Your Acne Questions, Answered!

The following questions were submitted by attendees during the GW Virtual Acne Appraisal Conference held on July 30th, 2020. To watch the on-demand recording of each lecture presented during the conference, click here.


Topical Management of AcneJames Q. Del Rosso, DO, FAOCD
Is there any risk of minocycline foam causing minocycline-induced hyperpigmentation? Or is that more an adverse effect of systemic minocycline?

Minocyclineiasdociated hyperpigmentation patterns seen at times with oral minocycline were not observed in the clinical studies with minocycline foam. That does not mean it may never happen but was not seen in the studies.

Use of Antibiotics in AcneNeal Bhatia, MD
Is there an improved effect on antibiotic resistance for acne if alternating between doxy /mino/sarecycline?

Only when combined with topical BPO and retinoids as discussed in the recently updated guidelines from the JAAD and European literature.

In keeping with the concept of not using chemically dissimilar antibiotics used at the same time in patients, can you comment on using a topical and oral agent that are not similar, say Benzaclin (topical clindamycin) and oral doxycycline. I prefer to just use OTC BOP when on oral abx…is this necessary??

Nothing wrong with this approach depending on the morphology of the presentation of acne although I personally would add a retinoid to that recipe.

How difficult is it for a patient to get Sarecycline? How much more expensive is it for insurance companies (ie translates to cost to the health care system)?

This is, unfortunately, a question for Almirall to answer, and the question about cost to the health care system is more of an editorial than factual discussion.

Use of Hormonal Therapies in AcneJulie C. Harper, MD
What is the youngest age you will prescribe spironolactone?

I treat this similarly to oral contraceptives.  I prefer for the patient to have established their menstrual cycle for about 2 years prior to using spironolactone.   I don’t use a lot of spironolactone in my youngest patients because I know that it will likely be something they will need for years.  If acne is stubborn and not responding to oral antibiotics and combination topicals, I would prefer a course of isotretinoin over starting long-term spironolactone in this age group.

What is the comparison between the dosing of spironolactone for acne vs those with cardiovascular issues such as High blood pressure or CHF?

I am not certain.  Just looking at the prescribing information, it appears that 100mg is a common starting dose.  It does say that doses can be initiated at 100-400mg QD for primary hypoaldosteronism prior to surgery.

Oldest age using OCP and spironolactone?

I don’t have an upper limit for spironolactone.  For OCP’s, I would generally not start them in someone over 35 but I am not against continuing them to mid 40’s if someone has been on their OCP for a long time and has proven to be a good candidate for ongoing treatment.

The black box warning on spironolactone confuses me because it is listed as a warning for but unlike most other medications I know with a black box warning it’s not listed on uptodate or epocrates. What is this about?!

This black box only talks about spironolactone being a tumorigen in rats.  We have no evidence that it increases the risk of cancer in humans.

When would mino be a better choice than doxy?

Out of the two, I prefer doxycycline.  Overall, I am more comfortable with the risks of phototoxicity and GI issues than I am with autoimmune hepatitis or DRESS.  Of course, these risks are not common.  Doxycycline phototoxicity is real though and I am hesitant to use it during the summer months in people who are fair and either work or play outside a great deal.  That is a scenario when I would consider minocycline.

You mentioned using spironolactone and isotretinoin together in some patients. Do you start together? Do you use the same dose you would use separately? Any considerations on using them together? Adverse effects?

I don’t do this often but it is an option.  It usually happens like this: A patient has been on isotretinoin (2 or more courses) and they continue to relapse.  We try another round of isotretinoin, but co-prescribe with spironolactone.  I keep the doses of both similar to if they were being used alone.  When we get to the end of the course or isotretinoin, we stop it but continue on with spironolactone.  I do not see any additive risk from using the 2 together.

Issues with Isotretinoin: Fact vs Fiction Jenna Lester, MD
Do you find a difference in efficacy between different brands of isotretinoin? ​

I have not personally seen a difference though most often any one patient I have is on one brand throughout the whole course.

Can Accutane permanently shrink oil glands?

​I am not sure there is literature to support this long term though studies do demonstrate that isotretinoin shrinks sebaceous glands.

What do you suggest to families who want wisdom teeth extraction while on isotretinoin?

I would recommend against extraction while on isotretinoin. Discuss with the oral surgeon about the appropriate timing after discontinuing treatment. 

Please clarify about suicide while on isotretinoin

​Most studies suggest the suicide rate is at or slightly lower than that of the general population while on isotretinoin. There is a study that found a slightly higher rate of suicidal ideation/attempt in 6 months after therapy is discontinued.

How do you counsel patients with severe acne that may have daily alcohol consumption/alcohol dependence? Do you treat if baseline labs are acceptable? ​Not use isotretinoin unless they abstain? Monitor LFTs more closely?

​I recommend against alcohol consumption while on Accutane. This is a medication that is for temporary use so I think it is reasonable to ask people to abstain given the potential risks. 

Diet and Alternative Therapies: What to Know for Acne Management – Vivian Y. Shi, MD


Does chocolate cause acne?

We currently don’t have enough evidence to suggest whether pure cocoa itself can influence acne, but the dairy and sugar used to make chocolate products can cause acne.

Role of keto diet??

There are some (but not high quality) data showing that a high-protein, low glycemic-load diet could be better for acne than a conventional high glycemic load diet. However, some keto diet practices are quite extreme and could cause other physiologic imbalances; so it’s good to do nutritional changes in moderation.

Thank you for this lecture. It was awesome. Do you tend to test for vitamin d/zinc levels or do you just treat empirically?

No, I don’t regularly do it. I just do the supplementation.

Name of the 4% niacinamide?

There are a lot of formulations out there (check Amazon), search for “nicotinamide gel”.

Name of the supplement with zinc, copper, niacinamide…?

There are a lot out there on the market. The one that was used in the study was called Nicomide (nicotinamide 750 mg, zinc 25 mg, copper 1.5 mg, and folic acid 500 mcrgm).

Do you utilize these nutritional guides/supplements for pregnant patients with acne since we are limited by what Rx we can offer them?

Yes! I typically tell the patient to get the okay from their OB before starting them though.

Should a high-protein diet be avoided for acne patients?

Not necessarily – a balanced diet is more important. I recommend acne patients to avoid intense protein-loading, especially with scoops and scoops of whey protein supplement.

How can we assure a high proportion of probiotics are alive when patients take them?

That’s the billion-dollar question. Currently, there is a lack of regulatory standards on manufacturing and marketing of probiotics. They can be under more than one FDA definition: food vs. supplements. Also, we still don’t know if probiotics really need to be live in order to impose an effect in our body; some researchers hypothesize that a simple pass-through or short visit in the gut may already have some effects. More research will tell!

Management Considerations for Skin of Color Patients with Acne – Andrew F. Alexis, MD, MPH

When evaluating a treatment for efficacy, how long should you wait? Are there specific benchmarks you use to know you need to escalate or change therapy?

I have patients return 2 months after initiation of a new regimen. At this time point, I expect to see significant improvement in overall severity such that I can encourage the patient to stay on course for further improvement. If a significant response is not seen at this time point, I will escalate or change therapy.

I feel that we know all these topicals for PIH and we prescribe them to our patients but I’ve been experiencing adult acne suddenly. I’m a dermatologist myself and use everything in the book and all mentioned by Dr. Alexis. None of it seems to work on me. Makes me question if all these things we are all repeating actually work. I would have never known if I wasn’t experiencing non-efficacy myself. So when the patient comes after a period of time and claims they have been consistent and nothing works, this makes me see that it’s true that these treatments don’t work on everybody.

When it comes to PIH secondary to acne there is no silver bullet and success takes months of consistent treatment. Many patients perceive nothing is working because as one PIH macule resolves, a new one develops – that is if their acne is not completely controlled. My therapeutic approach is to ensure strong control of the acne with combination therapy that includes a topical retinoid and targets multiple pathogenic factors associated with acne. The purpose of this is to: 1) prevent new PIH lesions by controlling the acne which causes PIH, and 2) speed up the resolution of existing PIH lesions (leveraging the effects of topical retinoids +/- azelaic acid). After at least 2 months of combination medical therapies (ie. After control of the acne), I will typically add chemical peels and/or topical bleaching agents for persistent PIH (as needed).

Which is the best moisturizer and sunscreen for acne patients with skin of color?

Some of my preferred products that are well-suited for skin of color patients with acne include Cetaphil DermaControl Oil Absorbing Moisturizer with SPF 30, Aveeno Positively Radiant with SPF 30, Toleriane Double Repair Moisturizer with SPF 30, and Cerave AM.

Andrew, how difficult to get these newer retinoids covered for patients?
I leverage the patient savings cards and specialty pharmacies to allow patients to get these at a reasonable cost (even if not on formulary). When using these savings cards most commercially insured patients can get the recently approved retinoid formulations. For those who are not eligible or when the cost is prohibitive, I will consider tretinoin 0.025% or 0.05% cream, tazarotene 0.05% cream, adapalene 0.3% gel, or adapalene 0.1% gel OTC depending on patient’s budget and insurance formulary.
This was a great lecture! I was wondering about your thoughts regarding Vit C for PIH from acne. Where does this fall on your treatment ladder?

I think that Vitamin C is a great skin brightener and can reduce hyperpigmentation. I position it as a potential adjunct to a regimen that includes a retinoid nightly.

Are there any products that help hyperpigmentation in lips for patients of color?

No specific products. My approach would depend on the cause of lip hyperpigmentation (e.g. Fixed drug, irritant contact dermatitis, cheilitis, smoking, etc).

Dr. Alexis – what is your experience with Accutane in skin of color and any special considerations?

As in lighter skin types, isotretinoin produces terrific results for acne in skin of color, but may also have the advantage of faster resolution of the PIH. One special consideration and caveat is that since the skin becomes dryer and more sensitive, the risk of having irritation from skin care regimens the patient may choose to use is higher and this in turn can lead to PIH. Therefore, educating patients on preferred skin care during isotretinoin therapy is paramount (e.g. gentle hydrating cleansers, effective facial moisturizers; and avoidance of peeling agents, scrubs, exfoliating treatments, etc.).

How many more weeks after clearance would you recommend continuing Adapalene 0.3%+BPO for acne scars and post-inflammatory erythema?

 I keep patients on therapy for as long as their skin is prone to the development of acne, which is typically for years. However, to specify an endpoint, I would say continue therapy for at least 6 months after acne resolution (without recurrence during that time frame).

The GW Virtual Acne Appraisal Conference was hosted by the George Washington School of Medicine & Health Sciences, in partnership with ODAC & Next Steps in Derm. 

This enduring activity is supported by an independent medical education grant provided by Almirall, LLC.