AcneManagementintoday’steens:Factsvs.Fads

IngridPolcariMDAssistantProfessorofDermatologyandPediatrics

UniversityofMinnesotaFridayMay3,2019

Disclosures

• Ihavenorelevantfinancialrelationshipswiththemanufacturer(s)ofanycommercialproduct(s)and/orprovider(s)ofcommercialservicesdiscussedinthisCMEactivity• Iwillmentionoff-labeluse

Learningobjectives

• Understandtrendsinacnetreatment• Reviewtheevidencebehind“alternative”therapies• Knowthegoldstandardtreatmentsforacne

Acnetrends

• Gettinghardertokeepupwithteenagetrends• Teensaregettingadvicefromeachother andfromsocialmedia• Virtualacnetreatmentbecomingmoreavailable

• Lotsofacnesystemsonthemarket• Dothesework?

• Lotsof“natural”treatmentscirculating• Whicharehelpfulandwhichmightbeharmful?

• Thepublichasimplicateddietasanunderlyingfactorinmanyconditions

FactorFad:OTCacnesystems?

• Firstwell-knownacnesystemcameontothemarketin1995• createdby2youngdermatologists:KatieRodan andKathyFields• catchyname• celebrityendorsements

• Subscriptionswithmonthlyshipments• Countlessmimicsnowavailable

FactorFad:OTCacnesystems?

• Tendtobecostly• MostarecombinationsofBenzoylPeroxideandSalicylicacid• Somehavesulfur• Washes• Leave-onproducts• Toners/astringents

• Tossthese!Norolefortheseinacnecare

• Bottomline:Theymayworkformildacne!Butconsiderteachingyourpatientsaboutlesscostlyversionsofthesameproducts

Benzoylperoxide

• Antibacterial• Nopacnesresistance

• Mildlycomedolytic• Availablein2.5-10%strengths• Washorleave-onproducts• Canbeirritating,canbleachtowelsandclothing

• Canbemonotherapyformildacne• Studiesshowthatthiscanrivaloralantibiotics• Bottomline:agreatproductasmonotherapyorcombinationtherapy

SalicylicAcid

• Keratolytic• LessevidencetosupportusethanBPO• Tendstobelessirritating• Avoidharshscrubs:overscrubbingcanworsenacne

• Bottomline:• Useinpatientswhodon’ttolerateBPO• Considerasa“firststep”forverymildacneinyoungerpatients

Topicalantibiotics

• Antiinflammatory andantibacterialeffects• P.acnesisnowresistanttotopicalerythromycinsolesspreferred• Clindamycin1%gelorsolutionispreferred• Butneedtocombinewithbenzoylperoxidewashortopicaltoreduceriskofantibioticresistance• Canprescribeseparatelyorasacombinationagent

• Clinda 1%/BP5%orClinda 1%/BP3.5%

• Bottomline:Don’tusetopicalantibioticsasmonotherapy

Updateonantibiotics

• Oralantibiotics:• Tetracyclineclassstillfirstline(doxycyclineandminocycline)• Formoderatetosevereacneorthoserecalcitranttotopicaltherapy• Limitdurationto3monthsifpossible• UseatopicalBPOproductatthesametimetodecreaseantibioticresistance

• Proceedtohormonaltreatmentsorisotretinoinifneeded

FactorFad:theroleofdietinacne

• Emergingdata(RTC)suggeststhathighglycemicindexdietsmaybeassociatedwithacne• Limitedretrospectivedatasuggeststhatsometypesofdairymayinfluenceacne• Skimmilkinparticular

• Antioxidants:oralzinc,fishoil:evidencenotstrongenough

Bottomline:dietmayplayaverylimitedroleinacne

Factorfad:probioticsinacne

• Hottopic,staytuned• Currentstudiesfailtoshowbenefit• Bottomline:Existingevidenceisnotstrongenoughtosupportrecommendationforthisindication

Whichofthefollowingalternativetherapieshassomeevidencesuggestingefficacyforacnetreatment?

A)acupunctureB)cuppingC)teatreeoilD)lavenderoil

“natural”treatmentsforacne

• Bydefinition,theseare“alternative”becausetheylackhighqualityevidencetobecomemainstream

CharcoalsoapandmasksEssentialoils(teatree,others)ApplecidervinegarAloeVera

Alternativetherapies

• Mostlyfad!• Littletonoevidencethattheyworkinacne• Essentialoilsarevolatilecompoundsthatshouldn’tbeputdirectlyontotheskin• Lowqualityevidenceshowsthatteatreeoilcanloweracnelesioncount

• Patientstendtobeproudoftheirroutinessobecarefulnottocriticize• Mystrategy:“setasidefornow”

• Bottomline:otherthanteatreeoil,alternativetherapieslackevidencetosupportuse

FactorFad:lighttherapymaskforacne?

Fact.

• RedandBluelightreduceinflammationandp.acnes• Attachedactivatorhaslimitednumberofusessothereisongoingcostforthedeviceandplasticwaste• Bottomline:canberecommendedformildacne

FactorFad:OTCretinoids?• Anti-wrinklecreamscontainRetinol• notasstrongasretinoids

• Asof2016,adapalene0.1%gelavailableoverthecounter• Costabout$20• Coveredbysomeinsurances• Moredryingthanthecream

Bottomline:adapalene0.1%gelisacost-effectivealternativetoprescriptionretinoidsbutmaynotbestrongenoughforsomepatients

TopicalRetinoids• VitaminAderivatives:adapalene,tretinoin,tazarotene• Thecoretreatmentforacne!MostFDAapproved12andolder• Antiinflammatory,comedolyticandpreventmicrocomedone precursors• Startlowstrengthandworkyourwayup• Choosevehiclecarefully:

• gelsmoredryingthancreams• Lotionsandfoamsmorecostly

• Takeafewminutestocounselre:use:• Peasizefortheface• Notaspottreatment• Starteveryothernight• WearlotionwithSPF

Treatmentofsevereacne

• Systemicmedication• Oralantibiotics• Oralcontraceptivepills• Isotretinoin

Acne:OCPs• Typicallyreservedforfemales>2yearspostmenarche• OCPswithFDAapprovalforacne:• Ortho-Tri-Cyclin• Estrostep• Yaz• Beyaz

• Consider”continuoususe”tokeephormonesatasteadystate• Progesterone-onlybirthcontrolcanworsenacne

Whichistrueaboutisotretinoin?

• A)newdatasuggestslongertreatmentcoursesresultinlessreboundacne• B)ithasbeenconclusivelylinkedtodevelopmentofinflammatoryboweldisease• C)patientsshouldbecounseledthathe/shemaynotreachfullpotentialheight• D)depressionisanabsolutecontraindicationtoitsuse

Isotretinoin

• Veryeffectivemedicationforacne• Usedforseverenodularacne,treatment-resistantmoderateacne,oracnecausingscarringand/orpsychosocialdistress• Requiresperiodiclabmonitoring• PatientsandprovidermustadheretoiPLEDGEprogramrequirements• Femalesofchild-bearingageneedcontraceptivecounseling

Isotretinoin

• Veryeffectivemedicationforacne• Usedforseverenodularacne,treatment-resistantmoderateacne,oracnecausingscarringand/orpsychosocialdistress• Requiresperiodiclabmonitoring• PatientsandprovidermustadheretoiPLEDGEprogramrequirements• Femalesofchild-bearingageneedcontraceptivecounseling

Isotretinoin:lengthoftherapy

• Previouslyweaimedforagoaldoseof120-150whichisa4-6monthcourse• Newdatasuggeststhatahighergoaldose/longercoursemayresultinlessrebound• largerstudiesneeded

Isotretinoinandinflammatoryboweldisease

• EarlierstudiessuggestedalinkbetweenisotretinoinandIBD• Butoralantibioticusealsoassociated• CouldsevereacnebeamarkerfordevelopmentofIBD?

• 2016meta-analysis:noincreasedriskofIBD

Isotretinoin:Bonyeffects?

• TheoreticalrisksbasedonfindingsofChronicVit Atoxicity:diffuseskeletalhyperostosis,osteophyteformation,prematureepiphysealclosure• Potentialwithretinoids dependsondoseandduration• JAAD2004:singlecourseofisotretinoinhadnoeffectonbonemineraldensityordevelopmentofcervicalhyperostosis• 2casereportsofprematureepiphysealclosure• Carefullyconsiderrisksandbenefitsifstartinginapreadolescent• Noroleforxrays orDEXAinabsenceofsymptomsorprolongedtreatmentcourse

Isotretinoinanddepression• Literatureshowsanxietyimproves,suggestivethatdepressivesymptomsimprovetoo• Sporadicreportsofdepression,suicidalideationandsuicide

• Mediaattention:2000suicideofa17yearoldsonofaCongressman

• Nostudiestosuggestanevidence-basedlink• Considergettingclearancefrompsychiatristpriortotreatingapatientwithknowndepression

Conclusions

• Benzoylperoxideandsalicylicacidusefulformildacne• Don’tusetopicalororalantibioticsasmonotherapy• Topicalretinoidsareagoldstandardtreatment• Mostalternativetherapieslackevidencetosupportuseinacne• Teatreeoilandred/bluelighteffectiveinmildacne

• Dietplaysalimitedroleinacne• Noevidencetoproveprobioticshelpacne• Oralcontraceptivepillscanbeeffectiveforacne• Isotretinoinissafeandeffectiveforsevereacne

Thanksforyourattention!

References

• Blasiak RC,Stamey CR,BurkhartCN,Lugo-Somolinos A,MorrellDS.High-doseisotretinointreatmentandtherateofretrial,relapse,andadverseeffectsinpatientswithacnevulgaris. JAMADermatol. 2013;149:1392-1398.• Luthi F,Eggel Y,Theumann N.Prematureepiphysealclosureinanadolescenttreatedbyretinoidsforacne:anunusualcauseofanteriorkneepain. JointBoneSpine. 2012;79:314-316.• SteeleRG,LuggP,RichardsonM.Prematureepiphysealclosuresecondarytosingle-coursevitaminAtherapy. Aust NZJSurg. 1999;69:825-827.• LeeSY1,JamalMM,NguyenET,BechtoldML,NguyenDL.Doesexposureto isotretinoin increasetheriskforthedevelopmentof inflammatory boweldisease?Ameta-analysis.Eur JGastroenterolHepatol.2016Feb;28(2):210-6.

• SmithRN,MannNJ,Braue A,Makelainen H,Varigos GA.Theeffectofahigh-protein,lowglycemic-loaddietversusaconventional,highglycemic-loaddietonbiochemicalparametersassociatedwithacnevulgaris:arandomized,investigator-masked,controlledtrial. JAmAcadDermatol. 2007;57:247-256.• JungGW,Tse JE,Guiha I,RaoJ.Prospective,randomized,open-labeltrialcomparingthesafety,efficacy,andtolerabilityofanacnetreatmentregimenwithandwithoutaprobioticsupplementandminocyclineinsubjectswithmildtomoderateacne. JCutan MedSurg. 2013;17:114-122.