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12993
REVIEW ARTICLE
National Skin Centre, Singapore, 2Department of Dermatology, Jose R. Reyes Memorial Medical Center, Manila, Philippines,
National University Hospital, Dermatology Clinic, Singapore, 4Department of Dermatology, Hospital Melaka, Melaka, 5Department of
Dermatology, Hospital Pulau Pinang, Pulau Pinang, Malaysia, 6Ho Chi Minh Dermatology and Venereology Hospital, Ho Chi Minh
City, Vietnam, 7Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, 8Rophi
Clinic, Mount Elizabeth Novena Specialist Centre, Singapore, 9Department of Dermatology, Research Institute for Tropical Medicine,
Muntinlupa, Philippines, 10Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, King Chulalongkorn
Memorial Hospital, Bangkok, Thailand, 11Cosmetic Dermatology Division, Department of Dermatovenereology, Faculty of Medicine,
Universitas Indonesia, 12Department of Dermato-Venereology, Faculty of Medicine, University of Indonesia/Dr Cipto Mangunkusumo
Hospital, Jakarta, Indonesia, 13Dr SN Wong Skin, Hair, Nails & Laser Specialist Clinic, Mt Elizabeth Medical Centre, Singapore
3
ABSTRACT
The management of acne in South-East Asia is unique, as Asian skin and local variables require a clinical approach
unlike that utilized in other parts of the world. There are different treatment guidelines per country in the region, and
a group of leading dermatologists from these countries convened to review these guidelines, discuss current practices and recent advances, and formulate consensus guidelines to harmonize the management of acne vulgaris in
the region. Emphasis has been placed on formulating recommendations to impede the development of antibiotic
resistance in Propionibacterium acnes. The group adopted the Acne Consensus Conference system for grading
acne severity. The group recommends that patients may be treated with topical medications including retinoids,
benzoyl peroxide (BPO), salicylic acid, a combination of retinoid and BPO, or a combination of retinoids and BPO
with or without antibiotics for mild acne; topical retinoid with topical BPO and a oral antibiotic for moderate acne;
and oral isotretinoin if the patient fails first-line treatment (a 6- or 8-week trial of combined oral antibiotics and topical retinoids with BPO) for severe acne. Maintenance acne treatment using topical retinoids with or without BPO is
recommended. To prevent the development of antibiotic resistance, topical antibiotics should not be used as monotherapy or used simultaneously with oral antibiotics. Skin care, comprised of cleansing, moisturizing and sun protection, is likewise recommended. Patient education and good communication is recommended to improve
adherence, and advice should be given about the characteristics of the skin care products patients should use.
Key words:
INTRODUCTION
Acne vulgaris is a chronic inflammatory disease of the pilosebaceous unit with polymorphic manifestations. Clinically, it is
diagnosed by the presence of comedones (its pathognomonic
feature), papules, pustules, nodules and cysts. In recent years,
significant advancements in the understanding of acne have
altered the way it is managed. Food with high glycemic indices
is to be avoided as it is now known that it is associated with
acne. Acne has been recognized as a chronic disease, and
therefore maintenance therapy has been deemed necessary to
Correspondence: Chee Leok Goh, M.D., MBBS., MMed, MRCP(UK), FRCPE., National Skin Center, 1 Mandalay Road, Singapore 308205.
Email: clgoh@nsc.gov.sg
Received 6 January 2015; accepted 11 May 2015.
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METHODS
In 2014, the SASA group convened in Singapore to discuss
and provide their insights on current practices and guidelines
regarding acne and its treatment in SEA. Recent developments
and evidence supporting these practices were also shared and
presented. Discussions were then held to assess and determine which practices to adopt and recommend based on evidence and the groups collective experience and expertise.
RESULTS
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conference
Description
Grade
Nodules
Mild
Moderate
Severe
Few to several
Several to many
Numerous/extensive
None
Few to many
Many
Table 2. Acne
classification6
classification,
combined
acne
severity
Description
Grade
Comedones
Inflammatory
lesions
Mild
Moderate
Severe
<20
20100
>100
<15
1550
>50
Total
lesion
count
Pseudocyst
<30
30125
>125
None
None
>5
Adherence to treatment
Acne requires prolonged treatment, and patient adherence is
important for treatment success. Evidence has shown that
approximately half (48%) of Asian patients are likely to adhere
poorly to their acne treatment regimen.12 Multivariate analysis
of study data revealed the profile of poorly adherent patients.
These patients are usually accompanied during consultation,
do not use moisturizing creams and cleansers, and are poorly
informed about acne.12
Antibiotic resistance
Propionibacterium acnes colonization and proliferation has an
important role in the pathogenesis of inflammatory acne, and
antibiotics have been routinely utilized as the primary treatment for the condition.1315 However, this approach has con-
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No. of
subjects
Percentage of
isolates
Percentage of
resistant isolates
Prior/present
antibiotic history
Doxycycline
Tetracycline
Minocycline
Co-trimoxazole
Clindamycin
Erythromycin
6
3
3
10
13
18
3.4
1.7
1.7
5.7
7.5
10.3
23
11.5
11.5
38.5
50
69.2
4
3
3
3
9
11
Clindamycin
Erythromycin
Oxytetracycline
Spain
91
91
USA
79
81
63
Greece
75
75
Doxycycline
57
Egypt
65
48
18
Italy
58
58
UK
55.5
55.5
26.4
Hong
53.5
20.9
16.3
16.3
>11.5
Kong
DISCUSSION
Diagnosis and treatment of acne
The SASA group adopts the ACC grading system for acne
severity (Table 1), and recommends the treatment of patients
based on disease severity (Table 5).1,3941
There is no consensus on a single or best grading or classification system, but the ACC system is simple to use with only
three grades of acne severity, while being, as a global evaluation system, both quantitative and cognizant of the variable
expression of the disease.5,40 It is simpler than the CASS,
which has six grades of severity (05), and more clearly separates lesion types per grade.5,7 Although equally easy to use,
the system developed by Japans Acne Study Group does not
differentiate between different types of inflammatory eruptions,
which have a bearing on the risk of development of acne
scars.10 Although the ACC system is Western in origin, it is
applicable to the Asian setting as the pathogenesis of acne
and acne scarring (atrophic and hypertrophic scars) appears to
be both the same in Caucasians and Asians. The main difference in the sequelae of the disease between Caucasians and
Asians is the postinflammatory hyperpigmentation, which commonly occurs among those with a darker skin color but generally resolves with time; thus, it is not considered true scarring
in Asia.4,42
Prior to treatment initiation, it is recommended that differential diagnoses be ruled out. These include acne mechanica
(localized acneiform eruption due to friction or occlusion that is
common in athletes), acne cosmetica (a low-grade, persistent
acneiform eruption due to concurrent use of multiple cosmetic
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Singapore
>50
>50
>11.5
50
52
35
Iran
France
75.1
9.5
9.5
Recommended
Alternatives
Maintenance
Mild
Moderate
Severe
Topical retinoids
(tretinoin, isotretinoin,
adapalene)
Topical BPO
Topical retinoid + BPO
Topical retinoid and
BPO ! topical antibiotics
Topical salicylic acid, azelaic
acid, topical sulfur, and
azelaic acid with topical sulfur
Oral antibiotics
(doxycycline, tetracycline,
minocycline, lymecycline,
erythromycin) + topical
retinoids + topical BPO
Topical antibiotics should not be used as monotherapy. Oral antibiotics should not be used as monotherapy. BPO + topical retinoids fixed combinations may be used. BPO, benzoyl peroxide.
Medication
Therapy
Adapalene
Adapalene 0.1% + BPO 2.5%
1A1
1A1
1A40
1A1,39
1A40
1A40
1A40,41
1A40,41
1A40,41
1A45,46
1A40
1A11,40,7981
2C40
Few well-designed trials of salicylic acids safety and efficacy exist; however, it has been used for many years for the treatment of acne.40 BPO,
benzoyl peroxide.
the absence of clinical response or improvement after this period, patients with severe acne may be treated with oral isotretinoin, which may be administrated at a dose of 0.51 mg/kg
per day. No substantial additional benefit is expected beyond
a cumulative dose of 120150 mg/kg, and remission is typically
achieved with a 1624-week course of treatment.47 Hormonal
therapy is an alternative approach for female patients with
severe acne, and oral contraceptives with or without antiandrogens may be prescribed.
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CONCLUSION
The management of acne vulgaris in SEA is different from that
practiced elsewhere in the world, owing to local variation and
the differences between Asian and Caucasian skin. SASAs
review of the current guidelines used in the region has enabled
the group to devise evidence-based recommendations for the
management of acne.
Compared with the US, European and other SEA guidelines,
the SASA guidelines on the management of acne vulgaris in
SEA patients adopts the use of the ACC grading system for
classification and selection of treatment for patients; specifies
durations of treatment and time frames for expected results
and patient reassessment; and discusses a fuller range of adjuvant acne treatments including chemical peels, laser and PDT.
Among all the guidelines, the SASA guidelines uniquely
address the need for skin care, including cleansing, moisturizing and protection from UV radiation, in the management of
acne and the importance and relationship of skin care to
patient adherence.
Following proper diagnosis of acne, disease severity may be
classified according to the ACC grading system. Patients may
be treated according to disease severity, noting that treatment
must still be individualized. Mild acne may be treated with topical medications including retinoids, BPO, a combination of retinoid and BPO, or a combination of retinoids and BPO with or
without antibiotics. Moderate acne may be treated with a combination of topical retinoid, BPO and an oral antibiotic. Hormonal therapy may be used if indicated in female patients.
Severe acne may be treated with oral isotretinoin if the patient
fails a 68-week trial of combined oral antibiotics and topical
retinoids with BPO. Maintenance treatment is recommended,
and patients may be prescribed topical retinoids with or without BPO. To prevent the development of antibiotic resistance,
topical antibiotics should not be used as monotherapy or used
concurrently with oral antibiotics. These should be used with
good compliance for a maximum of 12 weeks, and the
response to the regimen should be assessed every 8
12 weeks. Skin care during treatment is recommended and
patients should be educated and informed about cleansing,
moisturizing and sun protection. Patient education and communication between the treating physician and the patient is
CONFLICT OF INTEREST:
REFERENCES
1 Thiboutot D, Gollnick H, Bettoli V et al. New insights into the management of acne: an update from the Global Alliance to Improve
Outcomes in Acne group. J Am Acad Dermatol 2009; 60 (5 Suppl):
S1S50.
2 Bowe WP, Joshi SS, Shalita AR. Diet and acne. J Am Acad Dermatol 2010; 63: 124141.
3 Abad-Casintahan F, Chow SK, Goh CL et al. Toward evidencebased practice in acne: consensus of an Asian Working Group.
J Dermatol 2011; 38: 10411048.
4 Chan HH, Alam M, Kono T, Dover JS. Clinical application of lasers
in Asians. Dermatol Surg 2002; 28: 556563.
5 Pochi PE, Shalita AR, Strauss JS et al. Report of the Consensus
Conference on Acne Classification. Washington, D.C., March 24
and 25, 1990. J Am Acad Dermatol 1991; 24: 495500.
6 Issued by funding/sponsoring agency: Management of Acne Volume 1: Evidence Report and Appendixes. Rockville, Md: Dept. of
Health and Human Services (US),Public Health Service; 2001 Sep.
Report No.: 01-E019.Issued by performing agency: Lehmann HP,
Andrews JS, Robinson KA, Holloway VL, Goodman SN. Johns
Hopkins Evidence-based Practice Center. Contract No. 29097
006. Sponsored by the Agency for Healthcare Research and
Quality.
7 Tan JK, Tang J, Fung K et al. Development and validation of a comprehensive acne severity scale. J Cutan Med Surg 2007; 11(6): 211
216.
8 MOH Malaysia. Malaysian Clinical Practice Guidelines on Management of Acne Vulgaris. Malaysia, 2012. Available at: http://
www.moh.gov.my/attachments/7190.pdf. Accessed on 25 June,
2014.
9 Acne Board of the Philippines. Multidisciplinary Treatment Guidelines for Acne. Manila, Philippines: MIMS Pte, 2013.
10 Hayashi N, Akamatsu H, Kawashima M, Acne Study Group. Establishment of grading criteria for acne severity. J Dermatol 2008; 35:
255260.
!no B, Bettoli V et al. European evidence-based (S3)
11 Nast A, Dre
guidelines for the treatment of acne. J Eur Acad Dermatol Venereol
2012; 26 (Suppl 1): 129.
!no B, Thiboutot D, Gollnick H et al. Large-scale worldwide
12 Dre
observational study of adherence with acne therapy. Int J Dermatol
2010; 49: 448456.
13 Gollnick H, Cunliffe W, Berson D et al. Management of acne: a
report from a Global Alliance to Improve Outcomes in Acne. J Am
Acad Dermatol 2003; 49 (1 Suppl): S1S37.
14 Tzellos T, Zampeli V, Makrantonaki E, Zouboulis CC. Treating acne
with antibiotic-resistant bacterial colonization. Expert Opin Pharmacother 2011; 12: 12331247.
15 World Health Organization. The Evolving Threat of Antimicrobial
Resistance - Options for Action. Geneva, Switzerland: World Health
Organization, 2012.
16 Ross JI, Snelling AM, Carnegie E et al. Antibiotic-resistant acne: lessons from Europe. Br J Dermatol 2003; 148: 467478.
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