A CME/CE CERTIFIED SUPPLEMENT TO
SUPPLEMENT 3
VOL. 37, NO. 3S
JUNE 2018
EDITORS
Kenneth A. Arndt, MD
Philip E. LeBoit, MD
Bruce U. Wintroub, MD
Acne and Rosacea:
Applying Emerging Science
to Improve Outcomes
GUEST EDITORS
Linda F. Stein Gold, MD, Chair
Andrew F. Alexis, MD, MPH
Julie C. Harper, MD
Jerry K. L. Tan, MD, FRCPC
Introduction
S59
Current Concepts in Acne Pathogenesis:
Pathways to Inflammation
S60
Advances in Acne and Rosacea Therapy
S63
Treating Acne in Adult Women
S67
Treating Acne in Patients With Skin of Color
S71
CME/CE Post-Test and Evaluation Form
S74
Acne and Rosacea: Applying Emerging Science to Improve Outcomes
Original Release Date: June 2018
Expiration Date: June 30, 2020
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Target Audience
This journal supplement is intended for dermatologists, nurse practitioners,
registered nurses, physician assistants, and other clinicians who treat patients
with acne and rosacea.
Educational Needs
Acne and rosacea are common skin conditions that, if inadequately treated,
can significantly affect an individual’s quality of life. Clinicians need to
stay current on recent scientific research that is revealing the underlying
pathophysiology of these conditions, because such knowledge can support
the choice of appropriate therapy to improve outcomes. Inflammation is now
known to be a primary factor in acne and may persist throughout the lesion
life cycle, even beyond the disappearance of visible lesions. Proliferation of
Propionibacterium acnes bacteria contributes to the inflammatory process;
the cytokines activated by P acnes infection have been identified as targets
for acne therapy, including the use of new and emerging topical and systemic
agents. Clinicians should be familiar with new data on traditional, novel, and
emerging therapies for rosacea, their mechanisms of action, and their efficacy
and safety as monotherapy and in combination. Clinicians should also be
familiar with acne treatment strategies targeted for special populations,
including adult women (especially those who are or want to become
pregnant) and in individuals with skin of color.
Jointly provided by
Learning Objectives
By reading and studying this supplement, participants should be better able to:
• Design a comprehensive treatment plan for patients with acne based on
clinical guidelines and updated research, incorporating pharmacologic and
physical modalities
• Discuss and design treatment plans for patients of color, pregnant patients,
and those with truncal acne, scarring, and photoaging
• Recognize the significant impact of acne in patients’ lives, and of treating
promptly and appropriately
• Apply treatment strategies, based on knowledge of the indications, efficacy,
and risks of available rosacea therapies, to achieve therapeutic goals in
rosacea treatment
Disclosure Declarations
Individuals in a position to control the content of this educational activity are
required to disclose: 1) the existence of any relevant financial relationship with
any entity producing, marketing, re-selling, or distributing health care goods or
services consumed by, or used on, patients with the exemption of non-profit or
government organizations and non-health care related companies, within the
past 12 months; and 2) the identification of a commercial product/device that is
unlabeled for use or an investigational use of a product/device not yet approved.
Andrew F. Alexis, MD, MPH, Consultant: Allergan plc, BioPharmX, Inc.,
Galderma Laboratories, L.P. Contracted Research: Allergan plc, BioPharmX,
Inc., Galderma Laboratories, L.P., Novan, Inc.
Julie C. Harper, MD, Consultant: Allergan plc, Bayer AG, BioPharmX, Inc.,
Galderma Laboratories, L.P., La Roche-Posay, Novan, Inc., Ortho Dermatologics.
Contracted Research: Bayer AG. Speakers Bureau: Allergan plc, Bayer AG, La
Roche-Posay, Ortho Dermatologics.
Linda F. Stein Gold, MD, Consultant: Allergan plc, Dermira, Inc.,
Foamix Pharmaceuticals Ltd., Galderma Laboratories, L.P., Medimetriks
Pharmaceuticals, Inc., Novan, Inc., Valeant Pharmaceuticals International,
Inc. Contracted Research: Allergan plc, Dermira, Inc., Foamix Pharmaceuticals
Ltd., Galderma Laboratories, L.P., Novan, Inc., Valeant Pharmaceuticals
International, Inc. Speakers Bureau: Allergan plc, Galderma Laboratories, L.P.,
Valeant Pharmaceuticals International, Inc.
Jerry K. L.Tan, MD, FRCPC, Consultant: Allergan plc, Galderma Laboratories, L.P.,
Valeant Pharmaceuticals International, Inc. Contracted Research: Dermira, Inc.,
Galderma Laboratories, L.P.,Valeant Pharmaceuticals International, Inc. Speakers
Bureau: Galderma Laboratories, L.P., Valeant Pharmaceuticals International, Inc.
University of Louisville CME & PD Advisory Board and Staff Disclosures:
The CME & PD Advisory Board and Staff have nothing to disclose.
CME/CE Reviewers: Cindy E. Owen, MD, Clinical Assistant Professor, Division
of Dermatology, Department of Medicine, University of Louisville School of
Medicine, has nothing to disclose. The Postgraduate Institute of Medicine
planners and managers have nothing to disclose.
Global Academy for Medical Education Staff: Eileen A. McCaffrey, MA;
Tristan M. Nelsen, MNM, CMP, HMCC; Sylvia H. Reitman, MBA, DipEd; and
Ron Schaumburg have nothing to disclose.
Off-Label/Investigational Use Disclosure
This CME/CE activity discusses the off-label use of certain approved medications as well as data from clinical trials on investigational agents. Such
material is identified within the text of the articles.
The Guest Editors acknowledge the editorial assistance of Global
Academy for Medical Education and Eileen A. McCaffrey, MA, medical
writer, in the development of this supplement. The manuscript was
reviewed and approved by the Guest Editors as well as the Editors of
Seminars in Cutaneous Medicine and Surgery. The ideas and opinions
expressed in this supplement are those of the Guest Editors and do not
necessarily reflect the views of the supporter, Global Academy for Medical
Education, University of Louisville, Postgraduate Institute for Medicine, or
the publisher.
Supported by an
independent educational
grant from Bayer
STATEMENT OF PURPOSE
Seminars in Cutaneous Medicine and Surgery presents
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Editors and Guest Editors selected because of their
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EDITORS
Kenneth A. Arndt, MD
Clinical Professor of Dermatology,
Emeritus
Harvard Medical School
Adjunct Professor of Surgery
Dartmouth Medical School
Hanover, New Hampshire
Adjunct Professor of Dermatology
Brown Medical School
Providence, Rhode Island
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Philip E. LeBoit, MD
Professor of
Clinical Dermatology
School of Medicine
University of California,
San Francisco
San Francisco, California
Bruce U. Wintroub, MD
Associate Dean
Professor and Chair
of Dermatology
School of Medicine
University of California,
San Francisco
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Seminars in Cutaneous Medicine and Surgery is indexed in Index
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June 2018, Vol. 37, No. 3S
TABLE OF CONTENTS
Acne and Rosacea: Applying Emerging
Science to Improve Outcomes
S59
Introduction
Linda F. Stein Gold, MD
S60
Current Concepts in Acne Pathogenesis: Pathways to Inflammation
Jerry K. L. Tan, MD, FRCPC, Linda F. Stein Gold, MD, Andrew F. Alexis, MD, MPH, and Julie C. Harper, MD
S63
Advances in Acne and Rosacea Therapy
Linda F. Stein Gold, MD, Andrew F. Alexis, MD, MPH, Julie C. Harper, MD, and Jerry K. L. Tan, MD, FRCPC
S67
Treating Acne in Adult Women
Julie C. Harper, MD, Linda F. Stein Gold, MD, Andrew F. Alexis, MD, MPH, and Jerry K. L. Tan, MD, FRCPC
S71
Treating Acne in Patients With Skin of Color
Andrew F. Alexis, MD, MPH, Julie C. Harper, MD, Linda F. Stein Gold, MD, and Jerry K. L. Tan, MD, FRCPC
S74
CME/CE Post-Test and Evaluation Form
GUEST EDITORS
Linda F. Stein Gold, MD, Chair
Julie C. Harper, MD
Director of Dermatology Clinical Research
Division Head of Dermatology
Henry Ford Hospital
Detroit, Michigan
Clinical Associate Professor of Dermatology
University of Alabama at Birmingham
Dermatology and Skin Care Center
of Birmingham
Birmingham, Alabama
Andrew F. Alexis, MD, MPH
Jerry K. L. Tan, MD, FRCPC
Chair, Department of Dermatology
Director of The Skin of Color Center
Mount Sinai St. Luke’s and Mount Sinai West
Associate Professor of Dermatology
Icahn School of Medicine at Mount Sinai
New York, New York
Adjunct Professor
Schulich School of Medicine & Dentistry
Western University
Windsor, Ontario, Canada
Vol. 37, No. 3S, June 2018
INTRODUCTION
A
cne, one of the most common skin conditions in the United States, challenges the clinician in multiple ways. Research illuminating
the pathophysiology of acne has revealed the centrality of inflammation in the development of acne and identified new potential
targets of therapy. It also has identified new and investigational therapies for rosacea, another inflammatory skin disease. This
supplement represents the perspectives of myself and three of my colleagues on the pathophysiology of acne and the management of acne
and rosacea.
Jerry K. L. Tan, MD, FRCPC, explains current concepts in acne pathogenesis and the research linking inflammation, insulin-like growth
factor-1, diet, sebum quantity and composition, and Propionibacterium acnes overgrowth and virulence. He also explains that some P acnes
strains may be healthy.
Andrew F. Alexis, MD, MPH, describes the differences in clinical presentation, patient concerns, and sequelae of acne based on Fitzpatrick
skin type. Postinflammatory hyperpigmentation (PIH), a darkened area of skin following trauma or cutaneous inflammation following acne,
appears to be more common in non-Caucasian patients. PIH may be more distressing to patients with darker skin tones than to Caucasian
patients. The need for early aggressive treatment of acne to prevent PIH must be balanced against the importance of avoiding skin irritation,
which can cause dyspigmentation and aggravate PIH. Dr Alexis reviews the data for the efficacy of various topical therapies on acne and
PIH in patients with skin of color (Fitzpatrick skin types IV-VI).
Julie C. Harper, MD, discusses considerations when treating acne in adult women, including childbearing potential, use of or desire for
systemic contraception, addressing or avoiding exacerbation of other skin conditions such as dryness or photoaging, compatibility with
cosmetics, and maintaining a professional appearance. Dr Harper discusses the evidence for use of topical therapies in adult women, the
use of and contraindications to combined oral contraception for acne, off-label treatment of acne with spironolactone in adult women, use
of isotretinoin, and evidence related to treatment of acne during pregnancy and lactation.
I review evidence for new and investigational topical therapies in the management of patients with moderate to severe acne—a patient
group whose options have been limited. New topical therapies have demonstrated efficacy in up to half of patients with severe acne.
A topical treatment has been studied in patients with truncal acne—another difficult-to-treat population. Data evaluating new topical
therapies for rosacea—and a new regimen using existing topical therapies—also are presented.
Advances in our understanding of acne pathophysiology are opening new possibilities for therapies, some of which are reflected in
investigational agents. Familiarity with the special considerations when managing acne in adult women and patients with skin of color—
as well as with the data evaluating the use of newer therapies in these populations—can improve our ability to address our patients’ needs.
Linda F. Stein Gold, MD, Chair
Director of Dermatology Clinical Research
Division Head of Dermatology
Henry Ford Hospital
Detroit, Michigan
Publication of this CME/CE article was jointly provided by University
of Louisville, Postgraduate Institute for Medicine, and Global Academy
for Medical Education, LLC, and is supported by an educational
grant from Bayer. The authors have received an honorarium for their
participation in this activity. They acknowledge the editorial assistance
of Eileen A. McCaffrey, MA, medical writer, and Global Academy
for Medical Education in the development of this continuing medical
education journal article.
Linda F. Stein Gold, MD, Consultant: Allergan plc, Dermira, Inc.,
Foamix Pharmaceuticals Ltd., Galderma Laboratories, L.P., Medimetriks
Pharmaceuticals, Inc., Novan, Inc., Valeant Pharmaceuticals International,
Inc. Contracted Research: Allergan plc, Dermira, Inc., Foamix Pharmaceuticals
Ltd., Galderma Laboratories, L.P., Novan, Inc., Valeant Pharmaceuticals
International, Inc. Speakers Bureau: Allergan plc, Galderma Laboratories, L.P.,
Valeant Pharmaceuticals International, Inc.
Address reprint requests to: Linda F. Stein Gold, MD, Henry Ford
Health System, 6530 Farmington Road, West Bloomfield, MI 48322;
lstein1@hfhs.org
1085-5629/13/$-see front matter © 2018 Frontline Medical Communications
doi: 10.12788/j.sder.2018.023
Vol. 37, No. 3S, June 2018, Seminars in Cutaneous Medicine and Surgery S59
Current Concepts in Acne Pathogenesis:
Pathways to Inflammation
Jerry K. L. Tan, MD, FRCPC,* Linda F. Stein Gold, MD,† Andrew F. Alexis, MD, MPH,‡
and Julie C. Harper, MD§
■ Abstract
Acne is a disease of pilosebaceous inflammation. Pivotal
in pathogenesis are the roles of hormones (insulin, insulinlike growth factor-1, androgens), Propionibacterium acnes,
lipogenesis, and a proinflammatory lipid profile. Innate
immune responses are induced through interaction with
toll-like receptors and inflammasome activation initially
and subsequently through adaptive immune activation.
These insights into pathogenic inflammatory pathways can
translate into novel therapeutic approaches for acne.
Semin Cutan Med Surg 37(supp3):S60-S62
© 2018 published by Frontline Medical Communications
■ Keywords
Acne; caspase-1; inflammasome; nitric oxide; P acnes
phylotypes; pathophysiology; toll-like receptor
* Adjunct Professor, Schulich School of Medicine & Dentistry, Western
University, Windsor, Ontario, Canada
†
Director of Dermatology Clinical Research, Division Head of
Dermatology, Henry Ford Hospital, Detroit, Michigan
‡
Chair, Department of Dermatology, Director of The Skin of Color
Center, Mount Sinai St. Luke’s and Mount Sinai West, Associate
Professor of Dermatology, Icahn School of Medicine at Mount Sinai,
New York, New York
§ Clinical Associate Professor of Dermatology, University of Alabama
at Birmingham, Dermatology and Skin Care Center of Birmingham,
Birmingham, Alabama
Publication of this CME/CE article was jointly provided by University
of Louisville, Postgraduate Institute for Medicine, and Global Academy
for Medical Education, LLC, and is supported by an educational
grant from Bayer. The authors have received an honorarium for their
participation in this activity. They acknowledge the editorial assistance
of Eileen A. McCaffrey, MA, medical writer, and Global Academy
for Medical Education in the development of this continuing medical
education journal article.
Jerry K. L. Tan, MD, FRCPC, Consultant: Allergan plc, Galderma
Laboratories, L.P., Valeant Pharmaceuticals International, Inc.
Contracted Research: Dermira, Inc., Galderma Laboratories, L.P.,
Valeant Pharmaceuticals International, Inc. Speakers Bureau: Galderma
Laboratories, L.P., Valeant Pharmaceuticals International, Inc.
Linda F. Stein Gold, MD, Consultant: Allergan plc, Dermira, Inc.,
Foamix Pharmaceuticals Ltd., Galderma Laboratories, L.P., Medimetriks
Pharmaceuticals, Inc., Novan, Inc., Valeant Pharmaceuticals International,
Inc. Contracted Research: Allergan plc, Dermira, Inc., Foamix Pharmaceuticals
Ltd., Galderma Laboratories, L.P., Novan, Inc., Valeant Pharmaceuticals
International, Inc. Speakers Bureau: Allergan plc, Galderma Laboratories, L.P.,
Valeant Pharmaceuticals International, Inc.
Andrew F. Alexis, MD, MPH, Consultant: Allergan plc, BioPharmX, Inc.,
Galderma Laboratories, L.P. Contracted Research: Allergan plc,
BioPharmX, Inc., Galderma Laboratories, L.P., Novan, Inc.
Julie C. Harper, MD, Consultant: Allergan plc, Bayer AG, BioPharmX,
Inc., Galderma Laboratories, L.P., La Roche-Posay, Novan, Inc., Ortho
Dermatologics. Contracted Research: Bayer AG. Speakers Bureau:
Allergan plc, Bayer AG, La Roche-Posay, Ortho Dermatologics.
Address reprint requests to: Jerry K. L. Tan, MD, FRCPC, Schulich School
of Medicine & Dentistry, Western University, 2224 Walker Road,
Suite 300, Windsor, Ontario, N8W 5L7 Canada; jerrytan@bellnet.ca
S60 Seminars in Cutaneous Medicine and Surgery, Vol. 37, No. 3S, June 2018
A
cne pathogenesis is characterized by hyperproliferation
and abnormal differentiation of the follicular epithelium;
excess sebum production; inflammation; and proliferation and biofilm formation of Propionibacterium acnes. 1,2
Inflammation is present in all acne lesions, including preclinical
microcomedones.3,4 Immunohistochemical studies show higher
levels of CD4 cells, macrophages, and interleukin (IL)-1–alpha
in uninvolved skin of patients with acne compared with skin of
those without acne. These findings suggest that inflammation
precedes hyperproliferation in the development of acne. 4
“Noninflammatory acne” is thus a misnomer; it appears that all
primary acne lesions are inflammatory.
Although serum androgens have been viewed as the major
hormonal trigger in acne during puberty, recent evidence suggests
a pivotal role for insulin-like growth factor (IGF)-1. Individuals
congenitally deficient in IGF-1 due to Laron syndrome do not
develop acne, for example. However, high-dose IGF-1 replacement
therapy leads to acne and hyperandrogenism.5
Multiple mechanisms of IGF-1 may promote the development of acne. IGF-1 has been shown to: (1) induce androgen
synthesis and increase the cutaneous availability of dihydrotestosterone; (2) disinhibit the forkhead box O1 (FoxO1) transcription
factor, which normally suppresses the androgen receptor; and (3)
activate peroxisome proliferator-activated receptor–gamma, liver X
receptor–alpha, and sterol regulatory element binding protein-1c
(SREBP-1c). The latter actions increase sebum triglycerides and
fatty acid desaturation, leading to a proinflammatory and comedogenic monosaturated fatty acid profile.6 Increased sebum
production also leads to increased levels of squalene. Squalene
monohydroperoxide is comedogenic and results from ultraviolet
A–triggered photooxidation of squalene in sebum.7
Compelling evidence on the roles of hyperglycemic carbohydrates (high glycemic index), dairy products, and saturated fats
in promoting acne has been reported.6 Refined carbohydrates and
dairy products lead to disinhibition of FoxO1 and activation of
the mechanistic target of rapamycin complex 1 (mTORC1) through
escalation of insulin and IGF-1 levels. Saturated fats directly activate
mTORC1. The effect of the latter is stimulation of SREBP-1c, which
is central to sebaceous lipogenesis, sebum fatty acid production,
and monosaturation.2,6
Diet-mediated changes in sebum quantity and composition
promote P acnes overgrowth and biofilm formation. P acnes
produces triglyceride lipase, which increases levels of free palmitic
and oleic acids. Palmitic acid, along with P acnes–derived damageassociated molecular patterns, stimulates toll-like receptor 2
(TLR2), thereby triggering inflammasome activation and IL-1–
beta signaling. Oleic acid stimulates P acnes adhesion, keratinocyte
proliferation, and IL-1–alpha release.8-10 Furthermore, oleic acid
can induce formation of comedones (Figure).6,11,12
P acnes acts on the innate immune system through multiple
proinflammatory pathways.3,13 It activates TLR2 on monocytes,
leading to the release of proinflammatory cytokines IL-12 and
© 2018 Frontline Medical Communications 1085-5629/13/$-see front matter
doi: 10.12788/j.sder.2018.024
Jerry K. L. Tan, MD, FRCPC, Linda F. Stein Gold, MD, Andrew F. Alexis, MD, MPH, and Julie C. Harper, MD
K P acnes
Lipases
Free fatty acids
(oleic, palmitic acid)
Hormonal triggers
(eg, androgens, IGF-1, insulin)
Comedones
L FoxO1 +
K mTORC1
K Lipid quantity +
∆ lipid quality
(saturated and
monounsaturated FAs)
Inflammasome
activation/
innate immunity
IL-1β
Adaptive
immunity
Squalene
monohydroperoxide,
oleic acid
IL-1α
Comedones
Papules,
pustules,
nodules
■ FIGURE Pathways to Inflammation in Acne Pathogenesis
Hormonal initiators in acne include elevated insulin, IGF-1, and androgen levels. These lead to disinhibition of FoxO1 and activation of mTORC1, resulting in
increased local pilosebaceous androgenesis, lipogenesis, and increased squalene, fatty acid production, and desaturation. Increased sebum production
results in proliferation of Propionibacterium acnes, and the attendant lipase catalysis of triglycerides to the free fatty acids palmitic and oleic acid,
leading to inflammasome activation. The latter, plus IL-1–beta upregulation and subsequent adaptive immune response activation, leads to development
of inflammatory papules, pustules, and nodules. Comedo formation results from the direct effect of squalene monohydroperoxide and oleic acid from
lipogenesis (oleic acid) and UVA photooxidation of squalene (monohydroperoxide) or from the degradative effect of P acnes lipases on triglycerides
(oleic acid).
FAs=fatty acids; FoxO1=forkhead box O1; IGF-1=insulin-like growth factor-1; IL=interleukin; mTORC1=mechanistic target of rapamycin complex 1;
UVA=ultraviolet A.
Sources: Melnik BC6; Lovászi M, et al.12
IL-8. 14 It promotes secretion of the proinflammatory cytokines IL-1–beta and IL-18 through an inflammasome pathway
involving caspase-1 and the nucleotide oligomerization domainlike receptor protein (NLRP) 3.15,16 The inflammasome is a group
of intracellular proteins that convert procaspase-1 to caspase-1.
Caspase-1 converts the inactive precursor of IL-1–beta to its
active form.17 Additionally, P acnes induces monocyte production
of matrix metalloproteinases. These enzymes are associated with
numerous inflammatory conditions and may play a role in matrix
degradation and formation of acne scars.18,19
P acnes also stimulates an adaptive immune response, inducing
IL-17A and interferon (IFN)-gamma secretion from CD4+ T cells
in vitro. Type 17 helper T cells (TH17) and type 1/type 17 helper
T cells (TH1/TH17) that react to P acnes stimulation are found in
the peripheral blood of patients with and without acne, but cells
from patients with acne displayed stronger responses to P acnes.20
P acnes influences the development of acne in ways beyond
promoting inflammation. P acnes biofilm formation has been
detected in the sebaceous follicles of patients with acne. Biofilm
formation leads to increased P acnes virulence, manifested in part
by the increased expression of P acnes triglyceride lipase, which
increases the sebum concentration of palmitic and oleic acids.
These changes in sebum lipid composition contribute to inducing
inflammatory acne. As noted, oleic acid increases P acnes adherence and growth. Therefore, P acnes triglyceride lipase may
indirectly contribute to biofilm formation by promoting increased
concentration of oleic acid.8
P acnes is not always pathogenic, however. The organism is
present in both healthy and acne-affected skin, and all P acnes
strains do not exert the same effects. Immune system responses to
P acnes rather than microbial density may influence progression
to disease. Some P acnes phylotypes are associated with healthy
skin rather than with skin affected by acne; others are more
likely found in skin affected by acne than in healthy skin.21 Acneassociated P acnes phylotypes have been shown to induce higher
levels of IFN-gamma and IL-17 in peripheral blood mononuclear
cells than those associated with healthy skin. In recent studies,
phylotypes associated with healthy skin induced higher levels of
IL-10, an anti-inflammatory cytokine.22,23 Future studies might
determine whether P acnes strains associated with healthy skin
can reduce TH1 or TH17 inflammation.23
These current pathogenic concepts suggest new targets for
therapy, including FoxO1, mTORC1, TLR2, the NLRP3 inflammasome, caspase-1, and IL-1–beta.14,15 Consumption of foods that
increase FoxO1 or inhibit mTORC1 and inflammasome activation
should alleviate acne. A paleolithic diet—ie, eliminating hyperglycemic carbohydrates and dairy products—and consumption of
vegetables, berries, sea fish, and green tea may be a nutritional
therapy for acne.6
Treatments eradicating P acnes may leave a microbiome
vacuum that could be repopulated by P acnes strains promoting
anti-inflammatory profiles. Sebum production and altered proinflammatory lipid content represent additional targets for acne
therapies. An analysis of clinical trials found that sebum reduction
Vol. 37, No. 3S, June 2018, Seminars in Cutaneous Medicine and Surgery S61
■ ■ ■ Current Concepts in Acne Pathogenesis: Pathways to Inflammation
is associated with acne improvement.24 Acetyl coenzyme A carboxylase (ACC) catalyzes the rate-limiting step in synthesis of fatty
acids that become components of sebaceous lipids.25 IGF-1
and androgens upregulate expression of a transcription factor
that promotes ACC expression.26 Investigational acne therapies
include a topical antiandrogen medication and a topical inhibitor
of ACC (see Advances in Acne and Rosacea Therapy, page S63).
Another potential intervention involves nitric oxide. Nitricoxide–releasing nanoparticles (NO-np) have been shown to
suppress IL-1–beta, tumor necrosis factor–alpha, and IL-8
release from human monocytes, and IL-8 and IL-6 release from
human keratinocytes. NO-np reduce IL-1–beta secretion in part
by inhibition of caspase-1. NO-np also kill P acnes in vitro.27
A nitric-oxide–releasing macromolecule formulated in an alcoholic gel is under study for the treatment of acne.28 (For more
information, see Advances in Acne and Rosacea Therapy, page
S63.) Current therapies address some elements of pathogenic
pathways. Azelaic acid 15% gel; an oral contraceptive (drospirenone 3 mg/ethinyl estradiol 20 μg); the topical retinoids adapalene,
tazarotene, and tretinoin; and oral isotretinoin have each been
associated with reduced expression of TLR2.29-34 Azelaic acid has
demonstrated anti-inflammatory action in vitro by inhibiting the
generation of reactive oxygen species.35
Summary
Inflammation plays a central role in acne pathogenesis and insulin.
IGF-1 and androgens are prime orchestrators, with initiation likely
due to consumption of dairy foods and a high glycemic index diet.
The hormones lead to increased sebum production and a more
inflammatory composition of sebaceous lipids. These changes
promote P acnes overgrowth and inflammation through multiple
pathways, triggering both innate and adaptive immune activation
(Figure). TLR2, caspase-1, the inflammasome, IL-1–beta, and
mediators of sebum production offer possible therapeutic targets
in acne. All P acnes phylotypes do not act in the same way; some
have been associated with healthy skin, rather than acne, and have
anti-inflammatory effects. Beneficial P acnes phylotypes may lend
themselves to future therapies.
References
1. Isard O, Knol AC, Ariès MF, et al. Propionibacterium acnes activates the IGF-1/IGF-1R
system in the epidermis and induces keratinocyte proliferation. J Invest Dermatol.
2011;131:59-66.
2. Melnik BC. p53: Key conductor of all anti-acne therapies. J Transl Med. 2017;15:195.
3. Dreno B, Gollnick HP, Kang S, et al; Global Alliance to Improve Outcomes in Acne.
Understanding innate immunity and inflammation in acne: Implications for management.
J Eur Acad Dermatol Venereol. 2015;29(suppl 4):3-11.
4. Jeremy AH, Holland DB, Roberts SG, Thomson KF, Cunliffe WJ. Inflammatory events
are involved in acne lesion initiation. J Invest Dermatol. 2003;121:20-27.
5. Ben-Amitai D, Laron Z. Effect of insulin-like growth factor-1 deficiency or administration
on the occurrence of acne. J Eur Acad Dermatol Venereol. 2011;25:950-954.
6. Melnik BC. Linking diet to acne metabolomics, inflammation, and comedogenesis:
An update. Clin Cosmet Investig Dermatol. 2015;8:371-388.
7. Chiba K, Yoshizawa K, Makino I, Kawakami K, Onoue M. Comedogenicity of squalene
monohydroperoxide in the skin after topical application. J Toxicol Sci. 2000;25:77-83.
8. Gribbon EM, Cunliffe WJ, Holland KT. Interaction of Propionibacterium acnes with skin
lipids in vitro. J Gen Microbiol. 1993;139:1745-1751.
9. Katsuta Y, Iida T, Hasegawa K, Inomata S, Denda M. Function of oleic acid on
epidermal barrier and calcium influx into keratinocytes is associated with N-methyl
D-aspartate-type glutamate receptors. Br J Dermatol. 2009;160:69-74.
10. Katsuta Y, Iida T, Inomata S, Denda M. Unsaturated fatty acids induce calcium influx
into keratinocytes and cause abnormal differentiation of epidermis. J Invest Dermatol.
2005;124:1008-1013.
11. Choi EH, Ahn SK, Lee SH. The changes of stratum corneum interstices and calcium
distribution of follicular epithelium of experimentally induced comedones (EIC) by oleic
acid. Exp Dermatol. 1997;6:29-35.
12. Lovászi M, Szegedi A, Zouboulis CC, Törőcsik D. Sebaceous-immunobiology is
orchestrated by sebum lipids. Dermatoendocrinol. 2017:9:e1375636.
S62 Seminars in Cutaneous Medicine and Surgery, Vol. 37, No. 3S, June 2018
13. Thiboutot DM. Inflammasome activation by Propionibacterium acnes: The story of IL-1
in acne continues to unfold. J Invest Dermatol. 2014;134:595-597.
14. Kim J, Ochoa MT, Krutzik SR, et al. Activation of toll-like receptor 2 in acne triggers
inflammatory cytokine responses. J Immunol. 2002;169:1535-1541.
15. Qin M, Pirouz A, Kim MH, Krutzik SR, Garban HJ, Kim J. Propionibacterium acnes
induces IL-1ß secretion via the NLRP3 inflammasome in human monocytes. J Invest
Dermatol. 2014;134:381-388.
16. Kistowska M, Gehrke S, Jankovic D, et al. IL-1ß drives inflammatory responses to
Propionibacterium acnes in vitro and in vivo. J Invest Dermatol. 2014;134:677-685.
17. Dinarello CA. Interleukin-1 in the pathogenesis and treatment of inflammatory diseases.
Blood. 2011;117:3720-3732.
18. Jalian HR, Liu PT, Kanchanapoomi M, Phan JN, Legaspi AJ, Kim J. All-trans retinoic
acid shifts Propionibacterium acnes-induced matrix degradation expression profile toward
matrix preservation in human monocytes. J Invest Dermatol. 2008;128:2777-2782.
19. Sato T, Kurihara H, Akimoto N, Noguchi N, Sasatsu M, Ito A. Augmentation of gene
expression and production of promatrix metalloproteinase 2 by Propionibacterium acnesderived factors in hamster sebocytes and dermal fibroblasts: A possible mechanism for
acne scarring. Biol Pharm Bull. 2011;34:295-299.
20. Kistowska M, Meier B, Proust T, et al. Propionibacterium acnes promotes TH17 and TH17/
TH1 responses in acne patients. J Invest Dermatol. 2015;135:110-118.
21. Fitz-Gibbon S, Tomida S, Chiu BH, et al. Propionibacterium acnes strain populations in
the human skin microbiome associated with acne. J Invest Dermatol. 2013;133:2152-2160.
22. Iyer SS, Cheng G. Role of interleukin 10 transcriptional regulation in inflammation and
autoimmune disease. Crit Rev Immunol. 2012;32:23-63.
23. Yu Y, Champer J, Agak GW, Kao S, Modlin RL, Kim J. Different Propionibacterium
acnes phylotypes induce distinct immune responses and express unique surface
and secreted proteomes. J Invest Dermatol. 2016;136:2221-2228.
24. Janiczek-Dolphin N, Cook J, Thiboutot D, Harness J, Clucas A. Can sebum reduction
predict acne outcome? Br J Dermatol. 2010;163:683-688.
25. Munday MR. Regulation of mammalian acetyl-CoA carboxylase. Biochem Soc Trans.
2002;30:1059-1064.
26. Melnik BC. Olumacostat glasaretil, a promising topical sebum-suppressing agent
that affects all major pathogenic factors of acne vulgaris. J Invest Dermatol.
2017;137:1405-1408.
27. Qin M, Landriscina A, Rosen JM, et al. Nitric oxide-releasing nanoparticles prevent
Propionibacterium acnes-induced inflammation by both clearing the organism and
inhibiting microbial stimulation of the innate immune response. J Invest Dermatol.
2015;135:2723-2731.
28. Baldwin H, Blanco D, McKeever C, et al. Results of a phase 2 efficacy and safety study
with SB204, an investigational topical nitric oxide-releasing drug for the treatment of
acne vulgaris. J Clin Aesthet Dermatol. 2016;9:12-18.
29. Rocha MAD, Guadanhim LRS, Sanudo A, Bagatin E. Modulation of toll like
receptor-2 on sebaceous gland by the treatment of adult female acne. Dermatoendocrinol.
2017;9:e1361570.
30. Jones DA. The potential immunomodulatory effects of topical retinoids. Dermatol Online J.
2005;11:3.
31. Dispenza MC, Wolpert EB, Gilliland KL, et al. Systemic isotretinoin therapy normalizes
exaggerated TLR-2-mediated innate immune responses in acne patients. J Invest
Dermatol. 2012;132:2198-2205.
32. Gregoriou S, Kritsotaki E, Katoulis A, Rigopoulos D. Use of tazarotene foam for the
treatment of acne vulgaris. Clin Cosmet Investig Dermatol. 2014;7:165-170.
33. Tenaud I, Khammari A, Dreno B. In vitro modulation of TLR-2, CD1d and IL-10
by adapalene on normal human skin and acne inflammatory lesions. Exp Dermatol.
2007;16:500-506.
34. Zuliani T, Khammari A, Chaussy H, Knol AC, Dréno B. Ex vivo demonstration of a
synergistic effect of adapalene and benzoyl peroxide on inflammatory acne lesions. Exp
Dermatol. 2011;20:850-853.
35. Jones DA. Rosacea, reactive oxygen species, and azelaic acid. J Clin Aesthet Dermatol.
2009;2:26-30.
Advances in Acne and Rosacea Therapy
Linda F. Stein Gold, MD,* Andrew F. Alexis, MD, MPH,† Julie C. Harper, MD,‡ and
Jerry K. L. Tan, MD, FRCPC§
■ Abstract
New topical therapies have demonstrated efficacy
in patients with moderate or severe acne who might
otherwise have required therapy with systemic antibiotics or
isotretinoin. Increasing knowledge about the pathogenesis
of acne has facilitated the development of therapies with
novel modes of action. New and investigational therapies
also are available or in development for the treatment of
both the papulopustular and erythematous manifestations
of rosacea.
Semin Cutan Med Surg 37(supp3):S63-S66
© 2018 published by Frontline Medical Communications
■ Keywords
Acne; adapalene; azelaic acid; ivermectin; rosacea; topical
minocycline; truncal acne
* Director of Dermatology Clinical Research, Division Head of
Dermatology, Henry Ford Hospital, Detroit, Michigan
† Chair, Department of Dermatology, Director of The Skin of Color
Center, Mount Sinai St. Luke’s and Mount Sinai West, Associate
Professor of Dermatology, Icahn School of Medicine at Mount Sinai,
New York, New York
‡ Clinical Associate Professor of Dermatology, University of Alabama
at Birmingham, Dermatology and Skin Care Center of Birmingham,
Birmingham, Alabama
§ Adjunct Professor, Schulich School of Medicine & Dentistry, Western
University, Windsor, Ontario, Canada
Publication of this CME/CE article was jointly provided by University
of Louisville, Postgraduate Institute for Medicine, and Global Academy
for Medical Education, LLC, and is supported by an educational
grant from Bayer. The authors have received an honorarium for their
participation in this activity. They acknowledge the editorial assistance
of Eileen A. McCaffrey, MA, medical writer, and Global Academy
for Medical Education in the development of this continuing medical
education journal article.
Linda F. Stein Gold, MD, Consultant: Allergan plc, Dermira, Inc.,
Foamix Pharmaceuticals Ltd., Galderma Laboratories, L.P., Medimetriks
Pharmaceuticals, Inc., Novan, Inc., Valeant Pharmaceuticals International,
Inc. Contracted Research: Allergan plc, Dermira, Inc., Foamix Pharmaceuticals
Ltd., Galderma Laboratories, L.P., Novan, Inc., Valeant Pharmaceuticals
International, Inc. Speakers Bureau: Allergan plc, Galderma Laboratories, L.P.,
Valeant Pharmaceuticals International, Inc.
Andrew F. Alexis, MD, MPH, Consultant: Allergan plc, BioPharmX, Inc.,
Galderma Laboratories, L.P. Contracted Research: Allergan plc,
BioPharmX, Inc., Galderma Laboratories, L.P., Novan, Inc.
Julie C. Harper, MD, Consultant: Allergan plc, Bayer AG, BioPharmX,
Inc., Galderma Laboratories, L.P., La Roche-Posay, Novan, Inc., Ortho
Dermatologics. Contracted Research: Bayer AG. Speakers Bureau:
Allergan plc, Bayer AG, La Roche-Posay, Ortho Dermatologics.
Jerry K. L. Tan, MD, FRCPC, Consultant: Allergan plc, Galderma
Laboratories, L.P., Valeant Pharmaceuticals International, Inc.
Contracted Research: Dermira, Inc., Galderma Laboratories, L.P.,
Valeant Pharmaceuticals International, Inc. Speakers Bureau: Galderma
Laboratories, L.P., Valeant Pharmaceuticals International, Inc.
Address reprint requests to: Linda F. Stein Gold, MD, Henry Ford
Health System, 6530 Farmington Road, West Bloomfield, MI 48322;
lstein1@hfhs.org
1085-5629/13/$-see front matter © 2018 Frontline Medical Communications
doi: 10.12788/j.sder.2018.025
Overview
Patients with moderate or severe acne that does not respond to
topical therapies often receive systemic antibiotic therapy or
isotretinoin. The American Academy of Dermatology (AAD)
guidelines for management of acne recommend limiting the duration
of systemic antibiotics and avoiding monotherapy with them to
reduce the risk of antibiotic resistance (see Revisiting Antibiotic
Treatment).1 Topical therapy that can improve moderate to severe
acne without the need for systemic antibiotics or oral isotretinoin
is needed. New topical therapies have demonstrated efficacy in up
to half of patients with severe acne.2,3 A new treatment has been
studied in truncal acne as well (see Truncal Acne).4 Investigational
therapies with novel mechanisms of action in acne include a topical
nitric-oxide–releasing macromolecule,5 a melanocortin receptor-5
antagonist,6 and an antiandrogen cream (CB-03-01 1%).7
New therapies for rosacea include a 15% foam formulation
of azelaic acid, an antiparasitic agent (ivermectin 1% cream),
an alpha1A-adrenergic receptor agonist (topical oxymetazoline
hydrochloride cream 1%), and a cationic antimicrobial peptide
(omiganan). Separate formulations of topical minocycline are in
development for acne and rosacea.
Revisiting Antibiotic Treatment
The current AAD guidelines and a recent consensus statement
from the Global Alliance to Improve Outcomes in Acne recommend
limiting antibiotic use in acne therapy to reduce the risk of antibiotic
resistance, as follows1,8:
• Use topical and systemic antibiotics in combination with
nonantibiotic therapies (eg, topical benzoyl peroxide [BPO],
topical retinoids)
– Monotherapy with antibiotics is not recommended
• Use systemic antibiotics for the shortest possible duration,
with reevaluation after 3 to 4 months
– Evaluate response time in 6 to 8 weeks8
Truncal Acne
Approximately half of patients with acne have disease manifestations on the back and/or chest.9 Because patients may incorrectly
report no acne in these areas, physical examination by the clinician
is mandatory.10 The difficulty of applying topical therapies to all of the
affected truncal areas, and the time required to do so, can complicate use of this approach. For this reason, oral therapies are often
prescribed for truncal acne in clinical practice. However, their use
is limited by AAD guidelines meant to reduce the risk of antibiotic
resistance (see Revisiting Antibiotic Treatment).1
A recent open-label study evaluated the efficacy of azelaic acid
15% foam in moderate truncal acne. Twice-daily foam application
resulted in a 1-grade reduction on the 5-grade Investigator Global
Assessment (IGA) scale for 16 of 18 patients with acne. After 16 weeks
of therapy, 8 of 18 patients (44%) were judged to be clear or almost
clear. The medication also improved facial acne.4
Vol. 37, No. 3S, June 2018, Seminars in Cutaneous Medicine and Surgery S63
■ ■ ■ Advances in Acne and Rosacea Therapy
What’s New in Acne?
Approved Agents
Adapalene 0.3% / benzoyl peroxide 2.5% (ADAP 0.3% / BPO 2.5%)
gel. In a randomized, double-blind study on ADAP 0.3%/BPO
2.5% applied once daily, about one-third of patients with moderate
or severe inflammatory acne achieved an IGA score of clear/almost
clear with at least a 2-grade improvement on the IGA scale at week
12 (Table 1).3,11-13 The mean reduction in baseline in inflammatory
and noninflammatory lesion counts was significantly greater with
ADAP 0.3%/BPO 2.5% than with vehicle. Skin irritation (2.8%)
and a burning sensation (0.9%) were the most common treatmentrelated adverse events (AEs).3
Improvements also occurred among patients with severe acne at
baseline. Nearly one-third of these patients demonstrated at least
a 3-grade improvement to clear/almost clear on the IGA scale at
12 weeks with single-agent topical therapy (31.9% vs 11.8%; 95%
confidence interval, 6.0%-34.2%; P=0.029).3
Clindamycin 1.2% / BPO 3.75% gel. This therapy demonstrated
efficacy compared with vehicle in a randomized trial of patients
with moderate or severe acne (Table 1).11 More than half (55.1%)
of patients with severe acne attained at least a 2-grade reduction in
Evaluator Global Severity Score (EGSS) at week 12.2 The overall
rates of treatment-emergent adverse events (TEAEs) with active
therapy in the main trial and both subgroups (severe acne and
adolescents) were similar to that of vehicle.2,11,14
Dapsone 7.5% gel. This agent, applied once daily, has demonstrated
efficacy in two identically designed randomized, vehicle-controlled
studies in adults and adolescents with moderate acne (Table 1).12,13
The rate of TEAEs was similar for dapsone 7.5% gel and vehicle.12,13
Investigational Therapies
Sarecycline is a once-daily, oral, narrow-spectrum, tetracyclinederived antibiotic with anti-inflammatory properties. At 1.5 and
3.0 mg/kg, it significantly reduced inflammatory lesion counts
from baseline compared with placebo (by 52.7%, 51.8%, and
38.3%, respectively), with no significant difference from placebo in
noninflammatory lesion counts in a phase 2 trial of patients with
moderate or severe acne. The rate of TEAEs was similar across
treatment groups. AEs leading to discontinuation from sarecycline
and considered treatment-related were hypoesthesia, increased
creatine phosphokinase, and decreased white blood cell count. The
1.5-mg/kg dose has entered phase 3 development.15
SB204. This agent contains a nitric oxide–releasing macromolecule
formulated in an alcoholic gel.16 Nitric oxide has been shown
to inhibit Propionibacterium acnes growth as well as P acnesstimulated release of interleukin (IL)-1–beta and other cytokines.5
Once-daily therapy with SB204 4% significantly reduced the
percentage of inflammatory lesions from baseline by week 4 and
the absolute inflammatory and noninflammatory lesion count
at week 12, compared with vehicle, in subjects with moderate or
severe acne.17 A study including patients with mild disease produced
similar findings.16 The rate of TEAEs was similar across treatment
groups. The rate of IGA success (clear/almost clear and ≥2-grade
improvement vs baseline) with SB204 4% was low (2.0%) and did
not differ from that of vehicle (1.9%).16
Topical olumacostat glasaretil (OG) 7.5%. Following an announcement that this agent did not meet any of its coprimary endpoints in
two phase 3 trials, development of this therapy is not proceeding at
the time of this writing.
Melanocortin receptor-5 antagonist (MTC896). A phase 2, doseranging study of MTC896 delivered in a topical gel and applied
twice daily is ongoing.18
Topical minocycline. Minocycline 4% foam applied once daily
demonstrated efficacy in a phase 2, 12-week-long trial (N=139;
moderate or severe acne). More than one-third of patients (36.2%)
achieved at least a 2-grade improvement on the IGA scale at week
12 with topical minocycline, compared with 15.2% for vehicle
(P=0.021). Topical minocycline 4% foam produced a significantly
greater mean percentage reduction from baseline in inflammatory
and noninflammatory lesion count compared with vehicle.
Tolerability did not differ significantly between treatment groups.19
In two identical phase 3 studies of this agent (N=466, N=495),
the change from baseline to week 12 in absolute inflammatory
lesion count for topical minocycline 4% foam was significantly
greater than that observed with a foam vehicle. The other coprimary
endpoint—IGA score of clear or almost clear plus at least a 2-grade
improvement from baseline—was significant in only one of the two
phase 3 studies.20
■ TABLE 1 New Therapies for Acne: Efficacy Data
Agent
Study Population
Results (12 weeks)
ADAP 0.3%/BPO 2.5% gel
once daily vs vehicle3
N=503; 50:50
moderate:severe acne
Clear/almost clear and ≥2-grade IGA improvement: 33.7% active
therapy; 11.0% vehicle (P<0.001)
Clindamycin 1.2%/BPO
3.75% gel once daily
vs vehicle11
N=498; 82.7% with
moderate acne
Change in inflammatory lesion counts: 60.6% vs 31.4% with vehicle
(P<0.001)
Noninflammatory lesion counts: 51.6% vs 27.4% with vehicle
(P<0.001)
34.3% vs 15.6% with vehicle achieved ≥2-grade reduction in EGSS
(P<0.001)
Dapsone 7.5% gel
vs vehicle12,13
N=2,238 and N=2,102
aged ≥12 years,
moderate acne
GAAS, 0 or 1: 29.9% and 29.8%, respectively, with dapsone vs 21.2% and
20.9%, respectively, with vehicle (P<0.001)
Total lesion count decreased by 48.7% and 48.9%, respectively, vs 42.4%
and 43.2% with vehicle (P<0.001)
ADAP=adapalene; BPO=benzoyl peroxide; EGSS=Evaluator Global Severity Score; GAAS=Global Acne Assessment Score; IGA=Investigator Global Assessment.
Sources: Stein Gold L, et al3; Pariser DM, et al11; Stein Gold LF, et al12; Eichenfield LF, et al.13
S64 Seminars in Cutaneous Medicine and Surgery, Vol. 37, No. 3S, June 2018
Linda F. Stein Gold, MD, Andrew F. Alexis, MD, MPH, Julie C. Harper, MD, and Jerry K. L. Tan, MD, FRCPC
A phase 3 trial is ongoing.21 A phase 2b, 12-week-long, dose-ranging
trial of a topical minocycline gel (1% or 2% vs vehicle) in patients
with moderate or severe inflammatory acne has been completed.22
CB-03-01 1% cream. In an 8-week, phase 2 trial, this once-daily
antiandrogen cream was statistically superior to placebo at 8 weeks
in terms of total lesion count, inflammatory lesion count, and acne
severity index (N=77 men; mild to moderate acne).7 It was not
superior to placebo in its effect on IGA score.23 Phase 3 studies are
in progress.24,25
What’s New in Rosacea?
New Topical Agents
Azelaic acid (AZA) 15% foam. Significantly higher proportions of
patients achieved an IGA score of clear/almost clear plus at least
a 2-point improvement at week 12 with AZA foam than with
vehicle (Table 2).26-30 Change in inflammatory lesion count also was
significantly greater with AZA 15% foam (−13.2 ± 9.5 vs −10.3 ± 9.8;
P <0.001). Application-site pain, pruritus, and dryness were reported
more frequently with AZA 15% foam than with vehicle.26
Ivermectin 1% cream. Significantly higher proportions of those
treated with ivermectin 1% cream achieved IGA scores of clear/
almost clear compared with vehicle, in two 12-week studies
(Table 2).27,28 Dermatologic AEs were less common with ivermectin
than with vehicle.27 The rate of treatment-related dermatologic AEs
was numerically lower with ivermectin 1% cream in a long-term
extension trial of both studies (7.8% vs 12.9%, and 9.8% vs 16.3%;
ivermectin and vehicle, respectively). Statistical comparisons were
not performed.28
Ivermectin cream and brimonidine gel have reduced
papulopustular lesions and erythema, respectively.27,31 More than
60% of subjects with moderate or severe rosacea randomized to
concomitant therapy with both agents for 12 weeks (ivermectin
1% cream, brimonidine 0.33% gel) attained IGA scores of clear/
almost clear at the end of treatment (week 12; 3 hours after
brimonidine application [61.2% vs 36.8% with vehicle, respectively;
P=0.007]). Half of the patients who received ivermectin 1% cream
for 12 weeks with vehicle gel for 4 weeks and brimonidine gel for
8 weeks attained clear/almost clear IGA scores at 12 weeks.32
Topical oxymetazoline hydrochloride cream 1%. An alpha1Aadrenergic receptor agonist that causes vasoconstriction of the
skin microvasculature, this agent received US Food and Drug
Administration approval in January 2017 for persistent facial
erythema associated with rosacea in adults. Significantly larger
proportions of patients achieved at least a 2-grade improvement on
both the Clinician Erythema Assessment (CEA) and Subject SelfAssessment (SSA) after 29 days of treatment with oxymetazoline
hydrochloride cream compared with vehicle, in two pivotal phase 3,
vehicle-controlled studies in patients with moderate or severe facial
erythema of rosacea (Table 2).29,30
Investigational Therapies
Omiganan (CONTRols001). A synthetic, cationic antimicrobial
peptide, omiganan is in phase 3 development for the treatment of
severe papulopustular rosacea.33-36
Topical minocycline. Three topical minocycline products are
under study for the treatment of rosacea. In a phase 2, randomized,
vehicle-controlled study, topical minocycline 1.5% and 3% foam
each reduced the inflammatory lesion count significantly more
than vehicle after 12 weeks of therapy in a study population of
232 patients with moderate to severe facial papulopustular rosacea
(21.1 and 19.1 vs 7.8, respectively; P<0.001). Significantly more
patients receiving active therapy achieved IGA scores of clear/
almost clear and at least a 2-grade IGA improvement at week 12
(41.8%, 33.3%, and 17.9%; 1.5% and 3.0% topical minocycline
foam and vehicle, respectively; P<0.01). Rates of patients
reporting treatment-related AEs were 2.5%, 5.3%, and 6.4%, with
topical minocycline 1.5% and 3% foam, and vehicle, respectively.
No serious treatment-related AEs were reported.37 A phase 3
study and a long-term safety study of the 1.5% formulation are
underway.38,39
Two topical minocycline gels are in phase 2 or phase 1/2 studies
in patients with moderate to severe papulopustular rosacea.39,40
Summary
New and investigational topical therapies are expanding the
options for patients with moderate or severe acne, potentially
enabling a larger number of patients to avoid systemic antibiotic
or isotretinoin therapy. New treatments are increasing the options
for rosacea as well.
■ TABLE 2 New Therapies for Rosacea: Efficacy Data
Agent
Study Population
Results
Azelaic acid 15% foam
twice daily vs vehicle26
N=961; moderate or severe PPR
12 weeks: Clear/almost clear and ≥2-grade IGA improvement:
32.0% vs 23.5% with vehicle (P<0.001)
Ivermectin 1% cream vs
vehicle once daily27,28
N=683 and N=688; moderate
or severe PPR; 12 weeks
12 weeks: Clear/almost clear: 38.4% and 40.1% vs 11.6% and 18.8%
with vehicle (P<0.001)
40 weeks (N=622, N=636)a: Clear/almost clear: 71.1% and 76.0%
Topical oxymetazoline
hydrochloride cream 1%
vs vehicle29
N=440; moderate or severe
facial erythema of rosacea
CEA and SSA successb; day 29, hours post dose (active therapy vs vehicle):
3 hours: 11.9% vs 5.5%; P<0.05; 6 hours: 15.5% vs 8.3%; P<0.05;
9 hours: 17.7% vs 6.0%; P<0.001; 12 hours: 14.8% vs 6.0%; P<0.01
Topical oxymetazoline
hydrochloride cream 1%
vs vehicle30
N=445; moderate or severe
facial erythema of rosacea
CEA and SSA successb; day 29, hours post dose (active therapy vs vehicle):
3 hours: 14.3% vs 7.4%; P<0.05; 6 hours: 13.4% vs 4.8%; P<0.01;
9 hours: 15.5% vs 8.5%; P<0.05; 12 hours: 12.3% vs 6.1%; P<0.05
CEA=Clinician Erythema Assessment; PPR=papulopustular rosacea; SSA=Subject Self-Assessment.
ªLong-term extension of the two 12-week studies.
bDefined as ≥2-grade decrease (composite success) from baseline on both the CEA and SSA at 3, 6, 9, and 12 hours post dose on day 29.
Sources: Draelos ZD, et al26; Stein Gold L, et al27; Stein Gold L, et al28; Kircik LH, et al29; Baumann L, et al.30
Vol. 37, No. 3S, June 2018, Seminars in Cutaneous Medicine and Surgery S65
■ ■ ■ Advances in Acne and Rosacea Therapy
References
1. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of
acne vulgaris. J Am Acad Dermatol. 2016;74:945-973.e33.
2. Stein Gold L. Efficacy and tolerability of a fixed combination of clindamycin phosphate
(1.2%) and benzoyl peroxide (3.75%) aqueous gel in moderate and severe acne vulgaris
subpopulations. J Drugs Dermatol. 2015;14:969-974.
3. Stein Gold L, Weiss J, Rueda MJ, Liu H, Tanghetti E. Moderate and severe inflammatory
acne vulgaris effectively treated with single-agent therapy by a new fixed-dose combination
adapalene 0.3 %/benzoyl peroxide 2.5 % gel: A randomized, double-blind, parallel-group,
controlled study. Am J Clin Dermatol. 2016;17:293-303.
4. Hoffman LK, Del Rosso JQ, Kircik LH. The efficacy and safety of azelaic acid 15% foam
in the treatment of truncal acne vulgaris. J Drugs Dermatol. 2017;16:534-538.
5. Qin M, Landriscina A, Rosen JM, et al. Nitric oxide-releasing nanoparticles prevent
Propionibacterium acnes-induced inflammation by both clearing the organism and
inhibiting microbial stimulation of the innate immune response. J Invest Dermatol.
2015;135:2723-2731.
6. Eisinger M, Li WH, Anthonavage M, et al. A melanocortin receptor 1 and 5 antagonist
inhibits sebaceous gland differentiation and the production of sebum-specific lipids.
J Dermatol Sci. 2011;63:23-32.
7. Trifu V, Tiplica GS, Naumescu E, Zalupca L, Moro L, Celasco G. Cortexolone
17α-propionate 1% cream, a new potent antiandrogen for topical treatment of acne
vulgaris. A pilot randomized, double-blind comparative study vs. placebo and tretinoin
0.05% cream. Br J Dermatol. 2011;165:177-183.
8. Thiboutot DM, Dréno B, Abanmi A, et al. Practical management of acne for clinicians:
An international consensus from the Global Alliance to Improve Outcomes in Acne.
J Am Acad Dermatol. 2018;78(suppl):S1-S23.e1.
9. Del Rosso JQ, Bikowski JB, Baum E, et al. A closer look at truncal acne vulgaris:
Prevalence, severity, and clinical significance. J Drugs Dermatol. 2007;6:597-600.
10. Tan JK, Tang J, Fung K, et al. Prevalence and severity of facial and truncal acne in a
referral cohort. J Drugs Dermatol. 2008;7:551-556.
11. Pariser DM, Rich P, Cook-Bolden FE, Korotzer A. An aqueous gel fixed combination
of clindamycin phosphate 1.2% and benzoyl peroxide 3.75% for the once-daily treatment
of moderate to severe acne vulgaris. J Drugs Dermatol. 2014;13:1083-1089.
12. Stein Gold LF, Jarratt MT, Bucko AD, et al. Efficacy and safety of once-daily dapsone
gel, 7.5% for treatment of adolescents and adults with acne vulgaris: First of two
identically designed, large, multicenter, randomized, vehicle-controlled trials. J Drugs
Dermatol. 2016;15:553-561.
13. Eichenfield LF, Lain T, Frankel EH, et al. Efficacy and safety of once-daily dapsone
gel, 7.5% for treatment of adolescents and adults with acne vulgaris: Second of two
identically designed, large, multicenter, randomized, vehicle-controlled trials. J Drugs
Dermatol. 2016;15:962-969.
14. Cook-Bolden FE. Efficacy and tolerability of a fixed combination of clindamycin
phosphate (1.2%) and benzoyl peroxide (3.75%) aqueous gel in moderate or severe
adolescent acne vulgaris. J Clin Aesthet Dermatol. 2015;8:28-32.
15. Leyden JJ, Sniukiene V, Berk DR, Kaoukhov A. Efficacy and safety of sarecycline, a
novel, once-daily, narrow spectrum antibiotic for the treatment of moderate to severe
facial acne vulgaris: Results of a phase 2, dose-ranging study. J Drugs Dermatol.
2018;17:333-338.
16. Baldwin H, Blanco D, McKeever C, et al. Results of a phase 2 efficacy and safety study
with SB204, an investigational topical nitric oxide-releasing drug for the treatment of
acne vulgaris. J Clin Aesthet Dermatol. 2016;9:12-18.
17. Eichenfield LF, Gold LS, Nahm WK, Cook-Bolden FE, Pariser DM. Results of a phase
2, randomized, vehicle-controlled study evaluating the efficacy, tolerability, and safety
of daily or twice daily SB204 for the treatment of acne vulgaris. J Drugs Dermatol.
2016;15:1496-1502.
18. ClinicalTrials.gov. A study to determine the efficacy of topically applied MTC896 gel in
subjects with acne vulgaris. Updated June 16, 2016. NCT02395549.
19. Shemer A, Shiri J, Mashiah J, Farhi R, Gupta AK. Topical minocycline foam for
moderate to severe acne vulgaris: Phase 2 randomized double-blind, vehicle-controlled
study results. J Am Acad Dermatol. 2016;74:1251-1252.
20. Stein Gold L, Dhawan S, Weiss J, Draelos Z, Ellman H. The efficacy and safety of
FMX101, minocycline foam 4%, for the treatment of acne vulgaris: A pooled analysis of
phase 2 and phase 3 studies. Presented at: Fall Clinical Dermatology Conference; October
11-15, 2017; Las Vegas, NV.
21. ClinicalTrials.gov. A study to evaluate the efficacy and safety of topical administration of
FMX101 in the treatment of moderate-to-severe acne vulgaris. Updated September 1, 2017.
NCT03271021.
22. ClinicalTrials.gov. BPX-01 minocycline topical gel in the treatment of acne vulgaris
(OPAL). Updated April 14, 2017. NCT02815332.
23. Celasco G, Piacquadio D, Moro L. Cortexolone 17a-propionate 1% cream, a new potent
antiandrogen: A first-in-man assessment in the treatment of acne vulgaris. J Am Acad
Dermatol. 2012;66:AB15.
24. ClinicalTrials.gov. A study to evaluate the safety and efficacy of CB-03-01 cream, 1% in
subjects with facial acne vulgaris (25). Updated November 29, 2017. NCT02608450.
25. ClinicalTrials.gov. A study to evaluate the safety and efficacy of CB-03-01 cream, 1% in
subjects with facial acne vulgaris (26). Updated October 26, 2017. NCT02608476.
26. Draelos ZD, Elewski BE, Harper JC, et al. A phase 3 randomized, double-blind, vehiclecontrolled trial of azelaic acid foam 15% in the treatment of papulopustular rosacea.
Cutis. 2015;96:54-61.
27. Stein Gold L, Kircik L, Fowler J, et al. Efficacy and safety of ivermectin 1% cream in
treatment of papulopustular rosacea: Results of two randomized, double-blind, vehiclecontrolled pivotal studies. J Drugs Dermatol. 2014;13:316-323.
28. Stein Gold L, Kircik L, Fowler J, et al. Long-term safety of ivermectin 1% cream vs
azelaic acid 15% gel in treating inflammatory lesions of rosacea: Results of two 40-week
controlled, investigator-blinded trials. J Drugs Dermatol. 2014;13:1380-1386.
29. Kircik LH, DuBois J, Draelos ZD, et al. Pivotal trial of the efficacy and safety of
oxymetazoline cream 1.0% for the treatment of persistent facial erythema associated
with rosacea: Findings from the first REVEAL trial. J Drugs Dermatol. 2018;17:97-105.
S66 Seminars in Cutaneous Medicine and Surgery, Vol. 37, No. 3S, June 2018
30. Baumann L, Goldberg DJ, Stein Gold L, et al. Pivotal trial of the efficacy and safety of
oxymetazoline cream 1.0% for the treatment of persistent facial erythema associated with
rosacea: Findings from the second REVEAL trial. J Drugs Dermatol. 2018;17:290-298.
31. Fowler J Jr, Jackson M, Moore A, et al. Efficacy and safety of once-daily topical
brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of
rosacea: Results of two randomized, double-blind, and vehicle-controlled pivotal studies.
J Drugs Dermatol. 2013;12:650-656.
32. Gold LS, Papp K, Lynde C, et al. Treatment of rosacea with concomitant use of topical
ivermectin 1% cream and brimonidine 0.33% gel: A randomized, vehicle-controlled study.
J Drugs Dermatol. 2017;16:909-916.
33. ClinicalTrials.gov. Study to evaluate the safety and efficacy of a once-daily CLS001
topical gel versus vehicle. Updated March 2, 2018. NCT02576860.
34. ClinicalTrials.gov. Study to evaluate the safety and efficacy of a once-daily CLS001
topical gel versus vehicle. Updated January 25, 2018. NCT02547441.
35. ClinicalTrials.gov. Study to evaluate the long-term safety of a once-daily omiganan
topical gel. Updated January 25, 2018. NCT02576847.
36. Rubinchik E, Dugourd D, Algara T, Pasetka C, Friedland HD. Antimicrobial and
antifungal activities of a novel cationic antimicrobial peptide, omiganan, in experimental
skin colonisation models. Int J Antimicrob Agents. 2009;34:457-461.
37. Mrowietz U, Kedem TH, Keynan R, et al. A phase II, randomized, double-blind clinical
study evaluating the safety, tolerability, and efficacy of a topical minocycline foam,
FMX103, for the treatment of facial papulopustular rosacea. Am J Clin Dermatol. 2018.
doi:10.1007/s40257-017-0339-0.
38. ClinicalTrials.gov. A study to evaluate the safety and efficacy of FMX103 1.5% topical
minocycline foam in the treatment of facial papulopustular rosacea. Updated September
6, 2017. NCT03142451.
39. ClinicalTrials.gov. A study to evaluate the long-term safety of topical administration
of FMX103 in the treatment of moderate to severe papulopustular rosacea. Updated
October 25, 2017. NCT03276936.
40. ClinicalTrials.gov. Study to evaluate the safety and efficacy of topical minocycline gel in
patients with papulopustular rosacea. Updated February 26, 2018. NCT03263273.
Treating Acne in Adult Women
Julie C. Harper, MD,* Linda F. Stein Gold, MD,† Andrew F. Alexis, MD, MPH,‡
and Jerry K. L. Tan, MD, FRCPC§
■ Abstract
Acne can persist into adulthood or erupt de novo at any point
after adolescence. Adult acne is more common in women
than in men. Considerations for treating acne in adult women
include childbearing potential, pregnancy, lactation, and
concomitant skin conditions.
Semin Cutan Med Surg 37(supp3):S67-S70
© 2018 published by Frontline Medical Communications
■ Keywords
Acne; adult women; lactation; oral contraceptives; pregnancy
A
lthough acne most often appears in adolescence, it can
continue into adulthood or can develop de novo during that
stage of life. The self-reported prevalence of adult acne is
* Clinical Associate Professor of Dermatology, University of Alabama
at Birmingham, Dermatology and Skin Care Center of Birmingham,
Birmingham, Alabama
†
Director of Dermatology Clinical Research, Division Head of
Dermatology, Henry Ford Hospital, Detroit, Michigan
‡
Chair, Department of Dermatology, Director of The Skin of Color
Center, Mount Sinai St. Luke’s and Mount Sinai West, Associate
Professor of Dermatology, Icahn School of Medicine at Mount Sinai,
New York, New York
§ Adjunct Professor, Schulich School of Medicine & Dentistry, Western
University, Windsor, Ontario, Canada
Publication of this CME/CE article was jointly provided by University
of Louisville, Postgraduate Institute for Medicine, and Global Academy
for Medical Education, LLC, and is supported by an educational
grant from Bayer. The authors have received an honorarium for their
participation in this activity. They acknowledge the editorial assistance
of Eileen A. McCaffrey, MA, medical writer, and Global Academy
for Medical Education in the development of this continuing medical
education journal article.
Julie C. Harper, MD, Consultant: Allergan plc, Bayer AG, BioPharmX,
Inc., Galderma Laboratories, L.P., La Roche-Posay, Novan, Inc., Ortho
Dermatologics. Contracted Research: Bayer AG. Speakers Bureau:
Allergan plc, Bayer AG, La Roche-Posay, Ortho Dermatologics.
Linda F. Stein Gold, MD, Consultant: Allergan plc, Dermira, Inc.,
Foamix Pharmaceuticals Ltd., Galderma Laboratories, L.P., Medimetriks
Pharmaceuticals, Inc., Novan, Inc., Valeant Pharmaceuticals International,
Inc. Contracted Research: Allergan plc, Dermira, Inc., Foamix Pharmaceuticals
Ltd., Galderma Laboratories, L.P., Novan, Inc., Valeant Pharmaceuticals
International, Inc. Speakers Bureau: Allergan plc, Galderma Laboratories, L.P.,
Valeant Pharmaceuticals International, Inc.
Andrew F. Alexis, MD, MPH, Consultant: Allergan plc, BioPharmX, Inc.,
Galderma Laboratories, L.P. Contracted Research: Allergan plc,
BioPharmX, Inc., Galderma Laboratories, L.P., Novan, Inc.
Jerry K. L. Tan, MD, FRCPC, Consultant: Allergan plc, Galderma
Laboratories, L.P., Valeant Pharmaceuticals International, Inc.
Contracted Research: Dermira, Inc., Galderma Laboratories, L.P.,
Valeant Pharmaceuticals International, Inc. Speakers Bureau: Galderma
Laboratories, L.P., Valeant Pharmaceuticals International, Inc.
Address reprint requests to: Julie C. Harper, MD, Dermatology and Skin
Care Center of Birmingham, 2470 Rocky Ridge Road, Birmingham, AL
35243; juharper@yahoo.com
1085-5629/13/$-see front matter © 2018 Frontline Medical Communications
doi: 10.12788/j.sder.2018.026
significantly higher in women than in men, according to a survey
conducted in medical center waiting areas and a campus library
(N=1,013).1 More than half (51%) of women and 43% of men
reported having acne in their 20s, with percentages dropping to 26%
and 12% in their 40s, and 15% and 7% in those 50 and older (women
and men, respectively). An online survey found that one-third
of adult women with facial acne (33.7% of 208 women aged 2545 years) reported that the condition was diagnosed in adulthood.2
The treatment of acne in adult women is similar in many respects
to that of men and younger females, although treatment choices
will be influenced by a woman’s childbearing potential, pregnancy,
use of or desire for systemic contraception, and lactation status.
Other considerations particular to adult women may include the
need to address—or at least avoid—exacerbating multiple skin
conditions (eg, dryness, hyperpigmentation, photoaging) along
with acne. Optimally, acne therapy should be compatible with
cosmetics or other facial care products.
Table 1 lists considerations for taking a history of an adult woman
with acne.3-5
Topical Therapies
Topical Retinoid Therapy
These medications offer the advantage of efficacy in postinflammatory hyperpigmentation and photodamage, as well as in acne. Side
effects include skin irritation.5
Adapalene (ADAP) 0.3% demonstrated superiority to vehicle
in adult women (18-41 years old; n=117) in reducing inflammatory, noninflammatory, and total lesion counts after 12 weeks of
therapy, in a post hoc analysis of data from two clinical studies.6
■ TABLE 1 Taking a History of an Adult Woman
With Acne
• Age of first onset; history of any adolescent acne
• Other clinicians consulted for acne
• Previous acne treatments, including over-the-counter and
prescription medications, facials, peels, light therapy, or
microdermabrasion
• History of birth control: use of hormonal agents, including
oral contraceptives; spironolactone; intrauterine or
implanted devices; or injectable agents
• Signs/symptoms of androgen excess, eg, hirsutism,
alopecia, irregular or missed menses, or inability to
conceive a child
• Concomitant medical conditions
• Current medications
• All products used on the face and hair, including
cosmetics, moisturizers, and personal hygiene products
• Expectations regarding results of therapy
Sources: Del Rosso JQ, et al3; Del Rosso JQ, et al4; Del Rosso JQ, et al.5
Vol. 37, No. 3S, June 2018, Seminars in Cutaneous Medicine and Surgery S67
■ ■ ■ Treating Acne in Adult Women
■ TABLE 2 Combination Oral Contraceptives Indicated for Treatment of Acne
Drug
Acne Indication
Norgestimate 0.180, 0.215, or
0.250 mg/ethinyl estradiol 35 μg13
Moderate acne vulgaris in females aged ≥15 years who have achieved menarche, have no known
contraindication to oral contraceptive therapy, and desire oral contraception for birth control.
Norethindrone acetate 1 mg/
ethinyl estradiol 20, 30, or 35 μg +
ferrous fumarate in the hormonefree interval14
Moderate acne vulgaris in females aged ≥15 years who have achieved menarche, have
no known contraindication to oral contraceptive therapy, desire oral contraception for birth
control, and are unresponsive to topical anti-acne medications. Should be used for the
treatment of acne only if the patient plans to stay on it for ≥6 months.
Drospirenone 3 mg/ethinyl
estradiol 20 μg15
Moderate acne for women aged ≥14 years who have achieved menarche, have no known
contraindications to oral contraceptive therapy, and desire oral contraception for birth control.
Sources: Ortho Tri-Cyclen [package insert]13; Estrostep Fe [package insert]14; Yaz [package insert].15
ADAP 0.1%/benzoyl peroxide (BPO) 2.5% reduced the risk of scar
formation compared with vehicle in a small (N=38) study of adult
men and women. Participants applied active therapy and vehicle to
separate halves of the face. Scar counts remained stable with active
therapy but increased by about 25% with vehicle over a 6-month
treatment period. The proportion of patients rated almost clear
(ie, hardly visible scars) at 6 months rose from 10% to 45% with
ADAP/BPO but did not change from baseline with vehicle.7 A
study of higher-strength ADAP (0.3%)/BPO 2.5% (N=67) also
demonstrated reduction and prevention of scarring, again using
intraindividual comparison. At week 24, change from baseline in
scar count rose by 14.4% with vehicle and decreased by 15.5% with
ADAP/BPO (P<0.0001). Higher proportions achieved scores of
clear/almost clear on the Scar Global Assessment at week 24 with
ADAP/BPO than with vehicle (32.9% vs 16.4%; P<0.01).8
Dapsone 5% / 7.5% has demonstrated efficacy in treatment of
acne in adult women.4,9 Compared with adolescent females (n=347),
a higher proportion of adult women (n=434) achieved a rating of
clear or almost clear after 12 weeks of therapy with dapsone 5%
applied twice daily (53.5% vs 45.3%; P=0.022).4 Regardless of
age, a higher proportion of females (n=753) than males (n=700)
achieved a rating of clear or almost clear after 12 weeks of therapy
with dapsone 5% than with vehicle (48.6% vs 34.4%; P=0.0003).10
Higher proportions of females than males achieved a Global
Acne Assessment Score (GAAS) of 0 or 1 after 12 weeks of therapy
with once-daily dapsone 7.5% (33.9% and 24.7%, respectively) in
a pooled subgroup analysis of data from two identical trials. The
GAAS success rate (score 0 or 1) at week 12 for participants treated
with dapsone 7.5% was significantly higher for females than males
at week 12 (odds ratio, 0.80; 95% confidence interval, 0.68-0.93).9
Clindamycin 1.2% / BPO 3.75% gel once daily. A post hoc analysis of data from 72 adult women (aged ≥25 years) demonstrated
superior efficacy of clindamycin 1.2%/BPO 3.75% compared
with vehicle, with 44% of women receiving active therapy rating
themselves as clear/almost clear compared with 13.5% of those
using vehicle (P=0.026).11 Another post hoc analysis reported
higher efficacy among females than males treated with clindamycin 1.2%/BPO 3.75%.12
Combination Oral Contraceptives
Table 2 lists combination oral contraceptives (COCs) that are
approved by the US Food and Drug Administration (FDA) for
use in acne.13-15 COCs may be used with other topical and oral
therapies for acne. Patients should be counseled that at least three
monthly cycles may pass before acne lesion counts decrease appreciably. Side effects of COCs can include nausea, breast tenderness,
breakthrough bleeding, and weight gain.16 Note that progestin-only
contraceptives, including injectables or intrauterine devices, can
cause or worsen acne.3 Table 3 lists contraindications to COCs.17
S68 Seminars in Cutaneous Medicine and Surgery, Vol. 37, No. 3S, June 2018
Spironolactone
Although not FDA-approved for this use, the oral aldosterone
antagonist and potassium-sparing diuretic spironolactone is
accepted as an option for the treatment of acne.16 In a retrospective evaluation of data from adult women treated with low-dose
(≤150 mg/day) spironolactone, treatment was deemed successful
in 90% of patients for whom full data were available. Success was
defined as no more than 2 superficial inflammatory lesions, no
more than 5 retentional lesions (open or closed comedones), no
nodules on the face, and fewer than 5 superficial inflammatory
lesions on the trunk, including the neck. Median time to response
was 6 months.18
In another retrospective study, 94 of 110 patients demonstrated
improvement and 65 were characterized as clear after four or fewer
follow-up visits. A total of 37 women were clear after the first
follow-up visit, at a median of 4 weeks. Most patients (101/110)
were started on spironolactone 100 mg/day.19 Reported side effects
included breakthrough vaginal bleeding, lightheadedness, dizziness,
low blood pressure, and breast tenderness.18,19
■ TABLE 3 Contraindications to Use of
Combination Oral Contraceptives
• Pregnancy
• Smoking (any amount) and aged >35 years
• Uncontrolled hypertension
• Breastfeeding <6 months postpartum
• History
– Breast cancer (past or current)
– Ischemic heart disease
– Migraine and aged >35 years
– Migraine with focal symptoms
– Stroke
– Venous thromboembolic disease
• Hypercholesterolemia (low-density lipoprotein >160 mg/dL)
• Diabetes and aged >35 years or evidence of end organ
damage
• Viral hepatitis
• Cirrhosis
• Liver tumor (benign or malignant)
• Major surgery with prolonged immobilization
Source: Frangos JE, et al.17
Julie C. Harper, MD, Linda F. Stein Gold, MD, Andrew F. Alexis, MD, MPH, and Jerry K. L. Tan, MD, FRCPC
Spironolactone carries a warning to monitor serum potassium
because of its association with hyperkalemia,20 but its approved
uses are in patients with heart failure, hypertension, primary
hyperaldosteronism, and edema associated with cirrhosis.20 A retrospective analysis of more than 13 years of data from 974 healthy
young women taking spironolactone for acne revealed a hyperkalemia rate of 0.72%, equivalent to the 0.76% baseline rate for this
population. Routine monitoring of serum potassium is unnecessary
in otherwise healthy young women taking spironolactone for acne.21
One study following 96 patients given isotretinoin (0.5-1 mg/
kg/dL, with a cumulative dose of 120-150 mg/kg) reported acne
relapses in eight patients during the first posttreatment year and
in 16 patients during the second posttreatment year.22 A systematic literature review including 20 studies found that the cumulative
dose required to induce remission varied with disease severity.23
Isotretinoin
Table 4 lists therapies for acne and their FDA pregnancy risk categories.24-27 The topical agents azelaic acid, BPO, and clindamycin
(known by the mnemonic “ABC”) and the systemic medications
amoxicillin, cephalexin, and erythromycin (mnemonic “ACE”) can
be used during pregnancy, although under the restrictions noted
in Table 4.
Oral isotretinoin is highly teratogenic and must be prescribed with
strict adherence to the federally mandated iPLEDGE risk management program (https://www.ipledgeprogram.com/), which, among
other strategies, mandates the use of two effective forms of contraception in women of childbearing potential.
Managing Acne During Pregnancy
and Lactation
■ TABLE 4 Acne Therapies: Pregnancy Categories
Acne Severity
Medication
Pregnancy
Category
Comments
Topicals
Azelaic acid
B
About 4%-8% absorption; no known fetal effects24
Benzoyl peroxide
C
May be used on limited areas24
Clindamycin, erythromycin
B
Minimal data; no known fetal effects24
Dapsone
C
Limited data; use during pregnancy has not been associated with
increased risk of fetal malformations25
Glycolic acid
N
No evidence of adverse effects during pregnancy25
Salicylic acid
C
Low risk if restricted to local areas for limited duration25
Topical retinoids
Mild/
moderate/
severe
C-X
Not recommended during pregnancy24,25
Systemic medications
Amoxicillin
B
Short-term; avoid in first trimester—associated with oral clefts24,25
Cephalexin
B
No malformations in animal studies25
Macrolides (erythromycin is
drug of choice)
B
Short-term use; avoid in first trimester; AVOID erythromycin estolate,
as it is associated with hepatotoxicity in the second trimester25
Spironolactone
D
Feminization of male fetus24
Tetracyclines
D
Contraindicated after the 15th week of pregnancy24
Zinc
C
<75 mg/day; no increased risk of fetal abnormalities in animal
and human studies25,26
Photodynamic therapy
Narrowband and broadband
ultraviolet B light
Severe/
acne
fulminans
Considered acceptable during pregnancy25
Isotretinoin
X
Teratogenic; contraindicated in females of childbearing
potential unless patient is not pregnant or breastfeeding and
agrees to comply with mandatory contraceptive measures
(eg, concurrent use of two forms of contraception) in
accordance with the System to Manage Accutane Related
Teratogenicity™ (SMART™)27
Oral glucocorticoids
C
Human studies showed an increased risk of oral cleft and
a slight increase in miscarriage rates and preterm births;
short-term use after first trimester24
Doses limited to <20 mg/day over a course of ≤1 month during
the third trimester25
Sources: Murase JE, et al24; Chien AL, et al25; Dréno B, Blouin E26; Isotretinoin capsules [package insert].27
Vol. 37, No. 3S, June 2018, Seminars in Cutaneous Medicine and Surgery S69
■ ■ ■ Treating Acne in Adult Women
The Drugs and Lactation Database (LactMed) offered by
the National Institutes of Health (https://toxnet.nlm.nih.gov/
newtoxnet/lactmed.htm or LactMed@NIH) and available as a
mobile phone app (LactMed) enables users to search medications
for compatibility with lactation. Short-term use of oral azithromycin, clarithromycin, doxycycline, erythromycin (oral or topical),
minocycline, or tetracycline is considered compatible with lactation.
Oral clindamycin may cause adverse gastrointestinal (GI) effects in
the breastfed infant. Topical azelaic acid, topical clindamycin, and
oral spironolactone are considered acceptable for use during breastfeeding. Tetracycline may cause rash or GI effects in the infant.28
Summary
Acne is not uncommon in adult women.1 Treatment considerations specific to adult women include childbearing potential,
pregnancy, lactation, the presence of other dermatologic concerns
(eg, photoaging, hyperpigmentation, dryness), and the patient’s
desire to use acne therapies with cosmetics or other skin products.
Familiarity with the options for managing medical care for women
in the childbearing years and during pregnancy and lactation can
enhance the clinician’s capacity to address acne throughout a
woman’s adult years.
References
1. Collier CN, Harper JC, Cafardi JA, et al. The prevalence of acne in adults 20 years and
older. J Am Acad Dermatol. 2008;58:56-59.
2. Tanghetti EA, Kawata AK, Daniels SR, Yeomans K, Burk CT, Callender VD.
Understanding the burden of adult female acne. J Clin Aesthet Dermatol. 2014;7:22-30.
3. Del Rosso JQ, Harper JC, Graber EM, et al. Status report from the American Acne &
Rosacea Society on medical management of acne in adult women, part 1: Overview,
clinical characteristics, and laboratory evaluation. Cutis. 2015;96:236-241.
4. Del Rosso JQ, Kircik L, Gallagher CJ. Comparative efficacy and tolerability of dapsone
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2015;8:31-37.
5. Del Rosso JQ, Harper JC, Graber EM, Thiboutot D, Silverberg NB, Eichenfield LF.
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acne in adult women, part 2: Topical therapies. Cutis. 2015;96:321-325.
6. Berson D, Alexis A. Adapalene 0.3% for the treatment of acne in women. J Clin Aesthet
Dermatol. 2013;6:32-35.
7. Dréno B, Tan J, Rivier M, Martel P, Bissonnette R. Adapalene 0.1%/benzoyl peroxide
2.5% gel reduces the risk of atrophic scar formation in moderate inflammatory acne:
A split-face randomized controlled trial. J Eur Acad Dermatol Venereol. 2017;31:737-742.
8. Dréno B, Bissonnette R, Gagné-Henley A, et al. Prevention and reduction of atrophic
acne scars with adapalene 0.3%/benzoyl peroxide 2.5% gel in subjects with moderate
or severe facial acne: Results of a 6-month randomized, vehicle-controlled trial using
intra-individual comparison. Am J Clin Dermatol. 2018;19:275-286.
9. Draelos ZD, Rodriguez DA, Kempers SE, et al. Treatment response with once-daily
topical dapsone gel, 7.5% for acne vulgaris: Subgroup analysis of pooled data from two
randomized, double-blind studies. J Drugs Dermatol. 2017;16:591-598.
10. Tanghetti E, Harper JC, Oefelein MG. The efficacy and tolerability of dapsone 5% gel in
female vs male patients with facial acne vulgaris: Gender as a clinically relevant outcome
variable. J Drugs Dermatol. 2012;11:1417-1421.
11. Zeichner JA. The efficacy and tolerability of a fixed combination clindamycin (1.2%) and
benzoyl peroxide (3.75%) aqueous gel in adult female patients with facial acne vulgaris.
J Clin Aesthet Dermatol. 2015;8:21-25.
12. Harper JC. The efficacy and tolerability of a fixed combination clindamycin (1.2%) and
benzoyl peroxide (3.75%) aqueous gel in patients with facial acne vulgaris: Gender as a
clinically relevant outcome variable. J Drugs Dermatol. 2015;14:381-384.
13. Ortho Tri-Cyclen [package insert]. Titusville, NJ: Janssen Pharmaceuticals Inc; 2015.
14. Estrostep Fe [package insert]. Rockaway, NJ: Warner Chilcott (US) LLC; 2009.
15. Yaz [package insert]. Whippany, NJ: Bayer HealthCare Pharmaceuticals Inc; 2017.
16. Del Rosso JQ, Harper JC, Graber EM, Thiboutot D, Silverberg NB, Eichenfield LF.
Status report from the American Acne & Rosacea Society on medical management of
acne in adult women, part 3: Oral therapies. Cutis. 2015;96:376-382.
17. Frangos JE, Alavian CN, Kimball AB. Acne and oral contraceptives: Update on women’s
health screening guidelines. J Am Acad Dermatol. 2008;58:781-786.
18. Isvy-Joubert A, Nguyen JM, Gaultier A, et al. Adult female acne treated with spironolactone: A retrospective data review of 70 cases. Eur J Dermatol. 2017;27:393-398.
19. Charny JW, Choi JK, James WD. Spironolactone for the treatment of acne in women, a
retrospective study of 110 patients. Int J Womens Dermatol. 2017;3:111-115.
20. Aldactone [package insert]. New York, NY: Pfizer Inc; 2018.
21. Plovanich M, Weng Q, Mostaghimi A. Low usefulness of potassium monitoring among
healthy young women taking spironolactone for acne. JAMA Dermatol. 2015;151:941-944.
S70 Seminars in Cutaneous Medicine and Surgery, Vol. 37, No. 3S, June 2018
22. Cakir GA, Erdogan FG, Gurler A. Isotretinoin treatment in nodulocystic acne with and
without polycystic ovary syndrome: Efficacy and determinants of relapse. Int J Dermatol.
2013;52:371-376.
23. Tan J, Knezevic S, Boyal S, Waterman B, Janik T. Evaluation of evidence for acne remission with oral isotretinoin cumulative dosing of 120-150 mg/kg. J Cutan Med Surg.
2016;20:13-20.
24. Murase JE, Heller MM, Butler DC. Safety of dermatologic medications in pregnancy
and lactation: Part I. Pregnancy. J Am Acad Dermatol. 2014;70:401.e1-401.e14.
25. Chien AL, Qi J, Rainer B, Sachs DL, Helfrich YR. Treatment of acne in pregnancy. J Am
Board Fam Med. 2016;29:254-262.
26. Dréno B, Blouin E. Acne, pregnant women and zinc salts: A literature review [in French].
Ann Dermatol Venereol. 2008;135:27-33.
27. Isotretinoin capsules [package insert]. Bridgewater, NJ: Amneal Pharmaceuticals LLC; 2017.
28. US National Library of Medicine. Drugs and Lactation Database (LactMed). https://
toxnet.nlm.nih.gov/newtoxnet/lactmed.htm. Accessed April 8, 2018.
Treating Acne in Patients With Skin of Color
Andrew F. Alexis, MD, MPH,* Julie C. Harper, MD,† Linda F. Stein Gold, MD,‡
and Jerry K. L. Tan, MD, FRCPC§
■ Abstract
Patients with skin of color are more likely to develop acne and
postinflammatory hyperpigmentation (PIH). Many therapies
for acne have demonstrated efficacy in darker skin types and
in the treatment of PIH.
Semin Cutan Med Surg 37(supp3):S71-S73
© 2018 published by Frontline Medical Communications
■ Keywords
Acne; Fitzpatrick skin types IV-VI; postinflammatory hyperpigmentation; skin of color
A
cne has been reported as one of the most common dermatologic conditions in numerous racial/ethnic groups studied.1,2
Although differences in acne prevalence between racial/
ethnic groups have not been well established, distinct variations in
clinical presentation, exacerbating factors, and sequelae of acne are
frequently observed in patients with skin of color (ie, Fitzpatrick
skin types [FST] IV-VI). These distinctions inform patient care.
* Chair, Department of Dermatology, Director of The Skin of Color
Center, Mount Sinai St. Luke’s and Mount Sinai West, Associate
Professor of Dermatology, Icahn School of Medicine at Mount Sinai,
New York, New York
† Clinical Associate Professor of Dermatology, University of Alabama
at Birmingham, Dermatology and Skin Care Center of Birmingham,
Birmingham, Alabama
‡
Director of Dermatology Clinical Research, Division Head of
Dermatology, Henry Ford Hospital, Detroit, Michigan
§
Adjunct Professor, Schulich School of Medicine & Dentistry, Western
University, Windsor, Ontario, Canada
Publication of this CME/CE article was jointly provided by University
of Louisville, Postgraduate Institute for Medicine, and Global Academy
for Medical Education, LLC, and is supported by an educational
grant from Bayer. The authors have received an honorarium for their
participation in this activity. They acknowledge the editorial assistance
of Eileen A. McCaffrey, MA, medical writer, and Global Academy
for Medical Education in the development of this continuing medical
education journal article.
Andrew F. Alexis, MD, MPH, Consultant: Allergan plc, BioPharmX, Inc.,
Galderma Laboratories, L.P. Contracted Research: Allergan plc,
BioPharmX, Inc., Galderma Laboratories, L.P., Novan, Inc.
Julie C. Harper, MD, Consultant: Allergan plc, Bayer AG, BioPharmX,
Inc., Galderma Laboratories, L.P., La Roche-Posay, Novan, Inc., Ortho
Dermatologics. Contracted Research: Bayer AG. Speakers Bureau:
Allergan plc, Bayer AG, La Roche-Posay, Ortho Dermatologics.
Linda F. Stein Gold, MD, Consultant: Allergan plc, Dermira, Inc.,
Foamix Pharmaceuticals Ltd., Galderma Laboratories, L.P., Medimetriks
Pharmaceuticals, Inc., Novan, Inc., Valeant Pharmaceuticals International,
Inc. Contracted Research: Allergan plc, Dermira, Inc., Foamix Pharmaceuticals
Ltd., Galderma Laboratories, L.P., Novan, Inc., Valeant Pharmaceuticals
International, Inc. Speakers Bureau: Allergan plc, Galderma Laboratories, L.P.,
Valeant Pharmaceuticals International, Inc.
Jerry K. L. Tan, MD, FRCPC, Consultant: Allergan plc, Galderma
Laboratories, L.P., Valeant Pharmaceuticals International, Inc.
Contracted Research: Dermira, Inc., Galderma Laboratories, L.P.,
Valeant Pharmaceuticals International, Inc. Speakers Bureau: Galderma
Laboratories, L.P., Valeant Pharmaceuticals International, Inc.
Address reprint requests to: Andrew F. Alexis, MD, MPH, Mount Sinai
St. Luke’s and Mount Sinai West, 100 Amsterdam Avenue, Suite 11B,
New York, NY 10025; alexisderm@yahoo.com
1085-5629/13/$-see front matter © 2018 Frontline Medical Communications
doi: 10.12788/j.sder.2018.027
Prevalence
At least one study (N=2,895)—an evaluation based on photographs—
reported that acne is more common in African American and
Hispanic women (37% and 32%, respectively) than in Continental
Indian, Caucasian, and Asian women (23%, 24%, and 30%, respectively).3 Findings await confirmation by a comparable study.
Postinflammatory Hyperpigmentation
Postinflammatory hyperpigmentation (PIH), a darkened area of
skin following trauma or cutaneous inflammation following acne,
results from an abnormal release or overproduction of melanin
(Figure).4,5 It is more common in African American and Hispanic
women than in Continental Indian, Asian, or Caucasian women,
according to a survey of 208 adult women with facial acne (49%
non-Caucasian, 51% Caucasian).1,3 Nearly half (49.5%) of the nonCaucasian women reported “a lot” or “extensive” PIH, compared
with 22.5% of Caucasian women.1 A study of photographs from
2,895 females aged 10 to 70 years old also found that hyperpigmentation was more common in African American and Hispanic
women (65% and 48%, respectively) than in Continental Indian,
Asian, and Caucasian (10%, 18%, and 25%, respectively) women.3
PIH may be more distressing to people of color than to lighterskinned patients; it was rated as “severely troublesome” by nearly
half (48.5%) of non-Caucasian women with acne in one study.1
Another analysis confirmed this finding.6 PIH-associated discoloration may persist well beyond the acne lesions that triggered it.
Epidermal PIH may persist for 6 to 12 months; dermal PIH can
last for years.5,7
■ FIGURE Postinflammatory Hyperpigmentation
Source: Courtesy of Andrew F. Alexis, MD, MPH
Vol. 37, No. 3S, June 2018, Seminars in Cutaneous Medicine and Surgery S71
■ ■ ■ Treating Acne in Patients With Skin of Color
A histological examination of acne lesions from black females
showed marked inflammation, beyond what would be expected
based on clinical examination. Skin taken from sites not near
the acne lesions also displayed inflammation. Hyperpigmented
macules with melanin granules were identified in the epidermis,
with pigment-filled macrophages detected in the dermis.8 According
to an analysis of patients seen at a single center specializing in the
care of skin of color, acne hyperpigmented macules were identified
in 65.3% of 239 African American patients, 52.7% of 55 Hispanic
patients, and 47.4% of 19 Asian patients. These findings could
account for the development of PIH in patients with skin of color.9
Patient History and Education
The use of certain hair oils and emollients to moisturize the hair
and scalp can result in pomade acne, characterized by closely
packed, closed comedones and small papules along the hairline.10
Makeup or skin care products may induce or worsen acne, or may
irritate or dry the skin. Skin lightening or bleaching creams may
irritate the skin or cause acne, especially if they contain steroids.
Patient history should include a list of all skin, hair, and cosmetic
products used. Some products may lead to dryness or irritation
when combined with topical acne medications.11 Educating patients
to avoid substances that may contribute to their acne or PIH is an
important aspect of therapy.
Daily sunscreen use can reduce the intensity of PIH, even
in people with darker skin.12 A study in African American and
Hispanic individuals who did not use sunscreen found that 8 weeks
of sunscreen use with sun protection factor 30 or 60 lightened
facial and hand pigmentary abnormalities.13 Patients who do not
use sunscreen should be educated to do so.14
In a study of patients of Afro-Caribbean ancestry, family history
was associated with the formation of keloid scars in multiple sites
rather than a single site.15
More than two-thirds of Caucasian and non-Caucasian women
alike expected to see results from acne treatment within 2 weeks,
according to a patient survey. Some expected benefits overnight.1 To
set expectations and promote adherence to therapy, patients should be
educated that resolution of acne and PIH often takes several weeks.4,5
Topical Therapy for Acne and PIH
Early, aggressive treatment is recommended in patients with skin
of color to minimize the risk of PIH and scarring. This imperative
must be balanced by the need to avoid skin irritation due to therapy,
which can result in dyspigmentation and can worsen PIH.4,5,11
Treatment of acne is key to the management of PIH to prevent or
reduce the risk of further dark marks. In patients with PIH and
acne, consider therapies that address both conditions.
Several therapies recommended in the management of acne and/or
PIH have data supporting their efficacy in patients with skin of color.
Topical Retinoids
These agents represent first-line acne therapy both in patients with
skin of color and in Caucasian patients.2,11 Starting at a lower
concentration (0.025% tretinoin, for example) or applying every
other day is recommended in patients with skin of color to reduce
the risk of irritation.
Topical retinoids are an attractive option in patients with skin
of color because they can treat acne and may lighten areas of
hyperpigmentation in black patients (P<0.001 vs vehicle after 40
weeks of therapy). In one study, half of 24 subjects randomized
to topical tretinoin 0.1% developed retinoid reactions where the
medication was applied; reactions diminished in severity, duration, and frequency as the study progressed.16
S72 Seminars in Cutaneous Medicine and Surgery, Vol. 37, No. 3S, June 2018
Once-daily tazarotene 0.1% cream has demonstrated efficacy
compared with vehicle in the treatment of PIH in 74 patients with
skin of color.17
A recent post hoc analysis of data from a 12-week, phase 3
study of adapalene 0.3%/benzoyl peroxide 2.5% (ADAP 0.3%/
BPO 2.5%) found that the active therapy was significantly superior
to vehicle for reduction of both inflammatory and noninflammatory lesions. When the study population was analyzed by FST, the
proportion of subjects achieving scores of clear or almost clear
on the Investigator Global Assessment (IGA) with active therapy
was superior to vehicle only for those with lighter skin (FST I-III;
n=128, ADAP 0.3%/BPO 2.5%; n=43, vehicle).18 These authors
noted that only a small number of subjects were randomized to
vehicle in the FST IV-VI group (n=89, ADAP 0.3%/BPO 2.5%;
n=26, vehicle), reducing the statistical power of the analysis.
They also speculated that the presence of PIH lesions might
have affected the IGA. This study did not examine the impact of
therapy on PIH.
Topical Antibiotics
A post hoc analysis of data from a phase 3, 12-week, vehiclecontrolled clinical trial of clindamycin 1.2%/BPO 3.75% gel found
that efficacy in Hispanic subjects (n=136) with moderate to severe
acne was similar to that of the general study population. The
treatment was well tolerated in the Hispanic cohort; no treatmentrelated adverse events were reported, and no subjects discontinued
therapy due to adverse events.19
Dapsone
Topical dapsone 5% is recommended for the treatment of
inflammatory acne, especially in adult females.2 In a study of 68
adult women with acne and skin of color (FST IV-VI), topical
dapsone gel 5% monotherapy applied twice daily for 12 weeks
significantly reduced the investigator-rated 5-point Global Acne
Assessment Score (GAAS) from baseline (mean, −1.2; 95% confidence interval, −1.4 to −1.0; P<0.001; 39% improvement). Nearly
43% of subjects had a GAAS of 0 or 1 at week 12. No treatment-related adverse events were observed.20 Race (Caucasian/
non-Caucasian) did not affect the efficacy of dapsone 7.5% gel
in a pooled subgroup analysis of data from two phase 3 trials
(N=4,340; moderate inflammatory and noninflammatory acne).21
A pooled analysis of data from two phase 3 trials of dapsone 7.5%
and vehicle in patients (N=4,327) with moderate acne stratified by
FST (I-III, IV-VI) supported these findings, reporting efficacy in
both groups.22
Azelaic Acid
A pilot study of azelaic acid 15% gel twice daily led to improvement
of both acne and PIH in adults (N=20) with FST IV and mild or
moderate acne and moderate or severe PIH.23 After 16 weeks, 85%
of patients had achieved at least a 2-point improvement in IGA for
acne, and all (100%) had at least a 2-point improvement in IGA
for PIH.23
Hydroquinone
Topical hydroquinone is considered the gold standard therapy
for skin lightening and is often the first therapy used in treating
PIH.4,11 Hydroquinone 4% combined with 0.15% retinol and antioxidants can reduce lesion size, pigmentation, and disease severity
in patients with hyperpigmentation on the face and body (FST
II-VI).24
Andrew F. Alexis, MD, MPH, Julie C. Harper, MD, Linda F. Stein Gold, MD, and Jerry K. L. Tan, MD, FRCPC
To avoid unwanted lightening of normal skin, hydroquinone
should be applied only to areas of PIH. In our practice, we limit
the use of hydroquinone to lesions large enough to be amenable
to spot application (>4 mm). For smaller areas, consider using
topical retinoids or azelaic acid because these agents can be
applied to normal as well as affected skin. Exogenous ochronosis,
a blue-black darkening of the skin, is a risk of long-term hydroquinone use.25
Procedural Therapies for PIH
Topical agents, considered to be first-line choices for PIH, are more
likely to be efficacious in epidermal than dermal lesions. Superficial
chemical peels and laser therapy offer alternatives for treating
dermal lesions and in those that respond inadequately to topical
options.26 Caution must be exercised because these interventions
can cause or exacerbate PIH.3 Medium-depth peels are associated
with a higher risk of postprocedure PIH than superficial chemical
peels. Deep peels are contraindicated in patients with skin of color
due to the effects on skin pigment and risk of scarring.4
Superficial Chemical Peels
Adding serial glycolic acid peels (every 3 weeks) to a topical
regimen containing hydroquinone 2%, tretinoin 0.05%, and hydrocortisone 1% improved the results of facial PIH treatment in
30 patients with FST III-V, compared with the topical
regimen alone.25 Patients were treated for 18 weeks. The mean
Hyperpigmentation Area and Severity Index score at 12 and 21
weeks showed significantly greater improvement with the peels.27
Salicylic acid peels have demonstrated efficacy in PIH when
combined with topical therapy but not as monotherapy.4,28-31
In our practice, we instruct patients to stop retinoid therapy
1 week prior to chemical peel therapy to reduce the risk of crusting,
erosion, and PIH. BPO, azelaic acid, or dapsone can be used up to
the day of the peel.
Laser Therapy
The quality of the evidence for the use of lasers in the treatment
of PIH for patients with skin of color is low; most data come from
small, nonrandomized clinical trials, case reports, and case studies.4
Summary
PIH and scarring occur more often in patients with skin of color
than in Caucasian patients. These sequelae may be more distressing
to the patient than acne. The need for early, aggressive treatment of
acne to prevent PIH and scarring must be balanced with the need to
avoid skin irritation, which itself can cause dyspigmentation. Many
therapies for acne have been studied in patients with skin of color.
Treatments that address both acne and PIH are good choices for
patients with both conditions.
References
1. Callender VD, Alexis AF, Daniels SR, et al. Racial differences in clinical characteristics,
perceptions and behaviors, and psychosocial impact of adult female acne. J Clin Aesthet
Dermatol. 2014;7:19-31.
6. Gorelick J, Daniels SR, Kawata AK, et al. Acne-related quality of life among female
adults of different races/ethnicities. J Dermatol Nurses Assoc. 2015;7:154-162.
7. Lacz NL, Vafaie J, Kihiczak NI, Schwartz RA. Postinflammatory hyperpigmentation:
A common but troubling condition. Int J Dermatol. 2004;43:362-365.
8. Halder RM, Holmes YC, Bridgeman-Shah S, Kligman AM. A clinicohistopathologic study
of acne vulgaris in black females [abstract]. J Invest Dermatol. 1996;106:888.
9. Taylor SC, Cook-Bolden F, Rahman Z, Strachan D. Acne vulgaris in skin of color. J Am
Acad Dermatol. 2002;46(2 suppl understanding):S98-S106.
10. Davis EC, Callender VD. A review of acne in ethnic skin: Pathogenesis, clinical
manifestations, and management strategies. J Clin Aesthet Dermatol. 2010;3:24-38.
11. Callender VD, Barbosa V, Burgess CM, et al. Approach to treatment of medical and
cosmetic facial concerns in skin of color patients. Cutis. 2017;100:375-380.
12. Maymone MBC, Neamah HH, Wirya SA, Patzelt NM, Zancanaro PQ, Vashi NA.
Sun-protective behaviors in patients with cutaneous hyperpigmentation: A cross-sectional
study. J Am Acad Dermatol. 2017;76:841-846.e2.
13. Halder R, Rodney I, Munhutu M, et al. Evaluation and effectiveness of a photoprotection
composition (sunscreen) on subjects of skin of color [abstract]. J Am Acad Dermatol.
2015;72(suppl):AB215.
14. Davis EC, Callender VD. Postinflammatory hyperpigmentation: A review of the
epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet
Dermatol. 2010;3:20-31.
15. Bayat A, Arscott G, Ollier WE, McGrouther DA, Ferguson MW. Keloid disease: Clinical
relevance of single versus multiple site scars. Br J Plast Surg. 2005;58:28-37.
16. Bulengo-Ransby SM, Griffiths CE, Kimbrough-Green CK, et al. Topical tretinoin
(retinoic acid) therapy for hyperpigmented lesions caused by inflammation of the skin in
black patients. N Engl J Med. 1993;328:1438-1443.
17. Grimes P, Callender V. Tazarotene cream for postinflammatory hyperpigmentation and
acne vulgaris in darker skin: A double-blind, randomized, vehicle-controlled study. Cutis.
2006;77:45-50.
18. Alexis AF, Cook-Bolden FE, York JP. Adapalene/benzoyl peroxide gel 0.3%/2.5%: A safe
and effective acne therapy in all skin phototypes. J Drugs Dermatol. 2017;16:574-581.
19. Alexis AF, Cook-Bolden F, Lin T. Treatment of moderate-to-severe acne vulgaris in a
Hispanic population: A post-hoc analysis of the efficacy and tolerability of clindamycin
1.2%/benzoyl peroxide 3.75% gel. J Clin Aesthet Dermatol. 2017;10:36-43.
20. Alexis AF, Burgess C, Callender VD, et al. The efficacy and safety of topical dapsone
gel, 5% for the treatment of acne vulgaris in adult females with skin of color. J Drugs
Dermatol. 2016;15:197-204.
21. Draelos ZD, Rodriguez DA, Kempers SE, et al. Treatment response with once-daily
topical dapsone gel, 7.5% for acne vulgaris: Subgroup analysis of pooled data from two
randomized, double-blind studies. J Drugs Dermatol. 2017;16:591-598.
22. Taylor SC, Cook-Bolden FE, McMichael A, et al. Efficacy, safety, and tolerability of
topical dapsone gel, 7.5% for treatment of acne vulgaris by Fitzpatrick skin phototype.
J Drugs Dermatol. 2018;17:160-167.
23. Kircik LH. Efficacy and safety of azelaic acid (AzA) gel 15% in the treatment of postinflammatory hyperpigmentation and acne: A 16-week, baseline-controlled study. J Drugs
Dermatol. 2011;10:586-590.
24. Cook-Bolden FE, Hamilton SF. An open-label study of the efficacy and tolerability
of microencapsulated hydroquinone 4% and retinol 0.15% with antioxidants for the
treatment of hyperpigmentation. Cutis. 2008;81:365-371.
25. Hydroquinone 4% cream [package insert]. Bronx, NY: Perrigo; 2017.
26. Vashi NA, Wirya SA, Inyang M, Kundu RV. Facial hyperpigmentation in skin of color:
Special considerations and treatment. Am J Clin Dermatol. 2017;18:215-230.
27. Sarkar R, Parmar NV, Kapoor S. Treatment of postinflammatory hyperpigmentation
with a combination of glycolic acid peels and a topical regimen in dark-skinned patients:
A comparative study. Dermatol Surg. 2017;43:566-573.
28. Joshi SS, Boone SL, Alam M, et al. Effectiveness, safety, and effect on quality of life of
topical salicylic acid peels for treatment of postinflammatory hyperpigmentation in dark
skin. Dermatol Surg. 2009;35:638-644.
29. Grimes PE. The safety and efficacy of salicylic acid chemical peels in darker racial-ethnic
groups. Dermatol Surg. 1999;25:18-22.
2. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of
acne vulgaris. J Am Acad Dermatol. 2016;74:945-973.e33.
30. Mohamed Ali BM, Gheida SF, El Mahdy NA, Sadek SN. Evaluation of salicylic acid
peeling in comparison with topical tretinoin in the treatment of postinflammatory
hyperpigmentation. J Cosmet Dermatol. 2017;16:52-60.
3. Perkins AC, Cheng CE, Hillebrand GG, Miyamoto K, Kimball AB. Comparison of the
epidemiology of acne vulgaris among Caucasian, Asian, Continental Indian and African
American women. J Eur Acad Dermatol Venereol. 2011;25:1054-1060.
31. Ahn HH, Kim IH. Whitening effect of salicylic acid peels in Asian patients. Dermatol
Surg. 2006;32:372-375.
4. Kaufman BP, Aman T, Alexis AF. Postinflammatory hyperpigmentation: Epidemiology,
clinical presentation, pathogenesis and treatment. Am J Clin Dermatol. 2017. doi:
0.1007/540257-017-0333-6.
5. Yin NC, McMichael AJ. Acne in patients with skin of color: Practical management.
Am J Clin Dermatol. 2014;15:7-16.
Vol. 37, No. 3S, June 2018, Seminars in Cutaneous Medicine and Surgery S73
Acne and Rosacea: Applying Emerging Science to Improve Outcomes
CME/CE Post-Test and Evaluation Form
FOR REVIEW PURPOSES ONLY.
MUST BE COMPLETED ONLINE.
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for Medical Education office at info@globalacademycme.com.
1. Which of the following accurately describes the use of
medications for acne during pregnancy:
A. Any topical medication is safe
B. Topical retinoids should not be used at any time during
pregnancy
C. All systemic medications for acne should be avoided
during all of pregnancy
D. Large studies generating high-quality data document the
appropriate use of acne medications during pregnancy
2. Truncal acne:
A. Is present in no more than a quarter of patients with acne
B. Is not responsive to topical treatments
C. Has responded to therapy with azelaic acid foam 15% in a
small open-label study
D. Is an exception to the American Academy of Dermatology
(AAD) guidelines’ recommended limits on the use of
systemic antibiotics
3. Which of the following acne therapies also is efficacious in
the treatment of photodamage?
A. Topical antibiotics
B. Topical azelaic acid
C. Topical benzoyl peroxide (BPO)
D. Topical retinoids
4. Data suggest that postinflammatory hyperpigmentation (PIH):
A. Is more common in African American and Hispanic women
than in Continental Indian, Asian, or Caucasian women
B. Virtually always resolves at the same time as the acne
lesions that triggered it
EVALUATION FORM
MD/DO
MSN/BSN/RN
C. Is not responsive to the use of sunscreen in patients with
darker skin
D. Is best treated separately from, and after resolution of, the
acne with which it is associated
5. What percentage of patients with moderate or severe rosacea
achieved an Investigator Global Assessment (IGA) score of
clear/almost clear after concomitant use of ivermectin 1%
cream and brimonidine 0.33% gel for 12 weeks?
A. <30%
B. 35% to 45%
C. 50% to 60%
D. >60%
6. Which of the following topical therapies has been
associated with reduced risk of scar formation due to acne?
A. Dapsone 5%
B. Adapalene (ADAP) 0.1%/BPO 2.5% and ADAP 0.3%/BPO
2.5%
C. Clindamycin 1.2%/BPO 3.75% gel
D. Azelaic acid 15% gel
7. Procedural therapies for PIH:
A. Are first-line alternatives for treating both epidermal and
dermal lesions
B. Cannot worsen PIH
C. Include superficial peels that can be combined with
topical therapies
D. Include deep peels, which can be especially successful in
patients with skin of color
8. Research indicates that Propionibacterium acnes:
A. Is always pathogenic
B. Includes some phylotypes associated with healthy skin and
anti-inflammatory effects
C. Overgrowth is triggered by hormones (insulin-like growth
factor–1, insulin, and androgens), which promote increased
sebum production and a change in sebum quality
D. B and C
9. According to the AAD guidelines and a consensus statement
from the Global Alliance to Improve Outcomes in Acne:
A. Monotherapy with systemic antibiotics is not
recommended; short-term monotherapy (3 months) with
topical antibiotics is acceptable
B. Monotherapy with antibiotics—either topical or systemic—
is not recommended
C. Long-term systemic antibiotic use is acceptable in
combination with nonantibiotic therapy and with
appropriate monitoring
D. Combining two antibiotic therapies is an acceptable alternative
to combining an antibiotic and a nonantibiotic therapy
10. What percentage of patients with moderate or severe
papulopustular rosacea achieved an IGA score of clear/
almost clear and ≥2-grade improvement after 12 weeks of
azelaic acid 15% foam twice daily?
A. <20%
B. 20% to 30%
C. 30% to 40%
D. 40% to 50%
Please indicate your profession/background: (check one)
PA
APN/NP
PharmD/RPh
Resident/Fellow Researcher
Administrator
LEARNING OBJECTIVES: Having completed this activity, you are better able to:
Student
Strongly Agree
Other; specify ________________________________
Agree
Somewhat Agree
Disagree
Strongly Disagree
Design a comprehensive treatment plan for patients with acne based on clinical guidelines and updated research,
incorporating pharmacologic and physical modalities
5
4
3
2
1
Discuss and design treatment plans for patients of color, pregnant patients, and those with truncal acne, scarring,
and photoaging
5
4
3
2
1
Recognize the significant impact of acne in patients’ lives, and of treating promptly and appropriately
5
4
3
2
1
Apply treatment strategies, based on knowledge of the indications, efficacy, and risks of available rosacea therapies, to
achieve therapeutic goals in rosacea treatment
5
4
3
2
1
If you do not feel confident that you can achieve the above objectives to some extent, please
describe why not.
___________________________________________________________________________________
___________________________________________________________________________________
Based on the content of this activity, what will you do differently in the care of your patients/
regarding your professional responsibilities? (check one)
Implement a change in my practice/workplace.
Seek additional information on this topic.
Do nothing differently. Current practice/job responsibilities reflect activity recommendations.
Do nothing differently as the content was not convincing.
Do nothing differently. System barriers prevent me from changing my practice/workplace.
OVERALL EVALUATION
If you anticipate changing one or more aspects of your practice/professional responsibilities as a
result of your participation in this activity, please briefly describe how you plan to do so.
___________________________________________________________________________________
If you plan to change your practice/workplace, may we contact you in 2 months to see how you
are progressing?
Yes. E-mail address: ___________________________________________
No.
I don’t plan to make a change.
If you are not able to effectively implement what you learned in this activity, please tell us what
the system barriers are (eg, institutional systems, lack of resources, etc)?
___________________________________________________________________________________
___________________________________________________________________________________
Strongly Agree
Agree
Somewhat Agree
Disagree
Strongly Disagree
The information presented increased my awareness/understanding of the subject.
5
4
3
2
1
The information presented will influence how I practice/do my job.
5
4
3
2
1
The information presented will help me improve patient care/my job performance.
5
4
3
2
1
The program was educationally sound and scientifically balanced.
5
4
3
2
1
Overall, the program met my expectations.
5
4
3
2
1
I would recommend this program to my colleagues.
5
4
3
2
1
Author demonstrated current knowledge of the topic.
5
4
3
2
1
Author was organized in the written materials.
5
4
3
2
1
Author demonstrated current knowledge of the topic.
5
4
3
2
1
Author was organized in the written materials.
5
4
3
2
1
Author demonstrated current knowledge of the topic.
5
4
3
2
1
Author was organized in the written materials.
5
4
3
2
1
Author demonstrated current knowledge of the topic.
5
4
3
2
1
Author was organized in the written materials.
5
4
3
2
1
Andrew F. Alexis, MD, MPH
Julie C. Harper, MD
Linda F. Stein Gold, MD
Jerry K. L. Tan, MD, FRCPC
What topics do you want to hear more about, and what issue(s) regarding your practice/professional
responsibilities will they address?
___________________________________________________________________________________
___________________________________________________________________________________
Please provide additional comments pertaining to this activity and any suggestions
for improvement.
___________________________________________________________________________________
___________________________________________________________________________________
The University of Louisville, Postgraduate Institute for Medicine, and Global Academy for Medical Education thank you for your participation in this CME/CE activity. All information provided improves the scope and purpose of our programs and your patients’ care.
© 2018 Global Academy for Medical Education, LLC. All Rights Reserved.