establishing possible contributing etiological factors and observing whether clinical features differ from adolescent acne. METHODS: Patients over the age of 25 years presenting with acne in a tertiary care hospital were included in the study. A detailed history and examination was carried out, with a stress on aggravating factors. Hormonal imbalances were investigated in females with alopecia, obesity, hirsutism and menstrual irregularity. Severity of acne and complications like scarring and psychological stress were included. RESULTS: Out of 280 patients included in the study 82.1% were women and 17.9% were men. The mean age of the patients was 30.5 years. Persistent acne was observed in 73.2%, while it was late onset in 26.8%. Majority of the patients had inflammatory papular acne (55%), whereas comedonal acne was the least common (6%). Most common predominant site of involvement was cheek (81%), followed by chin (67%), and mandibular area (58.3%). Family history of acne was present in 38.6%. Premenstrual flare was seen in 11.7% of female patients, obesity in 6.4%, hirsutism in 5.7% and alopecia in 1.8%, but raised laboratory markers of hyperandrogenism were observed in only 3.08%. Scarring was observed in a majority of patients (76.4%) and psychological stress in 52.8% patients. CONCLUSION: Adult acne is predominant in women, and as compared to adolescent acne is more inflammatory, with involvement of the cheeks and lower half of the face, while comedones are rare. Facial scarring occurs in a majority and stress is common, which emphasizes that adult acne should not be neglected.

Efficacy of low-dose isotretinoin in acne vulgaris.

Low-dose isotretinoin (0.5 mg/kg/day) is a mode of therapy for mild to moderate grades of acne. We analyzed the various trials of this mode of therapy with or without combination with topical agents. We also statistically analyzed the results, efficacy and relapse rates of standard therapy in comparison with the low-dose therapy. Our analysis of the data revealed that the efficacy and relapse rates of low-dose isotretinoin in mild to moderate grades of acne is comparable with the standard regimen (1 mg/kg/day), which is given in the severe grade of acne vulgaris. Thus, the grade of acne vulgaris should dictate the dose of administration of isotretinoin and the standard dose of 1 mg/kg/day is an unnecessary overtreatment for mild to moderate grades of acne.

Clindamycin lotion alone versus combination lotion of clindamycin phosphate plus tretinoin versus combination lotion of clindamycin phosphate plus salicylic acid in the topical treatment of mild to moderate acne vulgaris: a randomized control trial.

BACKGROUND: Acne vulgaris is a common skin disease that affects 85% to 100% of people at some time during their lives. It is characterized by noninflammatory follicular papules or comedones and by inflammatory papules, pustules, and nodules in its more severe forms. AIMS: To compare the efficacy of combination treatment of clindamycin+salicylic acid, versus clindamycin+tretinoin versus clindamycin alone in the treatment of the mild-to-moderate acne vulgaris. METHODS: This was a single-blinded, randomized clinical trial.Forty-two female patients (age range: 15-25 years) with mild-to-moderate acne vulgaris were selected randomly and subsequently randomized to 3 groups. Group A patients were treated with 1% clindamycin lotion (C lotion) twice daily. Group B patients were treated with 1% clindamycin+0.025% tretinoin lotion once nightly (CT lotion). Group C patients were treated with 1% clindamycin+2% salicylic acid lotion twice daily (CS lotion) for 12 weeks. For comparison of efficacy of these treatments, and regarding the skewed distribution of the data, Kruskal-Wallis Test and Mann-Whitney U test were used. SPSS software was used for statistical analysis. RESULTS: There was a significant difference between 3 types of treatment in the respect of the total lesion count (TLC) improvement (P = 0.039). The efficacy of treatment on Acne Severity Index (ASI) was maximum for CS lotion (81.80% reduction in ASI). CT lotion reduced ASI by as much as 73.73% during 12 weeks of treatment. The efficacy of C lotion was calculated to be 37.87% in the reduction of ASI. CONCLUSIONS: Our data suggested that the efficacy of CS lotion was significantly more than C lotion with respect to the TLC and ASI, although there was no significant difference between CS and CT lotion.

Azathioprine versus betamethasone for the treatment of parthenium dermatitis: a randomized controlled study.

BACKGROUND: Parthenium hysterophorus is the commonest cause of airborne contact dermatitis in India. Azathioprine has been shown to be effective and safe in parthenium dermatitis, but there are no reports of comparison of steroids and azathioprine in this condition. AIMS: To study the therapeutic efficacy of azathioprine versus betamethasone in patients having contact dermatitis to parthenium and compare the side effects of the drugs. METHODS: Fifty-five patients of airborne contact dermatitis to parthenium were randomly assigned to treatment with azathioprine 100 mg daily (group A) or betamethasone 2 mg daily (group B), for 6 months in a blinded manner. The patients were evaluated every month for 6 months to determine the response to treatment and side effects and then further followed up for another 6 months to determine any relapse. RESULTS: There were 26 patients in group A and 29 in group B, of which 20 patients of group A and 21 of group B completed the study. Nineteen (95%) patients in group A and all 21 (100%) patients in group B had an excellent response (complete remission) to treatment (P=0.0156 vs. 0.0005). The patients in group B, however, had more adverse effects (Fisher exact, P

Standard guidelines of care for acne surgery.

UNLABELLED: Acne surgery is the use of various surgical procedures for the treatment of postacne scarring and also, as adjuvant treatment for active acne. Surgery is indicated both in active acne and post-acne scars. PHYSICIANS' QUALIFICATIONS: Any Dermatologist can perform most acne surgery techniques as these are usually taught during postgraduation. However, certain techniques such as dermabrasion, laser resurfacing, scar revisions need specific "hands-on" training in appropriate training centers. FACILITY: Most acne surgery procedures can be performed in a physician's minor procedure room. However, full-face dermabrasion and laser resurfacing need an operation theatre in a hospital setting. ACTIVE ACNE: Surgical treatment is only an adjunct to medical therapy, which remains the mainstay of treatment. Comedone extraction is a process of applying simple mechanical pressure with a comedone extractor, to extract the contents of the blocked pilosebaceous follicle. Superficial chemical peel is a process of applying a chemical agent to the skin, so as to cause controlled destruction of the epidermis leading to exfoliation. Glycolic acid, salicylic acid and trichloroacetic acid are commonly used peeling agents for the treatment of active acne and superficial acne scars. CRYOTHERAPY: Cryoslush and cryopeel are used for the treatment of nodulocystic acne. Intralesional corticosteroids are indicated for the treatment of nodules, cysts and keloidal acne scars. Nonablative lasers and light therapy using Blue light, non ablative radiofrequency, Nd:YAG laser, IPL (Intense Pulsed Light), PDT (Photodynamic Therapy), pulse dye laser and light and heat energy machines have been used in recent years for the treatment of active inflammatory acne and superficial acne scars. Proper counseling is very important in the treatment of acne scars. Treatment depends on the type of acne scars; a patient may need more than one type of treatment. Subcision is a treatment to break the fibrotic strands that tether the scar to the underlying subcutaneous tissue, and is useful for rolling scars. Punch excision techniques such as punch excision, elevation and replacement are useful for depressed scars such as ice pick and boxcar scars. TCA chemical reconstruction of skin scars (CROSS) (Level C) is useful for ice pick scars. Resurfacing techniques include ablative methods (such as dermabrasion and laser resurfacing), and nonablative methods such as microdermabrasion and nonablative lasers. Ablative methods cause significant postoperative changes in the skin, are associated with significant healing time and should be performed by dermatosurgeons trained and experienced in the procedure. Fillers are useful for depressed scars. Proper case selection is very important in ensuring satisfactory results.

Standard guidelines of care for chemical peels.

UNLABELLED: Chemical peeling is the application of a chemical agent to the skin, which causes controlled destruction of a part of or the entire epidermis, with or without the dermis, leading to exfoliation and removal of superficial lesions, followed by regeneration of new epidermal and dermal tissues. Indications for chemical peeling include pigmentary disorders, superficial acne scars, ageing skin changes, and benign epidermal growths. Contraindications include patients with active bacterial, viral or fungal infection, tendency to keloid formation, facial dermatitis, taking photosensitizing medications and unrealistic expectations. PHYSICIANS' QUALIFICATIONS: The physician performing chemical peeling should have completed postgraduate training in dermatology. The training for chemical peeling may be acquired during post graduation or later at a center that provides education and training in cutaneous surgery or in focused workshops providing such training. The physician should have adequate knowledge of the different peeling agents used, the process of wound healing, the technique as well as the identification and management of complications. FACILITY: Chemical peeling can be performed safely in any clinic/outpatient day care dermatosurgical facility. PREOPERATIVE COUNSELING AND INFORMED CONSENT: A detailed consent form listing details about the procedure and possible complications should be signed by the patient. The consent form should specifically state the limitations of the procedure and should clearly mention if more procedures are needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures, presentations, and personal discussions. The need for postoperative medical therapy should be emphasized. Superficial peels are considered safe in Indian patients. Medium depth peels should be performed with great caution, especially in dark skinned patients. Deep peels are not recommended for Indian skin. It is essential to do prepeel priming of the patient's skin with sunscreens, hydroquinone and tretinoin for 2-4 weeks. ENDPOINTS IN PEELS: For glycolic acid peels: The peel is neutralized after a predetermined duration of time (usually three minutes). However, if erythema or epidermolysis occurs, seen as grayish white appearance of the epidermis or as small blisters, the peel must be immediately neutralized with 10-15% sodium bicarbonate solution, regardless of the duration of application of the peel. The end-point is frosting for TCA peels, which are neutralized either with a neutralizing agent or cold water, starting from the eyelids and then the entire face. For salicylic acid peels, the end point is the pseudofrost formed when the salicylic acid crystallizes. Generally, 1-3 coats are applied to get an even frost; it is then washed with water after 3-5 minutes, after the burning has subsided. Jessner's solution is applied in 1-3 coats until even frosting is achieved or erythema is seen. Postoperative care includes sunscreens and moisturizers Peels may be repeated weekly, fortnightly or monthly, depending on the type and depth of the peel.

Acne neonatorum in the eastern Saudi Arabia.

BACKGROUND: Acne neonatorum (AN) is characterized by a facial eruption of inflammatory and noninflammatory acne lesions in a neonate. Hyperactivity of sebaceous glands, stimulated by neonatal androgens, is implicated in its pathogenesis. AIM: To elucidate the clinical profile of AN in eastern Saudi Arabia. METHODS: All patients diagnosed with AN in King Fahd Hospital of the University in Khobar, Saudi Arabia, during the year 2005 were evaluated clinically. RESULTS: AN was diagnosed in 26 patients (male/female ratio 1:1). The lesions included mainly facial comedones (30.8%); papules and pustules (15.3% each); and combination of papules, pustules, and cysts (53.4%). CONCLUSION: All patients recovered spontaneously. In 50% of the cases, one of the parents reported having had acne vulgaris during adolescence. Hereditary factors seem to play a significant role in our series.

Oral isotretinoin is as effective as a combination of oral isotretinoin and topical anti-acne agents in nodulocystic acne.

BACKGROUND: Due to the late introduction of oral isotretinoin, there is only a single report of the use of this drug from India. AIMS: To evaluate the efficacy, acceptability and side effects of oral isotretinoin in Indian conditions and to compare the efficacy of oral isotretinoin monotherapy with that of a combination of oral isotretinoin and topical anti-acne agents. METHODS: Sixty clinically diagnosed patients of nodulocystic acne were divided into two groups of 30 each. Patients in group A were administered oral isotretinoin 20 mg twice a day along with topical clindamycin (1%) and adapalene (0.1%) for 24 weeks. Patients in group B were given only oral isotretinoin. An objective clinical scoring was repeated every four weeks and patients were followed up for six months on completion of treatment. RESULTS: Out of the 60 patients, 50 completed the treatment and 35 completed the follow-up at six months. The mean pretreatment score in group A came down from 12.8 to 1.24 and in group B from 12.4 to 1.48, thus showing a 90.55% and 88% reduction in pretreatment scores respectively. There was no statistical difference in the results obtained from the two groups. Side effects were common but minor in nature. CONCLUSION: Isotretinoin produces gratifying results in patients of nodulocystic acne in Indian conditions. Addition of topical antiacne agents does not alter the final outcome. This addition is well tolerated but requires careful monitoring.

The efficacy of 5% topical tea tree oil gel in mild to moderate acne vulgaris: a randomized, double-blind placebo-controlled study.

BACKGROUND: Finding an effective treatment for acne that is well tolerated by the patients is a challenge. One study has suggested the efficacy of tea tree oil in treatment of the acne vulgaris. AIM: To determine the efficacy of tea tree oil in mild to moderate acne vulgaris. METHODS: This was a randomized double-blind clinical trial performed in 60 patients with mild to moderate acne vulgaris. They were randomly divided into two groups and were treated with tea tree oil gel (n=30) or placebo (n=30). They were followed every 15 days for a period of 45 days. Response to treatment was evaluated by the total acne lesions counting (TLC) and acne severity index (ASI). The data was analyzed statistically using t-test and by SPSS program. RESULTS: There were no significant differences regarding demographic characteristics between the two groups. There was a significant difference between tea tree oil gel and placebo in the improvement of the TLC and also regarding improvement of the ASI. In terms of TLC and ASI, tea tree oil gel was 3.55 times and 5.75 times more effective than placebo respectively. Side-effects with both groups were relatively similar and tolerable. CONCLUSION: Topical 5% tea tree oil is an effective treatment for mild to moderate acne vulgaris.

Dermatoses do pavilhäo auricular / External ear dermatosis

Apresentamos uma atualizaçäo sobre as dermatoses que ocorrem no pavilhäo auricular. Propomos uma classificaçäo em sete grupos e realizamos uma sucinta descriçäo clínica de cada uma das 84 entidades catalogadas, de forma didática, com a finalidade de auxiliar o médico, sobretudo o clínico geral, o dermatologista e o otorrinolaringologista, no diagnóstico de tais patologias.