Despite a 2006 study in a prestigious journal that showed some modest benefit from taking 100mg a day of Zinc Sufate, a more recent study with a dose of 220mg a day wasn’t able to replicate any benefits.

Worse still, this just-published study wasn’t able to prove that Zinc Sulfate helped at all.

In order to prove that a treatment works, researchers need to show that it works better than the placebo, when the trialists are blinded – that is have no idea if they are taking the active or an inactive tablet.

The abstract ends with a hopeful comment that further research might determine what role oral zinc plays in rosacea, but it seems clear that any role will be minimal at best.

Nothing to See Here, Move On

This is exactly the sort of research we need, a good study that shows Zinc Sulfate does not work for Rosacea.

Nothing to see here, move on.

Int J Dermatol. 2012 Apr;51(4):459-62.

Randomized, double-blind trial of 220 mg zinc sulfate twice daily in the treatment of rosacea

Bamford JT, Gessert CE, Haller IV, Kruger K, Johnson BP.

Essentia Health Duluth Clinic Essentia Institute of Rural Health Duluth Family Medicine Residency Program, Duluth, MN, USA.

A 2006 article published in the International Journal of Dermatology reported that oral zinc sulfate 100 mg three times daily was associated with improvement in the severity of facial rosacea (Sharquie et al. 2006; 45: 857-861). The current study was undertaken to further assess the role of zinc in the management of rosacea. This was a randomized, double-blind trial of 220 mg of zinc sulfate twice daily for 90 days in patients with moderately severe facial rosacea at baseline. Subjects were recruited in the Upper Midwest USA between August 2006 and April 2008, and followed until July 2008.

Forty-four subjects completed the trial (22 in each arm). Rosacea improved in both groups.

There were no differences in magnitude of improvement based on rosacea severity scores between subjects receiving zinc sulfate and subjects receiving placebo (P = 0.284).  Serum zinc levels were higher in subjects receiving zinc (P<0.001).

Oral zinc sulfate was not associated with greater improvement in rosacea severity compared with placebo in this study.

Additional studies are needed to determine what role oral zinc may have in the management of rosacea.

Related Articles

• Zinc Sulfate Trial Underway
• Visualising Evidence for Oral Supplements: Snake Oil All Round
• Forum Thread: Zinc Sulfate, Proven for rosacea

Children require special attention when presenting with acne as some of the adult treatments may be unsuitable for children.

The guidelines offer advice for adolescent acne, preadolescent acne, infantile and neonatal acne.

First-Ever Acne Treatment Guidelines for Children Revealed

By: BRUCE JANCIN, Family Practice News Digital Network

03/13/12. EXPERT ANALYSIS FROM THE SDEF HAWAII DERMATOLOGY SEMINAR

WAIKOLOA, HAWAII – New acne management recommendations from the American Acne and Rosacea Society are the first guidelines to specifically address pediatric acne.

Acne is a common problem, and the presentations and differential diagnosis differ among the various ages of childhood and adolescence. We had a strong desire to increase recognition and improve management of pediatric and adolescent acne across the spectrum of primary and specialty care," explained Dr. Lawrence F. Eichenfield, cochair of the guideline-writing panel comprised of general pediatricians, pediatric dermatologists, and acne experts.

…

Publication of the guidelines is pending, he noted. In the meantime, physicians can obtain an introduction to the guidelines, including full details of the treatment algorithms, while earning 1 hour of CME credit by viewing a 56-minute video featuring Dr. Eichenfield and other guideline panelists at www.acneandrosacea.org.

The AARS video is definitely worth viewing if you are looking for more information on how best to treat acne in children.

Video Link: AARS CME Webinar: National Pediatric Acne Guidelines of Care

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In January 2009 we learnt that Medicis was interested in trialing Ziana as a treatment for rosacea. Medicis may be known to rosacea sufferers because they also make Plexion and Solodyn.

Sadly the rigorous nature of a clinical trial was not able to show that Ziana could reduce the papules and pustules of rosacea any better than the placebo.

Some Small Good News

The trial did find “nearly significant” (a hopeful term if I ever heard one) improvement in how the doctors perceived the broken blood vessels and also provable significant improvement in the redness associated with the rosacea symptoms.

Note also that participants experienced statistically significant increased facial scaling.

So overall not a great result for Medicis, whom I’m sure would have liked to been able to promote Ziana as an official treatment for the papules and pustules of rosacea.

User Reviews

Did you try Ziana ? Did you find any reduction in redness and facial blood vessels ? Would you recommend it ?

A randomized, double-blind, placebo-controlled, pilot study to assess the efficacy and safety of clindamycin 1.2% and tretinoin 0.025% combination gel for the treatment of acne rosacea over 12 weeks.

J Drugs Dermatol. 2012 Mar 1;11(3):333-9.

Chang AL, Alora-Palli M, Lima XT, Chang TC, Cheng C, Chung CM, Amir O, Kimball AB.

Background: Papulopustular acne rosacea is a chronic inflammatory condition which can be difficult to treat. Many patients are unwilling to use systemic medications, and single topical agents alone may not address all the symptoms of rosacea. A combination topical clindamycin phosphate 1.2% and tretinoin 0.025% gel is efficacious for acne vulgaris, and may be helpful for rosacea, since acne vulgaris and rosacea shares many similar clinical and histologic features.

Objective: To assess the preliminary efficacy and safety of a combination gel consisting of clindamycin phosphate 1.2% and tretinoin 0.025% on papulopustular rosacea after 12 weeks of usage.

Methods: Randomized, double-blind, placebo controlled two site study of 79 participants with moderate to severe papulopustular acne rosacea using both physician and subjects’ validated assessment tools. Primary endpoint consisted of statistically significant reduction in absolute papule or pustule count after 12 weeks of usage.

Results: There was no significant difference in papule/pustule count between placebo and treated groups after 12 weeks (P=0.10).

However, there was nearly significant improvement in physicians’ assessments of the telangiectasia component of rosacea (P=0.06) and erythematotelangiectatic rosacea subtype (P=0.05) in treated versus placebo group after 12 weeks.

The only significant adverse event different was facial scaling, which was significantly increased in treated group (P=0.01), but this did not result in discontinuation of study drug.

Conclusions: A combination gel of clindamycin phosphate 1.2% and tretinoin 0.025% may improve the telangiectatic component of rosacea and appears to better treat the erythemotelangiectatic subtype of rosacea rather than papulopustular subtype.

Our preliminary study suggests that future studies with much larger sample size might confirm our findings.

Clinical Trials: NCT00823901.

Related Articles

• Medicis readies to trial Ziana for rosacea
• RSRP: Solodyn, Plexion

Good News for Accutane Users

This growing body of proof is actually quite important because oral isotretinoin is not officially approved as a treatment for rosacea. Doctors can prescribe accutane off-label for use in rosacea, so more comprehensive trials of accutane can only be a good thing. Further, the growing difficulty in finding a doctor who will actually prescribe accutane means that rosacea sufferers need all the proof that they can get their hands on.

My Take

The paper referenced below was highlighted last year as Doxycycline is as good as Low Dose Accutane (0.3mg/kg/day). It is worth repeating that even though doses of around 20mg a day of accutane compared favourably to 100/50mg of doxycycline, the two drugs have quite different safety profiles. The advice of your doctor is going to be important here.

Rosacea : Systemic therapy with retinoids

Hautarzt. 2011 Oct 22, Thielitz A, Gollnick H, Universitätsklinik für Dermatologie und Venerologie , Otto-von-Guericke Universität, Leipziger Str. 44, 39120, Magdeburg, Deutschland

[Article in German]

Systemic isotretinoin has been known for decades as an effective and safe therapeutic option in the treatment of severe and refractory forms of rosacea. It can also be used in special treatment-resistant forms of rosacea, e. g. granulomatous rosacea, as efficacious second-line therapy.

Previously, the effect of isotretinoin in rosacea has been mainly studied in small cohorts or anecdotal reports.

Recently, a big randomized double-blind dose-response and comparative study revealed that an optimized dosage of 0,3 mg/kg was superior to other dosages and non-inferior to doxycycline as gold standard of systemic rosacea treatment and proved effective and safe in papulopustular and phymatous subtypes.

However, the substance is still not licensed for this indication The efficacy of isotretinoin in rosacea is probably mainly related to anti-inflammatory mechanisms as well as anti-oxidative, anti-angiogenic and antifibrotic properties. The classical antiseborrheic effect of isotretinoin might play a role in special subtypes like the phymatous type or rosacea fulminans.

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• Dramatic Results with Low Dose Accutane
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Over at the Acne Blog, Daniel Kern has posted a few high level posts relating to recent readings he has undertaken on the topic of diet and acne. Daniel has read the latest published research to see what new trends are emerging.

It is encouraging to see that research is continuing in this area. Long gone are the days when my dermatologist told me that diet had absolutely nothing to do with skin and suggested I could eat whatever I wanted in whatever quantities I wanted and I would suffer no change in my skin.

Diet and Acne: Wrapping it up

The last few days I have spent going through all clinical studies/trials regarding acne and Omega-3 fats, iodine, antioxidants, chocolate, calorie intake, fatty/oily food, digestion, and zinc.

Adding to this what I have learned regarding dairy and glycemic load, I’m sorry to say that nothing stands out for me as a smoking gun when it comes to diet and acne.

We simply don’t have enough research yet, and nothing feels super compelling to me at this point. However, at least researchers are looking into how diet may affect acne, so hopefully by the next time I review the literature, the evidence available to the scientific community will start taking shape. In the meantime, based on digesting everything the research community has to offer regarding diet and acne, here is what I am personally going to do as far as diet goes:

Dan goes on to offer some advice about what he will personally be doing as far as his diet is concerned; keep taking fish oil, keep eating wild seafood, a zinc supplement of 30mg a day, be eat generally healthily and not worry too much about iodine or chocolate for fatty foods.

Latest Greatest Research: Glycemic Load and Acne

If you eat a high glycemic diet with foods like white bread, sugary soda, white potatoes, and white rice, you will experience insulin spikes. This we know. What we don’t know (sorry Josh) is whether this sort of diet will directly affect acne.

Scientists hypothesize that a high glycemic diet and its resulting insulin reaction will result in higher levels of hormones (IGF-1 and androgens) which may contribute to clogged pores and increased skin oil production.

When it comes to high glycemic diets in particular, scientists also postulate that eating this way may lower the amount of beneficial proteins (IGFBP-3) and natural retinoids, which help keep skin cell growth in check and pores from becoming clogged.

However, as is becoming customary in my research on diet and acne, we do not have enough research to make any strong correlations.

Sadly, as is the case with much research, good thorough studies that will satisfactorily prove or disprove a link are hard to come by. The holy grail here will be to prove that permanently reducing your glycemic load lead to a permanent reduction in acne symptoms. Now that is something I would like to see.

Of course there are many many health benefits from eating a low glycemic diet, so you really can’t lose by trying this out yourself.

Latest Greatest Research: Dairy and Acne

Hormones: Milk contains hormones such as IGF-1 (insulin-like growth factor) and androgen (male hormone) precursors.

Iodine: Milk often contains iodine, largely due to farmers dipping the teats of cows in an iodine solution before milking in order to sterilize. At large doses, iodine can cause what are called acneiform eruptions. Acneiform eruptions look similar to run-of-the-mill acne vulgaris but are different in important ways.

….

What stands out strongly now that I have read all of the evidence is that the design limitations in dairy and acne studies thus far leave us without any concrete answers. After performing a thorough review of existing evidence, authors in the Journal of Clinics in Dermatology agree: “Our conclusion, on the basis of the existing evidence, is that the association between dietary dairy intake and the pathogenesis of acne is slim.”

Although the inflammation associated with acne and that linked to rosacea may not be directly related, I think all this sort of research is important for rosacea sufferers as more is discovered about how what we eat controls so many functions in our body.

Are You Convinced?

Surely there is no argument that a low glycemic diet is good for everyone, good for general health and a good step for your skin. Beyond that, do you believe that there is a causative link between diet and rosacea

How strong would research need to be for you to totally change your diet, if it could be proven that your rosacea is related to what you eat ?

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In contrast to the ongoing disputes over generic Oracea, the makers of the low-dose minocycline Solodyn, Medicis have entered into a joint development and sales agreement with Lupin Pharmaceuticals.

Solodyn is a form of Minocycline, a member of the tetracycline famaily, available in 8 strengths, prescribed based primarily on your weight.

Solodyn tablets are available in 45 mg, 55 mg, 65 mg, 80 mg, 90 mg, 105 mg, 115 mg, and 135 mg.

Officially, Soldyn is indicated to treat the inflammatory lesions of non-nodular moderate to severe acne vulgaris.

Medicis are known to rosacea sufferers as the manufacturers of Ziana and Plexion.

The Agreement

This agreement allows Medicis and Lupin to set aside the legal wrangling over the patents that are said to protect Solodyn, and allow Lupin to progressively manufacture Generic Solodyn. Additionally the two companies will work together to further develop the market for generic versions of Solodyn.

Lupin vs. Galderma

We also know from other court filings that Lupin Pharmaceuticals, along with Mylan and Impax Laboratories are all fighting for the right to manufacture Generic Oracea. Galderma is engaged in an extended dispute, using the Oracea Patents to attempt to stop others from manufacturing a cheaper version of Oracea.

This is Good News

This sort of agreement is good news for those who would like access to Solodyn, but at a more affordable price.

Rosacea Sufferers can only hope that Galderma would consider a similar agreement over Oracea. Too much to expect? Maybe so.

Medicis and Lupin Settle Solodyn Infringement Dispute; Agree to Drug Development Collaboration

Medicis has entered into multiple agreements with Lupin over the acne drug Solodyn, allowing the generic drugmaker to enter the market prior to the expiration of Medicis’ patents.

In a separate agreement, Medicis agreed to join Lupin in a drug development collaboration worth an initial $20 million to the generic company.

Medicis claimed Lupin infringed U.S. Patent Nos. 5,908,838 and 7,790,705 by seeking to manufacture a generic version of Solodyn before the patents expire.  The ’838 patent covers a slow-dissolving form of tetracycline, a class of oral antibiotics commonly used to treat acne.  When tetracycline dissolves too rapidly after being swallowed, the incidence and severity of side effects such as vertigo, dizziness, and blurred vision can increase.  The ’705 patent relates to methods of administering the dosages.

On July 21, Judge J. Frederick Motz signed off on a consent judgment that permanently enjoined Lupin from selling generic Solodyn except under the terms of a separate licensing agreement.  The licensing agreement allows Lupin to sell a generic version of Solodyn in various different doses prior to the expiration of the patents.  Under the agreement, Lupin can move ahead with 45mg, 90mg, and 135-milligram doses in November, the 65mg and 115milligram doses in February 2018, and the 55mg, 80mg, and 105milligram doses in February 2019. 

Under certain conditions that were not disclosed, Lupin could begin making the generic earlier.

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• Community Forum: Solodyn
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acne.org is a large online community of acne suffers that includes a small area for rosacea sufferers. The site is run mostly by volunteers and doesn’t accept any advertising. This in itself is something uncommon, a large internet site that isn’t owned by a commercial interest that doesn’t accept advertising. The site tells us that it uses the sales of their custom products to help pay for the running of the site.

The acne.org Regime

The regime has been developed by Mr. Kern as he was unhappy with the formulation, availability and cost of commercially available regimes for acne. Certainly the products that have been developed are generously sized and very cheap.

I applaud Mr. Kern and acne.org for developing their own treatment regime. Well done!

The acne.org regime consists of a Cleanser, a 2.5% Benzoyl Peroxide based Treatment Gel, Moisturizer with Licochalcone, Jojoba Oil and also a 10% Glycolic Acid based AHA+ product.

Even though the regime includes a benzoyl peroxide gel and a Glycolic Acid product, I thought that 3 other components; the cleanser, moisturizer and jojoba oil were worth highlighting.

If you are looking for a  cheap and simple cleansing and moisturizing regime, with a very short list of ingredients, then read on.

Acne.org Cleanser

Here is their description of the cleanser: “Liquid cleansers are less drying and can more easily achieve pH balance. However, liquid cleansers never lathered enough for me. I like a nice lather with my cleanser. So I asked several manufacturers for the impossible–a pH neutral liquid cleanser that lathers well. After trying 11 or 12 samples, the winning manufacturer came through with a carefully combined ingredient list which achieved an exact pH of 5.5. Since the pH of human skin is about 5.5, the result is a cleanser that leaves the skin in an even harmony without over drying or stripping the skin. And it lathers well! I was thrilled. I also made sure there were no perfumes or dyes. If you’re looking for a colored or scented cleanser, this is not the one for you. Instead, it is as simple as possible–a neutral pH, a nice substantial feeling in the palm, a gratifying lather, and a clean rinse.”

Cleanser Ingredients

Water, PEG-80 Sorbitan Laurate, Cocamidopropyl Betaine, Sodium Trideceth Sulfate, Glycerin, Sodium Lauroamphoacetate, PEG-150 Distearate, Sodium Laureth 13 Carboxylate, Disodium Cocamphodiacetate, Butylene Glycol, Sage Extract, Cucumber Extract, White Oak Bark Extract, Panthenol, Allantoin, Acrylates Copolymer, Methylgluceth-20, Polysorbate-20, Quaternium-15, DMDM Hydantoin, Disodium EDTA.

Read some honest reviews in the review area: Acne.org Cleanser

Purchase Cleanser at danielkern.com: $7 for 8 oz (235ml) or $9.50 for 16 oz (475ml).

Acne.org Moisturizer

The acne.org moisturizer contains Licochalcone, the same active ingredient promoted by the Eucerin Redness Relief range who claim that their products are proven to provide redness relief.

“Generously sized moisturizer with licochalcone. Also contains jojoba oil. Intensely hydrating, non-comedogenic lotion designed to eliminate dry, flaky skin. Goes on clear and absorbs quickly, leaving no residue. Super light feel, fragrance free and dye free.”

Moisturizer Ingredients

Water, Simmondsia chinensis (Jojoba) Seed Oil, Methyl Gluceth-20, Squalane, Saccharide Isomerate, Butylene Glycol, Sodium Hyaluronate, Glycyrrhiza glabra (Licorice) Root Extract, Panthenol, Tocopheryl Acetate, Cetearyl Alcohol, Sorbitan Olivate, Cetearyl Olivate, PEG-12 Glyceryl Distearate, PEG-23 Glyceryl Distearate, Carbomer, Triethanolamine, Phenoxyethanol, Ethylhexylglycerin

Great to see Jojoba Oil being used here and the use of Licochalcone is also interesting.

Read some honest reviews in the review area: Acne.org Moisturizer, Dan’s New Formula

Purchase the Moisturizer at danielkern.com: $14.92 for 8 oz (235ml) or $24.19 for 16oz (475ml).

Acne.org Jojoba Oil

Great to see that our fellow skin sufferees (is that a word?) also love jojoba oil. For very dry skin this is great. Apply a few drops to your palms and gently rub into very wet skin. The oil absorbs really easily allowing you to further apply a moisturizer if required. I used to use vita oil when my skin was really dry and would recommend it to kick start your regime.

“Generously sized 8 oz. certified organic jojoba oil. I recommend people try a few drops of jojoba oil in whichever moisturizer they are currently using. It will not clog pores at all. Quite the contrary, it makes my skin look great and keeps my skin’s oil balanced. “

Jojoba Oil Ingredients

Jojoba Oil (100% Organic)

Read some honest reviews in the review area: Acne.org Jojoba Oil

Purchase Jojoba Oil at danielkern.com: $14.75 for 8oz (235ml).

Love To Hear From You!

I was excited to find that such a simple, elegant and inexpensive cleanser and moisturizer was easily available.

I’m quietly hopeful that these products might also become popular with rosacea sufferers. It would be a great result if rosacea sufferers were able to find here a gentler, simpler and cheaper regime that they thought possible.

Please let us know if you decide to give them a try.

Featured Products

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Even though this press release relates to Acne, it is still interesting to see companies searching for the next killer acne treatment. Whilst only some acne treatments are successful as rosacea treatments, we can still hope that this sort of research may lead to new treatments that are gentle and effective for rosacea sufferers as well. Certainly there is need for a treatment for severe acne to replace the maligned accutane.

Medicis is known to rosacea sufferers for making the medicated cleanser Plexion and the slow release minocycline Solodyn. Recently Medicis have announced that they are also trialing Ziana Gel (clindamycin phosphate 1.2% and tretinoin 0.025%) as a rosacea treatment.

Anacor and Medicis Enter Into Research and Development Collaboration for the Treatment of Acne

February 10, 2011

PALO ALTO, Calif. & SCOTTSDALE, Ariz.–(BUSINESS WIRE)– Anacor Pharmaceuticals, Inc. (NASDAQ:ANAC) and Medicis Pharmaceutical Corporation (NYSE:MRX) today announced that the two companies have entered into a research and development agreement to discover and develop boron-based small molecule compounds directed against a target for the potential treatment of acne.

…

Anacor is a biopharmaceutical company focused on discovering, developing and commercializing novel small-molecule therapeutics derived from its boron chemistry platform. Anacor has discovered five clinical compounds which are currently in development, including its three lead programs:

• AN2690, a topical antifungal for the treatment of onychomycosis;
• AN2728, a topical anti-inflammatory PDE-4 inhibitor for the treatment of psoriasis; and
• GSK 2251052, or GSK ‘052 (formerly referred to as AN3365), a systemic antibiotic for the treatment of infections caused by Gram-negative bacteria, which has been licensed to GlaxoSmithKline under the companies’ research and development agreement.

In addition, Anacor is developing

• AN2718 as a topical antifungal product candidate for the treatment of onychomycosis and skin fungal infections, and
• AN2898 as a topical anti-inflammatory product candidate for the treatment of psoriasis and atopic dermatitis.

For some background see; A Novel Borinic Acid Ester with Antibacterial Activity Against Propionibacterium acnes, an AAD Poster Session handout from 2006 referring to AN0128;

AN0128 (3-hydroxypyridine-2-carbonyloxy-bis(3-chloro-4-methylphenyl)-borane) is a novel compound that contains a boron atom within a borinic acid complex. AN0128 has broad spectrum activity against a wide variety of Gram positive bacteria, including many that are known skin colonizers.  Of particular and its causal role in acne vulgaris. 

The rise in antibiotic  P. acnes importance is to standard antibiotics necessitates the development of new P. acnes resistance of treatment agents.

AN0128 is a good candidate for a topical antibiotic and is currently being developed by Anacor as a novel therapeutic for acne and atopic dermatitis.

Related Articles

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Have read of this comic. Lets talk after you finish reading it.

xkcd: Significant

So what is all this about then ?

You mean what apart from highlighting how news articles cherry pick research findings and just confuse us to get a headline?

Often you see things like (p < 0.05) in a journal abstract. What does that mean? Well it is based on probability theory and relates to the confidence of one thing causing another.

What is a P-value?

The “P-value” is a measure of how likely something is to occur compared to just pure chance. For us who read medical abstracts, often we seem them used in statements like “Treatment X Significantly Reduced Symptom Y (p<0.05)”.

Here the value 0.05 means the probability that the result is related to pure chance is less than 5/100 or 5%.

This says that there was a strongly significant link between using Treatment X and seeing your Symptom Y reduced. The element of chance has been mostly eliminated as contributing to the result.

Once chance has been reduced to less than 5% researchers can say that there is strong significance in the results. This is the best result for a researcher looking for a new treatment; being able to use statistics to prove their treatment actually works.

The Punch Line

By the way, the punch line from the comic, visible if you hover over the graphic was “So, uh, we did the green study again and got no link. It was probably a “RESEARCH CONFLICTED ON GREEN JELLY BEAN/ACNE LINK; MORE STUDY RECOMMENDED!”

So there you go, our comic researcher just made a mistake

Want to ask a Question?

Statistics and probability theory can be quite complicated. Is there something you always wanted to ask about this topic? Leave it in the comments below and I’ll do my best to answer it.

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Being a teenager can be tough. Being a teenager with bad skin and good mental health can be even tougher.

If this study bears out in the larger population, then it is worth knowing that acne alone can be responsible for teenagers, most especially boys, thinking about suicide.

Suicidal Ideation, Mental Health Problems, and Social Impairment Are Increased in Adolescents with Acne: A Population-Based Study

Journal of Investigative Dermatology (2011) 131, 363–370;

Jon A Halvorsen, Robert S Stern, Florence Dalgard, Magne Thoresen, Espen Bjertness and Lars Lien

We performed a cross-sectional, questionnaire-based study to explore the relationship of suicidal ideation, mental health problems, and social functioning to acne severity among adolescents aged 18–19 years. A total of 4,744 youth were invited and 3,775 (80%) participated. In all, 14%reported having substantial acne (a lot and very much). Among those with very much acne, as compared those with no/little acne, suicidal ideation was twice as frequently reported among girls (25.5 vs. 11.9%) and three times more frequently reported among boys (22.6 vs. 6.3%). Suicidal ideation remained significantly associated with substantial acne (odds ratio 1.80, 95% confidence interval 1.30–2.50) in a multivariate model including adjustments of symptoms of depression, ethnicity, and family income. Mental health problems, as assessed by the Strengths and Difficulties Questionnaire (2.25, 1.69–3.00), low attachment to friends (1.52, 1.21–1.91), not thriving at school (1.41, 1.12–1.78), never having had a romantic relationship (1.35, 1.05–1.70), and never having had sexual intercourse (1.51, 1.21–1.89) were all associated with substantial acne in a multivariate model. Acne is frequently found in late adolescence and is associated with social and psychological problems. Adverse events including suicidal ideation and depression that have been associated with therapies for acne may reflect the burden of substantial acne rather than the effects of medication.

…

In this study, we could not directly address the claim that isotretinoin intake increases suicidal ideation and depression.

..

Although psychiatric difficulties are the main risk factor for suicide (Bridge et al., 2006), lack of attachment to friends and family is also associated with increased suicide risk (de Jong, 1992; Ledgerwood, 1999). In our study, the separate introduction of social variables (relation with family and friends, thriving at school, bullying, and experience with romantic relationships and sexual intercourse) in the multivariate model did not change the association between acne and suicidal ideation. As such relationships are important for many adolescents, these findings further strengthen our suggestion that acne is an independent risk factor for suicidal ideation.

…

Our study demonstrates and quantifies the association of reported acne to increased risk of suicidal ideation, mental health problems, and social impairment in a large population-based sample. Acne may influence life in a large number of adolescents in the community, as seen in the percentage of increase, even though the relative increase reflected in the Odds Ratios is quite modest. Especially relevant is the 80% higher level of suicidal ideation in adolescents with substantial acne than among those with no/little acne, independent of symptoms of depression, ethnicity, and family income in this population with low use of isotretinoin. Our results are helpful for clinicians, as subjective complaints are important when choosing treatment. Furthermore, these findings have public health implications because they underscore the need of appropriate health care for adolescent boys and girls in the community.

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