Arielle R. Nagler

The use of oral antibiotics before isotretinoin therapy in patients with acne

BACKGROUND Systemic antibiotics are used widely to treat moderate to severe acne, but increasing antibiotic resistance makes appropriate use a priority. OBJECTIVE We sought to determine the duration of systemic antibiotic use in patients with inflammatory/nodulocystic acne who eventually required isotretinoin. METHODS We performed a retrospective, single-site chart review of patients with acne diagnostic codes evaluated January 1, 2005 to December 31, 2014, at a dermatology practice in an academic medical center. Included patients were prescribed isotretinoin during the study period and received 30 days or more of antibiotics. RESULTS The average duration of antibiotic use was 331.3 days. In all, 21 patients (15.3%) were prescribed antibiotics for 3 months or less, 88 patients (64.2%) for 6 months or more, and 46 patients (33.6%) for 1 year or longer. Patients treated only at the study site had a mean duration of antibiotic treatment of 283.1 days whereas patients who also received antibiotics from another institution had a mean duration of 380.2 days. This difference approached statistical significance (P = .054). LIMITATIONS This study was limited to a single center. CONCLUSION Expert guidelines recommend responsible use of antibiotics in acne in light of emerging resistance. We found that patients who eventually received isotretinoin had extended exposure to antibiotics, exceeding recommendations. Early recognition of antibiotic failure and the need for isotretinoin can curtail antibiotic use.

Aesthetic use of BoNT: Options and outcomes

There are a multitude of uses for BoNT in the aesthetic realm. Efficacy has been shown in softening glabellar creases, crows feet, forehead rhytides, and in correcting facial asymmetries, including mild eyelid ptosis. Facial shape can be altered through injections of BoNT into masseter, and smiles can be altered with BoNT. Clinical examples of the above will be shown, as well as adverse outcomes with inaccurate injection techniques.

Laser treatments of active acne

The utility of laser therapy is increasingly being recognized in the treatment of active acne vulgaris. We aimed to perform a narrative review of the medical literature on the use of laser therapy for the treatment of active acne vulgaris. We performed a PubMed literature search on September 1, 2016 using the search terms “active acne,” “acne,” “laser therapy,” and “laser surgery.” Case reports, case series, cohort, and controlled trials were included. Studies of lasers in the treatment of acne, including erbium glass, Nd:YAG, pulse dye laser (PDL), potassium titanyl phosphate (KTP) laser, and laser-based photodynamic therapy, have been published. While treatment of active acne with lasers has been successful, many studies are limited by small patient number and lack of control populations and comparison to standard therapies for active acne. Laser therapies are increasingly becoming part of or an adjunct to the medical treatment of active acne and are a useful treatment modality.

Oral Antibacterial Therapy for Acne Vulgaris: An Evidence-Based Review

BackgroundTo some degree, acne vulgaris affects nearly every individual worldwide. Oral antibiotic therapy is routinely prescribed for the treatment of moderate to severe inflammatory acne; however, long-term use of oral antibiotics for acne may have unintended consequences.ObjectiveThe aim of this study was to provide a systematic evaluation of the scientific evidence on the efficacy and appropriate use of oral antibiotics in the treatment of acne.MethodsA systematic search of MEDLINE was conducted to identify randomized controlled clinical trials, systematic reviews, and meta-analyses evaluating the efficacy of oral antibiotics for acne. Overall, 41 articles that examined oral antibiotics compared with placebo, another oral therapy, topical therapy, alternate dose, or duration were included in this study.ResultsTetracyclines, macrolides, and trimethoprim/sulfamethoxazole are effective and safe in the treatment of moderate to severe inflammatory acne. Superior efficacy of one type or class of antibiotic could not be determined, therefore the choice of antibiotic is generally based on the side-effect profile. Although different dosing regimens have been studied, there is a lack of standardized comparator trials to determine optimal dosing and duration of each oral antibiotic used in acne. The combination of oral antibiotics with a topical therapy is superior to oral antibiotics alone.ConclusionThis article provides a systematic evaluation of the scientific evidence of the efficacy of oral antibiotics for acne. Due to heterogeneity in the design of the trials, there is insufficient evidence to support one type, dose, or duration of oral antibiotic over another in terms of efficacy; however, due to increasing resistance to antibiotics, dermatologists should heed consensus guidelines for their appropriate use.

In response to Ginsberg et al: “A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community”

To the Editor: We read with interest the article of Ginsberg et al, ‘‘A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community.’’ Ginsberg et al provided an excellent overview of the surgical and cosmetic interventions that dermatologists may provide to patients undergoing a gender transition. Their article also raised important questions regarding medical dermatology for the transgender community, and in particular, the use of isotretinoin. Dermatologists are familiar with the iPLEDGE system, which regulates the use of isotretinoin. The iPLEDGE program patient introductory brochure consistently refers to patient gender in binary terms, but does not account for the fact that for many patients, gender identity and chromosomal sex may be incongruent. With increased visibility of the transgender community and the risk of acneiform eruptions in patients taking hormones to assist in gender transitions, dermatologists have a duty to be more sensitive to the needs of these patients. Not only does the iPLEDGE system potentially alienate transgendered patients with its binary reference to gender, but it also may inadvertently lead to confusion between the transgendered patient and physician. For example, how should a dermatologist treat a patient who was born with the chromosomal sex of a woman, identifies as male gender, and is currently transitioning to male sex? Although the potential for pregnancy is the main concern in determining laboratory monitoring and counseling for isotretinoin, confusion over sex and gender

Validated Patient-Reported Outcome Measurements for Psoriasis may not Reflect Patients’ Current Preferences

To the Editor: Health care reform initiatives have emphasized patient-reported outcomemeasurements (PROMs) to promote patient-centric services. PROMs have been developed and validated for psoriasis and may be tied to reimbursement going forward. However, it is debated whether existing instruments accurately reflect patients’ priorities given a changing therapeutic landscape. In this study, we characterized current validated psoriasis-specific PROMs (psPROMs) and compared them with patient-reported priorities from a psoriasis specialty clinic. Validated psPROMs were identified through a structured PubMed search. Two investigators independently reviewed and categorized the questions in each psPROM into 6 focus areas: clearance, cost, mood and quality of life (MQOL), symptoms, frequency of doctor visits (FDV), and treatment form. Additionally, an 8-question survey regarding patients’ perceptions of disease severity, therapy preferences, and treatment priorities and satisfaction was administered to English-speaking

Androgens in Women: Androgen mediated skin disease and patient evaluation (Part I)

Androgens are produced throughout the body in steroid-producing organs, such as the adrenal glands and ovaries, and in other tissues, like the skin. Several androgens are found normally in women, including dehydroepiandrosterone, dehydroepiandrosterone-sulfate, testosterone, dihydrotestosterone, and androstenedione. These androgens are essential in the development of several common cutaneous conditions in women, including acne, hirsutism, and female pattern hair loss (FPHL)-androgen-mediated cutaneous disorders (AMCDs). However, the role of androgens in the pathophysiology of these diseases is complicated and incompletely understood. In the first article in this Continuing Medical Education series, we discuss the role of the skin in androgen production and the impact of androgens on the skin in women. Specifically, we review the necessary but insufficient role that androgens play in the development of acne, hirsutism, and FPHL in women. Dermatologists face the challenge of differentiating physiologic from pathologic presentations of AMCDs in women. There are currently no dermatology guidelines outlining the indications for endocrinologic evaluation in women presenting with acne, hirsutism, or FPHL. We review the available evidence regarding when to consider an endocrinologic workup in women presenting with AMCDs, including the appropriate type and timing of testing.

Clinical evidence for washing and cleansers in acne vulgaris: a systematic review

Abstract Purpose: Washing and over-the-counter cleansers are common interventions in acne vulgaris (AV), but the clinical evidence for their benefit is poorly understood. This systematic review presents clinical studies of washing and cleanser efficacy in acne vulgaris to guide treatment recommendations of dermatologists. Materials and methods: We surveyed English-language articles indexed in MEDLINE (1951–March 2017) and EMBASE (1974–March 2017). Articles were required to be prospective studies of a single over-the-counter cleanser or washing intervention in AV with an objective AV outcome measurement published in a peer-reviewed journal. Results and conclusions: Fourteen prospective studies representing 671 participants were included in this review. Modalities investigated included face washing frequency, true soap/syndet cleansing bars, antiseptic cleansers, alpha and beta-hydroxy (i.e. salicylic) acid cleansers, and several proprietary formulations. Given the low number of well-performed clinical studies of cleansers and washing, it is difficult to formulate reliable recommendations. We hope that our findings highlight the necessity of further investigation in this area.