Insights From Spring AAD 2024: Acne Guidelines and Beyond

In this feature video, Dr John S. Barbieri goes over what his session “Acne Guidelines and Beyond”, will cover prior to Spring AAD 2024.

John Barbieri, MD, MBA, is an assistant professor at Harvard Medical School and the director of the Advanced Acne Therapeutics Clinic at the Brigham and Women’s Hospital. He is an associate editor at JAMA Dermatology and is also the co-chair of the American Academy of Dermatology Acne Guidelines Work Group. His research is focused on conducting innovative clinical trials, health economic, and epidemiology studies to identify the best approaches to care for patients with acne. He also focuses on exploring the role of patient-reported outcomes to ensure we are capturing the patient’s voice and perspective on their care.

Transcript:

Can you go over what your session will cover regarding acne guidelines?
Dr Barbieri: We're going to cover a lot of different aspects in the management of acne both treatments in terms of topical creams and washes and gels, pill medicines like oral antibiotics, hormonotherapy, and isotretinoin. An, then, potentially also some discussion of procedural treatments as well. And all of these different treatment modalities are covered in in the updated acne guidelines.

What are the newest updates for acne management that physicians can look forward to or implement their practice via the guidelines?
Dr Barbieri: Since the prior guidelines in 2016 came out, there have been a number of new treatments that have been introduced.

We have some new topical treatments like minocycline foam, trifarotene and some new fix dose combination products as well. In addition, we have a narrow spectrum oral antibiotic sarecycline that's been introduced. And we also have our first ever topical antienergen that's FDA approved for use in both men and women with acne, clascoterone.

So, the new guidelines go into these exciting new treatment modalities. I particularly, I'm excited about clascoterone. Since it really gives us a totally new treatment mechanism that we can use to help our patients with acne.

And I think some of these fix those foundation products, there's one that's not quite in the guidelines because it came out just a little bit after them, but this new triple combination cream with the adapalene, benzoyl peroxide, and clindamycin. It looks incredibly efficacious in the phase three trials.

And I think certainly will offer increased convenience for patients who are using it, which we know improves both adherence and also outcomes compared to just using things individually. And then sarecycline a narrow spectrum antibiotic may help us reduce some of those issues of off target antibiotic effects on our gut microbiome or other bacteria that we don't want to target with oral antibiotics. And it's a once-a-day antibiotic, which is nice to some more convenient for patients.

So, I do think that's an exciting new addition to our treatment, armamentarium and so together, I think we have a lot of exciting and innovative treatments that can help our patients with acne. And it will be important now for us to be able to have the full access as dermatologists to treatments that we need to provide our patients with the highest quality care.

How can the latest acne guidelines assist physicians in managing patients with acne?
Dr Barbieri: I think they can help in a variety of different ways. The first is just giving people the updated evidence about what are the treatments, effectiveness and safety when it comes to managing acne. So, we can do effective shared decision making and decide the best treatments for our patients. In addition, the guidelines address important topics like lab monitoring for isotretinoin and spironolactone.

And over in the recent years, we started to have increasing evidence that frequent lab monitoring is likely of low value for both of these medications. And the new guidelines really highlight that. And I hope that will be helpful for clinicians who maybe were thinking about changing their practice, considering doing less frequent lab monitoring, but maybe didn't quite feel comfortable yet either because they're waiting for more evidence, or they were waiting for just some kind of more definitive recommendations about what to do.

So, I do think for those who are interested in reducing their lab monitoring, I think the guidelines can be really helpful, kind of backbone for supporting those kinds of changes to improve the value of care we're providing for our patients. The guidelines also provide some updated information about use of oral antibiotics and acne. And right now, oral antibiotics are the most common treatment that we use for acne.

When it comes to systemic medications and dermatologists, we prescribe more antibiotics per doctor than any other specialty in medicine. So, this is a really important issue to think about antibiotic stewardship and what are the best choices for a patient? One of the first things that we talked about of course, is just trying to limit oral antibiotic use for the treatment of acne. And I think we have new treatments like topical antienergen, like clascoterone around things like hormonal therapy that have been growing in popularity spironolactone and then considering who are the right patients right to try now and getting them on that treatment sooner because it is a disease modifying treatment that can cause a remission to acne for many.

So, we have opportunities to reduce the number of people that we're treating with oral antibiotics and thinking about how we can reduce the duration of treatment for those where we do use them because they are a very important helpful treatment.

And then we talk about which antibiotics use as well. So, when we look at tetracyclines and we think about doxycycline and minocycline, which are the two most commonly prescribed. About 1 to 1 in use. doxycycline has some safety advantages compared to minocycline. It isn't associated with severe cutaneous drug eruptions like DRESS syndrome.

It isn't associated with neurologic side effects. And unfortunately, there have been people who have from minocycline DRESS syndrome and the treatment of acne. We haven't seen that with things like doxycycline and there's no clear evidence that one is better than the other.

Certainly, there might be some theoretical reasons or anecdotal evidence that one works better when it comes to just a typical patient. You know, we kind of encourage using doxycycline as opposed to minocycline doesn't mean we should never use it, but maybe doxycycline should be where we start more often than minocycline. Another important one we discuss is trimethoprim-sulfamethoxazole and the issue here is about 5 or 10% of antibiotics that are used just across medicine for acne are trimethoprim, self-inspiratory failure in the setting of using trimethoprim-sulfame for acne.

You know, since acne is a noninfectious condition, since we have other treatments like doxycycline and serocycline, that may have a better safety profile. I think trying to limit our use of especially trimethoprim-sulfame but also maybe even improve kind of the overall quality and safety of care that we're providing for patients with acne.

What else would you like to share with your colleagues regarding your session at Spring AAD 2024?
Dr Barbieri: Yeah, I'll particularly be talking about spironolactone in the session, and as I mentioned earlier, hormonal therapy for female patients with acne is a really valuable tool and our acne treatment armament area. I mean, there has been tremendous growth in the use of spironolactone over the past decade. It went from being about 7x more antibiotics of spironolactone to now it's getting closer to 1 to 1. So, there's been a lot of growth in the use of spironolactone.

We traditionally have mostly had kind of case series evidence. We haven't had great randomized control trials. But in the past year, really, in the past few months, we've had two large exciting, randomized control trials come out.

There's the SAFA trial from the UK which compared spironolactone 100 mg a day versus placebo and shows spironolactone was effective in treating adult blood with acne. It also helps us really understand the side effect profile because we have a good comparator group. And it really highlights that at 100 mg a day, the side effect profile looks great.

About 5 to 7% of people have some lightheadedness, dizziness, headache type of symptoms, probably from a blood pressure affects the spironolactone. But beyond that, they really didn't observe much of a side effect signal. There wasn't really evidence of a regular menstrual period of this 100 mg dose or other important side effects, which is great to see and to have that data to be able counsel our patients.

And more recently, there's FASSE trial in France which compared spironolactone versus doxycycline. A very important question. They looked at doxycycline 100 mg a day for 3 months versus and then going to benzoyl peroxide versus spironolactone, at 150 mg a day for 6 months.

And they showed it 4 and 6 months after starting these treatments that spironolactone actually looks like it's superior to doxycycline in the study. So very helpful data to guide our practices. And I do think even though spironolactone has grown a lot, I really think one day maybe it should be maybe our first line treatment for female patients with acne need a systemic treatment rather than using oral antibiotics because I do think it's a very safe and effective long term treatment in this population and around 100 to 150 mg a day, I think is the optimal dose.

And this really confirms pretty much everybody could tolerate 100 mg a day. So, I think that helps to start a dose that's more likely to be effective, especially as spironolactone is a slower medicine. So, rather than starting really low, like 25 or 50 mg then over many months ramping up and people sometimes getting frustrated, but they're not better yet, it may make more sense to start higher. And then if people do have those side effects of blood pressure effects to then go down the dose based on that.