Challenging Acne Cases

In her Dermatology Week 2022 session “Challenging Acne Cases,” Hilary Baldwin, MD, discussed reasons for relapse after isotretinoin therapy and explored choices for treating acne during pregnancy and lactation, in patients with a history of gastrointestinal disease, and in patients with a history of depression.

She began by explaining the risk factors for isotretinoin relapse, including:

• Male gender
• Back/trunk involvement
• Severity (milder or more severe)
• Linear lesions
• Macrocomedone predominance
• Younger age
• Ovarian dysfunction
• Insufficient dosing

She then offered therapeutic options for recurrence:

• Return to prior best regimen
• Spironolactone +/- oral contraceptives (in women)
• Additional course of isotretinoin
• Photodynamic therapy (PDT)

Dr Baldwin talked through how to handle isotretinoin flares, from slight worsening to pseudo acne fulminans (PAF). To avoid minor flares, she recommended starting with no more than 0.5 mg/k/day and gradually increasing the dose. If the flare is caused by the introduction of isotretinoin therapy, continue topical therapy and consider continuing low-dose oral antibiotics for the first month of treatment. To avoid PAF, start high-risk patients on a low dose of isotretinoin, 10 to 20 mg/day, and consider adding prednisone. To manage PAF, stop or cut the isotretinoin dose by 50%, add prednisone 1 mg/kg, consider adding trimethoprim-sulfamethoxazole, and slowly reinstitute isotretinoin.

She then moved on to treating severe acne in pregnancy. Options include topical and oral medications, or procedures such as laser and PDT. When treating acne during lactation, a risk-benefit analysis is needed. Most medications that are safe in infants are generally safe during breast feeding, and most medications are transferred into milk by a concentration gradient. In addition, retrograde diffusion of a medication from breast milk back into plasma may remove it from the breast milk. Dr Baldwin suggested reducing the drug concentration in breast milk by having the patient breast feed immediately before taking an oral medication and taking the medication right before the baby’s longest sleep interval. For topical medications, the patient can apply all medications once a day to provide the least exposure.

For treating acne in patients with inflammatory bowel disease (IBD), Dr Baldwin presented the results of several studies looking at isotretinoin in patients with IBD. In one case-control study, there was a minimal dose-dependent risk for ulcerative colitis but not Crohn’s disease. In 4 large case-control and cohort studies, there was no link with IBD, and the Mayo Clinic reported a reduced incidence of IBD. In a meta-analysis of 9.7 million pooled patients, there was no link with IBD.

Lastly, Dr Baldwin reviewed treatment options for patients with a history of depression. Having acne is an independent risk factor for depression, anxiety, and suicidal ideation. In a meta-analysis of isotretinoin and depression, it was concluded that isotretinoin does not appear to be associated with depression, and the treatment of acne appears to ameliorate symptoms of depression. In another meta-analysis and systemic review, it was concluded that the use of isotretinoin is associated with a significant improvement in depression symptoms.

Reference

Baldwin H. Challenging acne cases. Presented at: Dermatology Week 2022; May 11–14, 2022; Virtual.