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Combination therapy is preferred, not only because monotherapy is less effective, but because topical antibiotic monotherapy is associated with rapid antibiotic resistance.41,42 Consider alternative antibacterials, such as BPO, salicylic acid, or dermocosmetics.


Topical BPO (2.5%, 5%) is effective against P. acnes and efficacious in inflammatory acne. Its use is encouraged over topical antibiotics to reduce development of antibiotic resistance, but widespread use is limited by irritation. The combination therapy of BPO and adapalene is more effective than adapalene or BPO alone.43 A summary of recommendations regarding topical therapies is provided in Table 4.

In three 12-week trials in patients 12 years of age or older with moderate acne, success rates were significantly higher with adapalene 0.1%/BPO 2.5% gel than with adapalene 0.1% gel or BPO 2.5% gel alone, and combination therapy had an earlier onset of action. A rapid onset of action was observed using this combination treatment, reducing lesions from the first week. Additionally, this combination therapy clears both inflammatory and non-inflammatory lesions, targets three out of four pathogenic causes of acne, is antibiotic-free (removing the risk of antibiotic resistance) and has shown long-term efficacy and tolerability.49

Maintenance treatment. Acne typically recurs soon after cessation of active treatment, making maintenance treatment necessary. About 28 percent of sections of normal-appearing skin from patients with acne show histologic features of microcomedones, the subclinical precursors to both inflammatory and noninflammatory acne lesions, and biopsy of papules demonstrates the presence of microcomedones in 52 percent of patients with acne.50 Maintenance anticomedogenic agents have been shown to effectively control acne and prevent relapses and minimize sequelae.50

In Singapore, there has been a reported increase in resistance rates of P. acnes from eight percent in 1999 to 14.9 percent in 2007.4,39 Further, Tan et al4 documented resistant P. acnes in school-attending adolescents who had not been previously treated for acne. The concern over antibiotic resistance warrants judicious use. Patient education and adherence are essential to ensure good outcomes while minimizing the risk of resistance.

Chemical peels. Chemical peels for acne and acne scars in Asian patients have been shown to be safe and effective.92,93 More trials with better study designs and higher numbers of subjects are needed to further establish the role of chemical peels in Asian patients with acne.92 For instance, glycolic acid 40% has been found to significantly improve moderate acne.93

Azelaic acid 20% is a mild comedolytic with anti-inflammatory activity.115 It is safe and effective as a treatment and maintenance option for women with adult acne with noninferior efficacy to adapalene (0.1%) in the control of inflammatory acne.116 It can be used during pregnancy117 and can be useful in patients with acne and PIH, as it induces hypopigmentation in darker skin.118 BPO (2.5%, 5%, and 10%) has anti-inflammatory, antibacterial, and mild comedolytic activities and does not induce bacterial resistance.119 Lower concentrations of BPO (2.5% or 5%) are preferred, as there is increased irritation with increasing concentrations of BPO and without a significant increase in efficacy between the 2.5% and 10% concentrations.120

Pediatric patients. For children 1 to 7 years old with significant acne, evaluation for systemic associations is warranted, with referral to a pediatric endocrinologist to rule out a gonadal/ovarian pathology.134,135 Recommendations are summarized in Table 17. A low starting BPO concentration is recommended, due to increased risk of irritation; this can minimize antibiotic resistance when used with antibiotics.135 Topical retinoids may be used as monotherapy or in combination products and in regimens of care for all types and severities of acne in children and adolescents of all ages.135 If topical antibiotic treatment is extended beyond a few weeks, topical BPO should be added or used in combination products.135

ActiveFX fractional CO2 laser therapy (Lumenis, San Jose, California, USA) is a new technology for the treatment of facial acne scars, using a diffractive lens array and 755-nm picosecond laser.149 This laser produced improvement in appearance and texture of acne scars at three months after the last treatment, with objective findings similar to those of fractional ablative laser treatments. Histologic findings suggest that improvement in scarring from this treatment goes beyond collagen remodeling.150

The aim of AV treatment is to prevent excessive keratosis, reduce seborrhoea and inhibit the growth of Cutibacterium acnes. The treatment regimen involves administration of both local treatments and antibiotics (erythromycin, clindamycin, tetracyclines and macrolides), retinoids (tretinoin, isotretinoin, adapalene and tazarotene), benzoyl peroxide or azelaic acid. A properly balanced diet also plays an important role in relieving AV symptoms [2].

A diet rich in carbohydrates with a high GI is associated with the occurrence of hyperglycaemia, hyperinsulinemia and increased production of insulin-like growth factor 1 (IGF-1) as well as development of insulin resistance [36]. Insulin may affect the function of the liver and the adrenal and pituitary glands, thus promoting the production of, among others, androgen and sex hormone binding globulin (SHBG) as well as participating in sebum production. The glycaemic load (GL) is also important, as it is a measure that takes into account the GI and carbohydrate content in a portion of food. This was confirmed in a group of men aged 17 4 years, some of whom (n = 5) consumed 45% of their calories from carbohydrates, while some (n = 5) consumed 55% of their calories from carbohydrates. It was demonstrated that SHBG levels were significantly lower in the group with higher carbohydrate consumption, indicating that a rise in GL may increase IGF-1 and sex steroid levels. Therefore, low SHBG concentrations may be the cause of high levels of androgens in their free form in the blood, which increases sebum secretion by the sebaceous glands [20,35].

A study by Reynolds et al. (2010) showed that a diet with a low GI (51 1), compared with a diet with a high GI (62 2), enhanced the appearance of the skin of AV patients, but it was not a statistically significant change. The authors suggest that observations longer than 8 weeks and greater reductions in the glycaemic index are necessary to confirm improvement in AV in adolescent boys [15].

A 10 week dietary intervention was conducted which involved adherence to a diet with a low GL, rich in vegetables, fruit, beans, fish, barley and whole wheat bread. Histopathological skin examination revealed a reduction in inflammation, a decrease in the size of the sebaceous glands as well as lower expression of sterol-regulating element-binding protein-1 and interleukin-8. An increase in IGF-1 levels contributes to an increase in the bioavailability of androgens, enhanced growth of skin cells and, thus, clogging of hair follicles and formation of comedones. These factors also stimulate the growth of sebaceous gland keratinocytes, causing abnormal peeling of dead epidermal cells, corneocytes and sebum overproduction, which promotes inflammation induced by Cutibacterium acnes [12].

B vitamins useful in the treatment of AV include vitamin B1, B2, B3, B5, B6 an B7. Their action is mainly based on inhibiting sebum secretion and reducing colonisation of Cutibacterium acnes. A study on a group of 41 individuals with AV revealed that 12 week supplementation with pantothenic acid (two tablets twice a day containing a total of 4.4 g of the substance) resulted in a reduction of inflammation as well as an increase in the Dermatology Life Quality Index (DLQI) [27].

1. After cleansing, with the embossed side, gently swipe across the face from the center outwards 2. With the silky side, gently swipe your face one more time for a final polishing touch 3. Lightly pat remaining toner into skin to enhance absorption NOTE Vita C Ampoule cannot be used together with Zero Pore Pad. Please check FAQ for more details.

(ANSA) - ROMA, 07 MAR - "Su 12,2 milioni di edifici residenziali l'Italia ha ben 9 milioni di edifici particolarmente energivori e non in grado di garantire le performance energetiche richieste dalla direttiva europea 'case green'". E' quanto evidenzia la vicepresidente di Ance, Vanessa Pesenti, in audizione presso la commissione Finanze del Senato, chiedendo "un Piano Marshall per l'efficientamento energetico del patrimonio edilizio, che sia di lungo periodo con regole stabili nel tempo, a differenza di quanto accaduto con il Superbonus". "Il Superbonus e i bonus minori - ha detto - sono gli strumenti principali per il conseguimento degli obiettivi di transizione ecologica e per lo sviluppo sostenibile del nostro territorio. Occorre che questi incentivi siano stabilizzati in modo da premiare a regime chi investe nell'efficientamento e nella messa in sicurezza del proprio immobile". "Per massimizzare gli effetti positivi i crediti di imposta devono avere determinate caratteristiche: circolare in maniera diffusa, un utilizzo pieno, stabilità nelle regole, superamento delle limitazioni alla loro compensazione", sottolinea Pesenti. (ANSA).

We, the Department of Theatre and Dance at California State University, Sacramento, commit ourselves and our programs to call out systemic racism and to actively promote a truly diverse, equitable, and inclusive environment onstage, in rehearsals, in classrooms, and among each other. This commitment is rooted in providing a broad and thorough foundation of the history, theory, literature, performance, design/technical, and management practices of theatre and dance. Our imaginative and ambitious curriculum, supported by studio work and productions, challenges and nurtures our students to be interdependent, inclusive leaders who embody diverse practices in theater and dance. Our collaborative, artistic environment reflects a complex global perspective, complemented by national and international faculty and staff experience. 041b061a72


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