Isotretinoin and Tetracycline in the Management of Severe Nodulocystic Acne

ABSTRACT: Thirty patients with treatment-resistant cystic and conglobulate acne entered a randomized double-blind protocol, testing the efficacy of isotretinoin versus tetracycline. After 16 weeks of isotretinoin treatment, the mean number of cysts decreased by 64% and the mean sum of the longest diameters was reduced by 68%. After 16 weeks of tetracycline therapy, the total number of cysts showed a mean decrease of 52%, and the mean sum of the longest diameters decreased by 60%. The reduction in the number of cysts and the sum of their longest diameters that occurred after 16 weeks of treatment was statistically significant for each of the treatment groups, but there was no statistically significant difference between the treatment groups at the end of therapy. Eight weeks after the discontinuation of treatment in the isotretinoin group, there was an overall reduction from baseline of 82% in the cyst count and 88% in the sum of the longest diameters. In the tetracycline treatment group, the overall reduction from baseline in the cyst count was 54% and in the sum of the longest diameters, 60%. This led to a statistically significant difference in the two treatment groups at 24 weeks. All patients on isotretinoin experienced side effects that were primarily related to the integumentary system but necessitated discontinuation of the drug for a short period of time in only one patient. Long-term follow-up, 8 months after discontinuation of the study, showed a prolonged significant remission of acne in the isotretinoin group but not in the tetracycline group.     

Isotretinoin and Tetracycline in the Management of Severe Nodulocystic Acne

Abstract: Thirty patients with treatment-resistant cystic and conglobulate acne entered a randomized double-blind protocol. testing the efficacy of isotretinion versus tetracycline. After 16 weeks of isotretinoin treatment, the mean number of cysts decreased by 64% and the mean sum of the longest diameters was reduced by 68%. After 16 weeks of tetracycline therapy, the total number of cysts showed a mean decrease of 52%, and the mean sum of the longest diameters decreased by 60%. The reduction in the number of cysts and the sum of their longest diameters that occurred after 16 weeks of treatment was statistically significant for each of the treatment groups, but there was no statistically significant difference between the treatment groups at the end of therapy. Eight weeks after the discontinuation of treatment in the isotretinoin group, there was an overall reduction from baseline of 82% in the cyst count and 88% in the sum of the longest diameters. In the tetracycline treatment group, the overall reduction from baseline in the cyst count was 54% and in the sum of the longest diameters, 60%. This led to a statistically significant difference in the two treatment groups, at 24 weeks. All patients on isotretinoin experienced side effects that were primarily related to the integumentary system but necessitated discontinuation of the drug for a short period of time in only one patient. Long-term followup, 8 months after discontinuation of the study, showed a prolonged significant remission of acne in the isotretinoin group but not in the tetracycline group.     

Acne analysis,grading and computational assessment methods: an overview

Introduction: This paper presents a comprehensive review of acne grading and measurement. Acne is a chronic disorder of the pilosebaceous units, with excess sebum production, follicular epidermal hyperproliferation, inflammation and Propionibacterium acnes activity. Most patients are affected with acne vulgaris, which is the prevalent type of acne. Acne vulgaris consists of comedones (whitehead and blackhead), papules, pustules, nodules and cysts. Objectives: To review and identify the issues for acne vulgaris grading and computational assessment methods. To determine the future direction for addressing the identified issues. Methods: There are two main methods of assessment for acne severity grading, namely, lesion counting and comparison of patient with a photographic standard. For the computational assessment method, the emphasis is on computational imaging techniques. Results: Current acne grading methods are very time consuming and tedious. Generally, they rely on approximation for counting lesions and hence the assessment is quite subjective, with both inter and intra‐observer variability. It is important to accurately assess acne grade to evaluate its severity as this influences treatment selection and assessment of response to therapy. This will further help in better disease management and more efficacious treatment. Conclusion: Semi‐automated or automated methods based on computational imaging techniques should be devised for acne grade assessment.     

Historical Aspects of the Oral Use of Retinoids in Acne

A number of investigations of the effects of vitamin A deficiency in animals and man and its treatment with natural products containing vitamin A were carried out in the twenties and thirties. In 1942, a clinical study in patients with acne treated with vitamin A yielded encouraging results. Further trials in the forties and fifties, trying to confirm the beneficial effect of oral vitamin A in acne, met with equivocal success. In the sixties, all-trans retinoic acid (tretinoin) became clinically available, and its topical efficacy in acne could be demonstrated. In 1971, oral tretinoin also was shown to be active in patients with acne. Coincidentally, the efficacy of oral 13-cis retinoic acid (isotretinoin) became evident in a series of unpublished studies in Europe. Then, in 1978, a trial carried out at the NIH, Bethesda, Maryland, yielded convincing evidence that isotretinoin is a potent new drug for the treatment of severe cystic acne. In 1982, isotretinoin was registered in the United States and one year later in Europe for the treatment of severe, recalcitrant, cystic acne. Since then, many thousands of patients suffering psychologically and physically from the severity of their disease have been treated successfully with this drug. However, the main concern of physicians prescribing isotretinoin has to focus on its potentially severe side effects, particularly its teratogenicity.     

Acne fulminans: explosive systemic form of acne

Acne fulminans (AF) is a rare severe form of acne vulgaris associated with systemic symptoms. It primarily affects male adolescents. Although the aetiology of AF remains unknown, many theories have been advanced to explain it. There have been reported associations with increased androgens, autoimmune complex disease and genetic pre‐disposition. The disease is destructive, with the acute onset of painful, ulcerative nodules on the face, chest and back. The associated systemic manifestations such as fever, weight loss and musculoskeletal pain are usually present at the onset. The patients are febrile, with leucocytosis and an increased erythrocyte sedimentation rate. They may require several weeks of hospitalization. The treatment of AF has been challenging; the response to traditional acne therapies is poor. The recommended treatment is aggressive and consists of a combination of oral steroids and isotretinoin. To avoid the relapses, duration of such treatment should not be less than 3–5 months. Although the prognosis for patients treated appropriately is good, these acute inflammatory nodules often heal with residual scarring.     

Acne inversa

Acne inversa is a chronic inflammatory skin disease featuring cutaneous and subcutaneous nodular inflammation, fistula formation and discharge of foul‐smelling secretions. The disease can lead to functional impairment and psychological problems. There is inflammation of the terminal hair follicles in intertriginous regions, especially perianal, axillary and inguinal areas. Less often there is submammary, periumbilical, retroauricular or nuchal involvement. Without treatment the disease is chronic and progressive. The causes of acne inversa are multifactorial and pathogenesis is still not well understood. Besides a positive family history, obesity and cigarette smoking are trigger factors. Early diagnosis and therapy of acne inversa saves the patient years of suffering. The most effective treatment is undoubtedly the radical wide excision of the affected areas. Local measures such as radiotherapy, photodynamic therapy and cryotherapy have provided little benefit; the same is true for systemic antibiotic treatment or hormonal therapy with anti‐androgens. TNF‐alpha antagonists seem to have a promising influence on the disease. Further studies investigating the effect of these substances on acne inversa are warranted.     

反常性痤疮

报告1例反常性痤疮。患者男,23岁。因全身反复丘疹、脓疱、结节及囊肿5年就诊。根据临床表现及明确的家族史,符合家族性反常性痤疮(AI)的诊断。AI又名化脓性汗腺炎,任何年龄均可发病,临床表现为腋窝、腹股沟、肛周及会阴部等褶皱部位出现疼痛性皮下结节和囊肿,并伴有溃疡、窦道和瘢痕的形成,皮损疼痛、异味明显,给患者带来很大的痛苦。该例患者经过外科手术治疗——脓肿切开引流术后,取得较好疗效。     

Ectrodactyly,Soft-Tissue Syndactyly,and Nodulocystic Acne: Coincidence or Association?

Abstract: We report severe nodulocystic acne in a 21-year-old man associated with ectrodactyly of the right foot and soft-tissue syndactyly of the third and fourth left fingers, and the first to fourth left toes. His acne was resistant to conventional topical (clindamycin phosphate, erythromycin, tretinoin, peeling agents) and systemic (tetracycline, erythromycin) antiacne medications. Moderate improvement was achieved with systemic isotretinoin. Apart from presenting this case, we imply the disparity of the clinical characteristics of our case and those of Apert syndrome, a rare congenital condition with craniofacial anomalies, symmetric syndactyly of the digits, and acneiform eruption. We discuss the possible explanation for the association of acne lesions and bone deformities based on recent reports of mutations of fibroblast growth factor receptor 2 in the great majority of patients with this syndrome, as well as current experimental data on the involvement of the keratinocyte growth factor in the process of hair follicle growth, development, and differentiation.     

Efficacy of tetracyclines in the treatment of acne vulgaris: a review

BACKGROUND: Oral tetracyclines are routinely used for the management of inflammatory acne. However, there is a lack of evidence-based data on their relative effectiveness and appropriate dosages. OBJECTIVES: To assess the relative effectiveness and the optimal dosage of tetracyclines for the treatment of inflammatory acne. METHODS: We designed a systematic review of the clinical trials (1962-2006) investigating oral tetracyclines for the treatment of inflammatory acne. We obtained data from MEDLINE, PubMed, Current Contents, reference lists and specialist textbooks. RESULTS: There was substantial heterogeneity in the design of the trials. We identified only seven randomized trials which were set up to compare the efficacy of tetracyclines in reducing acne lesion counts. These showed no evidence of superiority of one tetracycline over another. Overall, there was also no significant difference between the available tetracyclines in terms of improvement in inflammatory (32 trials, P=0.898) and noninflammatory (23 trials, P=0.429) lesions. In the range of investigated dosages, the antibiotic dosage had no impact on efficacy in inflammatory (P=0.609) and noninflammatory (P=0.654) lesions. There was no decrease in efficacy during the study period. CONCLUSIONS: There is insufficient evidence to support one tetracycline rather than another in terms of efficacy. In the range of investigated dosages, the antibiotic dosage seems to have no impact on efficacy. Despite increased resistance to antibiotics, oral tetracycline formulations displayed no change in efficacy during the study period. Further studies are, however, required to determine if the anti-inflammatory properties of tetracyclines are sufficient in managing acne.     

Mild Insulin Resistance during Oral Glucose Tolerance Test (OGTT) in Women with Acne

The purpose of this study was to evaluate serum levels of basal insulin and glucose-stimulated insulin, and to evaluate their correlations with androgen levels in women with acne. Serum levels of total testosterone (T), free testosterone (FT), dihydrotestosterone (DHT), dehydroepiandrosterone sulfate (DHEA-S), sex hormone binding globulin (SHBG), insulin-like growth factor-1 (IGF-1), and immunoreactive insulin (IRI) were measured and compared in thirty women with moderate or severe acne and thirteen healthy controls. Serum FT, DHT and DHEA-S levels in the acne group were significantly higher than those in the control group. In the acne group, there were no significant correlations between insulin or IGF-1 levels and T, FT, DHT and SHBG, despite the positive correlation between insulin and IGF-1. In order to determine the effects of insulin secretion as a dynamic response to an oral glucose tolerance test (OGTT) on serum androgen levels in acne patients, we examined the responses of serum insulin and androgen levels to a 75 g, 2 hour OGTT in the acne group and in the control group. Basal insulin levels were not significantly higher than those in the control group, but the summed insulin levels during the OGTT in the acne group were significantly higher than those in the control group. Serum T and FT levels in the acne group decreased during the OGTT, but these changes were not so significant when compared to normal controls. In conclusion, we tried to demonstrate mild insulin resistance during the OGTT in acne patients. However, postmeal transient hyperinsulinemia does not seem to play an important role in determining hyperandrogenemia in acne patients.     

Acne and social media: A cross‐sectional study of content quality on TikTok

Our objective was to assess the quality of acne‐related medical information present on TikTok, the world's fastest growing social media platform. We queried the TikTok mobile application for videos tagged with “#acne” on May 1, 2020, and assessed the top 100 videos meeting inclusion criteria for content quality using DISCERN, a validated and reliable instrument for evaluating consumer health information. The mean content quality rating of videos was 2.03 (SD 0.47) which, according to the DISCERN instrument, indicates information with serious to potentially important shortcomings. Dermatologists should be aware that adolescents are using TikTok to gather acne‐related information, and should prioritize acne education in this patient demographic due to the generally low content quality of such information.     

Acne vulgaris and depression: a retrospective examination

Background  Acne vulgaris is a common skin disease that affects patients both physically and mentally.
Purpose  To examine the prevalence of reported depression in acne patients.
Methods  Patient information was obtained from a medical claims database and analyzed using the Total Resource Utilization Benchmarks™ process. Benchmarks in this study include: age, gender, co-morbid depression, antidepressant utilization, and acne treatment modality. Depression prevalence in acne patients was compared with general population.
Results  Depression was two to three times more prevalent in acne patients than in the general population, with a reported 8.8% of acne patients having clinical depression. The majority of cases of depression and antidepressant therapy utilization were observed in acne patients aged 18 and over with the highest percentage in the 36–64 age group. Approximately 65.2% of the acne patient population was female, with twice as many reported to have depression as males (10.6% females vs. 5.3% males).
Limitations  This analysis included only patients that sought treatment for their acne and had also reported having clinical depression. This may underestimate the total prevalence of acne and associated depression.
Conclusions  Acne is a disease that affects people of all ages both physically and psychologically. A correlation exists between clinical depression and acne patients, particularly those older than 36. "There is no single disease which causes more psychic trauma and more maladjustment between parents and children, more general insecurity and feelings of inferiority and greater sums of psychic assessment than does acne vulgaris" (Sulzberger, 1948 ¹ ).     

Fractional carbon dioxide (CO2) laser combined with topical tretinoin for the treatment of different forms of cystic acne

Nodulocystic acne is prone to scarring and difficult to treat with treatments other than oral isotretinoin. The aim of this article is to discuss the role of a single session of a fractional carbon dioxide (CO₂) laser combined with a topical treatment with a tretinoin and antibiotic gel for a month as a successful treatment to improve nodulocystic acne and chronic microcystic acne. Two cases were involved: the first with nodulocystic acne lesions that persisted after oral retinoids and the second with chronic microcystic acne resistant to topical treatments. After only one session of treatment with the CO₂ laser and the topical treatment, a complete healing of the nodulocystic acne lesions was observed with minimal secondary effects. The microcystic acne showed great improvement. No other topical or oral treatment was needed. This treatment could be a safe and effective treatment for nodulocystic acne lesions and microcystic acne when other treatments fail. More studies should be performed to confirm our results.     

Acne fulminans and 13-cis-retinoic acid.

We report a case of acne fulminans occurring during treatment with 13-cis-retinoic acid for cystic acne. Continuing the treatment with 13-cis-retinoic acid without systemic steroid eventually cleared the systemic manifestations and skin lesions. We review the literature and discuss its pathogenesis.     

An Unusual Panniculitis Appearing in the Winter with Good Response to Tetracycline

Cold panniculitis is a form of physical panniculitis due to exposure of skin to severe cold. It usually appears on the cheeks of infants and children. It has also been reported on the thighs and buttocks of young females. Its clinical manifestations include red, cold, indurated plaques or nodules which appear one to three days after exposure to low temperatures and resolve spontaneously within several weeks without scarring. The histopathological picture shows a perivascular infiltrate of lymphoid and histiocytic cells at the dermal-subcutaneous junction in the early phase of the reaction (1). After 48 to 72 hours, a well developed panniculitis appears. We report an unusual case of an adult female patient with recurrent panniculitis on her legs appearing in the winter but without any preceding repeated or prolonged exposure to cold. She responded dramatically to oral tetracycline. This drug was successful as a prophylactic agent as well.     

502例寻常型痤疮临床及相关因素分析

目的：了解广州地区寻常型痤疮临床流行病学现状，指导临床治疗。方法：2002年12月至2003年3月，每周固定2个门诊日，采用痤疮流行病学调查表对年龄14～45岁的确诊痤疮患者进行调查。数据通过专门设计的软件录入，采用SAS6．12软件包进行分析。结果：共调查502例门诊痤疮患者。Ⅰ、Ⅱ级痤疮占63．1％，初发年龄以14-19岁最多(55．7％)，好发部位为颊、额部为主；痤疮严重度与性别、年龄、皮肤类型、伴发脂溢性皮炎、家庭史阳性、睡眠不足、吸烟和女性月经不调有关；33．2％的患者有瘢痕，好发部位为颊部，男性，阳性家庭史，重度痤疮患者更易留下瘢痕。近一年61．4％患者接受了治疗，以联合治疗为主；10．9％患者生活质量因痤疮受到影响。结论：痤疮仍是青春期的常见病，但成人痤疮有增加趋势；睡眠少于8小时，女性患者的月经不调与其病情严重度相关；对男性，阳性家庭史及重度痤疮患者应及早治疗，以预防瘢痕的形成，并且在临床上应重视维持治疗和心理治疗。