jurding acne new treat ment

8/13/2019 Jurding Acne new treat ment

1/32

Newer Approaches to

the Treatment of AcneVulgaris

Supervisor: dr.Vitalis Pribadi, Sp.KK

Presented by:Wisnu Adiputra07120080072


2/32

Introduction

Current treatments include:topical retinoids, benzoyl peroxide, topicaland systemic antibiotics, azelaic acid, andsystemic isotretinoin.Adjunctive and/or emerging approachesinclude topical dapsone, taurine bromamine,resveratrol, chemical peels, opticaltreatments, as well as complementary andalternative medications.


3/32

Aim New treatment strategies (i.e. re-evaluation of the

use of oral antibiotics and avoidance of topicalantibiotic monotherapy, use of subantimicrobialantibiotic dosing, use of low-dose isotretinoin,optical treatments),

New formulations (microsponges, liposomes,nanoemulsions, aerosol foams),

New combinations (fixed-combination products of

topical retinoids and topical antibiotics [essentiallyclindamycin] or benzoyl peroxide),

New agents (topical dapsone, taurine bromamine,resveratrol) and their rationale and likely place in

treatment


4/32


5/32


6/32


7/32

Prospective drugs based on acnepathogenesis

Isoretinoin Rectinoic acid metabolism blocking agents (RAMBA) Ectopeptidase inhibitor Antibiotic/anti-inflammatory agents Antiandrogens Insulin-sensitizing agents 5 - reductase inhibitors 5-lipoxygenase inhibitors Diet Antisense oligonucleotides


8/32


9/32

Retinoids

Topical Retinoid TherapyTopical retinoids represent a mainstay of acne treatment because-expel mature comedones,- reduce microcomedone formation, and exert anti-inflammatory effectsthrough a number of pathways including down regulating toll-likereceptors, cytokines, and nitric oxideFixed-combinatio n products of topical retinoids and topical antibiotics(essentially clindamycin) or benzoyl peroxide are significantly moreefficacious in reducing the number of inflammatory and non inflammatory

lesions compared with retinoid monotherapy.Furthermore, patients taking combination therapy show faster signs ofimprovement.


10/32

Cont Lately, formulation technology has focused on providing more

efficient penetration of the retinoids into the skin ,so thatlower concentrations of retinoids might afford bettertolerability, but maintain good efficacy.

-A micronized formulation of tretinoin (0.05%) gel has beendeveloped that provides a more efficient delivery of tretinoin ,because of its optimal particle size, no degradation by benzoylperoxide, and better cutaneous tolerability than tretinoinmicrosphere (0.1%) gel without compromising efficacy .'


11/32

Cont Retinoic acid-loaded, solid, lipid nanoparticles represent an-

other interesting alternative to reduce retinoic acid-inducedskin irritation without reducing efficacy.

Retinol has a lower biologic activity but a better tolerability .

Combination products using retinol with substances with anti-inflammatory and antibacterial activity might increase thisbiologic


12/32

Isotretinoin

First line treatment for severe papulopustula r, moderatenodular, and severe nodular/ conglobate acne .Reasonssupporting oral iso tretinoin as a first line treatment for severeacne include clinical effectiveness, prevention of scarring, and

quick improvement of a patient's quality of life.


13/32

Most trials, higher dosages have lead to better response rates whilsthaving less favorable safety/tolerability profiles . However , there iscumulative evidence that low-dose isotretinoin might be a usefultreatment option for moderate acne.

Although effective against severe acne, isotretinoin is associatedwith significant adverse effect including:

cheilitis, dry skin and mucous membranes, epistaxis, increased risk of cutaneous Staphylococcus aureus

infections, temporary worsening of lesions, photosensitivity, increased serum lipids, myalgias, hyperlipidemia, pseudotumor cerebri, and teratogenicity, induce psychopathology .


14/32

Antibiotic Topical Antibiotic

How topical antibiotics improve acne has not been clearlydefined, but they seem to act directly on P. acnes colonizationand its subsequent proinflammatory effects on comedogenesisThe most commonly used topical antibiotics are clindamycin anderythromycin.


15/32

However, studies on P. acnei resistance have highlighted theneed for treatment guidelines to restrict the use of antibioticsin order to limit the emergence of resistant strains

Monotherapy with topical antibiotics is thus no longer

recommended .


16/32

Cont

Systemic Antibiotic Although antibiotics have shown effectiveness in terms of

reducing the number of acne lesions , most antibiotic coursesare not curative . The use of antibiotics for acne has been

questioned owing to resistance concerns, especially since theyare repeatedly used for long periods at low doses .

Furthermore, there is a low evidence level that oral antibioticsare more effective than topical preparations for mild-to-moderate facial acne.


17/32

Cont

As a consequence of resistance concerns, the use of oralantibiotics should be limited (indication, duration) and topicalantibiotic monotherapy should be avoided.'


18/32

Benzoyl Peroxide Benzoyl peroxide is a safe and effective over-the-counter

preparation that reduces the number of P. acnes by suppress-ing growth without the risk of resistance selection

Low concentration (2.5% or 5%) benzoyl peroxide is

recommended, since it is less irritating and there is no clearevidence that stronger preparations are more effective.''


19/32

Single agent benzoyl peroxide works as well as oral antibiotics .It has greater activity than topical tretinoin againstinflammatory lesions .

Several studies suggest that the efficacy of benzoyl peroxide

can be enhanced when used in combination with topicalretinoids, antibiotics (more recently, nadifloxacin), and tertiaryamines, such as an allylamine.


20/32

Azelaic Acid Azelaic acid has both antimicrobial and anticomedonal prop-

erties. The data on azelaic acid (15% or 20%) show an inferiorefficacy compared with benzoyl peroxide in reducing non-inflammatory lesions but a similar efficacy in reducing inflam-

matory lesion. Azelaic acid shows a trend towards a better tolerability/safety

profile compared with benzoyl peroxide (5%)) topicaladapalene and tretinoin.']


21/32

Topical Dapsone Topical dapsone 5% gel offers documented efficacy for the

reduction of both inflammatory and non-inflammatory acnelesions. Topical dapsone is superior to placebo but has yet tobe compared with standard topical treatments

Data suggest the vehicle formulation enhances healing andcontributes to tolerability, making topical dapsone 5% gel aworthwhile anti-inflammatory treatment for patients withmild-to-moderate


22/32

Taurine Bromamine Taurine bromamine, the product of taurine and hypobro-

mous acid, exerts anti-inflammatory and antibacterialproperties against P. acnes and Staphylococcus epidermidis.

In a double- blind investigation, the efficacy and safety of

3.5mM taurine bromamine cream versus clindamycin gel werecomparable

These data suggest that taurine bromamine can be used as atopical agent in the treatment of acne, especially in patientswho have already developed antibiotic resistance, but needsto be confirmed by further studies


23/32

Chemical Peels The most common chemicals used include a hydroxy acids

such as glycolic acid and -hydroxy acids such as salicylicacids.l In vitro data demonstrate that glycolic acid has mod-erate growth inhibitory and bactericidal effects on P. acnes .

Search of the literature revealed very few clinical trials ofpeels in acne Notably, no studies of chemical peels have used an acne

medication.


24/32

Other Topical Therapies Salicylic acid : is an exfoliant , No studies support

routine use of salicylic acid in preference toother topical therapies

Foam , containing sodium sulfacetaminde 10%and sulfur 5% exhibiting moisturizationproperties as well as antibacterial activitiesagainst P. acnes in vitro has been shown to beeffective in a limited series of patients with acne.Further studies are obviously required to assessits usefulness.


25/32

Cont Resveratrol on acneic skin .

Resveratrol is a natural phytoalexin exhibiting activity againstP. acnes as well as anti-inflammatory properties and isproduced by some spermatophytes, such as grapes and otherplants


26/32

Oral Contraceptives All types of combined oral contraceptives seem

to be effective in reducing inflammatory andnon-inflammatory acne lesions, but there is no

clear evidence that those containing additionalcyproterone offered any further benef lt. hormonal therapy is regarded as an excellent

choice for women who need oral contraception .


27/32

,Light Sources, and PhotodynamicTherapy)-Broad-spectrum continuous wave visible light (blue and red),-intense pulsed light,-pulsed dye lasers,potassium titanyl phosphate lasers,

photodynamic therapy (PDT), and pulsed diode laser. The clinical development of optical therapies is also limited by

adverse effects, including pain, erythema, edema, crusting,hyperpigmentation, and pustular eruptions.

Thus, although optical therapy may improve acne initially, astandardized treatment protocol, longer term outcomes,comparisons with conventional acne therapies, and widespreadclinical experience are still lacking . Accordingly, optical treatmentsare not included among first-line treatments,especially with currenthigh costs.


28/32

Complementary and AlternativeMedications

A systematic review of CAMs for the treatment of acne in2006 identified 15 randomized controlled trials coveringvarious approaches such as;

Aloe vera, pyridoxine, fruit-derived acids, kampo (Japanese

herbal medicine), and ayurvedic herbal treatments. Although mechanisms of potential benefit for some of the

CAMs were biologically plausible, the included studies weregenerally of poor me thodologie quality and inconclusive

There is no controlled trial evaluating the efficacy ofhomeopathic remedies in acne


29/32

Nutrition Some level of evidence supports the association

of acne and high glyce mie loads, certain dairyproducts (especially milk), and refined sugarproduct ingestion.

Perhaps through:hyperinsulinemia leading to increased an-

drogens, increased insulin-like growth-factor-1,and altered retinoid signaling. Future studies are required to determine if

dietary modification will reduce long- term acneburden .


30/32

Promising TherapiesIn the more distant future, vaccination with killedP. acnes and sialidase-based vaccines may lead tonovel avenues of immunologie intervention.Several antimicrobial peptides including:

-Epinecidin and granulysin-derived peptides

-omiganan pentahydrochloride,-frog skin peptides

-Cathelicidin

-Lauric acidhave been found to exert activity against P. acne.


31/32

Conclusions

Acne continues to remain a challenge topracticing clnicians and dermatologists.

Despite significant developments, oral

isotretinoin remains so far the most effectiveacne medication available.

Given the restrictions placed on the use ofisotretinoin and the increase in antibioticresistant strains of P. acnes, there is a highclinical need for new treatments .


32/32

jurding acne new treat ment

Documents