Updates on Acne Management

During her session “2021 Acne Management Updates” at Dermatology Week 2021, Hilary Baldwin, MD, started by discussing what kind of medication to use and when for treating acne. She mentioned this is determined by types of lesions, severity of the disease, distribution, and scarring.

Dr Baldwin presented the various treatment options available for acne, including:

• Oral: antibiotics, hormonal treatment
• Topical: retinoids, benzoyl peroxide
• Other: laser/light therapies, chemical peels

“Your average successfully treated acne patient is on two or three different medications. So, it’s very common to need more than one medication to do the job,” Dr Baldwin added.

She presented some of the topical treatments starting with retinoids—a mainstay of acne treatment. She listed tretinoin (first topical natural retinoid approved for acne), adapalene (third-generation synthetic retinoid), tazarotene (third-generation synthetic retinoid (prodrug), and trifarotene (fourth-generation synthetic retinoid) as the four therapeutics available in this class. The latter three mentioned are photostable and stable in the presence of benzoyl peroxide; however, tretinoin is not unless altered or protected.

“Something has to be done to it to protect it from sunlight and benzoyl peroxide,” stated Dr Baldwin.

She discussed how topical retinoids are used and added what strategies could be used to minimize retinoid irritation including detailed patient history, any past tolerability problems, patient education (eg, mild irritation to be expected 1 to 2 weeks, skin care recommendations), and titration of retinoid dose at initiation of therapy.

She continued by discussing topical antimicrobials, particularly topical antibiotics (clindamycin, minocycline, benzoyl peroxide) including erythromycin, adding that it is no longer used by most practitioners. For clindamycin, Dr Baldwin stated that it should never be used as a monotherapy due to a rise in baseline resistance; however, combined with benzoyl peroxide this does not happen. Dr Baldwin mentioned the importance of combination therapy as it is nearly always indicated, increases efficacy of therapy, and fixed combination increases compliance.

Moving onto oral antibiotics, Dr Baldwin referenced the tetracycline class (doxycycline, minocycline, and sarecycline), trimethoprim-sulfamethoxazole, and trimethoprim alone. Regarding other antibiotics, recently documented cases have shown that azithromycin, cephalospsorins, flouroquinolones, and clindamycin are effective in improving acne; however, clindamycin reported 5% to 20% cases of diarrhea alongside pseudomembranous colitis which limits its use.

Dr Baldwin added, “In addition to the problem of antibiotic resistance increasing over the years, we’ve also seen a decrease in the development of new antibiotics—so called, pipeline void. Only 5% of drugs in the development pipeline are antibiotics.”

She addressed the question should physicians be worried about using antibiotics? She argued absolutely, referencing data from the Centers for Disease Control and Prevention that found that antibiotics illicit more than 2 million illnesses and 23,000 deaths in 2013 alone. The CDC acknowledged that physicians are called to be “better stewards” on antibiotics.

Yet, antibiotics are an integral part of acne treatment protocols, so it is important for physicians to recognize that their hands might be tied when treating moderate to severe acne. Physicians should consider:

• Using antibiotics sparingly and for a short duration
• Combination therapy that nearly always indicates:
• Topical retinoids for all
• Benzoyl peroxide should always be utilized with topical/oral antibiotics
• Maintenance therapy should not include long-term use of antibiotics

Next, Dr Baldwin moved to oral contraceptives (estrostep, drospirenone/ethinyl estradiol, etc), which have all been approved by FDA in treating acne. Some may be more effective for this purpose, because oral contraceptives usually take 3 to 6 months to see full effect. Dr Baldwin mentioned while antibiotics are effective at 3 months, oral contraceptive’s equivalent results start at 6 months.

Dr Baldwin continued to discuss spironolactone, which was FDA approved for hypertension in 1960, and commonly used in United States for androgen-related disorders in women. While poorly studied, consensus groups and experts favor use, and spironolactone takes 3 to 6 months to reach potential alongside combination therapy.

Isotretnoin can also be used for nodulocystic acne unresponsive to conventional therapies such as oral antibiotics. It is the only acne therapy that could promise cure, but with numerous potential side effects, such as mucocutaneous irritation or hepatic function test abnormalities. However, these AEs affect 1 in 20 million people, making the chances of AEs very low.

Finally, Dr Baldwin closed with maintenance therapy by stating it must be effective, tolerable, simple, unobtrusive, and nonantibiotic if possible. Long-term maintenance choices should including limiting systemic exposure to broad-spectrum antibiotics and considering topical retinoids, benzoyl peroxide, azelaic acid/topical dapsone, minocycline foam, oral contraceptives, and laser/light.

Reference
Baldwin, H. 2021 Acne management updates. Presented at: Dermatology Week 2021; September 16-19, 2021; virtual.