Spironolactone and cimetidine in treatment of acne

In an open therapeutic trial, 50 patients with acne vulgaris were randomly allocated to one of two groups. One group received spironolactone 100 mg daily and the other cimetidine 1.6 g daily for 12 weeks. Clinical severity of acne and sebum excretion decreased significantly at the end of the trial with both drugs, but significantly more with spironolactone. Mean serum levels of testosterone, androstenedione and dehydroepiandrosterone-sulfate decreased significantly with spironolactone but showed no change with cimetidine. Our data suggest that spironolactone may be useful as antiandrogen in the short term therapy of acne vulgaris.     

Topical retinoids in the treatment of acne vulgaris

Topical retinoids are highly effective in the treatment of both comedonal and inflammatory lesions of acne and are a vital part of almost any acne regimen. A better understanding of the structure and function of this class of medications has led to better outcomes in treatments of patients with acne. In this article, the structure and function of retinoids is first reviewed. Then, the clinical effectiveness and tolerability of each of the available topical retinoid formulations is summarized.     

Topical ALA-photodynamic therapy for the treatment of acne vulgaris

Topical aminolevulinic acid is converted into a potent photosensitizer, protoporphyrin, in human hair follicles and sebaceous glands. Photodynamic therapy with topical aminolevulinic acid was tested for the treatment of acne vulgaris, in an open-label prospective human study. Each of 22 subjects with acne on the back was treated in four sites with aminolevulinic acid plus red light, aminolevulinic acid alone, light alone, and untreated control. Half of the subjects were treated once; half were treated four times. Twenty percent topical aminolevulinic acid was applied with 3 h occlusion, and 150 J per cm2 broad-band light (550-700 nm) was given. Sebum excretion rate and auto-fluorescence from follicular bacteria were measured before, and 2, 3, 10, and 20 wk after, treatment. Histologic changes and protoporphyrin synthesis in pilosebaceous units were observed from skin biopsies. Aminolevulinic acid plus red light caused a transient acne-like folliculitis. Sebum excretion was eliminated for several weeks, and decreased for 20 wk after photodynamic therapy; multiple treatments caused greater suppression of sebum. Bacterial porphyrin fluorescence was also suppressed by photodynamic therapy. On histology, sebaceous glands showed acute damage and were smaller 20 wk after photodynamic therapy. There was clinical and statistically significant clearance of inflammatory acne by aminolevulinic acid plus red light, for at least 20 wk after multiple treatments and 10 wk after a single treatment. Transient hyperpigmentation, superficial exfoliation, and crusting were observed, which cleared without scarring. Topical aminolevulinic acid plus red light is an effective treatment of acne vulgaris, associated with significant side-effects. Aminolevulinic acid plus red light causes phototoxicity to sebaceous follicles, prolonged suppression of sebaceous gland function, and apparent decrease in follicular bacteria after photodynamic therapy. Potentially, aminolevulinic acid plus red light may be useful for some patients with acne.     

Topical therapy in acne

The majority of acne patients will receive a topical treatment either as monotherapy or in combination with a systemic drug therapy depending on the severity of the disease. The currently available topical agents affect at least one of the four main pathogenetic factors responsible for the development of acne, i.e. hyperkeratosis, microbial colonization, immune response and inflammation. Retinoids, azelaic acid, benzoyl peroxide and topical antibiotics represent the spectrum of the established and proven topical agents. Presumably, antiandrogenic agents will soon be available for topical use to treat the important factor of seborrhea. In general, by combining topical agents, their potency can be enhanced and toxicity diminished. Unfortunately, bacterial resistances are beginning to emerge as a significant problem.     

Topical aminolevulinic acid-photodynamic therapy for the treatment of acne vulgaris

BACKGROUND: Photodynamic therapy (PDT) is useful for the treatment of epidermal neoplasia but may also have use in the treatment of inflammatory dermatoses. The purpose of this study was to evaluate the safety and efficacy of PDT in the treatment of acne on the face. METHODS: Eight patients with mild-to-moderate acne vulgaris on the face were treated with one session of topical aminolevulinic acid (ALA)-PDT using a red light. Each patient's face was divided into two areas (right side and left side) for ALA-PDT and untreated control. Twenty percent topical ALA was applied with 4 h occlusion, and 18 J/cm(2) red light (630+/-63 nm) was administered. Each patient's acne was visually assessed by a spot count of both inflamed and non-inflamed lesions at baseline and at 1, 3, and 6 months following PDT. RESULTS: At 1, 3, and 6 months, the mean percentage reduction in inflamed lesions count was 27.6%, 37.9%, and 41.9%, respectively, in the ALA-PDT-treated area, whereas in the control area, it was 8.0%, 14.7%, and 15.4%, respectively, compared with the baseline. This showed a higher reduction of a spot count of inflamed lesions in the ALA-PDT-treated area, which was statistically significant (P<0.05). There was a slightly higher reduction of a spot count of non-inflamed lesions in the ALA-PDT-treated area, which was statistically not significant (P>0.05). The adverse effects were minimal. CONCLUSION: ALA-PDT with red light was found to be effective in the reduction of the number of inflamed lesions in patients with mild-to-moderate acne vulgaris, with no significant short-term adverse effects.     

Topical vitamin A acid in the treatment of acne vulgaris

Summary A controlled non-blind multicenter trial was conducted in 211 acne patients to test the activity of topical retinoic acid against sulfur-resorcinol—salicylic acid and placebo. Uniform evaluation criteria were used. After 8 weeks' treatment in comparable groups of patients, retinoic acid proved to be superior to the standard and to the placebo. The difference was statistically significant.Side effects were present in a number of patients treated with the active substances and with the placebo (mainly erythema), but rarely was the treatment discontinued.

---

Zusammenfassung Um die lokale Wirksamkeit von Retinoic Säure im Vergleich zu Schwefel-Resorzin — Salizylsäure und Placebo zu testen, wurde im Rahmen einer multizentrischen Prüfung bei 211 Acne-Patienten eine kontrollierte Untersuchung durchgeführt. Es kamen einheitliche Auswertungskriterien zur Anwendung. Nach einer 8wöchigen Behandlung mit vergleichbaren Patientengruppen hat sich die Retinoic-Säure dem Vergleichspräparat und dem Placebo als überlegen gezeigt. Der Unterschied war statistisch signifikant.Nebenwirkungen waren in einer Anzahl von Patienten sei es unter der Behandlung mit den Wirksubstanzen als auch mit Placebo vorhanden (hauptsächlich Erytheme); eine Unterbrechung der Behandlung war jedoch nur selten notwendig.

     

Topical treatment in acne: current status and future aspects

During the last 20 years, the number of topical and systemic drugs for the treatment of acne vulgaris has been enriched. Topical drugs on the one hand have been newly discovered or further developments of already available agents such as in the group of retinoids or galenic formulation have improved efficacy or local tolerance. Topical retinoids are a mainstay in acne treatment since 1962. All-trans retinoic acid was the first and is still in use. Its irritative potential has led to the new galenics, i.e. incorporation in microsponges and in propolyomers, which increased the tolerability significantly. The isomer of tretinoin, isotretinoin, has the same clinical efficacy, but also a lower irritancy. A real breakthrough was adapalene, a retinoid-like agent, with a different retinoid receptor-binding profile, but in addition to the same clinical efficacy on inflammatory and non-inflammatory acne lesions compared to tretinoin, a better tolerability and, therefore, compliance. Unfortunately, over the past years topical retinoids have been less used in inflammatory acne than they should be, taking the the mechanisms of action into account. Topical antimicrobials, in particular topical antibiotics, should be used less often than in the past and only for short periods to avoid the development of resistances. It seems better to combine those agents with topical retinoids, with BPO or with azelaic acid to enhance the efficacy and slow down the development of resistance. BPO is still the gold standard for papular-pustular acne of mild-to-moderate type in concentrations of 2-5%. Azelaic acid is an alternative with efficacy on the comedo and is antibacterial without development of resistances. Finally, the physical removal by electrocautery or CO(2) laser of multiple densely packed closed comedones, macrocomedones and microcysts is necessary to enhance the efficacy of topical comedolytic agents and to speed up the therapeutic results. Photodynamic therapy has not yet been proven efficacious in controlled studies. Blue and red light can probably be used in association with local agents but enhancement of the irritative potential of topical and systemic agents has to be considered.     

Topical dermocosmetics and acne vulgaris

Acne is a highly common skin disease especially among teenagers. Modern acne treatments are based also on the use of moisturizers, cleansers and sunscreens. In choosing the right cleanser, it is important to consider some aspects: the interaction between skin type and the cleanser, the optimal time and method of cleaning and the cosmetic perception of the patient. The aim of our review is to highlight the importance of choosing the most suitable topical dermocosmetics for the different skin types, as well as the most effective timing and method to combine dermocosmetics with the standard acne treatment. A search in literature for selected key words was performed using PubMed. Additional papers were identified based on author expertise. Treatment of acne patients should include education for proper daily skin hygiene, including protection from environmental damage. However, given the low number of clinical studies on cleansers, it is difficult to make reliable recommendations. The correct choice and use of topical dermocosmetics are fundamental in the management of acne patients. Daily use of moisturizers, cleansers and sunscreens can reduce both inflammatory and non‐inflammatory acne lesion counts and may be helpful for acne treatment if combined with specific drugs.     

Topical erythromycin for acne vulgaris

The clinical response of topical erythromycin (1%) in a new penetrative vehicle was evaluated in a double-blind investigation on 28 patients with severe and moderate acne vulgaris. The verum preparation was superior to the placebo in 21 of the patients, while in 4 the reverse was true and in 3 no differences were seen. It is thus obvious that topical erythromycin in the penetrative vehicle is a potent agent for acne treatment. The risk for development of resistant Propionibacterium acnes strains must, however, be considered in topical as well as in systemic antibiotic therapy of acne vulgaris.     

5-氨基酮戊酸光动力疗法治疗痤疮

目的 探索5-氨基酮戊酸光动力疗法（ALA-PDT）治疗中、重度痤疮的安全性及有效性。方法 将70例中、重度痤疮患者随机分为两组。治疗组35例,给予ALA-PDT治疗,每2周治疗1次,共治疗1 ~ 3次;对照组35例,口服异维A酸胶囊治疗,共服用6周。在治疗第2、4、6周对两组患者进行疗效判断和比较。结果 35例接受ALA-PDT治疗的患者经过1 ~ 3次治疗后（第2、4、6周）,总有效率达97.1%;对照组于6周时总有效率为80.0%,治疗组疗效明显优于对照组（P < 0.05）。另外,ALA-PDT组复发程度明显轻于对照组,且病情控制时间明显延长。ALA-PDT组有个别患者局部出现暂时性色素沉着,但无瘢痕发生。结论 ALA-PDT是一种简单、高效、不良反应轻微的治疗中、重度痤疮的新疗法。     

Topical v systemic agent treatment for papulopustular acne. A cost-effectiveness analysis

We used cost-effectiveness analysis to compare the costs, risks, and benefits of two strategies for clearing papulopustular acne; topical therapy alone as initial therapy or a combination of systemic antibiotics and topical agents used at the first visit. Patients treated with combination therapy had fewer weeks of morbidity from acne, and lower dollar costs but have a greater risk of side effects. If the topical therapy alone was chosen to reduce the risk of side effects in a population of patients there would be an additional $764 in costs and 238 weeks of morbidity from acne to avert a single additional instance of side effects. Initial treatment of papulopustular acne with combined oral antibiotics and topical agents thus seems to be cost-effective. After clearing is achieved, maintenance therapy with topical agents should be considered.     

Topical treatment of acne vulgaris with erythromycin and benzoylperoxide (author's transl)

16 healthy persons were treated for 7 weeks with a 1% erythromycin containing ointment. Another 25 persons (among them 10 acne patients) were treated during the same period of time with a combination therapy consisting of erythromycin (1% in an unspecific ointment base) and benzoylperoxide (5% in a gel base). The combined therapy reduces the micrococcaceae in the pilosebaceous ducts significantly. On the other side the therapy consisting only of erythromycin causes only initially a decrease and then an increase in the number of micrococcaceae. Induction of resistance to erythromycin is in both cases considerable. In both cases a reduction of propionibacteria which are most important for the pathogenesis of acne must be assumed. Because of the probable pathogenetic role of staphylococci in acne vulgaris an additional improvement of the therapeutical results can be expected in the case of combination therapy. In vitro experiments demonstrate further that an erythromycin treatment leads to considerable resistance induction in S. aureus, regardless of whether it is applied alone or in combination with benzoyl peroxide.     

Topical isotretinoin vs. topical retinoic acid in the treatment of acne vulgaris

This is a clinical, prospective, and longitudinal study comparing the efficacy and incidence of averse effects of topical isotretinoin against those of topical retinoic acid in the treatment of acne vulgaris. The 30 participants were recruited from the patients attending the outpatient clinic of the Department of Dermatology of “Dr Manuel Gea González” General Hospital in Mexico City. They belonged to either sex and any race, their ages ranged between 13 and 30 years, and they presented with 15 to 100 facial inflammatory lesions (papulo-pustules) and/or 15 to 100 noninflammatory lesions (comedones) and no more than three nodulo-cystic lesions. The criteria of exclusion were as follows: pregnancy or lactation, systemic treatment with steroids, antibiotics, antiandrogens, or oral retinoids in the preceding 24 months, treatment with ultraviolet radiation, hypersensitivity to retinoids, or a severe systemic illness. From 44 interviewed patients, 14 were excluded. A detailed clinical history was obtained from the remaining individuals, the degree of seborrhea was recorded, and acne lesions were counted. Each patient received either isotretinoin gel 0.05% or retinoic acid cream 0.05%. The patients were instructed to wash their faces in the mornings and evenings with a neutral soap, and to apply the product after the evening cleansing. The patients were examined again after 2, 4, 8, and 12 weeks of treatment and, at each appointment, the number of lesions was recorded and the severity of acne was graded according to the classification of Plewig and Kligman.¹ The seriousness of the adverse effects, such as stinging, pruritus, erythema, xerosis, and desquamation, was evaluated blindly by an investigator who did not know what group the patient belonged to, and graded as 1=mild, 2=moderate, and 3=severe. The efficacy of each drug was determined by the reduction in the number of lesions between weeks 0 and 12 of treatment. An excellent response corresponded to a 76%–100% reduction of the lesions, a good response to a 51%–75% reduction, a fair response to a 26%–50% reduction, and a poor response to a 0%–25% reduction. The results were analyzed statistically using the chi-square test, the exact test of Fisher and the test of Wilcoxon–Mann–Whitney. The changes in the numbers of lesions between weeks 0 and 12 were analyzed separately for each group of treatment, and the level of statistical significance was fixed at 0.05. The analysis was performed with the aid of a Stat program, version 4.0. Results The patients were assigned randomly to either Group I (isotretinoin) or Group II (retinoic acid). Each group was composed of 15 individuals and, as a coincidence, in each group there were nine women and six men. The clinical differences between the groups at the first visit were not statistically significant. In both groups, there was, in general, a good response to treatment (Fig. 1). Both drugs had a similar degree of efficacy on inflammatory lesions. At the first visit, grades III and IV predominated, whereas, after 12 weeks of treatment, most patients were classified in grades I or II (Fig. 2). Similar results were observed regarding noninflammatory lesions (Fig. 3). Ten of the patients of Group II complained of stinging associated with the treatment, especially at weeks 8 and 12, as well as erythema and desquamation at the 12th week. Erythema and stinging lasted for minutes or hours, whereas desquamation persisted for several days. Seven individuals receiving isotretinoin mentioned irritation, which was of a mild degree.     

Topical clindamycin phosphate compared with oral tetracycline in the treatment of acne vulgaris

Sixty patients (aged 12–30 years) were enrolled in a 12-week, double-blind, randomized study to compare the efficacy of clindamycin phosphate 1% topical solution with oral tetracycline for the treatment of moderate acne. Forty-four patients (22 in each group) were evaluable. All patients experienced significant reductions in numbers of pustules, papules and inflamed nodules, and there were no significant differences between the two groups. Both treatment regimens were well tolerated, and no systemic side-effects were reported. Topical clindamycin phosphate 1% is considered a safe and effective alternative to oral tetracycline for the treatment of moderate acne vulgaris.