Challenges in Adult Acne and the Role of Skin Care in Managing the Condition.

BACKGROUND: Acne vulgaris is a complex, multifactorial, inflammatory skin condition. Although frequently presented at dermatology clinics, the literature on adult acne is scarce, particularly concerning skin barrier function and management. We aimed to provide insights into the role of skin barrier integrity in adult acne patients and the role of cleansers and moisturizers as adjunctive to treating and maintaining adult acne.   Methods: A panel of eight dermatologists who treat adult patients with acne developed a consensus paper on the role of skin barrier function and skin care in adult acne management. The modified Delphi method comprised a face-to-face meeting and online follow-up to discuss the results of a scoping literature review. Drawing from their experience and opinions, they agreed on seven consensus statements.   Results: Epidermal barrier dysfunction plays a vital role in acne pathogenesis and asymmetrically impacts adult female acne. Erythema, pruritus, peeling, and xerosis are common adverse effects of first-line acne treatment options and, if not appropriately counseled and managed, can exacerbate, leading to regimen nonadherence and poor patient experience and outcomes. CONCLUSION: Improving patient knowledge of comprehensive acne treatments, including quality adjunctive cleansers and moisturizers, may maximize regimen efficacy and provide patients with personalized and successful acne treatment and maintenance tools. J Drugs Dermatol. 2024;23(8):674-679.     doi:10.36849/JDD.8471.

Minimally Invasive Injectable Cosmetic Procedures Increase Feelings of Authenticity.

BACKGROUND: Minimally invasive cosmetic dermatology procedures continue to be increasingly popular; however, the extant literature has poorly documented the psychological antecedents of interest in cosmetic procedures and their psychological consequences. OBJECTIVE: To better inform dermatologists on their patients' motivations for cosmetic enhancement. MATERIALS AND METHODS: In a general population survey, an online representative sample of 984 Americans reported the extent to which they feel authentic using the validated authenticity scale and whether they were interested in undergoing a cosmetic procedure. In a prospective dermatology office survey, 102 participants reported their feelings of authenticity immediately before and 2 weeks after receiving a minimally invasive injectable cosmetic procedure. RESULTS: In the general population survey, participants interested in cosmetic procedures felt significantly less authentic than participants who were not interested ( p = .003). In the prospective dermatology office survey, participants felt significantly more authentic 2 weeks after their minimally invasive injectable cosmetic procedure than before ( p = .018). CONCLUSION: Lower feelings of authenticity are associated with interest in cosmetic procedures. Participants felt more authentic 2 weeks after receiving a minimally invasive injectable cosmetic procedure. Cosmetic procedures may present patients with an opportunity to feel more like their real, genuine selves.

Appearance Dissatisfaction and Body Dysmorphic Disorder in the Dermatology Patient.

Dermatologists routinely see patients with inflammatory skin conditions and aesthetic concerns that involve substantial psychological comorbidity. However, most dermatologists do not receive formal training in this area, and many are unsure how to best help treat certain patients holistically. Body dysmorphic disorder (BDD) is a common and distressing psychiatric condition that disproportionately impacts dermatology patients, including patients living with chronic inflammatory skin conditions such as acne and atopic dermatitis. BDD is characterized by preoccupation with nonexistent or minimally noticeable flaws in physical appearance that cause clinically significant distress or impairment in functioning. Adolescent populations may be particularly vulnerable to clinically significant body image dissatisfaction, including BDD, due to the high prevalence of acne and the pervasive role of social media platforms. The rise of social media may exacerbate body image issues through repetitive exposure to idealized and often unrealistic beauty standards. Though screening questionnaires can assist dermatologists in recognizing BDD, dermatologists must collaborate with mental health providers to provide comprehensive care to vulnerable patients, including adolescents.J Drugs Dermatol. 2024;23(7):545-550.  doi:10.36849/JDD.8156.

INDIVIDUAL ARTICLE: Impact of Acne Vulgaris and Sarecycline on Social/Emotional Functioning and Daily Activities: PROSES Study.

BACKGROUND: Concise patient-reported outcome (PRO) instruments addressing the consequences of facial acne vulgaris (AV) on patients’ functioning and activities of daily living (ADL) are needed. METHODS: A 12-week, single-arm, prospective cohort study was conducted in patients ≥9 years old with moderate/severe non-nodular facial AV prescribed sarecycline as part of usual care. The primary endpoint included AV-specific patient- and caregiver-reported outcomes assessed with the expert panel questionnaire (EPQ, developed by 10 experts using a Delphi method) in patients (>12 years) and caregivers (for patients 9-11 years). Additional assessments included parental/caregiver perspectives on children’s AV. RESULTS: A total of 253 patients completed the study. Following 12-weeks of treatment, there were significant (P ≤.0001) changes from baseline in the proportion of patients responding that they never or rarely: felt angry (31.6%), worried about AV worsening (28.9%), had thoughts about AV (20.9%), had a certain level of worries about AV (38.7%), altered their social media/selfie activity (23.7%), had an impact on real-life plans due to AV (22.9%), made efforts to hide AV (21.3%), felt picked-on/judged due to AV (15.0%), were concerned about their ability to reach future goals due to AV (13.8%), or had sleep impacted due to AV (18.2%). No significant change from baseline was observed for parent/caregiver’s understanding of the child’s AV concerns, from both patient and parent/caregiver perspectives. CONCLUSIONS: Over 12 weeks of AV management with oral sarecycline, patients reported significant reductions in AV-related effects on emotional/social functioning and ADL as measured by the EPQ, a simple PRO with potential for use in clinical practice. J Drugs Dermatol. 2024;23:1(Suppl 1):s4-11.

INDIVIDUAL ARTICLE: Sarecycline Improves Acne Severity, Symptoms, and Psychosocial Burden in Non-nodular Acne Vulgaris: PROSES Study.

BACKGROUND: Patient-reported outcomes (PROs) are emerging as a fundamental component of disease impact assessment in acne vulgaris (AV), complementing clinician-reported outcomes. No data is available on PROs for patients with AV using sarecycline in real-world settings. METHODS: A single-arm, prospective cohort study that included patients ≥9 years old diagnosed with moderate or severe non-nodular AV was implemented as part of routine care in clinical practices (N=30). Patients received oral sarecycline (60 mg, 100 mg, or 150 mg) for 12 weeks, as part of usual care. The primary endpoint was Acne Symptom and Impact Scale (ASIS) responses from patients (≥12 years) and caregivers (for patients 9-11 years) at week 12 and change from baseline (CFB). Investigator’s Global Assessment (IGA) of AV severity and adverse events (AEs) were also recorded. RESULTS: A total of 253 patients with AV completed the study (adults: 60.1%, females: 77.6%). ASIS mean scores significantly decreased (P <.0001) at week 12 for: signs (mean CFB ± standard deviation [SD]: –0.8 ± 0.7), impact (–1.0 ± 1.0), emotional impact (–1.2 ± 1.1), and social impact (0.6 ± 1.1). Significant reductions in AV severity (P <.0001) were reported by patients and caregivers. The IGA success rate was 58.9% and physician satisfaction with treatment outcomes was 88.1%. A total of 31 (10.3%) patients reported ≥1 AE during the study. CONCLUSIONS: Patients with moderate-to-severe AV receiving acne management with an oral antibiotic for 12 weeks experienced a significant improvement in AV-related symptoms and psychosocial burden. J Drugs Dermatol. 2024;23:1(Suppl 1):s12-18.

Dermatology in Contemporary Times: Building Awareness of Social Media's Association With Adolescent Skin Disease and Mental Health.

BACKGROUND: The contribution of psychological disorders to the burden of skin disease has been poorly explored in adolescent patients. The review aims to provide insights into the psychological, social, occupational, and social medias' association with acne, atopic dermatitis (AD), and aesthetics in adolescent patients. METHODS: The project used a modified Delphi process comprising face-to-face discussions followed up online.  The systematic literature search results informed the 14 draft statements. During an expert panel meeting, the draft statements underwent the panel's evaluation at a workshop, followed by a plenary discussion adopting five statements using evidence from the literature coupled with the panel's opinions and experiences.  Results: Studies reported an association between poor sleep, social impairment, and mental health disorders, including body dysmorphic disorder (BDD) with acne or AD in adolescents with acne or AD. Education for patients and parents may improve self-management skills and self-responsibility, promoting better outcomes for acne and AD. The use of certain types of social media can contribute to unrealistic expectations regarding the outcomes of cosmetic procedures. Social media use may also be associated with, and potentially contribute to unrealistic appearance expectations and certain mental health conditions. However, social media use may have benefits, such as connection, diversity, social support, increased self-esteem, safe identity experimentation, and an increased opportunity for self-disclosure.  Conclusions: The association with negative life events, BDD, suicidal ideation, depression, and anxiety are thought to be high for adolescent patients with acne or AD. Using social media for information has both positive and negative aspects. Awareness of the risks and benefits of receiving health information about dermatological disease among adolescents needs to be improved through the education of patients and clinicians. Action-oriented items need to be developed to help dermatologists address these issues in clinical practice.Rieder EA, Andriessen A, Cutler V, et al. Dermatology in contemporary times: building awareness of social media's association with adolescent skin disease and mental health. J Drugs Dermatol. 2023;22(8):817-825. doi:10.36849/JDD.7596.

Motivations for Seeking Cosmetic Enhancing Procedures of the Face: A Systematic Review.

BACKGROUND: Cosmetic enhancing procedures continue to grow in demand. Physicians should understand the complex factors that drive patient motivation for seeking such procedures. OBJECTIVE: In contrast to a lens of psychopathology, this review reveals the driving power of everyday intrapersonal, social, and behavioral factors that motivate interest in elective facial cosmetic procedures. MATERIALS AND METHODS: The review was conducted according to PRISMA guidelines and included studies with at least 50 adult patients seeking facial cosmetic enhancements between January 1, 2000, and July 1, 2022. RESULTS: Among 1,239 identified publications, 21 studies with 9,005 participants were selected for inclusion. The review documents everyday factors as patient motivators for pursuing cosmetic enhancements of the face, with the majority of work focusing on intrapersonal factors (17 of 21 studies), such as preventing aging or negative appearance based self-appraisals. For studies reporting social factors (15 of 21 studies), the most common motivators were the patient's social network and a desire to promote social standing. Behavioral factors revealed that social media and media consumption impact patient motivation for cosmetic enhancements (5 of 21 studies). CONCLUSION: In summary, this review demonstrates that patient motivations for facial cosmetic enhancements may be best understood through everyday intrapersonal, social, and behavioral factors.

Psychosocial issues and body dysmorphic disorder in aesthetics: Review and debate.

Body dysmorphic disorder (BDD) is a serious and debilitating psychiatric condition that disproportionately presents in dermatologic and cosmetic surgery patients. BDD is currently underrecognized in cosmetic medical settings and is thought to be underdiagnosed by behavioral health professionals. The significant comorbidities associated with this disorder, as well as potential harm done to both patient and physician, raise ethical and medicolegal concerns regarding its treatment. Although cosmetic interventions have historically been discouraged in BDD, recent studies have provided controversial evidence of benefit in certain cohorts. The rise of "snapchat dysmorphia" and the proposed explanatory phenomenon of perception drift have generated further debate around the de novo development or unmasking of BDD. We critically review and summarize existing debates around the treatment of BDD in cosmetic medicine. We provide guidance for screening, clinical interviewing, and the provision of psychoeducation in cases of suspected BDD.

Revisiting Solitary Pedunculated Lipofibromas.

OBJECTIVES: Pedunculated lipofibromas are soft, compressible, skin-colored nodules that typically present as an acquired solitary lesion, predominantly located on the buttocks and thighs. We aimed to differentiate between pedunculated lipofibromas and nevus lipomatosus superficialis. Although benign, this may be important as treatment options vary. METHODS: We describe 3 cases of solitary pedunculated lipofibromas occurring in older, obese adults that required clinicopathologic correlation for the correct diagnosis. RESULTS: The histopathologic features of pedunculated lipofibromas include a broad-based lesion with aggregates of mature adipocytes extending upwards into the dermis without an associated inflammatory infiltrate. The primary histopathologic differential diagnoses include fibroepithelial polyps with adipocytes and nevus lipomatosus superficialis, which is more frequently found in children or young adults and is typically characterized clinically by multiple lesions with a cerebriform to verrucoid surface. CONCLUSIONS: While the precise relationship between pedunculated lipofibromas and nevus lipomatosus is still unknown, we propose using pedunculated lipofibroma as a more specific clinical term to refer to solitary pedunculated or broad-based fatty lesions with a smooth surface that occur in older patients and in a wide anatomic distribution.

Psychiatric disorders and suicidal behavior in patients with acne prescribed oral antibiotics versus isotretinoin: Analysis of a large commercial insurance claims database.

BACKGROUND: The association between isotretinoin and psychiatric disturbance, including depression and suicidal behavior, is controversial. OBJECTIVE: To investigate whether acne patients prescribed isotretinoin or antibiotics were more likely to have psychiatric disorders and/or engage in suicidal behavior. METHODS: Retrospective cohort study using the IBM MarketScan Research Databases, which contain commercial insurance claims in the United States, to identify acne patients who were prescribed isotretinoin or oral antibiotics between 2011 and 2017 and who were diagnosed with psychiatric disorders or suicidal behavior. RESULTS: A total of 72,555 patients were included in the study. Patients in the general population were 1.47 times more likely to be diagnosed with suicidal ideation or attempt compared to acne patients prescribed isotretinoin (adjusted odds ratio [OR] 1.47; confidence interval [95% CI], 1.27, 1.70; P < .0001). The general population (adjusted OR 0.87; 95% CI, 0.84, 0.89; P < .0001) and acne patients prescribed antibiotics (adjusted OR 0.88; 95% CI, 0.85, 0.91; P < .0001) were less likely to have a psychiatric diagnosis compared to acne patients prescribed isotretinoin. The prevalence of suicidal behavior during isotretinoin treatment was lower (0.10%; P = .082) than in the year prior to isotretinoin treatment (0.22%) and in the year following treatment (0.34%; P = .004). LIMITATIONS: The study excluded individuals with public insurance and those who were uninsured, and the data in the study relied on the accuracy of the medical coding. CONCLUSIONS: Compared to the general population, acne patients prescribed isotretinoin were less likely to engage in suicidal behavior. Further exploration into the slight increase in suicidal behavior seen in isotretinoin patients 1 year after therapy is warranted.

Psychosocial Stress and Mechanisms of Skin Health: A Comprehensive Update.

Although the relationship between psychosocial stress and skin health is commonly invoked in both the scientific and popular literature, its underlying mechanisms are still not well understood. In this review, we provide a comprehensive update on the pathophysiology of stress and its clinical impact on skin homeostasis. The recent characterization of a bidirectional HPA stress axis in the skin has illuminated peripheral stress pathways, with effects spanning inflammation, atopy, barrier function, dermal thinning, wound healing, and melanogenesis. Additionally, new research into the cutaneous microbiome suggests the development of stress-induced dysbiosis through the “gut-brain-skin” axis. These new findings help contextualize how lifestyle factors such as diet, personal care practices, and sleep patterns may mediate and sometimes amplify the cutaneous impacts of psychological stress. We aim to clarify these clinically important relationships and highlight areas of future study that have widespread academic, clinical, and commercial implications. J Drugs Dermatol. 2021;20(1):62-29. doi:10.36849/JDD.5608.

The "bumpy" adolescent nose: Acne associated angiofibroma-like nasal papules.

BACKGROUND/OBJECTIVE: Papular scars are a recently described clinical phenotype of acne scarring characterized by papules occurring on the nose and chin. We have observed a similar presentation of nasal papules among patients seen in our clinic for acne and sought to further characterize the clinical and histopathological characteristics of this entity. METHODS: In this single-site case series, a retrospective review of electronic medical records of patients with nasal papules in association with acne vulgaris between April 2018 and April 2019 was performed. Clinical and histopathologic findings were recorded. RESULTS: We identified 20 patients who presented with a similar clinical phenotype of predominantly skin-colored, dome-shaped papules concentrated on the nose and chin in association with a history of more classic facial acne vulgaris. Papular lesions were seen predominately in adolescent Hispanic males. Concomitant acne on other areas of the face was identified in 18 patients at presentation while two patients had a history of adolescent acne. Biopsies were performed for five patients. Histopathologic examination demonstrated features of fibrosis and dilated thin-walled blood vessels, typical of angiofibromas. CONCLUSION: We present a series of adolescent patients with large, flesh-colored to erythematous papules seen predominantly on the nose. These lesions are histologically indistinguishable from angiofibromas and may represent an under-recognized yet disfiguring sequela of acne that may disproportionately affect adolescents with skin of color.

Observer-Reported Outcomes and Cosmetic Procedures: A Systematic Review.

BACKGROUND: Cosmetic procedures have demonstrated beneficial effects on physical appearance based on anatomic markers as well as patient-perceived self-image and quality of life. Recent studies of observer-reported outcomes (OROs) suggest an additional benefit from aesthetic interventions. OBJECTIVE: The authors aimed to review the evidence of OROs from cosmetic procedures performed on the head and neck. PATIENTS, METHODS AND MATERIALS: PubMed, Embase, and Cochrane Library databases were searched for relevant studies, yielding 24 included original investigations. RESULTS: These studies captured 686 total patients, 8,257 observer evaluations, and a variety of interventions including face-lifts, blepharoplasty, rhinoplasty, and minimally invasive treatments including botulinum toxins and hyaluronic acid fillers. Forty-one distinct reported OROs were grouped into 12 descriptive domains. Domains were further grouped into 3 higher-order categories: aesthetics and wellness, social capacities, and skills and competencies. Improved perception after cosmetic intervention is most reproducibly demonstrated for the following ORO domains: age, attractiveness, sociability, relationship success, and occupational and financial competency. CONCLUSION: The synthesized findings imply a tertiary layer of benefit for cosmetic intervention beyond anatomical and patient-centered outcomes through enhanced perceptions of others. These findings may inform the pre-procedure risk-benefit discussion with patients of cosmetic medicine and drive future research into longitudinal outcomes.

Cosmetic procedure use as a type of substance-related disorder.

BACKGROUND: A role for addiction psychiatry in aesthetic treatment-seeking behavior has been evidenced for ultraviolet light tanning. OBJECTIVE: We aim to demonstrate an initial proof of concept for the presence of addictive behaviors in cosmetic procedure use. METHODS: Adults visiting a cosmetic dermatology practice with history of at least 1 cosmetic procedure and consideration of at least 1 cosmetic procedure in the past 12 months were included. Two previously validated instruments in the detection of alcohol use disorder, the Cut Down, Annoyed, Guilty, Eye-Opener (CAGE) questionnaire, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria were modified to evaluate participants for a substance-related disorder (SRD) in cosmetic procedures. RESULTS: Of 153 adults, 34 (22.2%) met modified CAGE criteria, and 40 (26.1%) met modified DSM-V criteria. Results from both instruments were significantly associated (P < .0002). Significant differences in consideration and use of cosmetic treatments were found in SRD positive versus negative groups (P < .0001 and P = .009, respectively). LIMITATIONS: Preliminary criteria for SRD in cosmetic procedure use in this study has not yet been validated. CONCLUSIONS: A type of SRD involving cosmetic procedures may exist, and qualifying individuals may have increased cosmetic treatment use. Future efforts to rigorously validate an instrument for SRD detection in cosmetic procedures use are warranted for future research and clinical application.