Practical management of acne for clinicians: An international consensus from the Global Alliance to Improve Outcomes in Acne.

Scientific advances are continually improving the knowledge of acne and contributing to the refinement of treatment options; it is important for clinicians to regularly update their practice patterns to reflect current standards. The Global Alliance to Improve Outcomes in Acne is an international group of dermatologists with an interest in acne research and education that has been meeting regularly since 2001. As a group, we have continuously evaluated the literature on acne. This supplement focuses on providing relevant clinical guidance to health care practitioners managing patients with acne, with an emphasis on areas where the evidence base may be sparse or need interpretation for daily practice.

Effects of Extracellular Calcium and 1,25 dihydroxyvitamin D3 on Sebaceous Gland Cells In vitro and In vivo.

Calcium and 1,25 dihydroxyvitamin D3 (1,25(OH)2D3) are promoters of epithelial cell functions; however their effects on sebaceous glands are unknown. In this study, morphology, ultrastructure, cell numbers, lipid synthesis and apoptosis of SZ95 sebocytes were assessed in vitro under different concentrations of extracellular calcium with or without 1,25(OH)2D3. Moreover, serum calcium and 1,25(OH)2D3 levels were assessed in acne and non-acne patients (controls). Under conditions of low extracellular calcium, lipogenesis and cell detachment were observed. Increasing extracellular calcium enhanced sebocyte numbers, induced epithelial morphology and reduced lipogenesis. Moreover, a reduction in extracellular calcium reduced E-cadherin and enhanced caspase 3/7 activity (apoptosis), whereas calcium chelation by EGTA (ethylene glycol-bis(ß-aminoethyl ether)-N,N,N',N'-tetraacetic acid) resulted in enhanced lipogenesis. 1,25(OH)2D3 decreased sebaceous lipogenesis, but also induced signs of autophagy. In the clinical study, patients and controls exhibited normal serum calcium levels. Younger acne patients presented lower 1,25(OH)2D3 levels than did older ones. In conclusion, extracellular calcium and 1,25(OH)2D3 regulate sebocyte morphology, increase cell numbers, decrease sebaceous lipogenesis and induce cell autophagy in vitro. The increased ionized calcium and the reduced 1,25(OH)2D3 levels detected in the serum of younger patients with acne may contribute respectively to increased sebaceous gland volume and enhanced lipogenesis.

Meeting the Challenges of Acne Treatment in Asian Patients: A Review of the Role of Dermocosmetics as Adjunctive Therapy.

Conventional acne treatment presents several challenges such as intolerable side effects and antibiotic resistance. Dermocosmetic products may be used to reduce these unwanted effects. Dermocosmetics include skin cleansers, topical sebum-controllers, skin antimicrobial/anti-inflammatory agents, moisturizers, sunscreens, and camouflage products. Appropriate use of these products may help augment the benefit of acne treatment, minimize side effects, and reduce the need for topical antibiotics. In Asia, there is currently limited scientific data on the application and recommendations for dermocosmetic use in acne vulgaris (AV). This article reviews the evidence on dermocosmetics for AV and provides practice recommendations as discussed during the 4(th) Asia-Pacific Acne Leaders' Summit held in Bangkok, Thailand, on 7 and 8 February 2015. Through a premeeting survey, a series of plenary lectures, a stepwise program of discussion sessions, and Medline article review, the Expert Panel set forth relevant recommendations on the role of dermocosmetics as adjunct for treating AV in Asian patients.

Frequency and characteristics of acne-related post-inflammatory hyperpigmentation.

In patients with darker skin types (Fitzpatrick phototypes III-VI), acne is often accompanied by post-inflammatory hyperpigmentation (PIH). Further, acne-related pigmentation can pose a greater concern for the patient than the acne lesions. There has been little formal study of this acne-related PIH. Recently, the Asian Acne Board - an international group of dermatologists with interest in acne research - made a preliminary evaluation of the frequency and characteristics of PIH in seven Asian countries. A total of 324 sequential acne subjects were evaluated for the presence of PIH. The majority (80.2%) of subjects had mild to moderate acne and there were more females than males (63.0% vs 37.0%). In this population of patients consulting a dermatologist for acne, 58.2% (188/324) had PIH. The results also showed that pigmentation problems are often long lasting: at least 1 year for more than half of subjects and 5 years or longer in 22.3%. In accordance with our clinical experience, patients reported that PIH is quite bothersome, often as bothersome or more so than the acne itself and sometimes more problematic. Excoriation was commonly reported by patients, and may represent a modifiable risk factor that could potentially be improved by patient education.

Evaluating acne-related post-inflammatory hyperpigmentation is a challenge even amongst experts.

Post-inflammatory hyperpigmentation (PIH) is a problematic and distressing acne sequela. The difficulty of clinically assessing and managing post-inflammatory hyperpigmentation is especially prevalent in Asian populations. The Asian Acne Board conducted a study to evaluate concordance in diagnosis of post-inflammatory hyperpigmentation in patients with active acne, acne scarring, and pigmentation problems. Seven dermatologists reviewed 64 anonymous clinical photographs projected onto a screen during a single session. Results showed that there were two groups of raters, those who found a high frequency of PIH and those who found a low frequency. There was significant variability in these two groups in rating the presence of PIH, with an average of 30 diagnoses (24%) difference between high- and low-frequency raters. Results of severity ratings showed that while most cases of PIH were assessed as mild, there was marked variability between raters in their assessments of severity. Overall, variability in PIH diagnosis was greatest when active acne was present; in these cases, low PIH raters were more likely to report skin coloration as erythema instead of PIH. These findings uphold the importance of utilizing specific clinical criteria to improve accurate evaluation of skin color and we advocate future research into this area.

Argyria an unrecognized cause of cutaneous pigmentation in Indian patients: a case series and review of the literature.

Argyria is an uncommon grey-blue pigmentation of skin and mucous membranes caused by prolonged silver exposure. The impetus behind this review is our experience with cases of generalized argyria resulting from a uniquely Indian socio-cultural practice and belief that it is under reported. Our objective is to increase the awareness for this esoteric entity through a review of the pertinent literature and to highlight clinical and histological features using our four well worked-up cases as examples.

Clinicopathological correlation of acquired hyperpigmentary disorders.

Acquired pigmentary disorders are group of heterogenous entities that share single, most significant, clinical feature, that is, dyspigmentation. Asians and Indians, in particular, are mostly affected. Although the classic morphologies and common treatment options of these conditions have been reviewed in the global dermatology literature, the value of histpathological evaluation has not been thoroughly explored. The importance of accurate diagnosis is emphasized here as the underlying diseases have varying etiologies that need to be addressed in order to effectively treat the dyspigmentation. In this review, we describe and discuss the utility of histology in the diagnostic work of hyperpigmentary disorders, and how, in many cases, it can lead to targeted and more effective therapy. We focus on the most common acquired pigmentary disorders seen in Indian patients as well as a few uncommon diseases with distinctive histological traits. Facial melanoses, including mimickers of melasma, are thoroughly explored. These diseases include lichen planus pigmentosus, discoid lupus erythematosus, drug-induced melanoses, hyperpigmentation due to exogenous substances, acanthosis nigricans, and macular amyloidosis.

Clinicopathological correlation of acquired hypopigmentary disorders.

Acquired hypopigmentary disorders comprise a significant group of disorders that affect Indians and Asians. The pigment disturbance in darker skin individuals can be very distressing to the patient and the family. These disorders cover a wide array of pathologies including infections, autoimmune processes, lymphoproliferative disorders, and sclerosing diseases. Histological diagnosis is particularly important because treatments for these diseases are varied and specific. This review will focus on histopathological diagnosis based on clinicopathological correlation for commonly encountered disorders such as leprosy, vitiligo, lichen sclerosus, pityriasis alba (PA), and pityriasis versicolor (PV). Atypical or uncommon clinical presentation of classic diseases such as hypopigmented mycosis fungoides (HMF) and hypopigmented sarcoidosis are also included.

Toward evidence-based practice in acne: consensus of an Asian Working Group.

Acne vulgaris is common throughout the world and often perceived by both patients and clinicians as an inconsequential disease of adolescence. In reality, however, acne is a chronic medical disease that lasts for years and causes a considerable impact on quality of life. Many patients with acne experience emotional problems due to their disease, which can lead to reduced social interactions and even a lower likelihood of employment. Little has been written specifically about acne in Asian patients in the English-language medical published work, perhaps due to an assumption that the management of acne is the same in all populations. A group of acne experts from nine Asian countries and the USA met to review and discuss acne care within the Asia-Pacific region, focusing on evidence-based medicine. This group developed a care algorithm using results of clinical trials as well as knowledge of practice patterns.

Porokeratotic eccrine ostial and dermal duct nevus.

Porokeratotic eccrine ostial and dermal duct nevus (PEODDN) is a rare variant of porokeratosis with characteristic histological feature of cornoid lamella involving the acrosyringium. We report a classic case of a 20-year-old male, who clinically presented to us with keratotic papules and plaque with pits, few having comedo like plugs, on right palm and sole since 1 year of age. A punch biopsy from palm was diagnostic as well as confirmatory showing cornoid lamella involving an eccrine duct which is the characteristic histopathological feature of PEODDN.

New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne group.

The Global Alliance to Improve Outcomes in Acne published recommendations for the management of acne as a supplement to the Journal of the American Academy of Dermatology in 2003. The recommendations incorporated evidence-based strategies when possible and the collective clinical experience of the group when evidence was lacking. This update reviews new information about acne pathophysiology and treatment-such as lasers and light therapy-and relevant topics where published data were sparse in 2003 but are now available including combination therapy, revision of acne scarring, and maintenance therapy. The update also includes a new way of looking at acne as a chronic disease, a discussion of the changing role of antibiotics in acne management as a result of concerns about microbial resistance, and factors that affect adherence to acne treatments. Summary statements and recommendations are provided throughout the update along with an indication of the level of evidence that currently supports each finding. As in the original supplement, the authors have based recommendations on published evidence as much as possible.