Ebook Treatment for skin color: Part 1

(BQ) Part 1 book Treatment for skin color presents the following contents: Acneiform disorders, bullous and pustular disorders, collagen vascular diseases, eczematous disorders, granulomatous disorders, hypersensitivity and allergic disorders, infectious diseases,...

T reatments FOR

Project Manager: Beula Christopher

Design: Charles Gray

Illustration Manager: Bruce Hogarth

Illustrator: Gillian Richards

Marketing Manager: Richard Jones

Assistant Clinical Professor of Dermatology

College of Physicians and Surgeons

Columbia University

Society Hill Dermatology

Phildelphia, PA, USA

Advanced Dermatology, Laser, and Plastic Surgery Institute

Danville, CA, USA

Valerie D Callender MD

Associate Professor of Dermatology

Howard University College of Medicine

Washington DC, USA

Callender Skin and Laser Center

Glenn Dale, MD, USA

Raechele Cochran Gathers MD

Senior Staff PhysicianHenry Ford HospitalMulticultural Dermatology CenterDetroit, MI, USA

David A Rodriguez MD

Voluntary Associate ProfessorDermatology and Cutaneous SurgeryUniversity of Miami

Medical DirectorDermatology Associates and ResearchCoral Gables, FL, USA

For additional online content visit

www.expertconsult.com

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:

of others, including parties for whom they have a professional responsibility

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treat-ment for each individual patient, and to take all appropriate safety precautions

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or opera-tion of any methods, products, instructions, or ideas contained in the material herein

British Library Cataloguing in Publication Data

Treatments for skin of color

1 Skin – Diseases – Treatment 2 Pigmentation disorders – Treatment 3 Human skin color

I Taylor, Susan C

616.5′0089 – dc22

ISBN-13: 9781437708592

Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of Congress

Working together to grow

libraries in developing countries

www.elsevier.com | www.bookaid.org | www.sabre.org

The publisher’s policy is to use

paper manufactured from sustainable forests

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

PREFACE xi

LIST OF CONTRIBUTORS xiii

EVIDENCE LEVELS xv

ACKNOWLEDGEMENTS xvii

Introduction xix

Part 1 Medical Dermatology 1

1 Acneiform Disorders 3

Sonia Badreshia-Bansal and Vivek Bansal Acne 3

Acne vulgaris 3

Pomade acne 12

Steroid acne 13

Pediatric perspectives: Infantile acne Candrice R Heath 13

Pediatric perspectives: Neonatal acne (acne neonatorum) Candrice R Heath 14

Acne rosacea 14

Hidradenitis suppurativa 19

Perioral dermatitis 21

2 Bullous and Pustular Disorders 25

Janelle Vega and David A Rodriguez Bullosis diabeticorum 25

Bullous pemphigoid 26

Impetigo 29

Infantile acropustulosis 32

Pemphigus foliaceus 33

Pemphigus vulgaris 35

3 Collagen Vascular Diseases 39

Sumayah J Taliaferro, Erica Chon Davis and Valerie D Callender Dermatomyositis 39

Livedoid vasculopathy 44

Lupus 47

Chronic cutaneous lupus 47

Subacute cutaneous lupus erythematosus (SCLE) 52

Systemic lupus erythematosus 53

Scleroderma 58

Localized scleroderma (morphea) 58

Systemic sclerosis 61

4 Eczematous Disorders 69

Sonia Badreshia-Bansal Allergic contact dermatitis 69

Atopic dermatitis 74

Dyshidrotic eczema/Pomphylox 81

Irritant contact dermatitis 84

Lichen simplex chronicus 87

Nummular dermatitis 90

5 Granulomatous Disorders 93

Sonia Badreshia-Bansal Granuloma annulare 93

Localized granuloma annulare 93

Generalized granuloma annulare 95

Sarcoidosis 97

6 Hypersensitivity and Allergic Disorders 101

Ninad Pendharkar, Sonia Badreshia-Bansal, Janelle Vega, and David A Rodriguez Arthropod bites 101

Fixed drug eruption 102

Erythema multiforme 104

Erythema nodosum 108

Exfoliative dermatitis/Erythroderma 111

Polymorphous light eruption 113

Urticaria 115

7 Infectious Diseases 119

Rashmi Sarkar, Vivek Nair, Surabhi Sinha, Vijay K Garg and David A Rodriguez Candidiasis 119

Oral candidiasis 119

Candidal intertrigo/Cutaneous candidiasis 120

Cellulitis and Erysipelas 121

Chancroid 123

Chlamydia trachomatis 125

Donovanosis (Granuloma inguinale) 126

Exanthems 128

Folliculitis 130

Furunculosis 131

Human papilloma virus (HPV) 133

Lymphogranuloma venereum (LGV) 135

Pityriasis versicolor 137

Syphilis 139

Tinea capitis 142

Tinea corporis 145

Tinea unguium 146

8 Lichenoid Disorders 149

Sonia Badreshia-Bansal Lichen amyloidosis 149

Lichen nitidus 152

Lichen planus 154

Cutaneous lichen planus 155

Mucosal involvement 156

Lichen sclerosus 158

Pediatric perspectives: Lichen sclerosus et atrophicus Candrice R Heath 160

Lichen striatus 161

9 Papulosquamous Disorders 163

Sonia Badreshia-Bansal Parapsoriasis 163

Pityriasis rosea 166

Plaque psoriasis 168

Pediatric perspectives: Psoriasis Candrice R Heath 174

Seborrheic dermatitis 177

Facial seborrheic dermatitis 177

Scalp seborrheic dermatitis 179

Part 2 Pigmentary Disorders 181

10 Hyperpigmented Disorders 183

David A Rodriguez Acanthosis nigricans 183

Benign melanonychia 185

Confluent and reticulated papillomatosis of Gougerot and Carteaud (CRPGC) 187

Drug-induced pigmentation 189

Erythema dyschromicum perstans 191

Exogenous ochronosis 192

Gingival hyperpigmentation 194

Melasma 195

Mongolian spots 199

Nevus of Ota 201

Pigmentary demarcation lines 203

Post-inflammatory hyperpigmentation (PIH) 204

Solar lentigines 207

Pediatric perspectives: Transient neonatal pustular melanosis Candrice R Heath 209

11 Hypopigmented Disorders 211

David A Rodriguez Hypomelanosis of Ito 211

Hypopigmented cutaneous T-cell lymphoma 212

Hypopigmented sarcoidosis 215

Pityriasis alba 216

Vitiligo 217

Pediatric perspectives: Vitiligo Candrice R Heath 221

Part 3 Follicular Disorders and Alopecias 225

12 Alopecias 227

Raechele Cochran Gathers Alopecia areata 227

Alopecia mucinosa 232

Central centrifugal cicatricial alopecia 234

Dissecting cellulitis 236

Discoid lupus erythematosus 239

Traction alopecia Crystal Y Pourciau 242

Traumatic alopecia: chemical, heat and mechanical 244

Trichotillomania 246

13 Follicular Disorders 249

Raechele Cochran Gathers Acne keloidalis nuchae 249

Folliculitis decalvans Crystal Y Pourciau 251

Pseudofolliculitis barbae 254

Part 4 Tumors Benign and Malignant 257

14 Benign Tumors 259

Erica Mailler-Savage, Matthew Joseph Turner, David Robert Crowe, Erica Chon Davis and Hugh Morris Gloster Jr Introduction 259

Acrochordon 260

Dermatofibroma 260

Dermatosis papulosa nigra 261

Epidermal nevus 263

Congenital melanocytic nevus 264

Dysplastic nevus 265

Epidermoid cyst 266

Keloid 267

15 Malignant Neoplasms 271

Erica Mailler-Savage, Matthew Joseph Turner, David Robert Crowe, Erica Chon Davis and Hugh Morris Gloster Jr Basal cell carcinoma 271

Cutaneous T-cell lymphoma (CTCL) 273

Dermatofibrosarcoma protuberans (DFSP) 276

Malignant melanoma 277

Squamous cell carcinoma 279

Part 5 Cosmetics 287

16 Cosmetic Applications 289

Valerie D Callender and Erica Chon Davis Hair cosmetics 289

Shampoos 289

Hair moisturizers 292

Chemical processing 293

Hair dyes 294

Glossary of terms 296

Camouflage techniques 301

Skin cosmetics 301

Skin lightening agents 301

Photoprotection 306

Camouflage techniques 306

17 Cosmetic Treatments 309

Valerie D Callender, Vic A Narurkar and Erica Chon Davis Introduction 309

Botulinum neurotoxin-A (BoNT-A) 311

Chemical peels 315

Fillers 321

Hair transplantation 326

Lasers, light sources and other devices 332

Part 6 Complementary and Alternative Medicine 349

18 An Overview of Complementary and Alternative Medicine 351

Janet L Nelson and Sonia Badreshia-Bansal Introduction 351

Acne 357

Alopecia 361

Eczema / Atopic dermatitis 364

Psoriasis 368

Index 375

There are many complexities associated with selection of

appropriate treatment for cutaneous diseases These

complexi-ties increase when selecting treatment for patients with skin of

color due to structural and functional differences in their skin

and hair as well as differing adverse event profiles Treatment

for Skin of Color is an important resource that will allow the

practicing clinician to quickly identify evidence-based

treat-ment options for their skin of color patients The scope of the

book is extensive beginning with medical dermatology

fol-lowed by follicular disorders, tumors, cosmetics and

conclud-ing with alternative medicine Each therapy covered has been

assigned an evidence level from A (the strongest scientific

evidence) to E (anecdotal case reports) reflecting the amount

of published evidence available to support its use

The truly outstanding authors of Treatment for Skin of Color,

to whom I am indebted, were chosen for this project based

upon the strength of their clinical skills, and their ability to educate and present information in an organized, succinct and easily absorbable manner The work of Drs Rodriguez, Gathers, Badreshia-Bansal, and Callender with diverse patient popula-tions coupled with their clinical research experience have allowed us to produce a unique resource

When a question or therapeutic dilemma arises in a

teach-ing clinic or private office settteach-ing, Treatment for Skin of Color is

a quick reference for either the dermatology resident or the more experienced clinician Additionally, by providing exten-sive references, it provides the first step for a seamless in-depth look into topics of interest

Susan C Taylor, MD

Preface

Advanced Dermatology, Laser, and Plastic Surgery Institute

Danville, CA, USA

Vivek Bansal MD

Medical Director of Plastic Surgery

Elite MD, Inc

Advanced Dermatology, Laser, and Plastic Surgery Institute

Danville, CA, USA

Valerie D Callender MD

Associate Professor of Dermatology

Howard University College of Medicine

Washington DC, USA

Callender Skin and Laser Center

Glenn Dale, MD, USA

David Robert Crowe MD

Dermatology Resident

Department of Dermatology

University of Cincinnati

Cincinnati, OH, USA

Erica Chon Davis MD

Dermatology Research Fellow

Callender Skin and Laser Center

Glenn Dale, MD, USA

Vijay K Garg MD MNAMS

Professor and Head of Department

Department of Dermatology

Maulana Azad Medical College

New Delhi, India

Raechele Cochran Gathers MDSenior Staff Physician

Henry Ford HospitalMulticultural Dermatology CenterDetroit, MI, USA

Hugh Morris Gloster Jr MDProfessor of DermatologyDirector of Dermatologic Surgery and Mohs SurgeryUniversity of Cincinnati

Cincinnati, OH, USACandrice R Heath MDPhysician

Children’s Healthcare of AtlantaAtlanta, GA, USA

Erica Mailler-Savage MDClinical Instructor

Dermatology DepartmentUniversity of CincinnatiCincinnati, OH, USAVivek Nair MDSenior ResidentDepartment of DermatologyMaulana Azad Medical CollegeNew Delhi, India

Vic A Narurkar MD FAADChairman

Department of DermatologyCalifornia Pacific Medical CenterSan Fransisco, CA, USA

List of Contributors

Janet L Nelson MS Lac

Practitioner of Asian Medicine

Elite MD, Inc

Advanced Dermatology, Laser, and Plastic Surgery Institute

Danville, CA, USA

Ninad Pendharkar MD

Dermatology Resident

Penn State, College of Medicine

Department of Dermatology

Milton S Hershey Medical Center

Hershey, PA, USA

Crystal Y Pourciau MD MPH

Resident Physician

Department of Dermatology

Henry Ford Hospital

Detroit, MI, USA

David A Rodriguez MD

Clinical Assistant Professor

University of Miami School of Medicine

Dermatology and Cutaneous Surgery

Miami, FL, USA

Rashmi Sarkar MD MNAMS

Associate Professor

Department of Dermatology

Maulana Azad Medical College

New Delhi, India

Surabhi Sinha MD MNAMS DNBSenior Resident

Department of DermatologyMaulana Azad Medical CollegeNew Delhi, India

Sumayah J Taliaferro MDDermatologist

Private PracticeMetro Atlanta DermatologyAtlanta, GA, USA

Matthew Joseph Turner MD PhDDermatology Resident

Department of DermatologyUniversity of CincinnatiCincinnati, OH, USAJanelle Vega MDDermatology ResidentUniversity of Miami Miller School of MedicineMiami, FL, USA

Each therapy covered has been assigned a letter from A (most

evidence) to E (least evidence) signifying the amount of

pub-lished evidence available to support its use The following

table shows the criteria used in making this classification

A DOUBLE-BLIND STUDY

At least one prospective randomized, double-blind,

controlled trial without major design flaws (in the

author’s view)

B CLINICAL TRIAL ≥ 20 SUBJECTS

Prospective clinical trials with 20 or more subjects; trials

lacking adequate controls or another key facet of design,

which would normally be considered desirable (in the

author’s opinion)

C CLINICAL TRIAL < 20 SUBJECTSSmall trials with fewer than 20 subjects with significant design limitations, very large numbers of case reports (at least 20 cases in the literature), retrospective analyses

of data

D SERIES ≥ 5 SUBJECTSSeries of patients reported to respond (at least 5 cases in the literature)

E ANECDOTAL CASE REPORTSIndividual case reports amounting to published experience

of less than 5 cases

Evidence Levels

Each of us had the invaluable opportunity to collaborate with

extraordinary colleagues on various chapters of this book We

thank them for their expertise and commitment to making this

book a success

We also thank Claire Bonnett of Elsevier Publishing who

guided this project from the very beginning and Nani Clansey

and Beula Christopher for their assistance in completing this extensive project

Drs Taylor, Badreshia-Bansal, Callender, Gathers, and Rodriguez

Acknowledgements

Each day in dermatology practices and clinics throughout the

United States, we find ourselves increasingly challenged as we

attempt to select the most appropriate treatments for our skin

of color patients Our challenges are two-fold First, in the

United States, the number of individuals with skin of color

has increased significantly and continues to do so Those who

were previously considered in the minority, by the year 2056

will become the majority of US citizens Thus, we are

increas-ingly encountering skin of color patients including those

with more complicated and difficult to treat dermatologic

disorders Secondly, differences in the skin and hair of

indi-viduals with skin of color have important implications

regard-ing treatment selection, success and sequelae Treatment for

Skin of Color is designed to assist and guide clinicians in the

selection of the best therapeutic options for their skin of color

patients, assess the likelihood of success, and educate

regard-ing common and unexpected adverse events

Who is the patient that we are primarily addressing in

Treat-ment for Skin of Color? For the purposes of this book, we are

defining skin of color patients as those who have Fitzpatrick

Skin Phototypes IV through VI (Table 1) Thus, we are

concen-trating on individuals with darker skin hues including patients

with light brown, brown and black skin tones as compared to

patients with white skin tones

Additionally, individuals of several racial and ethnic groups

are highly represented in the group of patients with darker skin

hues including those of Southeast and South Asian, Latino or

Hispanic, African, and Native American descent Although

there is clearly variability in skin hue amongst individuals of

these racial and ethnic groups, many have darker skin hues

Why is it important to distinguish skin of color patients

from others when considering treatment options?

Fundamen-tal structural and functional differences exist between

indi-viduals with skin of color and those with white skin tones

These differences may have a direct effect upon a clinician’s

selection of appropriate treatment as well as for the rate of

success of the treatment and occurrence of adverse effects Key

differences involve melanin content and pigmentation,

fibro-sis and scarring, and tightly coiled hair and follicular disorders,

to name just a few For example, facial seborrheic dermatitis is

a common cutaneous disorder in individuals of all skin types

However, because of the lability of melanocytes in individuals

with darker skin tones, post-inflammatory hypopigmentation

is often the presenting complaint in skin of color seborrheic dermatitis patients In this patient population, treatment con-siderations will include agents that simultaneously treat the seborrheic dermatitis as well as the post-inflammatory hypo-pigmentation such as lower potency corticosteroids or topical immune modulators Additionally, patients should be coun-seled that the pigmentary alteration is temporary and does not represent the more serious disorder, vitiligo Furthermore, for patients with concomitant scalp seborrheic dermatitis, daily shampooing is often not the most appropriate treatment given the tightly coiled hair with low water content and increased fragility of this population Rather, the addition of daily topical treatment agents coupled with once weekly shampooing often yields appropriate treatment results and avoids potential adverse events

Often, adverse event profiles are different in skin of color patients Consequently, the selection of treatment may vary As

an example, a disorder in which liquid nitrogen is an accepted treatment for white skin hues may not be the appropriate treatment for skin of color patients due to the sequelae of hypopigmentation or depigmentation Additionally, cosmetic procedures, such as laser hair removal may need to be per-formed with a lower fluence or a particular laser may be required given the propensity of skin of color toward laser induced hyperpigmentation

Some disorders may occur at increased frequency or even exclusively in skin of color patient populations An important example is central centrifugal cicatricial alopecia (CCCA) Whereas alopecia areata is covered in general treatment books, central centrifugal cicatricial alopecia is usually not included CCCA appears to be responsible for more cases of scarring alopecia in African American women as compared to all other forms of scarring alopecia combined For this disorder, under-standing treatment selection, success and sequelae is critically

important Treatment for Skin of Color will provide insight into

these types of disorders

Likewise, there are differences in the occurrence of temic disorders in certain skin of color populations Hyper-tension and diabetes affect individuals of African and Latino descent disproportionately as compared to those of Caucasian descent One would expect increased dermatologic disorders related to these disorders Examples would include dis-orders such as drug-induced eruptions which may present

sys-Introduction

Table 1 Fitzpatrick Skin Phototypes and Corresponding Color Hues

Type I Always burns, never tans (white skin tones)

Type II Always burns, minimal tan (white skin tones)

Type III Burns minimally, tans moderately and gradually (white

skin tones)

Type IV Burns minimally, tans well (light brown skin tones)

Type V Rarely burns, tans deeply (brown skin tones)

Type VI Never burns, tans deeply (dark brown/black skin tones)

differently in skin of color patients, such as photodistributed

hyperpigmentation

Finally, the definition of treatment success may vary with

skin of color patients as compared to those of Caucasian

descent Skin of color patients may view acne as unsuccessfully

treated if post-inflammatory hyperpigmentation (PIH) remains

after papules, pustules and comedones have resolved

There-fore, treatment of PIH is as important as treatment of the acne

in skin of color populations Either the selection of topical

agents that can simultaneously address acne and PIH, or the

simultaneous use of acne and PIH agents are required in this

population

How should you use this book?

Treatment for Skin of Color is a great resource that should not

be read once and then filed away in a bookcase Rather, it

should be kept near you in your practice or clinic to be referred

to on a daily basis It will provide you with the most up to

date treatment recommendations and you will find that it will

be particularly helpful as you navigate treatment dilemmas

In addition, under each disease, you will find two invaluable

sections: Commonly Encountered Pitfalls in Skin of Color and

Special Management and Counseling Considerations These

sec-tions provide diagnostic pearls, examples of potential

hin-drances to achieving treatment goals and how to avoid them,

and effective ways to counsel your skin of color patient

Organization of the book

Treatment for Skin of Color is organized into six easy to use

sections Pediatric perspectives on treatment have been added

at the end of certain sections

• Medical dermatology

• Pigmentary disorders

• Follicular disorders including alopecia

• Tumors benign and malignant

• Cosmetics

• Alternative medicine

In each section, treatment will be outlined specifically with your skin of color patients in mind Additionally, each treat-ment will be evaluated and assessed based upon the current evidence available in the literature The evidence level scale utilized in this book is one that you may be familiar with as

it encompasses five grades, A through E

A Double blind, control trial

B Clinical trial involving more than 20 subjects

C Clinical trial involving fewer than 20 subjects

D Case series involving more than 5 subjects

E Anecdotal case reports involving fewer than 5 subjects

As you will see, there is a relative paucity of data for the ment of certain diseases that occur in your skin of color patients In recent years, the FDA has required populations of diverse subjects in pivotal trials for new drugs and devices Existing clinical trials or case series that include skin of color patients, when available, have been cited for each treatment Nevertheless, there are many disorders in which there are no clinical trials or case reports that include skin of color subjects

treat-In these instances, we rely on anecdotal case reports, the rience of skin of color experts or experience with non-skin of color patients

expe-Unlike other books that provide a guide to treatment, we thought it important to include a section on complementary and alternative medicine (CAM) because of its importance to many skin of color populations Even if you do not suggest or prescribe to these particular treatments, the CAM section in this book will provide a firm foundation for you to understand the fundamentals of these treatments As you will learn in this chapter, Americans spend $34 billion dollars annually on complementary and alternative medicine CAM’s use by adults with dermatologic disorders in the US has been estimated at between 50% and 62% It has been estimated that in skin of color patients, 50% of Native Americans, 40% of Asians, 25%

of Blacks and 25% of Hispanics utilize some form of CAM This section will provide insight and guide you as to treat-ments that your patients may already be participating in

We trust that you will find Treatment for Skin of Color a

valu-able and trusted resource The treatment sections offer line, second-line and third-line recommendations which will provide the entire scope of available therapeutic options We

first-trust that Treatment for Skin of Color will allow you to select the

most effective and safest treatments for your skin of color patients

Susan C Taylor, MD

Medical Dermatology PART 1

Part 1 Medical Dermatology

Pediatric perspectives: Infantile acne .13

Pediatric perspectives: Neonatal acne

Acne vulgaris is a multifactorial disorder of the pilosebaceous

unit.1–4 The pathogenesis involves a complex interaction of

multiple internal and external factors The four main factors

that cause acne include excess sebum from increased

andro-genic hormonal stimulation (especially at adrenarche),

fol-licular epidermal hyperkeratosis with subsequent plugging of

the follicle, elevated P acnes population, and subsequent

inflammation.1–4 Medications that can precipitate acneiform

lesions include corticosteroids, lithium, some antiepileptics,

and iodides.5 Genetic factors may also play a role.6

Acne vulgaris is a common skin disease that affects over

85% of people at some time point It is also an extremely

common dermatological problem among ethnic patients and

is found predominantly during adolescence.7 Acne may be present in the first few weeks and months of life while a newborn is still under the influence of maternal hormones and when the androgen-producing portion of the adrenal gland is disproportionately large.8 Neonatal acne resolves spontaneously Adolescent acne commonly begins prior to the onset of puberty, when the adrenal gland begins to produce and release higher levels of the androgen hormone However, acne is not limited to adolescence – 12% of women and 5%

of men at 25 years of age have acne By 45 years of age 5% of both men and women are still affected.7

The diagnosis of acne is primarily clinical and may be acterized by comedones, papules, pustules, nodules and cysts Acne vulgaris affects areas of the skin more densely populated with sebaceous follicles, including the face, upper chest, and back A severe inflammatory variant of acne, acne fulminans, can be associated with fever, arthritis, and additional systemic symptoms Darker skin types represent a particular clinical challenge for dermatologists treating acne due to the higher risk of post-inflammatory hyperpigmentation (PIH), hyper-trophic scarring, and keloids (Fig 1.1) Additionally, acne lesions may lead to permanent scarring Although the overall prognosis is good, acne can result in long-lasting psychosocial impairment and physical scarring

char-The differential diagnosis of acne is extensive During the neonatal period, it includes transient sebaceous hyperplasia, miliaria, and Candida In adolescence and adulthood, append-ageal tumors such as trichoepithelioma, trichodiscomas, cysts, steatocystoma multiplex, and eruptive vellus hair cysts should

be considered in the differential diagnosis Bacterial tis, pseudomonas folliculitis (if on the lower trunk), rosacea, pseudofolliculitis barbae, acne keloidalis nuchae, perioral

folliculi-Topical antibiotics are helpful in controlling P acnes

colo-nization and its pro-inflammatory mediators The ment of resistance is significant when antibiotics are used as monotherapy, and greatly lowered when used in combination treatment with benzoyl peroxide Clindamycin inhibits bacterial protein synthesis by binding to the 50S ribosomal subunits, causing inhibition of peptide-bond formation.19

develop-Clindamycin suppresses the complement-derived chemotaxis

of polymorphonuclear leukocytes in vitro, thereby reducing the potential for inflammation.20 Azelaic acid is a naturally

occurring dicarboxylic acid which inhibits growth of P acnes,

alters hyperkeratinization and may help to lighten PIH.21

Sodium sulfacetamide is a generally well tolerated topical

anti-biotic that restricts P acnes growth.22 It is available in a 10% lotion in combination with 5% sulfur with tinted formula-tions available Salicylic acids are widely used over-the-counter products for their comedolytic and mild anti-inflammatory ability

Moderate to severe inflammatory acne unresponsive to a topical combination regimen will require systemic treatment First-line antibiotic therapy with tetracycline or its derivatives

doxycycline and minocycline, suppress growth of P acnes and

are anti-inflammatory At this time, minocycline is felt to have less antibiotic resistance but increased side effects including nausea, vomiting, esophagitis, yeast infection, and sun sensi-tivity compared to tetracycline.23,24 In addition, minocycline crosses the blood–brain barrier and increases susceptibility to pseudotumor cerebri and also can cause a serum sickness- like reaction, drug-induced lupus, or blue-black pigmenta-tion.23,24 Erythromycin has the greatest amount of resistance.25

Other antibiotics reportedly useful include trimethoprim- sulfamethoxazole, and azithromycin Hormonal therapies may be effective in the treatment of acne When hyperandro-genism is suspected, especially in a female patient with dys-mennorhea or hirsutism, a hormonal evaluation including total and free testosterone and DHEA sulfate should be performed Oral contraceptive agents have been shown to

be effective in decreasing circulating free testosterone while spironolactone binds the androgen receptor and reduces androgen production.26 Side effects with spironolactone include breast tenderness, dysmennorhea, and abnormalities

in blood pressure

Severe, scarring acne is best treated with the oral retinoid,

13-cis-retinoic acid Isotretinoin normalizes follicular

hyper-keratinization and causes sebaceous gland atrophy, thus reducing sebum production and producing an unfavorable

environment for P acnes.9 In patients with marked tory acne, lower starting doses may be indicated to prevent the induction of severe flares during the first month of treatment.28

inflamma-In cases of acne fulminans or initial retinoid induced flares, prednisone may decrease the severity of the flare and sub-sequent exuberant granulation tissue formation Potential adverse events are numerous and may include generalized xerosis, eczematous dermatitis, and elevated triglycerides, decreased night vision, arthralgias, myalgias, headache, depression, skeletal hyperkeratosis, elevations in liver function tests or an abnormal blood count Teratogenicity is among the

dermatitis (if previously treated with topical corticosteroids),

and steroid acne (if treated with oral corticosteroids) may also

be considered Cultures of skin lesions to rule out

Gram-negative folliculitis are necessary when acne is unresponsive

to treatment or when improvement is not maintained with

treatment

As with all patients, therapy should be directed toward the

known patho genic factors The grade and the severity of the

acne determines which of the following treatments is most

appropriate (Fig 1.2) When using a topical or systemic

anti-biotic, a benzoyl peroxide should be utilized in conjunction

to reduce the emergence of bacterial resistance The patient’s

skin color, skin type, and propensity for PIH can influence

choice of formulation of a topical regimen The ideal acne

treatment for ethnic skin would specifically target the

inflam-matory process as well as the resulting hyperpigmentation

There are several components to the treatment of mild acne

including topical retinoids, antibiotics and benzoyl peroxide

Topical retinoids, including tretinoin, adaalene and

tazaro-tene, are comedolytic, normalize follicular

hyperkeratiniza-tion, and are anti-inflammatory.9–11 Retinoids may enhance the

penetration of other topical products and medications.12 They

are known to thin the stratum corneum, cause irritation, and

increase the risk of sunburn.13 Therefore, the use of sunscreen

is essential Short contact method and gradual titration may

be attempted to increase tolerance and minimize contact

irri-tant dermatitis.14 Although topical retinoids may result in

improvement of PIH, the potential for irritation may provoke

further PIH Each retinoid has unique characteristics For

example, the synthetic retinoid, adapalene is light stable and

resistant to oxidation by benzoyl peroxide.15 Finally, retinoids

are known teratogens and contraceptive counseling must be

provided to women of childbearing age

Benzoyl peroxide is an important bacteriostatic agent that

exerts its affect through the interaction of oxidized

intermedi-ates with elements of bacterial cells It decreases inflammatory

damage by inhibiting the release of reactive oxygen species

from polymorphonuclear leukocytes.16 However, the risk of

irritation with subsequent PIH may occur Benzoyl peroxide is

most effective when used in a combination as resistance to this

agent has not been reported.17–18

Figure 1 1: This African-American patient presents with active acne and PIH

1 Acneiform Disorders • Acne

glycolic acid, and trichloracetic acid can decrease corneocyte cohesion.28

The sequela of acne includes acne scarring and PIH which may be improved after the active acne has been treated (Fig 1.3) Options for acne scarring may include dermabra-sion, laser resurfacing, and soft tissue augmentation PIH will improve with time regardless of therapy However, resolution can be hastened with vigilant use of sunscreen along with topical skin lightening agents such as hydroquinone, retinoic acid, kojic acid, soy, niacinamide, licorice extract, azelaic acid, glycolic acid, salicylic acid, antioxidants such as vitamin C, as well as chemical peels and lasers.20

most serious adverse events and pregnancy should not occur

during or one month post-treatment with oral isotretinoin

Thorough contraception counseling in females of child bearing

age must be performed and two forms of contraception must

be used concomitantly

Several other options may be used adjunctively which

include comedone extraction, intralesional injections,

chemi-cal peels, and photodynamic therapy Comedone extraction

may improve responsiveness to prescribed comedolytic agents,

but inflamed lesions should be avoided For deep or inflamed

cysts, intralesional corticosteroids can be effective Chemical

peels with lipophilic comedolytics such as salicylic acid,

Figure 1 2: Acne algorithm 20,27–31

TRADITIONAL MEDICAL ACNE THERAPY

Light+/-PDT

Chemical peels Comedoneextraction ItralesionalinjectionsMild Moderate Severe

Superficial Deep Keloids

Skin lightening agents

Chemical peels+/-Microdermabrasion+/-Laser

+/-Lasers+/-Fillers+/-Subcision or punch excision

Chemical peels+/-Microdermabrasion+/-Dermabrasion

OCP = Oral contraceptive pill

BPO + R + oral Abx(OR Isotretinoin)

if hyperandrogenic: addOCP +/- spironolactone

Intralesional injections+/-Silicone gel sheets+/-Lasers

Skin

lightening

agents

A comparison of adapalene gel 0.1% vs tretinoin gel 0.025% in the treatment of acne vulgaris in China Tu P,

Li GQ, Zhu XJ, Zheng J, Wong WZ J Eur Acad Dermatol reol 2001; 15(Suppl 3):31–36

Vene-In this Chinese patient population, 150 patients with grade II-III acne vulgaris were randomized to 8 weeks of daily treat-ment with either adapalene gel 0.1% or tretinoin gel 0.025% Both adapalene and tretinoin produced dramatic reductions

in total, inflammatory and non-inflammatory lesion counts,

in the range of 69–74% on average More than 70% of patients in both groups had complete clearance or marked improvement In general, irritation was mild, but was more common and more severe in the tretinoin group vs the ada-palene group

Tretinoin gel microspheres 0.04% versus 0.1% in cents and adults with mild to moderate acne vulgaris: A 12-week, multicenter, randomized, double-blind, parallel- group, phase IV trial Berger R, Rizer R, Barba A, Wilson D,

adoles-Stewart D, Grossman R Clin Ther 2007 Jun; 29(6):1086– 1097

In this multicenter, double-blind, controlled, group, Phase IV dose-ranging study, patients with facial acne were randomized to apply either tretinoin gel 0.04%

parallel-or 0.1% each night fparallel-or 12 weeks in 156 patients (57.1% white, 19% Black, 2% Asian, 18.6% Hispanic, 2% Native American, 1.3% Other) Both resulted in effective and similar reductions in inflammatory and noninflammatory lesions, likely from its action on the microcomedone, the precusor lesion of acne However, there was greater reduction in inflam-matory lesions with the 0.1% concentration The 0.4% con-centration resulted in fewer side effects such as dryness during the early phase of the treatment, but this was not found to be significant

A multicenter, double-blind, randomized comparison study

of the efficacy and tolerability of once-daily tazarotene 0.1% gel and adapalene 0.1% gel for the treatment of facial acne vulgaris Webster GF, Guenther L, Poulin YP, Solomon BA,

Loven K, Lee J Cutis 2002; 69(2 Suppl):4–11

The efficacy and tolerability of tazarotene 0.1% gel and adapalene 0.1% gel over 12 weeks was compared in a multi-center, double-blind, randomized, parallel-group study in 145 patients with mild-to-moderate facial acne vulgaris Compared with adapalene, treatment with tazarotene was associated with

a significantly greater incidence of treatment success and significantly greater reductions in overall disease severity, non-inflammatory lesion count, and inflammatory lesion count However, adapalene demonstrated a superior tolerabil-ity profile, especially in the early weeks of therapy By the end

of treatment, patients considered both treatments to be parably well tolerated

com-Although retinoids can improve PIH in ethnic patients, caution must be taken to slowly titrate upward so as to avoid irritant contact dermatitis and subsequent PIH.

Comparison of five antimicrobial regimens for treatment

of mild to moderate inflammatory facial acne vulgaris in

Figure 1 3: Asian patient with acne scarring and biopsy consistent with osteoma

cutis

First-Line Therapies (For Mild to Moderate Acne

Vulgaris)

The mainstay of acne treatment includes a regimen that

targets the four pathogenic factors There is strong evidence to

support the use of retinoids and benzoyl peroxide in every

acne regimen In addition, in mild to moderate acne, topical

and oral anti biotics can be considered to reduce the

inflam-matory com ponent found in ethnic skin which is felt to lead

to PIH

Adapalene in the treatment of African patients Jacyk WK

J Eur Acad Dermatol Venereol 2001; 15(Suppl 3):37–42

To assess the efficacy and safety of topical adapalene gel

0.1% as a treatment for acne vulgaris in Black South African

patients, an open-label study was performed over a 12-week

period In the 44 subjects completing the trial, adapalene

gel 0.1% showed clear efficacy against both inflammatory

and non-inflammatory lesions In two-thirds of cases, patients

experienced reductions in both the number of hyperpigmented

macules and the density of hyperpigmentation Adapalene gel

0.1% is an effective, well-tolerated topical therapy for Black

patients

1 Acneiform Disorders • Acne

without causing excessive tolerability problems The turer of this dual product shows at least 90% of tretinoin

sizes ≤10 µm In addition, the gel contains a mixture of bilized and crystalline tretinoin which may impact tolerability

solu-by slowing the delivery of tretinoin.

Adapalene-benzoyl peroxide, a fixed-dose combination for the treatment of acne vulgaris: results of a multicenter, randomized double-blind, controlled study Thiboutot DM,

Weiss J, Bucko A, Eichenfield L, Jones T, Clark S; BPO Study Group J Am Acad Dermatol 2007 Nov; 57(5): 791–799

Adapalene-This was a randomized, multicenter, double-blind, parallel group study conducted at 36 centers in the United States in

517 patients 12 years and older Patients were 72% Caucasion, 11% Black, 13% Hispanic, 1% Asian, 3% other They were randomized in a 2 : 2 : 2 : 1 ratio to receive either adapalene-BPO gel, adapalene gel, BPO gel, or gel vehicle for 12 weeks The combination therapy regimen consistently provided an additional decrease of inflammatory and noninflammatory lesions, with statistically significant differences in total lesion counts observed as early as the first postbaseline assessment with good tolerability Total acne lesions were reduced by 51%, inflammatory lesions by 63%, and noninflammatory lesions

by 51%

Combination therapies are highly effective Retinoids are comedogenic, antiinflammatory, and enhance penetration Adapalene is stable when combined with BPO in the presence

anti-or absence of light Adapalene and tretinoin have been shown

to induce a dose-dependent inhibition of toll-like receptor 2 in cultured human monocytes P acnes acts through the toll-like receptor 2 to induce the production of proinflammatory cytokines There is likely a synergistic anti-inflammatory action where BPO kills P acnes and adapalene down-regulates the cell surface receptor that P acnes uses to induce cytokine production.

Comparison of a salicylic acid cleanser and a benzoyl oxide wash in the treatment of acne vulgaris Shalita AR Clin

per-Ther 1989; 11(2):264–267

A 4-week crossover study to compare the efficacy of an acne cleanser containing 2% salicylic acid with that of a 10% benzoyl peroxide wash was conducted in 30 patients with mild-moderate acne vulgaris A review of four clinical studies and a comedolytic assay attests to the efficacy and safety of 0.5% and 2% solutions of salicylic acid for the treatment of acne vulgaris Interestingly, patients treated with the salicylic acid cleanser for the first 2 weeks showed a significant improve-ment in acne, but worsened during benzoyl peroxide therapy over the following 2 weeks In contrast, patients initially treated with the benzoyl peroxide wash for the first 2 weeks continued to improve with salicylic acid cleanser over the next

2 weeks

Utilizing combination therapy for ethnic skin Taylor SC

Cutis 2007; 80(1 Suppl):15–20

the community: randomised controlled trial Ozolins M,

Eady EA, Avery AJ, Cunliffe WJ, Po AL, O’Neill C Lancet 2004;

364(9452):2188–2195

In this randomized, observer-masked trial, participants

with facial and/or truncal acne were allocated to one of five

antibacterial regimens Of approximately 130 participants for

each regimen, moderate or greater improvement at 18 weeks

was reported in about 55% of participants assigned either oral

oxytetracycline or oral minocycline plus topical placebo; in an

average of 63% assigned topical benzoyl peroxide or topical

erythromycin and benzoyl peroxide in a combined

formula-tion plus oral placebo; and in an average of 63% assigned

topical erythromycin and benzoyl peroxide separately Most

improvement occurred in the first 6 weeks Differences in

effi-cacy were small and, generally not statistically significant In

particular, modified-release minocycline, the most expensive

regimen, was not found to be superior Benzoyl peroxide alone

was the most cost-effective regimen for mild to moderate facial

acne and represents the best value antimicrobial for first-line

use if irritant potential is limited

Comparison of the efficacy and safety of a combination

topical gel formulation of benzoyl peroxide and

clindamy-cin with benzoyl peroxide, clindamyclindamy-cin and vehicle gel in

the treatments of acne vulgaris Leyden JJ, Berger RS, Dunlap

FE, Ellis CN, Connolly MA, Levy SF Am J Clin Dermatol 2001;

2(1):33–39

Combined use of benzoyl peroxide with topical antibiotics

has been shown to decrease the emergence of antibacterial

resistant species To determine the efficacy and safety of a

combination benzoyl peroxide plus clindamycin gel, a

10-week, multicenter, double-blind trial of 480 patients with

moderate to severe acne was performed Patients were

randomized to receive twice-daily treatment with 5% benzoyl

peroxide plus 1% clindamycin, 5% benzoyl peroxide, 1%

clin-damycin, or vehicle Significantly greater reductions in the

number of inflammatory and total lesions were demonstrated

in patients using combination therapy compared with those

using any of its three individual components

A novel gel formulation of 0.25% tretinoin and 1.2%

clin-damycin phosphate: efficacy in acne vulgaris patients aged

12 to 18 years Eichenfield LF, Wortzman M Pediatr Dermatol

2009 May-Jun; 26(3):257–261

This was a subgroup analysis of a phase 3, 12-week,

multi-center, double-blind, randomized, placebo-controlled study

that compared clindamycin/retinoic acid(CLIN/RA) gel,

clin-damycin phosphate, tretinoin, and vehicle in 1710 patients

aged 12–18 years old (23% non-Caucasian) CLIN/RA is

sig-nificantly more effective in reducing mean lesion counts for

all types of lesions regardless of baseline severity than vehicle,

clindamycin, or tretinoin (p < 0.001) The difference in efficacy

was significant at or before week 2 when compared with

vehicle, week 4 when compared with tretinoin monotherapy,

and week 8 when compared with clindamycin monotherapy

Combination therapy is ideal to offer synergy in their

mecha-nism of action The medications should penetrate the follicle

Second-Line Therapies (or First-Line Therapies For Moderate to Severe Acne Vulgaris)

Oral contraceptive pills (if clinically hyperandrogenic) AAntiandrogens (if clinically hyperandrogenic) B

Combination therapy has become the gold standard for the

management of acne, particularly for moderate-to-severe cases

In an attempt to treat and prevent PIH, subjects received

com-bination clindamycin 1%-benzoyl peroxide (BPO) 5% topical

gel containing glycerin and dimethicone Subjects were

rand-omized to receive this combination therapy in addition to

either a tretinoin microsphere (RAM) gel at concentrations of

either 0.04% or 0.1% or adapalene gel 0.1% There was a trend

toward better resolution of hyperpigmentation in the subjects

receiving the clindamycin-BPO topical gel in combination

with RAM gel 0.04% Retinoids have anti-inflammatory

activ-ity while decreasing microcomedo formation resulting in dual

function for acne and PIH

Early and aggressive treatment of acne and PIH while

minimiz-ing side effects is essential for successful treatment in ethnic

skin.

Versatility of azelaic acid 15% gel in treatment of

inflamma-tory acne vulgaris Thiboutot D J Drugs Dermatol 2008;

7(1):13–16

Two randomized, multicenter, controlled clinical trials

compared the effects of azelaic acid (AzA) 15% gel with either

topical benzoyl peroxide 5% or topical clindamycin 1%, using

a twice-daily dosing regimen AzA 15% gel resulted in a 70%

median reduction of facial papules and pustules compared

with a 77% reduction with benzoyl peroxide 5% gel and a

63% reduction with clindamycin 93.9% of physicians reported

patient improvement after an average of 73.1 days The

major-ity of patients were more satisfied with AzA than with previous

therapies

Azelaic acid represents a mild but effective treatment option for

active acne, the maintenance phase of acne, and in reducing

PIH due to its skin lightening properties.

Two randomized studies demonstrate the efficacy and safety

of dapsone gel, 5% for the treatment of acne vulgaris

Draelos ZD, Carter E, Maloney JM, Elewski B, Poulin Y, Lynde

C; United States/Canada Dapsone Gel Study Group J Am Acad

Dermatol 2007 Mar; 56(3):439

Two 12-week, randomized, double-blind phase III studies

were conducted under identical protocols to evaluate the

effi-cacy and safety of twice daily dapsone 5% gel monotherapy

compared with a vehicle gel control in the treatment of acne

vulgaris in 3010 patients (72.9% Caucasian, 14% African

American, 9.4% Hispanic, Asian 2.2%, 1.6% other) Although

clinical improvement was observed with both inflammatory

and noninflammatory lesions, dapsone gel was particularly

effective for inflammatory acne lesions Reductions in

inflam-matory lesions occurred earlier, within 2 weeks, and were of

greater magnitude by the end of treatment No significant

change in hemoglobin or other laboratory values, even among

the 44 patients with G6PD deficiencies (glucose-6-phosphate

dehydrogenase) was noted

Potential mechanisms of action of this sulfone medication in

acne include antiinflammatory and antimicrobial properties

such as direct inhibition of leukocyte trafficking, inhibition of

chemical mediators of inflammation, and altered levels and/or

activity of propionibacteria located in the upper third of the follicles Although oral dapsone has been associated with adverse hematologic reactions especially in G6PD, topical for- mulation has minimal systemic absorption Although African Americans are more likely to have G6PD deficiency, topical dapsone is considered a safe and well tolerated option.

Topical therapy of acne vulgaris using 2% tea lotion in comparison with 5% zinc sulphate solution Sharquie KE,

Noaimi AA, Al-Salih MM Saudi Med J 2008; 29(12): 1757–1761

This is a randomized, single-blinded comparative clinical trial in Iraq of 40 patients, ages 13–27 years 2% tea lotion was statistically significant in decreasing the number of inflamma-tory lesions in acne vulgaris, while 5% zinc sulphate solution was beneficial, but did not reach a statistical significance 2% tea lotion was felt to be a good alternative remedy in the treat-ment of acne vulgaris, and was superior to topical 5% zinc sulphate solution

Use of more aggressive treatment options including oral antibiotics in conjunction with retinoids and benzoyl peroxide containing products has been observed to be effective in first line therapies for moderate to severe acne or second line therapy for mild to moderate acne In addition, hormonal flares have been treated effectively with oral contraceptive pills and anti-androgenic agents Treatment of individual nodulo-cystic lesions with intralesional corticosteroids is effective

Intralesional corticosteroids in the treatment of cystic acne Levine RM, Rasmussen JE Arch Dermatol 1983;

nodulo-119(6):480–481

Triamcinolone acetonide at a concentration of 0.63 mg/mL was as efficacious as the higher concentration of 2.5 mg/mL

in the treatment of nodulocystic acne Lower concentrations

of intralesional corticosteroids are effective, while minimizing side effects including skin atrophy Intralesional steroid injec-tions are most effective as adjunctive treatment for nodulo-cystic acne when a more rapid response is desired

Lymecycline in the treatment of acne: an efficacious, safe and cost-effective alternative to minocycline Bossuyt L,

Bosschaert J, Richert B, Cromphaut P, Mitchell T, Al Abadie M Eur J Dermatol 2003 Mar-Apr; 13(2):130–135

A randomized, investigator masked UK study comparing lymecycline and minocycline in two parallel groups of 134 patients with acne vulgaris was conducted Lymecycline

300 mg day is comparable to minocycline in terms of percent

1 Acneiform Disorders • Acne

decrease in lesion counts and slightly superior in terms of

efficacy compared to lowered dose of lymecycline Treatment

with lymecycline was found to be 4 times more cost-effective

than with minocycline

Doxycycline plus levamisole: combination treatment for

severe nodulocystic acne Ansarin H, Savabynasab S, Behzadi

AH, Sadigh N, Hasanloo J J Drugs Dermatol 2008; 7(8):

737–740

A double-blind, randomized, placebo-controlled trial in

60 Iranian patients with severe and reclacitrant acne vulgaris

were randomly administered oral levamisole 2.5 mg/kg/wk

(up to 150 mg/wk) plus doxycycline 100 mg daily or 100 mg

of oral doxycycline daily and a placebo This study is the first

clinical trial that suggests levamisole as an effective and well

tolerated new treatment for severe acne vulgaris

Optimizing use of oral antibiotics in acne vulgaris Del

Rosso JQ, Kim G Dermatol Clin 2009; 27(1):33–42

For moderate to severe facial or truncal disease, the most

common oral antibiotics for treating acne vulgaris are the

tetracycline derivatives, although macrolide agents such as

erythromycin have also been used extensively Due to increased

resistance, efficacy of oral tetracycline and erythromycin has

markedly diminished, leading to increased use of doxycycline,

minocycline, and other agents, such as trimethoprim/

sulfamethoxazole and azithromycin Oral azithromycin has

been reported to be effective in treating acne vulgaris in four

open and two investigator-blinded clinical trials, inclusive

of 187 subjects and 341 subjects, respectively, using various

treatment regimens Most commonly used regimens included

intermittent dosing schedules, such as three 250 mg doses per

week, because of a long terminal half-life of 68 hours

Despite documentation of widespread global prevalence of

antibiotic-resistant P acnes, topical and oral antibiotics that

have been used extensively over several years, such as topical

clindamycin, oral minocycline, and oral doxycycline, continue

to show efficacy in acne vulgaris

These oral treatments are most appropriately used in

combina-tion with a topical regimen containing benzoyl peroxide and a

topical retinoid Trimethoprim/sulfamethoxazole may be

associ-ated with adverse reactions that are uncommon but potentially

severe, including toxic epidermal necrolysis (TEN) and

Stevens-Johnson syndrome (SJS), primarily within the first 1 to 2

months after initiation of therapy, and hematologic reactions,

including agranulocytosis, hrombocytopenia, and pancytopenia,

when used in high doses or preexisting folic acid deficiency or

megaloblastic hematopoiesis.

Low-dose adjunctive spironolactone in the treatment of

acne in women: a retrospective analysis of 85 consecutively

treated patients Shaw JC J Am Acad Dermatol 2000;

43(3):498–502

Spironolactone, an established androgen receptor blocker,

is successful in treating adult women with acne, but side

effects are common at the doses reported in published studies

to date 85 women with acne were treated with low dose

spironolactone at 50–100 mg/day, administered either as single-drug therapy or as an adjunct to standard therapies for

a maximum of 24 months Clearing or marked improvement

of acne occurred in 66% of patients treated with low doses of spironolactone while 27% showed partial improvement, and 7% showed no improvement

Anti-androgenic therapy using oral spironolactone for acne vulgaris in Asians Sato K, Matsumoto D, Iizuka F,

Aiba-Kojima E, Watanabe-Ono A, Suga H Aesthetic Plast Surg 2006; 30(6):689–694

Spironolactone (initial dose, 200 mg/day) was administered orally to 139 Japanese patients (116 females and 23 males) with severe, recurring, or widespread acne Most female patients exhibited excellent improvement over 20 weeks, although some discontinued treatment because of menstrual disturbances or other reasons The treatment was less efficacious for the males than for the females, and because gynecomastia developed in three male patients, spironolactone treatment for males was stopped Drug eruptions and edema in the lower extremities were seen in three patients Hormonal anti-androgenic treat-ments can inhibit sebum production and acne Obtaining this race-specific information is important because Caucasians and Asians respond differently to hormone therapy

Despite its proven efficacy, other hormonal anti-androgenic treatments have limitations For instance, cyproterone acetate

is potentially carcinogenic, but is still widely used for severe acne in many countries Flutamide is also restricted due to its hepatotoxicity.

Norgestimate and ethinyl estradiol in the treatment of acne vulgaris: a randomized, placebo-controlled trial Redmond

GP, Olson WH, Lippman JS, Kafrissen ME, Jones TM, Jorizzo

JL Obstet Gynecol 1997; 89(4):615–622

A prospective study of 250 women (84% white, 11% black, 1.7% oriental, 3.4% hispanic) were enrolled in a multicenter, randomized, double-blind, placebo-controlled clinical trial with moderate acne vulgaris Subjects received either 3 con-secutive weeks of active triphasic oral contraceptive treatment followed by 1 week of inactive drug for 6 months or 4 weeks

of placebo tablets Oral contraceptive group was better than placebo for inflammatory lesions, total lesions, and investi gator’s global assessment Free testosterone decreased significantly and sex hormone-binding globulin increased sig-nificantly in the oral contraceptive group thereby reducing the androgen stimulus in acne pathogenesis

A combined oral contraceptive containing 3-mg drospirenone/20-microg ethinyl estradiol in the treatment

of acne vulgaris: a randomized, double-blind, controlled study evaluating lesion counts and participant self-assessment Lucky AW, Koltun W, Thiboutot D, Niknian

placebo-M, Sampson-Landers C, Korner P Cutis 2008; 82(2):143– 150

This study compared the efficacy of a low-dose combined oral contraceptive containing 3-mg drospirenone and 20- microg ethinyl estradiol administered in a 24-day active pill/ 4-day inert pill (24/4) regimen and placebo in 534 women

Other therapies Acne

• Topicals:

– Lightening agents (see Chapter 10)– Azelaic acid

– Retinoids– Sunscreens

Third-Line Therapies (or First Line Therapies For Severe

Acne Vulgaris)

with moderate acne vulgaris Greater reduction was noted

from baseline to end point in individual lesion counts

(papules, pustules, open and closed comedones) compared

with placebo, but did not affect nodule count

Effectiveness of norgestimate and ethinyl estradiol in

treat-ing moderate acne vulgaris Lucky AW, Henderson TA, Olson

WH, Robisch DM, Lebwohl M, Swinyer LJ J Am Acad

Derma-tol 1997; 37(5 Pt 1):746–754

To evaluate the efficacy of a triphasic combination oral

contraceptive compared with placebo in the treatment of

moderate acne vulgaris, 257 healthy female subjects (82%

Caucasian, 9.1% Black, 2.7% Oriental, 5.5% Hispanic, 0.9%

Other) with moderate comedonal or inflammatory acne

vul-garis were enrolled in a multicenter, randomized,

double-blind, placebo-controlled clinical trial Each month for 6

months, subjects received either 3 weeks of the oral

contracep-tive containing 0.035 mg of ethinyl estradiol combined with

the triphasic regimen of norgestimate followed by 7 days of

inactive drug The mean decrease in inflammatory lesion count

was 62.0% and the mean decrease in total lesion count was

53.1% in the oral contraceptive group

The most effective medication in the treatment of severe or

resistant acne is oral isotretinoin However, the close

monitor-ing required can be a limitmonitor-ing factor for patients and the

increased regulation of the medication can be a barrier to

physicians wishing to prescribe it

Roaccutane treatment guidelines: results of an international

survey Cunliffe WJ, van de Kerkhof PC, Caputo R, et al

Dermatology 1997; 194(4):351–357

Twelve dermatologists from several countries reviewed the

surveys of 1000 patients 55% of patients had severe nodular

cystic acne or severe inflammatory acne resistant to

conven-tional treatment and 45% of patients had either moderate or

mild acne which was either recalcitrant, scarring or

psychologi-cally distressing Treatment was initiated at daily doses of

0.5 mg/kg and increased to 1.0 mg/kg, with the aim of

achiev-ing a cumulative dose of > 100–120 mg/kg Mucocutaneous

side effects occur frequently but were manageable while severe

systemic side effects were rarely problematic (2%) Significant

cost savings when treating acne patients with oral isotretinoin

as compared to other treatment modalities were further proven

in this study

This study highlights the important role that oral isotretinoin

plays not only in patients with severe disease but also in

patients with less severe acne, especially if there is scarring and

significant psychological stress associated with their disease

Acne patients should, when appropriate, be prescribed

isotretin-oin early in their condition to prevent further scarring.

1 Acneiform Disorders • Acne

cosmetic camouflage that are available over the counter are

addressed

Commonly encountered pitfalls

Acne is the number one reason that the African-American

population consults a dermatologist.32 Acne vulgaris displays

histological and clinical differences in people with skin of color

compared with Caucasians.33 Differences may include a trend

toward greater P acnes density and differences in sebaceous

gland size and activity.34 In skin of color acne patients, acne is

primarily inflammatory Surprisingly comedonal lesions in

Blacks display marked inflammation and points towards a

subcategory of inflammatory comedonal acne which may

pre-dispose to PIH This may be important when selecting

appro-priate therapy Of the available topical treatments, benzoyl

peroxide is effective as an anti-inflammatory Retinoids act on

both the comedonal and inflammatory components of acne

and have skin lightening properties However, a commonly

encountered pitfall with these agents is the occurrence of an

irritant contact dermatitis It is important that dermatologists

minimize epidermal irritation when treating skin of color

because of the risk of either PIH or postinflammatory

hypop-igmentation In Dakar, Senegal, acne patients are commonly

treated with benzoyl peroxide and a topical retinoid for their

more advanced disease.4 It is important to note that the use of

alternative medicine occurs frequently, particularly in Asian

populations, where increasing PIH can occur.5

The family of tetracyclines are useful in the treatment of

acne in skin of color but they are not without adverse events

which can lead to common pitfalls The tetracycline family of

antibiotics are useful in the treatment of acne in skin of color

as they are anti-inflammatory However, they are not without

adverse events which can lead to pitfalls Although

minocy-cline has been used safely in this population, it has been

reported to cause a drug hypersensitivity syndrome that can

resemble infectious mononucleosis, as well as fatalities in the

ethnic population.35 In addition, minocycline can induce

generalized dark brown to gray discolorations or dark

blue-black macules (localized at sites of inflammation) on the

lower legs or sun exposed areas Doxycycline is an effective

treatment, but has photosensitizing properties

Acne patients with ethnic skin are at an increased risk for

developing post-inflammatory hyperpigmentation and

keloi-dal scarring Treatment approaches for acne in darker skin

patients must balance early aggressive intervention with the

selection of efficacious and non-irritating agents For most

patients, a combination of topical retinoids, and topical or oral

antibiotics, with hydroquinone to control hyperpigmentation,

will be successful For patients with sensitive skin, topical

agents in lower concentrations and with cream vehicles are

preferred While PIH tends to gradually disappear over time, it

is the number one complaint among acne patients with darker

skin tones PIH should be treated aggressively with a

combina-tion of sunblock, hydroquinone, retinoid, chemical peels, and

microdermabrasion, when appropriate Caution must be taken

when treating ethnic skin with ablative or nonablative lasers

and superficial or deep chemical peels due to the high risk of

further PIH, scarring, and permanent hypopigmentation Keloid scarring secondary to acne can be treated with pressure, silicone gels, intralesional coritcosteroids, surgery, laser treat-ment or radiation therapy However, keloids treated with surgi-cal excision can have rates of recurrence as high as 50%.Special management & counseling considerationsSuccessful management of acne in ethnic patients can be achieved with early initiation of an appropriate combination drug regimen coupled with good patient compliance Topical medications, such as retinoids, may be used safely and effec-tively to treat acne in skin of color patients Dryness and irrita-tion can be minimized by counseling patients to use retinoids initially in lower concentrations with every other day applica-tion in addition to daily use of a hydrating agent Patients should also be instructed to treat their skin gently, avoiding scrubbing and picking of acne lesions Mild, non-abrasive cleansers, non-comedogenic moisturizers and cosmetics are preferred Moisturizers treat the dry skin and prevent irritant contact dermatitis that may commonly occur In addition, use

of cocoa butter, a comedogenic agent, is very common among Black patients and should be avoided For best results, clini-cians should manage the entire grooming regimen of the skin and hair of their ethnic patients Patients should be advised to avoid comedogenic hair and scalp preparations that can cause

or exacerbate acne

Sunscreen use has been found to be scarce in ethnic patients.32 Chemical sunscreens have a higher likelihood of exacerbating acne and causing contact dermatitis Physical sun-blocks containing micronized zinc oxide or titanium dioxide are preferred for best protection, especially with coexisting post inflammatory hyperpigmentation The administration of a skin bleaching agent combined with a photo protective agent for application in the morning, instead of hydrating cream, is acceptable to patients, improves com pliance, and is effective.Additionally, acne may be improved by controlling hor-mones and inflammation, both of which may be influenced

by diet Concurrent with standard anti-acne therapy, a trial of discontinuing all dairy products and high glycemic foods should be stopped for at least 6 months to evaluate the effect, since it is thought to contribute to elevations in growth factors and hormones that cause acne Vitamin A supplementation may help reduce plugging of pores in deficient individuals, while foods containing ω-3 essential fatty acids (EFAs) may help to control inflammation.36–42 Individualized care and close monitoring is required

References

1 Norris JF, Cunliffe WJ A histological and immunocytochemical study

of early acne lesions Br J Dermatol May 1988; 118(5):651–659.

2 Thiboutot D, Gilliland K, Light J, Lookingbill D Androgen lism in sebaceous glands from subjects with and without acne Arch Dermatol Sep 1999; 135(9):1041–1045.

metabo-3 Pochi PE, Strauss JS Sebaceous gland activity in black skin Dermatol Clin Jul 1988; 6(3):349–351.

4 Kim J, Ochoa MT, Krutzik SR, Takeuchi O, Uematsu S, Legaspi AJ,

et al Activation of toll-like receptor 2 in acne triggers inflammatory cytokine responses J Immunol Aug 1 2002; 169(3):1535–1541.

5 Weiss JS Current options for the topical treatment of acne vulgaris

Pediatr Dermatol 1997; 14:480–488.

6 Goulden V, McGeown CH, Cunliffe WJ The familial risk of adult acne:

a comparison between first-degree relatives of affected and unaffected

individuals Br J Dermatol Aug 1999; 141(2):297–300.

7 Krowchuk DP, Lucky AW Managing adolescent acne Adolesc Med

2001 Jun; 12(2).

8 Katsambas AD, Katoulis AC, Stavropoulos P Acne neonatorum: a study

of 22 cases Int J Dermatol 1999 Feb; 38(2):128–130.

9 Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, Leyden JJ, et al

Global Alliance to Improve Outcomes in Acne Management of acne:

a report from a Global Alliance to Improve Outcomes in Acne J Am

Acad Dermatol 2003; 49(suppl 1):S1–S37.

10 Thielitz A, Helmdach M, Röpke EM, Gollnick H Lipid analysis of

fol-licular casts from cyanoacrylate strips as a new method for studying

therapeutic effects of antiacne agents Br J Dermatol 2001;

145:19–27.

11 Verschoore M, Bouclier M, Czernielewski J, Hensby C Topical

retin-oids: their uses in dermatology Dermatol Clin 1993; 11:107–115.

12 Mills OH Jr, Kligman AM Treatment of acne vulgaris with topically

applied erythromycin and tretinoin Acta Derm Venereol 1978; 58:

555.

13 Halder RM, Brooks HL, Callender VD Acne in ethnic skin Dermatol

Clin 2003 Oct; 21(4):609–615, vii.

14 Embil K, Nacht S The Microsponge Delivery System (MDS): a topical

delivery system with reduced irritancy incorporating multiple

trigger-ing mechanisms for the release of actives J Microencapsul 1996 Sep–

Oct; 13(5):575–588.

15 Martin B, Meunier C, Montels D, Watts O Chemical stability of

ada-palene and tretinoin when combined with benzoyl peroxide in

pres-ence and in abspres-ence of visible light and ultraviolet radiation Br J

Dermatol 1998; 139(suppl 52):8–11.

16 Cove H, Holland KT The effect of benzoyl peroxide on cutaneous

micro-organisms in vitro J Appl Bacteriol 1983; 54:379–382.

17 Cunliffe WJ, Holland KT The effect of benzoyl peroxide on acne Acta

Derm Venereol 1981; 61(3):267–269.

18 Bojar RA, Cunliffe WJ, Holland KT The short-term treatment of acne

vulgaris with benzoyl peroxide: effects on the surface and follicular

cutaneous microflora Br J Dermatol 1995; 132:204–208.

19 Crawford WW, Crawford IP, Stoughton RB, Cornell RC Laboratory

induction and clinical occurrence of combined clindamycin and

eryth-romycin resistance in Corynebacterium acnes J Invest Dermatol 1979

Apr; 72(4):187–190.

20 Badreshia-Bansal S, Draelos ZD Insight into skin lightening

cosmeceuticals for women of color J Drugs Dermatol 2007;

6(1):32–39.

21 Webster G Combination azelaic acid therapy for acne vulgaris J Am

Acad Dermatol 2000 Aug; 43(2 Pt 3):S47–S50.

22 Gupta AK, Nicol K The use of sulfur in dermatology J Drugs Dermatol

25 Eady EA, Jones CE, Tipper JL, Cove JH, Cunliffe WJ, Layton AM

Antibiotic resistant propionibacterium in acne: need for policies to

modify antibiotic usage BMJ 1993; 306:555.

26 Kurokawa I, Danby FW, Ju Q, Wang X, Xiang LF, Xia L, et al New

developments in our understanding of acne pathogenesis and

treat-ment Exp Dermatol 2009 Oct; 18(10):821–832.

27 Zaenglein AL, Thiboutot DM Expert Committee Recommendations

for Acne Management Pediatrics 2006 Sep; 118(3):1188–1199.

28 Quarles FN, Brody H, Johnson BA, Badreshia S Chemical peels

in richly pigmented patients Dermatol Ther 2007 May–Jun;

20(3):147–148.

29 Badreshia S, Verma S Laser and light modalities in the treatment

of acne vulgaris The CSI Journal of Cosmetic Dermatology Feb 2006;

Vol 1:5–9.

30 Davis EC, Callender VD A Review of acne in ethnic skin pathogenesis,

clinical manifestations, and management strategies J Clin Aesthet

Dermatol 2010 April; 3(4):24–38.

31 Quarles FN, Johnson BA, Badreshia S, Vause SE, Brauner G, Breadon

JY, et al Acne vulgaris in richly pigmented patients Dermatol Ther

2007 May–Jun; 20(3):122–127.

32 Poli F Acne on pigmented skin Int J Dermatol 2007; 46(Suppl 1):39–41.

33 Taylor SC, Cook-Bolden F, Rahman Z, Strachan D Acne vulgaris

in skin of color J Am Acad Dermatol 2002; 46(2 Suppl Understanding): S98–S106.

34 Paul Kelly, Susan C Taylor Dermatology for Skin of Color Chapter 12 The Structure and Function of Skin of Color, Sonia Badreshia-Bansal and Susan C Taylor New York: McGraw-Hill; 2009.

35 Tsuruta D, Someda Y, Sowa J, Kobayashi H, Ishii M Drug tivity syndrome caused by minocycline J Cutan Med Surg 2006; 10(3):131–135.

hypersensi-36 Koldovsky O Hormones in milk Vitam Horm 1995; 50:77–149.

37 Hoyt G, Hickey MS, Cordain L Dissociation of the glycaemic and insulinaemic responses to whole and skimmed milk Br J Nutr 2005; 93:175–177.

38 Charakida A, Charakida M, Chu AC Double-blind, randomized, placebo-controlled study of a lotion containing triethyl citrate and ethyl linoleate in the treatment of acne vulgaris Br J Dermatol 2007; 157:569–574.

39 Treloar V, Logan AC, Danby FW, Cordain L, Mann NJ Comment on acne and glycemic index J Am Acad Dermatol 2008; 58:175–177.

40 Namazi MR Further insight into the pathomechanism of acne by considering the 5-alpha-reductase inhibitory effect of linoleic acid Int

Figure 1 4: Pomade acne on the forehead

1 Acneiform Disorders • Acne

usually consists of comedones, papules, and pustules One

study showed half of Blacks with acne used hair oil or pomade.1

Treatment of pomade acne requires discontinuing or

mini-mizing pomade use and substituting with silicone-based hair

products If a pomade is used to decrease scalp dryness, it

should be applied 2.5 cm (1 inch) behind the hairline When

used to style or improve hair manageability, the pomade

should be applied only to the distal ends of the hair to avoid

contact with the scalp and hairline Pomade acne will

gradu-ally clear if it is discontinued or if no contact is made with the

skin However, if pomade acne persists, it should be treated as

described above for acne vulgaris

Reference

1 Taylor SC, Cook-Bolden F, Rahman Z, Strachan D Acne vulgaris in

skin of color J Am Acad Dermatol 2002; 46(2 Suppl Understanding):

S98–106.

Steroid acne

Steroid acne presents as monomorphous papulo-pustules

located predominantly on the trunk, extremities and face

Characteristically, it appears after the administration of topical

or systemic corticosteroids, including intravenous and

inhala-tion therapy The erupinhala-tion usually resolves after

discontinua-tion of the corticosteroid and, in addidiscontinua-tion, may respond to

the usual acne treatment regimens In some African and Asian

immigrant groups, use of corticosteroid-containing fade

creams is common and acne is increasingly observed in adults

using these depigmenting agents (Fig 1.5) Discontinuation

of the corticosteroid will lead to resolution of the acne

Pediatric perspectives: Infantile acne

Candrice R Heath

Figure 1 5: (A) Steroid acne resulting from long-term topical

clobetasol use (B) and (C) Steroid containing fade creams

A

B

C

First-Line Therapies

Infantile acne: a retrospective study of 16 cases Hello M,

Prey S, Léauté-Labrèze C, et al Pediatr Dermatol 2008; 25(4):

434–438

In this retrospective review of 16 cases (11 boys and 5 girls),

the cheeks were the primary site of involvement Cystic lesions

were reported in 25% of the patients Information regarding

treatment was available for 15 patients; 3 of 15 resolved

without treatment, 4 were treated with benzoyl peroxide, 5

with topical antibiotics and 7 with topical retinoids Oral

medications were used in 8 patients: 4 with zinc salts, 2 with

macrolides and 2 with isotretinoin The disease duration was

between 9 and 42 months Of the 8 patients who reached

adolescence at the time of the review, only one developed severe adolescent acne Of the 16 total cases reviewed, 9 reported scarring, generally atrophic

Isotretinoin is only approved for children 12 years and older with nodulocystic acne, though there have been reports in the literature of use in younger age groups for recalcitrant cases.

Third-Line Therapies

Pediatric perspectives: Neonatal acne (acne neonatorum)

Candrice R Heath

Although predominately a disease of adults and adolescents, acne may occur in newborns and infants The acne that presents in newborns and infants is more common in males Hyperactivity of the sebaceous glands stimulated by androgens has been the implicated cause of acne in both boys and girls

in this group Open and closed comedones predominate, but other inflammatory lesions may occur as well Neonatal acne appears within the first few weeks of life While infantile acne occurs in infants between 3 months and 6 months of age When infantile acne occurs, it usually persists and may be severe

First-Line Therapies

Daily Cleansing with Gentle Soap

Acne neonatorum: a study of 22 cases Katsambas AD,

Katoulis AC, Stavropoulos P Int J Dermatol 1999; 38(2):128–130

22 patients (18 males and 4 females) with acne rum were evaluated The average age of onset was 3 weeks, with an average duration of 4 months The cheeks were involved in 81.8% of the cases Papules and pustules were the predominant lesion type in 72.7% and only 22.7% of the patients had comedones A family history of acne was present

neonato-in 3 cases 18 patients were treated with a regimen of daily cleansing with soap and water Benzoyl peroxide 5% gel was used in 3 patients and 1 patient was treated with benzoyl peroxide 5% gel combined with topical clindamycin alcohol solution Though this is a self-limiting disorder, treatments hastened resolution

Neonatal acne occurs within the first few weeks of life while infantile acne usually does not occur until 3 to 6 months

of age.

Second-Line Therapies

Topical antibiotic (erythromycin or clindamycin) C

A clinical and therapeutic study of 29 patients with infantile

acne Cunliffe WJ, Baron SE, Coulson IH Br J Dermatol 2001;

145(3):463–466

In this retrospective review of 29 patients (24 boys and 5

girls) with infantile acne, 24% of the cases were mild, 62%

were moderate and 14% of the cases were severe

Inflamma-tory acne occurred in 59% of the cases, while comedonal

lesions in 17%, nodular lesions in 7% and a mixture of lesions

was seen in 17% The patients with mild acne were treated

successfully with benzoyl peroxide, erythromycin and topical

retinoids All of the infants with moderate acne responded

well with a combination of oral erythromycin and topical

treatment, except 2 infants The two erythromycin resistant

cases were treated with trimethoprim The majority of the

infants treated with oral antibiotics were treated with oral

therapy for 18 months or less However 38% of the infants

treated with oral antibiotics required over 24 months of

treat-ment The acne lasted between 6 and 40 months One case

was treated successfully with a 4-month course of isotretinoin

Five of the 29 patients were left with residual scarring

Topical acne medications should be used very sparingly on the

skin of infants to avoid irritation.

Adapalene gel 0.1% in the treatment of infantile acne: an

open clinical study Kose O, Koç E, Arca E Pediatr Dermatol

2008; 25(3):383–386

12 patients were treated with adapalene gel 0.1% once per

day for 16 weeks Clearance of lesions was achieved in 4

patients after 3 months of treatment and the remaining 8

patients cleared in 4 months There was no residual scarring,

however at a one-year follow-up evaluation, 3 patients had a

few mild lesions

Oral tetracycline is not recommended in children under 8 years old due to decreased bone growth and tooth staining.

Acne rosacea

Rosacea is a common skin disease characterized by vascular

hyper-reactivity, facial flushing, erythema, and telangiectasias

The pathogenesis appears to be multifactorial Demodex

mites, normal inhabitants of the human hair follicle, are

found in greater numbers in rosacea patients and are thus theorized to play a role in its pathogenesis.1–3 However, more

studies are needed to conclusively determine if Demodex

truly is pathogenic Also, inconclusive evidence suggests that

Helicobacter pylori (H pylori) is associated with the etiology

of rosacea, as increased levels of H pylori antibodies have

been detected.4,5 However, many of the studies were not controlled

1 Acneiform Disorders • Acne rosacea

Rosacea is most common in middle aged fair skinned

indi-viduals, but it can also be seen in individuals of any skin type

Data on the incidence of rosacea in different racial groups is

variable and generally lacking Rosacea appears to be more

common in light skinned and Asian populations and less

common in people who have darker skin However, in ethnic

skin, the diagnosis can be obscured due to skin hue, causing

rosacea to appear more hyperpigmented and less

erythema-tous in darker patients with resulting misdiagnosis Although

it is considered to be rare among Black patients, it may be

more common than believed to be in the past.6

There are four main subtypes of rosacea: vascular rosacea

characterized by flushing and persistent central erythema (Fig

1.6); papulopustular rosacea characterized by central facial

papules or pustules; phymatous rosacea with thickened,

irreg-ular, nodular skin, (referred to as rhinophyma when the

nose is involved, Fig 1.7); and ocular rosacea characterized by

burning, stinging, or the sensation of a foreign body in

the eye Patients may present with one or a combination of

symptoms and signs such as facial burning and stinging,

edema, erythematous plaques, dryness, ocular manifestations,

or phymatous changes Extrafacial involvement may occur

on the neck and the upper chest Common rosacea triggers

include hot and/or cold temperatures, wind, hot drinks,

caf-feine, exercise, spicy food, alcohol, stress, topical products

that irritate the skin and decrease the stratum corneum

barrier, or medications that cause flushing Rosacea fulminans

(pyoderma faciale) is a rare complication characterized by the

development of nodules and abscesses with sinus tract

formation accompanied by systemic signs A rare caseating

granulomatous variant of rosacea, called lupus miliaris

dis-seminatus faciei, can manifest with inflammatory red-brown

or flesh-colored papules distributed symmetrically across the

upper part of the face, particularly around the eyes and the

nose

Figure 1 6: Rosacea with persistent central erythema in an Asian woman

Figure 1 7: Rhinophyma in an Indian man

Unlike with acne vulgaris, patients with rosacea generally

do not report oily skin but instead they experience dryness and peeling The absence of comedones and lack of scarring

is another helpful distinguishing feature from acne vulgaris Other cutaneous disorders that mimic rosacea include poly-cythemia vera, connective tissue diseases (e.g lupus erythema-tous, dermatomyositis, mixed connective tissue disease), perioral dermatitis, seborrheic dermatitis, photosensitivity, mastocytosis, neuroendocrine tumor such as pheochromocy-toma or carcinoid, long-term application of topical steroids, anticancer agents such as epidermal growth factor receptor inhibitor (Fig 1.8), contact dermatitis, and photosensitivity Clues to an endocrinopathy include tachycardia, hypertension, sweats, hot flashes, or diarrhea

Figure 1 8: Skin eruption induced by an epidermal growth factor receptor

inhibitor (Courtesy of Emmy Graber MD, Dave Adams MD, and Diane Thiboutot MD; Department of Dermatology, Penn State Milton S Hershey Medical Center)

Rosacea is a challenging disease to treat and there are very

few large well controlled studies Additionally, vasodilation, a

key component of rosacea, is unresponsive to therapy However,

avoiding triggers described above may help with symptoms.7-9

Sunblock may have an effect on vasodilatation since exposure

to ultraviolet radiation leads to destruction of collagen and the

surrounding supportive connecting tissue, which contributes

to vaso dilation.10,11 Topical therapy includes the use of

metro-nidazole for inflammatory rosacea with resulting slow, gradual

response Azelaic acid has been helpful in reducing erythema

Sodium sulfacetamide, as an adjunct to therapy, may improve

severe disease A combination of topical and oral therapy

usually provides the best results for initial flares Oral therapy

consists of the tetracycline class of antibiotics administered

over several weeks with a gradual taper for initial flares Other

options may include trimethoprim/sulfamethoxazole and

cip-rofloxacin but these may be limited by cost and resistant micro-

organisms In the most severe cases of rosacea with resistant

inflammatory lesions and nodules or rhinophyma,

isotretin-oin therapy may be required Persistent erythema may respond

best with vascular lasers, which are the mainstay of rosacea

therapy Cosmetic improvement of rhinophyma may be

pro-duced by mechanical dermabrasion, surgical shave techniques,

CO2 laser or hot loop recontouring Anecdotal evidence

indicates treatment of rosacea with medications including

beta-blockers, clonidine, naloxone, ondansetron, and

selective serotonin reuptake inhibitors may improve

Efficacy and safety of azelaic acid (15%) gel as a new ment for papulopustular rosacea: results from two vehicle- controlled, randomized phase III studies Thiboutot D,

treat-Thieroff-Ekerdt R, Graupe K J Am Acad Dermatol 2003; 48(6):836–845

Two multicenter, double-blind, randomized, group, vehicle-controlled studies were conducted enrolling

parallel-665 subjects (92.5% Caucasian, 0.75% African American, 5.75% Hispanic, 0.25% Asian, 0.75% Asian) with moderate papulopustular rosacea Azelaic acid 15% gel yielded statistically significantly higher reductions in mean inflamma-tory lesion count with improvement in erythema and thera-peutic success as compared to placebo within 12 weeks of treatment In vitro investigations indicate that azelaic acid may exert an anti-inflammatory effect by scavenging or reducing the generation and/or release of proinflammatory reactive oxygen species by neutrophils (much like the effect of tetracyclines in rosacea)

Randomized placebo-controlled trial of metronidazole 1% cream with sunscreen SPF 15 in treatment of rosacea

Tan JK, Girard C, Krol A, Murray HE, Papp KA, Poulin Y, Chin DA, Jeandupeux D J Cutan Med Surg 2002; 6(6):529–534

120 patients with moderate to severe rosacea were enrolled

in a randomized, placebo-controlled, double-blind study Study cream was applied twice daily to the entire face over

a 12-week period Treatment with metronidazole 1% cream with SPF 15 sunscreen resulted in significant improvement in inflammatory lesion count, erythema and telangiectasia scores, and investigator and patient global assessment scores com-pared with baseline and placebo

Rosacea patients are prone to irritation, including from dients found in sunscreen It is preferable to use physical block- ers containing zinc oxide or titanium dioxide and/or ones that contain dimethicone or cyclomethicone to reduce possible contact dermatitis.

ingre-Combined effect of anti-inflammatory dose doxycycline (40-mg doxycycline, usp monohydrate controlled-release capsules) and metronidazole topical gel 1% in the treat- ment of rosacea Fowler JF Jr J Drugs Dermatol 2007;

6(6):641–645

This 16-week, randomized, double-blind, controlled study of an anti-inflammatory dose of doxycycline plus topical metronidazole gel 1% for mild to moderate rosacea is presented At week 12, metronidazole was discon-tinued and patients continued on either placebo or doxycy-cline Combination therapy significantly reduced inflammatory lesion counts as early as week 4 and through week 12 com-pared to topical metronidazole 1% gel monotherapy

placebo-There is evidence to support the use of topical metronidazole

and azelaic acid in the maintenance of rosacea For

acute, inflammatory flares, oral antibiotics in combination

with topical agents will result in improvement Finally,

laser therapy may help diminish the erythema associated

with rosacea, but care must be exercised when treating

ethnic patients

American Acne & Rosacea Society rosacea medical

manage-ment guidelines Del Rosso JQ, Baldwin H, Webster G,

American Acne & Rosacea Society J Drugs Dermatol 2008;

7(6):531–533

The pharmacologic agents discussed are inclusive of those

that are FDA-approved based on phase 3 pivotal trials The

mainstay of treatment for inflammatory lesions has been oral

antibiotics, but topical metronidazole also may be effective

Antibiotics are more effective for inflammatory lesions than

for erythema and telangiectasia Isotretinoin may be effective

1 Acneiform Disorders • Acne rosacea

Second-Line Therapies

Long-pulsed (6-ms) pulsed dye laser treatment of

rosacea-associated telangiectasia using subpurpuric clinical

thresh-old Jasim ZF, Woo WK, Handley JM Dermatol Surg 2004;

30(1):37–40

To examine the effect of long-pulsed PDL at subpurpuric

clinical threshold in the treatment of rosacea-associated

tel-angiectasia, 12 patients with rosacea-associated telangiectasia

were recruited into the study The 595-nm PDL at a pulse

duration of 6 ms was titrated up to a fluence between 7 and

9 J/cm2 to produce immediate purpura lasting only a few

seconds Pretreatment cooling was achieved by cryogen spray

Patients were evaluated 6–8 weeks after one PDL treatment

Two of 12 patients had more than 75% improvement, another

two had 50–75% improvement, and five had 25–50%

improve-ment Overall, 9 (75%) of 12 patients had more than

25% improvement after a single treatment of PDL None of

the patients reported lasting post-treatment purpura or

complications

Caution must be taken when treating ethnic skin, especially

with lasers containing cryogen spray due to possible risk of

M, Stewart D Cutis 2005; 75(6):357–363

In an investigator-blinded, randomized, parallel-group study at 6 sites, after 12 weeks of treatment with sodium sul-facetamide 10% and sulfur 5% cream with sunscreens, there was a significantly greater percentage reduction in inflamma-tory lesions compared with metronidazole 0.75% cream, as well as a significantly greater percentage of subjects with improved erythema Seven subjects had poor tolerance to the sodium sulfacetamide 10% and sulfur 5% cream with sun-screens, possibly caused by a sulfa drug allergy

Double-blind, randomized, vehicle-controlled clinical trial

of once-daily benzoyl peroxide/clindamycin topical gel in

the treatment of patients with moderate to severe rosacea

Breneman D, Savin R, VandePol C Int J Dermatol 2004; 43(5):381–387

This 12-week, double-blind, vehicle-controlled, mized, prospective, parallel-group study in 53 patients with moderate to severe rosacea showed a difference in favor of benzoyl peroxide/clindamycin by the third week of treatment

rando-as compared to placebo Severity scores for erythema, papules/pustules, and flushing/blushing decreased more with benzoyl peroxide/clindamycin than with vehicle Application site reac-tions were reported in 14% of patients

Caution must be taken in skin of color with topical agents that can cause irritant contact dermatitis, and subsequent post- inflammatory hyperpigmentation.

Comparison of efficacy of azithromycin vs doxycycline in

the treatment of rosacea: a randomized open clinical trial

Akhyani M, Ehsani AH, Ghiasi M, Jafari AK Int J Dermatol 2008; 47(3):284–288

A randomized, open clinical trial was conducted in Iran to compare the efficacy of azithromycin with doxycycline in 77 rosacea patients who were randomized to receive either azi-thromycin 500 mg three times weekly (on Monday, Wednes-day, and Saturday) in the first month, 250 mg three times weekly in the second month, and 250 mg twice weekly (on Tuesday, and Saturday) in the third month The other group was given doxycycline 100 mg/day for the three months Clini-cal assessment was made at baseline, at the end of first, second, third, and fifth months after treatment Statistically significant improvement was obtained with both drugs In the azithromy-cin group, 4 patients had diarrhea, while epigastric burning was seen in 2 patients using doxycycline This study indicates that azithromycin is at least as effective as doxycycline in the treatment of rosacea

Supporting evidence of treatment with topical

immuno-modulators, benzoyl peroxide, and oral antibiotics has been

varied

Pimecrolimus 1% cream for the treatment of steroid-induced

rosacea: an 8-week split-face clinical trial Lee DH, Li K, Suh

DH Br J Dermatol 2008; 158(5):1069–1076

This investigator-blided, split-face study evaluated the

effi-cacy and safety of pimecrolimus 1% cream for the treatment

of steroid-induced rosacea Patients applied pimecrolimus 1%

cream twice daily to a randomly allocated half face for the first

2 weeks, and then applied pimecrolimus 1% cream to both

sides of the face for 6 more weeks After 1 week of application,

a statistically significant improvement in erythema was

observed Asian subjects (type IV) were included in the study

but no mention was made regarding demographics Some

patients developed hyperpigmentation as papules and

pus-tules resolved This was most common in ethnic patients and

was considered to be PIH

Efficacy of pimecrolimus for the treatment of steroid induced

rosacea is debated Other case reports have concluded that

post-inflammatory hyperpigmentation The daily use of spectrum sunblock is recommended for all patients, including ethnic patients in whom sunscreen use is low A sunscreen that protects against both ultraviolet A and ultraviolet B rays should

broad-be selected Physical blockers with micronized titanium dioxide and/or zinc oxide are well tolerated in ethnic skin but may produce a temporary white or purple skin hue Green tinted sunscreens or cosmetics can provide coverage of ery-thema if present in patients with lighter skin hues Patients should be encouraged to avoid astringents, toners, menthols, camphor, waterproof cosmetics requiring solvents to be removed, or products containing sodium lauryl sulfate which can irritate the skin Dietary modulation should aim at avoid-ance of triggers

3 Bonnar E, Eustace P, Powell FC The Demodex mite population in rosacea J Am Acad Dermatol 1993; 28(3):443–448.

4 Rebora A, Drago F, Picciotto A Helicobacter pylori in patients with rosacea Am J Gastroenterol 1994; 89(9):1603–1604.

5 Utas˛ S, Ozbakir O, Turasan A, Utas˛ C Helicobacter pylori eradication treatment reduces the severity of rosacea J Am Acad Dermatol 1999; 40(3):433–435.

6 Rosen T, Stone MS Acne rosacea in blacks J Am Acad Dermatol 1987; 17(1):70–73.

7 Jansen T, Plewig G Rosacea: classification and treatment J R Soc Med 1997; 90:144–150.

8 Wilkin JK Flushing reactions: consequences and mechanisms Ann Intern Med 1981; 95:468–476.

9 Guarrera M, Parodi A, Cipriani C, Divano C, Rebora A Flushing in rosacea: a possible mechanism Arch Dermatol Res 1982; 272:311– 316.

10 Wilkin JK Rosacea Pathophysiology and treatment Arch Dermatol 1994; 130:359–362.

11 Plewig G, Jansen T Rosacea In: Freedberg IM, Eisen AZ, Wolff K, et al, editors Dermatology in General Medicine 5th ed New York, NY: McGraw-Hill Health Professions Division; 1999 p 785–794.

12 Koffi-Aka V, Kouassi AA, D’Horpock FA, Boka NJ, Ehouo F [Rhinophyma in a black African] Rev Laryngol Otol Rhinol (Bord) 2002; 123(2):109–110.

13 Furukawa M, Kanetou K, Hamada T Rhinophyma in Japan Int J Dermatol 1994; 33(1):35–37.

14 Allah KC, Kossoko H, Yéo S, Richard Kadio M, Assi Djè Bi Djè V [Rhinophyma in a black African male patient] Rev Stomatol Chir Maxillofac 2009 Dec; 110(6):347–349.

15 Khoo CT, Saad MN Rhinophyma in a negro: case report Br J Plast Surg 1980 Apr; 33(2):161–163.

16 Browning DJ, Rosenwasser G, Lugo M Ocular rosacea in blacks Am J Ophthalmol 1986; 101(4):441–444.

Commonly encountered pitfalls

The various forms of rosacea are more common than once

believed in ethnic skin The caseating granulomatous variant

may be more common in Asian or Black patients and acne

rosacea may be more common in Black patients than

previ-ously thought However, rhinophyma has remained relatively

uncommon in Japanese and reported in only 3 cases in

African-Americans.12-15 Ocular rosacea in Black patients has

been found to range from blepharitis and conjunctival

hyper-emia to sight-threatening problems such as corneal

neovascu-larization, thinning, ulceration, and perforation.16

Treating rhinophyma is difficult due to the technical

chal-lenges of producing a good cosmesis In Japan, almost all cases

are located to the lower half of the nose, which is treated by

full-thickness excision followed by application of either skin

grafts or direct closure.13 Laser therapy and dermabrasion,

a commonly used treatment in the US for rhinophyma, should

be used with caution in ethnic patients since risk of scarring

and pigment dyschromias are high

Special management & counseling considerations

Combination therapy with mild skin care products, vigilant

use of sunblock, and maintenance medical therapy as well as

vascular lasers may optimize treatment results As discussed,

care must be taken to avoid irritant contact dermatitis and

1 Acneiform Disorders • Hidradenitis suppurativa

Hidradenitis

suppurativa

Hidradenitis suppurativa (HS) results from rupture of the hair

follicle into the surrounding dermis, which leads to

inflamma-tion and subsequent abscess formainflamma-tion.1 A familial form with

autosomal dominance inheritance has been described HS

occurs around puberty and women are three times more likely

to develop HS than men It is common in Europeans and

African-Americans

HS is a debilitating disease characterized by chronic

inflamed, swollen, painful nodules and sterile abscesses in

apocrine gland-bearing sites including the axillae, groin, and

inframmamary areas Over time, recurrent boils lead to a

hall-mark of the disease, draining sinus tracts, fistulae, and

subse-quent hypertrophic scars (Fig 1.9, Fig 1.10) Often patients

are afflicted with acne, pilonidal cysts, and scalp folliculitis,

giving rise to the term follicular occlusion triad.2 Exacerbating

factors include being overweight, cigarette use, and moisture

Several complications can occur including scarring,

contrac-ture at the sites of lesions, urethral or rectal fistulas, squamous

cell carcinomas, anemia secondary to chronic infection, and

lymphedema from chronic inflammation and scarring.3

Several treatments have been tried with varied success

Weight reduction, limiting friction and moisture from

sweat-ing by employsweat-ing maneuvers such as wearsweat-ing loose

undergar-ments, using absorbent powders, antiseptic soaps, and topical

aluminum chloride, are somewhat helpful In early lesions,

topical and intralesional corticosteroids or topical antibiotics

such as clindamycin have proven to be beneficial In acute

cases, oral antibiotics may be necessary as a short- or long-term

treatment option Culture of exudates often reveal

staphyloco-cci, streptocostaphyloco-cci, pseudomonas, and/or anaerobic bacteria

Female patients presenting with HS should be screened for

underlying polycystic ovary syndrome (PCOS) and insulin resistance In severe cases, the best results occur with radical excision with primary closure or grafts Although extensive surgery is usually considered the most effective curative therapy, there is little experience with this approach, with most being reports from European studies An alternative has been the use of ablative laser treatment with secondary intention healing or radiation treatment Systemic retinoids may reduce flares but have not been a reliable cure Acitretin may have better results as compared to isotretinoin Systemic cortico-steroids often lead to dramatic improvement but results are not sustained upon discontinuation Topical antibacterials containing benzoyl peroxide may be helpful to prevent or diminish relapses Individual lesions are slow to heal, usually with drainage of pus Remissions may last months to years and recurrences are common with progressive scarring and sinus tracts

clin-Combination therapy with clindamycin and rifampicin for hidradenitis suppurativa: a series of 116 consecutive patients

Gener G, Canoui-Poitrine F, Revuz JE, Faye O, Poli F, Gabison

Figure 1 9: Severe hidradenitis supparativa (Courtesy of Dave Adams MD,

Department of Dermatology, Penn State Milton S Hershey Medical Center)

Figure 1 10: Hidradenitis supparativa affecting the axilla (Courtesy of Dave Adams

MD; Department of Dermatology, Penn State Milton S Hershey Medical Center)