You are at the end of a busy afternoon clinic, with only a single patient standing between you and freedom to go visit a good friend and watch the Stanley Cup playoffs, of course after completing a metric ton of electronic charting. The chart in the door (or more likely on the EMR tablet) says “CHIEF COMPLAINT: ACNE”. Do you smile or groan? Acne vulgaris, or “common” acne, is itself among the most common reasons that patients visit a dermatologist. You do not have to be a highly skilled clinician to follow an algorithm and plug into a regimen the individual medications that “should work”. In fact, effective treatment requires not only selecting and correlating the appropriate therapies but also involves establishing an early and strong connection with the patient (and often an anxious and/or overbearing parents) that gains their confidence in you specifically as their dermatologist. Acne is a chronic and often fluctuating skin disorder, so inherently, reasonable expectations and responsibilities must be explained upfront to help ensure compliance. As part of the recent GW Virtual Appraisal of Advances in Acne conference, James Q. Del Rosso, DO, FAAD, FAOCD, provided a fast-paced and comprehensive guide to the topical treatment of acne, combining both the science and art of treating this frustrating and often disfiguring disease. Keep reading to learn about:
- What an initial topical treatment regimen for acne should contain
- Pearls to increase patient compliance and manage patient expectations
- Upcoming topical treatment options to add to your acne “toolbox”
So the patient is in your office, and they’re looking for a miracle treatment for their acne. What are some things Dr. Del Rosso recommends to consider even before starting medications?
- Patient knowledge: Any time spent on Instagram or other social media sites these days will expose patients to many “influencers” and self-proclaimed acne “gurus” who are often peddling ineffective and sometimes hazardous treatment options for acne. The “hazardous” component is often that the therapy does not match up with the type or severity of acne that is affecting the person scanning the internet for answers, so they are subjected to a greater risk of adverse sequelae such as scarring and dyspigmentation. By seeing a dermatologist who is motivated to treat acne, patients are demonstrating their willingness to invest their time and money to learn from a specialist who can cut through the “noise” and provide a safe and effective acne treatment regimen that is tailored specifically to their needs.
- Confusion about medication use: How many times a day do I put this on? Do I continue to use this “special soap” for acne or essential oil scrub I bought on Facebook? Being concise and clear in your instructions can provide ease of mind to the patient and prevent your phone from blowing up later with patient questions. Of course, you want patients to know they can contact your office if they have any questions or concerns.
- Weak Doctor-patient relationship: All the knowledge and treatment in the world won’t work if the patient doesn’t have confidence that the doctor believes in the treatment regimen they are selecting for them specifically. Acne therapy is not “cookie-cutter” and patients need to hear that the recommended regimen, which includes both skin care and medication recommendations, is designed specifically for their acne and type of skin (ie dry, oily, sensitive, etc). You may need to spend the majority of the first patient visit establishing rapport with the patient (and “helicopter parents”) before even moving on to treatment. Close follow up is a must to assist in monitoring response to treatment and adjusting therapy if there are side effects or inadequate response after an adequate trial of the regimen!
- Concern about side effects: I heard tretinoin makes you more sensitive to the sun? Why did this medication bleach my towels?! By being upfront about possible side effects of topical medications, you set patient expectations and continue to demonstrate why dermatologists are the recognized leaders in skin care.
- Cost and access to medications: Just like a weak doctor-patient relationship, prohibitive medication costs can derail treatment even before it starts. While frustrating to navigate the insurance landscape of “prior auths” and medication costs, this information is critical to getting a strong topical treatment regimen started on the first try.
How often do patients tell you their acne was worse the week before their visit? As untreated or undertreated acne can be both frustrating emotionally and not effective enough in prevention of scarring, Dr. Del Rosso advocates initially being more aggressive with topical therapies to get the acne under control and help win the patient’s trust and continued compliance. He magnifies the visible appearance of the acne on the day of the visit by 25% to 30% to account for times when their acne is worse.
Expectations set, patients (and parents) appeased…let’s treat some acne!
What are some tried and true topical medications Dr. Del Rosso recommends to get their regimen started?
- Include a topical retinoid! Considered a foundation in any regimen for acne, topical retinoids serve both anti-inflammatory and anti-comedonal purposes, helping to prevent the formation of the microcomedone and also inflammatory lesions. Through modulation of matrix metalloproteinases, topical retinoids may theoretically prevent and improve acne scarring that is “in flux” and not deeply established over several years.
Patient: But Doctor, this retinoid makes my skin dry and flaky!
You: That is partly because it’s working! As long as this is a mild reaction, it is important to try and work through over the first few weeks.
By briefly describing the mechanism of retinoids to the patient, the initial dryness and flaking become understandable. As long as there is not a significant tolerability issue, educate them on how to keep going with lessened frequency of use for a few weeks until their skin adjusts.
This “pearl” is a very important one. What is an easy way for patients to tell if their treatment is working? Tell them to feel the texture of their face on Day 1 and once every month thereafter. If they feel fewer raised bumps on their face, this means that the treatment is working as older acne is going away and fewer new acne “bumps” are coming in! They need to know that flat discolored spots that they cannot feel should not be considered to be active acne, and that the discoloration can take several weeks to months to fade. Continuing use of their complete regimen as recommended is vital to the success of acne treatment.
- Leverage fixed combination topical formulations. In life, 2 is often better than 1, and this is especially true with regards to topical acne medications. Combined topical formulations that contain two active medications in one tube, jar, or pump, can offer the patient “one-stop” shopping and fewer individual products to apply, as each ingredient augments the efficacy of the other. Many combination topical medications contain benzoyl peroxide, which acts both as an antimicrobial agent with reduction of pro-inflammatory Cutibacterium acnes and also reduces comedonal lesions. Other combination products are also available in the marketplace, including benzoyl peroxide and clindamycin in a well-formulated vehicle that mitigates skin irritation.
- Beware of topical antibiotic resistance! Drilled into our heads during our residency, the need to avoid resistance of acnes to topical antibiotics is a real concern. Monotherapy use of topical antibiotics such as clindamycin and erythromycin induce resistant C. acnes as well as other bacteria such as staphylococci, which can be transferred by the patient to remote body sites including the anterior nares. Use of a combination product that contains benzoyl peroxide with an antibiotic reduces the emergence of antibiotic-resistant C. acnes strains (and likely other bacteria) but, if combination medications are not available or too expensive, encourage the patient to invest in an over-the-counter benzoyl peroxide product that has published clinical study data supporting it. For the face, a leave-on topical formulation containing benzoyl peroxide 5.5% and lipohydroxy acid is supported by clinical study data. For truncal acne, Dr. Del Rosso cautions that for use on the chest and back, benzoyl peroxide washes have been shown to not be effective in reducing C. acnes. One must use benzoyl peroxide concentrations of 9-8% to 10%, preferably with the emollient foam formulation, with a contact time of 2 to 5 minutes on moistened truncal skin affected by acne prior to showering off. Don’t forget to tell the patient about the bleaching properties of leave-on benzoyl peroxide when in contact with colored fabrics (washcloths can be expensive!)
- The future of topical acne treatments is bright. New formulations of established compounds are available, such as a minocycline 4% foam that uses a novel lipid-based vehicle to maximize efficacy and minimize systemic exposure to the drug. Due to high concentrations in skin and minimal systemic exposure, there is a good potential that emergence of antibiotic-resistant bacterial strains is circumvented. Clascoterone, the first topical androgen receptor inhibitor, is pending FDA approval and would provide another mode of action that is of major importance in acne pathogenesis and does not depend on antibiotic activity. Stay tuned!
Doctor, why do I still have these red or brown marks on my face? Counsel patients that persistent inflammatory erythema or hyperpigmentation is not an indication of active acne; rather, it represents resolving acne that should continue to improve over time as treatment is continued.
Just like that, by using Dr. Del Rosso’s pearls, you magically have a happy and informed patient ready to go out and hopefully get their acne under control! Well maybe it is not quite that easy, but these pearls should be of assistance to many of you. What are some other ways that you have found success in the topical treatment of acne?
Please share your comments at the end of this post, and on Instagram @nextstepsinderm !
This information was presented by James Q. Del Rosso, DO, FAAD, FAOCD, at the GW Virtual Appraisal of Advances in Acne Conference held July 30th, 2020.
Views expressed are those of Dr. Willett and do not reflect the official policy or position of the DON, DOD or USG.
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