Truncal Acne Research Articles

Malassezia Folliculitis versus Truncal Acne Vulgaris (Clinical and Histopathological Study)

Background: Malassezia folliculitis is an infection of the hair follicle, which commonly affects young adult, and is often misdiagnosed as truncal acne. Objectives: To shed light on different clinical, histopathological, and microbiological aspects of Malassezia folliculitis and to be compared with truncal acne. Patients and Methods: This is a descriptive comparative cross sectional, out patient based study, which was conducted at the Department of Dermatology, Basrah Teaching Hospital from October 2008 to October 2009. Total number of 113 patients with papular and/or pustular follicular skin lesions on the trunk were enrolled in this study. They were divided according to the clinical features, Wood’s light examination, direct microscopic examination, PAS stained skin biopsy and the response to a trial of antifungal drugs into two groups: group 1: patient with Malassezia folliculitis and group 2: patient with truncal acne vulgaris. Results: Group 1: They were 53(46.9%) out of a total 113, 33(62.3%) males and 20(37.7%) females, their ages ranged from 19 - 40 years. Group 2 consisted of 60(53.1%) patients, 25(41.6%) males and 35(58.4%) females, whose ages ranged from 14 - 29 years. The ages were earlier in the acne group in comparison with MF group (p Malassezia folliculitis was more common among males than females, while in truncal acne, females predominated males. The center of the back was the predominant site among MF group affecting (90.6%) of patients with sparing the face, in contrast to truncal acne where the periphery of the back was involved in (91.7%) and the face in (75%) (p 0.0001). Wood’s light examination, skin scrapping and PAS stained skin biopsies were also positive in all patients with MF in contrast to acne group where all these tests were negative. All MF patients showed marked response to a two weeks trial of antifungal while the reverse is true for the acne patients, whereas the antibiotic was the second most common leading aggravating factor in 20 (37.7%) of cases with MF, which was significantly different from acne group (p 0.0001). Conclusion: Malassezia folliculitis should be considered in young adults with an itchy papulopustulr follicular eruptions affecting the trunk that should be differentiated from truncal acne by their characteristic clinical, histopathological features and its remarkable response to antifungal therapy.

A Single‐Blinded, Randomized Pilot Study to Evaluate the Effect of Exercise‐Induced Sweat on Truncal Acne

To assess the effect of exercise-induced sweat on truncal acne, a prospective, single-blinded, randomized, controlled, institution review board-approved clinical trial was conducted on physically active males. Subjects were instructed to exercise long enough to break a sweat 5 days a week for 2 weeks. Group 1 did not exercise (n = 7), group 2 showered within 1 hour of exercise (n = 8), and group 3 waited at least 4 hours to shower after exercising (n = 8). No statistically significant differences in truncal acne were noted between (p = 0.84) nor within (p = 0.74 for group 1, 0.07 for group 2, and 0.09 for group 3) study groups at the end of the study period.

Development and Validation of a Comprehensive Acne Severity Scale

Although more than 25 acne grading systems exist, only 2 are inclusive of truncal acne. There is neither a gold standard nor a consistently used standardized system. Our purpose was to develop and validate an acne grading system incorporating severity at the face, chest, and back. We developed a comprehensive acne severity scale (CASS) by modifying a preexisting facial acne scale, the Investigator Global Assessment, to include truncal acne. The validity and responsiveness of CASS grades were correlated with Leeds scores at baseline and after 6 months of standard acne treatment. Spearman correlations were significant between Leeds and CASS grades for the face (0.823), chest (0.854), and back (0.872), respectively (p < .001). After 6 months of therapy, changes in these scores were also significantly correlated (p < .001) at all three sites. Concurrent validity of CASS is demonstrated by a very strong correlation with Leeds grading. CASS is simpler to use than the Leeds system and more appropriate for translation of research trial results to clinical practice.

Patients' Reluctance to Seek Treatment For Truncal Acne Surprisingly Common

Patients' Reluctance to Seek Treatment For Truncal Acne Surprisingly Common

Prevalence of truncal acne vulgaris: A population study based on private practice experience

Prevalence of truncal acne vulgaris: A population study based on private practice experience

Successful Acne Management in Apert Syndrome Twins

Apert syndrome, or acrocephalosyndactyly, is characterized by craniosynostosis and early epiphyseal closure resulting in various deformities of the skull, hands, and feet. Typically a sporadic condition, autosomal dominant inheritance with complete penetrance has been known to occur. Most adolescents with the disorder are prone to the development of severe pustular facial and truncal acne, with extension to the upper arms and forearm. We report twin brothers with Apert syndrome who, after 2 years of standard management by their pediatrician, were referred for management of complicated acne. In our patients there were a constellation of findings consistent with the disorder and, of importance to this report, significant dermatological manifestations. On presentation, each brother was found to have acne vulgaris of a different stage. Our patients were refractory to conventional treatment for acne but one required and had a significant response to isotretinoin. The risk/benefit ratio in treating acne lesions with isotretinoin in a teenager with Apert syndrome is reviewed.

Debunking the exercise and acne myth: A single-blinded randomized study on the effect of exercise-induced occlusion on truncal acne

Debunking the exercise and acne myth: A single-blinded randomized study on the effect of exercise-induced occlusion on truncal acne

Randomised controlled multiple treatment comparison to provide a cost-effectiveness rationale for the selection of antimicrobial therapy in acne

To determine the relative efficacy and cost-effectiveness of five of the most commonly used antimicrobial preparations for treating mild to moderate facial acne in the community; the propensity of each regimen to give rise to local and systemic adverse events; whether pre-existing bacterial resistance to the prescribed antibiotic resulted in reduced efficacy; and whether some antimicrobial regimens were less likely to give rise to resistant propionibacterial strains. This was a parallel group randomised assessor-blind controlled clinical trial. It was a pragmatic design with intention-to-treat analysis. All treatments were given for 18 weeks, after a 4-week treatment free period. Outcomes were measured at 0, 6, 12 and 18 weeks. Primary care practices and colleges in and around Nottingham and Leeds, and one practice in Stockton-on-Tees, England. Participants were 649 people aged 12--39 years, all with mild to moderate inflammatory acne of the face. Study participants were randomised into one of five groups: 500 mg oral oxytetracycline (non-proprietary) twice daily (b.d.) + topical vehicle control b.d.; 100 mg oral Minocin MR (minocycline) once daily (o.d.) + topical vehicle control b.d.; topical Benzamycin (3% erythromycin + 5% benzoyl peroxide) b.d. + oral placebo o.d.; topical Stiemycin (2% erythromycin) o.d. + topical Panoxyl Aquagel (5% benzoyl peroxide) o.d. + oral placebo o.d., and topical Panoxyl Aquagel (5% benzoyl peroxide) b.d. + oral placebo o.d. (the active comparator group). The two primary outcome measures were: (1) the proportion of patients with at least moderate self-assessed improvement as recorded on a six-point Likert scale, and (2) change in inflamed lesion count (red spots). The best response rates were seen with two of the topical regimens (erythromycin plus benzoyl peroxide administered separately o.d. or in a combined proprietary formulation b.d.), compared with benzoyl peroxide alone, oxytetracycline (500 mg b.d.) and minocycline (100 mg o.d.), although differences were small. The percentage of participants with at least moderate improvement was 53.8% for minocycline (the least effective) and 66.1% for the combined erythromycin/benzoyl peroxide formulation (the most effective); the adjusted odds ratio for these two treatments was 1.74 [95% confidence interval (CI) 1.04 to 2.90]. Similar efficacy rankings were obtained using lesion counts, acne severity scores and global rating by assessor. Benzoyl peroxide was the most cost-effective and minocycline the least cost-effective regimen (ratio of means 12.3; difference in means -0.051 units/GBP, 95% CI -0.063 to -0.039). The efficacy of oxytetracycline was similar to that of minocycline, but at approximately one-seventh of the cost. For all regimens, the largest reductions in acne severity were recorded in the first 6 weeks. Reductions in disability scores using the Dermatology Quality of Life Scales were largest for both topical erythromycin-containing regimens and minocycline. The two topical erythromycin-containing regimens produced the largest reductions in the prevalence and population density of cutaneous propionibacteria, including antibiotic-resistant variants, and these were equally effective in participants with and without erythromycin-resistant propionibacteria. The clinical efficacy of both tetracyclines was compromised in participants colonised by tetracycline-resistant propionibacteria. None of the regimens promoted an overall increase in the prevalence of antibiotic-resistant strains. Systemic adverse events were more common with the two oral antibiotics. Local irritation was more common with the topical treatments, particularly benzoyl peroxide. Residual acne was present in most participants (95%) at the end of the study. The response of mild to moderate inflammatory acne to antimicrobial treatment in the community is not optimal. Only around half to two-thirds of trial participants reported at least a moderate improvement over an 18-week study period; extending treatment beyond 12 weeks increased overall benefit slightly. Around one-quarter dropped out when using such treatments, and 55% sought further treatment after 18 weeks. Topical antimicrobial therapies performed at least as well as oral antibiotics in terms of clinical efficacy. Benzoyl peroxide was the most cost-effective and minocycline the least cost-effective therapy for facial acne. The efficacy of all three topical regimens was not compromised by pre-existing propionibacterial resistance. Benzoyl peroxide was associated with a greater frequency and severity of local irritant reactions. It is suggested that the use of a combination of topical benzoyl peroxide and erythromycin gives less irritation and better quality of life. There was little difference between erythromycin plus benzoyl peroxide administered separately and the combined proprietary formulation in terms of efficacy or local irritation, except that the former was nearly three times more cost-effective. The data on cost-effectiveness, and outcomes in patients with resistant propionibacterial floras, did not support the first line use of minocycline for mild to moderate inflammatory acne of the face. Three priority areas for clinical research in acne are: defining end-points in acne trials (i.e. what is a satisfactory outcome?); developing and validating better patient-based measures for assessing treatment effects on facial and truncal acne; and exploring patient characteristics that may modify treatment effects (efficacy and tolerability).

The Leeds revised acne grading system

A simple, reproducible and rapid means of assessing a patients acne is essential for the GP, dermatologist and clinical trialist. In this article a colour photographic acne grading scheme for the face and trunk (back and chest) is presented. A series of colour photographs of facial and truncal acne were examined and ranked in order of severity. The criteria for severity included extent of inflammation, range and size of inflamed lesions and associated erythma. This produced 12 colour pictorial grades of facial acne and 8 grades for the back and 8 grades for the chest. Also a basis for grading non-inflamed acne is introduced.

Treatment of acne with intermittent isotretinoin

Adults with acne represent an increasingly important population of acne sufferers referred for treatment. Acne, in these patients, is generally mild or moderate in severity but tends to be resistant to conventional antibiotic therapy. A study was carried out to assess the efficacy of intermittent moderate dose isotretinoin as a treatment for acne. Eighty consecutive patients, over the age of 25 years, referred with acne unresponsive to, or relapsing rapidly after three or more courses of conventional antibiotic therapy were recruited. Acne severity was assessed on the face, chest and back using the Leeds grading scale and the number of inflamed lesions was counted at the site showing the highest acne grade. The patients were 22 men and 58 women. The treatment regimen consisted of isotretinoin, 0.5 mg/kg per day for 1 week in every 4 week for a total period of 6 months. Seventy-five patients completed the study. The therapy was very well tolerated with mild cheilitis as the only side-effect. At the end of treatment, both total acne grade and lesion counts were significantly reduced (P < 0.0001). The acne had resolved in 68 (88%) patients. Twelve months after treatment, acne grades and inflamed lesion counts remained significantly improved (P < 0.0001) in the 68 patients who responded; however, 26 (39%) patients had relapsed. There was a significantly higher incidence of relapse in patients with predominantly truncal acne (P = 0.01). Patients who relapsed also had a significantly higher total acne grade, lesion count (P < 0.0001) and sebum excretion rate (P < 0.001) compared with those whose acne resolved. This study suggests that intermittent moderate dose isotretinoin may be a cost-effective alternative to full dose isotretinoin in a carefully selected group of adult patients with-acne. Selection criteria should include predominantly facial acne, total acne grade less than 1, inflamed lesion count less than 20 and sebum excretion rate less than 1.25 micrograms/cm2 per min.

Isotretinoin for acne vulgaris-10 years later; a safe and successful treatment

The purpose of this study was to assess the long-term benefit of isotretinoin in otherwise therapy-resistant acne. We also assessed risk factors which might influence the long-term outcome. We studied 88 patients (mean age 20.8 years), most of whom had suffered from acne for many years (mean 7.4 years). They received isotretinoin in an initial dose of 0.5 or 1.0 mg/kg/day. The dose was subsequently adjusted according to response and side-effects. Most patients only required 4 months' therapy to produce at least 85% clinical improvement. The patients were seen up to 10 years post-therapy (mean 9 years). Sixty-one patients were still virtually clear of disease. Of the others, 16% required further treatment with conventional antibiotics and 23% required a second course of isotretinoin. Of those who relapsed, 96% did so within 3 years of stopping therapy. The patients' age, sex, and duration of acne did not influence outcome. However, in patients with predominantly truncal acne, especially when severe, there was an increased incidence of relapse. Sebum excretion is known to correlate with acne severity, but the long-term degree of sebum suppression was found not to be related to relapse. The dose schedule, in particular cumulative dose, was an important factor in determining relapse rate. Those patients who received 0.5 mg/kg daily, or a cumulative dose of < 120 mg/kg, had a significantly higher relapse rate than patients receiving a larger dose. We did not elicit any long-term systemic or biochemical side-effects. We conclude that isotretinoin is a safe and effective therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Guidelines for optimal use of isotretinoin in acne

Isotretinoin is most effective for patients with acne who fail to respond to other forms of treatment; virtually all patients respond to isotretinoin, 0.5 to 1.0 mg/kg/day. As many as 61% of patients are cured after one course, but 39% require further isotretinoin (16%) or oral antibiotics (23%). The relapse rate can be reduced by the administration of the higher dose of 1 mg/kg/day (thus achieving a significant cumulative dose of > 120 mg/kg), especially to young patients and men with truncal acne and more severe disease. About 85% require a 4-month course, but 15% require longer treatment, with some up to 10 months. There are several reasons for a slow response to treatment, including the presence of macrocomedones, ovarian dysfunction, and as-yet unknown factors. Macrocomedones can be treated with light cautery, ovarian dysfunction with hormonal therapies, and in those persons who have no obvious explanation for slow response, persistence with isotretinoin alone is required. Repeat courses of isotretinoin can also be given. Six years ago most patients treated with isotretinoin had severe acne (60%), but today most patients (60%) have therapy-resistant moderate acne. Isotretinoin is a consideration in such patients to reduce the physical and psychological effects of acne, particularly because there is no simple method to treat acne scars.

Effects of Chronic Testosterone Administration in Normal Men: Safety and Efficacy of High Dosage Testosterone and Parallel Dose-Dependent Suppression of Luteinizing Hormone, Follicle-Stimulating Hormone, and Sperm Production*

In normal men, chronic testosterone (T) administration results in negative feedback suppression of gonadotropin and sperm production. However, azoospermia is achieved in only 50-70% of men treated with high dosages of T. Furthermore, the relative sensitivity of LH and FSH secretion to chronic administration of more physiological dosages of T is unclear. We determined whether a T dosage higher than those previously given would be more or less effective in suppressing spermatogenesis and whether, within the physiological range, T would exert a more selective effect on LH than on FSH secretion. After a 4- to 6-month control period, 51 normal men were randomly assigned to treatment groups (n = 9-12/group) receiving either sesame oil (1 mL) or T enanthate (25, 50, 100, or 300 mg, im) weekly for 6 months. Monthly LH and FSH levels by RIA and twice monthly sperm counts were determined. During treatment, T levels were measured daily between two weekly injections. Chronic T administration in physiological to moderately supraphysiological dosages resulted in parallel dose-dependent suppression of LH, FSH, and sperm production. T enanthate (50 mg/week) suppressed LH and FSH levels and sperm counts to 50% of those in placebo-treated men (ED50). T enanthate (300 mg/week), was no more effective than 100 mg/week in suppressing LH, FSH, and sperm production. Serum T levels in men who received 100 and 300 mg/week T enanthate were 1.5- and 3-fold higher than those in placebo-treated men, respectively. Except for mild truncal acne, weight gain, and increases in hematocrit, we detected no significant adverse health effects of chronic high dosage T administration. We conclude that 1) LH and FSH secretion are equally sensitive to the long term negative feedback effects of T administration; 2) sperm production is suppressed in parallel with the LH and FSH reductions induced by chronic T administration; and 3) even at the clearly supraphysiological dosage of 300 mg/week, T enanthate does not reliably induce azoospermia in normal men. However, there was also no evidence of a stimulatory effect of this T dosage on spermatogenesis. Furthermore, we found no evidence of major adverse health effects of T administered chronically even at the highest dosage.

Strategy of acne therapy with long-term antibiotics

A study of the outcome of conventional antibiotic treatment in 543 patients with acne was performed. All were treated initially with erythromycin 1 g/day and topical 5% benzoyl peroxide. The median improvement at 6 months was 78%, with an interquartile range of 67-90%. Four-hundred and eight of the 492 who completed 6 months' treatment showed over 50% improvement and 247 of the 279 patients treated for a subsequent 6 months with benzoyl peroxide alone, continued to do well. Another subgroup of 174 patients, was continued for 6 months with systemic antibiotic and 5% benozyl peroxide. No significant benefit was gained, however, by maintaining successfully treated patients on a further 6 months of systemic antibiotics. Of the 84 patients who did less well, 18 were given alternative treatment (Diane, isotretinoin). The other 60, subsequently referred to as slow responders, were continued on antibiotics (erythromycin, 31; minocin, 29; cotrimoxazole, 4; trimethoprim, 2) and benzoyl peroxide. Those prescribed minocycline for the second 6 months appeared to have greater benefit (64%) than those receiving erythromycin (57%). This level of improvement was still lower than that seen in those who responded well within 6 months (78%). Of the risk factors analysed, the poorest response occurred in males with truncal acne. Age at presentation, duration and severity did not adversely affect therapeutic outcome. Side-effects were minimal.

The use and long-term benefit of isotretinoin

Isotretinoin is effective in the treatment of acne, but at low doses (0·1 mg/kg) many patients relapse. Over the past 5 years we have treated 250 patients with either 0·5 mg/kg or 1·0 mg/kg of isotretinoin and have followed them up for up to 3 years to determine the relapse rate. All patients in each dose group responded well, with a 90% improvement in acne grade. The majority (86%) needed only 4 months'treatment, but 13% needed 6 months, and two patients required 9 months of continuous therapy. Patients with marked mucous membrane side‐effects tended to respond better than those without such side‐effects. The relapse rate in the 0·5 mg/kg group was significantly greater (42%) than in the 1·0 mg/kg group (13%) (P < 0·01); relapse was defined as the need for further oral therapy—either antibiotics or isotretinoin. Truncal acne was more likely to relapse than facial acne (P < 0·05). Younger patients relapsed more quickly than older patients (P < 0·05). Patients treated with isotretinoin fell into one of five categories: (i) severe acne with isotretinoin as first‐line therapy (18%); (2) failure to improve on conventional antibiotic therapy (55%); (3) rapid relapse after two courses of conventional antibiotic therapy (21%); (4) Gram‐negative folliculitis (3%); and (5) severe psychological disturbance about minor degrees of acne that normally would not require isotretinoin (3%). We thus recommend 1·0 mg/kg as the best dose of isotretinoin for long‐term benefit in acne, and that isotretinoin should now be considered as part of the treatment for less severe types of acne.

Evolution of a strategy for the treatment of acne

The management of skin disease may differ in different parts of the world, but in most countries, acne should be a most treatable disease. Acne therapy has not evolved in the most logical fashion, but this article reviews our demonstration of risk factors in the treatment of acne. Young patients, male patients, truncal acne, a marked seborrhea, and a low dose (500 mg/day or less) of tetracycline are factors associated with a poorer response and, when oral therapy is stopped, a greater relapse rate. One gram a day of tetracycline, given for 6 months, is the minimum course of oral therapy and should be given along with topical therapy. One of the most widely used topical treatments is benzoyl peroxide, and this presentation was given in honor of Dr. William Pace, who was possibly the first dermatologist to be aware of the benefit of benzoyl peroxide--a fact not adequately recorded in dermatologic history. A small number of patients do not respond well to conventional therapy, but alternative treatments should bring about a successful outcome. Alternative treatments include hormonal therapy (i.e., 2 mg cyproterone acetate plus 50 micrograms ethinyl estradiol; spironolactone, 100 mg twice daily; or isotretinoin, 1 mg/kg). The success of all these treatments bears some relationship to their effect in modulating the etiologic factors of acne: an enhanced sebum production, increased ductal cornification, abnormal bacterial colonization, and the production of inflammation. Isotretinoin is the most beneficial of all drug regimens, and this fact no doubt relates to its favorable effect on all etiologic factors.

Isotretinoin – An Explanation for Its Long-Term Benefit

Isotretinoin is of undisputed benefit in the treatment of acne. In doses of 1 mg/kg/day for 4 months the drug produces a highly significant reduction in sebum excretion rate (90 +/- 3%) in comedone formation as measured by assessing follicular casts (70 +/- 5%), and in surface Propionibacterium acnes. However, the mechanisms of long-term clinical remission are not well understood. There are however, risk factors which predetermine the outcome to treatment with isotretinoin. Younger subjects (14-19 years) and those who have had acne for less than 6 years, respond less well than older subjects. Subjects with more truncal acne also fare less well than those with predominantly facial acne. A return of the reduced sebum excretion rate to within 10% of the pre-treatment level also is a poor prognostic factor. This and future studies could lead to development of more logical dose regimes depending, for example, on the age of the patient; duration of acne and its site. However, until proven otherwise, this study confirms our earlier data, and that of the German multi-centres and Strauss et al (1), that the optimum dose schedule for treating acne patients is 1 mg/kg/day regime.

Evaluation of a therapeutic strategy for the treatment of acne vulgaris with conventional therapy.

Four hundred and twenty patients with moderate to severe acne vulgaris were treated with oral erythromycin and topical benzoyl peroxide to determine the optimum dose regimes. Our results show that the response was significantly less in patients with a greater severity of acne, with truncal acne and in those with a higher sebum excretion rate. There was a significantly better clinical result in patients given Ig erythromycin daily than in those given 0.5 g daily (plus topical therapy in both groups). The relapse rate on stopping antibiotics is also significantly less in patients given I g daily and this dosage did not produce any increase in side effects. We suggest that any patient requiring oral antibiotics should initially be given I g daily of erythromycin (or tetracycline) for up to six months, plus topical therapy.