A tiered approach to managing acne
There are several factors dermatologists need to access when deciding treatment options for acne: the acne severity, the impact of the disease on the patient’s quality of life, and the potential for or the existence of scarring.
The goal of a tiered approach to acne is to improve both the patient’s acne and quality of life, while promoting responsible use of antibiotics. “Extended durations of antibiotics are associated with P. acnes resistance and decreased responsiveness to treatment,” says Arielle Nagler, M.D., an assistant professor of dermatology at the Ronald O. Perelman Department of Dermatology at New York University. “We have also seen systemic infections related to P. acnes and an increase in upper respiratory tract infections associated with extended antibiotic use.”
One of the challenges of treating acne is evaluating patient severity. “Many scales are available. Some of them are used in research, while others are more clinically relevant,” Dr. Nagler tells Dermatology Times. “However, there is no standardized protocol for accessing acne, which makes it difficult to compare studies to determine which treatments are more effective.”
Dr. Nagler tends to broadly classify patients based on the most recent American Academy of Dermatology (AAD) guidelines and European guidelines, for which there are three broad categories: comedonal/mild inflammatory acne; moderate papulopustular acne; and severe papulopustular/nodular acne.
For comedonal or mild inflammatory acne, “topical retinoids are my work-horse,” says Dr. Nagler.
In February 2016, the Federal Drug Administration approved topical daponse 7.5%, which can be used once daily and has efficacy for both comedonal and inflammatory acne.
In an effort to limit antibiotic use, Dr. Nagler has been successfully prescribing this topical therapy in this patient population as well.
For moderate to severe papulopustular acne, systemic antibiotics are traditionally first-line therapy.
“One of the challenges that we encounter in dermatology is that acne can be a long-standing condition in many patients, and with the exception of isotretinoin, there are no cures. As a result, dermatologists tend to prescribe antibiotics for extended periods of time,” Dr. Nagler says. “Although dermatologists represent only about 1% of overall physicians in the U.S., they account for nearly 5% of yearly antibiotic prescriptions.”
A study co-authored by Dr. Nagler last year in the Journal of the American Academy of Dermatology found that, on average, antibiotics were used for nearly 6 months before initiating isotretinoin.
“We need to recognize when patients with moderate papulopustular acne are not getting better with oral antibiotics earlier, so that we can appropriately modify therapy and perhaps escalate these patients to isotretinoin, avoiding extended antibiotic courses,” Dr. Nagler says.
In general, whether it is topical or systemic antibiotic therapy, Dr. Nagler strongly dissuades the use of antibiotics alone, but rather encourages their use as part of combination therapy. “For instance, oral antibiotics should always be used in combination with a retinoid and benzoyl peroxide (BPO) to help prevent antibiotic resistance and improve the efficacy,” she says.
Hormone modulating therapy, such as combined oral contraceptives and spironolactone, is also an option in female patients with acne who need a systemic agent.
In some cases, Dr. Nagler uses hormone modulating therapy as first line in moderate acne, “which can be extremely useful, particularly for acne that appears along the jawline,” she says. “It can also be effective in patients with no obvious signs of hormonal triggers for acne.”
Moreover, if a female patient has failed an oral antibiotic, “but is resistant to taking isotretinoin, this is where I feel hormonal therapy comes heavily into play,” Dr. Nagler says.
Hormonal therapy is an attractive alternative to antibiotics for patients who are concerned about the effects of long durations of antibiotics on their gut flora and their risk for resistant bacterial infections.
For the most part, and when possible, Dr. Nagler prescribes combined oral contraceptives and spironolactone together because of the risk of teratogenicity with spironolactone alone.
For patients with nodulocystic acne and significant scarring, isotretinoin should probably be started immediately, according to Dr. Nagler.
“However, as is the case with all therapies and all diseases, patient expectations must be managed and patient ‘buy-in’ is needed,” Dr. Nagler says. “It is important that dermatologists realistically convey to their patients how long it takes for acne therapy to work.”
For example, hormone modulating therapy often takes 3 to 6 months to fully see the effects.
“One of the reasons why I believe a lot of our acne therapy fails is that patients expect that their acne will improve in a few weeks rather than in 6 to 8 weeks, and compliance wanes once patients do not believe the therapy is working after a few weeks,” Dr. Nagler says. “I have found that managing patient expectations has yielded much improved results with various treatments and has resulted in less treatment modification.”
As a result, Dr. Nagler spends a significant portion of each acne-patient visit educating patients on the delays of therapy and how to correctly use the medications.
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