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World Clinics Dermatology Acne Prelims_ACNE.indd 30-11-2013 17:37:29 Prelims_ACNE.indd 30-11-2013 17:37:29 World Clinics Dermatology Acne Editor-in-Chief Neena Khanna MD Guest Editor Raj Kubba MBBS MRCP (UK) FRCP (Canada) FRCP (Edinburgh) December 2013 Volume Number Jaypee Brothers Medical Publishers (P) Ltd New Delhi London Philadelphia Panama Prelims_ACNE.indd 30-11-2013 17:37:30 Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83 Victoria Street, London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: info@jpmedpub.com Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama Phone: +1 507-301-0496 Fax: +1 507-301-0499 Email: cservice@jphmedical.com Jaypee Medical Inc The Bourse 111 South Independence Mall East Suite 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liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work If not specifically stated, all figures and tables are courtesy of the contributing authors Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device Cover images: (Left) Mixed inflammatory, non-inflammatory lesions at lower face and chin Courtesy: Alison M Layton and Rebecca L Mawson (Middle) Inflammatory acne and scarring Courtesy: Alison M Layton and Rebecca L Mawson (Right) Lower face acne aggravated by topical pimecrolimus Courtesy: Raj Kubba World Clinics Dermatology: Acne December 2013, Volume 1, Number ISSN: 2347-7156 ISBN: 978-93-5090-976-8 Printed in India Prelims_ACNE.indd 30-11-2013 17:37:30 Contributors Editor-in-Chief Neena Khanna MD Professor, Department of Dermatology and Venereology All India Institute of Medical Sciences New Delhi 110 029, India Guest Editor Raj Kubba Mbbs Mrcp (UK) Frcp (Canada) Frcp (Edinburgh) Diplomate American Board of Dematology Delhi Dermatology Group, New Delhi 110 066, India Department of Dermatology, Boston University School of Medicine, Boston, MA, USA Contributing Authors Ma Flordeliz Abad-Casintahan MD FPDS Vice Chairman & Training Officer Department of Dermatology, Jose R Reyes Memorial Medical Center Manila, Philippines Craig G Burkhart MD MPH Clinical Professor, Department of Medicine The University of Toledo College of Medicine Clinical Assistant Professor, Department of Medicine Ohio University College of Medicine Toledo, Ohio, USA Craig N Burkhart MD Associate Professor, Department of Dermatology University of North Carolina Chapel Hill, North Carolina, USA Prelims_ACNE.indd 30-11-2013 17:37:30 Acne Vandana Chatrath MBBS MSc (USA) Fellowship Derm Surgery (USA) Consultant Dermatologist Delhi Dermatology Group New Delhi, India Goh Chee-Leok MBBS MD MMed FRCPE FAMS Senior Consultant and Clinical Professor, National Skin Centre Singapore Wenchieh Chen MD PhD Department of Dermatology and Allergy, Technische Universitọt Mỹnchen Munich, Germany Soyun Cho MD PhD Associate Professor Department of Dermatology Seoul National University Seoul, Korea Melissa S Crites MD Transitional Year Resident Mercy St Vincent Medical Center Toledo, Ohio, USA Federica DallOglio MD PhD Dermatology Clinic, University of Catania Catania, Italy Brigitte Drộno MD PhD Professor, Department of Dermatology and Skin Cancer University Hospital, Nantes France Pan Jiun-Yit MBBS FRCP FAMS Consultant, National Skin Centre Singapore Goknur Kalkan MD Department of Dermatology, Gaziosmanpasa University, School of Medicine Talỗiftlik yerlekesi, 60250 Tokat, Turkey vi Prelims_ACNE.indd 30-11-2013 17:37:30 Contributors Sewon Kang MD Noxell Professor and Chairman Department of Dermatology Johns Hopkins University, MD, USA Aye Serap Karada MD Department of Dermatology, Istanbul Medeniyet University Gửztepe Researh and Training Hospital Kadkửy, Istanbul, Turkey Yi-Tin Lin MD Department of Dermatology, Chang Gung Memorial Hospital Chang Gung University College of Medicine Taipei, Taiwan Alison M Layton MB ChB FRCP Consultant Dermatologist, Harrogate and District NHS Foundation Trust, Lancaster Park Road Harrogate, HG2 7SX, UK Munisamy Malathi MD Senior Resident Jawaharlal Institute of Postgraduate Medical Education and Research ( JIPMER) Puducherry, India Rebecca L Mawson MB ChB Bsc DRCOG Flat 1, 21 Cold Bath Road Harroagte, HG2 0NA, UK Bodo C Melnik MD Department of Dermatology, Environmental Medicine and Health Theory University of Osnabrỹck, Germany Giuseppe Micali MD Professor and Chairman, Dermatology Director, Residency Program in Dermatology University of Catania Catania, Italy vii Prelims_ACNE.indd 30-11-2013 17:37:30 Acne Dae Hun SUH MD PhD Professor, Department of Dermatology Seoul National University College of Medicine Acne Research Laboratory Seoul National University Hospital Seoul, South Korea Aurora Tedeschi MD PhD Dermatology Clinic, University of Catania Catania, Italy Devinder Mohan Thappa MD DHA MNAMS Professor and Head, Department of Dermatology and STD Jawaharlal Institute of Postgraduate Medical Education and Research ( JIPMER) Puducherry, India Christos C Zouboulis MD PhD Professor, Departments of Dermatology, Venereology, Allergology and Immunology Dessau Medical Center Dessau, Germany viii Prelims_ACNE.indd 30-11-2013 17:37:30 Contents Editorial xi Neena Khanna Abbreviations xiii Whats New in Acne Pathogenesis Soyun Cho, Sewon Kang The Role of Microbiology and Biofilms in Acne 31 Melissa S Crites, Craig G Burkhart, Craig N Burkhart The Sebaceous Gland and Its Role as an Endocrine Organ 37 Christos C Zouboulis, WenChieh Chen Nutrient and Growth Factor Signalling in Acne Sensed by FoxO1 and mTORC1 52 Bodo C Melnik Acne and PCOS 89 Ma Flordeliz Abad-Casintahan Acne Expression and Management in Indians 105 Raj Kubba, Vandana Chatrath Adult Acne 128 Alison M Layton, Rebecca L Mawson Acne Syndromes 144 Pan Jiun-Yit, Goh Chee-Leok Acne Comorbidities 155 Raj Kubba Update of Oral Isotretinoin in Acne Treatment 169 Aysáe Serap Karadag,Goknur Kalkan, Yi-Tin Lin, WenChieh Chen Prelims_ACNE.indd 30-11-2013 17:37:30 Acne Current Role of Light and Laser Therapy in Acne 201 Dae Hun Suh Evaluation and Management of Acne Scars 210 Brigitte Drộno Acneiform Drug Eruptions 218 Devinder Mohan Thappa, Munisamy Malathi The Role of Dermocosmetics in Modern Acne Treatment 234 Giuseppe Micali, Federica DallOglio, Aurora Tedeschi x Prelims_ACNE.indd 10 30-11-2013 17:37:30 Acne Expression and Management in Indians Figure 12: Acne associated with melasma-like pigmentation Figure 13: SAHA syndrome Note lower face acne, seborrhoea and hirsutism frequently encountered in female acne patients and is suggested by menstrual irregularity and physical signs of androgen excess Both obese and non-obese PCOS are seen In a cohort of 62 adult acne patients where PCOS was assessed it was confirmed in 27 patients (44%) (Kubba R, unpublished) In another 10 patients (16%) there was equivocal/partial evidence of PCOS highlighting the existence of a gray zone in this matter! Contrary to prevalent belief many PCOS patients have mild acne (Figure 14) and come to light because of therapeutic unresponsiveness and/or recalcitrant associated seborrheic dermatitis Non-classic congenital 113 World Clinic Dermatology (Acne).indd 113 30-11-2013 17:04:54 Kubba and Chatrath Figure 14: Mild acne in PCOS The association was suspected on the basis of recalcitrant seborrhoeic dermatitis and recalcitrant mild acne adrenal hyperplasia (NCAH) is often considered in cases of persistent adult acne with a strong family history of acne but only occasionally confirmed by elevated serum 17-hydroxyprogesterone (17-OHP) On the other hand, we encounter many patients with clinical suspicion of NCAH but with borderline or mildly elevated 17-OHP IR is associated with PCOS and HAIR-AN (hyperandrogenic, insulin-resistant and acanthosis nigricans) syndrome in women and APAAN (acne, patterned alopecia, acanthosis nigricans) syndrome in men APAAN syndrome is the counterpart of SAHA in females.2 It is commonly observed in Indian men starting as early as adolescence (Figure 15) Clinically, besides acne, these patients have Ludwig-type of male-pattern baldness, patterned or diffuse AN (vide supra), and hyperinsulinemia (acute and chronic) We occasionally see female acne patients with signs of IR, PCOS and NCAH suggesting an overlap (Figures 16A and B) Indians experience all grades of acne, both inflammatory and noninflammatory However, there is an impression that severe acne, nodulocystic acne, acne corporis, acne conglobata, acne associated with hidradenitis suppurativa, and acne syndromes such as SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) are less common or rare The darkest skin phototype (FST V and VI), many of whom also have IR, appear to be less liable to severe inflammatory acne Postinflammatory hyperpigmentation (PIH) and acne hyperpigmented macules (AHMs) are very common, especially in IRAA (Figure 17) Indians scar as much and the scarring is generally proportional to severity of the inflammation Atrophic scars are mostly seen on the cheeks and temples and include boxcar, icepick, and rolling Papular scars on the chin and body of the nose are common (Figure 18), and are sometimes 114 World Clinic Dermatology (Acne).indd 114 30-11-2013 17:04:54 Acne Expression and Management in Indians A B C Figure 15A-C: APAAN syndrome acronym for Acne, Patterned Alopecia, Acanthosis Nigricans Figure 16A: Persistent adult acne with clinical, biochemical, and ultrasonological features of IR, PCOS & NCAH 115 World Clinic Dermatology (Acne).indd 115 30-11-2013 17:04:55 Kubba and Chatrath Figure 16B: Schematic representation of overlap between insulin resistance (IR), polycystic ovarian syndrome (PCOS) and non-classic congenital adrenal hyperplasia (NCAH) Figure 17: Postinflammtory hyperpigmentation, also known as AHM (acne hyperpigmented macule) mistaken for closed comedones Hypertrophic scars/acne keloids are common, and seen in typical seborrheic distribution on the torso, but are rarely also seen on the jaw angles (Figure 19) Likewise, atrophic macular scars are occasionally observed on the upper back (Figure 20).4 Perifollicular fibrosis (Figure 21) is commonly seen on the sternal area and upper back as uniformly distributed 12 mm pale/ 116 World Clinic Dermatology (Acne).indd 116 30-11-2013 17:04:55 Acne Expression and Management in Indians A B Figure 18A and B: Acne papular scars Chin is a common site Figure 19: Hypertrophic scars are rare on the face They are rarely encounterd over the jaw angles Figure 20: Extensive atrophic macular scars on the back in a case of severe acne corporis 117 World Clinic Dermatology (Acne).indd 117 30-11-2013 17:04:56 Kubba and Chatrath Figure 21: Perifollicular fibrosis as fleshy papules on the posterior aspect of shoulder sequel to acne corporis Sternal area is another common site hypochromic dome-shaped persistent papules There is a perception that atrophic acne scars are less common in the darkest skin type (FST VI) Malassezia overcolonization is a frequent comorbidity in Indian acne patients and presents in a variety of ways including, stubborn dandruff, seborrheic dermatitis as malar erythema and scaling, with occasional blepharitis and otitis externa; MF as discrete superficial pustules on the nose, nasal folds, malar areas, beard area in men, and on the upper back and upper chest (Figure 22); and also as pityriasis versicolor The MF is often confused with pustular acne and it is the lack of response to antibiotics and a good response to antifungals both topical and oral that helps recognize the nature and etiologic basis of such recurrent asymptomatic pustules Malassezia overcolonization and its clinical manifestations sometime precede acne in preadolescent and adolescent subjects and express as sandpaper comedones5 on the forehead, keratosis pilaris on the upper arms, and trichostasis on the nose Malassezia overcolonization is viewed as a clue to IR and hypovitaminosis D (Kubba R, personal observation) Recurrent crops of painful pustules in the scalp, beard area in men, in the bathing trunk area (buttocks, pubic area, anterior, and posterior aspect of thighs) in both sexes is a frequent association of acne Clinically, it represents deep folliculitis (occasionally there are overt furuncles) and responds only to systemic antibiotics This too is a clue to IR Folliculitis nuchae is also common amongst Indian acne patients Bacterial folliculitis, as also impetigo, is sometimes encountered in acne patients on oral isotretinoin, and beauty procedures such as threading or waxing are often the trigger (Figure 23) 118 World Clinic Dermatology (Acne).indd 118 30-11-2013 17:04:56 Acne Expression and Management in Indians Figure 22: Concomitant malassezia folliculitis is a common occurrence in Indian acne patients It presents as superficial pustules in paranasal area, glabella, along the hairline on the forehead, on upper back and sternal area of the chest Figure 23: Impetigo over jaw area following waxing in a patient with acne being treated with oral isotretinoin There is scant literature on quality of life (QoL) and acne from India Active acne seems to have much less impact on self-image, self-esteem, relationships, and career prospects in dark skin people compared to the sequelae, especially PIH, making prevention and treatment of the latter the focus of therapy In India, acne is relatively well tolerated, and causes some degree of psychological impairment; however, the issue assumes great importance in the run up to marriage when 119 World Clinic Dermatology (Acne).indd 119 30-11-2013 17:04:56 Kubba and Chatrath perfect skin is desired and preexisting acne is viewed as a great impediment to finding a suitable match MAnAGEMEnt Understanding the subtle differences in acne in skin of color is essential in order to tailor therapy and individualize treatment International guidelines6 have made a major contribution and succeeded in creating a unified therapeutic vision However, acne treatments are also influenced by local beliefs and perceptions, by local regulations (or lack of them), on the availability of drugs and devices, and most of all by economic considerations It is the authors view that acne is treated differently in India as compared to Europe and the USA.7,8 In India all therapeutic modalities are freely available, many are generic and relatively inexpensive, and even though there are local guidelines and treatment algorithms,1 dermatologists are entirely free to treat acne as they choose In India, easy availability of over-the-counter medications and practice of alternate forms of medicine such as homeopathy and Ayurveda, affect not only the clinical features and severity of acne at the time of presentation, but also their response to standard forms of therapy, steroid acne being one such example Topical retinoids are the mainstay of acne treatment and are recommended in all types and all stages of acne and in acne prevention.6 However, it is known that Indians are less tolerant of topical retinoids, and episodes of irritant contact dermatitis are frequent, especially in the initial stages In a study conducted at the National Skin Center in Singapore, tolerance to topically applied retinoids was compared between Chinese, Indian, Malay and European women; it was observed that Indian and Chinese women were less tolerant of topical retinoids and experienced more itching and burning.9 The dermatologists in India have been aware of this fact and for this reason prior to introduction of adapalene, topical retinoids were unpopular in India.1 Even today, it is a common practice to dilute topical retinoids with moisturizers However, the availability of newer formulations of retinoids, such as microsponge delivery system, enabling controlled release of tretinoin, has encouraged more enthusiastic use of retinoids as monotherapy and as an adjunct to systemic acne treatments Antibiotics, topical and oral, are the most prescribed modalities in acne treatment in India and generally work well Topical clindamycin as cream, gel and lotion and in fixed combination with benzoyl peroxide (BPO), tretinoin, and adapalene, is readily available The combining of clindamycin with BPO has the threefold advantage of reducing development of bacterial resistance, increasing efficacy with respect to either drug alone and decreasing the incidence of irritant contact dermatitis that may occur when BPO is used alone in skin of color.10 Topical erythromycin has been withdrawn in India Topical azithromycin and 120 World Clinic Dermatology (Acne).indd 120 30-11-2013 17:04:56 Acne Expression and Management in Indians clarithromycin are commonly used despite the absence of critical data assessing or comparing their efficacy Topical nadifloxacin has been available in India but has not gained popularity Antibiotic resistance is suspected from lack of clinical response in some cases but no data are available Oral antibiotics are inexpensive, readily available, and are frequently employed to treat moderate-to-severe inflammatory acne Newer tetracyclines are preferred for their convenient dosing Doxycycline and minocycline are believed to be equal in efficacy Minocycline is comparatively more expensive in India Macrolides in pulse dosing are very popular and are easy to combine with matching topical preparations A typical regimen is azithromycin 250 mg BID for days every weeks or 250 mg BID for days every weeks One advantage of macrolides is that they cover concomitant staphylococcal folliculitis Whether this use of antibiotics (without standardization of dose and duration) impacts the development of antibiotic resistance in the future is yet to be determined Antifungal agents, topical miconazole, ketoconazole and oral itraconazole, are used in acne to treat dandruff, seborrheic dermatitis, and MF which are frequent comorbidities There is a perception that antifungal agents directly improve acne raising the question whether Malassezia furfur has a direct etiological role in acne? Oral itraconazole 100 mg BID for 1428 days appears to have beneficial effect in MF mimicking acne corporis (clinical experience of the authors) Oral isotretinoin is generic, relatively inexpensive, and unregulated in India It is well tolerated and is very effective in all types of acne (including comedonal acne) and for all age groups Written informed consents are mandated but not enforced, pretreatment and intratreatment pregnancy testing is not required As yet there are no reports of teratogenic complications from oral isotretinoin in India There is preference for lower dosages, typically below 0.5 mg/kg (perhaps due to the low tolerance of dark skin toward retinoids?) Pulse dosing is favored in adult acne.11 There is freedom to create combinations and innovative regimens which allow for greater individualizing of the treatment programs Oral isotretinoin also addresses sequelae of acne and improves the overall quality of skin It improves the skin complexion in dark skin acne patients, particularly FST IV-V (Figures 24A and B) The very dark skin acne patients (FST VI) not exhibit retinoid glow and rarely there are instances of unexplained paradoxical darkening.2 These are temporary effects typically lasting for 36 months Adverse effect profiles match those stated in the literature with a few exceptions The susceptibility to Staphylococcal infections increases in the form of impetigo, furuncles, and recurrent styes, especially during hot summer months Epistaxis, bleeding per rectum, reversible fibroadenomas of the breasts (in both sexes), and a solitary case of vasculitis on the legs, are some of the unusual adverse effects encountered by the authors Serious psychiatric adverse effects such as depression and suicidal tendency are rare Overall, oral isotretinoin is much liked by the patients and is popular with dermatologists in India 121 World Clinic Dermatology (Acne).indd 121 30-11-2013 17:04:56 Kubba and Chatrath A B Figure 24A and B: Improved complexion and retinoid glow after oral isotretinoin Antiandrogens are the cornerstone of therapy for adult acne Besides resolving acne they correct other signs of androgen excess and improve skin quality Antiandrogens are readily available, are socially well accepted, and dermatologists are free to prescribe them in India Combination oral contraceptive pills, Diane-35đ (cyproterone mg + ethinyl estradiol 35 àg) and Yasminđ (drospirenone mg + ethinyl estradiol 30 àg) are the popular choice in acne patients with PCOS and androgen excess Treatment is cyclical and typically of 612 months duration Beneficial effects are evident after three cycles and are mediated through reduction of ovarian androgen production and through elevation of serum sex hormone-binding globulin (SHBG) Diane-35đ and Yasminđ are comparable in efficacy and cost In India, the generics are available Yazđ (drospirenone mg + ethinyl estradiol 20 àg), a newer introduction, offers low estrogen content and is preferred by some Diane-35đ occasionally causes hypertension and is sometimes incriminated in weight gain Some dermatologists in India prefer Diane-35đ for adolescents and Yasminđ for mature adults Spironolactone (SL) 2550 mg BID is a good choice for adult acne, especially those with female pattern hair loss (FPHL), melasma, and hirsutism, but because it can cause virilization of the female fetus, it is often used in conjunction with oral contraceptives that in turn add to its antiandrogenic effect.12 SL is an androgen receptor antagonist and an inhibitor of 5ỏ-reductase Bicalutamide, a nonsteroidal androgen receptor antagonist, is readily available and is inexpensive; it is recommended for acne associated with hirsutism;13 the dose is 50 mg OD and the typical treatment duration is months Finasteride, inhibitor of 5a-reductase type 2, is routinely prescribed in APAAN syndrome, and occasionally for female adult acne with recalcitrant androgenetic alopecia 122 World Clinic Dermatology (Acne).indd 122 30-11-2013 17:04:57 Acne Expression and Management in Indians Dutasteride, inhibitor of both type and type 5a-reductase is sometimes recommended for recalcitrant APAAN syndrome patients It has been estimated that a 50% reduction in acne requires 3050% reduction in sebum secretion.14 The sebosuppressive effect, especially of SL and cyproterone acetate (CPA), is dose dependent Oral isotretinoin is the most sebosuppressive of them all In India, we frequently combine antiandrogens to limit dosages and toxicity and to enhance efficacy CPA 50100 mg OD for the first 10 days of the Diane-35đ cycle is another potent combination Oral antiandrogens are also combined with oral isotretinoin and/or oral antibiotics in difficult and refractory cases and in acne associated with hormonal disturbances (the therapeutic ladder) Metformin is a first-line treatment for PCOS where it improves acne and hirsutism besides correcting the irregular menstrual cycle even in non-obese patients.15 Metformin is increasingly being used in India to treat acne associated with insulin resistance (IRAA) The typical dose is 500 mg BID to start with reaching an ideal dose close to g/day in divided doses The treatment duration has to be individualized and greatly depends on ancillary factors pertaining to lifestyle such as diet and exercise We prefer slow release preparations for acne patients with high fasting insulin (chronic hyperinsulinemia) or high HbA1c Slow release metformin is not recommended for individuals under 18 years of age Metformin is a biguanide and was first used in France in 1979.16 It improves insulin sensitivity through improved binding of insulin to insulin receptors It also reduces hepatic gluconeogenesis, activates adenosine monophosphate (AMP)-activated protein kinase, increases peripheral glucose uptake, and reduces absorption of glucose from gastrointestinal tract.16,17 It reduces insulin levels but does not cause hypoglycemia Metformin can be combined with antiandrogens, oral isotretinoin, and oral antibiotics with the exception of cephalosporins Metformin can be administered to individuals over 10 years of age and is pregnancy category B Systemic steroids are prescribed to ameliorate scar-threatening acne inflammation, and to prevent pustular flares in acne patients with closed comedones or macrocomedones when oral isotretinoin is initiated.1 Methylprednisolone 8mg once in the morning suffices in most instances and the typical duration is 46 weeks This is also helpful in preventing PIH Suppressive dosages are required for NCAH and nonspecific adrenal hyperandrogenism In such cases, the typical protocol is to commence with methylprednisolone mg at bedtime till quiescence is attained and then to taper in an individualized manner keeping in mind the high probability of relapse.1 Dosages as low as mg/day or mg on alternate days are sufficient for maintenance Milder forms of inflammation is targeted with topical pimecrolimus, the concomitant use of which not only allows dark skin acne patients to tolerate topical retinoids, but also works as an adjunct prostaglandin 123 World Clinic Dermatology (Acne).indd 123 30-11-2013 17:04:57 Kubba and Chatrath inhibitor, helping to ameliorate acne macules faster Oral dapsone is another useful adjunct to combat severe inflammation in nodulocystic acne, acne corporis, and acne fulminans.1,18 It is freely available, very inexpensive, and Indian dermatologists are very familiar with it from treating leprosy and other skin diseases Dapsone gel,19 on the other hand, was found to be ineffective in India, where it has now been withdrawn from the market Another product, azelaic acid, a naturally occurring dicarboxylic acid which is both antibacterial and anticomedonal in 1020% cream formulation and known to reduce hyperpigmentation failed to make a mark in acne treatment in India Nutritional supplements, namely, vitamin A, vitaminD3, vitamin E, evening primrose oil, and oral zinc are popular adjuncts in acne treatment in India There are several mechanisms by which they are beneficial in acne one of which is their ability to combat oxidative stress.20 Chemical peels, like topical retinoids, in skin of color address both acne and PIH simultaneously The safety and efficacy of chemical peels for acne in skin of color is well established.21 However, there are a few precautions which when exercised can improve the outcome and minimize the adverse effects These include starting with lower concentrations of peels, proper sun protection, pretreatment with retinoids with or without hydroquinone, and stopping all topicals 23 days prior to the treatment for better tolerance Newer peels using salicylic-mandelic acid combination (SMPs) give superior results compared to glycolic acid peels both for active acne and PIH Chemical peels for management of active acne are infrequently utilized in India compared to Japan and Korea Lights and Lasers have been used in dark skin people7 to treat active acne and acne sequelae (PIH and scars) Practice patterns for these vary from country to country and reflect local conditions In India, where unrestricted medical treatments are available, physical devices such as blue light, red light, photodynamic therapy (PDT), and diode laser are rarely used for active acne, the exceptions being pregnant women and patients averse to medications Acne scars, on the other hand, are increasingly being treated with lasers Newly developed fractional lasers employ fractional thermolysis in which microscopic columns of epidermal and dermal injury stimulate collagen remodeling and thus result in dermal repair There are several studies reporting beneficial effects of fractional lasers in atrophic acne scars in dark skin people.22-24 Fractional lasers are color blind (to some extent), therefore, especially suitable for dark skin people There are as yet no guidelines for lasers in acne due to the plethora of devices available across the world and the fact that parameters are device specific making standardization difficult Nonablative fractional lasers are relatively less effective in darker skin types possibly due to the limitation of using higher energy levels and increased treatment density for the fear of risking pigment related side-effects Ablative fractional resurfacing lasers, on the other hand, are relatively more effective for such patients with the advantage of needing one to two treatments (maximum) 124 World Clinic Dermatology (Acne).indd 124 30-11-2013 17:04:57 Acne Expression and Management in Indians but the disadvantage of having much longer downtime and higher risk of PIH To reduce the incidence of side-effects it is recommended that the treatment density should be reduced and the number of treatments should be increased for both nonablative and ablative fractional lasers.25 For boxcar scars and ice-pick scars combination treatments with subcision, fractional lasers, and punch grafting offer added advantage Microneedling is yet another treatment for acne scars not biased by the color of the skin and because of this, and the mild to moderate degree of improvement that one can achieve at minimal cost, it is considered as a poor mans laser and it is, therefore, a popular treatment option in India either alone or in combination Postinflammatory hyperpigmentation (PIH) is of major concern in acne in dark skin people and warrants prevention as well as amelioration The degree of PIH is higher in prolonged and/or recurrent inflammation compared to short-term acute inflammation7 and PIH in color of skin causes more psychological impact than active acne itself warranting early and aggressive therapy The use of sunscreens is pivotal and we recommend their regular use Topical retinoids are helpful in both preventing and clearing PIH.7 Other topicals containing hydroquinone (24%), and triple combination creams are also helpful and we use them cautiously in selected patients Superficial chemical peels and microdermabrasion are other time tested beneficial options.8 Vascular lasers can be used to treat the acne macules by treating the vascular component of inflammation, thereby promoting early clearance and secondarily reducing the PIH risk.26 Pigment lasers such as the Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) are increasingly being used to treat PIH but at low fluences.27 The concept of laser-toning using large spot size, low fluence and multiple passes to achieve an endpoint of mild erythema at variable intervals of 14 weeks is yet another approach for post-acne hyperpigmentaion.28 With a rapid increase in IR in India the role of diet in the management of acne has assumed much greater importance.29 We routinely discuss diet with acne patients and in those with IRAA we emphasize the necessity to limit consumption of glycemic foods, milk, and dairy products.30 India is presently the worlds largest producer of milk and whereas the milk production is falling globally in India it is going up 6% annually Whey protein consumption is rising amongst young men as is obesity in both sexes; both issues are routinely discussed with acne patients concluSIon In conclusion, this article is an attempt by the authors to profile acne as it is observed in office practice in India, give an account of how it is managed, and to compare and contrast it with acne as it is recorded in the English literature 125 World Clinic Dermatology (Acne).indd 125 30-11-2013 17:04:57 Kubba and Chatrath Editors Comment Though Indians are considered to be people with skin of color, they display considerable heterogeneity (ranging from Fitzpatrick skin type IV-VI) in their skin color due to variation in their ethnicity Though acne is probably the most common dermatoses with which Indians present to the dermatologist, there is a paucity of clinicoepidemiological data on acne In this article, Drs V Chatrath and R Kubba have not only delved into the scanty reports available in literature on acne in Indians but also written from their extensive clinical experience They have rightly observed that acne is as common in Indians as it is elsewhere with a spurt in preadolescent acne presumably related to a tilt towards Western diet and lifestyle Many patients of adolescent acne evolve into adult acne The authors have tried to compare the clinical profile of Indian acne patients with their Western counterparts Though antibiotics both topical and systemic are frequently prescribed to treat acne in India, retinoids, especially the newer formulations (to which Indian skin is more tolerant) have now become popular The authors rightly point out that there are no reports of antibiotic sensitivity pattern of Propionibacterium spp from India However, in a recently concluded study done at the All India Institue of Medical Sciences, New Delhi, we observed that a third of Propionibacterium spp strains were resistant either to erythromycin, azithromycin or clindamycin Neena Khanna rEFErEncES Kubba R, Bajaj AK, Thappa DM, Sharma R, Vedamurthy M, Dhar S, et al Acne in India: guidelines for management - IAA consensus document Indian J Dermatol Venereol Leprol 2009;75:1-62 Kubba R Acne in dark skin people In: Schwartz RA, Micali G (Eds) Acne McMillan Medical Communications; Gurgaon, India 2013 pp 39-50 Ayers K, Sweeney SM, Wiss K Pityrosporum folliculitis: diagnosis and management in female adolescents with acne vulgaris Arch Pediatr Adolesc Med 2005;159:64-7 Cunliffe WJ, Gollnick HP Acne: Diagnosis and Management London, UK: Martin Dunitz; 2001 Cunliffe WJ, Holland DB, Clark SM, Stables GI Comedogenesis: Some new aetiological, clinical and therapeutic strategies Br J Dermatol 2000;142:1084-91 Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, Leyden JJ, et al Management of acne: a report from a Global Alliance to Improve Outcomes in Acne J Am Acad Dermatol 2003;49:S1-37 Davis EC, Callender VD A review of acne in ethnic skin: pathogenesis, clinical manifestations, and management strategies J Clin Aesthet Dermatol 2010;3:24-38 Shah SK, Alexis AF Acne in skin of color: practical approaches to treatment J Dermatolog Treat 2010; 21:206-11 Goh CL Data presented at the second Asian acne board meeting Singapore: November 2006 126 World Clinic Dermatology (Acne).indd 126 30-11-2013 17:04:57 Acne Expression and Management in Indians 10 Eichenfield LF, Krakowski AC Moderate to severe acne in adolescents with skin of color: benefits of a fixed combination clindamycin phosphate 1.2% and benzoyl peroxide 2.5% aqueous gel J Drugs Dermatol 2012;11:818-24 11 Goulden V, Clark SM, McGeown C, Cunliffe WJ Treatment of acne with intermittent isotretinoin Br J Dermatol 1998;137:106-8 12 Krunic A, Ciurea A, Scheman A Efficacy and tolerance of acne treatment using both spironolactone and a combined contraceptive containing drospirenone J Am Acad Dermatol 2008;58:60-2 13 Mỹderris I, Bayram F, Ozỗelik B, Gỹven M New alternative treatment in hirsutism: bicalutamide 25 mg/day Gynecol Endocrinol 2002;16:63-6 14 Janiczek-Dolphin N, Cook J, Thiboutot D, Harness J, Clucas A Can sebum reduction predict acne outcome? Br J Dermatol 2010;163:683-8 15 Tan S, Hahn S, Benson S, Dietz T, Lahner H, Moeller LC, et al Metformin improves polycystic ovary syndrome symptoms irrespective of pre-treatment insulin resistance Eur J Endocrinol 2007;157:669-76 16 Bailey CJ, Turner RC Metformin N Eng J Med 1996;334:574-9 17 Musi N, Hirshman MF, Nygren J, Svanfeldt M, Bavenholm P, Rooyackers O, et al Metformin increases AMP-activated protein kinase activity in skeletal muscle of subjects with type diabetes Diabetes 2002; 51:2074-81 18 Prendiville JS, Logan RA, Russell-Jones R A comparison of dapsone with 13-cis retinoic acid in the treatment of nodular cystic acne Clin Exp Dermatol 1988;13:67-71 19 Draelos ZD, Carter E, Maloney JM, Elewski B, Poulin Y, Lynde C, et al Two randomized studies demonstrate the efficacy and safety of dapsone gel, 5% for the treatment of acne vulgaris J Am Acad Dermatol 2007;56:439.e1-10 20 Bowe WP, Logan AC Clinical implications of lipid peroxidation in acne vulgaris: old wine in new bottles Lipids Health Dis 2010;9:141 21 Callender VD Acne in ethnic skin: special considerations for therapy Dermatol Ther 2004;17:184-95 22 Hasegawa T, Matsukura T, Mizuno Y, Suga Y, Ogawa H, Ikeda S Clinical trial of a laser device called fractional photothermolysis system for acne scars J Dermatol 2006;33:623-7 23 Alster TS, Tanzi EL, Lazarus M The use of fractional laser thermolysis for the treatment of atrophic scars Dermatol Surg 2007;33:295-9 24 Lee HS, Lee JH, Ahn GY, Lee DH, Shin JW, Kim DH, et al Fractional photothermolysis for the treatment of acne scars: a report of 27 Korean patients J Dermatolog Treat 2008;19:45-9 25 Kono T, Chan HH, Groff WF, Manstein D, Sakurai H, Takeuchi M, et al Prospective direct comparison study of fractional resurfacing using different fluences and densities for skin rejuvenation in Asians Lasers Surg Med 2007;39:311-4 26 Ruiz-Maldonado R, Orozco-Covarrubias ML Postinflammatory hypopigmentation and hyperpigmentation Semin Cutan Med Surg 1997;16:36-43 27 Eimpunth S, Wanitphadeedecha R, Manuskiatti W A focused review on acne-induced and aesthetic procedure-related postinflammatory hyperpigmentation in Asians J Eur Acad Dermatol Venereol 2013;27: 7-18 28 Arora P, Sarkar R, Garg VK, Arya L Lasers for treatment of melasma and post-inflammatory hyperpigmentation J Cutan Aesthet Surg 2012;5:93-103 29 Bowe WP, Joshi SS, Shalita AR Diet and acne J Am Acad Dermatol 2010;63:124-41 30 Melnik BC, Schmitz G Role of insulin, insulin-like growth factor-1, hyperglycemic food and milk consumption in the pathogenesis of acne vulgaris Exp Dermatol 2009;18:833-41 127 World Clinic Dermatology (Acne).indd 127 30-11-2013 17:04:57 ... W Week xvi Prelims _ACNE. indd 16 30 -11 -2 013 17 :37: 31 World Clin Dermatol 2 013 ;1( 1) :1- 30 Whats New in Acne Pathogenesis *,1Soyun Cho MD PhD, 2Sewon Kang MD MPH Department of Dermatology, Seoul... Email: neena_aiims@yahoo.co.in xii Prelims _ACNE. indd 12 30 -11 -2 013 17 :37: 31 Abbreviations 13 cRA 13 -cis-retinoic acid 17 -OHP 17 -hydroxyprogesterone 21- OH 21- hydroxylase 24OHase D-24-hydroxylase 4E-BP... response of acne to it) and on light and laser therapy And â 2 014 Jaypee Brothers Medical Publishers All rights reserved Prelims _ACNE. indd 11 30 -11 -2 013 17 :37: 31 Acne of course, no account of acne is