Neonatal Acne

Neonatal acne is present at birth or appears shortly after. It is more common than fully appreciated if the diagnosis is based in a few comedones more than 20 of newborns are affected 1 . The most common lesions are comedones, papules and pustules. They are few in number and usually localized on the face, more often cheeks and forehead. Involvement of the chest, back or groins has been reported. Most cases are mild and transient. Lesions appear mainly at 2-4 weeks healing spontaneously, without...

Therapeutic Targets and Acne Drugs

Several clinical observations point to the importance of androgens in acne 23 . Androgens play an essential role in stimulating sebum production androgen-insensitive subjects who lack functional androgen receptors do not produce sebum and do not develop acne. Moreover, systemic administration of testosterone and dehydro-epiandrosterone increases the size and secretion of sebaceous glands 24-27 . Sebosuppression, i.e. suppression of sebaceous gland hyperactivity, can classically be achieved by...

Abstract

Hypercornification is an early feature of acne and usually precedes inflammation. It is associated with ductal hy-perproliferation, and there are many controlling factors such as androgens, retinoids, sebum composition and cytokines. Cycling of normal follicles and of comedones may explain the natural resolution of comedones and, in the longer term, resolution of the disease itself. There is a need to tailor treatment according to comedonal type. Suboptimal therapy can often result from...

Tamibaroten Palmitate

During the last 20 years, the number of topical and systemic drugs for the treatment of acne vulgaris has been enriched. Topical drugs on the one hand have been newly discovered or further developments of already available agents such as in the group of retinoids or galenic formulation have improved efficacy or local tolerance. Topical retinoids are a mainstay in acne treatment since 1962. All-trans retinoic acid was the first and is still in use. Its irritative potential has led to the new...

Conclusion

We have made reference to less common therapies used in clinical forms of acne. Even though some of them may be rather infrequent nowadays, they are worth considering on the following grounds (a) cases of hypersensi-bility reactions or allergy to drugs (b) high cost of the drugs which render them unaffordable to large sectors of the population not covered by health insurance plans, even in industrialized countries, or to poor people in emerging countries (c) unavailability of the drug in the...

Sebaceous Glands in Acne

Pathogenesis Acne

It is generally accepted that sebaceous glands were not innervated and the peripheral nervous system has no effect on the sebaceous biology. Indeed, nerve fibers, as documented immunohistochemically using the general neuronal marker PGP 9.5, were rarely observed around the sebaceous glands in normal facial skin. In contrast, facial skin from acne patients shows numerous fine nerve fibers not only around but also within sebaceous acini 19 . Numerous nerve endings were also observed in close...

New Topical Retinoids

Comedonal Acne Anatomy

New topical anti-acne therapies are required for several reasons. There is no topical anti-acne therapy which reduces lesions by over 60 in contrast to, for example, oral isotretinoin which can suppress lesions by 100 . This may simply be a measure of penetration of the drug. Most topical therapies frequently produce an irritant dermatitis, and this will reduce compliance. Many antibiotics have been shown to produce resistant P. acnes, and this is associated in some patients with clinical...

Aetiology of Comedogenesis

Hybridization Vitro Technique

Comedogenesis is due to the accumulation of corneo-cytes in the pilosebaceous duct 5 . This could be due to hyperproliferation of ductal keratinocytes, inadequate separation of the ductal corneocytes or a combination of both factors 6 . There is reasonable evidence to support the hyperproliferation of ductal keratinocytes 7 . This has been demonstrated immunohistochemically using a monoclonal antibody to Ki67, a nuclear marker expressed by actively cycling cells, which labels increased numbers...

Infantile Acne

Infantile acne IA usually starts later than neonatal acne, generally between 6 and 9 months range 6-16 months 16 . It also presents a male predominance. Lesions are localized on the face with the cheeks being the area most affected. A large survey on IA has been recently published showing that IA was mainly moderate in 62 of cases and mild and severe in 24 and 17 of cases, respectively. In addition to open and closed comedones, there were 59 of cases with inflammatory lesions and 17 with scars...

Physical Treatment

Many abrasive materials, usually based on polyethylene and aluminum oxide, are of little value. Mechanical extraction of open comedones, by applying light pressure over individual lesions with a come-done extractor, may be useful. There is a great variety of specially shaped tools, particularly for blackhead removal. Light cautery after the application of a local anesthetic with EMLA cream 0.025 lidocaine and 0.025 prilo-caine for 60-90 min beneath an occlusive dressing, has been shown to help...

Screening for an Endocrine Disorder

A medical history and physical examination directed towards eliciting any symptoms or signs of hyperan-drogenism should be performed. Screening tests for hyperandrogenism include serum DHEAS, total testosterone, free testosterone, and luteinizing hormone follicle-stimulating hormone LH FSH ratio. In some cases additional information can be gained from a serum level of 17-hydroxypregnenolone. These tests should be obtained in the luteal phase of the menstrual cycle within 2 weeks prior to the...

Introduction

Both clinical observation and experimental evidence confirm the importance of hormones in the pathophysiology of acne. Hormones are best known for their effects on sebum excretion. It has also been suggested that hormones may play a role in the follicular hyperkeratinization seen in follicles affected by acne 1-3 . From a therapeutic standpoint, the importance of the role of hormones in acne is supported by the clinical efficacy of hormonal therapy in women with acne. Although we know that...

Adapalene

Adapalene is a third-generation retinoid available as cream, gel or solution in 0.1 concentration. Currently, clinical studies comparing 0.1-0.3 adapalene are being performed. In a survey on nearly 1,000 patients, it could be demonstrated that adapalene 0.1 gel has the same efficacy as tretinoin gel 0.025 . The number of acne lesions was reduced by between 49 and 62 . The compar ison of tretinoin microsphere formulation demonstrated a similar efficacy but lower irritative potential of adapalene...

Androgens and Sebum Production

Acne Vulgaris

The majority of potent androgens are produced by peripheral target tissues. For example, in postmenopausal women, 100 of active sex steroids are synthesized in peripheral target tissues from inactive steroid precursors while in adult men approximately 50 of androgens are locally made in intracrine target tissues 4 . The major androgens that interact with the androgen receptor are testosterone and dihydrotestosterone. Androgen receptors have been localized to the basal layer of the sebaceous...

References

1 Koo JY, Smith LL Psychologic aspects of acne. Pediatr Dermatol 1991 8 185-188. 2 Koblenzer CS Psychotherapy for intractable inflammatory dermatoses. J Am Acad Dermatol 1995 32 609-612. 3 Panconesi E, Hautmann G Psychotherapeutic approach in acne treatment. Dermatology 1998 196 116-118. 4 Ansel JC, Kaynard AH, Armstrong CA, Olerud J, Bunnett N, Payan D Skin-nervous system interactions. J Invest Dermatol 1996 106 198-204 5 Misery L Skin, immunity and the nervous system. Br J Dermatol 1997 137...

Mast Cells in Acne Inflammation

Human Inflammation Cells Pcr

Increasing attention has been directed towards interactions between components of the nervous system and multiple target cells of the immune system. Communication between nerves and MCs is a prototypic demonstration of such neuroimmune interactions. Several studies have demonstrated that MCs are often found in close contact with nerves and that there may be a functional interaction between mast cells and the nervous system 28 . In addition, recent evidence suggests that SP is an important...

Prepubertal Acne

Increasing number of early onset acne before obvious signs of puberty is a recognized phenomenon associated more with pubertal development than with age. There is apparently a genetic predisposition. Pubertal development has two components, normal adrenarche related to maturation of adrenal glands and true puberty because of maturation of testis and ovary mediated by the hypothalamic-pituitary axis. Adrenarche presents with high levels of DHEA and DHEAS that start rising at 6-7 years in girls...

Mid Childhood Acne

This type of acne occurs between 1 and 7 years of age. Acne is very rare in this group and when it occurs should be evaluated for hyperandrogenemia. Differential diagnosis includes Cushing's syndrome, congenital adrenal hyperplasia, gonadal or adrenal tumors and a true precocious puberty. Evaluation should be done with a bone age measurement, growth chart and laboratory tests that include serum total and free testosterone, DHEA, DHEAS, LH, FSH, prolactin and 17a-hydroxyprogesterone. Occasional...

Acne Genetics

The genetic influence on pathogenesis of acne is well documented in twins 30 and genealogic studies. In some types of acne, such as acne conglobata, hereditary factors are more apparent, and a correlation has been suggested between neonatal acne and familial hyperandrogenism 4 . Nodulocystic IA is often observed in relatives of patients with extensive steatocystoma, adolescent and postadolescent acne 31 . Fifty percent of postadolescent acne patients have at least one first-degree relative with...

Conclusions

Hormonal therapy is an option for treatment when acne is not responding to conventional therapy. If there are signs of hyperandrogenism, an endocrine evaluation is indicated, consisting of an assessment of DHEAS, total and free-testosterone levels and an LH FSH ratio. Although an indication for hormonal therapy is hyperandro-genism, women with normal serum androgen levels also respond well to treatment. Hormonal therapy choices consist of androgen-receptor blockers, androgen-produc-tion...

Comedonal Types

Submarine Comedones

The clinical type of comedo could, and perhaps should, influence the treatment prescribed. Biopsy sections of normal-looking skin in an acne-prone individual with comedonal acne will frequently 28 show histological features of microcomedones. Biopsies of papules taken at up to 72 h of development will reveal a microcomedone in 52 of subjects, a whitehead in 22 and a blackhead in 10 22 , confirming even further the practical need to apply topical therapies to apparently non-involved skin....

New Developments and Future Trends

Leukotrienes Inflammatory Mediators

After decades of stagnation, research on systemic acne treatment has expanded markedly in the last several years. The results of numerous studies have greatly increased our understanding of both the pathophysiology of the disease and the mechanisms of action for current therapies. New developments occurred including the low-dose long-term isotretinoin regimen, new isotretinoin formulations, understanding of isotretinoin's anti-sebotropic action, new antibiotics, and combination treatments to...

Options for Hormonal Therapy

Once the decision has been made to initiate hormonal therapy, there are various options to choose from 1 androgen receptor blockers, or antiandrogens this class of drugs block the effect of androgens on the sebaceous gland and on the infundibulum of the follicle 2 inhibition of androgen production by the ovary or adrenal gland, or 3 in the future, inhibition of androgen metabolizing enzymes in the skin may be possible see 'Enzyme inhibitors' section below . It is important to note that hormonal...

Estrogens and Sebum Production

Very little is known about the role of estrogens in modulating sebum production. Any estrogen given sys-temically in sufficient amounts will decrease sebum production. The dose of estrogen required to suppress sebum production however is greater than the dose required to suppress ovulation. Although some patients acne will respond well to lower-dose agents containing 0.035-0.050 mg of ethinyl estradiol or its esters, higher doses of estrogen are often required to demonstrate a reduction in...

Dr Christos Zouboulis

Prof Christos Zouboulis

4 Editorial Current and Future Aspects on Acne Zouboulis, Ch.C. Berlin Herane, M.I. Santiago Thiboutot, D. Hershey, Pa. 5 Foreword and Critical Remarks Dreno, B. Nantes Poli, F. Creteil 11 Comedogenesis Some Aetiological, Clinical and Therapeutic Strategies Cunliffe, W.J. Holland, D.B. Clark, S.M. Stables, G.I. Leeds 24 Acne in Infancy and Acne Genetics Herane, M.I. Santiago Ando, I. Kawasaki 29 Topical Treatment in Acne. Current Status and Future Aspects Gollnick, H.P.M. Krautheim, A....

John S Strauss

Acne Vulgar

Department of Dermatology, University of Iowa, Iowa City, Iowa, USA The acne symposium held at the 20th World Congress in Paris in July 2002 was an opportunity for some of those working in the field to present their findings on a wide selection of topics related to the pathogenesis and treatment of acne. The presentations were indeed world-wide, including investigators from Argentina, Chile, France, Germany, Japan, Taiwan, United Kingdom, United States, and Venezuela. As is appropriate for the...