Acne: Challenging Cases

Hilary Baldwin, MD, presented the session “Challenging Acne Cases,” on the last day of Fall Dermatology Week 2022.

She started off with a discussion of isotretinoin relapse and its risk factors. Dr Baldwin presented a case of 35-year-old woman with nodulocystic facial acne, treated with isotretinoin for 5 months, who had a relapse within 2 months. Some of the risk factors for isotretinoin relapse are:

• Gender
• Back/trunk involvement
• Severity
• Linear lesions (sinus track disease)
• Macrocomedone predominance
• Age
• Ovarian dysfunction
• Insufficient dosing

Dr Baldwin then moved on to the therapeutic options. She mentioned that isotretinoin relapses often respond to drugs that failed to work previously: “Whatever combination [patients] were on before they used isotretinoin, it didn't work very well or didn't work well enough. Sometimes after isotretinoin that prior best regimen does work.” She also offered a few more therapeutic options, such as adding spironolactone or oral contraceptives, an additional course of isotretinoin with variation in doses, and photodynamic therapy.

Next, Dr Baldwin discussed handling the two types of isotretinoin flares: slight worsening that frequently occurs in the first month of therapy and pseudo-acne fulminans. To avoid minor flares, she recommended starting isotretinoin therapy in lower doses, with no more than 0.5 mg/kg/day and gradually increasing the dose. “I also wonder if the flare is caused by the introduction of isotretinoin, or if it's due to the discontinuation of the medicines the patient was using prior to that. Isotretinoin, although not good enough, was doing something,” she said. “I always recommend that they continue their topical medications when they start their isotretinoin, continuing them until either they're doing very well and don't need them, or if they get so dry that they can't tolerate the use of the topical medications.”

As for pseudo-acne fulminans, which is more common in men, Dr Baldwin mentioned, “Those people who have severe inflamed acne and in patients with a lot of truncal involvement, there's the absence of systemic signs or symptoms of traditional acne fulminans and scarring is virtually a guarantee.” To treat pseudo-acne fulminans, Dr Baldwin recommended avoiding it all together by starting high-risk patients on low doses and prednisone. To manage pseudo-acne fulminans, she recommended:

• Stop or cut the isotretinoin dose by 50%
• Add prednisone 1 mg/kg
• Use trimethoprim-sulfamethoxazole in variations
• Slowly reinstitute isotretinoin

Dr Baldwin then covered treating severe acne in female patients during pregnancy. Some of the options she suggested include:

• Topical medications
  • Metronidazole, azelaic acid, clindamycin, erythromycin, salicylic acid (category C)
  • Benzoyl peroxide (category C): 5% absorbed, immediately metabolized into benzoic acid, rapidly cleared
• Oral medications
  • Azithromycin, amoxicillin, cephalexin, erythromycin
  • Metformin
  • Prednisone
• Procedural
  • Laser and light
  • Photodynamic therapy (aminolevulinic acid is category C)

For isotretinoin treatment in patients with inflammatory bowel disease (IBD), Dr Baldwin presented several case studies:

• Case-control study: minimal, dose-dependent risk of ulcerative colitis, not Crohn disease
• 4 large case-control and cohort studies: no link with IBD
• Mayo Clinic: reduced incidence of IBD
• Meta-analysis of 9.7 million pooled patients: no link with IBD

Next, Dr Baldwin discussed isotretinoin treatment in patients with depression. One conclusion was that isotone does not appear to be associated with depression. “The treatment of acne appears to actually ameliorate depressive symptoms.” Whereas in another meta-analysis and systemic review of 20 studies, “the conclusion of the authors was that use of isotretinoin is actually associated with significantly improved depressive symptoms.”

Lastly, Dr Baldwin discussed treating acne during lactation. All topical products appear to be safe, along with metformin and laser and light. The following antibiotics are considered safe during lactation:

• Erythromycin – “for short periods”
• Azithromycin – longer half life
• Clindamycin – 1 case bloody stools, unrelated
• Trimethoprim/sulfamethoxazole  – after 2 months of age
• Penicillin
• Cephalosporins
• Tetracycline
• Doxycycline/minocycline – lipophilic, toxicity possible

Reference
Baldwin H. Challenging acne cases. Presented at: Dermatology Week 2022; September 14-17, 2022; Virtual.