Optimizing the management of acne vulgaris corresponds with improved outcomes, reduced scarring and a positive influence on the profound psychosocial disability that frequently accompanies this debilitating skin condition. Many effective, cost-effective therapies are widely available, but significant improvement or clearance can only be achieved if these agents are employed with a logical approach. Patient variability makes the definition of optimum treatment strategies difficult, but with due consideration of the pathological mechanisms driving acne in each individual patient, an appropriate combination of topical, systemic and localized therapies can be prescribed that will yield a favorable outcome. In recent years, a range of physical techniques have emerged as an adjunct to conventional treatments, and with increasing patient interest and expectation, extensive research is underway into these and novel medical therapies that may further broaden our therapeutic armamentarium. This article provides details of currently available therapies, reviews the published evidence on efficacy and considers how best to optimize outcomes with a focus on acne pathogenesis.

Objective. To investigate whether sonographically determined subclinical enthesopathy in patients with moderateto-severe psoriasis regresses with the use of ustekinumab therapy for skin disease.Methods. Seventy-three patients with moderate-to-severe psoriasis, who were not treated with systemic therapy and did not have symptoms of psoriatic arthritis (PsA), and 23 healthy volunteers were screened by ultrasound for subclinical enthesitis. Subsequently, 23 patients with psoriasis whose ultrasound results showed inflammatory changes were treated with ustekinumab for 52 weeks. The evolution of sonographic abnormalities of the upper and lower limb entheses was assessed using an extensive gray-scale and power Doppler (PD) ultrasound protocol at weeks 0, 12, 24, and 52. For each parameter, a gray-scale or PD ultrasound score of >0 was determined to be abnormal, and a summative score based on the Glasgow Ultrasound Enthesitis Scoring System was calculated.Results. Of all the patients with psoriasis screened using ultrasound, 49.3% had at least 1 inflammatory entheseal abnormality. Mean ± SD inflammation scores were higher in the patients with psoriasis compared with the healthy volunteers (9.9 ± 6.6 versus 1.0 ± 1.4). With treatment, the mean inflammation scores decreased significantly by 42.2% from week 0 to week 24 (-4.2 [95% confidence interval -6.3, -2.1]; P < 0.001) and by 47.5% by week 42 (-4.7 [95% confidence interval -7.1, -2.3]; P = 0.001). Entheseal structural abnormalities did not change significantly during treatment.Conclusion. Within 12 weeks of treatment, interleukin-12 (IL-12)/IL-23 inhibition for psoriasis appears to suppress subclinical enthesopathy, and the suppression is maintained through week 52. Further longitudinal studies are needed to determine whether therapy initiated for skin disease may prevent the development of PsA.

Enthesitis is a characteristic feature of psoriatic arthritis (PsA) and is important in disease pathogenesis and classification. Use of clinical outcome measures for enthesitis is heterogeneous, and only 1 measure has been specifically developed and validated in PsA. Ultrasound and magnetic resonance imaging assessments of enthesitis may have advantages over clinical examination but are insufficiently studied. As part of an update of treatment recommendations by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), we performed a systematic literature review and identified randomized controlled trials with enthesitis outcomes in PsA. For each treatment agent we calculated treatment effect sizes (where applicable) and graded the level of evidence.