Development of an atrophic acne scar risk assessment tool.

BACKGROUND: Acne is a chronic dermatological disease predominantly afflicting young adults and is often associated with the development of scars. Acne scarring is usually avoidable when acne is managed early and effectively. However, acne patients often fail to seek early treatment. New and innovative tools to raise awareness are needed. OBJECTIVE: This study presents the development and assessment of a tool aiming to assess the risk of atrophic acne scars. METHODS: A systematic literature review of clinical risk factors for acne scars, a Delphi-like survey of dermatological experts in acne and secondary data analysis, were conducted to produce an evidence-based risk assessment tool. The tool was assessed both with a sample of young adults with and without scars and was assessed via a database cross-validation. RESULTS: A self-administered tool for risk assessment of developing atrophic acne scars in young adults was developed. It is a readily comprehensible and practical tool for population education and for use in medical practices. It comprises of four risk factors: worst ever severity of acne, duration of acne, family history of atrophic acne scars and lesion manipulation behaviours. It provides a dichotomous outcome: lower vs. higher risk of developing scars, thereby categorizing nearly two-thirds of the population correctly, with sensitivity of 82% and specificity of 43%. CONCLUSION: The present tool was developed as a response to current challenges in acne scar prevention. A potential benefit is to encourage those at risk to self-identify and to seek active intervention of their acne. In clinical practice, we expect this tool may help clinicians identify patients at risk of atrophic acne scarring and underscore their requirement for rapid and effective acne treatment.

4-Hexyl-1,3-phenylenediol, a nuclear factor-κB inhibitor, improves photodamaged skin and clinical signs of ageing in a double-blinded, randomized controlled trial.

BACKGROUND: The nuclear factor-κB (NF-κB) pathway is a key mediator of inflammation; however, few studies have examined the direct effects of NF-κB inhibition on the skin. OBJECTIVES: To investigate NF-κB activity in cultured human fibroblasts and to investigate the effects of 4-hexyl-1,3-phenylenediol (an NF-κB inhibitor) on elastin and collagen gene expression in vitro and on the clinical appearance of photodamaged skin. METHODS: The amount and activity of NF-κB in human fibroblasts obtained from donors (17-78 years old) was measured after transfection with a NF-κB reporter and a luciferase promoter system. The expression of extracellular matrix (ECM) genes was determined using quantitative polymerase chain reaction. Women with moderate skin photodamage were randomized to daily treatment with a topical lotion containing 4-hexyl-1,3-phenylenediol (n = 30) or vehicle (n = 29) for 8 weeks, with clinical assessments at baseline and weeks 2, 4 and 8. RESULTS: Fibroblasts obtained from donors older than 50 years had higher NF-κB activity compared with cells from younger donors; inhibition of the NF-κB pathway with 4-hexyl-1,3-phenylenediol enhanced the expression of ECM genes. In women, treatment for 8 weeks with 4-hexyl-1,3-phenylenediol significantly improved crow's feet fine lines, cheek wrinkles, age spots, mottled pigmentation and radiance compared with both the vehicle and baseline. Furthermore, treatment with 4-hexyl-1,3-phenylenediol resulted in a twofold greater clinical improvement in overall photodamage compared with the vehicle group. CONCLUSIONS: Inhibition of the proinflammatory NF-κB pathway resulted in increased expression of ECM proteins in vitro and significant clinical improvement in photodamaged skin.

Natural options for the management of hyperpigmentation.

Facial hyperpigmented disorders are a common complaint in the adult population of all races. First-line topical treatments are usually hydroquinone or topical retinoids, which can cause irritant reactions. The need for better tolerated, yet effective, skin lightening agents that could be utilized by a wider population has led to the investigation of several potential botanical/natural compounds. There are currently many topical cosmetic formulations claiming skin depigmenting effects. A few of the ingredients (e.g. soy) are supported not only by in vitro results but also by a body of controlled clinical efficacy studies; other ingredients, instead, are backed mostly by in vitro data and a few small uncontrolled clinical studies. In this review, we describe the most common natural ingredients used for skin depigmentation and their major published studies: soy, licorice extracts, kojic acid, arbutin, niacinamide, N-acetylglucosamine, COFFEEBERRY(™) and green tea.

A pilot methodology study for the photographic assessment of post-inflammatory hyperpigmentation in patients treated with tretinoin.

BACKGROUND: Post-inflammatory hyperpigmentation (PIH) is a common occurrence in patients with acne vulgaris, particularly in those with skin of colour. AIMS: A previous study has demonstrated the benefit of tretinoin (retinoic acid) in the treatment of PIH; however, there is currently no standard protocol to evaluate change in PIH following treatment. Based on these findings, we performed a pilot, exploratory, blinded, intraindividual-controlled methodology study that consisted of a photographic assessment protocol with facial mapping. MATERIALS AND METHODS: The study was based on a secondary analysis of a phase 4, community-based trial of 544 acne patients who were treated with tretinoin gel microsphere 0.04% or 0.1%. Only patients with Fitzpatrick types III-V (skin of colour) were included in the study; subjects with Fitzpatrick skin type VI were excluded because the photographic assessment did not allow for proper evaluation. RESULTS: Despite the small number of subjects evaluated (n=25), the results revealed consistent assessment of improvement in PIH between two independent graders (weighted κ=0.84). CONCLUSION: Further study with a larger population is recommended to validate the accuracy of this method.

Analyses of volatile organic compounds from human skin.

BACKGROUND: Human skin emits a variety of volatile metabolites, many of them odorous. Much previous work has focused upon chemical structure and biogenesis of metabolites produced in the axillae (underarms), which are a primary source of human body odour. Nonaxillary skin also harbours volatile metabolites, possibly with different biological origins than axillary odorants. OBJECTIVES: To take inventory of the volatile organic compounds (VOCs) from the upper back and forearm skin, and assess their relative quantitative variation across 25 healthy subjects. METHODS: Two complementary sampling techniques were used to obtain comprehensive VOC profiles, viz., solid-phase microextraction and solvent extraction. Analyses were performed using both gas chromatography/mass spectrometry and gas chromatography with flame photometric detection. RESULTS: Nearly 100 compounds were identified, some of which varied with age. The VOC profiles of the upper back and forearm within a subject were, for the most part, similar, although there were notable differences. CONCLUSIONS: The natural variation in nonaxillary skin odorants described in this study provides a baseline of compounds we have identified from both endogenous and exogenous sources. Although complex, the profiles of volatile constituents suggest that the two body locations share a considerable number of compounds, but both quantitative and qualitative differences are present. In addition, quantitative changes due to ageing are also present. These data may provide future investigators of skin VOCs with a baseline against which any abnormalities can be viewed in searching for biomarkers of skin diseases.

Colonisation rates of Streptococcus pyogenes and Staphylococcus aureus in the oropharynx of a young adult population.

There are very few reports on the rates of oropharyngeal colonisation by Streptococcus pyogenes and Staphylococcus aureus in young adults. The present study found colonisation rates of 9.6% and 26.2%, respectively. These rates are two-fold higher than historical rates, indicating that these organisms may be more prevalent than thought previously. This finding may have important clinical consequences in certain populations, and requires further investigation.

Experimental infections with group A streptococci in humans.

Experimental inoculation of 7 strains of Group A streptococci failed to result in either colonization or infection of normal intact skin of human volunteers. All strains rapidly died on normal skin; suppression of the resident microflora did not affect survival and no difference in survival was seen between inoculation on lipid-rich and lipid-poor body areas. Inoculation on skin damaged by superficial scarification resulted in localized infections when 1 x 10(4) or more organisms were inoculated into the wound by rubbing and covered with an impermeable plastic film. Intradermal inoculation resulted in localized cellulitis, regional lymphadenopathy, and fever. All strains were equally effective in producing localized infections in scarified skin.

Updated in vivo methods for evaluating topical antimicrobial agents on human skin.

Updated and expanded in vivo quantitative testing procedures to determine the efficacy of topical antimicrobial agents are presented. The occlusion test measures the ability of an agent to prevent the expansion of the resident microflora which occurs when an impermeable dressing is applied to the forearm. Measurements are made at 24 and 48 hr. The expanded flora test measures the ability of an agent to suppress a dense population of micro-organisms produced by expansion of the resident flora of the forearm by prior application of an impermeable occlusive dressing. Measurements are made at 6, 24 and 48 hr or after 10 min in the case for agents designed for immediate degerming. The persistence test measures the ability of an agent to establish a reservoir in skin and exert an antimicrobial effect up to 3 days after the last application of the test material. The ecological shift test determines any major alteration in cutaneous microbial ecology following several applications of the material under occlusive dressings. The serum inactivation test determines whether the presence of serum proteins interferes with antimicrobial activity.

Qualitative and quantitative changes in cutaneous bacteria associated with systemic isotretinoin therapy for acne conglobata.

Quantitative cultures in 40 patients treated with systemic isotretinoin demonstrated a significant reduction in the anaerobic diphtheroid, Propionibacterium acnes within one month of therapy and a continued suppression during 5 months of treatment. This reduction persisted after discontinuation of isotretinoin therapy despite a return of sebum excretion to pretreatment levels. Surface aerobic bacteria showed a significant reduction in the total number of organisms and significant qualitative changes. Gram negative bacteria were sharply reduced in both the anterior nares and skin while Staphylococcus aureus recovery increased significantly.

The relationship between bacteria and the abnormal follicular keratinization in acne vulgaris.

The structural organization and bacteriological profile of follicular casts and early comedones in prepuberal children were investigated. Follicular casts were present in all samples but were not as abundant as usually seen in older individuals with acne. When examined with the light microscope, all casts and comedones were composed of numerous layers of horny cells and sebum, but were devoid of bacteria. Neither follicular casts nor comedones yielded bacteria when cultured. Electron microscopy of the follicular casts revealed the presence of small round, discrete lipid droplets, and alternating dense and less dense lamellar configurations within the horny cells. Some horny cells closest to the sebum-filled lumen contained large lipid masses, resulting in "balloon-shaped" regions. Prepuberal follicular horny cells contained all of the abnormalities usually seen in follicular casts and biopsy material from acne patients, which suggests that these casts are potential comedones. These aberrations occurred in the complete absence of bacteria indicating that bacteria are not essential to the formation of casts or comedones. Furthermore, our findings indicate that bacteria play little if any role in the initial events of pathological keratinization.

Antibody titers to Propionibacterium acnes cell wall carbohydrate in nodulocystic acne patients.

In order to determine which structures in Propionibacterium acnes are most antigenic to severe acne patients, we studied the specificity of anti-P. acnes antibodies in serum from 15 nodulocystic acne patients and 5 normals. Complement fixation titers to P. acnes cell wall fractions were determined using guinea pig serum as a complement source. The mean titers of patients and normals to whole cells were 39.6 and 3 (p less than 0.1); to crude cell wall, 138 and 8 (p less than 0.01); and to protein and nucleic acid-free cell wall, 225 and 9.33 (p less than 0.001), respectively. The mean precipitin titer to P. acnes cytosol was 12.7 for patients and 0 for normals. Immunoelectrophoresis of cytosol from 8 P. acnes strains were developed with each of the 15 patient sera. A single broadly migrating anionic antigen was detected. The antigen was also present in P. acnes culture supernatants. Sephadex G-100 chromatography of cytosol revealed a single peak of antigenic reactivity at Mr = 100,000. Three patients' sera revealed a second weakly reacting antigen in the cytosol preparation. Twentyfold concentration of immunoglobulin from patient sera failed to reveal any other antigenic reactivities. The antigen was found to be resistant to nuclease, pronase, and lysozyme treatment; was precipitable with 70% ethanol; and was destroyed by sodium m-periodate--findings that are consistent with a carbohydrate structure.

Characterization of wax esters, triglycerides, and free fatty acids of follicular casts.

The abnormal impactation of a sebaceous follicle (the follicular cast) has been implicated as the preclinical lesion of acne vulgaris. We have characterized the lipid composition of these structures in the first of a series of studies aimed at the identification of sebaceous lipids that may be associated and/or responsible for the initiation of clinical lesions. The lipid composition of follicular casts was analyzed using thin-layer chromatography, gas chromatography, and mass spectrometry. The mean wet weight of the casts was 24.7 +/- 8.6 micrograms and 7.2 +/- 5.6 micrograms (29.4 +/- 13.5%) was lipid. Cholesterol (3.8 +/- 1.8%) and cholesterol esters (2.0 +/- 2.7%), wax esters (25.3 +/- 6.0%), squalene (19.9 +/- 6.6%), triglycerides (16.1 +/- 7.8%), and free fatty acids (33.0 +/- 10.0%) were all present in cast lipid. Fatty acids of the free fatty acid and triglyceride fraction ranged from C12 to C22. The major components of the free fatty acids were C14:0, C15:0, C16:1, C16:0, 2-me-C17:0, and C18:1. In the triglyceride fraction C14:0, C15:0, C16:0, C18:1, and C18:0 dominated. The free fatty acids were composed of normal saturated (50.6%), normal unsaturated (32.8%), and monomethyl branched (16.6%) acids; the triglyceride fraction contained (86.3%) normal saturated (10.8%), normal unsaturated, and (3.0%) monomethyl branched fatty acids. Wax esters of follicular casts included esters ranging from C26:1 to C38:0. Saturated esters predominated and both odd- and even-numbered esters were present. The most abundant fatty acid moieties of these esters were C16:0 and C15:0, whereas C14:0, C17:0, and C20:0 were the most frequently detected alcohol moieties.

Measurement of sebum output using a lipid absorbent tape.

A sebum absorbent tape is introduced as a reproducible and convenient method for estimation of sebaceous gland output. We have tested the reproducibility of this method by serial measurements of sebum excretion rates (SER) of 10 individuals over a 6-week period, and in addition we have correlated this method with the conventional hexane extraction technique. The sebum absorbent tapes gave consistent values for the SERs, and within subjects variation over the 6-week period was statistically nonsignificant. A coefficient of variation for the tapes was calculated as 16.25 +/- 6.78% based on these serial measurements. Furthermore, the amount of total lipid collected using this technique (n = 16) correlated well with the hexane extraction technique, r = 0.89. Free fatty acids (r = 0.87), triglycerides (r = 0.92), wax and cholesterol esters (r = 0.83), and squalene (r = 0.88) also showed a good correlation. Cholesterol occasionally suffered from incomplete separation on thin-layer chromatograms; however, a sample cleanup procedure was developed for tape extracts that removed interfering materials and allowed complete separation of all sebum components.

Polymorphonuclear leukocyte lysosomal release in response to Propionibacterium acnes in vitro and its enhancement by sera from inflammatory acne patients.

Propionibacterium acnes cells were tested for the ability to trigger lysosomal hydrolase release from human polymorphonuclear leukocytes. Representative strains of P. acnes serotype I and II failed to stimulate lysosomal release in the absence of serum. P. acnes growth culture supernatants failed to trigger release under any test condition. Addition of fresh or heat-inactivated human serum resulted in lysosomal hydrolase release directly proportional to the number of P. acnes/PMN. Pooled sera from acne patients, with a high anti-P. acnes titer stimulated release to P. acnes. Preabsorption of this reagent with P. acnes cells reduced the anti-P. acnes titer and produced 93.37 +/- 11.49% inhibition of lysosomal enzyme release compared to unabsorbed anti-serum. Electron microscopy indicated that P. acnes was readily phagocytosed by PMNs when fresh or heated serum was present.

Propionibacterium levels in patients with and without acne vulgaris.

Propionibacterium species were quantified on the foreheads and cheeks of persons with and without acne in three age groups: 11 to 15, 16 to 20, and 21 to 25. Propionibacteria were virtually absent in the pubertal non-acne group compared to a geometric mean density of 114,800 per sq cm in the acne group. A similar sharp difference existed between the acne subjects and normals in the age range of 16 to 20 years: 85,800 organisms per sq cm compared to 588 per sq cm. Patients with acne and normal subjects over age 21 showed no difference in Propionibacterium levels. In acne patients, while there was a trend for lower levels, no significant difference was seen as the severity of inflammation increased.

Age-related changes in the resident bacterial flora of the human face.

Quantitative levels of resident aerobic and anaerobic bacteria of the face, show a characteristic age-related pattern. The density of anaerobic diptheroids and surface aerobic micrococci is higher in infancy than in early childhood. At puberty the quantity of organisms increases, with significantly higher levels achieved in late adolescence. Maximum counts are attained in early adulthood and remain constant until old age when a trend toward lower numbers occurs. These changes seem to correlate with the production of sebum.

Quantitative microbiology of the scalp in non-dandruff, dandruff, and seborrheic dermatitis.

The composition of the scalp microflora was assessed quantitatively in normal individuals and in patients with dandruff and seborrheic dermatitis, disorders characterized by increasing scaling. Three organisms were constantly found: (1) Pityrosporum, (2) aerobic cocci, and (3) Corynebacterium acnes. Pityrosporum (mainly Pityrosporum ovale) made up 46% of the total microflora in normals, 74% in dandruff, and 83% in seborvheic dermatitis. The geometric mean number of organisms per cm-2 in non-dandruff subjects was 5.04 times 10-5; 9.22 times 10-5 in dandruff subjects; and 6.45 times 10-5 in those with seborrheic dermatitis. The cocci were dominantly Baird-Parker type SII and no quantitative or qualitative change occurred in the scaling disorders. C. acnes comprised 26% of the flora on the normal scalp, 6% in dandruff, and only 1% in seborrheic dermatitis. These results differ significantly from previous reports which describe a much more complex microflora and suggest an etiologic role for microorganisms in dandruff.

The microbiology of the human axilla and its relationship to axillary odor.

The axillary microflora of 229 subjects was characterized quantitatively and the results correlated with whether the odor was pungent body odor or instead a faint "acid odor". The axillary flora was found to be a stable mixture of Micrococcaceae, aerobic diphtheroids and Propionibacteria. Significantly higher numbers of bacteria were recovered from the axilla of those with pungent axillary odor than in those with acid odor. Aerobic diphtheroids in high numbers were recovered in all subjects having typical body odor. These included lipophilic as well as large-colony diphtheroids. When droplets of apocrine sweat placed on the forearm were inoculated with various bacteria which reside in the axilla, only diphtheroids generated typical body odor. Cocci produced a sweaty odor attributable to isovaleric acid.