Relapsing polychondritis

A 43-year-old Chilean man presented with a 5-month history of progressive hypertrophy of the ears bilaterally. He was seen initially by a dermatologist in Chile for complaints of erythema and swelling of the ears, and had been treated unsuccessfully with topical steroids and antimicrobial ointments. On presentation to our clinic, the hypertrophy had stabilized and the erythema had resolved, but he complained of decreased hearing due to narrowing of the external auditory canal. Associated symptoms included occasional pruritus, but he denied any pain. He also denied a history of sinus problems, respiratory symptoms, ocular pain, chest pain, and arthralgias. Physical examination revealed firm hypertrophy of the collagenous areas of both ears, sparing the ear lobes (Fig. 1). No pain was elicited on palpation. No conjunctivitis was noted and the nasal passages were clear. His chest was clear to auscultation. Histologic examination revealed a minimal perivascular infiltrate of lymphocytes and plasma cells in the dermis with fibrosis of the subcutis (Fig. 2). Blood tests showed a normal complete blood count, antinuclear antibody, and rheumatoid factor. Anti-collagen II antibodies were elevated at 29.2 Eu/ml (normal, 0-20 Eu/ml; borderline, 20-25 Eu/ml; elevated, > 25 Eu/ml).     

A systemic type I 5 alpha-reductase inhibitor is ineffective in the treatment of acne vulgaris

Excessive sebum production is a central aspect of the pathophysiology of acne vulgaris. Sebaceous gland function is under androgen control and it is hypothesized that dihydrotestosterone is formed by the action of 5 alpha-reductase. Type I is the controlling isoenzyme. This study describes a 3-month, multicenter, randomized, placebo-controlled clinical trial with a potent, selective inhibitor of type I 5 alpha-reductase used alone and in combination with systemic minocycline. Inhibition of type I 5 alpha-reductase was not associated with clinical improvement of acne when used alone and did not enhance the clinical benefit of systemic minocycline. These results indicate the need for further work at the molecular level to better understand the action of androgens on sebaceous gland function.     

Indoor tanning and ultraviolet-A radiation

The proliferation of indoor tanning facilities is a result of our society's belief that tanning is a symbol of wealth, health, and youth. This article examines the indoor tanning industry, the effects of ultraviolet-A radiation, and public education.     

Ketoconazole gel 2% in the treatment of moderate to severe seborrheic dermatitis

Seborrheic dermatitis traditionally has been treated with topical steroids. In current practice, however, antifungal agents such as ketoconazole often are used because Malassezia yeasts are thought to play a role in the disease pathogenesis. Ketoconazole gel 2% has been developed for the once-daily treatment of seborrheic dermatitis. This gel is almost invisible after application, unlike ketoconazole cream, and may offer advantages in patient acceptance and adherence to treatment. Three randomized, double-blinded, vehicle-controlled, multicenter, parallel-group phase 3 studies evaluated the efficacy and tolerability of ketoconazole gel 2% compared with a vehicle gel in more than 900 subjects with moderate to severe seborrheic dermatitis who applied treatment for 14 days and were followed for an additional 14 days. Two of these studies also compared a combination gel containing ketoconazole 2% and desonide 0.05%, each active gel individually, and a vehicle control. Subjects were considered effectively treated if the erythema and scaling as well as investigator global assessment (IGA) scores decreased to 0 (or 1 if the baseline score was > or =3) by day 28. Pooled data from these studies showed that the proportion of effectively treated subjects was significantly greater in the ketoconazole gel 2% treatment group compared with the vehicle group (P < .001). The comparison of the combination gel to its individual components revealed that the efficacy of ketoconazole alone was comparable to the combination gel as well as desonide gel alone for up to 2 weeks after the end of treatment. These data suggest that once-daily ketoconazole gel 2% is an effective treatment for seborrheic dermatitis and a viable alternative to the ketoconazole cream 2% formulation.     

Comparison of adapalene 0·1% solution and tretinoin 0·025% gel in the topical treatment of acne vulgaris

A multicentre study was conducted to compare clinical safety and efficacy of adapalene 0·1% solution and tretinoin 0·025% gel, both topical treatments for acne, in a once-daily dosage regimen for 12 weeks. A total of 297 patients were enrolled by eight investigators in this randomized, investigator-masked study in a parallel group design. An open label period using adapalene followed this study to assess the long-term safety of adapalene solution.
  Adapalene and tretinoin proved to be clinically and statistically effective in treating acne by reducing inflammatory (47% and 50%, respectively) and non-inflammatory lesions (57% and 54%) as compared to baseline. When comparing patients who had 75% or greater improvement in open comedones, adapalene was shown to be significantly more effective than tretinoin. No serious adverse event was reported during this study, including during the long-term period. The reactions that occurred were similar between treatments, i.e. burning, pruritus, scaling, dryness and erythema.     

A Three-Step Acne System Containing Solubilized Benzoyl Peroxide versus Benzoyl Peroxide/Clindamycin in Pediatric Patients with Acne

Objective. To evaluate the clinical benefit in adolescents of a three-step acne system containing solubilized benzoyl peroxide. Design. Patients in this multicenter, investigator-blind trial were randomly assigned to receive 10 weeks of treatment with either the three-step acne system for normal-to-oily skin (proprietary 2% salicylic acid cleanser twice daily + proprietary 2% salicylic acid toner once daily + solubilized 5% benzoyl peroxide gel twice daily) or with control cleanser + 5% benzoyl peroxide/1% clindamycin gel twice daily. Setting. Patients seeking acne treatment from a dermatologist. Pediatric subgroup analysis from a larger trial. Participants. Eighty-two adolescents with mild-to-moderate facial acne vulgaris. Measurements. Noninflammatory and inflammatory lesion counts, erythema, dryness, peeling, burning/stinging, and itching. Results. The three-step acne system was significantly more effective than benzoyl peroxide/clindamycin in reducing the noninflammatory lesion count at Weeks 2 and 4. The antibiotic-free acne system was also comparably effective to benzoyl peroxide/clindamycin in reducing the inflammatory lesion count at all timepoints. Both regimens were generally well tolerated with mean levels of erythema, dryness, peeling, burning/stinging, and itching less than mild in both groups at all timepoints. Conclusions. The three-step acne system is an effective antibiotic-free acne treatment. Relative to benzoyl peroxide/clindamycin, its ability to achieve comparable reductions in inflammatory lesions, and significantly greater reductions in noninflammatory lesions in the early weeks of treatment is likely attributable to the solubilization of the benzoyl peroxide enhancing the bioavailability and intrafollicular penetration of the benzoyl peroxide.Benzoyl peroxide (BPO) is a rational first-line treatment for acne vulgaris because it offers good efficacy against both inflammatory and noninflammatory acne lesions.¹ It is also a useful maintenance treatment because, unlike antibiotics, it is not associated with the development of resistance in Propionibacterium acnes or other bacteria.^2–4 However, BPO is challenging to formulate—it is only poorly soluble in aqueous vehicles and can aggregate into crystalline clusters that may be too large for intrafollicular penetration. It also tends to be unstable in other solvents.⁵ As a result of these physicochemical issues, the bioavailability, follicular penetration, and clinical efficacy of BPO may be suboptimal. To overcome these limitations, a solubilized formulation of BPO has been developed. This formulation consists of a homogeneous solution of BPO molecules whose diameters are ~0.0001μm. Follicles on the forehead have been reported to have a mean diameter of 66¼m⁶ ; therefore, the solubilized BPO molecules are easily small enough for unhindered follicular penetration. In contrast, some commercially available BPO formulations have BPO cluster diameters up to 100¼m, which would hinder follicular penetration.⁷The solubilized 5% BPO gel formulation has been reported to achieve relatively greater bactericidal activity on the surface of the cheeks and in follicles, and a significantly greater reduction in noninflammatory lesion count, than a BPO/antibiotic combination product.^8,9 Both products resulted in comparable reductions in the inflammatory lesion count despite the absence of antibiotic in the solubilized BPO regimen.⁹The solubilized 5% BPO formulation is available as part of a three-step acne system for either normal-to-oily skin (used in conjunction with a proprietary 2% salicylic acid cleanser and a proprietary 2% salicylic acid toner) or normal-to-dry skin (used in conjunction with a nonsoap cream cleanser and a noncomedogenic moisturizer containing glycerin and dimethicone).¹⁰The results from a clinical study evaluating the three-step acne system for normal-to-oily skin showed that the system was at least as effective as BPO/clindamycin (the formulation packaged in a pump) in reducing the noninflammatory lesion count and may enhance the speed at which these lesions are reduced in the early weeks of treatment. Both products resulted in comparable efficacy against inflammatory lesions and comparable tolerability.¹¹ We present a subgroup analysis of the pediatric patients in this study to demonstrate the clinical benefit of this three-step acne system, specifically in adolescents.     

Efficacy of a low-dose oral contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the treatment of moderate acne: A randomized,placebo-controlled trial

BACKGROUND: Acne is a multifactorial disease in which androgens appear to play an important role. A low-dose oral contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel (EE/LNG) has been shown to improve biochemical markers of androgenicity. Lowering bioavailable androgens may improve acne. OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of a low-dose oral contraceptive containing 20 microg of EE and 100 microg of LNG for the treatment of moderate acne. METHODS: In a randomized, double-blind, placebo-controlled clinical trial, healthy female subjects (n = 371; >/=14 years old) with regular menstrual cycles and moderate facial acne were randomly assigned to receive EE/LNG or placebo for 6 cycles of 28 days. Acne lesion counts and clinician global assessment were performed at the end of each cycle. Patient self-assessments were collected and biochemical markers of androgenicity were also measured. RESULTS: At the end of the study, the number of inflammatory and total lesions was significantly lower with EE/LNG compared with placebo (P <.05). Patients in the EE/LNG group also had significantly better scores for clinician global and patient self-assessments than those in the placebo group (P <.05). Biochemical markers of androgenicity improved during EE/LNG treatment compared with placebo and baseline values. CONCLUSION: A low-dose oral contraceptive containing EE/LNG is effective and safe for the treatment of moderate acne.