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Truncal Acne and Scarring: A Comprehensive Review of Current Medical and Cosmetic Approaches to Treatment and Patient Management (2022)
Stefano G. Daniel · Sa Rang Kim · Ayman Grada · Angela Y. Moore · Kathleen C. Suozzi · Christopher G. Bunick
Abstract
Acne vulgaris is one of the most common skin disorders worldwide. It typically affects skin areas with a high density of sebaceous glands such as the face, upper arms, chest, and/or back. Historically, the majority of research efforts have focused on facial acne vulgaris, even though approximately half of the patients with facial lesions demonstrate truncal involvement. Truncal acne vulgaris is challenging to treat and poses a significant psychosocial burden on patients. Despite these characteristics, studies specifically examining truncal acne vulgaris are limited, with treatment guidelines largely derived from facial protocols. Therefore, truncal acne remains an understudied clinical problem. Here, we provide a clinically focused review of the epidemiology, evaluation, and available treatment options for truncal acne vulgaris. In doing so, we highlight knowledge gaps with the goal of spurring a further investigation into the management of truncal acne vulgaris.
1 Introduction
Acne vulgaris (AV) is one of the most common skin disorders, present in nearly 10% of all individuals worldwide [1]. While AV affects more than 85% of adolescents, it often continues well into the fifth decade of life for both men and women [2, 3]. It is a multifactorial inflammatory condition of the pilosebaceous unit characterized by the appearance of various cutaneous lesions including closed and open comedones, inflammatory papules and pustules, nodules, and cysts. These lesions are typically limited to skin areas with a high density of sebaceous glands such as the face, shoulders, and trunk (chest and/or back) [4]
The majority of AV literature and guidelines have focused on facial acne [5, 6], despite the high percentage of patients exhibiting lesions on both the face and trunk [7–9] and the negative impact of truncal acne on a patient’s quality of life [9–11]. The overall paucity of clinical data and management options dedicated to truncal acne may be due in part to the greater visibility of facial lesions compared with lesions on the trunk. As such, truncal acne is a largely underappreciated clinical problem that requires further attention.
3 Background
3.1 Epidemiology
3.2 Distinguishing Truncal Acne
3.3 On the AV Spectrum: Acne Conglobata, Follicular Occlusion Tetrad, and Acne Fulminans
3.4 Psychosocial Burden of Truncal Acne
4 Evaluating Truncal Acne
5 Management of Truncal AV
5.1 Topical Therapies
Topical formulations are commonly utilized for mild truncal AV. Currently, common regimens include benzoyl peroxide (BPO), topical antibiotics, and first- or second-generation retinoids, either as single agents or in combination. Recently, several topical agents have been evaluated for truncal AV, including trifarotene [76], tazarotene [95], azelaic acid [96], and dapsone [97].
5.1.1 BPO
5.1.2 Antibiotics
5.1.3 Retinoids
5.1.4 Hormonal Topical Therapy
5.1.5 Azelaic Acid and Sulfone Agents
5.1.6 Advantages and Disadvantages of Topical Agents
5.2 Oral Therapy
The most widely utilized medication classes for oral therapy are antimicrobials, retinoids, and hormonal therapies, especially in moderate-to-severe cases. For truncal AV, clinicians often consider systemic treatment necessary, given the practical difficulties of treating extensive surface areas with topical agents alone. In clinical practice, it is also common to combine oral and topical treatments to address truncal involvement, such as the combination of systemic antibiotics and topical BPO. Importantly, oral therapy increases the possibility of systemic side effects, which may create difficulties for patients with multiple medical conditions.
5.2.1 Systemic Antibiotics
5.2.2 Systemic Retinoids
5.2.3 Systemic Hormonal Agents
6 Acne Scarring and Treatment
6.1 Scarring Rates
6.2 Treating AV Scarring
6.2.1 Vascular Lasers
6.2.1.1 PDL
6.2.1.2 IPL
6.2.2 Fractional Lasers
6.2.2.1 Ablative
6.2.2.2 Non‑Ablative
6.2.2.3 Fractional Picosecond Lasers
6.2.3 Non‑Laser Fractional Radiofrequency
6.2.3.1 Microneedling
6.2.4 Injection Treatments
6.2.4.1 Intralesional Injections
6.2.5 Fillers
6.2.5.1 PLLA
6.2.5.2 PMMA
6.3 Conclusions for Evaluation and Treatment of Acne Scarring
Overall, many therapeutic options exist for treating acne scarring; however, the vast majority of these interventions, except for intralesional injections of TAC and 5-FU, have been evaluated for treating scars on the face rather than on the trunk. Furthermore, navigating each treatment option can be challenging and requires careful analysis of scar characteristics to select the most optimal treatment plan (Fig. 5). Vascular lasers such as PDL and IPL are recommended if PIE/AIME is present. While not discussed above, sun protection is critical for PIH/AIMH, and hydroquinone or fractional picosecond lasers may be used as an adjunct therapy. In the case of atrophic scars, ablative and non-ablative fractional lasers, fractional picosecond lasers, fractional radiofrequency, and microneedling can be utilized. Fillers may also have an additional role, especially in the case of large rolling and boxcar scars. In the author’s experience, the improvement seen with truncal acne scar treatment is modest and often necessitates a multimodal approach (Fig. 4). Therefore, clinicians and patients should engage in open discussions about the limitations surrounding treatment options and undergo shared decision-making regarding cosmetic goals and expectations. While further research is needed to develop and optimize more effective interventions to treat truncal acne scarring, the best clinical course of action currently available is scar prevention via prompt medical management of acne lesions.
7 Conclusions
Even though truncal AV occurs in roughly half of patients with acne and leads to significant rates of disfigurement, it remains a largely neglected clinical concern, as compared with facial AV. As such, current guidelines for the treatment of truncal lesions are mainly derived from facial studies, which have led to sub-optimal outcomes. When truncal AV goes untreated, it can quickly lead to scar formation and reduced quality of life for patients. Currently, isotretinoin and oral tetracycline-class antibiotics are the most effective treatments for truncal acne owing to their rapid onset of efficacy and ease of use. If medical therapy is delayed or suboptimal, current corrective procedures for truncal scarring are available, with the caveat they may be limited in efficacy because they were primarily developed for facial scars. As dermatology moves deeper into the precision medicine era, especially for inflammatory disorders such as psoriasis vulgaris and atopic dermatitis, it is important that truncal AV therapy continues to receive the proper research and clinical attention it deserves. New targeted, effective, and safe therapies for truncal AV, along with its scarring sequelae, are much needed to enhance the quality of life of patients with AV.
Stefano G. Daniel · Sa Rang Kim · Ayman Grada · Angela Y. Moore · Kathleen C. Suozzi · Christopher G. Bunick
Abstract
Acne vulgaris is one of the most common skin disorders worldwide. It typically affects skin areas with a high density of sebaceous glands such as the face, upper arms, chest, and/or back. Historically, the majority of research efforts have focused on facial acne vulgaris, even though approximately half of the patients with facial lesions demonstrate truncal involvement. Truncal acne vulgaris is challenging to treat and poses a significant psychosocial burden on patients. Despite these characteristics, studies specifically examining truncal acne vulgaris are limited, with treatment guidelines largely derived from facial protocols. Therefore, truncal acne remains an understudied clinical problem. Here, we provide a clinically focused review of the epidemiology, evaluation, and available treatment options for truncal acne vulgaris. In doing so, we highlight knowledge gaps with the goal of spurring a further investigation into the management of truncal acne vulgaris.
1 Introduction
Acne vulgaris (AV) is one of the most common skin disorders, present in nearly 10% of all individuals worldwide [1]. While AV affects more than 85% of adolescents, it often continues well into the fifth decade of life for both men and women [2, 3]. It is a multifactorial inflammatory condition of the pilosebaceous unit characterized by the appearance of various cutaneous lesions including closed and open comedones, inflammatory papules and pustules, nodules, and cysts. These lesions are typically limited to skin areas with a high density of sebaceous glands such as the face, shoulders, and trunk (chest and/or back) [4]
The majority of AV literature and guidelines have focused on facial acne [5, 6], despite the high percentage of patients exhibiting lesions on both the face and trunk [7–9] and the negative impact of truncal acne on a patient’s quality of life [9–11]. The overall paucity of clinical data and management options dedicated to truncal acne may be due in part to the greater visibility of facial lesions compared with lesions on the trunk. As such, truncal acne is a largely underappreciated clinical problem that requires further attention.
3 Background
3.1 Epidemiology
3.2 Distinguishing Truncal Acne
3.3 On the AV Spectrum: Acne Conglobata, Follicular Occlusion Tetrad, and Acne Fulminans
3.4 Psychosocial Burden of Truncal Acne
4 Evaluating Truncal Acne
5 Management of Truncal AV
5.1 Topical Therapies
Topical formulations are commonly utilized for mild truncal AV. Currently, common regimens include benzoyl peroxide (BPO), topical antibiotics, and first- or second-generation retinoids, either as single agents or in combination. Recently, several topical agents have been evaluated for truncal AV, including trifarotene [76], tazarotene [95], azelaic acid [96], and dapsone [97].
5.1.1 BPO
5.1.2 Antibiotics
5.1.3 Retinoids
5.1.4 Hormonal Topical Therapy
5.1.5 Azelaic Acid and Sulfone Agents
5.1.6 Advantages and Disadvantages of Topical Agents
5.2 Oral Therapy
The most widely utilized medication classes for oral therapy are antimicrobials, retinoids, and hormonal therapies, especially in moderate-to-severe cases. For truncal AV, clinicians often consider systemic treatment necessary, given the practical difficulties of treating extensive surface areas with topical agents alone. In clinical practice, it is also common to combine oral and topical treatments to address truncal involvement, such as the combination of systemic antibiotics and topical BPO. Importantly, oral therapy increases the possibility of systemic side effects, which may create difficulties for patients with multiple medical conditions.
5.2.1 Systemic Antibiotics
5.2.2 Systemic Retinoids
5.2.3 Systemic Hormonal Agents
6 Acne Scarring and Treatment
6.1 Scarring Rates
6.2 Treating AV Scarring
6.2.1 Vascular Lasers
6.2.1.1 PDL
6.2.1.2 IPL
6.2.2 Fractional Lasers
6.2.2.1 Ablative
6.2.2.2 Non‑Ablative
6.2.2.3 Fractional Picosecond Lasers
6.2.3 Non‑Laser Fractional Radiofrequency
6.2.3.1 Microneedling
6.2.4 Injection Treatments
6.2.4.1 Intralesional Injections
6.2.5 Fillers
6.2.5.1 PLLA
6.2.5.2 PMMA
6.3 Conclusions for Evaluation and Treatment of Acne Scarring
Overall, many therapeutic options exist for treating acne scarring; however, the vast majority of these interventions, except for intralesional injections of TAC and 5-FU, have been evaluated for treating scars on the face rather than on the trunk. Furthermore, navigating each treatment option can be challenging and requires careful analysis of scar characteristics to select the most optimal treatment plan (Fig. 5). Vascular lasers such as PDL and IPL are recommended if PIE/AIME is present. While not discussed above, sun protection is critical for PIH/AIMH, and hydroquinone or fractional picosecond lasers may be used as an adjunct therapy. In the case of atrophic scars, ablative and non-ablative fractional lasers, fractional picosecond lasers, fractional radiofrequency, and microneedling can be utilized. Fillers may also have an additional role, especially in the case of large rolling and boxcar scars. In the author’s experience, the improvement seen with truncal acne scar treatment is modest and often necessitates a multimodal approach (Fig. 4). Therefore, clinicians and patients should engage in open discussions about the limitations surrounding treatment options and undergo shared decision-making regarding cosmetic goals and expectations. While further research is needed to develop and optimize more effective interventions to treat truncal acne scarring, the best clinical course of action currently available is scar prevention via prompt medical management of acne lesions.
7 Conclusions
Even though truncal AV occurs in roughly half of patients with acne and leads to significant rates of disfigurement, it remains a largely neglected clinical concern, as compared with facial AV. As such, current guidelines for the treatment of truncal lesions are mainly derived from facial studies, which have led to sub-optimal outcomes. When truncal AV goes untreated, it can quickly lead to scar formation and reduced quality of life for patients. Currently, isotretinoin and oral tetracycline-class antibiotics are the most effective treatments for truncal acne owing to their rapid onset of efficacy and ease of use. If medical therapy is delayed or suboptimal, current corrective procedures for truncal scarring are available, with the caveat they may be limited in efficacy because they were primarily developed for facial scars. As dermatology moves deeper into the precision medicine era, especially for inflammatory disorders such as psoriasis vulgaris and atopic dermatitis, it is important that truncal AV therapy continues to receive the proper research and clinical attention it deserves. New targeted, effective, and safe therapies for truncal AV, along with its scarring sequelae, are much needed to enhance the quality of life of patients with AV.
