Rosacea

WAIKOLOA, HAWAII – New acne management recommendations from the American Acne and Rosacea Society are the first guidelines to specifically address pediatric acne.

"Acne is a common problem, and the presentations and differential diagnosis differ among the various ages of childhood and adolescence. We had a strong desire to increase recognition and improve management of pediatric and adolescent acne across the spectrum of primary and specialty care," explained Dr. Lawrence F. Eichenfield, cochair of the guideline-writing panel comprised of general pediatricians, pediatric dermatologists, and acne experts.

The comprehensive guidelines provide a simple and efficient classification scheme in which acne is categorized as comedonal, inflammatory/mixed, or nodular, and graded as globally mild, moderate, or severe. The guidelines offer detailed algorithms for the treatment of each category.

The treatment algorithms are flexible, with multiple options available based upon considerations including financial cost and treatment history.

Regimen complexity is another major consideration. Treatment adherence in pediatric and adolescent acne patients is notoriously a much bigger problem than in adults. Simple, once-daily combination products addressing multiple acne pathogenic mechanisms are advantageous.

Adolescent Acne

The treatment algorithm for the adolescent with mild comedonal or inflammatory/mixed lesions begins with two broad options for initial therapy. Both are topical regimens. The first consists of monotherapy with benzoyl peroxide or a topical retinoid, which can be an inexpensive option. The second is topical fixed-dose combination therapy, which can cost far more but achieves faster clearance, Dr. Eichenfield said at the seminar sponsored by Skin Disease Education Foundation (SDEF). Recommended combinations include benzoyl peroxide with a topical antibiotic or retinoid.

Alternatively, the panel noted that topical dapsone can be used either as initial monotherapy or in place of a topical antibiotic. The panel was in agreement that a topical antibiotic should only be prescribed in conjunction with benzoyl peroxide in order to help prevent the emergence of bacterial resistance, he said.

Doxycycline and other oral antibiotics are to be reserved for treatment of moderate to severe acne, and their use should be limited to 3-6 months, according to the guidelines.

"An oral antibiotic alone is substandard care now. It needs to be accompanied by a topical retinoid, a retinoid/benzoyl peroxide, or retinoid/topical antibiotic combination to minimize resistance," Dr. Eichenfield said.

The guidelines note that it is appropriate for primary care physicians to immediately refer an adolescent who presents with severe acne to a dermatologist. Many such patients will be best-treated with oral isotretinoin, he noted.

Preadolescent Acne

Preadolescent acne arising in children aged 7-12 is common and considered normal. It typically begins with comedones over the forehead and midface, with truncal lesions being far less common.

Treatment follows the same algorithms as adolescent acne, with the caveat that most preadolescent therapy is off-label, since, until quite recently, nearly all treatment studies were restricted to patients aged 12 years and older. Therefore, in formulating a treatment strategy for preadolescents, the panel had to shift gears and switch from the evidence-based approach emphasized elsewhere in the guidelines to expert consensus, said Dr. Eichenfield, professor of clinical pediatrics and dermatology at the University of California, San Diego.

Infantile Acne

Infantile acne generally doesn’t show up until after the first several months of life. It is comedonal, although papules, pustules, nodules, and cysts may also be present. Infantile acne can do significant lasting damage, and treatment is warranted.

Neonatal Acne

Acne developing within the first 6 weeks after birth is classified as neonatal acne. However, the erythematous papules and pustules located on the face, neck, scalp, and torso are not true acne. The skin lesions, also known as neonatal cephalic pustulosis, are associated with skin colonization by Malassezia globosa and M. sympodialis. It is a self-limited condition, although it may clear faster if treated using topical ketoconazole cream or another anti-yeast medication.

Among the other issues addressed in the report are diet and acne, the appropriate use of the various classes of medications, when and how to use oral contraceptive pills for acne, the important distinction between neonatal and infantile acne, how to prescribe the big gun – isotretinoin – in young patients, and when to refer a child with acne for a endocrinology workup, said Dr. Eichenfield.

He explained that acne arising in mid-childhood – age 1-7 years – is a red flag for an increased risk of an endocrinologic disorder. Referral to a pediatric endocrinologist is warranted if a child displays any abnormalities in height and growth, blood pressure, or displays signs of early sexual maturation. Dr. Eichenfield picks up the phone personally, he said, to talk to the pediatric endocrinologist, and to make sure the child won’t wait long for an endocrinologic evaluation.

Publication of the guidelines is pending, he noted. In the meantime, physicians can obtain an introduction to the guidelines, including full details of the treatment algorithms, while earning 1 hour of CME credit by viewing a 56-minute video featuring Dr. Eichenfield and other guideline panelists at www.acneandrosacea.org.

The acne guidelines project was supported by the American Acne and Rosacea Society.

Dr. Eichenfield reported receiving research support or serving as a consultant to Galderma, Johnson & Johnson, Medicis, Stiefel, Valeant, and Ortho-McNeil (Jansen Pharmaceuticals).

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – New acne management recommendations from the American Acne and Rosacea Society are the first guidelines to specifically address pediatric acne.

"Acne is a common problem, and the presentations and differential diagnosis differ among the various ages of childhood and adolescence. We had a strong desire to increase recognition and improve management of pediatric and adolescent acne across the spectrum of primary and specialty care," explained Dr. Lawrence F. Eichenfield, cochair of the guideline-writing panel comprised of general pediatricians, pediatric dermatologists, and acne experts.

The comprehensive guidelines provide a simple and efficient classification scheme in which acne is categorized as comedonal, inflammatory/mixed, or nodular, and graded as globally mild, moderate, or severe. The guidelines offer detailed algorithms for the treatment of each category.

The treatment algorithms are flexible, with multiple options available based upon considerations including financial cost and treatment history.

Regimen complexity is another major consideration. Treatment adherence in pediatric and adolescent acne patients is notoriously a much bigger problem than in adults. Simple, once-daily combination products addressing multiple acne pathogenic mechanisms are advantageous.

Adolescent Acne

The treatment algorithm for the adolescent with mild comedonal or inflammatory/mixed lesions begins with two broad options for initial therapy. Both are topical regimens. The first consists of monotherapy with benzoyl peroxide or a topical retinoid, which can be an inexpensive option. The second is topical fixed-dose combination therapy, which can cost far more but achieves faster clearance, Dr. Eichenfield said at the seminar sponsored by Skin Disease Education Foundation (SDEF). Recommended combinations include benzoyl peroxide with a topical antibiotic or retinoid.

Alternatively, the panel noted that topical dapsone can be used either as initial monotherapy or in place of a topical antibiotic. The panel was in agreement that a topical antibiotic should only be prescribed in conjunction with benzoyl peroxide in order to help prevent the emergence of bacterial resistance, he said.

Doxycycline and other oral antibiotics are to be reserved for treatment of moderate to severe acne, and their use should be limited to 3-6 months, according to the guidelines.

"An oral antibiotic alone is substandard care now. It needs to be accompanied by a topical retinoid, a retinoid/benzoyl peroxide, or retinoid/topical antibiotic combination to minimize resistance," Dr. Eichenfield said.

The guidelines note that it is appropriate for primary care physicians to immediately refer an adolescent who presents with severe acne to a dermatologist. Many such patients will be best-treated with oral isotretinoin, he noted.

Preadolescent Acne

Preadolescent acne arising in children aged 7-12 is common and considered normal. It typically begins with comedones over the forehead and midface, with truncal lesions being far less common.

Treatment follows the same algorithms as adolescent acne, with the caveat that most preadolescent therapy is off-label, since, until quite recently, nearly all treatment studies were restricted to patients aged 12 years and older. Therefore, in formulating a treatment strategy for preadolescents, the panel had to shift gears and switch from the evidence-based approach emphasized elsewhere in the guidelines to expert consensus, said Dr. Eichenfield, professor of clinical pediatrics and dermatology at the University of California, San Diego.

Infantile Acne

Infantile acne generally doesn’t show up until after the first several months of life. It is comedonal, although papules, pustules, nodules, and cysts may also be present. Infantile acne can do significant lasting damage, and treatment is warranted.

Neonatal Acne

Acne developing within the first 6 weeks after birth is classified as neonatal acne. However, the erythematous papules and pustules located on the face, neck, scalp, and torso are not true acne. The skin lesions, also known as neonatal cephalic pustulosis, are associated with skin colonization by Malassezia globosa and M. sympodialis. It is a self-limited condition, although it may clear faster if treated using topical ketoconazole cream or another anti-yeast medication.

Among the other issues addressed in the report are diet and acne, the appropriate use of the various classes of medications, when and how to use oral contraceptive pills for acne, the important distinction between neonatal and infantile acne, how to prescribe the big gun – isotretinoin – in young patients, and when to refer a child with acne for a endocrinology workup, said Dr. Eichenfield.

He explained that acne arising in mid-childhood – age 1-7 years – is a red flag for an increased risk of an endocrinologic disorder. Referral to a pediatric endocrinologist is warranted if a child displays any abnormalities in height and growth, blood pressure, or displays signs of early sexual maturation. Dr. Eichenfield picks up the phone personally, he said, to talk to the pediatric endocrinologist, and to make sure the child won’t wait long for an endocrinologic evaluation.

Publication of the guidelines is pending, he noted. In the meantime, physicians can obtain an introduction to the guidelines, including full details of the treatment algorithms, while earning 1 hour of CME credit by viewing a 56-minute video featuring Dr. Eichenfield and other guideline panelists at www.acneandrosacea.org.

The acne guidelines project was supported by the American Acne and Rosacea Society.

Dr. Eichenfield reported receiving research support or serving as a consultant to Galderma, Johnson & Johnson, Medicis, Stiefel, Valeant, and Ortho-McNeil (Jansen Pharmaceuticals).

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – New acne management recommendations from the American Acne and Rosacea Society are the first guidelines to specifically address pediatric acne.

"Acne is a common problem, and the presentations and differential diagnosis differ among the various ages of childhood and adolescence. We had a strong desire to increase recognition and improve management of pediatric and adolescent acne across the spectrum of primary and specialty care," explained Dr. Lawrence F. Eichenfield, cochair of the guideline-writing panel comprised of general pediatricians, pediatric dermatologists, and acne experts.

The comprehensive guidelines provide a simple and efficient classification scheme in which acne is categorized as comedonal, inflammatory/mixed, or nodular, and graded as globally mild, moderate, or severe. The guidelines offer detailed algorithms for the treatment of each category.

The treatment algorithms are flexible, with multiple options available based upon considerations including financial cost and treatment history.

Regimen complexity is another major consideration. Treatment adherence in pediatric and adolescent acne patients is notoriously a much bigger problem than in adults. Simple, once-daily combination products addressing multiple acne pathogenic mechanisms are advantageous.

Adolescent Acne

The treatment algorithm for the adolescent with mild comedonal or inflammatory/mixed lesions begins with two broad options for initial therapy. Both are topical regimens. The first consists of monotherapy with benzoyl peroxide or a topical retinoid, which can be an inexpensive option. The second is topical fixed-dose combination therapy, which can cost far more but achieves faster clearance, Dr. Eichenfield said at the seminar sponsored by Skin Disease Education Foundation (SDEF). Recommended combinations include benzoyl peroxide with a topical antibiotic or retinoid.

Alternatively, the panel noted that topical dapsone can be used either as initial monotherapy or in place of a topical antibiotic. The panel was in agreement that a topical antibiotic should only be prescribed in conjunction with benzoyl peroxide in order to help prevent the emergence of bacterial resistance, he said.

Doxycycline and other oral antibiotics are to be reserved for treatment of moderate to severe acne, and their use should be limited to 3-6 months, according to the guidelines.

"An oral antibiotic alone is substandard care now. It needs to be accompanied by a topical retinoid, a retinoid/benzoyl peroxide, or retinoid/topical antibiotic combination to minimize resistance," Dr. Eichenfield said.

The guidelines note that it is appropriate for primary care physicians to immediately refer an adolescent who presents with severe acne to a dermatologist. Many such patients will be best-treated with oral isotretinoin, he noted.

Preadolescent Acne

Preadolescent acne arising in children aged 7-12 is common and considered normal. It typically begins with comedones over the forehead and midface, with truncal lesions being far less common.

Treatment follows the same algorithms as adolescent acne, with the caveat that most preadolescent therapy is off-label, since, until quite recently, nearly all treatment studies were restricted to patients aged 12 years and older. Therefore, in formulating a treatment strategy for preadolescents, the panel had to shift gears and switch from the evidence-based approach emphasized elsewhere in the guidelines to expert consensus, said Dr. Eichenfield, professor of clinical pediatrics and dermatology at the University of California, San Diego.

Infantile Acne

Infantile acne generally doesn’t show up until after the first several months of life. It is comedonal, although papules, pustules, nodules, and cysts may also be present. Infantile acne can do significant lasting damage, and treatment is warranted.

Neonatal Acne

Acne developing within the first 6 weeks after birth is classified as neonatal acne. However, the erythematous papules and pustules located on the face, neck, scalp, and torso are not true acne. The skin lesions, also known as neonatal cephalic pustulosis, are associated with skin colonization by Malassezia globosa and M. sympodialis. It is a self-limited condition, although it may clear faster if treated using topical ketoconazole cream or another anti-yeast medication.

Among the other issues addressed in the report are diet and acne, the appropriate use of the various classes of medications, when and how to use oral contraceptive pills for acne, the important distinction between neonatal and infantile acne, how to prescribe the big gun – isotretinoin – in young patients, and when to refer a child with acne for a endocrinology workup, said Dr. Eichenfield.

He explained that acne arising in mid-childhood – age 1-7 years – is a red flag for an increased risk of an endocrinologic disorder. Referral to a pediatric endocrinologist is warranted if a child displays any abnormalities in height and growth, blood pressure, or displays signs of early sexual maturation. Dr. Eichenfield picks up the phone personally, he said, to talk to the pediatric endocrinologist, and to make sure the child won’t wait long for an endocrinologic evaluation.

Publication of the guidelines is pending, he noted. In the meantime, physicians can obtain an introduction to the guidelines, including full details of the treatment algorithms, while earning 1 hour of CME credit by viewing a 56-minute video featuring Dr. Eichenfield and other guideline panelists at www.acneandrosacea.org.

The acne guidelines project was supported by the American Acne and Rosacea Society.

Dr. Eichenfield reported receiving research support or serving as a consultant to Galderma, Johnson & Johnson, Medicis, Stiefel, Valeant, and Ortho-McNeil (Jansen Pharmaceuticals).

SDEF and this news organization are owned by Elsevier.

MIAMI BEACH – Early and aggressive anti-inflammatory therapy – preferably combination – is the key to treating acne and postinflammatory hyperpigmentation in patients with skin of color.

Acne prevalence is about the same in black and white patients, said Dr. Valerie D. Callender. The same mechanisms cause acne and the same treatments, in general, are used regardless of skin type, she said. "What is important is ... there are sequelae of acne that make it a little different, and there are certain, special considerations we have to keep in mind when treating patients with darker skin types."

Prevention of keloids, hypertrophic scars, and postinflammatory hyperpigmentation are among the special considerations in this patient population, Dr. Callender said at the South Beach Symposium.

Keloids and hypertrophic scars usually result from inflammatory acne papules, nodules, and cysts, and can be challenging to treat. The keloids and scarring commonly arise along the jawline and on the chest, shoulder, and back. "It’s important to be very aggressive to resolve the inflammation, to treat them effectively. A lot of these patients do very well with isotretinoin and oral antibiotics," said Dr. Callender of the dermatology department at Howard University in Washington, D.C.

In patients with keloids, consider injection of 20 mg/cc intralesional triamcinolone every 4 weeks, sometimes every 2 weeks, to get these lesions to go down, she said. "Remember that is part of their acne regimen."

Postinflammatory hyperpigmentation (PIH) is a common presenting complaint among skin of color patients with acne or another inflammatory skin condition.

PIH is "psychologically devastating for these patients. We have to treat the PIH just as aggressively as we treat the acne," Dr. Callender said. In some cases, the disfigurement is severe and the hyperpigmented patches and macules can persist for months or even years.

In a study of 2,895 females aged 10-70, prevalence of PIH varied by ethnicity (J. Eur. Acad. Dermatol. Venereol. 2011;25:1054-60). The researchers at Massachusetts General Hospital in Boston found that PIH affected 65% of 384 black study patients and 48% of 258 Hispanic patients. "The other racial groups were less than 20% for PIH; this goes along with what we do in our practices," Dr. Callender said.

There are multiple options for prevention and treatment of PIH. Sunscreen, sun avoidance, and early diagnosis can prevent or minimize adverse effects. Hydroquinone, retinoids, azelaic acid, and/or kojic acid are recommended treatments.

"I love my hydroquinone, I use it a lot," Dr. Callender said. Hydroquinone lightens areas of hyperpigmentation through inhibition of tyrosine conversion to melanin, reduces the number of melanosomes, and inhibits DNA and RNA synthesis of melanocytes.

Topical retinoid agents are useful because they not only treat acne, but also address the hyperpigmentation, she said. Also, once the hyperpigmentation is under control, the topical retinoids help to exfoliate the skin and keep PIH from recurring. "We love to keep these patients on long-term topical retinoid therapy."

Tolerability is very important when prescribing topical retinoids and other agents. Carefully consider each patient’s potential risk for cutaneous irritation, including erythema, peeling, burning, and dryness. Be sure to inform nurses and office staff that when a patient calls about tolerability, "you have to inquire about any changes in pigmentation [as well], especially in skin of color patients," Dr. Callender said. Moisturizers, cleansers, and less irritating vehicles can improve tolerability.

"We also use adjunctive therapies and sunscreen protection [for PIH]. Remember combination therapy is the way to go," she said.

She and her associates conducted a meta-analysis looking at the tolerability of a fixed combination adapalene 0.1% and benzoyl peroxide 2.5% gel product (Epiduo) for acne in patients by Fitzpatrick skin type (J. Clin. Aesthet. Dermatol. 2010;3:15-9). They found erythema, scaling, and dryness scores higher for white patients in all three studies. Burning and stinging scores were not significantly different. "Tolerability is good for your skin of color patients. You don’t need to be overly concerned about a lot of irritation just because their skin is dark."

Chemical peels, lasers, and light-based therapies are additional treatment options for acne. Peels made with glycolic acid, salicylic acid, Jessner’s solution, or a combination is acceptable in skin of color patients. However, "be very, very careful with peels in skin of color patients. Make sure [to] use superficial peeling agents," Dr. Callender said.

More clinical studies of lasers and light-based therapies to treat acne are including the darker skin types, Dr. Callender said. Blue light, diode laser, intense pulse light, and photodynamic therapy are examples. "As we learn how to adjust the settings, they will be safer for skin of color patients," she said.

Dr. Callender disclosed that she is a consultant for Allergan and Galderma, which markets Epiduo; a researcher for Allergan, Galderma, and Intendis; and a member of the speakers’ bureau for Galderma.

MIAMI BEACH – Early and aggressive anti-inflammatory therapy – preferably combination – is the key to treating acne and postinflammatory hyperpigmentation in patients with skin of color.

Acne prevalence is about the same in black and white patients, said Dr. Valerie D. Callender. The same mechanisms cause acne and the same treatments, in general, are used regardless of skin type, she said. "What is important is ... there are sequelae of acne that make it a little different, and there are certain, special considerations we have to keep in mind when treating patients with darker skin types."

Prevention of keloids, hypertrophic scars, and postinflammatory hyperpigmentation are among the special considerations in this patient population, Dr. Callender said at the South Beach Symposium.

Keloids and hypertrophic scars usually result from inflammatory acne papules, nodules, and cysts, and can be challenging to treat. The keloids and scarring commonly arise along the jawline and on the chest, shoulder, and back. "It’s important to be very aggressive to resolve the inflammation, to treat them effectively. A lot of these patients do very well with isotretinoin and oral antibiotics," said Dr. Callender of the dermatology department at Howard University in Washington, D.C.

In patients with keloids, consider injection of 20 mg/cc intralesional triamcinolone every 4 weeks, sometimes every 2 weeks, to get these lesions to go down, she said. "Remember that is part of their acne regimen."

Postinflammatory hyperpigmentation (PIH) is a common presenting complaint among skin of color patients with acne or another inflammatory skin condition.

PIH is "psychologically devastating for these patients. We have to treat the PIH just as aggressively as we treat the acne," Dr. Callender said. In some cases, the disfigurement is severe and the hyperpigmented patches and macules can persist for months or even years.

In a study of 2,895 females aged 10-70, prevalence of PIH varied by ethnicity (J. Eur. Acad. Dermatol. Venereol. 2011;25:1054-60). The researchers at Massachusetts General Hospital in Boston found that PIH affected 65% of 384 black study patients and 48% of 258 Hispanic patients. "The other racial groups were less than 20% for PIH; this goes along with what we do in our practices," Dr. Callender said.

There are multiple options for prevention and treatment of PIH. Sunscreen, sun avoidance, and early diagnosis can prevent or minimize adverse effects. Hydroquinone, retinoids, azelaic acid, and/or kojic acid are recommended treatments.

"I love my hydroquinone, I use it a lot," Dr. Callender said. Hydroquinone lightens areas of hyperpigmentation through inhibition of tyrosine conversion to melanin, reduces the number of melanosomes, and inhibits DNA and RNA synthesis of melanocytes.

Topical retinoid agents are useful because they not only treat acne, but also address the hyperpigmentation, she said. Also, once the hyperpigmentation is under control, the topical retinoids help to exfoliate the skin and keep PIH from recurring. "We love to keep these patients on long-term topical retinoid therapy."

Tolerability is very important when prescribing topical retinoids and other agents. Carefully consider each patient’s potential risk for cutaneous irritation, including erythema, peeling, burning, and dryness. Be sure to inform nurses and office staff that when a patient calls about tolerability, "you have to inquire about any changes in pigmentation [as well], especially in skin of color patients," Dr. Callender said. Moisturizers, cleansers, and less irritating vehicles can improve tolerability.

"We also use adjunctive therapies and sunscreen protection [for PIH]. Remember combination therapy is the way to go," she said.

She and her associates conducted a meta-analysis looking at the tolerability of a fixed combination adapalene 0.1% and benzoyl peroxide 2.5% gel product (Epiduo) for acne in patients by Fitzpatrick skin type (J. Clin. Aesthet. Dermatol. 2010;3:15-9). They found erythema, scaling, and dryness scores higher for white patients in all three studies. Burning and stinging scores were not significantly different. "Tolerability is good for your skin of color patients. You don’t need to be overly concerned about a lot of irritation just because their skin is dark."

Chemical peels, lasers, and light-based therapies are additional treatment options for acne. Peels made with glycolic acid, salicylic acid, Jessner’s solution, or a combination is acceptable in skin of color patients. However, "be very, very careful with peels in skin of color patients. Make sure [to] use superficial peeling agents," Dr. Callender said.

More clinical studies of lasers and light-based therapies to treat acne are including the darker skin types, Dr. Callender said. Blue light, diode laser, intense pulse light, and photodynamic therapy are examples. "As we learn how to adjust the settings, they will be safer for skin of color patients," she said.

Dr. Callender disclosed that she is a consultant for Allergan and Galderma, which markets Epiduo; a researcher for Allergan, Galderma, and Intendis; and a member of the speakers’ bureau for Galderma.

MIAMI BEACH – Early and aggressive anti-inflammatory therapy – preferably combination – is the key to treating acne and postinflammatory hyperpigmentation in patients with skin of color.

Acne prevalence is about the same in black and white patients, said Dr. Valerie D. Callender. The same mechanisms cause acne and the same treatments, in general, are used regardless of skin type, she said. "What is important is ... there are sequelae of acne that make it a little different, and there are certain, special considerations we have to keep in mind when treating patients with darker skin types."

Prevention of keloids, hypertrophic scars, and postinflammatory hyperpigmentation are among the special considerations in this patient population, Dr. Callender said at the South Beach Symposium.

Keloids and hypertrophic scars usually result from inflammatory acne papules, nodules, and cysts, and can be challenging to treat. The keloids and scarring commonly arise along the jawline and on the chest, shoulder, and back. "It’s important to be very aggressive to resolve the inflammation, to treat them effectively. A lot of these patients do very well with isotretinoin and oral antibiotics," said Dr. Callender of the dermatology department at Howard University in Washington, D.C.

In patients with keloids, consider injection of 20 mg/cc intralesional triamcinolone every 4 weeks, sometimes every 2 weeks, to get these lesions to go down, she said. "Remember that is part of their acne regimen."

Postinflammatory hyperpigmentation (PIH) is a common presenting complaint among skin of color patients with acne or another inflammatory skin condition.

PIH is "psychologically devastating for these patients. We have to treat the PIH just as aggressively as we treat the acne," Dr. Callender said. In some cases, the disfigurement is severe and the hyperpigmented patches and macules can persist for months or even years.

In a study of 2,895 females aged 10-70, prevalence of PIH varied by ethnicity (J. Eur. Acad. Dermatol. Venereol. 2011;25:1054-60). The researchers at Massachusetts General Hospital in Boston found that PIH affected 65% of 384 black study patients and 48% of 258 Hispanic patients. "The other racial groups were less than 20% for PIH; this goes along with what we do in our practices," Dr. Callender said.

There are multiple options for prevention and treatment of PIH. Sunscreen, sun avoidance, and early diagnosis can prevent or minimize adverse effects. Hydroquinone, retinoids, azelaic acid, and/or kojic acid are recommended treatments.

"I love my hydroquinone, I use it a lot," Dr. Callender said. Hydroquinone lightens areas of hyperpigmentation through inhibition of tyrosine conversion to melanin, reduces the number of melanosomes, and inhibits DNA and RNA synthesis of melanocytes.

Topical retinoid agents are useful because they not only treat acne, but also address the hyperpigmentation, she said. Also, once the hyperpigmentation is under control, the topical retinoids help to exfoliate the skin and keep PIH from recurring. "We love to keep these patients on long-term topical retinoid therapy."

Tolerability is very important when prescribing topical retinoids and other agents. Carefully consider each patient’s potential risk for cutaneous irritation, including erythema, peeling, burning, and dryness. Be sure to inform nurses and office staff that when a patient calls about tolerability, "you have to inquire about any changes in pigmentation [as well], especially in skin of color patients," Dr. Callender said. Moisturizers, cleansers, and less irritating vehicles can improve tolerability.

"We also use adjunctive therapies and sunscreen protection [for PIH]. Remember combination therapy is the way to go," she said.

She and her associates conducted a meta-analysis looking at the tolerability of a fixed combination adapalene 0.1% and benzoyl peroxide 2.5% gel product (Epiduo) for acne in patients by Fitzpatrick skin type (J. Clin. Aesthet. Dermatol. 2010;3:15-9). They found erythema, scaling, and dryness scores higher for white patients in all three studies. Burning and stinging scores were not significantly different. "Tolerability is good for your skin of color patients. You don’t need to be overly concerned about a lot of irritation just because their skin is dark."

Chemical peels, lasers, and light-based therapies are additional treatment options for acne. Peels made with glycolic acid, salicylic acid, Jessner’s solution, or a combination is acceptable in skin of color patients. However, "be very, very careful with peels in skin of color patients. Make sure [to] use superficial peeling agents," Dr. Callender said.

More clinical studies of lasers and light-based therapies to treat acne are including the darker skin types, Dr. Callender said. Blue light, diode laser, intense pulse light, and photodynamic therapy are examples. "As we learn how to adjust the settings, they will be safer for skin of color patients," she said.

Dr. Callender disclosed that she is a consultant for Allergan and Galderma, which markets Epiduo; a researcher for Allergan, Galderma, and Intendis; and a member of the speakers’ bureau for Galderma.

MIAMI BEACH – Acne presentation, treatment, and counseling will vary according to whether your patient is a neonate, infant, child, preadolescent, or teenager, according to Dr. Jonette E. Keri.

Courtesy Dr. Lawrence F. Eichenfield

• Neonatal acne. These small, erythematous papules that arise before 6 weeks of life probably represent a heterogenous set of conditions. Ketoconazole cream 2% twice per day is a treatment option.

However, "a lot of doctors choose not to treat because it’s not a scarring process," Dr. Keri said. You can reassure parents that most neonatal acne improves relatively quickly, usually within a few months. If true comedones are present, consider treatment with the same acne mediations indicated for infantile acne.

• Infantile acne. Infantile acne appears in children up to 1 year, usually at 3-6 months of age. Male infants are more prone to acne than female infants, and lesions tend to appear on the cheeks and chin and have the appearance of classic adolescent acne. Increased sebum production and some comedones are often present.

"You should treat because it can cause scarring," Dr. Keri said. Also, "this acne may predispose [children] to worse acne in teenage years – that is shown to be true for any form of infantile acne. It doesn’t have to be severe," said Dr. Keri of the University of Miami and chief of dermatology services at the Miami VA Hospital.

She offered the following clinical tips for treating and managing acne based on developmental age:

Combine treatments and use products appropriate for a baby, Dr. Keri advised at the South Beach Symposium. Although some experts recommend benzoyl peroxide, proceed with caution. The concern is getting any benzoyl peroxide near a baby’s eyes, "so you probably want to stay away from the washes."

Treatment options include topical antibiotics, adapalene, or a retinoid like tretinoin. Oral erythromycin is another acceptable option, she said.

"Isotretinoin is actually indicated if a severe, scarring process is going on," said Dr. Keri. She said that she searched the literature and found that some clinicians prescribe isotretinoin in children as young as 5 months.

• Midchildhood acne. "It is a newer concept, but a very important concept," Dr. Keri said. Acne is relatively rare between the ages of 1 and 8 years. During this time androgens in the body should be low and stable.

If acne does arise, it could point to an underlying hormonal abnormality. Evaluate three things: bone age, the growth chart, and hormone levels. "That may be a bit much for a dermatologist, but a pediatrician does these evaluations often," she said.

Accelerated bone age on a wrist radiograph can point to androgen excess, whereas delayed bone age suggests Cushing’s disease. A growth chart that shows a child’s height crossing percentiles upward or increasing faster than would be expected can also suggest androgen excess.

"Hormone levels can be tricky," Dr. Keri said. High levels of androgens, free testosterone, or dehydroepiandrosterone also can occur with tumors or polycystic ovarian syndrome (PCOS). "Another reason they can be tricky is because the child is developing into an adult, so you may need a pediatric endocrinologist to tease this out."

• Preadolescent acne. Treatments for children aged 9-12 years are essentially the same as for infants and midchildhood patients. However, patient counseling plays a bigger role. "Adherence is a big issue with these kids, so try to give them a once-a-day regimen," Dr. Keri said. Isotretinoin is rarely prescribed in this age group, but if severity dictates the need, it is likely the child will need retreatment (two or three courses) over time.

Comedones, seborrhea, and even PCOS are associated with preteen acne. Rule out precocious puberty and distinguish abnormal hormonal changes from normal signs of puberty, Dr. Keri recommended.

"PCOS is very complicated; you are going to need some help, a multispecialty approach," Dr. Keri said. Early diagnosis is worthwhile, she added. "If you identify PCOS when these young ladies are younger, you can prevent infertility, diabetes, [and] coronary artery disease, because they get these things more often than a woman who doesn’t have PCOS."

• Adolescent acne. Speaking directly and appropriately with teenagers about their acne can facilitate better outcomes, Dr. Keri said. For example, instead of asking, "How many days a week do you use your medicines?" ask, "How do you use your acne medicines?" Also determine their expectations before prescribing, and find out if they have a prom or other major social event coming up.

It is also important to evaluate their previous acne-fighting strategies. "It can be painfully tiring to go through all they have done and used, but if you don’t do that, you’re not going to have a good starting point," she said. Find out what they like and dislike, and really listen to their answers. "They will be honest if you listen to them."

Also, adolescents like to use pads to apply their acne medicine, so keep those formulations in mind for this age group, she said.

Dr. Keri said she had no relevant financial disclosures.

MIAMI BEACH – Acne presentation, treatment, and counseling will vary according to whether your patient is a neonate, infant, child, preadolescent, or teenager, according to Dr. Jonette E. Keri.

Courtesy Dr. Lawrence F. Eichenfield

• Neonatal acne. These small, erythematous papules that arise before 6 weeks of life probably represent a heterogenous set of conditions. Ketoconazole cream 2% twice per day is a treatment option.

However, "a lot of doctors choose not to treat because it’s not a scarring process," Dr. Keri said. You can reassure parents that most neonatal acne improves relatively quickly, usually within a few months. If true comedones are present, consider treatment with the same acne mediations indicated for infantile acne.

• Infantile acne. Infantile acne appears in children up to 1 year, usually at 3-6 months of age. Male infants are more prone to acne than female infants, and lesions tend to appear on the cheeks and chin and have the appearance of classic adolescent acne. Increased sebum production and some comedones are often present.

"You should treat because it can cause scarring," Dr. Keri said. Also, "this acne may predispose [children] to worse acne in teenage years – that is shown to be true for any form of infantile acne. It doesn’t have to be severe," said Dr. Keri of the University of Miami and chief of dermatology services at the Miami VA Hospital.

She offered the following clinical tips for treating and managing acne based on developmental age:

Combine treatments and use products appropriate for a baby, Dr. Keri advised at the South Beach Symposium. Although some experts recommend benzoyl peroxide, proceed with caution. The concern is getting any benzoyl peroxide near a baby’s eyes, "so you probably want to stay away from the washes."

Treatment options include topical antibiotics, adapalene, or a retinoid like tretinoin. Oral erythromycin is another acceptable option, she said.

"Isotretinoin is actually indicated if a severe, scarring process is going on," said Dr. Keri. She said that she searched the literature and found that some clinicians prescribe isotretinoin in children as young as 5 months.

• Midchildhood acne. "It is a newer concept, but a very important concept," Dr. Keri said. Acne is relatively rare between the ages of 1 and 8 years. During this time androgens in the body should be low and stable.

If acne does arise, it could point to an underlying hormonal abnormality. Evaluate three things: bone age, the growth chart, and hormone levels. "That may be a bit much for a dermatologist, but a pediatrician does these evaluations often," she said.

Accelerated bone age on a wrist radiograph can point to androgen excess, whereas delayed bone age suggests Cushing’s disease. A growth chart that shows a child’s height crossing percentiles upward or increasing faster than would be expected can also suggest androgen excess.

"Hormone levels can be tricky," Dr. Keri said. High levels of androgens, free testosterone, or dehydroepiandrosterone also can occur with tumors or polycystic ovarian syndrome (PCOS). "Another reason they can be tricky is because the child is developing into an adult, so you may need a pediatric endocrinologist to tease this out."

• Preadolescent acne. Treatments for children aged 9-12 years are essentially the same as for infants and midchildhood patients. However, patient counseling plays a bigger role. "Adherence is a big issue with these kids, so try to give them a once-a-day regimen," Dr. Keri said. Isotretinoin is rarely prescribed in this age group, but if severity dictates the need, it is likely the child will need retreatment (two or three courses) over time.

Comedones, seborrhea, and even PCOS are associated with preteen acne. Rule out precocious puberty and distinguish abnormal hormonal changes from normal signs of puberty, Dr. Keri recommended.

"PCOS is very complicated; you are going to need some help, a multispecialty approach," Dr. Keri said. Early diagnosis is worthwhile, she added. "If you identify PCOS when these young ladies are younger, you can prevent infertility, diabetes, [and] coronary artery disease, because they get these things more often than a woman who doesn’t have PCOS."

• Adolescent acne. Speaking directly and appropriately with teenagers about their acne can facilitate better outcomes, Dr. Keri said. For example, instead of asking, "How many days a week do you use your medicines?" ask, "How do you use your acne medicines?" Also determine their expectations before prescribing, and find out if they have a prom or other major social event coming up.

It is also important to evaluate their previous acne-fighting strategies. "It can be painfully tiring to go through all they have done and used, but if you don’t do that, you’re not going to have a good starting point," she said. Find out what they like and dislike, and really listen to their answers. "They will be honest if you listen to them."

Also, adolescents like to use pads to apply their acne medicine, so keep those formulations in mind for this age group, she said.

Dr. Keri said she had no relevant financial disclosures.

MIAMI BEACH – Acne presentation, treatment, and counseling will vary according to whether your patient is a neonate, infant, child, preadolescent, or teenager, according to Dr. Jonette E. Keri.

Courtesy Dr. Lawrence F. Eichenfield

• Neonatal acne. These small, erythematous papules that arise before 6 weeks of life probably represent a heterogenous set of conditions. Ketoconazole cream 2% twice per day is a treatment option.

However, "a lot of doctors choose not to treat because it’s not a scarring process," Dr. Keri said. You can reassure parents that most neonatal acne improves relatively quickly, usually within a few months. If true comedones are present, consider treatment with the same acne mediations indicated for infantile acne.

• Infantile acne. Infantile acne appears in children up to 1 year, usually at 3-6 months of age. Male infants are more prone to acne than female infants, and lesions tend to appear on the cheeks and chin and have the appearance of classic adolescent acne. Increased sebum production and some comedones are often present.

"You should treat because it can cause scarring," Dr. Keri said. Also, "this acne may predispose [children] to worse acne in teenage years – that is shown to be true for any form of infantile acne. It doesn’t have to be severe," said Dr. Keri of the University of Miami and chief of dermatology services at the Miami VA Hospital.

She offered the following clinical tips for treating and managing acne based on developmental age:

Combine treatments and use products appropriate for a baby, Dr. Keri advised at the South Beach Symposium. Although some experts recommend benzoyl peroxide, proceed with caution. The concern is getting any benzoyl peroxide near a baby’s eyes, "so you probably want to stay away from the washes."

Treatment options include topical antibiotics, adapalene, or a retinoid like tretinoin. Oral erythromycin is another acceptable option, she said.

"Isotretinoin is actually indicated if a severe, scarring process is going on," said Dr. Keri. She said that she searched the literature and found that some clinicians prescribe isotretinoin in children as young as 5 months.

• Midchildhood acne. "It is a newer concept, but a very important concept," Dr. Keri said. Acne is relatively rare between the ages of 1 and 8 years. During this time androgens in the body should be low and stable.

If acne does arise, it could point to an underlying hormonal abnormality. Evaluate three things: bone age, the growth chart, and hormone levels. "That may be a bit much for a dermatologist, but a pediatrician does these evaluations often," she said.

Accelerated bone age on a wrist radiograph can point to androgen excess, whereas delayed bone age suggests Cushing’s disease. A growth chart that shows a child’s height crossing percentiles upward or increasing faster than would be expected can also suggest androgen excess.

"Hormone levels can be tricky," Dr. Keri said. High levels of androgens, free testosterone, or dehydroepiandrosterone also can occur with tumors or polycystic ovarian syndrome (PCOS). "Another reason they can be tricky is because the child is developing into an adult, so you may need a pediatric endocrinologist to tease this out."

• Preadolescent acne. Treatments for children aged 9-12 years are essentially the same as for infants and midchildhood patients. However, patient counseling plays a bigger role. "Adherence is a big issue with these kids, so try to give them a once-a-day regimen," Dr. Keri said. Isotretinoin is rarely prescribed in this age group, but if severity dictates the need, it is likely the child will need retreatment (two or three courses) over time.

Comedones, seborrhea, and even PCOS are associated with preteen acne. Rule out precocious puberty and distinguish abnormal hormonal changes from normal signs of puberty, Dr. Keri recommended.

"PCOS is very complicated; you are going to need some help, a multispecialty approach," Dr. Keri said. Early diagnosis is worthwhile, she added. "If you identify PCOS when these young ladies are younger, you can prevent infertility, diabetes, [and] coronary artery disease, because they get these things more often than a woman who doesn’t have PCOS."

• Adolescent acne. Speaking directly and appropriately with teenagers about their acne can facilitate better outcomes, Dr. Keri said. For example, instead of asking, "How many days a week do you use your medicines?" ask, "How do you use your acne medicines?" Also determine their expectations before prescribing, and find out if they have a prom or other major social event coming up.

It is also important to evaluate their previous acne-fighting strategies. "It can be painfully tiring to go through all they have done and used, but if you don’t do that, you’re not going to have a good starting point," she said. Find out what they like and dislike, and really listen to their answers. "They will be honest if you listen to them."

Also, adolescents like to use pads to apply their acne medicine, so keep those formulations in mind for this age group, she said.

Dr. Keri said she had no relevant financial disclosures.

Ablative fractional laser resurfacing is more effective than nonablative therapy for the treatment of acne scaring, albeit, with greater side effects and pain, according to a new review.

Ms. Michal Wen Sheue Ong and Dr. Saquib Bashir, of King’s College Hospital NHS Foundation Trust in London, conducted literature searches using the PubMed and Scopus databases for English-language articles published between 2003 and January 2011 that reported on "acne scars" and "fractional photothermolysis."

A total of 26 papers, published between 2008 and 2011, met the criteria – 13 papers on ablative fractional lasers and an equal number on nonablative fractional lasers (Br. J. Dermatol. 2012 Feb. 1 [doi: 10.1111/j.1365-2133.2012.10870.x]).

"Most ablative studies reported a percentage of improvement within the range of 26% to 75%," they wrote. In two cases, studies claimed 79.8% and 83% mean improvement, although the reviewers questioned the appropriateness of using mean values rather than medians, given that "the properties of the ordinal scales were unknown and points on the scale were not necessarily equidistant."

The nonablative studies reported an improvement range of 26% to 50%.

Only four studies were split-face randomized controlled trials, and most had follow-up criteria of just 1 to 6 months; only one study included a 2-year follow-up. Moreover, the methods and rating scales for measuring improvement varied widely.

Only five studies analyzed the histological degree of scar improvement, but in these, new collagen formation was noted with both ablative and nonablative fractional photothermolysis.

In one of the nonablative studies included in the review, an increase in elastic fibers framework in the papillary dermis, as well as the upper and mid dermis, was noted 12 weeks after final treatment (Photodermatol. Photoimmunol. Photomed. 2009;25:138-42).

Similarly, using 3D optical profiling, a study of ablative laser resurfacing showed a marked, statistically significant improvement in skin smoothness and scar volume 1 month after treatment. "However, there were no further improvements of skin smoothness or scar volume at 3- and 6-months follow-up," wrote the authors (J. Am. Acad. Dermatol. 2010;63:274-83).

Looking at side effects, "A higher proportion of patients (up to 92.3%) who undertake ablative FP [fractional photothermolysis] experience post inflammatory hyperpigmentation (PIH) than those who have nonablative FP (up to 13%)," wrote the reviewers, with a maximum duration of PIH of up to 6 months in ablative FP, vs. 1 week in nonablative treatment.

Pain ratings for nonablative procedures were also lower, compared with ablative procedures. "The mean pain score reported across ablative FP studies ranged from 5.9-8.1 (scale of 10)," reported the authors. In contrast, the mean pain scores for nonablative FP procedures were rated 3.9-5.7.

The authors pointed out that they found no evidence regarding the effects of FP lasers on patients’ psychological status and quality of life. "This information can be useful and should be obtained before and after treatment," they wrote.

Limitations of the review included the fact that none of the methods of assessing clinical outcome had had its validity or reliability investigated, wrote the reviewers. For the most part, however, the results were promising.

"Most studies had clinicians/dermatologists to assess overall scar improvement, and there were some studies which had patient assessment," they wrote. In many cases the evaluators were blinded, but at least three studies used evaluators who were not.

Fractional photothermolysis laser resurfacing improves facial acne scarring, despite dramatic methodological variability in efficacy studies. Nevertheless, more studies are needed, especially split-face, randomized controlled trials using objective assessment measures of improvement, like histological or 3D optical profiling, they concluded.

The review authors reported having no outside funding and stated that they had no conflicts of interest to declare.

Ablative fractional laser resurfacing is more effective than nonablative therapy for the treatment of acne scaring, albeit, with greater side effects and pain, according to a new review.

Ms. Michal Wen Sheue Ong and Dr. Saquib Bashir, of King’s College Hospital NHS Foundation Trust in London, conducted literature searches using the PubMed and Scopus databases for English-language articles published between 2003 and January 2011 that reported on "acne scars" and "fractional photothermolysis."

A total of 26 papers, published between 2008 and 2011, met the criteria – 13 papers on ablative fractional lasers and an equal number on nonablative fractional lasers (Br. J. Dermatol. 2012 Feb. 1 [doi: 10.1111/j.1365-2133.2012.10870.x]).

"Most ablative studies reported a percentage of improvement within the range of 26% to 75%," they wrote. In two cases, studies claimed 79.8% and 83% mean improvement, although the reviewers questioned the appropriateness of using mean values rather than medians, given that "the properties of the ordinal scales were unknown and points on the scale were not necessarily equidistant."

The nonablative studies reported an improvement range of 26% to 50%.

Only four studies were split-face randomized controlled trials, and most had follow-up criteria of just 1 to 6 months; only one study included a 2-year follow-up. Moreover, the methods and rating scales for measuring improvement varied widely.

Only five studies analyzed the histological degree of scar improvement, but in these, new collagen formation was noted with both ablative and nonablative fractional photothermolysis.

In one of the nonablative studies included in the review, an increase in elastic fibers framework in the papillary dermis, as well as the upper and mid dermis, was noted 12 weeks after final treatment (Photodermatol. Photoimmunol. Photomed. 2009;25:138-42).

Similarly, using 3D optical profiling, a study of ablative laser resurfacing showed a marked, statistically significant improvement in skin smoothness and scar volume 1 month after treatment. "However, there were no further improvements of skin smoothness or scar volume at 3- and 6-months follow-up," wrote the authors (J. Am. Acad. Dermatol. 2010;63:274-83).

Looking at side effects, "A higher proportion of patients (up to 92.3%) who undertake ablative FP [fractional photothermolysis] experience post inflammatory hyperpigmentation (PIH) than those who have nonablative FP (up to 13%)," wrote the reviewers, with a maximum duration of PIH of up to 6 months in ablative FP, vs. 1 week in nonablative treatment.

Pain ratings for nonablative procedures were also lower, compared with ablative procedures. "The mean pain score reported across ablative FP studies ranged from 5.9-8.1 (scale of 10)," reported the authors. In contrast, the mean pain scores for nonablative FP procedures were rated 3.9-5.7.

The authors pointed out that they found no evidence regarding the effects of FP lasers on patients’ psychological status and quality of life. "This information can be useful and should be obtained before and after treatment," they wrote.

Limitations of the review included the fact that none of the methods of assessing clinical outcome had had its validity or reliability investigated, wrote the reviewers. For the most part, however, the results were promising.

"Most studies had clinicians/dermatologists to assess overall scar improvement, and there were some studies which had patient assessment," they wrote. In many cases the evaluators were blinded, but at least three studies used evaluators who were not.

Fractional photothermolysis laser resurfacing improves facial acne scarring, despite dramatic methodological variability in efficacy studies. Nevertheless, more studies are needed, especially split-face, randomized controlled trials using objective assessment measures of improvement, like histological or 3D optical profiling, they concluded.

The review authors reported having no outside funding and stated that they had no conflicts of interest to declare.

Ablative fractional laser resurfacing is more effective than nonablative therapy for the treatment of acne scaring, albeit, with greater side effects and pain, according to a new review.

Ms. Michal Wen Sheue Ong and Dr. Saquib Bashir, of King’s College Hospital NHS Foundation Trust in London, conducted literature searches using the PubMed and Scopus databases for English-language articles published between 2003 and January 2011 that reported on "acne scars" and "fractional photothermolysis."

A total of 26 papers, published between 2008 and 2011, met the criteria – 13 papers on ablative fractional lasers and an equal number on nonablative fractional lasers (Br. J. Dermatol. 2012 Feb. 1 [doi: 10.1111/j.1365-2133.2012.10870.x]).

"Most ablative studies reported a percentage of improvement within the range of 26% to 75%," they wrote. In two cases, studies claimed 79.8% and 83% mean improvement, although the reviewers questioned the appropriateness of using mean values rather than medians, given that "the properties of the ordinal scales were unknown and points on the scale were not necessarily equidistant."

The nonablative studies reported an improvement range of 26% to 50%.

Only four studies were split-face randomized controlled trials, and most had follow-up criteria of just 1 to 6 months; only one study included a 2-year follow-up. Moreover, the methods and rating scales for measuring improvement varied widely.

Only five studies analyzed the histological degree of scar improvement, but in these, new collagen formation was noted with both ablative and nonablative fractional photothermolysis.

In one of the nonablative studies included in the review, an increase in elastic fibers framework in the papillary dermis, as well as the upper and mid dermis, was noted 12 weeks after final treatment (Photodermatol. Photoimmunol. Photomed. 2009;25:138-42).

Similarly, using 3D optical profiling, a study of ablative laser resurfacing showed a marked, statistically significant improvement in skin smoothness and scar volume 1 month after treatment. "However, there were no further improvements of skin smoothness or scar volume at 3- and 6-months follow-up," wrote the authors (J. Am. Acad. Dermatol. 2010;63:274-83).

Looking at side effects, "A higher proportion of patients (up to 92.3%) who undertake ablative FP [fractional photothermolysis] experience post inflammatory hyperpigmentation (PIH) than those who have nonablative FP (up to 13%)," wrote the reviewers, with a maximum duration of PIH of up to 6 months in ablative FP, vs. 1 week in nonablative treatment.

Pain ratings for nonablative procedures were also lower, compared with ablative procedures. "The mean pain score reported across ablative FP studies ranged from 5.9-8.1 (scale of 10)," reported the authors. In contrast, the mean pain scores for nonablative FP procedures were rated 3.9-5.7.

The authors pointed out that they found no evidence regarding the effects of FP lasers on patients’ psychological status and quality of life. "This information can be useful and should be obtained before and after treatment," they wrote.

Limitations of the review included the fact that none of the methods of assessing clinical outcome had had its validity or reliability investigated, wrote the reviewers. For the most part, however, the results were promising.

"Most studies had clinicians/dermatologists to assess overall scar improvement, and there were some studies which had patient assessment," they wrote. In many cases the evaluators were blinded, but at least three studies used evaluators who were not.

Fractional photothermolysis laser resurfacing improves facial acne scarring, despite dramatic methodological variability in efficacy studies. Nevertheless, more studies are needed, especially split-face, randomized controlled trials using objective assessment measures of improvement, like histological or 3D optical profiling, they concluded.

The review authors reported having no outside funding and stated that they had no conflicts of interest to declare.

WAIKOLOA, HAWAII – Topical cyclosporine 0.05% ophthalmic emulsion significantly outperformed artificial tears for the treatment of ocular rosacea in a double-blind, randomized, multicenter study.

"It’s a fairly small study, but I think it gives us some valuable information. This gives us a new option topically," Dr. Julie C. Harper said in highlighting the study at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

She referred to a clinical trial conducted by Florida ophthalmologists who randomized 37 patients with ocular rosacea to twice-daily topical cyclosporine 0.05% (Restasis) or artificial tears for 3 months.

The outcome that most impressed Dr. Harper was the topical cyclosporine group’s mean 11.5-point improvement from a baseline of 14.1 on the Ocular Surface Disease Index, a validated patient questionnaire assessing the eye disease’s impact on quality of life. Patients who received artificial tears – a widely prescribed treatment for ocular rosacea – had a significantly lesser mean 2.9-point improvement.

"People definitely felt better with this product than with artificial tears," observed Dr. Harper, a dermatologist at the University of Alabama at Birmingham.

In addition, the topical cyclosporine group fared significantly better in the other study end points, which focused on eye dryness and tear production. For example, mean scores on Schirmer\'s test (a measure of eye-surface wetness) improved by 2.7 mm over the course of 3 months of treatment, from a baseline of 8.3, compared with a 1.4-mm deterioration in the artificial tears group.

Also, tear break-up time (a measure of how quickly an eye becomes dry) increased by a mean of 3.56 seconds in the cyclosporine group, a significantly more favorable effect than the 0.04-second decrease in the artificial tears arm (Adv. Ther. 2009;26:651-9).

The investigators speculated that topical cyclosporine’s clinical benefits in ocular rosacea are due to the drug’s anti-inflammatory effects, including a cyclosporine-mediated reduction in the number of activated lymphocytes in the conjunctiva, in combination with stimulation of increased tear production

The ophthalmologists emphasized that ocular rosacea can be a serious and potentially even a blinding condition. They noted that in one classic study, 13 of 131 patients had corneal complications resulting in visual acuity loss at the time they presented to ophthalmology. Of those 13 patients, 7 were left with worse than 20/400 eyesight, and 6 of the 13 required penetrating keratoplasty during the course of their disease (Ophthalmology 1997;104:1863-7).

Dr. Harper said that since she learned of the randomized trial, she has tried using topical cyclosporine for ocular rosacea but doesn’t yet have enough experience to say how well it works in her own hands. Usually, she gives the topical agent in combination with an oral tetracycline in patients whose ocular disease isn’t responding adequately to oral therapy alone.

Her preferred oral agent is delayed-release doxycycline (Oracea) at the anti-inflammatory but subantimicrobial dose of 40 mg once daily, a dosage that is Food and Drug Administration approved for treatment of rosacea. She favors this regimen because it doesn’t contribute to the worsening, global, antibiotic-resistance public health problem, and the once-daily aspect is a real plus from the patient adherence standpoint.

For patients who don’t have insurance coverage for this relatively costly drug, her second-favorite option is generic doxycycline at 20 mg BID, which is also an anti-inflammatory yet subantimicrobial dosage. It’s important to recognize, however, that bumping up the dosage of generic doxycycline to 50 mg/day would cross the threshold into the antibacterial range that could contribute to the resistance problem, the dermatologist added.

Topical cyclosporine for ocular rosacea is off-label therapy. The drug’s approved indication is in treating chronic dry eyes. Conference codirector Dr. Joseph F. Fowler Jr. predicted that the product may never gain an indication for ocular rosacea. That’s because ophthalmologists have a difficult time in quantifying the severity of ocular rosacea for research purposes, and even in distinguishing it from dry eye.

"My own crude approach is that if you’ve got rosacea on the skin and you’ve got itchy, gritty eyes, then I generally assume you’ve got ocular rosacea," explained Dr. Fowler, a dermatologist at the University of Louisville (Ky.).

Like Dr. Harper, he typically prescribes topical cyclosporine for ocular rosacea in combination with oral doxycycline.

"I find it very useful," he added.

Dr. Fowler disclosed that he has received research grants from Allergan, which markets Restasis. He also serves as a consultant to Galderma, which markets Oracea, as well as to numerous other pharmaceutical companies. Dr. Harper is on the speakers bureaus for Allergan, Galderma, and a handful of other companies.

The SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Topical cyclosporine 0.05% ophthalmic emulsion significantly outperformed artificial tears for the treatment of ocular rosacea in a double-blind, randomized, multicenter study.

"It’s a fairly small study, but I think it gives us some valuable information. This gives us a new option topically," Dr. Julie C. Harper said in highlighting the study at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

She referred to a clinical trial conducted by Florida ophthalmologists who randomized 37 patients with ocular rosacea to twice-daily topical cyclosporine 0.05% (Restasis) or artificial tears for 3 months.

The outcome that most impressed Dr. Harper was the topical cyclosporine group’s mean 11.5-point improvement from a baseline of 14.1 on the Ocular Surface Disease Index, a validated patient questionnaire assessing the eye disease’s impact on quality of life. Patients who received artificial tears – a widely prescribed treatment for ocular rosacea – had a significantly lesser mean 2.9-point improvement.

"People definitely felt better with this product than with artificial tears," observed Dr. Harper, a dermatologist at the University of Alabama at Birmingham.

In addition, the topical cyclosporine group fared significantly better in the other study end points, which focused on eye dryness and tear production. For example, mean scores on Schirmer\'s test (a measure of eye-surface wetness) improved by 2.7 mm over the course of 3 months of treatment, from a baseline of 8.3, compared with a 1.4-mm deterioration in the artificial tears group.

Also, tear break-up time (a measure of how quickly an eye becomes dry) increased by a mean of 3.56 seconds in the cyclosporine group, a significantly more favorable effect than the 0.04-second decrease in the artificial tears arm (Adv. Ther. 2009;26:651-9).

The investigators speculated that topical cyclosporine’s clinical benefits in ocular rosacea are due to the drug’s anti-inflammatory effects, including a cyclosporine-mediated reduction in the number of activated lymphocytes in the conjunctiva, in combination with stimulation of increased tear production

The ophthalmologists emphasized that ocular rosacea can be a serious and potentially even a blinding condition. They noted that in one classic study, 13 of 131 patients had corneal complications resulting in visual acuity loss at the time they presented to ophthalmology. Of those 13 patients, 7 were left with worse than 20/400 eyesight, and 6 of the 13 required penetrating keratoplasty during the course of their disease (Ophthalmology 1997;104:1863-7).

Dr. Harper said that since she learned of the randomized trial, she has tried using topical cyclosporine for ocular rosacea but doesn’t yet have enough experience to say how well it works in her own hands. Usually, she gives the topical agent in combination with an oral tetracycline in patients whose ocular disease isn’t responding adequately to oral therapy alone.

Her preferred oral agent is delayed-release doxycycline (Oracea) at the anti-inflammatory but subantimicrobial dose of 40 mg once daily, a dosage that is Food and Drug Administration approved for treatment of rosacea. She favors this regimen because it doesn’t contribute to the worsening, global, antibiotic-resistance public health problem, and the once-daily aspect is a real plus from the patient adherence standpoint.

For patients who don’t have insurance coverage for this relatively costly drug, her second-favorite option is generic doxycycline at 20 mg BID, which is also an anti-inflammatory yet subantimicrobial dosage. It’s important to recognize, however, that bumping up the dosage of generic doxycycline to 50 mg/day would cross the threshold into the antibacterial range that could contribute to the resistance problem, the dermatologist added.

Topical cyclosporine for ocular rosacea is off-label therapy. The drug’s approved indication is in treating chronic dry eyes. Conference codirector Dr. Joseph F. Fowler Jr. predicted that the product may never gain an indication for ocular rosacea. That’s because ophthalmologists have a difficult time in quantifying the severity of ocular rosacea for research purposes, and even in distinguishing it from dry eye.

"My own crude approach is that if you’ve got rosacea on the skin and you’ve got itchy, gritty eyes, then I generally assume you’ve got ocular rosacea," explained Dr. Fowler, a dermatologist at the University of Louisville (Ky.).

Like Dr. Harper, he typically prescribes topical cyclosporine for ocular rosacea in combination with oral doxycycline.

"I find it very useful," he added.

Dr. Fowler disclosed that he has received research grants from Allergan, which markets Restasis. He also serves as a consultant to Galderma, which markets Oracea, as well as to numerous other pharmaceutical companies. Dr. Harper is on the speakers bureaus for Allergan, Galderma, and a handful of other companies.

The SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Topical cyclosporine 0.05% ophthalmic emulsion significantly outperformed artificial tears for the treatment of ocular rosacea in a double-blind, randomized, multicenter study.

"It’s a fairly small study, but I think it gives us some valuable information. This gives us a new option topically," Dr. Julie C. Harper said in highlighting the study at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

She referred to a clinical trial conducted by Florida ophthalmologists who randomized 37 patients with ocular rosacea to twice-daily topical cyclosporine 0.05% (Restasis) or artificial tears for 3 months.

The outcome that most impressed Dr. Harper was the topical cyclosporine group’s mean 11.5-point improvement from a baseline of 14.1 on the Ocular Surface Disease Index, a validated patient questionnaire assessing the eye disease’s impact on quality of life. Patients who received artificial tears – a widely prescribed treatment for ocular rosacea – had a significantly lesser mean 2.9-point improvement.

"People definitely felt better with this product than with artificial tears," observed Dr. Harper, a dermatologist at the University of Alabama at Birmingham.

In addition, the topical cyclosporine group fared significantly better in the other study end points, which focused on eye dryness and tear production. For example, mean scores on Schirmer\'s test (a measure of eye-surface wetness) improved by 2.7 mm over the course of 3 months of treatment, from a baseline of 8.3, compared with a 1.4-mm deterioration in the artificial tears group.

Also, tear break-up time (a measure of how quickly an eye becomes dry) increased by a mean of 3.56 seconds in the cyclosporine group, a significantly more favorable effect than the 0.04-second decrease in the artificial tears arm (Adv. Ther. 2009;26:651-9).

The investigators speculated that topical cyclosporine’s clinical benefits in ocular rosacea are due to the drug’s anti-inflammatory effects, including a cyclosporine-mediated reduction in the number of activated lymphocytes in the conjunctiva, in combination with stimulation of increased tear production

The ophthalmologists emphasized that ocular rosacea can be a serious and potentially even a blinding condition. They noted that in one classic study, 13 of 131 patients had corneal complications resulting in visual acuity loss at the time they presented to ophthalmology. Of those 13 patients, 7 were left with worse than 20/400 eyesight, and 6 of the 13 required penetrating keratoplasty during the course of their disease (Ophthalmology 1997;104:1863-7).

Dr. Harper said that since she learned of the randomized trial, she has tried using topical cyclosporine for ocular rosacea but doesn’t yet have enough experience to say how well it works in her own hands. Usually, she gives the topical agent in combination with an oral tetracycline in patients whose ocular disease isn’t responding adequately to oral therapy alone.

Her preferred oral agent is delayed-release doxycycline (Oracea) at the anti-inflammatory but subantimicrobial dose of 40 mg once daily, a dosage that is Food and Drug Administration approved for treatment of rosacea. She favors this regimen because it doesn’t contribute to the worsening, global, antibiotic-resistance public health problem, and the once-daily aspect is a real plus from the patient adherence standpoint.

For patients who don’t have insurance coverage for this relatively costly drug, her second-favorite option is generic doxycycline at 20 mg BID, which is also an anti-inflammatory yet subantimicrobial dosage. It’s important to recognize, however, that bumping up the dosage of generic doxycycline to 50 mg/day would cross the threshold into the antibacterial range that could contribute to the resistance problem, the dermatologist added.

Topical cyclosporine for ocular rosacea is off-label therapy. The drug’s approved indication is in treating chronic dry eyes. Conference codirector Dr. Joseph F. Fowler Jr. predicted that the product may never gain an indication for ocular rosacea. That’s because ophthalmologists have a difficult time in quantifying the severity of ocular rosacea for research purposes, and even in distinguishing it from dry eye.

"My own crude approach is that if you’ve got rosacea on the skin and you’ve got itchy, gritty eyes, then I generally assume you’ve got ocular rosacea," explained Dr. Fowler, a dermatologist at the University of Louisville (Ky.).

Like Dr. Harper, he typically prescribes topical cyclosporine for ocular rosacea in combination with oral doxycycline.

"I find it very useful," he added.

Dr. Fowler disclosed that he has received research grants from Allergan, which markets Restasis. He also serves as a consultant to Galderma, which markets Oracea, as well as to numerous other pharmaceutical companies. Dr. Harper is on the speakers bureaus for Allergan, Galderma, and a handful of other companies.

The SDEF and this news organization are owned by Elsevier.

NATIONAL HARBOR, MD. – Treating patients with both rosacea and small intestinal bacterial overgrowth with the drug rifaximin was associated with improved rosacea symptoms in some patients, in a small, preliminary study. The findings were presented at the annual meeting of the American College of Gastroenterology.

Previous studies have shown a relationship between gastrointestinal bacteria and various skin disorders such as scleroderma, and a small case series showed that rosacea improved when patients with small intestinal bacterial overgrowth (SIBO) were treated with rifaximin, said Dr. Leonard B. Weinstock of Specialists in Gastroenterology in St. Louis.

Dr. Weinstock identified 63 patients with rosacea; the average age of the patients was 56 years. Most of them, 57 patients, had been diagnosed with facial rosacea by a dermatologist, and 4 had been diagnosed with ocular rosacea by an ophthalmologist. The rosacea patients were compared to 30 healthy controls and 30 general population controls. All study participants underwent lactulose breath testing to determine whether they had SIBO.

Overall, SIBO was significantly more common in the rosacea patients (50%) than in the general population controls (23%) or the healthy controls (10%). All four patients with ocular rosacea had SIBO.

A total of 32 rosacea patients were positive for SIBO, and 28 of these (including all ocular rosacea patients) received 1200 mg/day of rifaximin (two 200-mg tablets 3 times daily) for 10 days. Of the treated patients, 46% showed clearance of, or marked improvement in, rosacea symptoms, while another 25% showed moderate improvement.

"All four patients with ocular rosacea and SIBO reported marked improvement in conjunctivitis, sclera erythema, and dry eyes following treatment with rifaximin," Dr. Weinstock noted.

A large, randomized clinical trial is underway to further explore the possible benefits of rifaximin in patients with rosacea and SIBO, Dr. Weinstock added.

The study was supported by a grant from Salix Pharmaceuticals, maker of rifaximin.

NATIONAL HARBOR, MD. – Treating patients with both rosacea and small intestinal bacterial overgrowth with the drug rifaximin was associated with improved rosacea symptoms in some patients, in a small, preliminary study. The findings were presented at the annual meeting of the American College of Gastroenterology.

Previous studies have shown a relationship between gastrointestinal bacteria and various skin disorders such as scleroderma, and a small case series showed that rosacea improved when patients with small intestinal bacterial overgrowth (SIBO) were treated with rifaximin, said Dr. Leonard B. Weinstock of Specialists in Gastroenterology in St. Louis.

Dr. Weinstock identified 63 patients with rosacea; the average age of the patients was 56 years. Most of them, 57 patients, had been diagnosed with facial rosacea by a dermatologist, and 4 had been diagnosed with ocular rosacea by an ophthalmologist. The rosacea patients were compared to 30 healthy controls and 30 general population controls. All study participants underwent lactulose breath testing to determine whether they had SIBO.

Overall, SIBO was significantly more common in the rosacea patients (50%) than in the general population controls (23%) or the healthy controls (10%). All four patients with ocular rosacea had SIBO.

A total of 32 rosacea patients were positive for SIBO, and 28 of these (including all ocular rosacea patients) received 1200 mg/day of rifaximin (two 200-mg tablets 3 times daily) for 10 days. Of the treated patients, 46% showed clearance of, or marked improvement in, rosacea symptoms, while another 25% showed moderate improvement.

"All four patients with ocular rosacea and SIBO reported marked improvement in conjunctivitis, sclera erythema, and dry eyes following treatment with rifaximin," Dr. Weinstock noted.

A large, randomized clinical trial is underway to further explore the possible benefits of rifaximin in patients with rosacea and SIBO, Dr. Weinstock added.

The study was supported by a grant from Salix Pharmaceuticals, maker of rifaximin.

NATIONAL HARBOR, MD. – Treating patients with both rosacea and small intestinal bacterial overgrowth with the drug rifaximin was associated with improved rosacea symptoms in some patients, in a small, preliminary study. The findings were presented at the annual meeting of the American College of Gastroenterology.

Previous studies have shown a relationship between gastrointestinal bacteria and various skin disorders such as scleroderma, and a small case series showed that rosacea improved when patients with small intestinal bacterial overgrowth (SIBO) were treated with rifaximin, said Dr. Leonard B. Weinstock of Specialists in Gastroenterology in St. Louis.

Dr. Weinstock identified 63 patients with rosacea; the average age of the patients was 56 years. Most of them, 57 patients, had been diagnosed with facial rosacea by a dermatologist, and 4 had been diagnosed with ocular rosacea by an ophthalmologist. The rosacea patients were compared to 30 healthy controls and 30 general population controls. All study participants underwent lactulose breath testing to determine whether they had SIBO.

Overall, SIBO was significantly more common in the rosacea patients (50%) than in the general population controls (23%) or the healthy controls (10%). All four patients with ocular rosacea had SIBO.

A total of 32 rosacea patients were positive for SIBO, and 28 of these (including all ocular rosacea patients) received 1200 mg/day of rifaximin (two 200-mg tablets 3 times daily) for 10 days. Of the treated patients, 46% showed clearance of, or marked improvement in, rosacea symptoms, while another 25% showed moderate improvement.

"All four patients with ocular rosacea and SIBO reported marked improvement in conjunctivitis, sclera erythema, and dry eyes following treatment with rifaximin," Dr. Weinstock noted.

A large, randomized clinical trial is underway to further explore the possible benefits of rifaximin in patients with rosacea and SIBO, Dr. Weinstock added.

The study was supported by a grant from Salix Pharmaceuticals, maker of rifaximin.

Taking oral antibiotics to treat acne tripled a patient’s risk of developing pharyngitis, according to a study published online Nov. 21 in Archives of Dermatology.

However, using topical antibiotics for acne had no such effect, said Dr. David J. Margolis of the department of dermatology and the department of epidemiology and biostatistics, University of Pennsylvania, Philadelphia, and his associates.

Previous retrospective cohort studies and cross-sectional studies have noted an association between acne therapy with oral antibiotics and pharyngitis, but no prospective study has examined the issue until now. Dr. Margolis and his colleagues conducted one cross-sectional study involving 266 patients seen on a single occasion and one prospective longitudinal study involving 579 different patients seen over the course of a school year.

In the cross-sectional study, male and female graduate and postgraduate students (mean age 21 years) reported whether they were currently using antibiotics for acne and whether they had pharyngitis, currently or within the preceding month, that was severe enough to warrant a visit to a health care provider.

Of the 15 students who said they were taking oral antibiotics for acne, 10 (66.7%) had current or recent pharyngitis, compared with 82 of the 251 students (32.7%) who were not taking oral antibiotics.

Thus, the rate of pharyngitis was more than twice as high among subjects taking oral antibiotics as among those who weren’t taking the drugs in the cross-sectional study.

In the prospective longitudinal study, male and female students (mean age also 21 years) reported during three survey periods whether they were taking antibiotics for acne and whether they had pharyngitis within the preceding month that was severe enough to warrant a visit to a health care provider.

A total of 11.3% of subjects taking oral antibiotics reported having pharyngitis, compared with 3.3% of subjects who weren’t taking oral antibiotics for acne.

Thus, in the prospective longitudinal study, the rate of pharyngitis was more than 3 times higher among subjects taking oral antibiotics than the rate among those who weren’t taking them, the investigators said (Arch. Dermatol. 2011 Nov. 21 [doi:10.1001/archdermatol.2011.355]).

In contrast, rates of pharyngitis were not significantly higher among subjects using topical antibiotics for acne than among those not using any antibiotics.

Before conducting the two studies, Dr. Margolis and his associates had postulated that the use of oral antibiotics may have changed the microbial flora in the throat – for example, increasing pharyngeal colonization with group A streptococcus, "with a resulting increase in the frequency of symptomatic infection."

They proposed that the drugs may have acted by reducing the presence of less virulent organisms known to prevent colonization with group A strep, such as Streptococcus salivarius.

Contrary to that hypothesis, however, there was no association between pharyngeal colonization with either of those organisms and oral antibiotic use in the two studies.

The studies were limited in that they relied on students’ self reports both of antibiotic use and health care visits for pharyngitis; the student health clinic would not reveal the contents of students’ medical histories because of privacy concerns. In addition, the two studies may have missed some confounding risk factor that could be associated with both pharyngitis and antibiotic use, such as smoking status, the researchers said.

The National Institutes of Health supported the two studies. No financial conflicts of interest were reported.

Taking oral antibiotics to treat acne tripled a patient’s risk of developing pharyngitis, according to a study published online Nov. 21 in Archives of Dermatology.

However, using topical antibiotics for acne had no such effect, said Dr. David J. Margolis of the department of dermatology and the department of epidemiology and biostatistics, University of Pennsylvania, Philadelphia, and his associates.

Previous retrospective cohort studies and cross-sectional studies have noted an association between acne therapy with oral antibiotics and pharyngitis, but no prospective study has examined the issue until now. Dr. Margolis and his colleagues conducted one cross-sectional study involving 266 patients seen on a single occasion and one prospective longitudinal study involving 579 different patients seen over the course of a school year.

In the cross-sectional study, male and female graduate and postgraduate students (mean age 21 years) reported whether they were currently using antibiotics for acne and whether they had pharyngitis, currently or within the preceding month, that was severe enough to warrant a visit to a health care provider.

Of the 15 students who said they were taking oral antibiotics for acne, 10 (66.7%) had current or recent pharyngitis, compared with 82 of the 251 students (32.7%) who were not taking oral antibiotics.

Thus, the rate of pharyngitis was more than twice as high among subjects taking oral antibiotics as among those who weren’t taking the drugs in the cross-sectional study.

In the prospective longitudinal study, male and female students (mean age also 21 years) reported during three survey periods whether they were taking antibiotics for acne and whether they had pharyngitis within the preceding month that was severe enough to warrant a visit to a health care provider.

A total of 11.3% of subjects taking oral antibiotics reported having pharyngitis, compared with 3.3% of subjects who weren’t taking oral antibiotics for acne.

Thus, in the prospective longitudinal study, the rate of pharyngitis was more than 3 times higher among subjects taking oral antibiotics than the rate among those who weren’t taking them, the investigators said (Arch. Dermatol. 2011 Nov. 21 [doi:10.1001/archdermatol.2011.355]).

In contrast, rates of pharyngitis were not significantly higher among subjects using topical antibiotics for acne than among those not using any antibiotics.

Before conducting the two studies, Dr. Margolis and his associates had postulated that the use of oral antibiotics may have changed the microbial flora in the throat – for example, increasing pharyngeal colonization with group A streptococcus, "with a resulting increase in the frequency of symptomatic infection."

They proposed that the drugs may have acted by reducing the presence of less virulent organisms known to prevent colonization with group A strep, such as Streptococcus salivarius.

Contrary to that hypothesis, however, there was no association between pharyngeal colonization with either of those organisms and oral antibiotic use in the two studies.

The studies were limited in that they relied on students’ self reports both of antibiotic use and health care visits for pharyngitis; the student health clinic would not reveal the contents of students’ medical histories because of privacy concerns. In addition, the two studies may have missed some confounding risk factor that could be associated with both pharyngitis and antibiotic use, such as smoking status, the researchers said.

The National Institutes of Health supported the two studies. No financial conflicts of interest were reported.

Taking oral antibiotics to treat acne tripled a patient’s risk of developing pharyngitis, according to a study published online Nov. 21 in Archives of Dermatology.

However, using topical antibiotics for acne had no such effect, said Dr. David J. Margolis of the department of dermatology and the department of epidemiology and biostatistics, University of Pennsylvania, Philadelphia, and his associates.

Previous retrospective cohort studies and cross-sectional studies have noted an association between acne therapy with oral antibiotics and pharyngitis, but no prospective study has examined the issue until now. Dr. Margolis and his colleagues conducted one cross-sectional study involving 266 patients seen on a single occasion and one prospective longitudinal study involving 579 different patients seen over the course of a school year.

In the cross-sectional study, male and female graduate and postgraduate students (mean age 21 years) reported whether they were currently using antibiotics for acne and whether they had pharyngitis, currently or within the preceding month, that was severe enough to warrant a visit to a health care provider.

Of the 15 students who said they were taking oral antibiotics for acne, 10 (66.7%) had current or recent pharyngitis, compared with 82 of the 251 students (32.7%) who were not taking oral antibiotics.

Thus, the rate of pharyngitis was more than twice as high among subjects taking oral antibiotics as among those who weren’t taking the drugs in the cross-sectional study.

In the prospective longitudinal study, male and female students (mean age also 21 years) reported during three survey periods whether they were taking antibiotics for acne and whether they had pharyngitis within the preceding month that was severe enough to warrant a visit to a health care provider.

A total of 11.3% of subjects taking oral antibiotics reported having pharyngitis, compared with 3.3% of subjects who weren’t taking oral antibiotics for acne.

Thus, in the prospective longitudinal study, the rate of pharyngitis was more than 3 times higher among subjects taking oral antibiotics than the rate among those who weren’t taking them, the investigators said (Arch. Dermatol. 2011 Nov. 21 [doi:10.1001/archdermatol.2011.355]).

In contrast, rates of pharyngitis were not significantly higher among subjects using topical antibiotics for acne than among those not using any antibiotics.

Before conducting the two studies, Dr. Margolis and his associates had postulated that the use of oral antibiotics may have changed the microbial flora in the throat – for example, increasing pharyngeal colonization with group A streptococcus, "with a resulting increase in the frequency of symptomatic infection."

They proposed that the drugs may have acted by reducing the presence of less virulent organisms known to prevent colonization with group A strep, such as Streptococcus salivarius.

Contrary to that hypothesis, however, there was no association between pharyngeal colonization with either of those organisms and oral antibiotic use in the two studies.

The studies were limited in that they relied on students’ self reports both of antibiotic use and health care visits for pharyngitis; the student health clinic would not reveal the contents of students’ medical histories because of privacy concerns. In addition, the two studies may have missed some confounding risk factor that could be associated with both pharyngitis and antibiotic use, such as smoking status, the researchers said.

The National Institutes of Health supported the two studies. No financial conflicts of interest were reported.

LISBON – Contrary to conventional wisdom, atrophic acne scars may arise from what was clinically normal skin 3 months earlier.

Inflammatory acne lesions clearly play a major role in atrophic scarring, but scars can arise from erythematous macules and closed comedones as well.

"And it’s also important to emphasize that we’re able to identify atrophic scars arising from clinically normal skin," Dr. Sewon Kang said at the annual Congress of the European Academy of Dermatology and Venereology, during a session sponsored by Galderma.

His study of the natural history of acne over a 12-week time frame used computer-assisted spatial alignment and serial high-definition digital photographs to track new lesions and atrophic scarring in 25 subjects with untreated mild to moderate facial acne. Participants were formally assessed every 2 weeks.

Closed comedones accounted for 37% of all lesions, followed by erythematous macules at 26%, inflammatory papules at 15%, open comedones at 12%, with pustules and nodules accounting for the rest.

"Both non- inflammatory as well as inflammatory acne lesions need to be addressed in order to prevent the most terrible sequelae of acne: the formation of scars."

At 12 weeks, a total of 219 inflammatory lesions were present: 176 papules, 35 pustules, and 8 nodules. Working backward via the serial tracking system, Dr. Kang and coworkers determined that 41% of the inflammatory lesions were preceded by closed comedones, 13% by open comedones, 12% from erythematous macules, and 6% from ice pick scars. Importantly, 28% of inflammatory lesions arose from clinically normal-appearing skin, said Dr. Kang, professor and chair of the department of dermatology at Johns Hopkins University, Baltimore.

Also present at 12 weeks were a total of 104 atrophic scars as agreed upon by at least two of the three independent examining dermatologists. Nearly 70% were ice pick scars, 30% were boxcar acne scars, and 2% were rolling scars.

Of note, 23 of the 25 study participants had one or more acne scars at 3 months of follow-up.

In all, 30% of the scars were already present at baseline. Another 20% arose from inflamed papules or pustules or from closed comedones. But fully half of the scars arose from noninflammatory lesions.

The clinical implication of these findings is that aggressive treatment should be prescribed from the outset in acne patients – even in those with mild disease – to prevent acne scarring.

"Both noninflammatory as well as inflammatory acne lesions need to be addressed in order to prevent the most terrible sequelae of acne: the formation of scars," said Dr. Kang.

Based upon these findings, he said he favors multimodal acne therapy with a retinoid, an antimicrobial agent, and benzoyl peroxide.

Dr. Kang is a paid speaker for Galderma.

LISBON – Contrary to conventional wisdom, atrophic acne scars may arise from what was clinically normal skin 3 months earlier.

Inflammatory acne lesions clearly play a major role in atrophic scarring, but scars can arise from erythematous macules and closed comedones as well.

"And it’s also important to emphasize that we’re able to identify atrophic scars arising from clinically normal skin," Dr. Sewon Kang said at the annual Congress of the European Academy of Dermatology and Venereology, during a session sponsored by Galderma.

His study of the natural history of acne over a 12-week time frame used computer-assisted spatial alignment and serial high-definition digital photographs to track new lesions and atrophic scarring in 25 subjects with untreated mild to moderate facial acne. Participants were formally assessed every 2 weeks.

Closed comedones accounted for 37% of all lesions, followed by erythematous macules at 26%, inflammatory papules at 15%, open comedones at 12%, with pustules and nodules accounting for the rest.

"Both non- inflammatory as well as inflammatory acne lesions need to be addressed in order to prevent the most terrible sequelae of acne: the formation of scars."

At 12 weeks, a total of 219 inflammatory lesions were present: 176 papules, 35 pustules, and 8 nodules. Working backward via the serial tracking system, Dr. Kang and coworkers determined that 41% of the inflammatory lesions were preceded by closed comedones, 13% by open comedones, 12% from erythematous macules, and 6% from ice pick scars. Importantly, 28% of inflammatory lesions arose from clinically normal-appearing skin, said Dr. Kang, professor and chair of the department of dermatology at Johns Hopkins University, Baltimore.

Also present at 12 weeks were a total of 104 atrophic scars as agreed upon by at least two of the three independent examining dermatologists. Nearly 70% were ice pick scars, 30% were boxcar acne scars, and 2% were rolling scars.

Of note, 23 of the 25 study participants had one or more acne scars at 3 months of follow-up.

In all, 30% of the scars were already present at baseline. Another 20% arose from inflamed papules or pustules or from closed comedones. But fully half of the scars arose from noninflammatory lesions.

The clinical implication of these findings is that aggressive treatment should be prescribed from the outset in acne patients – even in those with mild disease – to prevent acne scarring.

"Both noninflammatory as well as inflammatory acne lesions need to be addressed in order to prevent the most terrible sequelae of acne: the formation of scars," said Dr. Kang.

Based upon these findings, he said he favors multimodal acne therapy with a retinoid, an antimicrobial agent, and benzoyl peroxide.

Dr. Kang is a paid speaker for Galderma.

LISBON – Contrary to conventional wisdom, atrophic acne scars may arise from what was clinically normal skin 3 months earlier.

Inflammatory acne lesions clearly play a major role in atrophic scarring, but scars can arise from erythematous macules and closed comedones as well.

"And it’s also important to emphasize that we’re able to identify atrophic scars arising from clinically normal skin," Dr. Sewon Kang said at the annual Congress of the European Academy of Dermatology and Venereology, during a session sponsored by Galderma.

His study of the natural history of acne over a 12-week time frame used computer-assisted spatial alignment and serial high-definition digital photographs to track new lesions and atrophic scarring in 25 subjects with untreated mild to moderate facial acne. Participants were formally assessed every 2 weeks.

Closed comedones accounted for 37% of all lesions, followed by erythematous macules at 26%, inflammatory papules at 15%, open comedones at 12%, with pustules and nodules accounting for the rest.

"Both non- inflammatory as well as inflammatory acne lesions need to be addressed in order to prevent the most terrible sequelae of acne: the formation of scars."

At 12 weeks, a total of 219 inflammatory lesions were present: 176 papules, 35 pustules, and 8 nodules. Working backward via the serial tracking system, Dr. Kang and coworkers determined that 41% of the inflammatory lesions were preceded by closed comedones, 13% by open comedones, 12% from erythematous macules, and 6% from ice pick scars. Importantly, 28% of inflammatory lesions arose from clinically normal-appearing skin, said Dr. Kang, professor and chair of the department of dermatology at Johns Hopkins University, Baltimore.

Also present at 12 weeks were a total of 104 atrophic scars as agreed upon by at least two of the three independent examining dermatologists. Nearly 70% were ice pick scars, 30% were boxcar acne scars, and 2% were rolling scars.

Of note, 23 of the 25 study participants had one or more acne scars at 3 months of follow-up.

In all, 30% of the scars were already present at baseline. Another 20% arose from inflamed papules or pustules or from closed comedones. But fully half of the scars arose from noninflammatory lesions.

The clinical implication of these findings is that aggressive treatment should be prescribed from the outset in acne patients – even in those with mild disease – to prevent acne scarring.

"Both noninflammatory as well as inflammatory acne lesions need to be addressed in order to prevent the most terrible sequelae of acne: the formation of scars," said Dr. Kang.

Based upon these findings, he said he favors multimodal acne therapy with a retinoid, an antimicrobial agent, and benzoyl peroxide.

Dr. Kang is a paid speaker for Galderma.