Acne

ISTANBUL, TURKEY – Azelaic acid 15% gel constitutes an effective and well-tolerated treatment option for women with adult acne, according to the findings of an investigator-blinded, 9-month, randomized clinical trial.

The results showed azelaic acid 15% gel was similar in effectiveness to adapalene 0.1% gel, a widely prescribed treatment for this common condition, Dr. Anja Thielitz reported at the annual congress of the European Academy of Dermatology and Venereology.

However, azelaic acid 15% gel had a clear advantage in terms of tolerability. Median scores for skin redness, dryness, and scaling were significantly lower in the azelaic acid–treated group, added Dr. Thielitz of Otto von Guericke University in Magdeburg, Germany.

The single-center study involved 55 women aged 18-45 years, all with mild to moderate adult acne. They were randomized to one of three study arms: azelaic acid 15% gel twice daily for 9 months; adapalene 0.1% gel once daily, or 3 months of twice-daily azelaic acid 15% gel followed by 6 months of observation with no treatment.

Inflammatory and noninflammatory acne lesion counts, microcomedones, acne grading scale scores, and Dermatology Life Quality Index scores improved similarly in all three groups after 3 months. For example, median total lesion counts decreased from approximately 50 to 20, and median scores on the Leeds revised acne grading system dropped from 4 to roughly 2.5. Similar degrees of additional improvement were seen during months 4-9 in the two groups who remained on active treatment.

In contrast, some backsliding – although less than Dr. Thielitz had anticipated occurred during the untreated observation period among patients who halted the azelaic acid 15% gel after 3 months. By month 9, their total lesion count was 31% greater than the group that stayed on the topical therapy for the full 9 months.

Of note, azelaic acid 15% gel is technically an off-label therapy for adult female acne. The medication’s approved indication is in treating mild to moderate rosacea.

Dr. Thielitz reported having no financial conflicts in this investigator-initiated randomized trial.

bjancin@frontlinemedcom.com

ISTANBUL, TURKEY – Azelaic acid 15% gel constitutes an effective and well-tolerated treatment option for women with adult acne, according to the findings of an investigator-blinded, 9-month, randomized clinical trial.

The results showed azelaic acid 15% gel was similar in effectiveness to adapalene 0.1% gel, a widely prescribed treatment for this common condition, Dr. Anja Thielitz reported at the annual congress of the European Academy of Dermatology and Venereology.

However, azelaic acid 15% gel had a clear advantage in terms of tolerability. Median scores for skin redness, dryness, and scaling were significantly lower in the azelaic acid–treated group, added Dr. Thielitz of Otto von Guericke University in Magdeburg, Germany.

The single-center study involved 55 women aged 18-45 years, all with mild to moderate adult acne. They were randomized to one of three study arms: azelaic acid 15% gel twice daily for 9 months; adapalene 0.1% gel once daily, or 3 months of twice-daily azelaic acid 15% gel followed by 6 months of observation with no treatment.

Inflammatory and noninflammatory acne lesion counts, microcomedones, acne grading scale scores, and Dermatology Life Quality Index scores improved similarly in all three groups after 3 months. For example, median total lesion counts decreased from approximately 50 to 20, and median scores on the Leeds revised acne grading system dropped from 4 to roughly 2.5. Similar degrees of additional improvement were seen during months 4-9 in the two groups who remained on active treatment.

In contrast, some backsliding – although less than Dr. Thielitz had anticipated occurred during the untreated observation period among patients who halted the azelaic acid 15% gel after 3 months. By month 9, their total lesion count was 31% greater than the group that stayed on the topical therapy for the full 9 months.

Of note, azelaic acid 15% gel is technically an off-label therapy for adult female acne. The medication’s approved indication is in treating mild to moderate rosacea.

Dr. Thielitz reported having no financial conflicts in this investigator-initiated randomized trial.

bjancin@frontlinemedcom.com

ISTANBUL, TURKEY – Azelaic acid 15% gel constitutes an effective and well-tolerated treatment option for women with adult acne, according to the findings of an investigator-blinded, 9-month, randomized clinical trial.

The results showed azelaic acid 15% gel was similar in effectiveness to adapalene 0.1% gel, a widely prescribed treatment for this common condition, Dr. Anja Thielitz reported at the annual congress of the European Academy of Dermatology and Venereology.

However, azelaic acid 15% gel had a clear advantage in terms of tolerability. Median scores for skin redness, dryness, and scaling were significantly lower in the azelaic acid–treated group, added Dr. Thielitz of Otto von Guericke University in Magdeburg, Germany.

The single-center study involved 55 women aged 18-45 years, all with mild to moderate adult acne. They were randomized to one of three study arms: azelaic acid 15% gel twice daily for 9 months; adapalene 0.1% gel once daily, or 3 months of twice-daily azelaic acid 15% gel followed by 6 months of observation with no treatment.

Inflammatory and noninflammatory acne lesion counts, microcomedones, acne grading scale scores, and Dermatology Life Quality Index scores improved similarly in all three groups after 3 months. For example, median total lesion counts decreased from approximately 50 to 20, and median scores on the Leeds revised acne grading system dropped from 4 to roughly 2.5. Similar degrees of additional improvement were seen during months 4-9 in the two groups who remained on active treatment.

In contrast, some backsliding – although less than Dr. Thielitz had anticipated occurred during the untreated observation period among patients who halted the azelaic acid 15% gel after 3 months. By month 9, their total lesion count was 31% greater than the group that stayed on the topical therapy for the full 9 months.

Of note, azelaic acid 15% gel is technically an off-label therapy for adult female acne. The medication’s approved indication is in treating mild to moderate rosacea.

Dr. Thielitz reported having no financial conflicts in this investigator-initiated randomized trial.

bjancin@frontlinemedcom.com

Botox Cosmetic

Allergan, Inc, obtains US Food and Drug Administration approval of Botox Cosmetic (onabotulinumtoxinA) for temporary improvement of moderate to severe lateral canthal lines (crow’s-feet) in adults. It blocks nerve impulses and reduces muscle movements around the eyes. This indication will allow physicians to treat both crow’s-feet and frown lines (approved in 2002 for this latter indication) with little downtime for patients. For more information, visit www.allergan.com.

Fabior Foam 0.1%

Stiefel, a GSK company, receives US Food and Drug Administration approval of Fabior (tazarotene) Foam 0.1% for the treatment of acne vulgaris in patients 12 years and older. Fabior Foam is applied once daily before bedtime. For more information, visit www.fabiorfoam.com.

NIA24 Intensive Retinol Repair

Niadyne, Inc, introduces NIA24 Intensive Retinol Repair for photodamage. It targets the major signs of UV damage including wrinkles, hyperpigmentation, lack of firmness, and uneven texture and tone. Formulated with ProNiacin and retinol, NIA24 Intensive Retinol Repair strengthens the skin barrier and increases collagen. It is an alternative for patients who cannot tolerate retinoic acid or traditional retinol treatments. A prescription is not required, and it can be applied daily. For more information, visit www.NIA24.com.

Stelara

Janssen Biotech Inc obtains US Food and Drug Administration approval of Stelara (ustekinumab) to treat patients with active psoriatic arthritis, alone or in combination with methotrexate. Stelara targets the cytokines IL-12 and IL-23 to control joint pain, swelling, and stiffness associated with psoriatic arthritis, in addition to psoriasis plaque thickness, scaling, and redness. Stelara is administered every 12 weeks after 2 starter doses for the treatment of psoriatic arthritis. For more information, visit www.stelarainfo.com.

XTRAC Velocity 7

PhotoMedex Inc introduces XTRAC Velocity 7 with an advanced user interface for psoriasis and vitiligo. Using UVB light, the XTRAC excimer laser treats areas of the skin affected by psoriasis or vitiligo without harming the surrounding tissue. XTRAC Velocity 7 offers increased efficiency, with the rate of output increasing the speed for delivery of treatment. Treatment guidelines and suggestions based on body area are provided using the touch screen. It can be used on hard-to-reach areas such as the elbows, knees, and scalp. Before and after photographs can be stored to show progression of resolution, enhancing patient compliance. The manufacturer also offers a patient advocacy program for patients to call and obtain answers to product and insurance questions from a live operator; patients also can book appointments with a participating physician faster using the XTRAC TeleCare Center. For more information, visit www.xtracnow.com

Botox Cosmetic

Allergan, Inc, obtains US Food and Drug Administration approval of Botox Cosmetic (onabotulinumtoxinA) for temporary improvement of moderate to severe lateral canthal lines (crow’s-feet) in adults. It blocks nerve impulses and reduces muscle movements around the eyes. This indication will allow physicians to treat both crow’s-feet and frown lines (approved in 2002 for this latter indication) with little downtime for patients. For more information, visit www.allergan.com.

Fabior Foam 0.1%

Stiefel, a GSK company, receives US Food and Drug Administration approval of Fabior (tazarotene) Foam 0.1% for the treatment of acne vulgaris in patients 12 years and older. Fabior Foam is applied once daily before bedtime. For more information, visit www.fabiorfoam.com.

NIA24 Intensive Retinol Repair

Niadyne, Inc, introduces NIA24 Intensive Retinol Repair for photodamage. It targets the major signs of UV damage including wrinkles, hyperpigmentation, lack of firmness, and uneven texture and tone. Formulated with ProNiacin and retinol, NIA24 Intensive Retinol Repair strengthens the skin barrier and increases collagen. It is an alternative for patients who cannot tolerate retinoic acid or traditional retinol treatments. A prescription is not required, and it can be applied daily. For more information, visit www.NIA24.com.

Stelara

Janssen Biotech Inc obtains US Food and Drug Administration approval of Stelara (ustekinumab) to treat patients with active psoriatic arthritis, alone or in combination with methotrexate. Stelara targets the cytokines IL-12 and IL-23 to control joint pain, swelling, and stiffness associated with psoriatic arthritis, in addition to psoriasis plaque thickness, scaling, and redness. Stelara is administered every 12 weeks after 2 starter doses for the treatment of psoriatic arthritis. For more information, visit www.stelarainfo.com.

XTRAC Velocity 7

PhotoMedex Inc introduces XTRAC Velocity 7 with an advanced user interface for psoriasis and vitiligo. Using UVB light, the XTRAC excimer laser treats areas of the skin affected by psoriasis or vitiligo without harming the surrounding tissue. XTRAC Velocity 7 offers increased efficiency, with the rate of output increasing the speed for delivery of treatment. Treatment guidelines and suggestions based on body area are provided using the touch screen. It can be used on hard-to-reach areas such as the elbows, knees, and scalp. Before and after photographs can be stored to show progression of resolution, enhancing patient compliance. The manufacturer also offers a patient advocacy program for patients to call and obtain answers to product and insurance questions from a live operator; patients also can book appointments with a participating physician faster using the XTRAC TeleCare Center. For more information, visit www.xtracnow.com

Botox Cosmetic

Allergan, Inc, obtains US Food and Drug Administration approval of Botox Cosmetic (onabotulinumtoxinA) for temporary improvement of moderate to severe lateral canthal lines (crow’s-feet) in adults. It blocks nerve impulses and reduces muscle movements around the eyes. This indication will allow physicians to treat both crow’s-feet and frown lines (approved in 2002 for this latter indication) with little downtime for patients. For more information, visit www.allergan.com.

Fabior Foam 0.1%

Stiefel, a GSK company, receives US Food and Drug Administration approval of Fabior (tazarotene) Foam 0.1% for the treatment of acne vulgaris in patients 12 years and older. Fabior Foam is applied once daily before bedtime. For more information, visit www.fabiorfoam.com.

NIA24 Intensive Retinol Repair

Niadyne, Inc, introduces NIA24 Intensive Retinol Repair for photodamage. It targets the major signs of UV damage including wrinkles, hyperpigmentation, lack of firmness, and uneven texture and tone. Formulated with ProNiacin and retinol, NIA24 Intensive Retinol Repair strengthens the skin barrier and increases collagen. It is an alternative for patients who cannot tolerate retinoic acid or traditional retinol treatments. A prescription is not required, and it can be applied daily. For more information, visit www.NIA24.com.

Stelara

Janssen Biotech Inc obtains US Food and Drug Administration approval of Stelara (ustekinumab) to treat patients with active psoriatic arthritis, alone or in combination with methotrexate. Stelara targets the cytokines IL-12 and IL-23 to control joint pain, swelling, and stiffness associated with psoriatic arthritis, in addition to psoriasis plaque thickness, scaling, and redness. Stelara is administered every 12 weeks after 2 starter doses for the treatment of psoriatic arthritis. For more information, visit www.stelarainfo.com.

XTRAC Velocity 7

PhotoMedex Inc introduces XTRAC Velocity 7 with an advanced user interface for psoriasis and vitiligo. Using UVB light, the XTRAC excimer laser treats areas of the skin affected by psoriasis or vitiligo without harming the surrounding tissue. XTRAC Velocity 7 offers increased efficiency, with the rate of output increasing the speed for delivery of treatment. Treatment guidelines and suggestions based on body area are provided using the touch screen. It can be used on hard-to-reach areas such as the elbows, knees, and scalp. Before and after photographs can be stored to show progression of resolution, enhancing patient compliance. The manufacturer also offers a patient advocacy program for patients to call and obtain answers to product and insurance questions from a live operator; patients also can book appointments with a participating physician faster using the XTRAC TeleCare Center. For more information, visit www.xtracnow.com

NEW YORK – In May 2013, the American Acne and Rosacea Society, with the endorsement of the American Academy of Pediatrics, published evidence-based recommendations for the diagnosis and treatment of pediatric acne that incorporated mid-childhood acne, which is a sign of hyperandrogenism that must be worked up.

The guidelines "are a great reference for you for treatment algorithms and an excellent resource for treating pediatric acne," Dr. Andrea L. Zaenglein said during a presentation at the American Academy of Dermatology’s summer meeting.

Dr. Zaenglein provided a brief, but detailed summary of the classifications during her presentation, and offered some tips and practice pearls along the way.

Neonatal acne

This acne occurs in less than 20% of healthy infants who are between 2 weeks and 3 months old, and it presents in the form of papules and pustules. This common eruption rarely needs treatment, but clinicians can prescribe a topical antifungal, such as 2% ketoconazole cream, if pressed by the parents, Dr. Zaenglein noted.

Infantile acne

Unlike neonatal acne, this condition is true acne, said Dr. Zaenglein, professor of dermatology and pediatrics at Penn State/Hershey (Penn.) Medical Center. The acne, which usually presents as comedones, occurs between 3 and 6 months of age and lasts for about 1-2 years. This form of acne is usually caused by increased adrenal production of DHA, or dehydroepiandrosterone, and in boys, increased testicular androgens.

"It’s a temporary problem and usually fixes itself," said Dr. Zaenglein. "Take a full history and make sure they don’t have any signs of an underlying cause for hyperandrogenism."

Data from retrospective studies have shown that family history plays an important role, and babies with infantile acne may be at a higher risk of developing adolescent acne.

"It’s important to treat infantile acne, because it can cause scarring," said Dr. Zaenglein. The treatment principles are the same as adolescent acne. "However, remember that babies are not little adults," she said. Do not use benzoyl peroxide wash, because it can get into babies’ eyes. Instead, prescribe leave-on formulations in form of creams at lower strengths (2.5%-5%). Topical retinoids should also be used, but in a gentler formulation. Oral erythromycin is another option for more severe inflammatory acne (30 mg-50 mg/kg per day divided two or three times a day), although it might cause an upset stomach. In that case, try azithromycin, she said.

Mid-childhood acne

This new acne classification presents between 1 and 7 years of age, and requires a full exam to assess secondary sexual characteristics. Always rule out hyperandrogen states, such as Cushing’s syndrome, congenital adrenal hyperplasia, premature adrenarche, and precocious puberty, or a hormone-producing tumor, said Dr. Zaenglein. Early adrenarche also can be a risk factor for polycystic ovary syndrome. "Follow these patients closely throughout the teenage years," she advised.

The work-up for this mid-childhood acne is extensive, she said. In addition to various hormones, look at bone age and the growth chart. "And if you’re not sure, send them to a pediatric endocrinologist," she recommended.

To treat these children, apply the same principles as adolescent acne, but know that adherence is typically an issue. "Simplify the regimen, and encourage the parents to get involved," Dr. Zaenglein said.

Preadolescent acne

Acne in preadolescents is becoming more common as puberty begins earlier worldwide, said Dr. Zaenglein. The acne can present as a result of early onset of adrenarche in girls around 6 or 7 years or age, and boys between ages 7 and 8, or earlier, depending on body mass index and race. Comedonal acne in particular could be the first sign of pubertal maturation in girls, "so make sure you follow these kids," Dr. Zaenglein advised.

Preadolescent acne commonly occurs in the T-zone, and it may be a predictor of severe acne in later years, she added.

Of note, pseudoacne can occur in the nasal creases, in the form of milia, comedones, or inflamed papules. However, these lesions are not really acne and can be associated with atopic dermatitis or other conditions, said Dr. Zaenglein. They can be treated with topical antibiotics, benzoyl peroxide, or comedone extraction, she said.

The treatment principles for adolescent acne apply to preadolescent acne as well, with some modifications, Dr. Zaenglein said. Try to simplify the routines to once-daily to improve adherence, and warn parents about benzoyl peroxide staining. Also, ask about the presence of permanent teeth before considering a tetracycline, since the therapy can stain the teeth, she noted. To help kids take the pills, use a favorite breakfast spread, she suggested.

Dr. Zaenglein added that hormonal therapies should be avoided within 3 years of menarche if possible.

Dr. Zaenglein is on the advisory board for Galderma, Valeant, and Promius; a speaker for Galderma; and involved in clinical trials with Galderma, Medicis, and Valeant.

nmiller@frontlinemedcom.com

On Twitter @NaseemSMiller

NEW YORK – In May 2013, the American Acne and Rosacea Society, with the endorsement of the American Academy of Pediatrics, published evidence-based recommendations for the diagnosis and treatment of pediatric acne that incorporated mid-childhood acne, which is a sign of hyperandrogenism that must be worked up.

The guidelines "are a great reference for you for treatment algorithms and an excellent resource for treating pediatric acne," Dr. Andrea L. Zaenglein said during a presentation at the American Academy of Dermatology’s summer meeting.

Dr. Zaenglein provided a brief, but detailed summary of the classifications during her presentation, and offered some tips and practice pearls along the way.

Neonatal acne

This acne occurs in less than 20% of healthy infants who are between 2 weeks and 3 months old, and it presents in the form of papules and pustules. This common eruption rarely needs treatment, but clinicians can prescribe a topical antifungal, such as 2% ketoconazole cream, if pressed by the parents, Dr. Zaenglein noted.

Infantile acne

Unlike neonatal acne, this condition is true acne, said Dr. Zaenglein, professor of dermatology and pediatrics at Penn State/Hershey (Penn.) Medical Center. The acne, which usually presents as comedones, occurs between 3 and 6 months of age and lasts for about 1-2 years. This form of acne is usually caused by increased adrenal production of DHA, or dehydroepiandrosterone, and in boys, increased testicular androgens.

"It’s a temporary problem and usually fixes itself," said Dr. Zaenglein. "Take a full history and make sure they don’t have any signs of an underlying cause for hyperandrogenism."

Data from retrospective studies have shown that family history plays an important role, and babies with infantile acne may be at a higher risk of developing adolescent acne.

"It’s important to treat infantile acne, because it can cause scarring," said Dr. Zaenglein. The treatment principles are the same as adolescent acne. "However, remember that babies are not little adults," she said. Do not use benzoyl peroxide wash, because it can get into babies’ eyes. Instead, prescribe leave-on formulations in form of creams at lower strengths (2.5%-5%). Topical retinoids should also be used, but in a gentler formulation. Oral erythromycin is another option for more severe inflammatory acne (30 mg-50 mg/kg per day divided two or three times a day), although it might cause an upset stomach. In that case, try azithromycin, she said.

Mid-childhood acne

This new acne classification presents between 1 and 7 years of age, and requires a full exam to assess secondary sexual characteristics. Always rule out hyperandrogen states, such as Cushing’s syndrome, congenital adrenal hyperplasia, premature adrenarche, and precocious puberty, or a hormone-producing tumor, said Dr. Zaenglein. Early adrenarche also can be a risk factor for polycystic ovary syndrome. "Follow these patients closely throughout the teenage years," she advised.

The work-up for this mid-childhood acne is extensive, she said. In addition to various hormones, look at bone age and the growth chart. "And if you’re not sure, send them to a pediatric endocrinologist," she recommended.

To treat these children, apply the same principles as adolescent acne, but know that adherence is typically an issue. "Simplify the regimen, and encourage the parents to get involved," Dr. Zaenglein said.

Preadolescent acne

Acne in preadolescents is becoming more common as puberty begins earlier worldwide, said Dr. Zaenglein. The acne can present as a result of early onset of adrenarche in girls around 6 or 7 years or age, and boys between ages 7 and 8, or earlier, depending on body mass index and race. Comedonal acne in particular could be the first sign of pubertal maturation in girls, "so make sure you follow these kids," Dr. Zaenglein advised.

Preadolescent acne commonly occurs in the T-zone, and it may be a predictor of severe acne in later years, she added.

Of note, pseudoacne can occur in the nasal creases, in the form of milia, comedones, or inflamed papules. However, these lesions are not really acne and can be associated with atopic dermatitis or other conditions, said Dr. Zaenglein. They can be treated with topical antibiotics, benzoyl peroxide, or comedone extraction, she said.

The treatment principles for adolescent acne apply to preadolescent acne as well, with some modifications, Dr. Zaenglein said. Try to simplify the routines to once-daily to improve adherence, and warn parents about benzoyl peroxide staining. Also, ask about the presence of permanent teeth before considering a tetracycline, since the therapy can stain the teeth, she noted. To help kids take the pills, use a favorite breakfast spread, she suggested.

Dr. Zaenglein added that hormonal therapies should be avoided within 3 years of menarche if possible.

Dr. Zaenglein is on the advisory board for Galderma, Valeant, and Promius; a speaker for Galderma; and involved in clinical trials with Galderma, Medicis, and Valeant.

nmiller@frontlinemedcom.com

On Twitter @NaseemSMiller

NEW YORK – In May 2013, the American Acne and Rosacea Society, with the endorsement of the American Academy of Pediatrics, published evidence-based recommendations for the diagnosis and treatment of pediatric acne that incorporated mid-childhood acne, which is a sign of hyperandrogenism that must be worked up.

The guidelines "are a great reference for you for treatment algorithms and an excellent resource for treating pediatric acne," Dr. Andrea L. Zaenglein said during a presentation at the American Academy of Dermatology’s summer meeting.

Dr. Zaenglein provided a brief, but detailed summary of the classifications during her presentation, and offered some tips and practice pearls along the way.

Neonatal acne

This acne occurs in less than 20% of healthy infants who are between 2 weeks and 3 months old, and it presents in the form of papules and pustules. This common eruption rarely needs treatment, but clinicians can prescribe a topical antifungal, such as 2% ketoconazole cream, if pressed by the parents, Dr. Zaenglein noted.

Infantile acne

Unlike neonatal acne, this condition is true acne, said Dr. Zaenglein, professor of dermatology and pediatrics at Penn State/Hershey (Penn.) Medical Center. The acne, which usually presents as comedones, occurs between 3 and 6 months of age and lasts for about 1-2 years. This form of acne is usually caused by increased adrenal production of DHA, or dehydroepiandrosterone, and in boys, increased testicular androgens.

"It’s a temporary problem and usually fixes itself," said Dr. Zaenglein. "Take a full history and make sure they don’t have any signs of an underlying cause for hyperandrogenism."

Data from retrospective studies have shown that family history plays an important role, and babies with infantile acne may be at a higher risk of developing adolescent acne.

"It’s important to treat infantile acne, because it can cause scarring," said Dr. Zaenglein. The treatment principles are the same as adolescent acne. "However, remember that babies are not little adults," she said. Do not use benzoyl peroxide wash, because it can get into babies’ eyes. Instead, prescribe leave-on formulations in form of creams at lower strengths (2.5%-5%). Topical retinoids should also be used, but in a gentler formulation. Oral erythromycin is another option for more severe inflammatory acne (30 mg-50 mg/kg per day divided two or three times a day), although it might cause an upset stomach. In that case, try azithromycin, she said.

Mid-childhood acne

This new acne classification presents between 1 and 7 years of age, and requires a full exam to assess secondary sexual characteristics. Always rule out hyperandrogen states, such as Cushing’s syndrome, congenital adrenal hyperplasia, premature adrenarche, and precocious puberty, or a hormone-producing tumor, said Dr. Zaenglein. Early adrenarche also can be a risk factor for polycystic ovary syndrome. "Follow these patients closely throughout the teenage years," she advised.

The work-up for this mid-childhood acne is extensive, she said. In addition to various hormones, look at bone age and the growth chart. "And if you’re not sure, send them to a pediatric endocrinologist," she recommended.

To treat these children, apply the same principles as adolescent acne, but know that adherence is typically an issue. "Simplify the regimen, and encourage the parents to get involved," Dr. Zaenglein said.

Preadolescent acne

Acne in preadolescents is becoming more common as puberty begins earlier worldwide, said Dr. Zaenglein. The acne can present as a result of early onset of adrenarche in girls around 6 or 7 years or age, and boys between ages 7 and 8, or earlier, depending on body mass index and race. Comedonal acne in particular could be the first sign of pubertal maturation in girls, "so make sure you follow these kids," Dr. Zaenglein advised.

Preadolescent acne commonly occurs in the T-zone, and it may be a predictor of severe acne in later years, she added.

Of note, pseudoacne can occur in the nasal creases, in the form of milia, comedones, or inflamed papules. However, these lesions are not really acne and can be associated with atopic dermatitis or other conditions, said Dr. Zaenglein. They can be treated with topical antibiotics, benzoyl peroxide, or comedone extraction, she said.

The treatment principles for adolescent acne apply to preadolescent acne as well, with some modifications, Dr. Zaenglein said. Try to simplify the routines to once-daily to improve adherence, and warn parents about benzoyl peroxide staining. Also, ask about the presence of permanent teeth before considering a tetracycline, since the therapy can stain the teeth, she noted. To help kids take the pills, use a favorite breakfast spread, she suggested.

Dr. Zaenglein added that hormonal therapies should be avoided within 3 years of menarche if possible.

Dr. Zaenglein is on the advisory board for Galderma, Valeant, and Promius; a speaker for Galderma; and involved in clinical trials with Galderma, Medicis, and Valeant.

nmiller@frontlinemedcom.com

On Twitter @NaseemSMiller

The issue of increasing antibiotic resistance has become a serious global threat. The World Health Organization proclaimed that World Health Day 2011 would be dedicated to a comprehensive consolidated strategy to prevent regression to a preantibiotic era when infections were the single leading causes of death. At the 2013 G8 summit, the health ministers of the 8 wealthiest nations in the world proclaimed that antibiotic resistance is the single biggest threat to health security facing the 21st century. In addition to the problem of resistance, the use of antibiotics can lead to long-lasting alterations in the gut flora, making posttraumatic septicemia due to enteric organisms difficult to manage. Antibiotic use also has been associated with the development of inflammatory bowel disease in a number of well-done studies. Acute antibiotic side effects have included dyschromia, photosensitivity, potential hepatic and/or renal dysfunction, gastrointestinal tract distress, and various cutaneous events ranging from morbilliform eruptions to hives and even toxic epidermal necrolysis. All of the foregoing begs for more rational, appropriate, and circumspect use of antibiotic medications by all health care providers.

If the preceding commentary didn’t catch your attention, perhaps the findings from a recent article published online in the British Journal of Dermatology will. In this thoughtful and comprehensive review, a meta-analysis was performed on 20 large-scale observational studies involving individuals aged 0 to 25 years, which assessed the impact of antibiotic exposure in utero or within the first year of life on the subsequent risk for developing eczema. Both cross-sectional and longitudinal studies demonstrated a consistently increased risk (odds ratio, 1.4) of developing atopic eczema associated with postnatal antibiotic exposure. In fact, this association was so reliable that a dose-response association could be determined, suggesting a 7% increased risk for eczema for each additional oral or parenteral antibiotic course received during the first year of life. Why this effect happens remains uncertain, but the association is clear.

What’s the issue?

Think about your use of antibiotics! Do you use open-ended and prolonged courses for acne, rosacea, hidradenitis suppurativa, dissecting cellulitis of the scalp, and other conditions in adults? Are you contributing to the ever-expanding pool of antibiotic-resistant microbes carried by the adult population? When you do utilize antibiotics, do you always verify the presence of infection by culture? Do you always obtain sensitivities on bacterial isolates? Do you explicitly admonish antibiotic recipients or their parents/guardians to finish the antibiotic course and not save or share? This recent article now makes concerns about antibiotic use early in life highly relevant. Do you treat impetigo, for example, with one of the several approved topical agents or still routinely administer oral antibiotics? How would you manage neonatal acne or furunculosis in a young child? This paper from the British Journal of Dermatology supplies us with yet another good reason to evaluate and refine our own prescribing habits when it comes to antibiotics.

We want to know your views! Tell us what you think.

The issue of increasing antibiotic resistance has become a serious global threat. The World Health Organization proclaimed that World Health Day 2011 would be dedicated to a comprehensive consolidated strategy to prevent regression to a preantibiotic era when infections were the single leading causes of death. At the 2013 G8 summit, the health ministers of the 8 wealthiest nations in the world proclaimed that antibiotic resistance is the single biggest threat to health security facing the 21st century. In addition to the problem of resistance, the use of antibiotics can lead to long-lasting alterations in the gut flora, making posttraumatic septicemia due to enteric organisms difficult to manage. Antibiotic use also has been associated with the development of inflammatory bowel disease in a number of well-done studies. Acute antibiotic side effects have included dyschromia, photosensitivity, potential hepatic and/or renal dysfunction, gastrointestinal tract distress, and various cutaneous events ranging from morbilliform eruptions to hives and even toxic epidermal necrolysis. All of the foregoing begs for more rational, appropriate, and circumspect use of antibiotic medications by all health care providers.

If the preceding commentary didn’t catch your attention, perhaps the findings from a recent article published online in the British Journal of Dermatology will. In this thoughtful and comprehensive review, a meta-analysis was performed on 20 large-scale observational studies involving individuals aged 0 to 25 years, which assessed the impact of antibiotic exposure in utero or within the first year of life on the subsequent risk for developing eczema. Both cross-sectional and longitudinal studies demonstrated a consistently increased risk (odds ratio, 1.4) of developing atopic eczema associated with postnatal antibiotic exposure. In fact, this association was so reliable that a dose-response association could be determined, suggesting a 7% increased risk for eczema for each additional oral or parenteral antibiotic course received during the first year of life. Why this effect happens remains uncertain, but the association is clear.

What’s the issue?

Think about your use of antibiotics! Do you use open-ended and prolonged courses for acne, rosacea, hidradenitis suppurativa, dissecting cellulitis of the scalp, and other conditions in adults? Are you contributing to the ever-expanding pool of antibiotic-resistant microbes carried by the adult population? When you do utilize antibiotics, do you always verify the presence of infection by culture? Do you always obtain sensitivities on bacterial isolates? Do you explicitly admonish antibiotic recipients or their parents/guardians to finish the antibiotic course and not save or share? This recent article now makes concerns about antibiotic use early in life highly relevant. Do you treat impetigo, for example, with one of the several approved topical agents or still routinely administer oral antibiotics? How would you manage neonatal acne or furunculosis in a young child? This paper from the British Journal of Dermatology supplies us with yet another good reason to evaluate and refine our own prescribing habits when it comes to antibiotics.

We want to know your views! Tell us what you think.

The issue of increasing antibiotic resistance has become a serious global threat. The World Health Organization proclaimed that World Health Day 2011 would be dedicated to a comprehensive consolidated strategy to prevent regression to a preantibiotic era when infections were the single leading causes of death. At the 2013 G8 summit, the health ministers of the 8 wealthiest nations in the world proclaimed that antibiotic resistance is the single biggest threat to health security facing the 21st century. In addition to the problem of resistance, the use of antibiotics can lead to long-lasting alterations in the gut flora, making posttraumatic septicemia due to enteric organisms difficult to manage. Antibiotic use also has been associated with the development of inflammatory bowel disease in a number of well-done studies. Acute antibiotic side effects have included dyschromia, photosensitivity, potential hepatic and/or renal dysfunction, gastrointestinal tract distress, and various cutaneous events ranging from morbilliform eruptions to hives and even toxic epidermal necrolysis. All of the foregoing begs for more rational, appropriate, and circumspect use of antibiotic medications by all health care providers.

If the preceding commentary didn’t catch your attention, perhaps the findings from a recent article published online in the British Journal of Dermatology will. In this thoughtful and comprehensive review, a meta-analysis was performed on 20 large-scale observational studies involving individuals aged 0 to 25 years, which assessed the impact of antibiotic exposure in utero or within the first year of life on the subsequent risk for developing eczema. Both cross-sectional and longitudinal studies demonstrated a consistently increased risk (odds ratio, 1.4) of developing atopic eczema associated with postnatal antibiotic exposure. In fact, this association was so reliable that a dose-response association could be determined, suggesting a 7% increased risk for eczema for each additional oral or parenteral antibiotic course received during the first year of life. Why this effect happens remains uncertain, but the association is clear.

What’s the issue?

Think about your use of antibiotics! Do you use open-ended and prolonged courses for acne, rosacea, hidradenitis suppurativa, dissecting cellulitis of the scalp, and other conditions in adults? Are you contributing to the ever-expanding pool of antibiotic-resistant microbes carried by the adult population? When you do utilize antibiotics, do you always verify the presence of infection by culture? Do you always obtain sensitivities on bacterial isolates? Do you explicitly admonish antibiotic recipients or their parents/guardians to finish the antibiotic course and not save or share? This recent article now makes concerns about antibiotic use early in life highly relevant. Do you treat impetigo, for example, with one of the several approved topical agents or still routinely administer oral antibiotics? How would you manage neonatal acne or furunculosis in a young child? This paper from the British Journal of Dermatology supplies us with yet another good reason to evaluate and refine our own prescribing habits when it comes to antibiotics.

We want to know your views! Tell us what you think.

To improve patient care and outcomes, leading dermatologists offered their recommendations on the top face washes. Consideration must be given to:

Cutis invites readers to send us their recommendations. Antiwrinkle treatments, men’s cosmetics, and facial moisturizers will be featured in upcoming editions of Cosmetic Corner Please e-mail your recommendation(s) to msteiger@frontlinemedcom.com.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on the top face washes. Consideration must be given to:

Cutis invites readers to send us their recommendations. Antiwrinkle treatments, men’s cosmetics, and facial moisturizers will be featured in upcoming editions of Cosmetic Corner Please e-mail your recommendation(s) to msteiger@frontlinemedcom.com.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on the top face washes. Consideration must be given to:

Cutis invites readers to send us their recommendations. Antiwrinkle treatments, men’s cosmetics, and facial moisturizers will be featured in upcoming editions of Cosmetic Corner Please e-mail your recommendation(s) to msteiger@frontlinemedcom.com.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

MILWAUKEE– Boosting cumulative isotretinoin doses above 220 mg/kg significantly reduced the risk of relapse without dramatically increasing side effects in patients with severe, treatment-resistant nodulocystic acne in a prospective, observational study.

During the 12-month study, 27% of patients who received more than 220 mg/kg and 47% of those who received less than 220 mg/kg had a relapse, defined as treatment with another prescription acne medicine (P = .029).

The number of patients needing retreatment with isotretinoin was similar in both groups (2 vs. 0; P = .31), Mr. Christopher Stamey reported at the annual meeting of the Society for Pediatric Dermatology.

He acknowledged that the dosing regimen in this study was considerably higher than in previous studies of isotretinoin, which support a cumulative dose of 120-150 mg/kg over conventional dosing of less than 100 mg/kg to decrease the risk of relapse/retrial.

Patrice Wendling/IMNG Medical Media

Low-dose regimens also have minimal rates of many side effects, but clinicians are becoming more comfortable giving higher doses, explained Mr. Stamey, a fourth-year medical student* and research fellow in dermatology at the University of North Carolina at Chapel Hill (UNC).

A study from a tertiary care center in the New York reported a 100% cure rate and significantly improved quality of life among 80 patients with nodulocystic acne, who were maintained on a cumulative dose of 290 mg/kg (average daily dose, 1.6 mg/kg per day) for an average of 178 days (Int. J. Dermatol. 2012;51:1123-30).

In the current 116-patient study, the average cumulative dose was 309.8 mg/kg in the high-dose group and 170.8 mg/kg in the low-dose group (P less than .000). The daily dose varied by patient and provider, but averaged 120-160 mg/day in the high-dose group, Mr. Stamey said.

Patients were started on 40 mg/day for the first month and then increased to greater than 1 mg/kg per day to avoid any kind of fulminant acne reaction that can occur with isotretinoin. Eventually, the dose was titrated and the patients in the high-dose group were maintained on 1.5-2 mg/kg per day.

In the low-dose group, treated at a cumulative dose less than 220 mg/kg, patients were given 30 mg twice per day.

Treatment duration was significantly longer in the high-dose group compared with the low-dose group (6.5 vs. 5.8 months).

During a discussion of the study at the meeting, concerns were raised about the dosing and the ability to maintain children who are highly inflammatory on such a high daily dose. By initiating the medication at a dose less than 1 mg/kg per day for the first month, brisk inflammatory reactions were avoided, Mr. Stamey said. No patient in the high-dose group had to discontinue isotretinoin for an inflammatory reaction, although two low-dose patients discontinued treatment for 1 month and 1 week, respectively, because of elevated triglycerides.

"The initiation of dosing was the most important aspect with regard to avoiding inflammatory reactions," Mr. Stamey said in an interview. "This is a general practice when using isotretinoin at UNC dermatology clinics."

Overall, the side effects were similar between the groups. Mr. Stamey said. Only retinoid dermatitis was significantly more common during high-dose treatment than lower-dose treatment (54% vs. 32%).

Laboratory abnormalities were slightly, but not significantly higher in the high-dose group. These values included aspartate aminotransferase greater than 90 U/L (6.41% vs. 0%), alanine aminotransferase greater than 105 U/L (1.3% vs. 0%), a total cholesterol level greater than 300 mg/dL (1.3% vs. 0%), and triglycerides greater than 300 mg/dL (11.5% vs. 5.3%).

No differences were observed in itching, muscle or joint aches, mood, or suicidal ideation, although 13.8% of all patients had nail changes, including paronychia in 7.8%, Mr. Stamey noted.

Three-fourths of the patient cohort were white, approximately half were female, and the average age in the high- and low-dose groups was 21 years and 18 years, respectively.

Mr. Stamey reported having no relevant financial disclosures.

*Correction, 7/26/2013: A previous version of this story misstated Mr. Stamey's position as resident. He is a medical student.

pwendling@frontlinemedcom.com

MILWAUKEE– Boosting cumulative isotretinoin doses above 220 mg/kg significantly reduced the risk of relapse without dramatically increasing side effects in patients with severe, treatment-resistant nodulocystic acne in a prospective, observational study.

During the 12-month study, 27% of patients who received more than 220 mg/kg and 47% of those who received less than 220 mg/kg had a relapse, defined as treatment with another prescription acne medicine (P = .029).

The number of patients needing retreatment with isotretinoin was similar in both groups (2 vs. 0; P = .31), Mr. Christopher Stamey reported at the annual meeting of the Society for Pediatric Dermatology.

He acknowledged that the dosing regimen in this study was considerably higher than in previous studies of isotretinoin, which support a cumulative dose of 120-150 mg/kg over conventional dosing of less than 100 mg/kg to decrease the risk of relapse/retrial.

Patrice Wendling/IMNG Medical Media

Low-dose regimens also have minimal rates of many side effects, but clinicians are becoming more comfortable giving higher doses, explained Mr. Stamey, a fourth-year medical student* and research fellow in dermatology at the University of North Carolina at Chapel Hill (UNC).

A study from a tertiary care center in the New York reported a 100% cure rate and significantly improved quality of life among 80 patients with nodulocystic acne, who were maintained on a cumulative dose of 290 mg/kg (average daily dose, 1.6 mg/kg per day) for an average of 178 days (Int. J. Dermatol. 2012;51:1123-30).

In the current 116-patient study, the average cumulative dose was 309.8 mg/kg in the high-dose group and 170.8 mg/kg in the low-dose group (P less than .000). The daily dose varied by patient and provider, but averaged 120-160 mg/day in the high-dose group, Mr. Stamey said.

Patients were started on 40 mg/day for the first month and then increased to greater than 1 mg/kg per day to avoid any kind of fulminant acne reaction that can occur with isotretinoin. Eventually, the dose was titrated and the patients in the high-dose group were maintained on 1.5-2 mg/kg per day.

In the low-dose group, treated at a cumulative dose less than 220 mg/kg, patients were given 30 mg twice per day.

Treatment duration was significantly longer in the high-dose group compared with the low-dose group (6.5 vs. 5.8 months).

During a discussion of the study at the meeting, concerns were raised about the dosing and the ability to maintain children who are highly inflammatory on such a high daily dose. By initiating the medication at a dose less than 1 mg/kg per day for the first month, brisk inflammatory reactions were avoided, Mr. Stamey said. No patient in the high-dose group had to discontinue isotretinoin for an inflammatory reaction, although two low-dose patients discontinued treatment for 1 month and 1 week, respectively, because of elevated triglycerides.

"The initiation of dosing was the most important aspect with regard to avoiding inflammatory reactions," Mr. Stamey said in an interview. "This is a general practice when using isotretinoin at UNC dermatology clinics."

Overall, the side effects were similar between the groups. Mr. Stamey said. Only retinoid dermatitis was significantly more common during high-dose treatment than lower-dose treatment (54% vs. 32%).

Laboratory abnormalities were slightly, but not significantly higher in the high-dose group. These values included aspartate aminotransferase greater than 90 U/L (6.41% vs. 0%), alanine aminotransferase greater than 105 U/L (1.3% vs. 0%), a total cholesterol level greater than 300 mg/dL (1.3% vs. 0%), and triglycerides greater than 300 mg/dL (11.5% vs. 5.3%).

No differences were observed in itching, muscle or joint aches, mood, or suicidal ideation, although 13.8% of all patients had nail changes, including paronychia in 7.8%, Mr. Stamey noted.

Three-fourths of the patient cohort were white, approximately half were female, and the average age in the high- and low-dose groups was 21 years and 18 years, respectively.

Mr. Stamey reported having no relevant financial disclosures.

*Correction, 7/26/2013: A previous version of this story misstated Mr. Stamey's position as resident. He is a medical student.

pwendling@frontlinemedcom.com

MILWAUKEE– Boosting cumulative isotretinoin doses above 220 mg/kg significantly reduced the risk of relapse without dramatically increasing side effects in patients with severe, treatment-resistant nodulocystic acne in a prospective, observational study.

During the 12-month study, 27% of patients who received more than 220 mg/kg and 47% of those who received less than 220 mg/kg had a relapse, defined as treatment with another prescription acne medicine (P = .029).

The number of patients needing retreatment with isotretinoin was similar in both groups (2 vs. 0; P = .31), Mr. Christopher Stamey reported at the annual meeting of the Society for Pediatric Dermatology.

He acknowledged that the dosing regimen in this study was considerably higher than in previous studies of isotretinoin, which support a cumulative dose of 120-150 mg/kg over conventional dosing of less than 100 mg/kg to decrease the risk of relapse/retrial.

Patrice Wendling/IMNG Medical Media

Low-dose regimens also have minimal rates of many side effects, but clinicians are becoming more comfortable giving higher doses, explained Mr. Stamey, a fourth-year medical student* and research fellow in dermatology at the University of North Carolina at Chapel Hill (UNC).

A study from a tertiary care center in the New York reported a 100% cure rate and significantly improved quality of life among 80 patients with nodulocystic acne, who were maintained on a cumulative dose of 290 mg/kg (average daily dose, 1.6 mg/kg per day) for an average of 178 days (Int. J. Dermatol. 2012;51:1123-30).

In the current 116-patient study, the average cumulative dose was 309.8 mg/kg in the high-dose group and 170.8 mg/kg in the low-dose group (P less than .000). The daily dose varied by patient and provider, but averaged 120-160 mg/day in the high-dose group, Mr. Stamey said.

Patients were started on 40 mg/day for the first month and then increased to greater than 1 mg/kg per day to avoid any kind of fulminant acne reaction that can occur with isotretinoin. Eventually, the dose was titrated and the patients in the high-dose group were maintained on 1.5-2 mg/kg per day.

In the low-dose group, treated at a cumulative dose less than 220 mg/kg, patients were given 30 mg twice per day.

Treatment duration was significantly longer in the high-dose group compared with the low-dose group (6.5 vs. 5.8 months).

During a discussion of the study at the meeting, concerns were raised about the dosing and the ability to maintain children who are highly inflammatory on such a high daily dose. By initiating the medication at a dose less than 1 mg/kg per day for the first month, brisk inflammatory reactions were avoided, Mr. Stamey said. No patient in the high-dose group had to discontinue isotretinoin for an inflammatory reaction, although two low-dose patients discontinued treatment for 1 month and 1 week, respectively, because of elevated triglycerides.

"The initiation of dosing was the most important aspect with regard to avoiding inflammatory reactions," Mr. Stamey said in an interview. "This is a general practice when using isotretinoin at UNC dermatology clinics."

Overall, the side effects were similar between the groups. Mr. Stamey said. Only retinoid dermatitis was significantly more common during high-dose treatment than lower-dose treatment (54% vs. 32%).

Laboratory abnormalities were slightly, but not significantly higher in the high-dose group. These values included aspartate aminotransferase greater than 90 U/L (6.41% vs. 0%), alanine aminotransferase greater than 105 U/L (1.3% vs. 0%), a total cholesterol level greater than 300 mg/dL (1.3% vs. 0%), and triglycerides greater than 300 mg/dL (11.5% vs. 5.3%).

No differences were observed in itching, muscle or joint aches, mood, or suicidal ideation, although 13.8% of all patients had nail changes, including paronychia in 7.8%, Mr. Stamey noted.

Three-fourths of the patient cohort were white, approximately half were female, and the average age in the high- and low-dose groups was 21 years and 18 years, respectively.

Mr. Stamey reported having no relevant financial disclosures.

*Correction, 7/26/2013: A previous version of this story misstated Mr. Stamey's position as resident. He is a medical student.

pwendling@frontlinemedcom.com