Dr. Friedman is the Director of Dermatologic Research of the Unified Division of Dermatology at the Montefiore-Albert Einstein College of Medicine, Bronx, New York.
Dr. Friedman is coinventor of the nitric oxide nanotechnology described here.
As one of the most common skin diseases, acne research, clinical guidelines, and therapeutic innovation are always a hot topic at the Annual Meeting of the American Academy of Dermatology (March 21-25, 2014). A new dimension in the chicken and egg, or rather microcomedone and inflammation, story of acne pathogenesis emerged in a recent Journal of Investigative Dermatology (2014;134:381-388) article, which demonstrated that Propionibacterium acnes triggers a key inflammatory mediator, IL-1β, via the inflammasome (a compilation of inflammatory proteins such as caspases and NOD-like receptors) activation, suggesting a role for inflammasome-mediated inflammation in acne pathogenesis in addition to and independent of toll-like receptor activation. A potential therapeutic target, perhaps?
Drs. Ted Rosen and Joshua Zeichner in 2 independent sessions (Treating Tumors and Inflammatory Skin Diseases With Immunomodulators and Biologics [Rosen] and Acne Treatment Controversies [Zeichner]) discussed the importance of purposeful utilization of oral antibiotics—less is more—to prevent the continued emergence of antimicrobial resistance. Dr. Rosen commented that doxycycline at doses ≥50 mg daily provides serum levels that have an impact on commensal or colonized organisms, while lower doses provide only the anti-inflammatory effects without any bacteriostatic impact. This finding highlights the importance of low-dose controlled-release formulations. Dr. Zeichner also stressed the importance of knowing when to quit; if a patient does not improve in 6 to 8 weeks of therapy, move on. He also commented on the importance of multimechanistic therapy (solo is a no-go), utilizing benzoyl peroxide–containing products and most importantly retinoids from day 1. Dr. Zeichner also stressed the importance of recognizing acne mimics, such as gram-negative folliculitis, and made it clear that hormonally driven acne must not be missed, especially in the adult female population.
Lastly, new directions in acne are emerging, utilizing the science of nanotechnology (nano is equivalent to 1 billionth of a part). Drug delivery with nanomaterials is being fervently pursued across the globe in the field of acne. Nanoparticles can allow for sustained and controlled release of established products, increasing efficacy and stability, compliance due to decreased dosing, and safety by limiting associated irritation and dryness. In a session on nanotechnology, Dr. Rox Anderson presented his work utilizing gold nanoparticles to selectively destroy sebaceous glands via selective photothermolysis. He commented, “Do we really need our sebaceous glands,” citing that babies and infants do just fine without their activity. This work is currently in clinical trials in Europe. Nanotechnology also can be used to deliver previously undeliverable actives, such as the gaseous molecule nitric oxide. It was shown that a nitric oxide–releasing nanoparticle technology effectively penetrated the pilosebaceous unit, killed P acnes in culture, and inhibited inflammatory cytokine production by keratinocytes exposed to P acnes.