Acne is one of the most common disorders treated by dermatologists and other health care providers. While it most often affects adolescents, it is not uncommon in adults and can also be seen in children. This evidence-based guideline addresses important clinical questions that arise in its management. Issues from grading of acne to the topical and systemic management of the disease are reviewed. Suggestions on use are provided based on available evidence.

https://www.jaad.org/article/S0190-9622(15)02614-6/pdf

Guidelines of care for the management of acne vulgaris

Disclaimer Adherence to these guidelines will not ensure successful treatment in every situation. Furthermore, these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient.

https://www.huidziekten.nl/richtlijnen/AAD-guideline-acne-vulgaris-2007.pdf

Guidelines of care for acne vulgaris management.

Context: Cushing's syndrome (CS) is a disorder associated with significant morbidity and mortality due to prolonged exposure to high cortisol concentrations. Objective: Our objective was to evaluate the safety and efficacy of mifepristone, a glucocorticoid receptor antagonist, in endogenous CS. Design and Setting: We conducted a 24-wk multicenter, open-label trial after failed multimodality therapy at 14 U.S. academic medical centers and three private research centers. Participants: Participants included 50 adults with endogenous CS associated with type 2 diabetes mellitus/impaired glucose tolerance (C-DM) or a diagnosis of hypertension alone (C-HT). Intervention: Mifepristone was administered at doses of 300-1200 mg daily. Main Outcome Measures: We evaluated change in area under the curve for glucose on 2-h oral glucose test for C-DM and change in diastolic blood pressure from baseline to wk 24 for C-HT. Results: In the C-DM cohort, an area under the curve for glucose (AUCglucose) response was seen in 60...

/pdf/mifepristone-a-glucocorticoid-receptor-antagonist-produces-nzzuev0d72.pdf

Mifepristone, a Glucocorticoid Receptor Antagonist, Produces Clinical and Metabolic Benefits in Patients with Cushing's Syndrome

Background Acne vulgaris is a distressing condition that affects the majority of adolescents, but its impact on mental health in this age group is poorly understood.

Objectives To determine the prevalence of acne, knowledge about acne and rates of help-seeking behaviour in English teenagers. It was hypothesized that presence of acne would be associated with higher rates of emotional and behavioural difficulties.

Methods Three hundred and seventeen pupils (80% response rate) aged 14–16 years participated from a comprehensive school in Nottingham. An age-appropriate, validated measure of emotional well-being, the Strengths and Difficulties Questionnaire (SDQ), and an Acne Management Questionnaire were used to assess participants' psychological health, level of acne knowledge and help-seeking behaviour. Acne severity was by graded by visual facial examination using an adaptation of the Leeds Acne Grading Technique.

Results There was a prevalence of acne in 50% of the study sample, with 11% of participants having moderate to severe acne (> 20 inflammatory lesions). Participants with definite acne (12+ lesions) (P < 0·01) and girls (P < 0·05) had higher levels of emotional and behavioural difficulties. Participants with acne were nearly twice as likely as those without acne to score in the abnormal/borderline range of the SDQ (32% vs. 20%; odds ratio 1·86, 95% confidence interval 1·03–3·34). Knowledge about the causes of acne was low (mean 45%), and was unrelated to acne status. Fewer than a third of participants with definite acne had sought help from a doctor.

Conclusions Acne is a common disorder in English adolescents and appears to have a considerable impact on emotional health in this age group. Low levels of acne knowledge and poor acne management are concerns that could be amenable to a school-based education programme.

Acne prevalence, knowledge about acne and psychological morbidity in mid-adolescence: a community-based study

Background The reported prevalence of acne in adolescence is variable; improved treatment may have modified its prevalence and severity; acne has been related to psychiatric morbidity for many years.



Methods Two thousand six hundred and fifty-seven high school students were examined, and adolescents with acne were interviewed about the subject of acne vulgaris. The severity of acne was graded using the Global Acne Grading System (GAGS). The Hospital Anxiety and Depression (HAD) scale was evaluated for one of every two subjects with acne (n = 308) and for the same number of sex-matched control subjects (n = 308) to determine the prevalence of depression and anxiety.



Results Six hundred and fifteen of the subjects (23.1%) were determined to have acne. Acne prevalence in girls and boys was 16.1% and 29.2%, respectively (P < 0.001). Two hundred and twenty-five (15.8%) of 1424 boys and only 109 (8.8%) of 1233 girls had moderate or severe/very severe acne (P < 0.001), but the GAGS scores in the groups of boys and girls with acne were not significantly different. The acne and control groups showed no significant differences in the HAD anxiety and depression subscale scores. The HAD anxiety subscale scores of girls were significantly higher than those of boys in the acne group. The severity of acne was not correlated with the HAD anxiety or depression subscale scores.



Conclusions Acne results in higher anxiety in adolescent girls. Although acne and moderate/severe acne are more common in adolescent boys, the severity of acne was found to be similar in boys and girls with acne. Adolescent girls are more vulnerable than boys to the negative psychological effects of acne.

Anxiety, depression, and nature of acne vulgaris in adolescents.

416 Systematic assessment of the severity of acne vulgaris continues to challenge the clinician. Acne is a pleomorphic disorder of variable course and anatomical distribution. For these reasons, no system has been accepted universally. An ideal grading system would (i) be accurate and reproducible, (ii) be simple to use by the clinician over serial office visits, (iii) eliminate the tediousness of lesion counting and the expense of photography, and (iv) reflect subjective criteria, i.e. psychosocial factors. Several research studies attempting to quantify the psychopathologic effect of acne have yielded iticotisistent results.' Until a more reliable quantitative psychometric instrument is developed, the psychosocial impact of acne must be documented elsewhere in the patient's record.

A comparison of current acne grading systems and proposal of a novel system

334 tn clinical dermatology, especially in drug trials, measurement of erythema is of paramount itnportance. Erythema is one of the most important parameters in the visual assessment of skin lesions. For example, the clitiical assessment of psoriasis includes evaluatioti of three major parameters: erythema, thickness, and scale. In atopic dermatitis, the clinical evaluation may include erythema as well as induration, oozing/weeping/crusting, scaling/ dryness, excoriation, and lichenification. Assessment of erythema is critical in determining the severity of allergic and irritant contact dermatitis, especially in patch testing, and in assessing the irritancy of cosmetics,^ Erythema is also crucial in evaluating the cutaneous response to ultraviolet radiation and in quantitating the efficacy of sunscreens. The measurement of erythema is therefore important in determining the severity of skin disease, the efficacy of pharmacologic agents, and the degree of irritancy of topical medications and cosmetics. The contact dermatitis clinic is the best known and most widely utilized testing ground for evaluating differetit methods of quantitating erythema. Visual grading of erythema as well as edema, scaling, and fissuring lacks objectivity and parametric properties;^ however, many instrumental methods of measuring irritancy are not applicable to the assessment of erythema alone. Eor example, the measurement of transepidermal water loss (TEWL) is based on the fact that the cutaneous water barrier becomes deficient in irritant skin reactions,' but TEWL does not by itself measure erythema. High-frequency ultrasound measurement of skin thickness and edema"* is also not useful for assessing erythetna as a single parameter. Similarly, electrical impedance measures the response of the skin to irritation without assessing erythema.5 Infrared thermography measures heat in the form of infra-red emissions from the skin surface. The temperature and area involved determine the severity of the response,^ but this technique also lacks the ability to assess erythema. Methods to assess erythema as a single variable include visual grading, laser Doppler flowmetry (LDF), photoplethysmography (PPG), diffuse refiectance spectroscopy (DRS), colorimetry, spectroradiotnetry, and the use of the two-channel erythema meter, all of which will be discussed below.

Methods for assessing erythema: a critique of parametric and nonparametric techniques

expression of inducible nitric oxide synthase in experimentally induced neurologic diseases. Proc NatI Acad Sci USA 1993; 90:3024-3027. 4. lalenti A, Laiiaro A, Moncada S, et al. Modulation of acute inflammation by endogenous nitric oxide. Eur J Pharmacol 1992; 211:177-182. 5. McCartney-Erancis N, Allen HB, Mizcl DE, et al. Suppression of arthritis by an inhibitor of nitric oxide syntbase. J Exp Med 1993; 178:749-754. 6. Eari-ell AJ, Blake DR, Palmer RMJ, et al. Increased concentrations of nitrite in synovial fluid and serum samples suggest increased nitric oxide synthesis in rheumatic disease. Ann Rheum 1992; 51:1219-1222.

Ahmed Zaheer

Papers

A comparison of current acne grading systems and proposal of a novel system

Methods for assessing erythema: a critique of parametric and nonparametric techniques

Umbilicated lesions in leprosy.