Acing Acne Care: Patient-Centered Approaches

Acne is one of the most common skin diseases, and nearly every individual will develop acne at some point in their lives. Treatment options range from OTC antimicrobials to prescription oral therapies, like isotretinoin. Hilary Baldwin, MD, Founding Director of the Acne Treatment and Research Center in Brooklyn, NY provides an overview of acne pathogenesis, gives insights on treatment selection, and shares tips to optimize topical treatment tolerability and outcomes. Plus, Alexa Hetzel, MS, PA-C talks sunscreens and Darren West, MPAS, PA-C addresses the importance of keeping up on new therapeutics.

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Transcript

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Speaker 1:

Welcome to the Dermalorian podcast from the Dermatology Education Foundation. In this episode, we get tips on making meaningful sunscreen recommendations and a fresh take on the importance of learning about emerging therapies. But first, Dr. Hillary Baldwin gives an update on topical acne treatments. Next month is National Acne Awareness month, and there is no better time to hear expert insights on treatment selection and patient counseling.

Hillary Baldwin:

Let's go back to our pillars of acne pathophysiology, because we said that that's how we were going to determine which medications to use. So if we wanted to make sure that we decreased sebum production, we can use oral hormonal therapy, Spironolactone or oral contraceptives, we can use Clascoterone cream, and of course Isotretinoin also suppresses sebum production better than any of our other medications.

What about follicular hyperkeratosis? Well, topical retinoids a perfect fit here. Benzoyl peroxide is also weakly comedolytic and helps with follicular hyperkeratinization as well. And finally, of course, the almighty Isotretinoin. If we want to decrease C. acnes, we can use an antibiotic, topical or oral. But again, Isotretinoin comes to our rescue.

It doesn't directly kill C. acnes, but it indirectly kills the suckers by depriving them of their food source because it decreases sebum so well. And finally, if we just want to suppress inflammation, we have a lot of drugs to choose from. We can use our oral antibiotics. In fact, that's primarily how they work in the treatment of acne. We could use topical retinoids, which are anti-inflammatory in nature, topical Dapsone.

That's its only mechanism of action. And finally, once again, Isotretinoin. So we see, of course, why it is that Isotretinoin is so darn effective in the treatment of acne, our only medication that hits all four pillars of acne pathogenesis. The tip off, the trick to treating patients well with acne is to use combination therapy.

You can pick a retinoid, an antibiotic, and Clascoterone and end up hitting all four pillars. So in addition to picking the right medication, we'd like to have appropriate clinical approach to the acne patient. If you ask a seasoned acneologist how long it takes him or her to figure out what medication she'd like to use, after she walks in the door and sees the patient for the very first time, they'll probably tell you in about five seconds.

In fact, before I sit down in my chair, I know what I'm going to treat them with. And as I'm looking carefully their skin to make them happy, I already know what I'm going to do. I knew from the door. And the easy way to do this is first to say to yourself, okay, what am I looking at? Is it mostly inflammatory comedonal lesions or is there a combination? And then within that framework, is it mild, moderate, and severe? You can determine that by the number of lesions, or you could also determine it by the size, right?

Are they big inflammatory papules or there tiny little papules? Is there truncal involvement, I should throw in there as well, because of course that changes your therapeutic approach? Perhaps most importantly is their scarring, because whatever their lesions look like, if they have a scarring diathesis, it puts this treatment at a whole different level.

It makes it sort of a cosmetic emergency as well as a medical problem. Is there psychological impairment? Is the patient depressed or even suicidal regarding their acne? Now, this I admit, is very difficult to assess, especially on that first visit, especially when it's a teenager, especially when it's a teenage boy.

They're unlikely to share with you to the extent that you recognize their psychological impairment, but at least it's worth a question. Do you think your acne is getting in the way of you enjoying life? Is it getting in the way of you participating in sports or participating in social engagements? You may or may not get an answer at that first visit, but it's something that you really need to ask and to ascertain if you can.

Another important question I find is to find out if the patient actually wants to be treated. I know that you know that sometimes teenagers are dragged in kicking and screaming by their moms, and the teenager has no interest in being treated. The question I like to ask is, on a scale of one to 10, how much do you hate your acne? And if they're way down at one or two or three, the chances of them actually doing what I ask them to do is extremely slim.

Whereas if they're up at eight, nine, or 10, they're going to use their medication. They're going to be compliant with therapy at least for the first two or three weeks. But I think it's a question worth asking. And then try to assess their ability to tolerate side effects. I don't mean drugs which are tolerable.

I mean patients who are tolerant of side effects. You can ask, what have you used for your acne in the past? If they say they've used some over-the-counter products and they've caused a great deal of irritation, you know you're dealing with an intolerant patient most of the time, you're going to have to be a little bit more careful with your drug choices.

So how do we choose that regimen? The real question is, how do we convince our patients to trust our choice that we haven't just picked something out of the air for them, that we've made a very careful decision? And yes, you have to use two medications or three medications because the combination is what's going to make you better.

I'm sure you've experienced this. You give the patients two or three medications and they come back and they say, well, I used the first two, but I didn't use the third one because it wasn't working. How do you know that, you were using three drugs? How did you know that that was the one that wasn't doing anything? I picked these very carefully for you so that I would pick from all the four pillars of acne pathogenesis.

So you really have to have the combination therapy conversation with them so that they understand that you're not just doing this as a plot to destroy their lives, that they really do need to use more than one medication. But we're always told, keep it simple, stupid. The more drugs you give them, the less likely they are to actually use anything.

So one of the ways to do this, to give them combinations yet keep it simple, is to use fixed combination drugs, ones that have more than one product so that they're attacking acne from more than one direction, even though the patient only has to uncap the tube or the pump once that day. We also want to make sure that we're using products with excellent vehicles so that we maximize tolerability.

Because when you give the patient right off the bat, first time in the office, a medication that makes them dry and irritated, sometimes you actually end up losing them. The premier drug that I'm speaking of course, is the topical retinoid. We have a problem here. Topical retinoids are crucial to the success in treating our acne patients.

Yet as you know, they can often create a problem with tolerability, but this is why we use them. The mechanism of action, they inhibit the formation of the microcomedo. That's the very first basic lesion for most acne lesions that form. If you inhibit the microcomedo, you inhibit everything that follows after that. They also reduce mature comedones, they're comedone busters. They get rid of the ones that the patients already have.

They reduce also inflammatory lesions, not just comedones. They enhance the penetration of other drugs with which and they maintain remission. So you make the patient better with whatever you make them better with. And continuing the use of the topical retinoid as a solo treatment can maintain that remission for months, sometimes even years. They actually also reduce post-inflammatory changes, both erythema and hyperpigmentation, and they reduce the formation of scars and can actually resolve some existing shallow scars.

Crucially important. Don't forget that they can sometimes do the trick all by themselves. So let's sum up here. Topical retinoids, advantages, comedolytic, anti-comedogenic, treats inflammatory lesions, ideal for maintenance. Disadvantage, certainly both concentration and especially vehicle dependent irritation. So again, picking a branded product with an excellent vehicle can be part of the solution here.

Our patients experience their maximum irritation one to two weeks into therapy, and after that, it's going to get better. So you need to be a cheerleader. You need to be a hand holder, and you need to do very good education. I tell all of my patients expect to have erythema and peeling and scaling and little itching, burning, stinging in those first two weeks. And if it doesn't happen, that's a great thing. But if it happens, they're not surprised and they don't stop using their medication. It also increases some sensitivity.

So we want to make sure that our patients are using adequate sun protection. We have four to pick from Tretinoin, adapalene, Tazarotene, and Trifarotene. Many of them have different concentrations and different vehicles, and you can start in general with a lower concentration and build up if there is more than one for that active. In general, foams and creams are a little bit better tolerated than our gels, but that's not always true.

It depends on the quality of the vehicle. There are two things you need to think about when prescribing a topical retinoid. The first is photo-stability. Tretinoin in particular is photolabile, which means if they put it on and go out into the sun, it gets destroyed. Now, that's not true for some of the protected versions of Tretinoin like micro-sphere, micronized and micro-encapsulated, but generic tretinoin is going to get destroyed in the sunshine.

So you have to think about what is your patient doing? Is he a lifeguard in Malibu putting it on and then going out at noon? That's not a great idea. But if they live here in New York and they're heading into the subway directly from their house, doesn't really make a difference. So you have to ask some questions. Adapalene and Tazarotene and Trifarotene, all photostable so they can be used in sunshine.

Stability with benzoyl peroxide is another question. Tretinoin, Tazarotene, maybe I just heard some new information that maybe it's not as stable as I thought it was. The benzoyl peroxide and Trifarotene has not yet been studied. So adapalene is the sole agent that we know to be stable in the presence of benzoyl peroxide. For tretinoin, again, the stability might be different, is different, I'm sorry, with the protected versions, the micronized, the micro-encapsulated, and the micro-sphere formulation.

So those can be co-applied with benzoyl peroxide. This is important because you want the patient for compliance's sake to be able to co-apply or stack one drug on top of the other. So you have to give it some thought if that's what you want to do. Otherwise, you have to separate it, one in the morning and one in the evening.

How can we improve the tolerability of retinoids? Well, the first is to make sure the patient is using only a tiny little pea-sized amount to the entire affected area. And I know this is going to sound stupid, but it's useful to ask the patient to show you what a pea looks like. Grab a tube of moisturizer, make them actually show you. You'd be amazed at how big they think a pea is. No spot treatment. Acne medicines don't work to take care of the pimples that we have.

They're preventative. You're using your medicine today to stop the development of next month's pimples. So spot treatment makes absolutely no sense. It might dry them out a little bit, have at it if that's what you're aiming for. But if you're trying to make your acne better in general, spot treatment does work.

Start with every other day application instead of every day. Moisturize regularly, maybe under the retinoid, put on a thin coating. Let it dry for a few minutes and then put on your topical retinoid. Consider changing formulation to one of the better branded products with these awesome vehicles they have these days that decrease tolerability issues, but the bottom line, be persistent.

Retinoids really need to be the part of every patient's regimen. And there's basically no such thing as retinoid, intolerability. An intolerable patient is one who hasn't been adequately educated and hasn't had his or her handheld sufficiently and has given up. Utilizing the tips here, every patient can end up being able to use a topical retinoid, maybe only twice a week, but they can all utilize it and benefit from it.

Speaker 1:

Before Dr. Baldwin discusses other topical treatment options, let's take a break for this episode's Dermalorian clinical clip. Are you asking your patients the right questions about UV safety? Physician assistant, Alexa Hetzel who joined the DEF Advisory Council this year shares some tips on patient education.

Alexa Hetzel:

I love sunscreens. My patients come into the room and I'm always asking them about sunscreens, especially 365, every day of the year because most people are like, I wear it when I go out to the beach. I'm like, "Well, do you wear it on your five-mile walk?" I'm like, "Absolutely not." So I have tear offs of different sunscreens that I recommend depending on what area of the body I recommend.

So I have scalp sunscreens that I recommend, facial sunscreens that are a little bit more cosmetically friendly so people are more likely to wear them every day, and then different body sunscreens to help with sensitive skin or skin that maybe breaks out with different sunscreens. So I have a slew of recommendations for sunscreens, and I tell everybody to wear it all the time.

Speaker 1:

Now we return to Dr. Baldwin as she discusses topical antimicrobials and more for the treatment of acne vulgaris.

Hillary Baldwin:

So now let's move on to topical antimicrobials. We have clinda, erythro, and minocycline as our topical antibiotics. Erythromycin is no longer used as resistance has developed to the extent that it's basically worthless. And of course, we have our old standby benzoyl peroxide.

The advantages of our topical antimicrobials is that they do a bang-up job killing C. acnes. Some of them, especially clindamycin, can be indirectly anti-inflammatory, and they're very well tolerated. The disadvantage is that antibiotic resistance develops quite rapidly. Erythromycin doesn't work. Clindamycin works for a couple of months, but unless it's combined with benzoyl peroxide after two months, dramatic increase in resistant C. acnes strains.

Topical minocycline may actually be less problematic in this regard. We don't have time to go into it today, but I'm always happy to talk to anybody about that, if they'd like. Benzoyl peroxide is 60 years old in the treatment of acne still, couldn't live without it.

The advantages is that it kills C. acnes more rapidly and more efficiently than the topical antibiotics. And it does so without producing resistant organisms. Benzoyl peroxide works by oxidizing little suckers to death. So it's like a dirty bomb. It lands on the bacterium and blows it up, and it's not possible for the bacterium to run away from that and mutate to become resistant to it.

It also decreases the development of resistant organisms with topical or oral antibiotics with which is co-applied or co-used. So I'm using benzoyl peroxide not only because it makes acne better, but also to prevent the development of resistant organisms to an antibiotic that I may be using. Disadvantages, again, concentration dependent irritant, which can be improved by micronization and microencapsulation.

Vehicle dependent irritant, you pick Pete's benzoyl peroxide on the pharmacy shelf. All bets are off. But you pick one of the beautiful branded benzoyl peroxides with excellent vehicles, and it's a completely different story. There's a low incidence of contact dermatitis. It's said to be around 5%. But honestly, every time a patient comes to me saying that they're allergic to benzoyl peroxide, it turns out it was an irritant reaction to cheap, poorly made benzoyl peroxide product.

And you can find that out by asking them to do what's called a use test, where they apply benzoyl peroxide to the thin part of the inside of their elbow, twice a day for two days in a row. And if they have an inflammatory reaction, okay, they're allergic. Otherwise, it's most likely an irritant reaction. And if you give them a good quality benzoyl peroxide, it probably won't happen again.

And the last thing, of course, which turns out to be probably the most important, is that it bleaches fabric and pisses off the mothers to no extent. So again, a dual purpose for benzoyl peroxide, treating acne, killing faster, doing a better job, reducing both inflammatory and comedonal lesions, and to help reduce the risk of antimicrobial resistance both to itself and to other antibiotics.

Topical Dapsone, we think it acts by being an anti-inflammatory agent. Although in general, Dapsone is antimicrobial, it does not apparently kill C. acnes. The topical formulation is very safe. It's not like oral Dapsone. And additionally, it's very well tolerated. Clascoterone 1% cream is the newest kid on the block, came out about two years ago.

It's our first new mechanism of action for the treatment of acne in many years, actually 40 years since the introduction of Isotretinoin. And believe it or not, it's an androgen receptor inhibitor, and it also has anti-inflammatory properties, rapidly metabolized in the skin into Cortexolone, which no longer has anti-androgenic activity.

And this is very important because it's metabolized in the skin into something which is no longer an anti-androgen, there is no anti-androgen activity circulating in the bloodstream. Therefore, it's safe for use in men. So it's the first product other than Isotretinoin that we can actually use in men that suppresses sebum production.

We have Isotretinoin, Spironolactone, and oral contraceptives, and the last two can only be used in women. So until this product came out, we had no way to suppress androgens and sebum production in men other than Isotretinoin. And obviously, not all patients are candidates for treatment with Isotretinoin.

This is how Clascoterone works. Normally, DHT you can see on the left is the lavender ball enters into the sebaceous gland, then it binds to the androgen receptor, and together they translocate into the nucleus where they say hello to DNA, producing in sebum, as well as pro-inflammatory cytokines. Clascoterone in the blue ball comes along, and instead of DHT binds to that androgen receptor.

DHT floats off into the atmosphere and it blocks the production of sebum and pro-inflammatory cytokines. Very simple mechanism of action. Very well tolerated, has a moisturizing base to it. So it's easy, it's well tolerated. It needs to be used twice a day. If you look at the phase IIB dose ranging studies, you'll see that BID was far superior to once a day.

So make sure that your patients are actually utilizing it twice a day. This is not an add-on drug that you say, well, why don't you try this and just use it once a day? You're not going to find the efficacy that the phase III trial showed us. It's also very slow in its onset of action. That kind of makes sense, right? These patients have gigantic sebaceous glands filled with sebum.

It's going to take a while for that to be used up, right? So yes, it's preventing the production of new sebum, but we've got to get rid of the old sebum first. So it takes a while for it to kick in. And if you looked at the phase III trial, the difference between efficacy in eight weeks and the efficacy at 12 weeks is gigantic.

So make sure you're a good cheerleader again, make sure they're using it twice a day and not quitting before the drug has had a chance to kick in. It is inactivated by benzoyl peroxide, so they should not be co-applied. So let's talk a bit about fixed combination therapy. We have numerous agents that have more than one ingredient in them, so they're coming at acne from different directions.

We have adapalene with benzoyl peroxide, benzoyl peroxide and Clindamycin, Clindamycin and Tretinoin, and Tretinoin and benzoyl peroxide is the newest kid on the block, the new combination of product. Now, we said before that Tretinoin and benzoyl peroxide are not stable together. They are in this preparation thanks to the micro-encapsulation of each individual agent within the container. So the advantage of fixed combination therapy probably improved compliance, right? Because the patient only has to use one medication a day.

Speaker 1:

Of course, some patients will require systemic intervention for acne. You can see more on the videos page at dermnppa.org, including Dr. Baldwin's take on Isotretinoin.

Hillary Baldwin:

Isotretinoin, in my opinion, should be the first line therapy for patients with very severe acne. Why are we waiting? Isotretinoin where the acne is best treated with the most effective medication that we have. It reduces the use of antibiotics, reduces both short and long-term psychological damage, as well as physical scarring.

Speaker 1:

Now for our Dermalorian derm decoder. Earlier this month, the DEF hosted the East Coast Biologic and Small Molecules CME Bootcamp, a two-day in-person learning experience. Faculty member and DEF Advisory Council member Darren West, a physician assistant in Scottsdale, Arizona, shares his thoughts on the meeting and the importance of staying up to date on emerging therapies.

Darren West:

It's been completely relevant to my clinical practice, everything that I have seen so far. All of the data is non-biased, very structured, backed by clinical studies, very relevant. So for me, it's really awesome to just see all that data. Dr. Cohen, the panel, Joe Gorelick, everybody has been doing a great job so far from what I can tell. So it's teaching me a lot.

In our space today, these newer medications are certainly where it's at. We have to learn this. If we don't understand small molecule biologics, I think we're doing a disservice to our patients. And so for me to come to this meeting to reinforce it, it just gives me that much more education and understanding.

And so I actually really appreciate having to be here and understanding that and to be a part of it too. So I get to participate this year, which is kind of nice, and share some of the words of wisdom that I have. So this has been a really wonderful opportunity for me.

Speaker 1:

Visit dermnnpa.org for updates on the West Coast Biologic and small Molecules CME Boot Camp. And of course, you can also get updates on the Derm 2024 NPPA CME Conference coming up July 24th to 28th in Las Vegas. The agenda is now available, including details on the recently announced career development reception on Wednesday evening, July 24th. Earn CME while learning about opportunities and resources for NPs and PAs in dermatology. Thanks for listening to the Dermalorian podcast.