Tips for incorporating new therapies for acne

Canadian experts are currently updating clinical guidelines for the treatment of acne vulgaris. While the basic treatment algorithm will probably stay the same as the 2016 guidelines, the update will need to incorporate new therapies and address the enhanced understanding of the pathophysiology of acne. The American Academy of Dermatology published new guidelines last year, but some therapies included are not available in Canada (e.g., the antibiotic sarecycline). We asked two dermatologists how they would advise incorporating new therapies into practice. Dr. Tess Peters practises in Victoria and is a clinical instructor at the University of British Columbia. Dr. Diana Diao practises in Vancouver and is a clinical assistant professor at UBC.1. Consider topical combination treatments for mild to moderate acne vulgarisAcne vulgaris is heterogeneous, with a number of different subtypes. Guidelines classify acne differently, Dr. Peters noted. Treatment is generally combination topical therapy for mild to moderate acne and systemic therapy for severe acne.“The emphasis as we gain new therapies is again on combination therapy so we address acne using different pathophysiologic mechanisms,” Dr. Peters explained. Topical therapies can tackle multiple factors that cause acne, such as ductal occlusion, hormones, sebum accretion or inflammation.Topical therapies include benzoyl peroxide, retinoids (i.e., adapalene, tretinoin and tazarotene), salicylic acid, azelaic acid and combination therapies that include a retinoid or antibiotic and benzoyl peroxide.A new triple therapy, marketed as Cabtreo, consists of the antibiotic clindamycin phosphate, adapalene and benzoyl peroxide. All are “tried and true” ingredients, Dr. Diao said, and combining them makes it convenient.Cabtreo is “proving to be quite effective,” Dr. Peters said. It comes as a gel and patients apply it once a day. It costs approximately $1,600 a year, according to Canada’s Drug Agency, which recommended in November that the cost of Cabtreo should be reimbursed by public insurers if the price is reduced.Another new therapy is the androgen blocker clascoterone, sold in a 1% cream. It targets sebum (oil) production. “For all acne, we know the cause of comedones are integrated in androgens, so we must address the hormonal component to get the best results,” Dr. Peters explained. Patients may benefit from topical clascoterone or systemic treatment such as combined oral contraceptive or oral spironolactone.2. Keep antimicrobial resistance in mind when prescribingTopical antibiotics shouldn’t be used as monotherapy due to the concerns about antimicrobial resistance. “When we combine topical antibiotics with topical benzyl peroxide, we have shown decreased antibacterial resistance,” Dr. Peters said. Limit the use of oral antibiotics to prevent antimicrobial resistance, the American guidelines note.3. Educate patients about proper care of benzoyl peroxide productsThe U.S. Food and Drug Administration recently tested benzoyl peroxide products for presence of benzene. While 90% of the 95 products tested contained undetectable or low levels of benzene, six acne products (now recalled) showed some benzene contamination.While there’s no current clinical evidence linking benzoyl peroxide products and cancer, the issue is evolving, Dr. Diao said. It’s an opportunity for physicians to remind patients to properly store benzoyl peroxide products at room temperature and discard them if old or expired.4. Remember to follow upPhysicians should remember to follow up with patients to evaluate if and how they’re responding to treatment and if they need escalation, Dr. Diao said. If there’s scarring, initiate isotretinoin.5. Tips for prescribing isotretinoinAcne tends to appear earlier and be more severe in young men, Dr. Peters said. It’s best to start isotretinoin earlier at a low dose and bring it up slowly, she said.“It is not a sprint. Occasionally it can be a bit of a marathon. It’s OK to start with a lower dose,” Dr. Diao said.Take time to counsel and prepare the patient when prescribing isotretinoin, Dr. Diao said. Patients should be moisturizing, applying emollient to their lips, and even petroleum jelly in their nostrils, particularly in the winter. Some patients may need artificial tears if they’re prone to dry eyes. These symptoms may vary depending on the dose.There is positive evidence that people on isotretinoin can take over-the-counter antihistamines, which will prevent some of the purging process where patients experience flaring, Dr. Diao noted.How long to keep patients on isotretinoin is an area of ongoing research. “The average course is about six months but it depends on dose, the severity of acne and the individual,” Dr. Peters said.

Tips for incorporating new therapies for acne

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