Acne: What’s New
Linda F. Stein Gold, MD*
Director of Dermatology Research
Henry Ford Health System
Acne vulgaris is one of the most prevalent skin conditions. Antibiotics, when considered, are most effective in combination with other therapies, and limited evidence suggests that submicrobial doses of antibiotics may improve acne without increasing the risk for antibiotic resistance. A small but significant risk for inflammatory bowel disease has also been identified in children treated with multiple courses of antibiotics. New topical agents are expanding therapeutic options for acne.
Semin Cutan Med Surg 35(supp6):S114-S116
© 2016 published by Frontline Medical Communications
Acne vulgaris; antibiotics; inflammatory bowel disease; topical therapy
Acne vulgaris affects a majority of young people worldwide and is one of the most prevalent skin conditions in the general population.1 A common approach to the treatment of moderate to severe acne is the use of antibiotics to target both Propionibacterium acnes and inflammation. However, the potential for antibiotic resistance is a serious consideration. According to the Centers for Disease Control and Prevention (CDC), at least 2 million Americans become infected with resistant bacteria each year, and 23,000 die as a result of these infections.2 What does the potential for antibiotic resistance mean for the treatment of acne?
Factors that affect the risk for the development of antibiotic resistance include the dose and duration of antibiotic treatment. Finding the most effective dose, frequency, and duration of administration for the treatment of acne could limit the risk for ineffective dosing or approaches that may increase the risk for the development of resistance.
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Rutgers, The State University of New Jersey and Global Academy for Medical Education. Rutgers, The State University of New Jersey is accredited by the ACCME to provide continuing medical education for physicians.
Rutgers, The State University of New Jersey designates this enduring material for a maximum of 2 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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This activity is awarded 2.33 contact hours. (60 minute CH)
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Method of Participation
Participants should read the CE information below, review the activity in its entirety, and complete the online post-test and evaluation. Upon completing this activity as designed and achieving a passing score on the post-test, you will be directed to a Web page that will allow you to receive your certificate of credit via e-mail or you may print it out at that time.
Research continues to expand our understanding of the pathophysiology and management of skin diseases and age-related skin damage. Based on this evidence, new pharmacologic agents and medical devices continue to be developed, researched, and approved for use in the United States. New evidence and therapies have been developed for acne vulgaris, rosacea, psoriasis, onychomycosis/tinea, and facial rejuvenation. Clinicians need to understand the safety and efficacy of these new therapies in specific patient types.
Acne vulgaris affects 40 to 50 million people in the United States, with a prevalence as high as 85% in teenagers. A wide range of effective treatment strategies are now available to manage acne vulgaris, and new agents continue to be developed, offering an enhanced range of options. Psoriasis is an inflammatory skin disease for which a variety of agents, including several tumor necrosis factor (TNF) inhibitors, are approved for treatment. Recently, the use of TNF inhibitors for pediatric psoriasis has been investigated, and new biosimilar agents are in late stages of development for psoriasis. Clinicians may be reluctant to use TNF inhibitors in children with psoriasis and do not yet have clinical experience with biosimilar agents.
Rosacea is a common chronic skin condition affecting the face, affecting approximately 14 million Americans. No cure exists for rosacea, but health care professionals have several options to treat the symptoms, including new agents to treat facial erythema and inflammation. The use of these agents requires an understanding of their safety and use in combination therapy. Onychomycosis and tinea pedis are common fungal infections affecting the nails and feet, respectively. Newly approved topical agents for onychomycosis and tinea have demonstrated high cure rates in clinical studies.
Among the most common cosmetic procedures performed in the United States are the use of botulinum toxin A, soft tissue fillers, and laser treatments. In the last decade, a multitude of new products and devices have been developed for these indications, including new soft tissue fillers and novel laser technologies. The increased availability of options also increases the challenge of selecting the most appropriate agent or combination of agents for each patien
By reading and studying this supplement, participants should be better able to:
- Integrate into daily practice evidence-based recommendations on new and emerging therapies for common and uncommon dermatologic diseases
- Implement updated strategies for managing acne, rosacea, and psoriasis
- Discuss the use of biologic agents in the treatment of adult and pediatric psoriasis
- Review the status of biosimilars for use in dermatology
- Incorporate the recent advances in the treatment of acne vulgaris
- Discuss the safety, efficacy, and dosing of antibiotics for acne vulgaris
- Analyze emerging treatments for tinea and onychomycosis
- Identify the considerations in the selection of appropriate filler agents for treating different areas of the face
- Compare and contrast the efficacy and safety of agents, devices, and techniques currently available in aesthetic and procedural dermatology
- Determine the appropriate nonsurgical techniques for facial rejuvenation
- Describe the appropriate use of neuromodulators in the treatment of the aging face.
Individuals in a position to control the content of this educational activity are required to disclose: 1) the existence of any relevant financial relationship with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients with the exemption of non-profit or government organizations and nonhealth care related companies, within the past 12 months; and 2) the identification of a commercial product/device that is unlabeled for use or an investigational use of a product/device not yet approved.
Joseph F. Fowler, Jr, MD
Consultant: Bayer Healthcare, Galderma Laboratories, L.P., GlaxoSmithKline, Johnson & Johnson, Medimetriks Pharmaceuticals, Inc., Ranbaxy Laboratories Ltd., SmartPractice Dermatology/Allergy, Valeant Pharmaceuticals North America LLC; Speakers Bureau: Galderma, SmartPractice, Valeant; Grant/Research Support: AbbVie Inc., Allergan, Inc., Amgen Inc., Anacor Pharmaceuticals, Inc., Bayer, Celgene Corporation, Centocor, Inc., Chugai Pharma USA, Inc., Dow Chemical Company, Eli Lilly and Company, Galderma, Genentech, Inc., Innovaderm Research Inc., Janssen Biotech, Inc., Johnson & Johnson, Merck & Co., Inc., Novartis Pharmaceuticals Corporation, Onset Dermatologics, LLC, Pfizer Inc., Precision Dermatology, Regeneron Pharmaceuticals, Inc., SmartPractice, Taisho Pharmaceutical Co., Ltd., Taro Pharmaceutical Industries Ltd., Valeant
Theodore Rosen, MD
Scientific Advisory Board: Anacor Pharmaceuticals, Inc., Merz Pharma North America Inc., Valeant
Jeffrey M. Sobell, MD
Grant/Research Support: Amgen, Celgene, Eli Lilly, Janssen, Merck, Novartis; Consultant: AbbVie, Amgen, Celgene, Eli Lilly, Janssen; Speakers Bureau: AbbVie, Amgen, Celgene, Janssen, Novartis
Nowell Solish, MD, FRCP(C)
Consultant/Grant/Research Support: Allergan, Galderma, Indeed Labs, Inc., Merz, Revance Therapeutics, Inc., Valeant
Linda F. Stein Gold, MD
Consultantand Scientific Advisory Board: Anacor, Bayer, Eli Lilly, Foamix Pharmaceuticals Inc., Galderma, LEO Pharma Inc., Medimetrix Pharmaceuticals, Inc., Novartis, Pfizer, Taro
Christopher B. Zachary, MBBS, FRCP
Consultant: Kythera Biopharmaceuticals, Inc., Sciton, Inc., Solta Medical; Scientific Advisory Board: Sciton and ZELTIQ Aesthetics, Inc.
In order to help ensure content objectivity, independence, and fair balance, and to ensure that the content is aligned with the interest of the public, CCOE has resolved all potential and real conflicts of interest through content review by a non-conflicted, qualified reviewer. This activity was peer-reviewed tor relevance, accuracy of content, and balance of presentation by: Jean Sines, RN, BSN, Staff Nurse, Department of Dermatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. Ms. Sines has no relevant financial relationships to disclose.
Field Testers: This activity was pilot-tested for time required by: Physicians: Brian Lee, MD, Sima Patel, DO, and Vijay Vanchinathan, MD. Nurses: Geraldine Bocchieri, RN, BSN, Kathleen Brown, LPN, and Stacy Johnson, RN. The field testers have no relevant financial relationships to disclose.
Rutgers, The State University of New Jersey: Tristan Nelsen, MNM, CMP, and Elizabeth Ward, MSJ, have no relevant financial relationships to disclose.
Global Academy for Medical Education Staff: Shirley V. Jones, MBA; Sylvia H. Reitman, MBA, DipEd; and Josh Kilbridge have no relevant financial relationships to disclose.
Off-Label/Investigational Use Disclosure
This activity discusses the off-label use of the following approved agents: adalimumab, cyclosporine ophthalmic emulsion, doxycycline, etanercept, fluconazole, isotretinoin, itraconazole, ketoconazole, methotrexate, minocycline (oral and foam), secukinumab, ustekinumab, and tumor necrosis factor inhibitors as a class.
Contact Information for Technical Questions
Please technical questions or concerns to Global Academy for Medical Education at 973-290-8225 or email [email protected].
This continuing medical education (CME/CE) supplement was developed from faculty presentations at the Skin Disease Education Foundation’s 40th Annual Hawaii Dermatology Seminar™, February 14-19, 2016. The Guest Editors/Faculty acknowledge the editorial assistance of Global Academy for Medical Education, LLC, and Josh Kilbridge, medical writer, in the development of this supplement. The manuscript was reviewed and approved by the Guest Editors as well as the Editors of Seminars in Cutaneous Medicine and Surgery for publication as a supplement to the journal. This activity was developed under the direction of the Faculty/Guest Editors, Global Academy for Medical Education, and Rutgers. The ideas and opinions expressed in this supplement are those of the Guest Editors and do not necessarily reflect the views of the supporters, Global Academy for Medical Education, Rutgers, or the Publisher.
Copyright © 2016 by Global Academy for Medical Education, LLC and Rutgers, The State University of New Jersey. All rights reserved. No part of this publication may be reproduced or transmitted in any form, by any means, without prior written permission of Global Academy for Medical Education and Rutgers. Global Academy for Medical Education and Rutgers will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein.
1. Bhate K, Williams HC. Epidemiology of acne vulgaris. Br J Dermatol. 2013;168:474-485.
2. Centers for Disease Control and Prevention. Antibiotic/Antimicrobial Resistance. 2016; http://www.cdc.gov/drugresistance/. Updated April 19, 2016. Accessed May 18, 2016.
3. Stewart DM, Torok HM, Weiss JS, Plott RT; Solodyn Phase 2 Study Group. Doseranging efficacy of new once-daily extended-release minocycline for acne vulgaris. Cutis. 2006;78(4 suppl):11-20.
4. Leyden JJ, Bruce S, Lee CS, et al. A randomized, phase 2, dose-ranging study in the treatment of moderate to severe inflammatory facial acne vulgaris with doxycycline calcium. J Drugs Dermatol. 2013;12:658-663.
5. Skidmore R, Kovach R, Walker C, et al. Effects of subantimicrobial-dose doxycycline in the treatment of moderate acne. Arch Dermatol. 2003;139:459-464.
6. Moore A, Ling M, Bucko A, Manna V, Rueda MJ. Efficacy and safety of subantimicrobial dose, modified-release doxycycline 40 mg versus doxycycline 100 mg versus placebo for the treatment of inflammatory lesions in moderate and severe acne: A randomized, double-blinded, controlled study. J Drugs Dermatol. 2015;14:581-586.
7. Stein Gold L, Cruz A, Eichenfield L, et al. Effective and safe combination therapy for severe acne vulgaris: A randomized, vehicle-controlled, double-blind study of adapalene 0.1%-benzoyl peroxide 2.5% fixed-dose combination gel with doxycycline hyclate 100 mg. Cutis. 2010;85:94-104.
8. Tan J, Stein Gold L, Schlessinger J, et al. Short-term combination therapy and long-term relapse prevention in the treatment of severe acne vulgaris. J Drugs Dermatol. 2012;11:174-180.
9. Leyden J, Thiboutot DM, Shalita AR, et al. Comparison of tazarotene and minocycline maintenance therapies in acne vulgaris: A multicenter, double-blind, randomized, parallel-group study. Arch Dermatol. 2006;142:605-612.
10. Margolis DJ, Fanelli M, Hoffstad O, Lewis JD. Potential association between the oral tetracycline class of antimicrobials used to treat acne and inflammatory bowel disease. Am J Gastroenterol. 2010;105:2610-2616.
11. Shaw SY, Blanchard JF, Bernstein CN. Association between the use of antibiotics and new diagnoses of Crohn’s disease and ulcerative colitis. Am J Gastroenterol. 2011;106:2133-2142.
12. Ungaro R, Bernstein CN, Gearry R, et al. Antibiotics associated with increased risk of new-onset Crohn’s disease but not ulcerative colitis: A meta-analysis. Am J Gastroenterol. 2014;109:1728-1738.
13. Kronman MP, Zaoutis TE, Haynes K, Feng R, Coffin SE. Antibiotic exposure and IBD development among children: A population-based cohort study. Pediatrics. 2012;130:e794-e803.
14. Stein Gold L, Shemer A, Sprecher E, Shiri Y. A phase 2 randomized trial of a new minocycline foam for the treatment of moderate-to-severe acne vulgaris. Presented at: 39th Annual Hawaii Dermatology Seminar; March 1-6, 2015; Kaua’I, HI.
15. Weiss J, Stein Gold L, Leoni M, Rueda MJ, Liu H, Tanghetti E. Customized single-agent therapy management of severe inflammatory acne: A randomized, double-blind, parallel-group, controlled study of a new treatment—Adapalene 0.3%-benzoyl peroxide 2.5% gel. J Drugs Dermatol. 2015;14:1427-1435.
16. Stein Gold L, et al. Efficacy and safety of once-daily dapsone gel 7.5% for treatment of adolescents and adults with acne vulgaris: First of two identically designed, large, multicenter, randomized, placebo-controlled trials. Presented at: Winter Clinical Dermatology Conference; January 15-20, 2016; Kauai, HI.
17. Pariser DM, Rich P, Cook-Bolden FE, Korotzer A. An aqueous gel fixed combination of clindamycin phosphate 1.2% and benzoyl peroxide 3.75% for the once-daily treatment of moderate to severe acne vulgaris. J Drugs Dermatol. 2014;13:1083-1089.
18. Qin M, Landriscina A, Rosen JM, et al. Nitric oxide-releasing nanoparticles prevent Propionibacterium acnes induced inflammation by both clearing the organism and inhibiting microbial stimulation of the innate immune response. J Invest Dermatol. 2015;135:2723-2731.
19. Niedbala W, Alves-Filho JC, Fukada SY, et al. Regulation of type 17 helper T-cell function by nitric oxide during inflammation. Proc Natl Acad Sci U S A. 2011;108:9220-9225.
20. Rico J, et al. Data on file. Novan, Inc. www.novantherapeutics.com. Accessed April 13, 2016.
21. Bissonnette R, et al. Early onset of action in a randomized, vehicle-controlled phase 2a study of DRM01, a novel topical sebum inhibitor, in subjects with acne vulgaris. Presented at: 24th European Academy of Dermatology and Venereology Congress. October 7-11, 2015; Copenhagen, Denmark.
22. Celasco G, Moro L, Bozzella R, et al. Biological profile of cortexolone 17α-propionate (CB-03-01), a new topical and peripherally selective androgen antagonist. Arzneimittelforschung. 2004;54:881-886.
23. Trifu V, Tiplica GS, Naumescu E, Zalupca L, Moro L, Celasco G. Cortexolone 17α-propionate 1% cream, a new potent antiandrogen for topical treatment of acne vulgaris. A pilot randomized, double-blind comparative study vs. placebo and tretinoin 0.05% cream. Br J Dermatol. 2011;165:177-183.
* Director of Dermatology Research, Henry Ford Health System, Detroit, Michigan
Publication of this CME/CE article was jointly provided by Rutgers, The State University of New Jersey, and Global Academy for Medical Education, LLC, with Skin Disease Education Foundation (SDEF) and is supported by educational grants from AbbVie Inc., Bayer Healthcare, Merz Pharma North America Inc., and Valeant Pharmaceuticals North America LLC.
Dr Stein Gold has received an honorarium for her participation in this activity. She acknowledges the editorial assistance of Josh Kilbridge, medical writer, and Global Academy for Medical Education in the development of this continuing medical education journal article.
Linda F. Stein Gold, MD: Consultant and Scientific Advisory Board: Anacor Pharmaceuticals, Inc., Bayer, Eli Lilly and Company, Foamix Pharmaceuticals Inc., Galderma Laboratories, L.P., LEO Pharma Inc., Medimetrix Pharmaceuticals, Inc., Novartis Pharmaceuticals Corporation, Pfizer Inc., Taro Pharmaceutical Industries Ltd.
Address reprint requests to: Linda F. Stein Gold, MD, 2360 Heronwood Drive, Bloomfield Hills, MI 48302; [email protected].