Pearls on treating acne from the recent Mauiderm conference

Acne is a very common skin condition, especially prevalent in adolescents, but can persist well into adulthood. About 15% of the US population suffers from acne, and some estimates In the United States, nearly nine out of ten young people also suffer from the condition, so most dermatology providers are familiar with treating acne. Julie Harper, M.D., a board-certified dermatologist in private practice in Birmingham, Alabama, founding director and former president of the American Acne and Rosacea Society, presents updates on acne treatment at the Maui Derm NP+PA Summer 2022 conference The we.

Before discussing treatment, Harper took the time to highlight the goals of acne treatment and shared the acronym for effective treatment, CLEAR. Achieving significant improvement, preventing sequelae, and improving quality of life. The CLEAR acronym helps achieve this by reminding providers how best to counsel patients about effective treatment. Do not resist isotretinoin. This was followed by a brief discussion of the role of topical therapies in acne treatment. Can be used as therapy. However, topical antibiotics are rarely used as monotherapy. There is also the utility of topical therapy in treating acne sequelae.

Harper has launched an update focused on treatments with topical retinoids that work by binding to retinoic acid receptors that regulate genes associated with acne pathogenesis. normalizes hyperkeratosis and is anti-inflammatory in nature. FDA-approved topical retinoids have had his fourth generation, most recently his triphalotene 0.005% cream, which was approved in 2019. This new topical therapy is the first new retinoid molecule to be FDA-approved in over 20 years and has been studied on the face and trunk. Acne. In a phase 3 clinical trial, triphalotene achieved his IGA/PGA success rate of 42% and his 65% absolute reduction in inflammatory lesions on both the face and torso at week 12. did.1 “Topical retinoids remain the cornerstone of acne treatment. , there’s an entirely new retinoid molecule, triphalotene,” Harper said.

Harper followed her discussion of triphalotene with another retinoid, tazarotene lotion 0.045%. The drug was approved by the FDA in 2019 for daily use in patients aged 9 and older with moderate to severe acne. showed superior results to tazarotene 0.1% cream in percent change in inflammatory and non-inflammatory lesions.2 A new vehicle, polymer emulsion technology, allows for a lower percentage of active ingredient, which makes the traditional stimulant tazarotene more tolerable. Before moving to oral agents, Harper also mentioned two other important topical treatments for him. Start with E-Tretinoin 0.1%/E-BPO 3% cream, stabilized by microencapsulation technology. This technology also improves the tolerability of the medication. Next, he focused on clascoterone and demonstrated its unique mechanism of action. Clascoterone is a topical antiandrogen that binds to androgen receptors and limits systemic activity.3 In one clinical trial, the IGA treatment success rate for clascoterone was 16.1% compared to 7% for vehicle. This drug is the first topical antiandrogen for acne and is suitable for use in both male and female patients. “We tend to think of it as a burden when it’s taken, but in reality, topical agents are the unsung heroes,” Harper said. have been consistently shown to achieve clear or near clear in more acne patients with topical agents.”

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Harper also talked about oral therapy, which she said was just as important as topical therapy. It is not recommended for inflammatory acne. Salecycline, a modern oral antibiotic therapy, offers a narrow spectrum of treatment as it has minimal effect on Gram-negative bacilli. A benefit of this narrow spectrum may be a reduced propensity to disrupt the normal gut flora.Four Salecycline is taken once daily with or without food, and although rare, adverse events such as nausea and vaginal yeast infections have occurred. Its activity against C. acnes is comparable to that of doxycycline and minocycline.

Dr. Harper emphasized oral therapy with spironolactone. It is not FDA-approved for treating acne, but it remains a popular choice. She reviewed several high-yielding pearls when using spironolactone. 45 years old), there is no need to check potassium.Five “Spironolactone has been shown to be a carcinogen in chronic toxicity studies in rats,” despite the FDA’s black box warning stating that there is no evidence of an increased risk of breast cancer.6 Spironolactone takes 2-3 months to reach its optimum effect. The ideal way to use this drug is in combination with other acne treatments (topical therapy or oral antibiotics), and it can also be used in combination with oral contraceptives.7 In practice, the dosage should be between 25 and 200 mg, but Harper prefers a maximum dosage of 100 mg.

Harper concluded with isotretinoin, one of the drugs most commonly used to treat acne. She said the goal of isotretinoin therapy is complete clearance in one course of treatment with minimal side effects and risks. However, Tan et al.’s study found that the traditional endpoint dose of 120-150 mg/kg appears to vary with severity.8 Optimal endpoint administration of isotretinoin has the goal of relapse prevention. Recurrence can be defined in a variety of ways, such as acne exacerbation requiring systemic therapy or those requiring retreatment with oral isotretinoin.9,10 Relapses still occur in 20% to 30% of cases, and cumulative doses below 120 mg/kg are considered too low. Patient characteristics that make relapses more common include young age, males, severe symptoms, females with polycystic ovary syndrome, and patients presenting with numerous comedones.

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Harper reviewed laboratory monitoring with isotretinoin therapy. A study by Zane et al. found that the greatest perturbations of isotretinoin laboratory abnormalities were in triglycerides and total cholesterol.11 Therefore, the FDA labeling states, “Blood lipid measurements should be performed prior to administration of isotretinoin and at intervals thereafter until a lipid response is established, which is usually about 4 It’s been a week.” In a meta-analysis of laboratory evaluations of isotretinoin, laboratory values ​​showed changes from baseline, none of which were considered high-risk changes.12 The authors performed a lipid and liver panel at baseline and 2 months after treatment, and recommended repeat testing based on medical history.

Harper concluded his presentation with a discussion of depression and suicide risk in patients receiving isotretinoin therapy. A systematic review on the topic conducted by Huang et al. American Journal of Dermatology An analysis of 31 studies found only one found evidence that isotretinoin significantly increases the risk of depression.12 Although individual susceptibility to depression cannot be ruled out, the authors concluded that isotretinoin is safe to use without increasing the risk of depression. Another health care cost panel research study utilizing isotretinoin found that patients taking isotretinoin had fewer depressive symptoms and less emotional distress than those taking oral antibiotics.13

It is exciting to witness new innovations in acne treatment and to see significant data on conventional treatments. It’s an important topic to keep up to date with.

Disclosure:

Harper is a consultant and/or speaker for Almirall, Cassiopea Pharmaceuticals, Cutera, EPI Health, Galderma, Journey Medical Corporation, L’Oréal, Ortho Pharmaceuticals, Sol-Gel, SUN Dermatology, and VYNE Therapeutics. She is also an Almiral investigator. See dermatology-times.com for a complete list of references.

References:

1. Tan J, Thiboutot D, Popp G, et al. A randomized phase 3 evaluation of triphalotene 50 μg/g cream treatment. J Am Acad Dermatol. 2019;80(6):1691-1699. doi:10.1016/j.jaad.2019.02.044

2. Tanghetti EA, Kircik LH, Green LJ, et al. Phase 2, Multicenter, Double-Blind, Randomized, To Compare the Safety and Efficacy of a Novel Tazarotene 0.045% Lotion Versus Tazarotene 0.1% Cream in the Treatment of Moderate to Severe Acne Vulgaris A solvent-controlled clinical trial. J-drugs dermatol. 2019;18(6):542.

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3. Hebert A, Thiboutot D, Stein Gold L, et al. Efficacy and Safety of Topical Classcoterone Cream 1% for Treatment of Patients with Facial Acne: Two Phase 3 Randomized Clinical Trials. JAMA Dermatol. 2020;156(6):621-630.doi:10.1001/jamadermatol.2020.0465

4. Zhanel G, Critchley I, Lin LY, Alvandi N. Microbiological profiles of salecyclines, novel target spectrum tetracyclines for the treatment of acne vulgaris. Antibacterial agent Chemsar. 2019;63(1):e01297-18. doi:10.1128/A AC.01297-18

5. Plovanich M, Weng QY, Mostaghimi A. The usefulness of potassium monitoring among healthy young women taking spironolactone for acne is low. JAMA Dermatology. 2015;151(9):941- 944. doi:10.1001/jamadermatol.2015.34

6. Wei C, Bovonratwet P, Gu A, Moawad G, Silver-berg JI, Friedman AJ. Spironolactone use does not increase the risk of breast cancer recurrence in women: a retrospective analysis. J Am Acad Dermatol. 2020;83(4):1021-1027. doi:10.1016/ j.jaad.2020.05.081

7. Garg V, Choi JK, James WD, Barbieri JS. Long-term use of spironolactone for acne in women: a case series of 403 patients. J Am Acad Dermatol. 2021;84(5):1348-1355. doi:10.1016/j.jaad.2020.12.071

8. Tan J, Knezevic S, Boyal S, Waterman B, Janik T. Evaluation of evidence of acne remission with cumulative oral isotretinoin doses of 120-150 mg/kg. J Cutan Med Surg. 2016;20(1):13-20. Doi:10.1177/1203475415595776

9. Strauss JS, Rapini RP, Shalita AR, et al. Isotretinoin therapy for acne: results of a multicenter dose-response study. J Am Acad Dermatol. 1984;10(3):490-496. doi:10.1016/s0190-9622(84)80100-0

10. Leighton AM, Naggs H, Taylor J, Cunliffe WJ. Isotretinoin for acne vulgaris – after 10 years: a safe and successful treatment. Br J Dermatol. 1993; 129(3):292-296. Doi: 10.1111/j.13 6 5 – 213 3.19 9 3. t b118 4 9.x

11. Zane LT, Leyden WA, Marqueling AL, Manos MM. Population-based analysis of laboratory abnormalities during isotretinoin therapy for acne vulgaris. arch dermatol. 20 06;142(8):1016-1022. doi:10.1001/archderm.142.8.1016

12. Huang YC, Cheng YC. Isotretinoin treatment for acne and depression risk: a systematic review and meta-analysis. J Am Acad Dermatol. 2017;76(6):1068 -1076.e9. doi:10.1016/ j.jaad.2016.12.028

13. Hekmatjah J, Chat VS, Sierro TJ, Read C, Kassardjian AA, Armstrong AW. Differences in depression and distress between acne patients taking isotretinoin and oral antibiotics. J Drug Zdermatol. 2021;20(2):172-177.doi:10.36849/JDD.5559

14. J. Harper, H. Baldwin, D. Eichenfield. Acne and Rosacea Update 2022 MauiDerm NP+PA Announced Summer 2022. June 23-25, 2022. Colorado Springs, Colorado.

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