Abir Saraswat

Oral isotretinoin remains the gold standard for severe acne, with expanding use in broader subtypes. However, clinical practice varies across regions in terms of dosing, monitoring, and adjunctive care. A consensus was developed by 20 dermatology experts through a modified Delphi process and literature review (2000-2024) to provide practical recommendations. High consensus supported first-line isotretinoin among adults for severe acne variants (conglobata, nodulocystic, and papulopustular), acne with scarring or psychological distress, and moderate acne featuring frequent relapse, significant scarring, strong family history, and marked psychosocial burden. Similar agreement was achieved for adolescents (12-18 years). High consensus supported isotretinoin for special clinical scenarios, including treatment-resistant acne, gram-negative folliculitis, and acne fulminans. Early initiation was favored to prevent acne progression and scarring, with high agreement on quality-of-life improvement with isotretinoin use. Conventional dosing (0.5-1 mg/kg/day) was preferred for severe acne forms; low-dose (0.1-0.5 mg/kg/day) was acceptable for moderate/persistent acne. The consensus acknowledged common adverse effects, less frequent systemic effects, and the well-established teratogenic risk of isotretinoin. Laboratory monitoring, especially in metabolic risk, was advised. Low consensus persisted around cumulative dosing, laboratory testing frequency, and duration of posttreatment washout before pregnancy. The Expert consensus on the Rational Approach to ISotretinoin usage for Effective management of ACNE (ERAISE ACNE) algorithm offers a practical guide for isotretinoin use in Indian clinical practice, emphasizing early initiation, tailored dosing, safety-focused monitoring, and is applicable to settings with similar patient demographics and challenges.

Background/Objectives: Acne vulgaris is a prevalent dermatological condition, yet clear, region-specific management guidelines, particularly for India’s diverse population, remain limited. Effective acne management extends beyond pharmacologic therapy, emphasizing proper skincare, patient education, and adherence strategies. This consensus aims to provide tailored, evidence-based recommendations for optimizing acne treatment in the Indian context. Methods: A panel of 14 dermatology experts with ≥15 years of experience reviewed literature, real-world clinical practices, and patient-centric factors relevant to acne management in India. Using a modified Delphi process with two virtual voting rounds, 61 statements across seven clinical domains were evaluated. Consensus was defined as ≥75% agreement. Results: Topical retinoids remain the first-line therapy, with combination regimens (benzoyl peroxide or topical antibiotics) preferred to enhance efficacy and minimize antibiotic resistance. Hormonal therapies, including combined oral contraceptives and spironolactone, are recommended for females with resistant acne. Guidance includes individualized treatment plans, baseline investigations, and selection of appropriate topical and systemic agents. Special considerations for pregnancy and lactation prioritize maternal and fetal safety. Conclusions: This expert consensus provides practical, evidence-based recommendations for acne management in India, integrating pharmacological and non-pharmacological approaches. The tailored guidance supports individualized care, antibiotic stewardship, and improved treatment adherence, aiming to enhance patient outcomes nationwide.

Corrigendum for the article Efficacy of Super-Bioavailable Itraconazole and Conventional Itraconazole at Different Dosing Regimens in Glabrous Tinea Infection - A Randomized Clinical Trial

Introduction: Itraconazole follows non-linear pharmacokinetics and hence is recommended once daily, but in real-world practice, is commonly prescribed as twice daily. Hence, this study aimed to evaluate the efficacy and safety of super-bioavailable-itraconazole-130 mg (SB-130) and conventional-itraconazole-200 mg (CITZ-200) once daily compared with conventional-itraconazole-100 mg (CITZ-100) twice daily in glabrous tinea. Methods: A total of 261 eligible patients were enrolled in this prospective, randomized, clinical study from December-2021 to August-2022 at seven centers in India. Efficacy and safety assessments were done at week-3 and 6, with follow-up at week-10 for relapse. The primary objective was to assess the proportion of patients who achieved complete cure at week-6 following treatment in all itraconazole groups. The secondary outcomes were safety and clinical and mycological cure rates. Results: Of 261 patients, 240 were included in the analysis. At week-6, 140 patients were completely cured; thus, overall cure rate was 58.33%. Fifty-five patients (69%) in SB-130 while 47/77 (61%) and 38/83 (46%) patients were completely cured in CITZ-200 and CITZ-100 groups respectively (p< 0.05; SB-130: CITZ-100, p=0.32; SB-130: CITZ-200, p=0.058; CITZ-200: CITZ-100). There was no statistical difference in the mycological cure rate and area clearance rate between any of the groups (p=0.14); however, a statistically significant difference was noted for OD dosing over BD dosing in achieving clinical cure rates (p< 0.05). A total of 13/140 patients (9%) relapsed following complete cure, with no statistically significant difference between any of the groups (p=0.50). All treatments were safe and well-tolerated, with no discontinuation. Conclusion: In this clinical study, moderate efficacy with all doses of ITZ was reported but was better with OD dosing. Although there was no statistical difference between SB-130 and CITZ-200, SB-130 may be preferred over CITZ-200 owing to the advantage of SB over the conventional ITZ.

Purpose: The primary objective of the study was to understand the therapeutic inertia in treatment and management of plaque psoriasis among dermatologists, along with determining the preferred treatment choices for management of plaque psoriasis; it also included the resulting treatment satisfaction among patients. The secondary objective was to identify the gaps in terms of knowledge and attitude among dermatologists and the expectations of patients. Patients and Methods: A multicentre, cross-sectional quantitative survey was conducted among dermatologists and patients with moderate to severe plaque psoriasis across India. The interviews were conducted either face to face or via telephone between September and November 2020, using structured and validated questionnaires based on specific themes. The data obtained were statistically analysed, wherever applicable. Results: Overall, 207 adult patients with moderate-to-severe plaque psoriasis and 303 dermatologists were interviewed. Post experiencing symptoms, 44% of the patients visited general physicians for treatment and there was an average 7.8-month delay by the patients to consult a dermatologist. Approximately one-fourth of patients used home remedies before seeking medical help. One-third of dermatologists used the Psoriasis Area and Severity Index (PASI) for assessing the disease severity. Majority of dermatologists preferred combination therapy for their patients. The lack of quick resolution and side effects were the major reasons for changing the treatment. Overall, only 35% of the patients complied to current treatment. Satisfaction with existing forms of therapies was highest for mild plaque psoriasis (62%) as confirmed by dermatologists, while 52% of the overall patients were satisfied with their therapy. Majority of the patients (64%) affirmed living with plaque psoriasis impacted their lives. Conclusion: This first-of-its-kind survey in India highlighted the gaps in terms of the disease journey between dermatologists and patients. The survey emphasises the need for shared decision-making and may benefit dermatologists in suggestive modifications of the treatment algorithm and disease management in clinical settings.

Topical corticosteroids play a key role in managing steroid responsive dermatoses (SRD). Current topical corticosteroid therapies are associated with various disadvantages. The current consensus article aims at providing a collation of evidence-based literature and clinical insights of the experts, regarding the efficacy, safety and usage of clobetasol propionate (CP) 0.025% cream in the management of SRD like plaque psoriasis. Clinical evidences suggest that the novel formulation of CP 0.025% cream has comparable efficacy and a better safety profile vs CP 0.05% cream in the management of plaque psoriasis. According to the doctors' experience, CP 0.025% can be used as first-line treatment for the management of SRD. In children 12-18-year-olds, CP 0.025% may be used cautiously, considering risk-benefit ratio. CP 0.025% may also be used as a maintenance therapy, after disease is brought under control with systemic therapy. Using moisturisers, salicylic acid, calcipotriol or tacrolimus as concomitant therapy with CP 0.025% cream may be beneficial in the management of SRD. In various comorbidities like diabetes and hypertension, CP 0.025% cream may be a better alternative verses CP 0.05% cream. Clinical evidences and experts suggest that for management of SRD, clobetasol propionate 0.025% cream can be recommended as a formulation with comparable efficacy and better safety profile versus CP 0.05% cream.