Acne

Several light devices based on red light–emitting diodes (LEDs) have made their way to the market in recent years. Although red light is not truly a cosmeceutical, it is a significant emerging adjuvant therapy that, like blue light, has been studied in comparison to and in conjunction with topical options primarily to treat acne. Of course, acne is the most common skin disorder prompting visits to the dermatologist, with an estimated 85% of adolescents affected, many into adulthood (J. Am. Acad. Dermatol. 2008;58:56-9).

This discussion will consider red light when used alone and when used in combination with blue light. Blue light is the most effective light to target Propionibacterium acnes (specifically at wavelengths of 407-420 nm). However, many devices are utilizing red light because it has a purported anti-inflammatory effect and penetrates deeper into the skin (Dermatol. Ther. 2005;18:253-66).

Erythrasma

Darras-Vercambre et al. evaluated the effects of red light for the treatment of erythrasma (a superficial skin infection provoked by Corynebacterium minutissimum) in 13 patients. One treatment (80 J/cm²) by red light (broadband, peak at 635 nm) without exogenous photosensitizing molecules was administered to each subject. Therapy was effective and well tolerated, with three patients experiencing complete recovery, and significant reduction of lesions in most other cases. The authors noted that the key to their study, given the absence of an exogenous photosensitizing agent, was capitalizing on the presence of porphyrins in the lesions. They concluded that the use of red light alone for this localized infection is easy and inexpensive, but that an optimal method has not yet been established (Photodermatol. Photoimmunol. Photomed. 2006;22:153-6).

Acne

In 2007, Na and Suh evaluated the efficacy of red light phototherapy with a portable device in 28 volunteers with mild to moderate acne in a split-face randomized trial. Phototherapy was performed twice daily for 15 minutes for a total of 8 weeks to one side of the face. The investigators concluded that red light phototherapy alone is an effective therapeutic option for acne, as they noted significant reductions in noninflammatory and inflammatory lesion counts on the treated side versus the untreated side, a drop from 3.9 to 1.9 in the visual analog scale on the treatment side, and significant disparities between the treatment and control sides after 8 weeks (Dermatol. Surg. 2007;33:1228-33, discussion 1233).

A 2006 article in the British Journal of Dermatology reported good clinical results from acne treatment with photodynamic therapy (PDT) using methyl aminolevulinate (MAL) and red light, but there were adverse side effects that prompted 7 of 19 subjects to discontinue the study (Br. J. Dermatol. 2006;154:969-76). In response to the study, Mavilia et al. wrote a letter to the journal acknowledging their more effective combination therapy using a lower concentration of MAL and low doses of red light. All 16 patients completed the study, in which the count of inflammatory lesions fell an average of 66% with mild but tolerable side effects, including a subtle sensation of heat, then minimal erythema during the procedure and slight scaling that began 3 days after treatment (Br. J. Dermatol. 2007;157:810-1).

In a small study of patients with moderate facial acne, Zane et al. exposed 15 women to 20 J/cm² of broadband red light (600-750 nm) twice weekly for 4 weeks. They also measured skin sebum, pH, hydration, and transepidermal water loss (TEWL). Untreated lesions of the trunk served as controls. The investigators found the treatment safe, well tolerated, and effective, with significant improvement in acne lesions and reduction of sebum excretion and TEWL after 4 weeks of therapy and at the 3-month follow-up visit. They speculated that the improvement was due to the decreased colonization of P. acnes, decimated by photoactivated endogenous porphyrin, and concluded that this inexpensive therapy warrants inclusion among treatment options for moderate acne (Photodermatol. Photoimmunol. Photomed. 2008;24:244-8).

In a 2009 study of 19 patients with moderate to severe facial acne who received a single treatment of low-dose, red-light PDT on the left cheek and MAL 3 hours before red light on the right cheek, both therapies yielded significant reductions in acne score. Red light was found to be as effective as MAL-PDT (Acta Derm. Venereol. 2009;89:372-8).

Combined Blue and Red Light Phototherapy

In 2006, Goldberg and Russell evaluated the combination of blue (415 nm) and red (633 nm) LED phototherapy in 24 patients with Fitzpatrick skin types II-V and mild to severe symmetric facial acne. Twenty-two patients completed the trial, which included two sessions per week (separated by 3 days) alternating between blue and red light for a total of eight sessions. Mild microdermabrasion was used at the start of each session. The mean decrease in lesion count was significant after 4 weeks (46%) and 12 weeks (81%). Inflammatory lesions responded better than did noninflammatory ones, and severe acne responded slightly better than mild acne. The investigators concluded that the combination of blue and red LED phototherapy is free of side effects and pain, and exhibits great potential for the treatment of mild to severe acne (J. Cosmet. Laser Ther. 2006;8:71-5).

In 2007, Lee et al. set out to examine the efficacy of combining blue and red LED phototherapy for acne in a study of 24 patients with mild to moderately severe facial acne. Twice weekly for 4 weeks, patients were treated with quasi-monochromatic LED devices, alternating blue (415 nm) and red (633 nm) light. Fourteen patients self-reported improvements in skin tone and texture. Improvements in noninflammatory and inflammatory lesions were substantial (34.28% and 77.93%, respectively). The researchers concluded that combined blue and red LED phototherapy is a safe and effective option, especially for papulopustular acne (Lasers Surg. Med. 2007;39:180-8).

In 2009, Sadick evaluated the efficacy of the combination of blue (415 nm) and near-infrared (830 nm) LED therapy for moderate acne in 13 females and 4 males ranging in skin type from II to VI and in Burton acne grade at baseline from 1 to 5. Twice-weekly 20-minute sessions were conducted for 4 weeks, alternating between blue and near-infrared light. Eleven patients exhibited improvement ranging from 0% to 83.3%, and 6 patients discontinued the study. A decreasing trend was observed in the Burton grade. Noninflammatory lesion counts improved in seven patients but increased in four. Sadick noted that these results paled in comparison to the effectiveness of the blue and red combination at lowering inflammatory lesions seen previously, but encouraged the study of the combination phototherapy in a much larger population (J. Cosmet. Laser Ther. 2009;11:125-8).

Several recent reviews have found that red light–activated MAL-PDT, the combination of blue and red light, and aminolevulinic acid as a photosensitizing agent before treatment with blue light, red light, or the 595-nm pulsed dye laser are among the most promising evidence-based laser- and light-based therapies for acne (Semin. Cutan. Med. Surg. 2008;27:207-11; J. Eur. Acad. Dermatol. Venereol. 2008;22:267-78; Dermatol. Surg. 2007;33:1005-26).

In a systematic literature review of randomized controlled trials of light and laser therapies for acne vulgaris (using the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PsycINFO, LILACS, ISI Science Citation Index, and Dissertation Abstracts International), Hamilton et al. found that trials of blue light, blue-red light, and infrared radiation were more successful, especially when multiple treatments were used. Notably, blue-red light demonstrated better short-term effectiveness than did topical 5% benzoyl peroxide cream (Br. J. Dermatol. 2009;160:1273-85).

Kim and Armstrong have noted that blue light has been demonstrated to photoinactivate P. acnes, but it does not penetrate deeply into the skin. It is believed to work synergistically, however, with red light, which is less effective than blue light at exciting porphyrins but can reach deeper sebaceous glands and may impart an anti-inflammatory effect by inciting cytokine release from macrophages (Dermatol. Surg. 2007;33:1005-26). Indeed, Kim and Armstrong found that combined blue-red light therapy was more effective at lowering the number of inflammatory acne lesions than were benzoyl peroxide monotherapy and blue light monotherapy (Lasers Surg. Med. 1989;9:497-505).

Conclusions

A lengthy review of the literature and personal experience treating patients have convinced me that blue light is an effective treatment for acne. P. acnes is most susceptible to the blue light wavelengths of 407-420 nm. Addition of red light may help speed resolution of inflammatory lesions through an anti-inflammatory effect. Blue and red light devices are efficacious when used in the office if the devices deliver enough joules.

Many at-home devices and iPhone apps have hit the market. These are a great alternative to irritating topicals and antibiotics, and they may help increase compliance. However, many at-home light devices are too weak (do not emit enough joules), or emit a broad range of light (rather than 407-420 nm). The manufacturers of some of these products claim that the heat produced by the devices improves acne, but there is a paucity of research proving this point. In my opinion, using an at-home device twice a day that delivers 407-420 nm (with or without the addition of red light), and delivers enough joules (at least 25 J/cm²), is an effective method of treating acne. For comparison purposes, the in-office Omnilux delivers around 49 J/cm² but is used only two or three times per week. Know your wavelengths and joules when trying to decide which device to sell in your practice or recommend to patients.

Several light devices based on red light–emitting diodes (LEDs) have made their way to the market in recent years. Although red light is not truly a cosmeceutical, it is a significant emerging adjuvant therapy that, like blue light, has been studied in comparison to and in conjunction with topical options primarily to treat acne. Of course, acne is the most common skin disorder prompting visits to the dermatologist, with an estimated 85% of adolescents affected, many into adulthood (J. Am. Acad. Dermatol. 2008;58:56-9).

This discussion will consider red light when used alone and when used in combination with blue light. Blue light is the most effective light to target Propionibacterium acnes (specifically at wavelengths of 407-420 nm). However, many devices are utilizing red light because it has a purported anti-inflammatory effect and penetrates deeper into the skin (Dermatol. Ther. 2005;18:253-66).

Erythrasma

Darras-Vercambre et al. evaluated the effects of red light for the treatment of erythrasma (a superficial skin infection provoked by Corynebacterium minutissimum) in 13 patients. One treatment (80 J/cm²) by red light (broadband, peak at 635 nm) without exogenous photosensitizing molecules was administered to each subject. Therapy was effective and well tolerated, with three patients experiencing complete recovery, and significant reduction of lesions in most other cases. The authors noted that the key to their study, given the absence of an exogenous photosensitizing agent, was capitalizing on the presence of porphyrins in the lesions. They concluded that the use of red light alone for this localized infection is easy and inexpensive, but that an optimal method has not yet been established (Photodermatol. Photoimmunol. Photomed. 2006;22:153-6).

Acne

In 2007, Na and Suh evaluated the efficacy of red light phototherapy with a portable device in 28 volunteers with mild to moderate acne in a split-face randomized trial. Phototherapy was performed twice daily for 15 minutes for a total of 8 weeks to one side of the face. The investigators concluded that red light phototherapy alone is an effective therapeutic option for acne, as they noted significant reductions in noninflammatory and inflammatory lesion counts on the treated side versus the untreated side, a drop from 3.9 to 1.9 in the visual analog scale on the treatment side, and significant disparities between the treatment and control sides after 8 weeks (Dermatol. Surg. 2007;33:1228-33, discussion 1233).

A 2006 article in the British Journal of Dermatology reported good clinical results from acne treatment with photodynamic therapy (PDT) using methyl aminolevulinate (MAL) and red light, but there were adverse side effects that prompted 7 of 19 subjects to discontinue the study (Br. J. Dermatol. 2006;154:969-76). In response to the study, Mavilia et al. wrote a letter to the journal acknowledging their more effective combination therapy using a lower concentration of MAL and low doses of red light. All 16 patients completed the study, in which the count of inflammatory lesions fell an average of 66% with mild but tolerable side effects, including a subtle sensation of heat, then minimal erythema during the procedure and slight scaling that began 3 days after treatment (Br. J. Dermatol. 2007;157:810-1).

In a small study of patients with moderate facial acne, Zane et al. exposed 15 women to 20 J/cm² of broadband red light (600-750 nm) twice weekly for 4 weeks. They also measured skin sebum, pH, hydration, and transepidermal water loss (TEWL). Untreated lesions of the trunk served as controls. The investigators found the treatment safe, well tolerated, and effective, with significant improvement in acne lesions and reduction of sebum excretion and TEWL after 4 weeks of therapy and at the 3-month follow-up visit. They speculated that the improvement was due to the decreased colonization of P. acnes, decimated by photoactivated endogenous porphyrin, and concluded that this inexpensive therapy warrants inclusion among treatment options for moderate acne (Photodermatol. Photoimmunol. Photomed. 2008;24:244-8).

In a 2009 study of 19 patients with moderate to severe facial acne who received a single treatment of low-dose, red-light PDT on the left cheek and MAL 3 hours before red light on the right cheek, both therapies yielded significant reductions in acne score. Red light was found to be as effective as MAL-PDT (Acta Derm. Venereol. 2009;89:372-8).

Combined Blue and Red Light Phototherapy

In 2006, Goldberg and Russell evaluated the combination of blue (415 nm) and red (633 nm) LED phototherapy in 24 patients with Fitzpatrick skin types II-V and mild to severe symmetric facial acne. Twenty-two patients completed the trial, which included two sessions per week (separated by 3 days) alternating between blue and red light for a total of eight sessions. Mild microdermabrasion was used at the start of each session. The mean decrease in lesion count was significant after 4 weeks (46%) and 12 weeks (81%). Inflammatory lesions responded better than did noninflammatory ones, and severe acne responded slightly better than mild acne. The investigators concluded that the combination of blue and red LED phototherapy is free of side effects and pain, and exhibits great potential for the treatment of mild to severe acne (J. Cosmet. Laser Ther. 2006;8:71-5).

In 2007, Lee et al. set out to examine the efficacy of combining blue and red LED phototherapy for acne in a study of 24 patients with mild to moderately severe facial acne. Twice weekly for 4 weeks, patients were treated with quasi-monochromatic LED devices, alternating blue (415 nm) and red (633 nm) light. Fourteen patients self-reported improvements in skin tone and texture. Improvements in noninflammatory and inflammatory lesions were substantial (34.28% and 77.93%, respectively). The researchers concluded that combined blue and red LED phototherapy is a safe and effective option, especially for papulopustular acne (Lasers Surg. Med. 2007;39:180-8).

In 2009, Sadick evaluated the efficacy of the combination of blue (415 nm) and near-infrared (830 nm) LED therapy for moderate acne in 13 females and 4 males ranging in skin type from II to VI and in Burton acne grade at baseline from 1 to 5. Twice-weekly 20-minute sessions were conducted for 4 weeks, alternating between blue and near-infrared light. Eleven patients exhibited improvement ranging from 0% to 83.3%, and 6 patients discontinued the study. A decreasing trend was observed in the Burton grade. Noninflammatory lesion counts improved in seven patients but increased in four. Sadick noted that these results paled in comparison to the effectiveness of the blue and red combination at lowering inflammatory lesions seen previously, but encouraged the study of the combination phototherapy in a much larger population (J. Cosmet. Laser Ther. 2009;11:125-8).

Several recent reviews have found that red light–activated MAL-PDT, the combination of blue and red light, and aminolevulinic acid as a photosensitizing agent before treatment with blue light, red light, or the 595-nm pulsed dye laser are among the most promising evidence-based laser- and light-based therapies for acne (Semin. Cutan. Med. Surg. 2008;27:207-11; J. Eur. Acad. Dermatol. Venereol. 2008;22:267-78; Dermatol. Surg. 2007;33:1005-26).

In a systematic literature review of randomized controlled trials of light and laser therapies for acne vulgaris (using the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PsycINFO, LILACS, ISI Science Citation Index, and Dissertation Abstracts International), Hamilton et al. found that trials of blue light, blue-red light, and infrared radiation were more successful, especially when multiple treatments were used. Notably, blue-red light demonstrated better short-term effectiveness than did topical 5% benzoyl peroxide cream (Br. J. Dermatol. 2009;160:1273-85).

Kim and Armstrong have noted that blue light has been demonstrated to photoinactivate P. acnes, but it does not penetrate deeply into the skin. It is believed to work synergistically, however, with red light, which is less effective than blue light at exciting porphyrins but can reach deeper sebaceous glands and may impart an anti-inflammatory effect by inciting cytokine release from macrophages (Dermatol. Surg. 2007;33:1005-26). Indeed, Kim and Armstrong found that combined blue-red light therapy was more effective at lowering the number of inflammatory acne lesions than were benzoyl peroxide monotherapy and blue light monotherapy (Lasers Surg. Med. 1989;9:497-505).

Conclusions

A lengthy review of the literature and personal experience treating patients have convinced me that blue light is an effective treatment for acne. P. acnes is most susceptible to the blue light wavelengths of 407-420 nm. Addition of red light may help speed resolution of inflammatory lesions through an anti-inflammatory effect. Blue and red light devices are efficacious when used in the office if the devices deliver enough joules.

Many at-home devices and iPhone apps have hit the market. These are a great alternative to irritating topicals and antibiotics, and they may help increase compliance. However, many at-home light devices are too weak (do not emit enough joules), or emit a broad range of light (rather than 407-420 nm). The manufacturers of some of these products claim that the heat produced by the devices improves acne, but there is a paucity of research proving this point. In my opinion, using an at-home device twice a day that delivers 407-420 nm (with or without the addition of red light), and delivers enough joules (at least 25 J/cm²), is an effective method of treating acne. For comparison purposes, the in-office Omnilux delivers around 49 J/cm² but is used only two or three times per week. Know your wavelengths and joules when trying to decide which device to sell in your practice or recommend to patients.

Several light devices based on red light–emitting diodes (LEDs) have made their way to the market in recent years. Although red light is not truly a cosmeceutical, it is a significant emerging adjuvant therapy that, like blue light, has been studied in comparison to and in conjunction with topical options primarily to treat acne. Of course, acne is the most common skin disorder prompting visits to the dermatologist, with an estimated 85% of adolescents affected, many into adulthood (J. Am. Acad. Dermatol. 2008;58:56-9).

This discussion will consider red light when used alone and when used in combination with blue light. Blue light is the most effective light to target Propionibacterium acnes (specifically at wavelengths of 407-420 nm). However, many devices are utilizing red light because it has a purported anti-inflammatory effect and penetrates deeper into the skin (Dermatol. Ther. 2005;18:253-66).

Erythrasma

Darras-Vercambre et al. evaluated the effects of red light for the treatment of erythrasma (a superficial skin infection provoked by Corynebacterium minutissimum) in 13 patients. One treatment (80 J/cm²) by red light (broadband, peak at 635 nm) without exogenous photosensitizing molecules was administered to each subject. Therapy was effective and well tolerated, with three patients experiencing complete recovery, and significant reduction of lesions in most other cases. The authors noted that the key to their study, given the absence of an exogenous photosensitizing agent, was capitalizing on the presence of porphyrins in the lesions. They concluded that the use of red light alone for this localized infection is easy and inexpensive, but that an optimal method has not yet been established (Photodermatol. Photoimmunol. Photomed. 2006;22:153-6).

Acne

In 2007, Na and Suh evaluated the efficacy of red light phototherapy with a portable device in 28 volunteers with mild to moderate acne in a split-face randomized trial. Phototherapy was performed twice daily for 15 minutes for a total of 8 weeks to one side of the face. The investigators concluded that red light phototherapy alone is an effective therapeutic option for acne, as they noted significant reductions in noninflammatory and inflammatory lesion counts on the treated side versus the untreated side, a drop from 3.9 to 1.9 in the visual analog scale on the treatment side, and significant disparities between the treatment and control sides after 8 weeks (Dermatol. Surg. 2007;33:1228-33, discussion 1233).

A 2006 article in the British Journal of Dermatology reported good clinical results from acne treatment with photodynamic therapy (PDT) using methyl aminolevulinate (MAL) and red light, but there were adverse side effects that prompted 7 of 19 subjects to discontinue the study (Br. J. Dermatol. 2006;154:969-76). In response to the study, Mavilia et al. wrote a letter to the journal acknowledging their more effective combination therapy using a lower concentration of MAL and low doses of red light. All 16 patients completed the study, in which the count of inflammatory lesions fell an average of 66% with mild but tolerable side effects, including a subtle sensation of heat, then minimal erythema during the procedure and slight scaling that began 3 days after treatment (Br. J. Dermatol. 2007;157:810-1).

In a small study of patients with moderate facial acne, Zane et al. exposed 15 women to 20 J/cm² of broadband red light (600-750 nm) twice weekly for 4 weeks. They also measured skin sebum, pH, hydration, and transepidermal water loss (TEWL). Untreated lesions of the trunk served as controls. The investigators found the treatment safe, well tolerated, and effective, with significant improvement in acne lesions and reduction of sebum excretion and TEWL after 4 weeks of therapy and at the 3-month follow-up visit. They speculated that the improvement was due to the decreased colonization of P. acnes, decimated by photoactivated endogenous porphyrin, and concluded that this inexpensive therapy warrants inclusion among treatment options for moderate acne (Photodermatol. Photoimmunol. Photomed. 2008;24:244-8).

In a 2009 study of 19 patients with moderate to severe facial acne who received a single treatment of low-dose, red-light PDT on the left cheek and MAL 3 hours before red light on the right cheek, both therapies yielded significant reductions in acne score. Red light was found to be as effective as MAL-PDT (Acta Derm. Venereol. 2009;89:372-8).

Combined Blue and Red Light Phototherapy

In 2006, Goldberg and Russell evaluated the combination of blue (415 nm) and red (633 nm) LED phototherapy in 24 patients with Fitzpatrick skin types II-V and mild to severe symmetric facial acne. Twenty-two patients completed the trial, which included two sessions per week (separated by 3 days) alternating between blue and red light for a total of eight sessions. Mild microdermabrasion was used at the start of each session. The mean decrease in lesion count was significant after 4 weeks (46%) and 12 weeks (81%). Inflammatory lesions responded better than did noninflammatory ones, and severe acne responded slightly better than mild acne. The investigators concluded that the combination of blue and red LED phototherapy is free of side effects and pain, and exhibits great potential for the treatment of mild to severe acne (J. Cosmet. Laser Ther. 2006;8:71-5).

In 2007, Lee et al. set out to examine the efficacy of combining blue and red LED phototherapy for acne in a study of 24 patients with mild to moderately severe facial acne. Twice weekly for 4 weeks, patients were treated with quasi-monochromatic LED devices, alternating blue (415 nm) and red (633 nm) light. Fourteen patients self-reported improvements in skin tone and texture. Improvements in noninflammatory and inflammatory lesions were substantial (34.28% and 77.93%, respectively). The researchers concluded that combined blue and red LED phototherapy is a safe and effective option, especially for papulopustular acne (Lasers Surg. Med. 2007;39:180-8).

In 2009, Sadick evaluated the efficacy of the combination of blue (415 nm) and near-infrared (830 nm) LED therapy for moderate acne in 13 females and 4 males ranging in skin type from II to VI and in Burton acne grade at baseline from 1 to 5. Twice-weekly 20-minute sessions were conducted for 4 weeks, alternating between blue and near-infrared light. Eleven patients exhibited improvement ranging from 0% to 83.3%, and 6 patients discontinued the study. A decreasing trend was observed in the Burton grade. Noninflammatory lesion counts improved in seven patients but increased in four. Sadick noted that these results paled in comparison to the effectiveness of the blue and red combination at lowering inflammatory lesions seen previously, but encouraged the study of the combination phototherapy in a much larger population (J. Cosmet. Laser Ther. 2009;11:125-8).

Several recent reviews have found that red light–activated MAL-PDT, the combination of blue and red light, and aminolevulinic acid as a photosensitizing agent before treatment with blue light, red light, or the 595-nm pulsed dye laser are among the most promising evidence-based laser- and light-based therapies for acne (Semin. Cutan. Med. Surg. 2008;27:207-11; J. Eur. Acad. Dermatol. Venereol. 2008;22:267-78; Dermatol. Surg. 2007;33:1005-26).

In a systematic literature review of randomized controlled trials of light and laser therapies for acne vulgaris (using the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PsycINFO, LILACS, ISI Science Citation Index, and Dissertation Abstracts International), Hamilton et al. found that trials of blue light, blue-red light, and infrared radiation were more successful, especially when multiple treatments were used. Notably, blue-red light demonstrated better short-term effectiveness than did topical 5% benzoyl peroxide cream (Br. J. Dermatol. 2009;160:1273-85).

Kim and Armstrong have noted that blue light has been demonstrated to photoinactivate P. acnes, but it does not penetrate deeply into the skin. It is believed to work synergistically, however, with red light, which is less effective than blue light at exciting porphyrins but can reach deeper sebaceous glands and may impart an anti-inflammatory effect by inciting cytokine release from macrophages (Dermatol. Surg. 2007;33:1005-26). Indeed, Kim and Armstrong found that combined blue-red light therapy was more effective at lowering the number of inflammatory acne lesions than were benzoyl peroxide monotherapy and blue light monotherapy (Lasers Surg. Med. 1989;9:497-505).

Conclusions

A lengthy review of the literature and personal experience treating patients have convinced me that blue light is an effective treatment for acne. P. acnes is most susceptible to the blue light wavelengths of 407-420 nm. Addition of red light may help speed resolution of inflammatory lesions through an anti-inflammatory effect. Blue and red light devices are efficacious when used in the office if the devices deliver enough joules.

Many at-home devices and iPhone apps have hit the market. These are a great alternative to irritating topicals and antibiotics, and they may help increase compliance. However, many at-home light devices are too weak (do not emit enough joules), or emit a broad range of light (rather than 407-420 nm). The manufacturers of some of these products claim that the heat produced by the devices improves acne, but there is a paucity of research proving this point. In my opinion, using an at-home device twice a day that delivers 407-420 nm (with or without the addition of red light), and delivers enough joules (at least 25 J/cm²), is an effective method of treating acne. For comparison purposes, the in-office Omnilux delivers around 49 J/cm² but is used only two or three times per week. Know your wavelengths and joules when trying to decide which device to sell in your practice or recommend to patients.

SAN DIEGO – Correctly diagnosed and adequately treated polycystic ovary syndrome can appreciably improve acne in a select group of female patients, according to Dr. Anne W. Lucky.

Dr. Lucky offered tips on evaluating and treating acne and PCOS at the annual meeting of the American Academy of Dermatology. She said that PCOS should be considered in female patients with early onset acne, acne that is refractory to conventional therapy, relapse that occurs after treatment with isotretinoin, persistence of acne beyond adolescence, or late onset of acne, she said.

Several laboratory tests are typically used to diagnose PCOS but agreement on which tests to use is limited. "This is somewhat controversial," said Dr. Lucky, a professor of dermatology at the University of Cincinnati. She recommended the following tests: free testosterone, DHEAS (dehydroepiandrosterone sulfate), and the ratio of LH (luteinizing hormone) to FSH (follicle-stimulating hormone). "If I have a good suspicion or find abnormalities – [I include] fasting glucose and insulin and a fasting lipid profile," she said.

Treatment options include combination oral contraceptives, glucocorticoids (for specific adrenal abnormalities), and anti-androgens among others.

"By and large, oral contraceptives are the No. 1 choice. I mentioned combination contraceptives because it’s the estrogen that’s helpful. Progesterone-only contraceptives can actually worsen acne," Dr. Lucky said. "We don’t treat girls before menarche because they don’t have a risk for pregnancy and we might influence bone growth if we treat too early. You can suspect PCOS very early but you may have to suspend your treatment until they get a little older."

Using contraceptives – especially in girls or adolescents -- usually involves discussions with a gynecologist, a parent, and the child. "Our biggest hurdle is that the teenage population has heard the word on the street that the pill is going to make them fat and they don’t want to take it. Actually [the gynecologists that I work with] tell me that the studies show that some children gain weight, some lose weight, but most stay the same weight with the combination pills," she said.

In the United States, spironolactone is the only antiandrogen treatment option. It works by being a competitive inhibitor of androgen receptors. The drug does not lower serum androgen levels, but it prevents the action of androgen – increasing estrogenicity. However, the use of spironolactone for PCOS is considered off label. The drug is indicated for the treatment of hypertension and the label carries a warning that it should only be used for this indication, Dr. Lucky noted.

Dr. Lucky reported that she has financial relationships with Amgen, Galderma, and Johnson & Johnson.

SAN DIEGO – Correctly diagnosed and adequately treated polycystic ovary syndrome can appreciably improve acne in a select group of female patients, according to Dr. Anne W. Lucky.

Dr. Lucky offered tips on evaluating and treating acne and PCOS at the annual meeting of the American Academy of Dermatology. She said that PCOS should be considered in female patients with early onset acne, acne that is refractory to conventional therapy, relapse that occurs after treatment with isotretinoin, persistence of acne beyond adolescence, or late onset of acne, she said.

Several laboratory tests are typically used to diagnose PCOS but agreement on which tests to use is limited. "This is somewhat controversial," said Dr. Lucky, a professor of dermatology at the University of Cincinnati. She recommended the following tests: free testosterone, DHEAS (dehydroepiandrosterone sulfate), and the ratio of LH (luteinizing hormone) to FSH (follicle-stimulating hormone). "If I have a good suspicion or find abnormalities – [I include] fasting glucose and insulin and a fasting lipid profile," she said.

Treatment options include combination oral contraceptives, glucocorticoids (for specific adrenal abnormalities), and anti-androgens among others.

"By and large, oral contraceptives are the No. 1 choice. I mentioned combination contraceptives because it’s the estrogen that’s helpful. Progesterone-only contraceptives can actually worsen acne," Dr. Lucky said. "We don’t treat girls before menarche because they don’t have a risk for pregnancy and we might influence bone growth if we treat too early. You can suspect PCOS very early but you may have to suspend your treatment until they get a little older."

Using contraceptives – especially in girls or adolescents -- usually involves discussions with a gynecologist, a parent, and the child. "Our biggest hurdle is that the teenage population has heard the word on the street that the pill is going to make them fat and they don’t want to take it. Actually [the gynecologists that I work with] tell me that the studies show that some children gain weight, some lose weight, but most stay the same weight with the combination pills," she said.

In the United States, spironolactone is the only antiandrogen treatment option. It works by being a competitive inhibitor of androgen receptors. The drug does not lower serum androgen levels, but it prevents the action of androgen – increasing estrogenicity. However, the use of spironolactone for PCOS is considered off label. The drug is indicated for the treatment of hypertension and the label carries a warning that it should only be used for this indication, Dr. Lucky noted.

Dr. Lucky reported that she has financial relationships with Amgen, Galderma, and Johnson & Johnson.

SAN DIEGO – Correctly diagnosed and adequately treated polycystic ovary syndrome can appreciably improve acne in a select group of female patients, according to Dr. Anne W. Lucky.

Dr. Lucky offered tips on evaluating and treating acne and PCOS at the annual meeting of the American Academy of Dermatology. She said that PCOS should be considered in female patients with early onset acne, acne that is refractory to conventional therapy, relapse that occurs after treatment with isotretinoin, persistence of acne beyond adolescence, or late onset of acne, she said.

Several laboratory tests are typically used to diagnose PCOS but agreement on which tests to use is limited. "This is somewhat controversial," said Dr. Lucky, a professor of dermatology at the University of Cincinnati. She recommended the following tests: free testosterone, DHEAS (dehydroepiandrosterone sulfate), and the ratio of LH (luteinizing hormone) to FSH (follicle-stimulating hormone). "If I have a good suspicion or find abnormalities – [I include] fasting glucose and insulin and a fasting lipid profile," she said.

Treatment options include combination oral contraceptives, glucocorticoids (for specific adrenal abnormalities), and anti-androgens among others.

"By and large, oral contraceptives are the No. 1 choice. I mentioned combination contraceptives because it’s the estrogen that’s helpful. Progesterone-only contraceptives can actually worsen acne," Dr. Lucky said. "We don’t treat girls before menarche because they don’t have a risk for pregnancy and we might influence bone growth if we treat too early. You can suspect PCOS very early but you may have to suspend your treatment until they get a little older."

Using contraceptives – especially in girls or adolescents -- usually involves discussions with a gynecologist, a parent, and the child. "Our biggest hurdle is that the teenage population has heard the word on the street that the pill is going to make them fat and they don’t want to take it. Actually [the gynecologists that I work with] tell me that the studies show that some children gain weight, some lose weight, but most stay the same weight with the combination pills," she said.

In the United States, spironolactone is the only antiandrogen treatment option. It works by being a competitive inhibitor of androgen receptors. The drug does not lower serum androgen levels, but it prevents the action of androgen – increasing estrogenicity. However, the use of spironolactone for PCOS is considered off label. The drug is indicated for the treatment of hypertension and the label carries a warning that it should only be used for this indication, Dr. Lucky noted.

Dr. Lucky reported that she has financial relationships with Amgen, Galderma, and Johnson & Johnson.

WAIKOLOA, HAWAII  – The androgen receptor–blocker spironolactone is highly effective and safe but underused for the treatment of acne in women, according to Dr. Julie C. Harper.

"The longer I’ve been in practice, the wider the age range where I use spironolactone as my drug of choice," Dr. Harper said at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Spironolactone is her first-line therapy for acne in postmenopausal women and in those who have had a hysterectomy. In such patients "it’s a really great drug to use by itself" because the women can’t get pregnant; the drug has a pregnancy category C rating, with an associated risk of feminization of a male fetus exposed to the drug late in the first trimester, explained Dr. Harper, a dermatologist at the University of Alabama, Birmingham.

"I have a tendency in my practice to start with an oral contraceptive in women of child-bearing potential and then maybe add spironolactone if I need to," she said.

However, Dr. Harper said that she will turn to spironolactone in women as young as 16 years of age with a contraindication to OCs. First, however, she carefully explains that the drug is safe as long as they don’t take it when pregnant. Spironolactone also cannot be used by nursing mothers because the drug’s major metabolite, canrenone, has been detected in breast milk.

Acne is a common problem in women. A survey of 1,013 adults in which Dr. Harper was a coinvestigator concluded that the prevalence of acne was significantly greater in women than men across all age groups. For example, the prevalence was 26% among 40- to 49-year-old women, compared with 12% in men of the same age, and 15% among women age 50-plus, compared to 7% in men (J. Am. Acad. Dermatol. 2008;58:56-9).

Acne is not only more common in women than men, it also differs in its characteristic presentation, which in women is typically lower-face acne in a U-shaped distribution.

Most women with adult acne have normal levels of circulating androgens. A leading hypothesis holds that their acne is the result of end-organ hyper-responsiveness to androgens. Androgen receptors are present in the sebaceous glands and the follicular wall, where comedones develop. This would explain why spironolactone is so effective clinically; the drug not only blocks the androgen receptor, it also reduces androgen synthesis in the adrenal gland and gonads, Dr. Harper noted.

She prescribes spironolactone in lower-range doses of 25-100 mg/day. At those doses she doesn’t bother to check serum potassium levels in relatively healthy young women so long as they’re not on other medications that may cause hyperkalemia, such as ACE inhibitors or chronic NSAIDs.

"You get good efficacy with fewer side effects at a maximum dose of 100 mg," according to the dermatologist.

Concomitant use of an OC lessens the menstrual irregularities and breast tenderness that can occur as side effects of spironolactone therapy. All combination OCs are probably effective in the treatment of acne. Four are approved for this indication: Ortho Tri-Cyclen, Estrostep, YAZ, and Beyaz.

Spironolactone should be thought of as long-term therapy. When spironolactone or an OC prescribed for adult acne is stopped, it’s highly likely that the acne will return within several months.

"When I plan to use spironolactone, I tell my patients they’re going to be on this for a long time if it works," Dr. Harper said.

The Food and Drug Administration has a long-standing Black Box Warning regarding spironolactone. Such warnings can send a chill down the spine of physicians and patients alike. However, there are widespread misconceptions about what this particular warning actually says. Here it is: "Spironolactone has been shown to be a tumorigen in chronic toxicity studies in rats. Spironolactone should be used only in those conditions described under Indications and Usage. Unnecessary use of this drug should be avoided."

The dosages used in those rat studies, by the way, were 25-100 times higher than those used in patients therapeutically.

"So we’re talking about rats, we’re talking about benign tumors, and we’re talking about super-duper high doses. That’s what’s in the Black Box Warning for spironolactone," she said.

Spironolactone is off-label therapy for acne, a point that caused another speaker at the seminar to bristle.

"If we used medications only for their approved indications, we couldn’t practice two-thirds of what we do," declared Dr. Theodore Rosen, professor of dermatology at Baylor College of Medicine, Houston.

"The FDA has said they’re not in the business of dictating how you practice medicine," he added. "You can use any approved drug in any fashion if you have some reasonable justification for it. If a plaintiff’s lawyer claims ‘This doctor used spironolactone off-label,’ she could line up 100 experts who’d say this is standard-of-care, and the standard of care determines what’s right and what’s wrong."

Dr. Harper is on the speakers bureaus for Allergan, Coria, Galderma, Intendis, Medicis, and Stiefel.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII  – The androgen receptor–blocker spironolactone is highly effective and safe but underused for the treatment of acne in women, according to Dr. Julie C. Harper.

"The longer I’ve been in practice, the wider the age range where I use spironolactone as my drug of choice," Dr. Harper said at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Spironolactone is her first-line therapy for acne in postmenopausal women and in those who have had a hysterectomy. In such patients "it’s a really great drug to use by itself" because the women can’t get pregnant; the drug has a pregnancy category C rating, with an associated risk of feminization of a male fetus exposed to the drug late in the first trimester, explained Dr. Harper, a dermatologist at the University of Alabama, Birmingham.

"I have a tendency in my practice to start with an oral contraceptive in women of child-bearing potential and then maybe add spironolactone if I need to," she said.

However, Dr. Harper said that she will turn to spironolactone in women as young as 16 years of age with a contraindication to OCs. First, however, she carefully explains that the drug is safe as long as they don’t take it when pregnant. Spironolactone also cannot be used by nursing mothers because the drug’s major metabolite, canrenone, has been detected in breast milk.

Acne is a common problem in women. A survey of 1,013 adults in which Dr. Harper was a coinvestigator concluded that the prevalence of acne was significantly greater in women than men across all age groups. For example, the prevalence was 26% among 40- to 49-year-old women, compared with 12% in men of the same age, and 15% among women age 50-plus, compared to 7% in men (J. Am. Acad. Dermatol. 2008;58:56-9).

Acne is not only more common in women than men, it also differs in its characteristic presentation, which in women is typically lower-face acne in a U-shaped distribution.

Most women with adult acne have normal levels of circulating androgens. A leading hypothesis holds that their acne is the result of end-organ hyper-responsiveness to androgens. Androgen receptors are present in the sebaceous glands and the follicular wall, where comedones develop. This would explain why spironolactone is so effective clinically; the drug not only blocks the androgen receptor, it also reduces androgen synthesis in the adrenal gland and gonads, Dr. Harper noted.

She prescribes spironolactone in lower-range doses of 25-100 mg/day. At those doses she doesn’t bother to check serum potassium levels in relatively healthy young women so long as they’re not on other medications that may cause hyperkalemia, such as ACE inhibitors or chronic NSAIDs.

"You get good efficacy with fewer side effects at a maximum dose of 100 mg," according to the dermatologist.

Concomitant use of an OC lessens the menstrual irregularities and breast tenderness that can occur as side effects of spironolactone therapy. All combination OCs are probably effective in the treatment of acne. Four are approved for this indication: Ortho Tri-Cyclen, Estrostep, YAZ, and Beyaz.

Spironolactone should be thought of as long-term therapy. When spironolactone or an OC prescribed for adult acne is stopped, it’s highly likely that the acne will return within several months.

"When I plan to use spironolactone, I tell my patients they’re going to be on this for a long time if it works," Dr. Harper said.

The Food and Drug Administration has a long-standing Black Box Warning regarding spironolactone. Such warnings can send a chill down the spine of physicians and patients alike. However, there are widespread misconceptions about what this particular warning actually says. Here it is: "Spironolactone has been shown to be a tumorigen in chronic toxicity studies in rats. Spironolactone should be used only in those conditions described under Indications and Usage. Unnecessary use of this drug should be avoided."

The dosages used in those rat studies, by the way, were 25-100 times higher than those used in patients therapeutically.

"So we’re talking about rats, we’re talking about benign tumors, and we’re talking about super-duper high doses. That’s what’s in the Black Box Warning for spironolactone," she said.

Spironolactone is off-label therapy for acne, a point that caused another speaker at the seminar to bristle.

"If we used medications only for their approved indications, we couldn’t practice two-thirds of what we do," declared Dr. Theodore Rosen, professor of dermatology at Baylor College of Medicine, Houston.

"The FDA has said they’re not in the business of dictating how you practice medicine," he added. "You can use any approved drug in any fashion if you have some reasonable justification for it. If a plaintiff’s lawyer claims ‘This doctor used spironolactone off-label,’ she could line up 100 experts who’d say this is standard-of-care, and the standard of care determines what’s right and what’s wrong."

Dr. Harper is on the speakers bureaus for Allergan, Coria, Galderma, Intendis, Medicis, and Stiefel.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII  – The androgen receptor–blocker spironolactone is highly effective and safe but underused for the treatment of acne in women, according to Dr. Julie C. Harper.

"The longer I’ve been in practice, the wider the age range where I use spironolactone as my drug of choice," Dr. Harper said at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Spironolactone is her first-line therapy for acne in postmenopausal women and in those who have had a hysterectomy. In such patients "it’s a really great drug to use by itself" because the women can’t get pregnant; the drug has a pregnancy category C rating, with an associated risk of feminization of a male fetus exposed to the drug late in the first trimester, explained Dr. Harper, a dermatologist at the University of Alabama, Birmingham.

"I have a tendency in my practice to start with an oral contraceptive in women of child-bearing potential and then maybe add spironolactone if I need to," she said.

However, Dr. Harper said that she will turn to spironolactone in women as young as 16 years of age with a contraindication to OCs. First, however, she carefully explains that the drug is safe as long as they don’t take it when pregnant. Spironolactone also cannot be used by nursing mothers because the drug’s major metabolite, canrenone, has been detected in breast milk.

Acne is a common problem in women. A survey of 1,013 adults in which Dr. Harper was a coinvestigator concluded that the prevalence of acne was significantly greater in women than men across all age groups. For example, the prevalence was 26% among 40- to 49-year-old women, compared with 12% in men of the same age, and 15% among women age 50-plus, compared to 7% in men (J. Am. Acad. Dermatol. 2008;58:56-9).

Acne is not only more common in women than men, it also differs in its characteristic presentation, which in women is typically lower-face acne in a U-shaped distribution.

Most women with adult acne have normal levels of circulating androgens. A leading hypothesis holds that their acne is the result of end-organ hyper-responsiveness to androgens. Androgen receptors are present in the sebaceous glands and the follicular wall, where comedones develop. This would explain why spironolactone is so effective clinically; the drug not only blocks the androgen receptor, it also reduces androgen synthesis in the adrenal gland and gonads, Dr. Harper noted.

She prescribes spironolactone in lower-range doses of 25-100 mg/day. At those doses she doesn’t bother to check serum potassium levels in relatively healthy young women so long as they’re not on other medications that may cause hyperkalemia, such as ACE inhibitors or chronic NSAIDs.

"You get good efficacy with fewer side effects at a maximum dose of 100 mg," according to the dermatologist.

Concomitant use of an OC lessens the menstrual irregularities and breast tenderness that can occur as side effects of spironolactone therapy. All combination OCs are probably effective in the treatment of acne. Four are approved for this indication: Ortho Tri-Cyclen, Estrostep, YAZ, and Beyaz.

Spironolactone should be thought of as long-term therapy. When spironolactone or an OC prescribed for adult acne is stopped, it’s highly likely that the acne will return within several months.

"When I plan to use spironolactone, I tell my patients they’re going to be on this for a long time if it works," Dr. Harper said.

The Food and Drug Administration has a long-standing Black Box Warning regarding spironolactone. Such warnings can send a chill down the spine of physicians and patients alike. However, there are widespread misconceptions about what this particular warning actually says. Here it is: "Spironolactone has been shown to be a tumorigen in chronic toxicity studies in rats. Spironolactone should be used only in those conditions described under Indications and Usage. Unnecessary use of this drug should be avoided."

The dosages used in those rat studies, by the way, were 25-100 times higher than those used in patients therapeutically.

"So we’re talking about rats, we’re talking about benign tumors, and we’re talking about super-duper high doses. That’s what’s in the Black Box Warning for spironolactone," she said.

Spironolactone is off-label therapy for acne, a point that caused another speaker at the seminar to bristle.

"If we used medications only for their approved indications, we couldn’t practice two-thirds of what we do," declared Dr. Theodore Rosen, professor of dermatology at Baylor College of Medicine, Houston.

"The FDA has said they’re not in the business of dictating how you practice medicine," he added. "You can use any approved drug in any fashion if you have some reasonable justification for it. If a plaintiff’s lawyer claims ‘This doctor used spironolactone off-label,’ she could line up 100 experts who’d say this is standard-of-care, and the standard of care determines what’s right and what’s wrong."

Dr. Harper is on the speakers bureaus for Allergan, Coria, Galderma, Intendis, Medicis, and Stiefel.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – New acne management recommendations from the American Acne and Rosacea Society are the first guidelines to specifically address pediatric acne.

"Acne is a common problem, and the presentations and differential diagnosis differ among the various ages of childhood and adolescence. We had a strong desire to increase recognition and improve management of pediatric and adolescent acne across the spectrum of primary and specialty care," explained Dr. Lawrence F. Eichenfield, cochair of the guideline-writing panel comprised of general pediatricians, pediatric dermatologists, and acne experts.

The comprehensive guidelines provide a simple and efficient classification scheme in which acne is categorized as comedonal, inflammatory/mixed, or nodular, and graded as globally mild, moderate, or severe. The guidelines offer detailed algorithms for the treatment of each category.

The treatment algorithms are flexible, with multiple options available based upon considerations including financial cost and treatment history.

Regimen complexity is another major consideration. Treatment adherence in pediatric and adolescent acne patients is notoriously a much bigger problem than in adults. Simple, once-daily combination products addressing multiple acne pathogenic mechanisms are advantageous.

Adolescent Acne

The treatment algorithm for the adolescent with mild comedonal or inflammatory/mixed lesions begins with two broad options for initial therapy. Both are topical regimens. The first consists of monotherapy with benzoyl peroxide or a topical retinoid, which can be an inexpensive option. The second is topical fixed-dose combination therapy, which can cost far more but achieves faster clearance, Dr. Eichenfield said at the seminar sponsored by Skin Disease Education Foundation (SDEF). Recommended combinations include benzoyl peroxide with a topical antibiotic or retinoid.

Alternatively, the panel noted that topical dapsone can be used either as initial monotherapy or in place of a topical antibiotic. The panel was in agreement that a topical antibiotic should only be prescribed in conjunction with benzoyl peroxide in order to help prevent the emergence of bacterial resistance, he said.

Doxycycline and other oral antibiotics are to be reserved for treatment of moderate to severe acne, and their use should be limited to 3-6 months, according to the guidelines.

"An oral antibiotic alone is substandard care now. It needs to be accompanied by a topical retinoid, a retinoid/benzoyl peroxide, or retinoid/topical antibiotic combination to minimize resistance," Dr. Eichenfield said.

The guidelines note that it is appropriate for primary care physicians to immediately refer an adolescent who presents with severe acne to a dermatologist. Many such patients will be best-treated with oral isotretinoin, he noted.

Preadolescent Acne

Preadolescent acne arising in children aged 7-12 is common and considered normal. It typically begins with comedones over the forehead and midface, with truncal lesions being far less common.

Treatment follows the same algorithms as adolescent acne, with the caveat that most preadolescent therapy is off-label, since, until quite recently, nearly all treatment studies were restricted to patients aged 12 years and older. Therefore, in formulating a treatment strategy for preadolescents, the panel had to shift gears and switch from the evidence-based approach emphasized elsewhere in the guidelines to expert consensus, said Dr. Eichenfield, professor of clinical pediatrics and dermatology at the University of California, San Diego.

Infantile Acne

Infantile acne generally doesn’t show up until after the first several months of life. It is comedonal, although papules, pustules, nodules, and cysts may also be present. Infantile acne can do significant lasting damage, and treatment is warranted.

Neonatal Acne

Acne developing within the first 6 weeks after birth is classified as neonatal acne. However, the erythematous papules and pustules located on the face, neck, scalp, and torso are not true acne. The skin lesions, also known as neonatal cephalic pustulosis, are associated with skin colonization by Malassezia globosa and M. sympodialis. It is a self-limited condition, although it may clear faster if treated using topical ketoconazole cream or another anti-yeast medication.

Among the other issues addressed in the report are diet and acne, the appropriate use of the various classes of medications, when and how to use oral contraceptive pills for acne, the important distinction between neonatal and infantile acne, how to prescribe the big gun – isotretinoin – in young patients, and when to refer a child with acne for a endocrinology workup, said Dr. Eichenfield.

He explained that acne arising in mid-childhood – age 1-7 years – is a red flag for an increased risk of an endocrinologic disorder. Referral to a pediatric endocrinologist is warranted if a child displays any abnormalities in height and growth, blood pressure, or displays signs of early sexual maturation. Dr. Eichenfield picks up the phone personally, he said, to talk to the pediatric endocrinologist, and to make sure the child won’t wait long for an endocrinologic evaluation.

Publication of the guidelines is pending, he noted. In the meantime, physicians can obtain an introduction to the guidelines, including full details of the treatment algorithms, while earning 1 hour of CME credit by viewing a 56-minute video featuring Dr. Eichenfield and other guideline panelists at www.acneandrosacea.org.

The acne guidelines project was supported by the American Acne and Rosacea Society.

Dr. Eichenfield reported receiving research support or serving as a consultant to Galderma, Johnson & Johnson, Medicis, Stiefel, Valeant, and Ortho-McNeil (Jansen Pharmaceuticals).

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – New acne management recommendations from the American Acne and Rosacea Society are the first guidelines to specifically address pediatric acne.

"Acne is a common problem, and the presentations and differential diagnosis differ among the various ages of childhood and adolescence. We had a strong desire to increase recognition and improve management of pediatric and adolescent acne across the spectrum of primary and specialty care," explained Dr. Lawrence F. Eichenfield, cochair of the guideline-writing panel comprised of general pediatricians, pediatric dermatologists, and acne experts.

The comprehensive guidelines provide a simple and efficient classification scheme in which acne is categorized as comedonal, inflammatory/mixed, or nodular, and graded as globally mild, moderate, or severe. The guidelines offer detailed algorithms for the treatment of each category.

The treatment algorithms are flexible, with multiple options available based upon considerations including financial cost and treatment history.

Regimen complexity is another major consideration. Treatment adherence in pediatric and adolescent acne patients is notoriously a much bigger problem than in adults. Simple, once-daily combination products addressing multiple acne pathogenic mechanisms are advantageous.

Adolescent Acne

The treatment algorithm for the adolescent with mild comedonal or inflammatory/mixed lesions begins with two broad options for initial therapy. Both are topical regimens. The first consists of monotherapy with benzoyl peroxide or a topical retinoid, which can be an inexpensive option. The second is topical fixed-dose combination therapy, which can cost far more but achieves faster clearance, Dr. Eichenfield said at the seminar sponsored by Skin Disease Education Foundation (SDEF). Recommended combinations include benzoyl peroxide with a topical antibiotic or retinoid.

Alternatively, the panel noted that topical dapsone can be used either as initial monotherapy or in place of a topical antibiotic. The panel was in agreement that a topical antibiotic should only be prescribed in conjunction with benzoyl peroxide in order to help prevent the emergence of bacterial resistance, he said.

Doxycycline and other oral antibiotics are to be reserved for treatment of moderate to severe acne, and their use should be limited to 3-6 months, according to the guidelines.

"An oral antibiotic alone is substandard care now. It needs to be accompanied by a topical retinoid, a retinoid/benzoyl peroxide, or retinoid/topical antibiotic combination to minimize resistance," Dr. Eichenfield said.

The guidelines note that it is appropriate for primary care physicians to immediately refer an adolescent who presents with severe acne to a dermatologist. Many such patients will be best-treated with oral isotretinoin, he noted.

Preadolescent Acne

Preadolescent acne arising in children aged 7-12 is common and considered normal. It typically begins with comedones over the forehead and midface, with truncal lesions being far less common.

Treatment follows the same algorithms as adolescent acne, with the caveat that most preadolescent therapy is off-label, since, until quite recently, nearly all treatment studies were restricted to patients aged 12 years and older. Therefore, in formulating a treatment strategy for preadolescents, the panel had to shift gears and switch from the evidence-based approach emphasized elsewhere in the guidelines to expert consensus, said Dr. Eichenfield, professor of clinical pediatrics and dermatology at the University of California, San Diego.

Infantile Acne

Infantile acne generally doesn’t show up until after the first several months of life. It is comedonal, although papules, pustules, nodules, and cysts may also be present. Infantile acne can do significant lasting damage, and treatment is warranted.

Neonatal Acne

Acne developing within the first 6 weeks after birth is classified as neonatal acne. However, the erythematous papules and pustules located on the face, neck, scalp, and torso are not true acne. The skin lesions, also known as neonatal cephalic pustulosis, are associated with skin colonization by Malassezia globosa and M. sympodialis. It is a self-limited condition, although it may clear faster if treated using topical ketoconazole cream or another anti-yeast medication.

Among the other issues addressed in the report are diet and acne, the appropriate use of the various classes of medications, when and how to use oral contraceptive pills for acne, the important distinction between neonatal and infantile acne, how to prescribe the big gun – isotretinoin – in young patients, and when to refer a child with acne for a endocrinology workup, said Dr. Eichenfield.

He explained that acne arising in mid-childhood – age 1-7 years – is a red flag for an increased risk of an endocrinologic disorder. Referral to a pediatric endocrinologist is warranted if a child displays any abnormalities in height and growth, blood pressure, or displays signs of early sexual maturation. Dr. Eichenfield picks up the phone personally, he said, to talk to the pediatric endocrinologist, and to make sure the child won’t wait long for an endocrinologic evaluation.

Publication of the guidelines is pending, he noted. In the meantime, physicians can obtain an introduction to the guidelines, including full details of the treatment algorithms, while earning 1 hour of CME credit by viewing a 56-minute video featuring Dr. Eichenfield and other guideline panelists at www.acneandrosacea.org.

The acne guidelines project was supported by the American Acne and Rosacea Society.

Dr. Eichenfield reported receiving research support or serving as a consultant to Galderma, Johnson & Johnson, Medicis, Stiefel, Valeant, and Ortho-McNeil (Jansen Pharmaceuticals).

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – New acne management recommendations from the American Acne and Rosacea Society are the first guidelines to specifically address pediatric acne.

"Acne is a common problem, and the presentations and differential diagnosis differ among the various ages of childhood and adolescence. We had a strong desire to increase recognition and improve management of pediatric and adolescent acne across the spectrum of primary and specialty care," explained Dr. Lawrence F. Eichenfield, cochair of the guideline-writing panel comprised of general pediatricians, pediatric dermatologists, and acne experts.

The comprehensive guidelines provide a simple and efficient classification scheme in which acne is categorized as comedonal, inflammatory/mixed, or nodular, and graded as globally mild, moderate, or severe. The guidelines offer detailed algorithms for the treatment of each category.

The treatment algorithms are flexible, with multiple options available based upon considerations including financial cost and treatment history.

Regimen complexity is another major consideration. Treatment adherence in pediatric and adolescent acne patients is notoriously a much bigger problem than in adults. Simple, once-daily combination products addressing multiple acne pathogenic mechanisms are advantageous.

Adolescent Acne

The treatment algorithm for the adolescent with mild comedonal or inflammatory/mixed lesions begins with two broad options for initial therapy. Both are topical regimens. The first consists of monotherapy with benzoyl peroxide or a topical retinoid, which can be an inexpensive option. The second is topical fixed-dose combination therapy, which can cost far more but achieves faster clearance, Dr. Eichenfield said at the seminar sponsored by Skin Disease Education Foundation (SDEF). Recommended combinations include benzoyl peroxide with a topical antibiotic or retinoid.

Alternatively, the panel noted that topical dapsone can be used either as initial monotherapy or in place of a topical antibiotic. The panel was in agreement that a topical antibiotic should only be prescribed in conjunction with benzoyl peroxide in order to help prevent the emergence of bacterial resistance, he said.

Doxycycline and other oral antibiotics are to be reserved for treatment of moderate to severe acne, and their use should be limited to 3-6 months, according to the guidelines.

"An oral antibiotic alone is substandard care now. It needs to be accompanied by a topical retinoid, a retinoid/benzoyl peroxide, or retinoid/topical antibiotic combination to minimize resistance," Dr. Eichenfield said.

The guidelines note that it is appropriate for primary care physicians to immediately refer an adolescent who presents with severe acne to a dermatologist. Many such patients will be best-treated with oral isotretinoin, he noted.

Preadolescent Acne

Preadolescent acne arising in children aged 7-12 is common and considered normal. It typically begins with comedones over the forehead and midface, with truncal lesions being far less common.

Treatment follows the same algorithms as adolescent acne, with the caveat that most preadolescent therapy is off-label, since, until quite recently, nearly all treatment studies were restricted to patients aged 12 years and older. Therefore, in formulating a treatment strategy for preadolescents, the panel had to shift gears and switch from the evidence-based approach emphasized elsewhere in the guidelines to expert consensus, said Dr. Eichenfield, professor of clinical pediatrics and dermatology at the University of California, San Diego.

Infantile Acne

Infantile acne generally doesn’t show up until after the first several months of life. It is comedonal, although papules, pustules, nodules, and cysts may also be present. Infantile acne can do significant lasting damage, and treatment is warranted.

Neonatal Acne

Acne developing within the first 6 weeks after birth is classified as neonatal acne. However, the erythematous papules and pustules located on the face, neck, scalp, and torso are not true acne. The skin lesions, also known as neonatal cephalic pustulosis, are associated with skin colonization by Malassezia globosa and M. sympodialis. It is a self-limited condition, although it may clear faster if treated using topical ketoconazole cream or another anti-yeast medication.

Among the other issues addressed in the report are diet and acne, the appropriate use of the various classes of medications, when and how to use oral contraceptive pills for acne, the important distinction between neonatal and infantile acne, how to prescribe the big gun – isotretinoin – in young patients, and when to refer a child with acne for a endocrinology workup, said Dr. Eichenfield.

He explained that acne arising in mid-childhood – age 1-7 years – is a red flag for an increased risk of an endocrinologic disorder. Referral to a pediatric endocrinologist is warranted if a child displays any abnormalities in height and growth, blood pressure, or displays signs of early sexual maturation. Dr. Eichenfield picks up the phone personally, he said, to talk to the pediatric endocrinologist, and to make sure the child won’t wait long for an endocrinologic evaluation.

Publication of the guidelines is pending, he noted. In the meantime, physicians can obtain an introduction to the guidelines, including full details of the treatment algorithms, while earning 1 hour of CME credit by viewing a 56-minute video featuring Dr. Eichenfield and other guideline panelists at www.acneandrosacea.org.

The acne guidelines project was supported by the American Acne and Rosacea Society.

Dr. Eichenfield reported receiving research support or serving as a consultant to Galderma, Johnson & Johnson, Medicis, Stiefel, Valeant, and Ortho-McNeil (Jansen Pharmaceuticals).

SDEF and this news organization are owned by Elsevier.

MIAMI BEACH – Early and aggressive anti-inflammatory therapy – preferably combination – is the key to treating acne and postinflammatory hyperpigmentation in patients with skin of color.

Acne prevalence is about the same in black and white patients, said Dr. Valerie D. Callender. The same mechanisms cause acne and the same treatments, in general, are used regardless of skin type, she said. "What is important is ... there are sequelae of acne that make it a little different, and there are certain, special considerations we have to keep in mind when treating patients with darker skin types."

Prevention of keloids, hypertrophic scars, and postinflammatory hyperpigmentation are among the special considerations in this patient population, Dr. Callender said at the South Beach Symposium.

Keloids and hypertrophic scars usually result from inflammatory acne papules, nodules, and cysts, and can be challenging to treat. The keloids and scarring commonly arise along the jawline and on the chest, shoulder, and back. "It’s important to be very aggressive to resolve the inflammation, to treat them effectively. A lot of these patients do very well with isotretinoin and oral antibiotics," said Dr. Callender of the dermatology department at Howard University in Washington, D.C.

In patients with keloids, consider injection of 20 mg/cc intralesional triamcinolone every 4 weeks, sometimes every 2 weeks, to get these lesions to go down, she said. "Remember that is part of their acne regimen."

Postinflammatory hyperpigmentation (PIH) is a common presenting complaint among skin of color patients with acne or another inflammatory skin condition.

PIH is "psychologically devastating for these patients. We have to treat the PIH just as aggressively as we treat the acne," Dr. Callender said. In some cases, the disfigurement is severe and the hyperpigmented patches and macules can persist for months or even years.

In a study of 2,895 females aged 10-70, prevalence of PIH varied by ethnicity (J. Eur. Acad. Dermatol. Venereol. 2011;25:1054-60). The researchers at Massachusetts General Hospital in Boston found that PIH affected 65% of 384 black study patients and 48% of 258 Hispanic patients. "The other racial groups were less than 20% for PIH; this goes along with what we do in our practices," Dr. Callender said.

There are multiple options for prevention and treatment of PIH. Sunscreen, sun avoidance, and early diagnosis can prevent or minimize adverse effects. Hydroquinone, retinoids, azelaic acid, and/or kojic acid are recommended treatments.

"I love my hydroquinone, I use it a lot," Dr. Callender said. Hydroquinone lightens areas of hyperpigmentation through inhibition of tyrosine conversion to melanin, reduces the number of melanosomes, and inhibits DNA and RNA synthesis of melanocytes.

Topical retinoid agents are useful because they not only treat acne, but also address the hyperpigmentation, she said. Also, once the hyperpigmentation is under control, the topical retinoids help to exfoliate the skin and keep PIH from recurring. "We love to keep these patients on long-term topical retinoid therapy."

Tolerability is very important when prescribing topical retinoids and other agents. Carefully consider each patient’s potential risk for cutaneous irritation, including erythema, peeling, burning, and dryness. Be sure to inform nurses and office staff that when a patient calls about tolerability, "you have to inquire about any changes in pigmentation [as well], especially in skin of color patients," Dr. Callender said. Moisturizers, cleansers, and less irritating vehicles can improve tolerability.

"We also use adjunctive therapies and sunscreen protection [for PIH]. Remember combination therapy is the way to go," she said.

She and her associates conducted a meta-analysis looking at the tolerability of a fixed combination adapalene 0.1% and benzoyl peroxide 2.5% gel product (Epiduo) for acne in patients by Fitzpatrick skin type (J. Clin. Aesthet. Dermatol. 2010;3:15-9). They found erythema, scaling, and dryness scores higher for white patients in all three studies. Burning and stinging scores were not significantly different. "Tolerability is good for your skin of color patients. You don’t need to be overly concerned about a lot of irritation just because their skin is dark."

Chemical peels, lasers, and light-based therapies are additional treatment options for acne. Peels made with glycolic acid, salicylic acid, Jessner’s solution, or a combination is acceptable in skin of color patients. However, "be very, very careful with peels in skin of color patients. Make sure [to] use superficial peeling agents," Dr. Callender said.

More clinical studies of lasers and light-based therapies to treat acne are including the darker skin types, Dr. Callender said. Blue light, diode laser, intense pulse light, and photodynamic therapy are examples. "As we learn how to adjust the settings, they will be safer for skin of color patients," she said.

Dr. Callender disclosed that she is a consultant for Allergan and Galderma, which markets Epiduo; a researcher for Allergan, Galderma, and Intendis; and a member of the speakers’ bureau for Galderma.

MIAMI BEACH – Early and aggressive anti-inflammatory therapy – preferably combination – is the key to treating acne and postinflammatory hyperpigmentation in patients with skin of color.

Acne prevalence is about the same in black and white patients, said Dr. Valerie D. Callender. The same mechanisms cause acne and the same treatments, in general, are used regardless of skin type, she said. "What is important is ... there are sequelae of acne that make it a little different, and there are certain, special considerations we have to keep in mind when treating patients with darker skin types."

Prevention of keloids, hypertrophic scars, and postinflammatory hyperpigmentation are among the special considerations in this patient population, Dr. Callender said at the South Beach Symposium.

Keloids and hypertrophic scars usually result from inflammatory acne papules, nodules, and cysts, and can be challenging to treat. The keloids and scarring commonly arise along the jawline and on the chest, shoulder, and back. "It’s important to be very aggressive to resolve the inflammation, to treat them effectively. A lot of these patients do very well with isotretinoin and oral antibiotics," said Dr. Callender of the dermatology department at Howard University in Washington, D.C.

In patients with keloids, consider injection of 20 mg/cc intralesional triamcinolone every 4 weeks, sometimes every 2 weeks, to get these lesions to go down, she said. "Remember that is part of their acne regimen."

Postinflammatory hyperpigmentation (PIH) is a common presenting complaint among skin of color patients with acne or another inflammatory skin condition.

PIH is "psychologically devastating for these patients. We have to treat the PIH just as aggressively as we treat the acne," Dr. Callender said. In some cases, the disfigurement is severe and the hyperpigmented patches and macules can persist for months or even years.

In a study of 2,895 females aged 10-70, prevalence of PIH varied by ethnicity (J. Eur. Acad. Dermatol. Venereol. 2011;25:1054-60). The researchers at Massachusetts General Hospital in Boston found that PIH affected 65% of 384 black study patients and 48% of 258 Hispanic patients. "The other racial groups were less than 20% for PIH; this goes along with what we do in our practices," Dr. Callender said.

There are multiple options for prevention and treatment of PIH. Sunscreen, sun avoidance, and early diagnosis can prevent or minimize adverse effects. Hydroquinone, retinoids, azelaic acid, and/or kojic acid are recommended treatments.

"I love my hydroquinone, I use it a lot," Dr. Callender said. Hydroquinone lightens areas of hyperpigmentation through inhibition of tyrosine conversion to melanin, reduces the number of melanosomes, and inhibits DNA and RNA synthesis of melanocytes.

Topical retinoid agents are useful because they not only treat acne, but also address the hyperpigmentation, she said. Also, once the hyperpigmentation is under control, the topical retinoids help to exfoliate the skin and keep PIH from recurring. "We love to keep these patients on long-term topical retinoid therapy."

Tolerability is very important when prescribing topical retinoids and other agents. Carefully consider each patient’s potential risk for cutaneous irritation, including erythema, peeling, burning, and dryness. Be sure to inform nurses and office staff that when a patient calls about tolerability, "you have to inquire about any changes in pigmentation [as well], especially in skin of color patients," Dr. Callender said. Moisturizers, cleansers, and less irritating vehicles can improve tolerability.

"We also use adjunctive therapies and sunscreen protection [for PIH]. Remember combination therapy is the way to go," she said.

She and her associates conducted a meta-analysis looking at the tolerability of a fixed combination adapalene 0.1% and benzoyl peroxide 2.5% gel product (Epiduo) for acne in patients by Fitzpatrick skin type (J. Clin. Aesthet. Dermatol. 2010;3:15-9). They found erythema, scaling, and dryness scores higher for white patients in all three studies. Burning and stinging scores were not significantly different. "Tolerability is good for your skin of color patients. You don’t need to be overly concerned about a lot of irritation just because their skin is dark."

Chemical peels, lasers, and light-based therapies are additional treatment options for acne. Peels made with glycolic acid, salicylic acid, Jessner’s solution, or a combination is acceptable in skin of color patients. However, "be very, very careful with peels in skin of color patients. Make sure [to] use superficial peeling agents," Dr. Callender said.

More clinical studies of lasers and light-based therapies to treat acne are including the darker skin types, Dr. Callender said. Blue light, diode laser, intense pulse light, and photodynamic therapy are examples. "As we learn how to adjust the settings, they will be safer for skin of color patients," she said.

Dr. Callender disclosed that she is a consultant for Allergan and Galderma, which markets Epiduo; a researcher for Allergan, Galderma, and Intendis; and a member of the speakers’ bureau for Galderma.

MIAMI BEACH – Early and aggressive anti-inflammatory therapy – preferably combination – is the key to treating acne and postinflammatory hyperpigmentation in patients with skin of color.

Acne prevalence is about the same in black and white patients, said Dr. Valerie D. Callender. The same mechanisms cause acne and the same treatments, in general, are used regardless of skin type, she said. "What is important is ... there are sequelae of acne that make it a little different, and there are certain, special considerations we have to keep in mind when treating patients with darker skin types."

Prevention of keloids, hypertrophic scars, and postinflammatory hyperpigmentation are among the special considerations in this patient population, Dr. Callender said at the South Beach Symposium.

Keloids and hypertrophic scars usually result from inflammatory acne papules, nodules, and cysts, and can be challenging to treat. The keloids and scarring commonly arise along the jawline and on the chest, shoulder, and back. "It’s important to be very aggressive to resolve the inflammation, to treat them effectively. A lot of these patients do very well with isotretinoin and oral antibiotics," said Dr. Callender of the dermatology department at Howard University in Washington, D.C.

In patients with keloids, consider injection of 20 mg/cc intralesional triamcinolone every 4 weeks, sometimes every 2 weeks, to get these lesions to go down, she said. "Remember that is part of their acne regimen."

Postinflammatory hyperpigmentation (PIH) is a common presenting complaint among skin of color patients with acne or another inflammatory skin condition.

PIH is "psychologically devastating for these patients. We have to treat the PIH just as aggressively as we treat the acne," Dr. Callender said. In some cases, the disfigurement is severe and the hyperpigmented patches and macules can persist for months or even years.

In a study of 2,895 females aged 10-70, prevalence of PIH varied by ethnicity (J. Eur. Acad. Dermatol. Venereol. 2011;25:1054-60). The researchers at Massachusetts General Hospital in Boston found that PIH affected 65% of 384 black study patients and 48% of 258 Hispanic patients. "The other racial groups were less than 20% for PIH; this goes along with what we do in our practices," Dr. Callender said.

There are multiple options for prevention and treatment of PIH. Sunscreen, sun avoidance, and early diagnosis can prevent or minimize adverse effects. Hydroquinone, retinoids, azelaic acid, and/or kojic acid are recommended treatments.

"I love my hydroquinone, I use it a lot," Dr. Callender said. Hydroquinone lightens areas of hyperpigmentation through inhibition of tyrosine conversion to melanin, reduces the number of melanosomes, and inhibits DNA and RNA synthesis of melanocytes.

Topical retinoid agents are useful because they not only treat acne, but also address the hyperpigmentation, she said. Also, once the hyperpigmentation is under control, the topical retinoids help to exfoliate the skin and keep PIH from recurring. "We love to keep these patients on long-term topical retinoid therapy."

Tolerability is very important when prescribing topical retinoids and other agents. Carefully consider each patient’s potential risk for cutaneous irritation, including erythema, peeling, burning, and dryness. Be sure to inform nurses and office staff that when a patient calls about tolerability, "you have to inquire about any changes in pigmentation [as well], especially in skin of color patients," Dr. Callender said. Moisturizers, cleansers, and less irritating vehicles can improve tolerability.

"We also use adjunctive therapies and sunscreen protection [for PIH]. Remember combination therapy is the way to go," she said.

She and her associates conducted a meta-analysis looking at the tolerability of a fixed combination adapalene 0.1% and benzoyl peroxide 2.5% gel product (Epiduo) for acne in patients by Fitzpatrick skin type (J. Clin. Aesthet. Dermatol. 2010;3:15-9). They found erythema, scaling, and dryness scores higher for white patients in all three studies. Burning and stinging scores were not significantly different. "Tolerability is good for your skin of color patients. You don’t need to be overly concerned about a lot of irritation just because their skin is dark."

Chemical peels, lasers, and light-based therapies are additional treatment options for acne. Peels made with glycolic acid, salicylic acid, Jessner’s solution, or a combination is acceptable in skin of color patients. However, "be very, very careful with peels in skin of color patients. Make sure [to] use superficial peeling agents," Dr. Callender said.

More clinical studies of lasers and light-based therapies to treat acne are including the darker skin types, Dr. Callender said. Blue light, diode laser, intense pulse light, and photodynamic therapy are examples. "As we learn how to adjust the settings, they will be safer for skin of color patients," she said.

Dr. Callender disclosed that she is a consultant for Allergan and Galderma, which markets Epiduo; a researcher for Allergan, Galderma, and Intendis; and a member of the speakers’ bureau for Galderma.

MIAMI BEACH – Acne presentation, treatment, and counseling will vary according to whether your patient is a neonate, infant, child, preadolescent, or teenager, according to Dr. Jonette E. Keri.

Courtesy Dr. Lawrence F. Eichenfield

• Neonatal acne. These small, erythematous papules that arise before 6 weeks of life probably represent a heterogenous set of conditions. Ketoconazole cream 2% twice per day is a treatment option.

However, "a lot of doctors choose not to treat because it’s not a scarring process," Dr. Keri said. You can reassure parents that most neonatal acne improves relatively quickly, usually within a few months. If true comedones are present, consider treatment with the same acne mediations indicated for infantile acne.

• Infantile acne. Infantile acne appears in children up to 1 year, usually at 3-6 months of age. Male infants are more prone to acne than female infants, and lesions tend to appear on the cheeks and chin and have the appearance of classic adolescent acne. Increased sebum production and some comedones are often present.

"You should treat because it can cause scarring," Dr. Keri said. Also, "this acne may predispose [children] to worse acne in teenage years – that is shown to be true for any form of infantile acne. It doesn’t have to be severe," said Dr. Keri of the University of Miami and chief of dermatology services at the Miami VA Hospital.

She offered the following clinical tips for treating and managing acne based on developmental age:

Combine treatments and use products appropriate for a baby, Dr. Keri advised at the South Beach Symposium. Although some experts recommend benzoyl peroxide, proceed with caution. The concern is getting any benzoyl peroxide near a baby’s eyes, "so you probably want to stay away from the washes."

Treatment options include topical antibiotics, adapalene, or a retinoid like tretinoin. Oral erythromycin is another acceptable option, she said.

"Isotretinoin is actually indicated if a severe, scarring process is going on," said Dr. Keri. She said that she searched the literature and found that some clinicians prescribe isotretinoin in children as young as 5 months.

• Midchildhood acne. "It is a newer concept, but a very important concept," Dr. Keri said. Acne is relatively rare between the ages of 1 and 8 years. During this time androgens in the body should be low and stable.

If acne does arise, it could point to an underlying hormonal abnormality. Evaluate three things: bone age, the growth chart, and hormone levels. "That may be a bit much for a dermatologist, but a pediatrician does these evaluations often," she said.

Accelerated bone age on a wrist radiograph can point to androgen excess, whereas delayed bone age suggests Cushing’s disease. A growth chart that shows a child’s height crossing percentiles upward or increasing faster than would be expected can also suggest androgen excess.

"Hormone levels can be tricky," Dr. Keri said. High levels of androgens, free testosterone, or dehydroepiandrosterone also can occur with tumors or polycystic ovarian syndrome (PCOS). "Another reason they can be tricky is because the child is developing into an adult, so you may need a pediatric endocrinologist to tease this out."

• Preadolescent acne. Treatments for children aged 9-12 years are essentially the same as for infants and midchildhood patients. However, patient counseling plays a bigger role. "Adherence is a big issue with these kids, so try to give them a once-a-day regimen," Dr. Keri said. Isotretinoin is rarely prescribed in this age group, but if severity dictates the need, it is likely the child will need retreatment (two or three courses) over time.

Comedones, seborrhea, and even PCOS are associated with preteen acne. Rule out precocious puberty and distinguish abnormal hormonal changes from normal signs of puberty, Dr. Keri recommended.

"PCOS is very complicated; you are going to need some help, a multispecialty approach," Dr. Keri said. Early diagnosis is worthwhile, she added. "If you identify PCOS when these young ladies are younger, you can prevent infertility, diabetes, [and] coronary artery disease, because they get these things more often than a woman who doesn’t have PCOS."

• Adolescent acne. Speaking directly and appropriately with teenagers about their acne can facilitate better outcomes, Dr. Keri said. For example, instead of asking, "How many days a week do you use your medicines?" ask, "How do you use your acne medicines?" Also determine their expectations before prescribing, and find out if they have a prom or other major social event coming up.

It is also important to evaluate their previous acne-fighting strategies. "It can be painfully tiring to go through all they have done and used, but if you don’t do that, you’re not going to have a good starting point," she said. Find out what they like and dislike, and really listen to their answers. "They will be honest if you listen to them."

Also, adolescents like to use pads to apply their acne medicine, so keep those formulations in mind for this age group, she said.

Dr. Keri said she had no relevant financial disclosures.

MIAMI BEACH – Acne presentation, treatment, and counseling will vary according to whether your patient is a neonate, infant, child, preadolescent, or teenager, according to Dr. Jonette E. Keri.

Courtesy Dr. Lawrence F. Eichenfield

• Neonatal acne. These small, erythematous papules that arise before 6 weeks of life probably represent a heterogenous set of conditions. Ketoconazole cream 2% twice per day is a treatment option.

However, "a lot of doctors choose not to treat because it’s not a scarring process," Dr. Keri said. You can reassure parents that most neonatal acne improves relatively quickly, usually within a few months. If true comedones are present, consider treatment with the same acne mediations indicated for infantile acne.

• Infantile acne. Infantile acne appears in children up to 1 year, usually at 3-6 months of age. Male infants are more prone to acne than female infants, and lesions tend to appear on the cheeks and chin and have the appearance of classic adolescent acne. Increased sebum production and some comedones are often present.

"You should treat because it can cause scarring," Dr. Keri said. Also, "this acne may predispose [children] to worse acne in teenage years – that is shown to be true for any form of infantile acne. It doesn’t have to be severe," said Dr. Keri of the University of Miami and chief of dermatology services at the Miami VA Hospital.

She offered the following clinical tips for treating and managing acne based on developmental age:

Combine treatments and use products appropriate for a baby, Dr. Keri advised at the South Beach Symposium. Although some experts recommend benzoyl peroxide, proceed with caution. The concern is getting any benzoyl peroxide near a baby’s eyes, "so you probably want to stay away from the washes."

Treatment options include topical antibiotics, adapalene, or a retinoid like tretinoin. Oral erythromycin is another acceptable option, she said.

"Isotretinoin is actually indicated if a severe, scarring process is going on," said Dr. Keri. She said that she searched the literature and found that some clinicians prescribe isotretinoin in children as young as 5 months.

• Midchildhood acne. "It is a newer concept, but a very important concept," Dr. Keri said. Acne is relatively rare between the ages of 1 and 8 years. During this time androgens in the body should be low and stable.

If acne does arise, it could point to an underlying hormonal abnormality. Evaluate three things: bone age, the growth chart, and hormone levels. "That may be a bit much for a dermatologist, but a pediatrician does these evaluations often," she said.

Accelerated bone age on a wrist radiograph can point to androgen excess, whereas delayed bone age suggests Cushing’s disease. A growth chart that shows a child’s height crossing percentiles upward or increasing faster than would be expected can also suggest androgen excess.

"Hormone levels can be tricky," Dr. Keri said. High levels of androgens, free testosterone, or dehydroepiandrosterone also can occur with tumors or polycystic ovarian syndrome (PCOS). "Another reason they can be tricky is because the child is developing into an adult, so you may need a pediatric endocrinologist to tease this out."

• Preadolescent acne. Treatments for children aged 9-12 years are essentially the same as for infants and midchildhood patients. However, patient counseling plays a bigger role. "Adherence is a big issue with these kids, so try to give them a once-a-day regimen," Dr. Keri said. Isotretinoin is rarely prescribed in this age group, but if severity dictates the need, it is likely the child will need retreatment (two or three courses) over time.

Comedones, seborrhea, and even PCOS are associated with preteen acne. Rule out precocious puberty and distinguish abnormal hormonal changes from normal signs of puberty, Dr. Keri recommended.

"PCOS is very complicated; you are going to need some help, a multispecialty approach," Dr. Keri said. Early diagnosis is worthwhile, she added. "If you identify PCOS when these young ladies are younger, you can prevent infertility, diabetes, [and] coronary artery disease, because they get these things more often than a woman who doesn’t have PCOS."

• Adolescent acne. Speaking directly and appropriately with teenagers about their acne can facilitate better outcomes, Dr. Keri said. For example, instead of asking, "How many days a week do you use your medicines?" ask, "How do you use your acne medicines?" Also determine their expectations before prescribing, and find out if they have a prom or other major social event coming up.

It is also important to evaluate their previous acne-fighting strategies. "It can be painfully tiring to go through all they have done and used, but if you don’t do that, you’re not going to have a good starting point," she said. Find out what they like and dislike, and really listen to their answers. "They will be honest if you listen to them."

Also, adolescents like to use pads to apply their acne medicine, so keep those formulations in mind for this age group, she said.

Dr. Keri said she had no relevant financial disclosures.

MIAMI BEACH – Acne presentation, treatment, and counseling will vary according to whether your patient is a neonate, infant, child, preadolescent, or teenager, according to Dr. Jonette E. Keri.

Courtesy Dr. Lawrence F. Eichenfield

• Neonatal acne. These small, erythematous papules that arise before 6 weeks of life probably represent a heterogenous set of conditions. Ketoconazole cream 2% twice per day is a treatment option.

However, "a lot of doctors choose not to treat because it’s not a scarring process," Dr. Keri said. You can reassure parents that most neonatal acne improves relatively quickly, usually within a few months. If true comedones are present, consider treatment with the same acne mediations indicated for infantile acne.

• Infantile acne. Infantile acne appears in children up to 1 year, usually at 3-6 months of age. Male infants are more prone to acne than female infants, and lesions tend to appear on the cheeks and chin and have the appearance of classic adolescent acne. Increased sebum production and some comedones are often present.

"You should treat because it can cause scarring," Dr. Keri said. Also, "this acne may predispose [children] to worse acne in teenage years – that is shown to be true for any form of infantile acne. It doesn’t have to be severe," said Dr. Keri of the University of Miami and chief of dermatology services at the Miami VA Hospital.

She offered the following clinical tips for treating and managing acne based on developmental age:

Combine treatments and use products appropriate for a baby, Dr. Keri advised at the South Beach Symposium. Although some experts recommend benzoyl peroxide, proceed with caution. The concern is getting any benzoyl peroxide near a baby’s eyes, "so you probably want to stay away from the washes."

Treatment options include topical antibiotics, adapalene, or a retinoid like tretinoin. Oral erythromycin is another acceptable option, she said.

"Isotretinoin is actually indicated if a severe, scarring process is going on," said Dr. Keri. She said that she searched the literature and found that some clinicians prescribe isotretinoin in children as young as 5 months.

• Midchildhood acne. "It is a newer concept, but a very important concept," Dr. Keri said. Acne is relatively rare between the ages of 1 and 8 years. During this time androgens in the body should be low and stable.

If acne does arise, it could point to an underlying hormonal abnormality. Evaluate three things: bone age, the growth chart, and hormone levels. "That may be a bit much for a dermatologist, but a pediatrician does these evaluations often," she said.

Accelerated bone age on a wrist radiograph can point to androgen excess, whereas delayed bone age suggests Cushing’s disease. A growth chart that shows a child’s height crossing percentiles upward or increasing faster than would be expected can also suggest androgen excess.

"Hormone levels can be tricky," Dr. Keri said. High levels of androgens, free testosterone, or dehydroepiandrosterone also can occur with tumors or polycystic ovarian syndrome (PCOS). "Another reason they can be tricky is because the child is developing into an adult, so you may need a pediatric endocrinologist to tease this out."

• Preadolescent acne. Treatments for children aged 9-12 years are essentially the same as for infants and midchildhood patients. However, patient counseling plays a bigger role. "Adherence is a big issue with these kids, so try to give them a once-a-day regimen," Dr. Keri said. Isotretinoin is rarely prescribed in this age group, but if severity dictates the need, it is likely the child will need retreatment (two or three courses) over time.

Comedones, seborrhea, and even PCOS are associated with preteen acne. Rule out precocious puberty and distinguish abnormal hormonal changes from normal signs of puberty, Dr. Keri recommended.

"PCOS is very complicated; you are going to need some help, a multispecialty approach," Dr. Keri said. Early diagnosis is worthwhile, she added. "If you identify PCOS when these young ladies are younger, you can prevent infertility, diabetes, [and] coronary artery disease, because they get these things more often than a woman who doesn’t have PCOS."

• Adolescent acne. Speaking directly and appropriately with teenagers about their acne can facilitate better outcomes, Dr. Keri said. For example, instead of asking, "How many days a week do you use your medicines?" ask, "How do you use your acne medicines?" Also determine their expectations before prescribing, and find out if they have a prom or other major social event coming up.

It is also important to evaluate their previous acne-fighting strategies. "It can be painfully tiring to go through all they have done and used, but if you don’t do that, you’re not going to have a good starting point," she said. Find out what they like and dislike, and really listen to their answers. "They will be honest if you listen to them."

Also, adolescents like to use pads to apply their acne medicine, so keep those formulations in mind for this age group, she said.

Dr. Keri said she had no relevant financial disclosures.

Ablative fractional laser resurfacing is more effective than nonablative therapy for the treatment of acne scaring, albeit, with greater side effects and pain, according to a new review.

Ms. Michal Wen Sheue Ong and Dr. Saquib Bashir, of King’s College Hospital NHS Foundation Trust in London, conducted literature searches using the PubMed and Scopus databases for English-language articles published between 2003 and January 2011 that reported on "acne scars" and "fractional photothermolysis."

A total of 26 papers, published between 2008 and 2011, met the criteria – 13 papers on ablative fractional lasers and an equal number on nonablative fractional lasers (Br. J. Dermatol. 2012 Feb. 1 [doi: 10.1111/j.1365-2133.2012.10870.x]).

"Most ablative studies reported a percentage of improvement within the range of 26% to 75%," they wrote. In two cases, studies claimed 79.8% and 83% mean improvement, although the reviewers questioned the appropriateness of using mean values rather than medians, given that "the properties of the ordinal scales were unknown and points on the scale were not necessarily equidistant."

The nonablative studies reported an improvement range of 26% to 50%.

Only four studies were split-face randomized controlled trials, and most had follow-up criteria of just 1 to 6 months; only one study included a 2-year follow-up. Moreover, the methods and rating scales for measuring improvement varied widely.

Only five studies analyzed the histological degree of scar improvement, but in these, new collagen formation was noted with both ablative and nonablative fractional photothermolysis.

In one of the nonablative studies included in the review, an increase in elastic fibers framework in the papillary dermis, as well as the upper and mid dermis, was noted 12 weeks after final treatment (Photodermatol. Photoimmunol. Photomed. 2009;25:138-42).

Similarly, using 3D optical profiling, a study of ablative laser resurfacing showed a marked, statistically significant improvement in skin smoothness and scar volume 1 month after treatment. "However, there were no further improvements of skin smoothness or scar volume at 3- and 6-months follow-up," wrote the authors (J. Am. Acad. Dermatol. 2010;63:274-83).

Looking at side effects, "A higher proportion of patients (up to 92.3%) who undertake ablative FP [fractional photothermolysis] experience post inflammatory hyperpigmentation (PIH) than those who have nonablative FP (up to 13%)," wrote the reviewers, with a maximum duration of PIH of up to 6 months in ablative FP, vs. 1 week in nonablative treatment.

Pain ratings for nonablative procedures were also lower, compared with ablative procedures. "The mean pain score reported across ablative FP studies ranged from 5.9-8.1 (scale of 10)," reported the authors. In contrast, the mean pain scores for nonablative FP procedures were rated 3.9-5.7.

The authors pointed out that they found no evidence regarding the effects of FP lasers on patients’ psychological status and quality of life. "This information can be useful and should be obtained before and after treatment," they wrote.

Limitations of the review included the fact that none of the methods of assessing clinical outcome had had its validity or reliability investigated, wrote the reviewers. For the most part, however, the results were promising.

"Most studies had clinicians/dermatologists to assess overall scar improvement, and there were some studies which had patient assessment," they wrote. In many cases the evaluators were blinded, but at least three studies used evaluators who were not.

Fractional photothermolysis laser resurfacing improves facial acne scarring, despite dramatic methodological variability in efficacy studies. Nevertheless, more studies are needed, especially split-face, randomized controlled trials using objective assessment measures of improvement, like histological or 3D optical profiling, they concluded.

The review authors reported having no outside funding and stated that they had no conflicts of interest to declare.

Ablative fractional laser resurfacing is more effective than nonablative therapy for the treatment of acne scaring, albeit, with greater side effects and pain, according to a new review.

Ms. Michal Wen Sheue Ong and Dr. Saquib Bashir, of King’s College Hospital NHS Foundation Trust in London, conducted literature searches using the PubMed and Scopus databases for English-language articles published between 2003 and January 2011 that reported on "acne scars" and "fractional photothermolysis."

A total of 26 papers, published between 2008 and 2011, met the criteria – 13 papers on ablative fractional lasers and an equal number on nonablative fractional lasers (Br. J. Dermatol. 2012 Feb. 1 [doi: 10.1111/j.1365-2133.2012.10870.x]).

"Most ablative studies reported a percentage of improvement within the range of 26% to 75%," they wrote. In two cases, studies claimed 79.8% and 83% mean improvement, although the reviewers questioned the appropriateness of using mean values rather than medians, given that "the properties of the ordinal scales were unknown and points on the scale were not necessarily equidistant."

The nonablative studies reported an improvement range of 26% to 50%.

Only four studies were split-face randomized controlled trials, and most had follow-up criteria of just 1 to 6 months; only one study included a 2-year follow-up. Moreover, the methods and rating scales for measuring improvement varied widely.

Only five studies analyzed the histological degree of scar improvement, but in these, new collagen formation was noted with both ablative and nonablative fractional photothermolysis.

In one of the nonablative studies included in the review, an increase in elastic fibers framework in the papillary dermis, as well as the upper and mid dermis, was noted 12 weeks after final treatment (Photodermatol. Photoimmunol. Photomed. 2009;25:138-42).

Similarly, using 3D optical profiling, a study of ablative laser resurfacing showed a marked, statistically significant improvement in skin smoothness and scar volume 1 month after treatment. "However, there were no further improvements of skin smoothness or scar volume at 3- and 6-months follow-up," wrote the authors (J. Am. Acad. Dermatol. 2010;63:274-83).

Looking at side effects, "A higher proportion of patients (up to 92.3%) who undertake ablative FP [fractional photothermolysis] experience post inflammatory hyperpigmentation (PIH) than those who have nonablative FP (up to 13%)," wrote the reviewers, with a maximum duration of PIH of up to 6 months in ablative FP, vs. 1 week in nonablative treatment.

Pain ratings for nonablative procedures were also lower, compared with ablative procedures. "The mean pain score reported across ablative FP studies ranged from 5.9-8.1 (scale of 10)," reported the authors. In contrast, the mean pain scores for nonablative FP procedures were rated 3.9-5.7.

The authors pointed out that they found no evidence regarding the effects of FP lasers on patients’ psychological status and quality of life. "This information can be useful and should be obtained before and after treatment," they wrote.

Limitations of the review included the fact that none of the methods of assessing clinical outcome had had its validity or reliability investigated, wrote the reviewers. For the most part, however, the results were promising.

"Most studies had clinicians/dermatologists to assess overall scar improvement, and there were some studies which had patient assessment," they wrote. In many cases the evaluators were blinded, but at least three studies used evaluators who were not.

Fractional photothermolysis laser resurfacing improves facial acne scarring, despite dramatic methodological variability in efficacy studies. Nevertheless, more studies are needed, especially split-face, randomized controlled trials using objective assessment measures of improvement, like histological or 3D optical profiling, they concluded.

The review authors reported having no outside funding and stated that they had no conflicts of interest to declare.

Ablative fractional laser resurfacing is more effective than nonablative therapy for the treatment of acne scaring, albeit, with greater side effects and pain, according to a new review.

Ms. Michal Wen Sheue Ong and Dr. Saquib Bashir, of King’s College Hospital NHS Foundation Trust in London, conducted literature searches using the PubMed and Scopus databases for English-language articles published between 2003 and January 2011 that reported on "acne scars" and "fractional photothermolysis."

A total of 26 papers, published between 2008 and 2011, met the criteria – 13 papers on ablative fractional lasers and an equal number on nonablative fractional lasers (Br. J. Dermatol. 2012 Feb. 1 [doi: 10.1111/j.1365-2133.2012.10870.x]).

"Most ablative studies reported a percentage of improvement within the range of 26% to 75%," they wrote. In two cases, studies claimed 79.8% and 83% mean improvement, although the reviewers questioned the appropriateness of using mean values rather than medians, given that "the properties of the ordinal scales were unknown and points on the scale were not necessarily equidistant."

The nonablative studies reported an improvement range of 26% to 50%.

Only four studies were split-face randomized controlled trials, and most had follow-up criteria of just 1 to 6 months; only one study included a 2-year follow-up. Moreover, the methods and rating scales for measuring improvement varied widely.

Only five studies analyzed the histological degree of scar improvement, but in these, new collagen formation was noted with both ablative and nonablative fractional photothermolysis.

In one of the nonablative studies included in the review, an increase in elastic fibers framework in the papillary dermis, as well as the upper and mid dermis, was noted 12 weeks after final treatment (Photodermatol. Photoimmunol. Photomed. 2009;25:138-42).

Similarly, using 3D optical profiling, a study of ablative laser resurfacing showed a marked, statistically significant improvement in skin smoothness and scar volume 1 month after treatment. "However, there were no further improvements of skin smoothness or scar volume at 3- and 6-months follow-up," wrote the authors (J. Am. Acad. Dermatol. 2010;63:274-83).

Looking at side effects, "A higher proportion of patients (up to 92.3%) who undertake ablative FP [fractional photothermolysis] experience post inflammatory hyperpigmentation (PIH) than those who have nonablative FP (up to 13%)," wrote the reviewers, with a maximum duration of PIH of up to 6 months in ablative FP, vs. 1 week in nonablative treatment.

Pain ratings for nonablative procedures were also lower, compared with ablative procedures. "The mean pain score reported across ablative FP studies ranged from 5.9-8.1 (scale of 10)," reported the authors. In contrast, the mean pain scores for nonablative FP procedures were rated 3.9-5.7.

The authors pointed out that they found no evidence regarding the effects of FP lasers on patients’ psychological status and quality of life. "This information can be useful and should be obtained before and after treatment," they wrote.

Limitations of the review included the fact that none of the methods of assessing clinical outcome had had its validity or reliability investigated, wrote the reviewers. For the most part, however, the results were promising.

"Most studies had clinicians/dermatologists to assess overall scar improvement, and there were some studies which had patient assessment," they wrote. In many cases the evaluators were blinded, but at least three studies used evaluators who were not.

Fractional photothermolysis laser resurfacing improves facial acne scarring, despite dramatic methodological variability in efficacy studies. Nevertheless, more studies are needed, especially split-face, randomized controlled trials using objective assessment measures of improvement, like histological or 3D optical profiling, they concluded.

The review authors reported having no outside funding and stated that they had no conflicts of interest to declare.