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Update on the Treatment of Acne Vulgaris
Kimberly W. Lai, BS, and Mary Gail Mercurio, MD
Four major factors associated with the pathogenesis of
To provide an evidence-based review of
acne are increased sebum production, follicular hyperkera-
tinization, Propionibacterium acnes
proliferation, and inflam-
Review of the literature.
Acne vulgaris is a chronic inflammatory
Androgenic stimulation causes sebum production from
condition affecting 40 to 50 mil ion people in the
the sebaceous glands. Excess sebum production can result
United States. Current treatments target at least 1 of
from pilosebaceous unit hyperresponsiveness, increased
the known pathophysiologic mechanisms involved
circulating androgens, or both . However, most patients
in acne development. Combination therapy with a
do not have significant endocrine abnormalities .
topical retinoid and antimicrobial agent is general y
Keratinocyte proliferation and abnormal desquamation
recommended as first-line treatment for most pa-
cause follicular hyperkeratinization . Keratinocytes accu-
tients. Oral antibiotics are often used for moderate to
mulate and become densely packed with monofilaments and
severe acne, and their combined use with benzoyl
sebum, forming a microcomedo [5,6]. Further sebum produc-
peroxide can prevent the development of bacterial
tion converts a microcomedo to a closed comedo (whitehead)
resistance. There is also good evidence to suggest
when the follicular orifice is closed, or to an open comedo
that oral contraceptives containing estrogen and
(blackhead) when the follicular orifice is open .
a progestin are effective in reducing acne lesions
is a gram-positive anaerobe that resides in the pi-
in women. Oral isotretinoin has been shown to be
losebaceous unit. These bacteria attract lymphocytes, which
effective in clearing severe nodulocystic acne and
invade and destroy the follicular wall . Rupture of the fol-
inducing remission, although it is unclear whether
licular epithelium causes lipids, keratinocytes, and P. acnes
an association between oral isotretinoin use and
to leak into the surrounding dermis . This leads to further
suicidal behaviors exists. Lasers, light sources, and
recruitment of inflammatory cytokines and neuropeptides,
photodynamic therapy are effective in the treatment
thus perpetuating the inflammatory process and resulting
of acne; however, further studies are needed to de-
in inflammatory papules or nodules .
termine the appropriate duration and light source.
Several systems for grading acne exist with most involv-
Effective treatment for acne is avail-
ing a global assessment of the severity (eg, mild, moderate,
able. Patient responses vary, and often more than
severe) that takes into account the number, type, and extent
of acne lesions . Although there is no consensus on which
classification system is the best, clinicians may find it useful
cne vulgaris is a chronic inflammatory dermatosis
to use a consistent system to select appropriate treatment
of the pilosebaceous unit characterized by open or
regimens and assess responses to treatment .
closed comedones and inflammatory papules, pus-
Routine endocrinologic testing is not necessary in the
tules, nodules, or cysts. It affects 40 to 50 million individuals
majority of patients with acne . However, laboratory
in the United States , including 70% to 87% of adolescents
evaluation of free testosterone, dehydroepiandrosterone sul-
. Acne is also a common skin problem in adults. Goulden
fate, luteinizing hormone, and follicle-stimulating hormone
et al  found that the prevalence of facial acne in men and
is indicated in females presenting with signs of hyperan-
women over age 25 determined by clinical examination was
drogenism. Such signs can include menstrual dysfunction,
3% and 12%, with 82% of cases being persistent from ado-
hirsutism, or polycystic ovaries in adult women [5,7].
lescence. More recently, Collier et al  assessed the preva-
lence of acne reported by women and men by age-group.
Prevalence for women and men, respectively, was 50.9% and
42.5% for ages 20 to 29 years, 35.2% and 20.1% for ages 30 to
39 years, 26.3% and 12.0% for ages 40 to 49 years, and 15.3%
and 7.3% in ages 50 years and older.
From the University of Rochester, Rochester, NY.
Vol. 16, No. 3 March 2009 JCOM
treatment for mild acne
First-line therapy for mild acne involves a topical retinoid [5,6].
Benzoyl peroxide is bactericidal and is effective in treating
If an inflammatory component exists, a topical antibiotic such
acne. Benzoyl peroxide plus a topical retinoid are often used
as clindamycin or erythromycin may be added to enhance
in conjunction with antibiotics to prevent or eliminate the
the efficacy [5,6]. Antibiotics should not be used as mono-
development of antibiotic-resistant P. acnes
therapy and should be discontinued when the inflammatory
In studies, patients using benzoyl peroxide 20% lotion
component is adequately treated in order to minimize the
, benzoyl peroxide 5% gel , and benzoyl peroxide 5%
occurrence of antibiotic-resistant bacteria . Topical benzoyl
gel or 10% cream  had a significantly greater reduction
peroxide or azelaic acid may be added to antibiotic therapy to
of acne lesions, including both inflammatory and nonin-
reduce the potential for developing P. acnes
flammatory lesions, compared with controls. There appears
to be no difference in efficacy among the benzoyl peroxide
Topical retinoids should be the foundation of treatment for
Randomized trials by Belknap  and Montes  showed
most patients with acne because they act to reduce obstruc-
that both topical tretinoin and benzoyl peroxide effectively re-
tion of the follicle and therefore treat both comedonal and
duced inflammatory and noninflammatory lesions. Montes
inflammatory acne . They are also recommended for
 also concluded that benzoyl peroxide was clinically better
maintenance therapy . Three topical retinoids are avail-
than topical tretinoin for reducing the total number of lesions,
able in the United States: tretinoin, adapalene, and tazaro-
tene. The number of inflammatory and noninflammatory
lesions is significantly reduced by topical tretinoin [8–11],
adapalene [12–14], and tazarotene [15–17].
Topical antibiotics are indicated for mild inflammatory acne
Tretinoin was the first topical retinoid used in the treat-
. Both erythromycin and clindamycin are topical antibiot-
ment of acne, and adapalene and tazarotene are synthetic
ics that have been shown to be effective and well-tolerated.
agents . Retinoids exert their effects by binding to nuclear
Because P. acnes
can develop resistance to either of these anti-
retinoid acid receptors (RAR) and retinoid X receptors (RXR)
biotics , their use as a single therapeutic agent is limited.
. Cellular binding proteins (CRBP I and II) and cellular
Double-blind, randomized controlled studies have dem-
retinoic acid binding proteins (CRABP I and II) are involved
onstrated the efficacy of various topical erythromycin prep-
in cellular transport and metabolism of retinoids . Studies
arations, including erythromycin 1.5% solution and erythro-
suggest that because adapalene activity is not dependent on
mycin 2% gel and ointment, in reducing inflammatory acne
CRABP II binding, it is associated with less irritation and less
erythema . Tretinoin may cause more adverse effects be-
Clindamycin has also been shown to be effective in the
cause of its involvement in several pathways, including RAR
treatment of acne. In several multicenter, investigator or
and RXR activation and CRABP II binding .
double-blind, randomized, placebo-controlled trials, pa-
Tazarotene appears to be the most efficacious topical
tients using clindamycin 1% hydrochloride solution, clinda-
retinoid. In randomized, double-blind controlled trials and a
mycin 1% phosphate solution, clindamycin 1% phosphate
meta-analysis, tazarotene 0.1% gel or cream was shown to be
lotion, or clindamycin 1% phosphate gel had a significantly
more effective than tretinoin 0.025% gel , tretinoin 0.1%
greater reduction in papule and pustule counts compared
microsphere gel , adapalene 0.1% gel , or adapalene
with patients receiving placebo [48–50]. Additionally, the
0.1% cream . However, some randomized, evaluator-
study by Ellis et al  showed the clindamycin solution and
blind, controlled trials showed that tazarotene 0.1% cream
gel both were associated with significant reduction of open
was equally efficacious to adapalene 0.1% gel and 0.3% gel
in total acne lesion reduction [23–25].
Topical clindamycin and erythromycin appear to have
Adverse effects of topical retinoids include erythema,
comparative efficacy. In double-blind and investigator-blind
dryness, itching, and stinging. Adapalene seems to be as-
randomized comparisons of topical erythromycin versus
sociated with fewer adverse effects. Adapalene 0.1% gel or
topical clindamycin, both formulations showed comparative
solution is equally effective or superior to tretinoin 0.025%
efficacy in reducing acne lesions [51–53].
gel [26,27], tretinoin microsphere 0.1% gel , and tretinoin
An analysis of clinical trials showed that the efficacy of
0.05% cream , but it is generally better tolerated and less
1.5% to 2% topical erythromycin formulations in the treat-
likely to cause skin irritation [26,28–33]. Topical retinoids
ment of inflammatory or noninflammatory acne decreased
are available in a variety of strengths and formulations and
over time, especially in studies of greater than 12 weeks’
generally should be started at a low strength to minimize
duration . The efficacy of topical clindamycin remained
stable throughout the study period .
March 2009 Vol. 16, No. 3
with baseline in patients treated with combination therapy,
Although few well-designed trials evaluating the safety and
whereas P. acnes
counts increased by greater than 1600% in
efficacy of topical salicylic acid exist, a review of 3 placebo-
those receiving clindamycin monotherapy.
controlled trials and 1 comedoytic assay concluded that
salicylic acids pads reduce the number of primary lesions
treatment for moderate acne
The use of systemic antibiotics is indicated for moderate or
Azelaic acid has comedolytic and antibacterial properties
severe acne . The most commonly used systemic antibiot-
and is effective in treating acne. Several studies have shown
ics are tetracycline and its derivatives . Other less com-
that 20% azelaic acid is superior to placebo in reducing inflam-
monly used antibiotics include macrolides, trimethoprim-
matory and noninflammatory acne lesions or total number of
sulfamethoxazole (TMP-SMX), and trimethoprim . Like
acne lesions [56–58]. One study showed that 20% azelaic acid
topical antibiotics, systemic antibiotics should be combined
had similar efficacy compared with 0.05% tretinoin cream and
with a topical retinoid to enhance efficacy . The addition of
another showed that although benzoyl peroxide has a more
topical benzoyl peroxide reduces the development of P. acnes
rapid effect, azelaic acid is better tolerated [57,59].
resistance . In women, oral contraceptives containing an
Randomized, double-blind, vehicle-controlled trials have
estrogen and progestin are indicated for moderate acne and
shown that topical dapsone 5% gel is effective in reducing
can be used as a component of combination therapy [5,6].
inflammatory and noninflammatory acne lesions and that
For moderate nodular acne that is resistant to primary treat-
adverse effects were comparable with those in the control
ments, oral isotretinoin may be used [5,7].
group [60–62]. Use of oral dapsone may be associated with
hematologic adverse effects; however, in patients with glucose-
6-phosphate dehydrogenase (G6PD) deficiency treated with
Systemic antibiotics are the standard of care for moderate
dapsone 5% gel, there was no clinical or laboratory evidence
and severe acne and treatment-resistant forms of acne .
They are generally not used as monotherapy and are ideally
discontinued within 8 to 12 weeks because of the concern
for increased bacterial resistance [5,7]. There is evidence to
Combination therapy is likely to have a more significant ef-
support the use of tetracycline, doxycycline, minocycline,
fect because it targets 3 major areas of acne pathophysiology:
erythromycin, TMP-SMX, trimethoprim, and azithromycin.
proliferation, inflammation, and hyperkeratiniza-
Oral antibiotics are also associated with a variety of side
tion . Topical retinoids in combination with topical or oral
effects . All antibiotics can result in vaginal candidiasis.
antimicrobials have been shown to reduce inflammatory
Tetracyclines should not be used in pregnant women and
and noninflammatory acne lesions faster and to a greater
children under age 8 due to deposition in bones and tooth
degree than antimicrobial agents alone . Additionally,
discoloration . Doxycycline is associated with photosensi-
combination therapy is one strategy to limit the increase in
tivity and esophageal irritation . Minocycline may cause
resistance of P. acnes
in patients [5,64].
vestibular disturbances, pigment deposition, and rarely au-
In an 8-week study by Mills and Kligman , groups of
toimmune hepatitis or a systemic lupus erythematosus–like
patients with moderate acne who received topical erythro-
mycin plus topical tretinoin experienced better results than
In double-blind randomized controlled studies, treat-
those receiving monotherapy or placebo. In double-blind
ment with oral tetracycline was associated with significantly
randomized trials, the combination topical clindamycin 1%
greater improvement in acne compared with placebo [78–
phosphate and a topical retinoid was found to be more effica-
84]. There are conflicting data on whether oral tetracycline is
cious in reducing inflammatory acne and noninflammatory
superior to topical tetracycline or whether there is no signifi-
acne lesions than either agent alone [66–69]. Topical retinoids
cant difference in efficacy [79–81], and it is unclear whether
plus benzoyl peroxide have also been effective in the treat-
topical clindamycin is equally efficacious or superior to oral
ment of acne in randomized, controlled investigator- and
There is insufficient evidence to support the use of 1 tet-
Several double- or single-blind randomized controlled
racycline over another [85,86]. A Cochrane review of mino-
studies have demonstrated the efficacy of topical antibiotics
cycline in the treatment of acne concluded that there was no
combined with benzoyl peroxide in treating inflamma-
reliable randomized controlled trial evidence to justify the
tory acne [64,72–75]. Additionally, 1 double-blind random-
use of minocycline as first-line treatment for acne, especially
ized study by Cunliffe et al  demonstrated a reduc-
considering the higher cost and concerns about more severe
tion in clindamycin-resistant P. acnes
counts as compared
Vol. 16, No. 3 March 2009 JCOM
A double-blind randomized controlled study by Gam-
mon et al  showed that oral erythromycin and oral tetra-
Spironolactone inhibits the biosynthesis of testosterone
cycline were equal in efficacy in the treatment of moderate
and also blocks androgen receptors . This results in
to moderately severe acne. Bacterial resistance is most com-
decreased androgen-stimulated sebocyte proliferation and
mon with erythromycin , and its use should be limited
to those who cannot use tetracyclines .
In randomized, placebo-controlled, double-blind studies,
Although oral TMP-SMX and oral trimethoprim are not
Muhlemann et al  showed that spironolactone is signifi-
recommended as first-line therapy, they have been shown to
cantly more effective than placebo in reducing the number
significantly reduce acne severity and can be used for acne
of inflamed acne lesions, and Goodfellow et al  found
treatment when other oral antibiotics cannot be used or pa-
that patients tended to have greater improvement when
tients are refractory to other oral antibiotic regimens [89–92].
taking higher doses (150–200 mg) of spironolactone. Hatwal
An open-label, noncomparative study by Bardazzi et al
et al  found that acne severity improved significantly
 demonstrated a significant reduction in inflammatory le-
more in participants using spironolactone compared with
sions in patients receiving azithromycin relative to baseline.
those using cimetidine, which has antiandrogenic effects.
However, these studies had relatively small sample popula-
Estrogen-containing oral contraceptives can be useful in
Side effects of spironolactone therapy may include hy-
the treatment of acne for women. In 5 randomized placebo-
perkalemia, menstrual irregularities, breast tenderness, or
controlled trials, oral contraceptives reduced inflamma-
hypotension . A retrospective analysis by Shaw 
tory and noninflammatory acne lesion counts and severity
showed that a lower frequency of adverse effects may be as-
grades and improved global and patient self-assessment
sociated with lower doses of spironolactone (50–100 mg).
compared with placebo [94–98]. These trials included com-
binations of ethinyl estradiol plus levonorgestrel, norethin-
treatment of Severe acne
Oral isotretinoin is indicated for severe nodulocystic acne or
The comparative effectiveness of combination oral con-
treatment-resistant moderate acne . Education of patient
traceptives with varying progestin components is unclear.
regarding the side effects, teratogenicity, potential psychiatric
Randomized controlled trials suggest that chlormadinone
effects, and monitoring is critical in patients who are interested
acetate–containing or cyproterone acetate–containing oral
in initiating oral isotretinoin . Alternatives to oral isotreti-
contraceptives improved acne better than those containing
noin treatment include the combination of a systemic antibiot-
levonorgestrel, but the superiority is based on little evidence
ic, topical retinoid, and topical benzoyl peroxide . In women,
[99,100]. Comparisons between other oral contraceptives con-
an oral contraceptive can be added to the combination .
taining diphasic desogestrel [101–105], cyproterone acetate
[101–103], levonorgestrel [104–107], drospirenone [108–112],
norgestimate , gestodene [110–112], and norethindrone
Although oral isotretinoin is approved for the treatment of
acetate  were either conflicting or found no differences
severe nodulocystic treatment-resistant acne, it is also indi-
between the combinations in the ability to reduce acne.
cated for all cases of treatment-resistant acne or acne that
In a multicenter, controlled trial by Monk et al , no
produces physical or psychological scarring . Isotretinoin
significant difference was found between low-dose cypro-
has been shown to be effective in clearing acne lesions
terone acetate and oral minocycline in the reduction of acne
and inducing remission. The prolonged remission may be
lesions or in the patients’ self-assessments.
related to continued sebaceous gland inhibition in some
Overall, good evidence suggests that combination oral
contraceptives containing an estrogen and a progestin are
In a randomized, double-blind study by Peck et al ,
effective for reducing acne lesions in women, even those
patients receiving isotretinoin had 95% improvement, which
without increased serum androgens . To date, ethi-
was significantly greater than those receiving placebo, who
nyl estradiol-drospirenone, ethinyl estradiol-norethindrone
had an overall 57% increase in the number of lesions. Sixteen
acetate, and ethinyl estradiol-norgestimate are the oral
of the 17 patients who initially received placebo were then
contraceptives that are specifically approved by the U.S.
given isotretinoin with a 98% improvement. Twenty-seven
Food and Drug Administration for the treatment of acne
of 32 patients cleared completely, with 18 receiving only one
, although few differences are found between various
4-month course of treatment. All patients were in remission
combination oral contraceptives. There are limited data to
at the time of the report, averaging 38 months of remission.
determine the comparative effectiveness between oral con-
A double-blind study concluded that there were no sig-
traceptives and antibiotics in reducing acne lesions.
nificant differences in efficacy between doses of 0.1 mg/kg,
March 2009 Vol. 16, No. 3
0.5 mg/kg, and 1 mg/kg, but they recommended 0.5 mg/kg
evidence to rule out a weak association . Therefore, pa-
as the initial dose for the initial course of isotretinoin treat-
tients must be aware of the potential effects, and physicians
ment because those treated with 1 mg/kg had more severe
should monitor for these adverse effects .
side effects and those treated with 0.1 mg/kg had a higher
incidence of relapse . Similarly, another double-blind
study concluded that the optimal dose-range for the treat-
Topical retinoids are the preferred agent for maintenance
ment of patients with nodulocystic acne is 0.5 to 1.0 mg/kg
therapy . Antibiotics should be discontinued once inflam-
because a lower dose was associated with much lower main-
matory lesions are well-controlled . If an antimicrobial
tenance of clinical improvement . In general, treatment
agent is need, benzoyl peroxide should be used in conjunc-
continues until a cumulative dose of 120 to 150 mg/kg is
Layton et al  concluded that isotretinoin is safe and
alternative acne treatments
effective and is capable of producing long-term remission in
A variety of alternative acne treatments exist. While there are
the majority of patients in a 10-year follow-up study. Factors
limited data to indicate their use as first-line therapy, these al-
associated with the need for further courses of treatment in-
ternatives may be used in conjunction with other treatments.
cluded lower dosage regimens (0.1 mg/kg and 0.5 mg/kg),
the presence of severe acne, females older than age 25 years,
and a prolonged history of acne .
There are limited data to support the effectiveness of oral
All patients are required to register and comply with the
corticosteroids in the treatment of acne. One study by Nader
iPLEDGE program . Isotretinoin has potential teratogenic
et al  showed that oral prednisone lowered elevated
effects, and therefore adequate contraception is necessary
androgen levels in hyperandrogenic women with acne and
before, during, and 6 weeks after treatment . Laboratory
was associated with clearing or significant improvement.
monitoring during therapy should include measurement
A consensus of expert opinion supports the idea that short
of triglycerides, cholesterol, transaminases, and complete
courses of high-dose oral corticosteroids may be of tempo-
blood counts . Common adverse effects of isotretinoin
rary benefit in patients with severe inflammatory acne .
therapy include dry skin and eyes, secondary skin infection,
myalgias, epistaxis, and decreased night vision .
In a multicenter, double-blind controlled study, patients
Corticosteroids can be injected intralesional y in order to obtain
with severe recalcitrant nodular acne were randomized
a high concentration of steroid at the lesion site with minimal
to either micronized isotretinoin or standard isotretinoin
systemic absorption. In smal studies, improvement has been
[127,128]. Both formulations had similar clinical efficacy
noted in the treatment of individual acne cysts and nodules
, but the micronized isotretinoin appeared to lower the
within 24 to 72 hours [133–135]. Injection of lesions may be as-
risk of mucocutaneous adverse events and hypertriglyceri-
sociated with local atrophy , and systemic absorption may
occur leading to suppression of the hypothalamic-pituitary-
Depression and suicidal behaviors have been reported in
adrenal axis . Decreasing the concentration or volume may
patients taking isotretinoin . However, a causal relation-
ship has not been established. A systematic review found
that rates of depression in the included studies showed simi-
lar rates of depression in antibiotic control groups, and there
Glycolic acid is an alpha-hydroxy acid that can be used as
was no significant increase in depression after isotretinoin
a chemical peeling agent by inducing removal and then
treatment compared with before treatment . A recent
regeneration of the epidermis and/or dermis . Salicylic
case-crossover study is the first controlled study to find
acid is a keratolytic agent that has a strong comedolytic ef-
a statistically significant association between isotretinoin
fect because of its lipophilic nature and ability to penetrate
and depression . Treatment of severe acne is often as-
deep into pores . However, there is little evidence in the
sociated with mood improvement [7,129]; however, given the
peer-reviewed literature supporting the efficacy of glycolic
profound consequences of depression in young patients, it is
acid–based or salicylic acid–based peeling preparations.
prudent to advise patients on isotretinoin that the possibility
One randomized controlled trial compared glycolic acid
of an association with depression has been raised and close
and Jessner’s solution (resorcinol, salicylic acid, lactic acid,
and ethanol) and demonstrated improvement in facial acne
Although these studies do not support a causal rela-
in both treatments compared with baseline . There
tionship between isotretinoin use and increased rate of
was no statistically significant difference between the treat-
depression or suicidal behavior, there may not be sufficient
ments. Several controlled trials and case series have also
Vol. 16, No. 3 March 2009 JCOM
reported improvement in inflammatory and noninflamma-
cacy of infrared lasers for the treatment of acne. A 1320-nm Nd:
tory acne in patients using chemical peels compared with
YAG laser produced a significantly greater reduction of open
comedones but had no difference in the reduction of papules,
Although chemical peels do not replace topical or sys-
pustules, or closed comedones compared with no treatment
temic medications for the treatment of acne, they can be
. A 1450-nm wavelength laser produced a significantly
greater reduction in the total acne lesion count compared to
the control . Clinical efficacy has not been demonstrated
to be enhanced with the addition of microdermabrasion to
There is little evidence in the peer-reviewed literature re-
1450-nm laser treatment  nor has a significant difference
garding the efficacy of comedo removal. The extraction of
been shown between 2 fluencies (14 and 16 J/cm2) .
comedones maybe more beneficial in superficial acne but
not in cystic acne . Comedo removal does not affect the
course of the disease but may provide immediate improve-
As part of its normal metabolism, P. acnes
ment of the patient’s appearance , increase patient satis-
rins, which can absorb light at the near ultraviolet and blue
faction , and positively impact compliance .
light spectrum [156,157]. Irradiation of P. acnes
light can induce photoexcitation, leading to singlet oxygen
Complementary and Alternative Medicines
production, and eventually bacterial destruction. Several
Complementary and alternative medicines are used to treat
trials have studied the efficacy of various light sources and
a variety of health conditions including acne. However,
there are very limited data addressing the safety and ef-
In a randomized, evaluator-blinded study by Sigurdsson
et al , green light and violet light significantly improved
Two clinical trials have shown that tea tree oil is an effec-
face, back, and/or chest acne, with a tendency toward violet
tive treatment for acne [144,145]. In double-blind, randomized,
placebo-controlled clinical evaluations, certain herbal tablets
Other randomized controlled trials evaluating blue light
have been associated with a significant reduction in the num-
have shown its safety and efficacy in the reduction of
ber of inflammatory and noninflammatory lesions [146,147].
inflammatory lesions [157,159,160] but worsening of nodulo-
In addition to causing stress and having a significant
psychological impact on patients, acne may be exacerbated
The randomized controlled trial by Na and Suh 
by stress because of an associated increased sebum excre-
concluded that red light alone is effective in the treatment of
tion rate, free fatty acid production, and endocrine activity.
inflammatory and noninflammatory acne lesions, although
The results of an intervention by Hughes et al  provided
it does not eradicate the lesions completely and effects are
support for the efficacy of biofeedback relaxation-imagery
therapy in the treatment of acne. However, the literature sup-
A randomized controlled study by Papageorgious et al
porting the possible benefit of biofeedback-assisted relaxation
 demonstrated that phototherapy with mixed blue and
and cognitive therapy in the treatment of acne is weak.
red light was significantly better that blue light alone, white
light, and benzoyl peroxide 5% cream in improving inflam-
matory acne, and nonsignificantly better in improving
Some data indicate that the use of pulsed dye lasers, potas-
sium titanyl phosphate lasers, and infrared lasers may be
of benefit in reducing acne lesions. However, data are very
Photodynamic therapy is a therapeutic modality that uti-
Two randomized controlled studies evaluated the efficacy
lizes a photosensitizing agent and its activating wavelength
of pulsed dye lasers versus sham treatments. Seaton et al
of light to selectively destroy target tissue . The few ran-
 showed significant reduction of inflammatory acne le-
domized controlled studies that have evaluated the efficacy
sions and total acne lesions, but Orringer et al  failed to
of photodynamic therapy have shown positive results.
show a significant difference between the laser-treated skin
Topically applied 5-aminolevulinic acid (ALA) is me-
tabolized to protoporphyrin IX, a potent photosensitizer, that
In a randomized controlled trial, Baugh and Kucaba 
accumulates in epidermal cells and pilosebaceous units .
showed that after 4 treatments with the potassium titanyl
When the ALA-treated skin is irradiated with light, protopor-
phosphate laser, patients had significant improvement in their
phyrin IX is excited and reacts with oxygen to form singlet,
acne at 1 week and nonsignificant improvement at 4 weeks.
causing membrane damage and cell destruction .
Four randomized control ed studies have evaluated the effi-
In a randomized controlled trials comparing photodynamic
March 2009 Vol. 16, No. 3
therapy with either treatment alone or no treatment, ALA
Treatment Recommendations for Acne Vulgaris
plus red light produced significantly greater reduction of
inflammatory acne lesions [163,164], and ALA plus blue
Addition of a topical antibiotic/benzoyl peroxide
light produced a greater reduction in papules, pustules, and
combination if papules/pustules present. Ben-
comedones . Significant improvement in acne lesions
zoyl peroxide without antibiotic also an option
was demonstrated using intense pulsed light (IPL) plus ALA
basing strength of formulation on skin dryness
and using IPL plus short-contact ALA [162,166]. Complete
(oily skin higher concentration) or azelaic acid with topical antibiotic
clearance of acne in all patients using long-pulsed dye laser
Topical retinoid plus systemic antibiotic
(LPDL) plus ALA was shown by Alexiades-Armenakas in a
Addition of a topical antibiotic/benzoyl peroxide
Methyl aminolevulinate (MAL) is another agent that has
If treatment-resistant, may consider isotretinoin
been studied in the photodynamic therapy of acne. It is de-
esterified to ALA by intracellular enzymes . Because of
If isotretinoin contraindicated or not tolerated,
its lipophilicity, MAL is expected to penetrate more easily
alternatives include a systemic antibiotic in com-
and deeper into the targeted tissue .
Randomized controlled trials have shown a significantly
greater reduction in inflammatory acne lesions in patients
treated with MAL plus red light compared with patients
receiving placebo or no treatment [168,170]. In a randomized,
half-face treatment study by Yeung et al , patients who
received MAL plus IPL had a nonsignificantly greater reduc-
tion in inflammatory acne lesions compared with controls
who received IPL alone or topical adapalene. The patients
Author contributions: conception and design, KWL, MGM; drafting of article, KWL; critical revision of the article, MGM; col ection and assem-
receiving MAL plus IPL and IPL alone had a significantly
greater reduction of noninflammatory acne lesions com-
pared with the adapalene group . Haedersdal et al 
found that the half of the face treated with MAL plus LPDL-
treated had a significantly greater reduction of acne lesions
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Journal of Dermatology 2010; 37: 708–713Anti-infliximab antibody status and its relation toclinical response in psoriatic patients: A pilot studyEsra ADIS¸EN,1 Arzu ARAL,2 Cemalettin AYBAY,2 Mehmet Ali GUDepartments of 1Dermatology and 2Immunology, Gazi University, Faculty of Medicine, Ankara, TurkeyAlthough the mechanisms underlying the loss of response to infliximab are not completely und
Introduction Over the last 20 years, scholars have devoted considerable attention to the ability of farmers, fishermen, pastoralists and other types of resource users to organize, adopt, monitor and enforce institutional arrangements that govern their use of common pool resources (CPRs) in a sustainable manner (Ostrom et al ., 2002). During this period, progress has been made in carefully iden