New therapies for acne offer choices

Determining the optimal therapies for patients with persistent acne should start with the patient interview, according to a presenter at the 67^th American Academy of Dermatology Annual Meeting, held here.

Sara Dill, MD, of Kaiser Permanente Medical Group, offered some clinical pearls for managing patients with persistent acne. “I always ask the patient what they did that morning [to manage their acne],” she said. She added that she asks her patients how much their acne bothers them. The answers to those questions guide Dill about how aggressive she will be in prescribing medications.

“I show them how much retinoid I want them to apply, and I never write ‘apply to affected area.’ I always put specific instructions on each prescription,” Dill said.

Dill said she often uses isotretinoin, since that remains the mainstay of treatment. But her discussion focused on other treatment modalities for those patients who have ‘tried everything,’ or those who have poor tolerability for isotretinoin.

There are several new topicals that have just been approved and are in the pipeline, Dill said. Two of these – Epiduo (Galderma), which was just approved in December 2008, and Acanya (Arcutis Pharmaceuticals), which was featured at the meeting this week – both feature lower doses of benzoyl peroxide (2.5%, which is lower than the amount contained in many of the other gels on the market). This lower dose of BP has been shown in some studies to result in less irritation but does not seem to so far in studies to diminish efficacy, Dill said. Epiduo gel contains adapalene 0.1% and benzoyl peroxide. Acanya contains clindamycin phosphate and benzoyl peroxide.

Dill said current recommendations urge limiting the use of oral antibiotics for acne management, to minimize the development of resistance. She typically will prescribe oral antibiotics for a few months until the acne has improved, and then she said she prescribes maintenance therapy with topicals.

“I will also add oral contraceptives or go to isotretinoin as needed,” Dill said. “I never use oral or topicals alone without a benzoyl peroxide product to minimize the risk of antibiotic resistance.”

Dill said oral contraceptives are gaining popularity in the long-term treatment of acne. She said patients taking orthotrycycline saw a 50% to 60% reduction in inflammatory lesions after six months of treatment in studies. Similar reductions have been noted with other oral contraceptives, but many of these products have not sought a specific indication for acne. She said she prescribes oral contraceptives to girls who have had their period for at least a year, those that do not smoke or have histories of clotting disorders or high blood pressure, and those girls with extreme acne flares. She said girls that have acne “along the jaw line or neck seem to respond very well to oral contraceptives.”

Another possibility for acne treatment is laser and light therapy, but Dill cautioned that cost is an issue and long-term effects of altering the sebaceous glands are unknown. – by Colleen Zacharyczuk

For more information:

Dill S. #S004. Presented at: the 67th Annual Meeting of the American Academy of Dermatology; March 6-10, 2009; San Francisco.