Guidance for the pharmacological management of acne vulgaris.

INTRODUCTION: Many international guidelines and expert consensuses are available to help the clinician diagnose and treat acne vulgaris; however, a simplified practical guidance that integrates current existing published recommendations is still lacking. This article aims to give practical and simplified insight into the treatment of acne. AREAS COVERED: Herein, the author discusses the treatment of comedonal, papulopustular, and nodular/cystic/conglobate acne. The author also proposes a simplified treatment escalation strategy that is based on disease severity and extension, starting with topical treatments for mild cases and progressing over to systemic therapies in more severe cases. EXPERT OPINION: The ideal acne treatment would simultaneously and safely target all the pathogenic factors implicated in the appearance of acne lesions with minimal side effects. Since no such treatment currently exists, combination therapies are usually recommended for most types of acne. A major limitation in choosing an appropriate treatment plan is the discrepant use of classification systems across the published literature making it difficult to draw clear and succinct conclusions about the recommendations given. Acne is not a traditional infectious disease and so while antibiotics may improve symptoms, they do not reliably resolve the condition. Thus, there is currently a tendency to opt for antibiotic-sparing treatment strategies whenever possible.

An overview of sarecycline for the treatment of moderate-to-severe acne vulgaris.

INTRODUCTION: Sarecycline is a novel, tetracycline-class antibiotic specifically designed to treat inflammatory acne. It offers a narrow spectrum of activity (mainly against Cutinebacterium acnes), and it shows less in vitro activity than other tetracyclines against enteric Gram-negative bacteria, offering advantages over older tetracyclines by decreasing the disruption of the gastrointestinal microbiome and the likelihood of developing bacterial resistance. AREAS COVERED: The drug's pharmacology, safety profile, and clinical efficacy are discussed. Results of phase I, II and III clinical trials have shown that 1.5 mg/kg/day sarecycline is safe, well tolerated and more effective than placebo in treating inflammatory acne in patients 9 years old and older. Furthermore, sarecycline's narrow spectrum of activity leads to a lower incidence of undesirable off-target antibacterial effects and consequently less adverse events such as diarrhea, fungal overgrowth and vaginal candidiasis. EXPERT OPINION: Sarecycline could become the first-line antibiotic therapy used in acne in the near future as it is an effective option for treating inflammatory acne lesions. Due to its narrow spectrum of activity, it could have a more adequate safety profile than older tetracyclines; however, head-to-head trials comparing the efficacy and safety profile of sarecycline with other tetracyclines are still needed to prove sarecycline's superiority.

Evaluating FMX-101 as a promising therapeutic for the treatment of acne.

INTRODUCTION: Oral minocycline is a mainstay of therapy for moderate-to-severe acne; however, systemic side effects which include hepatotoxicity, lupus-like syndrome, drug hypersensitivity syndrome, autoimmune hepatitis, polyarteritis nodosa, gastrointestinal side effects and skin hyperpigmentation are of concern. Topical antibiotics commonly used in acne, such as erythromycin and clindamycin, present high P. acnes resistance rates which has opened the market for new topical antibiotics. FMX-101 is a novel topical minocycline foam that has shown promising results in phase I, II and III trials for the treatment of moderate-to-severe acne with a better safety profile than oral minocycline. AREAS COVERED: The author provides an overview FMX-101 including its clinical efficacy and safety. The author then provides their expert opinion on this treatment and its potential for the treatment option for acne. EXPERT OPINION: The topical foam formulation of FMX-101 has been shown to reduce both inflammatory and non-inflammatory lesions and to improve IGA scores in patients with moderate-to-severe acne without significant systemic absorption thus limiting associated side effects. Overall, the proven efficacy and safety profile of FMX-101, together with the low systemic absorption, high skin tolerability and cosmetically acceptable foam formulations render this novel therapy an important addition to the acne treatment armamentarium.

New and emerging drugs for the treatment of acne vulgaris in adolescents.

INTRODUCTION: Acne vulgaris is the most common skin disease worldwide, yet current treatment options, although effective, are associated with unwanted side effects, chronicity, relapses and recurrences. The adequate control of the four pathogenic mechanisms involved in the appearance of acne lesions is key to treatment success. This paper aims to discuss the novel treatment modalities that have surfaced in consequence of new knowledge obtained in acne pathogenesis. AREAS COVERED: Pathogenic pathways are evaluated and discussed throughout the paper in relation to the mechanisms of action of novel molecules being investigated for the treatment of acne vulgaris. A comprehensive search was made in PubMed and Clinicaltrial.gov using a different combination of keywords, which included acne vulgaris, treatment, therapy, and therapeutic. EXPERT OPINION: In the near future, more effective treatments with less side effects are expected. The use of topical anti-androgens, coenzyme-A carboxylase inhibitors, and insulin growth factor-1inhibitors to control sebum production seem promising. Selective RAR-agonists have the potential of becoming an alternative to the currently available retinoid therapy in the management of infundibular dyskeratosis with a better safety profile. Antibiotic use will probably decline as more effective options for controlling Cutinebacterium acnes colonization and the inflammation cascade emerge.

Novel pharmacological approaches for the treatment of acne vulgaris.

INTRODUCTION: Acne vulgaris is the most common skin disease worldwide; yet, current treatment options, although effective, are associated with unwanted side effects, chronicity, relapses and recurrences. The adequate control of the four pathogenic mechanisms, involved in the appearance of acne lesions, is paramount to treatment success. AREAS COVERED: The authors discuss and evaluate the pathogenic pathways related to the mechanisms of action of novel molecules, which are currently under investigation for the treatment of acne vulgaris. The manuscript is based on comprehensive searches made through PubMed, GoogleScholar and ClinicalTrial.gov, using different combination of key words, which include acne vulgaris, pathogenesis, treatment, sebogenesis and Propionibacterium acnes. EXPERT OPINION: In the near future, more effective treatments with fewer side effects are expected. The use of topical antiandrogens, acetylcholine inhibitors and PPAR modulators seem to be promising options for controlling sebum production. Retinoic acid metabolism-blocking agents and IL-1α inhibitors have the potential to become legitimate alternative options to retinoid therapy in the management of infundibular dyskeratosis. Indeed, the authors believe that there will likely be a decline in the use of antibiotics for controlling P. acnes colonization and targeting the inflammation cascade.

Necrotic carpal tunnel syndrome in a child.

Median nerve entrapment at the wrist level causes carpal tunnel syndrome (CTS). Although frequent in adults, CTS is a rare entity in children. Bouvier described an exceptional necrotic variant in 1979 in which skin, nail, and bone lesions are typical. We report the case of a 10-year-old child with necrotic CTS secondary to trauma. To our knowledge, this is the first case reported in a child.

New investigational drugs for androgenetic alopecia.

INTRODUCTION: Androgenetic alopecia (AGA) is the most common form of hair loss, however current treatment options are limited and moderately effective. In the past few years, there has been an increased interest in deciphering the molecular mechanisms responsible for this disorder, which has opened the possibility of novel treatments that promise to not only stimulate hair growth, but also to induce formation of new hair follicles. AREAS COVERED: The future holds more effective topical treatments with less systemic side effects (such as topical 5-alfa-reductase inhibitors), prostaglandin analogs and antagonists, medications which act through the Wnt signaling pathway, stem cells for hair regeneration, platelet-rich plasma (PRP) and more effective ways of transplanting hair. A comprehensive search was made using PubMed, GoogleScholar and Clinicaltrial.gov using different combination of key words, which included AGA treatment, new treatments for AGA, Wnt pathway, prostaglandins, PRP and stem cells for hair regrowth. EXPERT OPINION: In the near future, treatments with topical 5-alfa-reductase inhibitors and prostaglandin agonists or antagonists are expected. More evidence is needed to verify the efficacy of PRP. Although hair follicle bioengineering and multiplication is a fascinating and promising field, it is still a long way from being available to clinicians.