LAUSR

To the Editor: Patients with severe acne1 are greatly afflicted by cosmetic problems due to postacne scarring1,2 that can impair their quality of life. Severe acne1 is characterized by cysts, nodules, or nodulocystic lesions in which postacne scarring1,2 occurs frequently.3 The basic treatment regimen1 is face washing, external antibiotic agent, and oral antibiotics. Recently, the topical retinoid, adapalene,4 has been reported to be useful in reducing scar formation in severe acne. Furthermore, this medication4 has a good safety profile in the treatment of moderate to severe inflammatory acne; however, topical adapalene gel5 and oral azithromycin showed no significant difference in their effect on severe acne. In recent years, however, tranilast6,7 (N-[39,49-dimethoxycinnamoyl]-anthranilic acid), which inhibits degranulation from mast cells and is primarily a therapeutic agent for allergy, can contribute to a number of biological processes, including wound healing. So far, blocking mast cell function6,8 by tranilast could be used to prevent or minimize scarring. The combined effects of tranilast 8% liposomal gel9 with oral isotretinoin have been reported to more effectively reduce scar formation. The aim of this study is to evaluate the effects of oral tranilast on preventing postacne scarring in severe acne patients. Twelve severe acne patients (7 males and 5 females) of grade 3 or 4 (indicated below) without treatment history at the start of this combination therapy were enrolled (Table 1). The mean age of the participants was 25 (range 14–41) years. At the first visit, there were 6 notable cases of grade 3 or 4 acne in 5 older patients and 1 younger patient (indicated with * in Table 1) with slight or mild atrophic scarring that already existed before the treatment. These patients had a history of recurrent relapse. The severity of acne was clinically graded by combining basic clinical grading with severity grade tables given by Adityan et al2 as follows: grade 4 5 almost entire face involved with numerous papules and pustules, and nodules already present; grade 35 more than half of the face with many papules and pustules, and a few nodules noted; grade 2 5 less than half of the face with recognizable papules and pustules; grade 1 5 under 20% scattered lesions with a few papules or pustules; and grade 0 5 clear skin with no inflammatory and scarring lesions. The patients were administered 100 mg/ d minocycline and 200 mg/d tranilast for up to 4–5 months depending on each patient’s severity. Face washing with soap and clindamycin cream, as routine therapy for acne vulgaris, were performed nightly. Clinical features were evaluated once per month. Table 1 describes the course of combination therapy. All participants healed almost all their acne lesions without newly developed hypertrophic scars. Severe acne patients (grade 4) took over 5 months to reach grade 0, but patients with grade 3 acne showed recovery after approximately 3–4 months of the combination therapy. Notably, older patients have recurrent severe acne from early age and had not been administered tranilast for severe inflammatory acne. Thereafter, patients with milder lesions of grade 3 preferred better therapeutic effects. However, in most severe cases (grade 4), the treatment should be extended to achieve healing over 4–5 months. Several chemical mediators from mast cells6,8 in inflammatory lesions, such as severe acne lesions, may result in the development of scar/keroid. So far, it is expected that tranilast reduces scar formation by suppressing activation of mast cells.6,8 Moreover, tranilast inhibits the release of transforming growth factor (TGF)-b1 from keloid fibroblasts,6,7 which enhances the collagen synthesis of keloid fibroblasts in hypertrophic scar tissue, but not healthy skin fibroblasts. The author has previously reported the therapeutic effects of tranilast combination therapy in addition to roxithromycin on uncontrollable prurigo nodularis,10 which is also believed to be related to the inhibition of excessive collagen production from the amplified dermal fibroblasts by tranilast. Although an improved effect of tranilast gel9 on acne scars has been reported, systemic tranilast administration will further ensure its effect. Based on these and other findings,6,7,9 patients with severe acne, American Journal of Therapeutics 0, 1–2 (2020)