Treatment options for acne vulgaris in Southeast Asia differ from the rest of the world due to factors such as local variation and differences between Asian and Caucasian skin. In response, a group of dermatologists from the South-East Asia study alliance (SASA) met and, after reviewing current guidelines in Southeast Asia, developed evidence-based guidelines for the treatment of acne in Southeast Asia, published in The Journal of Dermatology by Dr. Goh et al.
Diagnosis and Treatment
SASA adopted the Acne Consensus Conference (ACC) acne severity grading system (Table 1) and recommended different treatment options according to the severity of the patient (Table 2).
Table 1 Acne Consensus Conference acne severity grading
Table 2 Summary of recommended acne treatment regimens from the Southeast Asian Research Consortium
Note: Topical antibiotics should not be used alone; oral antibiotics should not be used alone; retinoids, benzoyl peroxide fixed-dose combinations may also be used.
Before treating acne, it is necessary to differentiate from the following diseases, including mechanical effects (localized acne-like lesions due to friction or occlusion, mostly in athletes), cosmetic effects (mild persistent acne-like lesions due to multiple cosmetics), drug-induced acne-like lesions, gram-negative folliculitis, and Malassezia folliculitis.
In addition, it is necessary to exclude underlying diseases and aggravating factors, the former including endocrine disorders such as polycystic ovary syndrome, Cushing’s syndrome, and 21 hydroxylase deficiency, and the latter including: occupational exposure (oils, fats, and aromatic hydrocarbons, etc.); cosmetics; medications (steroids, antiepileptics, isoniazid, lithium, danazol, iodide, and bromide, etc.); and specific medical history (friction, occlusion, and high-sugar diet, etc.).
For mild acne, SASA recommends monotherapy or a combination of the following medications: retinoids (adapalene, tazarotene, isotretinoin, all-trans retinoids) (once daily), benzoyl peroxide (once to twice daily), retinoid/benzoyl peroxide fixed-dose combination (once daily) and topical antibiotics (once to three times daily, depending on the specific antibiotic). Alternative topical medications include salicylic acid (1 to 3 times daily), azelaic acid (2 times daily), sulfur (2 times daily), and azelaic acid/sulfur combination (2 times daily) (Table 3).
Table 3 Evidence grading and recommended strength of acne medication
For moderate acne, topical benzoyl peroxide or retinoids (and possibly a retinoid/benzoyl peroxide fixed-dose combination) are recommended in combination with oral antibiotics, including doxycycline (100-200 mg/d), tetracycline (500-1000 mg/d), minocycline (100-200 mg/d), lymecycline (300-600 mg/d), and erythromycin. mg/d) and erythromycin (500-1000 mg/d). Antibiotics were administered for at least 6 weeks, and patients were reassessed after 6-8 weeks of treatment. Alternative topical regimens include salicylic acid and azelaic acid.
In female patients, hormonal therapy, i.e., oral contraceptives with or without androgens, such as chlormadinone acetate, cyproterone acetate, and drospirenone, may be used if necessary. The efficacy of birth control pills has been demonstrated to reduce both inflammatory and non-inflammatory facial acne, and a meta-analysis has shown that birth control pills are the best first-line alternative to a long course of systemic antibiotics for female acne patients. However, SASA notes that acceptance of the pill is lower in Asian patients due to concerns about side effects, cultural or religious factors, which need to be further communicated to patients.
For severe acne, patients should first receive the recommended treatment regimen of 6 to 8 weeks for moderate acne. If there is clinical progression or no improvement after treatment, oral isotretinoin may be administered at a dose of 0.5 to 1 mg/kg/d. There is no substantial additional benefit at cumulative doses above 120 to 150 mg/kg, and remission is usually achieved at 16 to 24 weeks of treatment.
Maintenance therapy
Acne is a chronic disease and patients may relapse after treatment. Microcomedema decreases during treatment and increases after discontinuation of topical medications. Therefore, maintenance therapy is important to prevent acne flare-ups. Although there is no consensus on the meaning of maintenance therapy for acne, Wolf et al. provide a strong definition: the regular use of appropriate therapeutic agents to ensure that acne is in an identifiable state of remission.
The most effective maintenance medications are topical retinoids due to their anti-acneogenic and acne-dissolving properties. Adapalene, a topical retinoid, has been shown to have a significant reduction in microcomedema formation in acne patients. Studies have shown a significant reduction in acne lesions after 16 weeks of maintenance treatment with 0.1% adapalene gel compared to the placebo group.
Adapalene can also be used as a fixed-dose combination of benzoyl peroxide. Studies have shown that 0.1% adapalene gel in combination with 2.5% benzoyl peroxide gel was effective and satisfactory as maintenance treatment for severe acne after 9 months, with Propionibacterium acnes remaining at low levels.
Adjunctive treatment
Patients with acne may use chemical peels. Glycolic acid may be used for acne-inflammatory damage and superficial scarring, polyethylene glycol salicylic acid or ethanol salicylic acid for acne-inflammatory damage, and trichloroacetic acid for superficial scarring. A randomized trial showed that a lipid-soluble hydroxy acid derivative of salicylic acid was as effective as 5% benzoyl peroxide gel for mild to moderate acne.
Energy output devices are available as options for acne patients who are intolerant or unresponsive to standard treatment regimens. These options include: intense pulsed light, pulsed dye laser, KTP laser, neodymium-doped yttrium aluminum garnet laser, Q-modulated laser, ultraviolet light, red light, blue light, and photodynamic therapy.
Prevention of drug resistance
SASA agrees with the guideline’s recommendations and emphasizes effective measures to prevent the development of antibiotic resistance. These measures include avoiding antibiotic monotherapy, avoiding concomitant oral and topical antibiotics, limiting the duration of antibiotic therapy, and avoiding antibiotics as a maintenance regimen. Topical antibiotics should be combined with benzoyl peroxide and topical retinoids. the SASA Collaborative Group recommends a course of oral and topical antibiotics for acne of less than 12 weeks with good adherence to treatment; it also recommends that the patient’s response to treatment be evaluated every 8 to 12 weeks.
Skin care
Skin care is also important to the treatment of acne, including cleansing, moisturizing and sun protection (protection from UV radiation).
Studies have shown that acne patients who wash their faces twice a day with a mild cleanser show significant improvement in their skin, and that cleansers reduce the number of inflammatory and non-inflammatory lesions. The ideal cleanser should be non-comedogenic, non-acneic, non-irritating and non-sensitizing. Cleansers should also meet the following requirements: be appropriate for the patient’s skin type; be mild, alcohol-free and non-abrasive; and may contain active anti-acne ingredients such as benzoyl peroxide or salicylic acid.
Moisturizers can be used on dry and irritated skin due to acne treatment and can improve topical tolerance of topical treatments. Moisturizers should be water-based, non-greasy, non-comedogenic, non-acneic and hypoallergenic.
UV radiation protection is an important adjunctive treatment for acne, preventing hyperemesis and reducing the incidence of photosensitivity dermatitis after oral and topical retinoids. Patients should be educated and encouraged to use umbrellas or hats and sunscreen preparations. A broad-spectrum, noncomedogenic sunscreen with a sun protection index above 30 is recommended; to avoid irritation, sunscreens with a water or light liquid base are preferred.
Improving adherence
Considering the non-adherence of patients, measures are recommended to improve this. The lack of patient understanding of acne can be addressed by educating/informing the patient and establishing open communication. It is important to discuss treatment expectations, the course of treatment, and the time needed to achieve significant results. In addition, skin care (cleansing and moisturizing) should be emphasized to patients to improve compliance.