Discuss how the components of topical acne therapies affect treatment outcomes

Review the clinical efficacy and safety of newer topical treatments for acne

FC24: A Roadmap for Clear Skin: Pathways to Put Acne in the Rearview Mirror: An Online Activity

Identify the most common allergen groups that provoke allergic contact dermatitis

Recognize the potential for systemic exposure to contact allergens can cause a patterned dermatitis

Describe the mechanism of action of lasers and light sources in treating acne.

Incorporate lasers and light sources into acne treatment protocols

2024 Virtual Grand Rounds Session 6: May 1, 2024 -  Treating Acne with Devices and Contact Dermatitis - What Allergens Should I Care about in 2024?

Summarize the pathophysiology of acne and relevant targets for newly available therapies.

Define the role of newly available topical therapies for treatment of acne.

Identify patients who would benefit from newly available topical acne treatments.

Topical Therapies in Acne: Why the Mechanism of Action (MOA) Matters In Practice Decisions Online CME Activity

Summarize the role of topical therapies for the management of acne

Identify patients who would benefit from topical acne treatments

Describe strategies to talk to patients about topical therapies to help improve adherence and patient outcomes

Topical Therapies for Acne Management: Evolving Skin One Patient at a Time: Online CME Activity

Hilary Baldwin, who I've known for a long time, and all acne all the time. Right. So we're going to be talking about, you're stuck with me two in a row. I apologize for that, but we'll get through it. Topical therapies for acne management, evolving skin one patient at a time. And you can see the learning objectives focusing on topical management. And there are newer agents, we have older existing agents, we have brands, we have generics. How do we integrate all these therapies? So that's what we're going to be talking about. And these are our affiliations. So the accreditation is the same as through the University of Nevada, Reno School of Medicine for a half hour of Amapra category credit. And these are the learning objectives. And we'll be talking about how we try to integrate them and give you some background data. We'll try to keep it as simple as possible, but still make it relevant for you. So in the pathophysiology of acne, which is a moving target, we're really looking at where we apply medications to really inhibit certain pathways or certain pathophysiologic buckets, if you will, that these therapies actually target. And there's many in acne, it's really hard to shut them all down. Isotretinone is the only one that really does that. So we're really looking at trying to fit in different agents, whether it be topical or systemic. A lot of these are available topically to really get the maximum effect against lesion formation. And we realize we have non inflammatory lesions, which are not really non inflammatory. If you look at them histologically, but visibly they're comodontal, they don't have any visible inflammation, and then we have inflammatory lesions. So at this point, I'm going to turn it over to Hillary, who has some great insights on a clinical approach to the acne patient. Thank you very much. Hello, everyone. It's a pleasure to be here to talk about this topic. So I often wonder how we do what we do so quickly when we see an acne patient. How many seconds do you think it takes you, when you walk into the room and see the patient sitting there to decide what all of the things being equal, you would do for this patient? Right? Maybe 5 seconds, five for me, maybe ten at most. The rest of the time is talking to the patient and trying to figure out how you're going to need to change what you want to do, to meet with their insurance, to meet with their lives, to meet with their exception, and that's obviously a very important part of the whole thing. But how do we do it in 5 seconds? Well, I do it by looking at what type of lesions I'm looking at, and then within that framework, is it a mild, moderate, or severe case? Is the trunk involved? Is there scarring? And do I see any evidence of psychological impairment? And those are going to help me to decide how I'm going to get to the endpoint of clear or near clear with all of these possibilities, how are we going to choose our regimen with the rich acne toolbox that we have at the present time with topical therapies? So, I think we all recognize that combination therapy is the most important thing that we do for most of our acne patients. Your average successfully treated acne patient is on 2.53 different medications. That's how we do what we do, and frankly, that's what makes dermatology providers different from everybody else who attempts to treat this disease with monotherapy. How do we then convince our patients to trust our choices? If we tell them that they have to use three products, we need to explain to them why that's necessary and that two is not the same as three. Have you had the experience where patients come back, you gave them three medicines, and they say, stop that one, because it wasn't working? How did you know that? Right. So we need to educate, we need to set expectations, and we need to tailor our regimen to our patient's lifestyle. People who can't deal with mornings should not be given medication in the mornings. Right, but we do it all the time, so keep it simple. Stupid, of course, the acronym that we're all supposed to be following, and the easiest way to do that in my mind is to, whenever possible, use fixed combinations. And I believe that this also improves compliance. So the way I start picking from all the medications that I have at hand is what Jim just said. We're trying to fix all four, or trying to treat all four pillars of acne pathogenesis. And only isotretinoin can do that. Can we do that topically? And the answer is now. Yes, we can. We can help with the sebum production with classcoderone, retinoids, and benzol peroxide for follicular hyperkeratinization, benzol peroxide, clindamycin, minocycline for C. Acneus, and a whole bunch of different medications for inflammation. So I'm picking and choosing from these columns, basically trying to create a topical isotretinoin for the patient sitting in front of me. This is the overall activity of our various topical agents. So you can see that you can pick one from column a, one come from column b, and put yourself together a nice regimen that's going to treat the patient from all aspects. So we have a couple of new medications, new kids on the block that I'd like to call out specifically, the first being classcoderone 1% cream. It's the first new mechanism of action in acne for many years. It's an androgen receptor inhibitor with antiinflammatory properties. It's rapidly metabolized in the skin into cortex alone, which has no to little antiandrogenic activity. So it's safe in guys. So we finally have an androgen inhibitor, a sebum inhibitor that we can utilize in our male patients. That's not isotretinoin. That was our only option for male patients. Clearly spronalactin and oral contraceptives, not much appreciated by our male patients in terms of the phase three trials on the left, we see success at about 20% in the blue compared to vehicle in the gray, with a nice big delta between the two. Reduction in noninflammatory lesions in the middle, very similar to the reduction in inflammatory lesions over on the right, between 30 and 40%. So what's the innovation here? Well, it's our only topical androgen inhibitor, and it's the only androgen inhibitor other than isotratinoin that's safe for use in men. It allows for completion of our pathogenesis. Tetrad with only topical medications. I believe it should be part of polytherapy. I rarely use this medication as a standalone, and I think it really does. And I'd love to hear your comments on this really does need to be used bid instead of QD. And that data was demonstrated into phase two B study. So now if we go back to looking at pathogenesis, what else could we do for our patients? How could we use combination therapy? Well, we talked before about wanting to treat follicular hyperkeretinization. Benzol peroxide, a topical retinoid. We talked about wanting to reduce inflammation, again with a topical retinoid. We wanted to kill C. Acneus. How about benzol peroxide? What if we combined those two in one container? We would hit three of the four pathogenic factors of acne and then maybe throw in classicodorone for a little bit of good luck to finish the tetrad. But we can hit three with topical medications only. And one of the new drugs on the market can do this. Microencapsulated benzel peroxide, 3%, tretinoin 3%, and tretinoin zero 1% cream. And what's unique about this is that both agents individually are microencapsulated in a silicone shell. So you're saying to yourself, wait, you can't put tretinoin and benzol peroxide on the skin together, much less in a bottle together? Well, yes, you can, if you segregate them inside the bottle. And that's what this product has done. This is the phase three clinical trial. Mean percent reduction of inflammatory on the left and noninflammatory on the right. A nice reduction as well as a nice separation from the vehicle. And finally, tolerability. That's the other thing we might think about. With 3% benzel peroxide and the strongest tretinoin there is, 0.1% cream. So, local tolerability, as you see here, with the combination product signs on the left, symptoms on the right. All parameters at all time points well below that first line, which represents mild. So what's the innovation here? Well, the ability to combine and coapply previously uncombinable agents, to combine two concentration dependent irritants in one product, yet make it tolerable, thanks to the slow dissolution of the medicine onto the surface of the skin, and once again fix combinations that can improve both adherence and therefore efficacy. And I'm going to turn it back over to you, Jim, if you don't mind. I don't mind at all. It's always so interesting you have two people from Brooklyn here doing this. We always tell the truth. So, to answer your question about the twice a day with closcodarone, there was no different, no doubt that twice a day, when it was used as a monotherapy worked better than once a day. However, we really don't know whether once a day, along with some other therapies, like if you use it in combination with a benzoyl peroxide and a retinoid, or potentially even with a triple combination if it comes to fruition, we don't know, maybe that once a day would be enough. When it's in combination with other things, we don't have that answer yet. But if we have patients using a combination product in the evening, right, and we're asking them to use the clascoderone twice a day, they may only get it on once a day if we can get them to be compliant at all on an everyday basis. So we may find out if we can get that information anecdotally. But I think there's more to be determined. So as far as selecting topical therapy, I like to break the ice with the patients, especially if there's an overbearing parent, I'm sorry to say, but I have to be honest. It's usually a mother, but sometimes it's a father. And I want to make sure I'm connecting with that patient. It's a teenager, or if the patient's there alone, they're not a minor. I want to make sure I connect with them and be talking with them about their acne. I found that asking them about diet surprises them, because I used to avoid diet because I really didn't know what to say. I was debunking myths. But there's actually a very nice article that Hillary and Jerry Tan wrote together in the American Journal of Clinical Dermatology that goes through what we know about diet. And there's a couple of things in there that are helpful. And I think it just shows them that we're interested in more than just prescribing medications. Right, getting the past treatments, and also letting them know I'm personalizing this management for you. That includes the skincare. That is exactly why what and when you use different things, I think if we look at some of the over the counter formulations that are out there, some of the regimens where we've seen countless infomercials, they tell people exactly what to do. And I think we could learn from that because they want to know exactly what to do. And then the reason for follow up, my trainer, Dave Horowitz, who's a brilliant clinician, used to say, if you don't tell people why you want them to come back, they think all you're interested is in their money. They don't realize that if you did some form of procedure in that time, you'd make a lot more money than you would on an acne visit. But this is not about the money. This is about getting the patient to understand what we want them to do. So I make sure they know that I need to see them to make sure they're doing okay and to assess their improvement. And I need them to do exactly what I'm telling them to do. And if they skip one component of it, they have to give me four more days. I made that up empirically. And unless you're having a problem, I need to see you in eight weeks. In eight weeks, if they come back and say, well, I didn't put on this topical or that topical, I need four more days to get where we agree we're going to get if you do everything exactly the way I ask you to do it, right, and you're not where we agree where that should be, and we go through that. My staff goes through that with them. My boss is here. I never told them I do this, but I'll give you that visit free. Right. And in my whole career, which is long, I've only given away three visits. Right. It's just a way to get an eye to eye, sort of a verbal contract. It doesn't always work, but it does help. So these are some of the things I do, and I think one of the most important things I do is, unless the patient is at the far end of the spectrum, where they're very severe, whether it's just inflammatory papules, pushals and comodones or nodules, I magnify where they're at right now by another 30% because I'm probably not seeing them at their worst and I want to treat ahead of it. Otherwise, I'm always catching up. And we know it sometimes takes weeks, even with strong compliance, for patients to get to where we want them to be. I make sure they utilize the dot method, which is where they apply. They take the medication, they put it in dots on their face. I published that some years ago, and they confidently apply it. If they take a glob and start in one place, they get a high concentration here and a low concentration everywhere else, especially along the fringe. That acne along the fringe is not always hair product. It's. They're just not getting the medication there. So let's look at a couple of different therapies, then we'll wrap up and I'll have Hillary make some final comments and maybe we'll banter back and forth a little bit. Is there still a role for integration of individual topical agents? Because we have combination agents and there's times we may want to do that, we may want to use individual agents. And one particular agent that I think is important for us to understand is tazarotene. Zero point 45% lotion for acne vulgaris. Tazaritine has been around since 1997, so tazaritine is not new, but the formulation, it's really important to understand the formulations. Some of them are smoke and mirrors, some of them are not. This one is not. So they were able to show in the phase two studies that tazarotene 00:40 5% lotion, less than half the concentration than tazarotene 0.1% cream, the branded formulation were the same in terms of efficacy. The lotion had some improvement in the tolerability, and they certainly had the phase three trials. Now, how do they do this? The same way they've done it with their topical tretinoin. And the way they've done it with their topical halibatazole and tazarotene for psoriasis is with this polymeric emulsion technology. It is the real deal. They basically use a matting that's made of silicates, which is very inert, where they can partition each active ingredient with the proper excipients to solubilize and deliver that ingredient. It increases the delivery and it actually improves the efficacy with lower concentrations. And there have been post hoc analyses that have shown this to be helpful in essentially any skin type, any race, oily skin, dry skin. And in females, because we often think about tazaritine, oh, it's only for males, you can't use it in females. That is not the case. It can certainly be used in females, and there's a lot of data on that. Now I'll end up with on tazaritine, there is some data on trunkle acne. It's a pilot study that was done open label, small number of patients, but it spreads very well. So it's something to consider. And it was highly tolerable. Now, what about combinations that seem to the most sense? Well, this is in development also with polymeric emulsion technology, and this is a triple combination. And look at what's in it. It has clindamycin, benzo peroxide and adapyline, and you can see the various concentrations. 1.2 means it's clindamycin phosphate, right? Clindamycin phosphate is 1.2. Clindamycin alone is 1%, but it's essentially the same thing. Why clindamycin? It's gotten a bad rap. I would argue that if you go back and look at monotherapy arms with clindamycin over 2000 patients, if you look at Ziana trials and Veltin trials, evaclin trials, it performed extremely well against comodontal and noncom and inflammatory acne lesions. It has activity, and I believe it has some antiinflammatory effects. Though not everybody believes that this combination in patients with a significant amount of acne outperformed all the dyads, and in terms of tolerability, also did extremely well. It appeared that the presence of the retinoid would be what you'd have to consider, especially in the beginning. So this is something to look forward to. And I think many of these combinations now that we have clascodorone, something finally that we can give for shutting down the androgen part of it, and the sebum modulation is really optimal combination. So I'm going to turn it over to Dr. Baldwin, some final thoughts and see if she can correct any mistakes that I made and see what you think. And we'll thank you very much before the course. I, of course, have no corrections, sir, but I use your dot method all the time. Take it one step further, though. I demonstrate. It takes 45 seconds for me to do this. I do it every single time. Piece size amount on the fingertips, split it up between your fingers, put a little bubble here, little puddle here, little puddle here. Go back with just these two fingers and rub it in all over your face. For example, if I took this cream, demonstrated on me and pretended this was my face and put these six bumps on and rubbed it in, you can see that it covers the back of both my hands, which is roughly the size of your face. Done. And I have a cream in the office that's either super, super greasy so my hand gets really shiny, or maybe a chalky white sunscreen. So you can really see it on the hands because everybody is sitting there saying a pea size amount isn't enough for my face. And we know it is. But I think this demonstrates it quite nicely, and I think it gets through to their heads a little bit better with the physical demonstration, which doesn't take much time, I have to say, I'm still looking for that person that first came up with pea size, and I want to take him out back behind the high school in Brooklyn, and I really want to beat the crap out of him because I really don't know what this pea size means. Do you know what this pea size means? Right? Yes. Do you? So explain it. Teach me. You mean, what does it look like? What kind of pea are we talking about? Okay, well, I actually. Now this is going to sound really stupid, too. In my freezer, I have a bag of frozen peas. Free use on wounds and such, right? But every morning I take a little handful of peas out, I put them in my desk, and when I say, I want you to use a pea size amount, I open the desk and I say, this is a pea. And I show it to them. They laugh. Teenage boys laugh. It's awesome. So that's what a pea is. That's great. So we want to thank you very much. We actually gave you one or two extra minutes, and I'm trying to think if there's anything else that what's your thought on the once a day versus twice a day closcodarone when it's used in combination, I think it's very important until we know more that we utilize it twice a day, lest we end up thinking that it doesn't work. That happened to me with dapzone 5% cream, which was supposed to be bid. And I said, I'll use it once a day. Didn't work, and I ended up not using the drug for many years, erroneously because I hadn't used it right.

Acne

WEDNESDAY, July 31, 2024 -- Patients with acne vulgaris have lower levels of serum zinc, selenium, and vitamin D compared with those without acne vulgaris, according to a study published online July 25 in the Journal of Cosmetic Dermatology.Armaghan Kazeminejad, M.D., from the Mazandaran University of Medical Sciences in Sari, Iran, and colleagues conducted a case-control study involving 100 adults with acne vulgaris attending a dermatology clinic in 2020 and 100 patients without acne vulgaris (controls) attending the same clinic. Sociodemographic characteristics were recorded and anthropometric indices were measured. For all participants, serum zinc, selenium, and vitamin D levels were assessed in peripheral blood samples.The researchers found that age, sex, weight, height, body mass index, occupation, alcohol consumption, and tobacco smoking were comparable for acne patients and controls. Compared with controls, acne patients had significantly lower levels of serum zinc, selenium, and vitamin D. The frequency of abnormal zinc and vitamin D levels was significantly higher in acne patients, while no difference was seen in abnormal serum selenium levels. Compared with other disease severity grades, patients with grade 4 acne had lower levels of serum zinc, selenium, and vitamin D levels. "Future research should take into account various factors that may influence the serum levels of nutrients or the occurrence of acne vulgaris, including nutrition status, sunlight exposure, and hormonal disorders," the authors write.

Levels also lower in patients with grade 4 acne compared with other disease severity grades

Serum Zinc, Selenium, Vitamin D Levels Lower in Acne Vulgaris Patients

TUESDAY, July 16, 2024 (HealthDay News) -- For patients experiencing migraine, direct calcitonin gene-related peptide (CGRP) inhibition with monoclonal antibodies (mAbs) is associated with reduced rates of acne and rosacea compared with no inhibition (topiramate) or indirect inhibition (triptans), according to a research letter published online July 10 in JAMA Dermatology.Christopher J. Thang, from the University of Texas Medical Branch in Galveston, and colleagues examined whether CGRP inhibition is associated with reduced rates of developing acne or rosacea in a cohort study. Patients experiencing migraines were stratified into four treatment cohorts: CGRP inhibitor (CGRPi) mAbs, CGRPi nonpeptide small molecules (gepants), triptans, and topiramate. Cohort comparisons were independently 1:1 propensity score-matched for age at index, demographics, and potential confounding medications and comorbidities using a greedy nearest-neighbor matching algorithm.The researchers found that among patients treated with CGRPi mAbs matched with those treated with triptans, CGRPi mAb exposure was associated with a significantly reduced rate of acne and rosacea. CGRPi mAb exposure was also associated with significantly reduced rates of acne and rosacea compared with topiramate. CGRPi mAb exposure was associated with a reduced rate of acne compared with gepants, although the difference was not statistically significant, and with a significantly reduced rate of rosacea. "While further studies, including randomized clinical trials, are needed to examine the effects of CGRP inhibition on acne and rosacea development, the present study highlights CGRP inhibition as a novel therapeutic avenue for both conditions," the authors write.One author disclosed receipt of personal fees from Dexcel Pharma.<a target="_blank" rel="noopener noreferrer" href="https://jamanetwork.com/journals/jamadermatology/article-abstract/2820913">Abstract/Full Text (subscription or payment may be required)</a>

Significantly reduced rate of acne and rosacea seen in patients treated with CGRPi mAbs versus triptans, topiramate

Direct CGRP Inhibition Cuts Acne, Rosacea in Patients With Migraine

WEDNESDAY, July 10, 2024 (HealthDay News) -- Adherence to a Mediterranean diet incorporating eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) reduces skin lesions and improves quality of life in patients with acne, according to a study published online July 10 in the Journal of Cosmetic Dermatology.Anne Guertler, M.D., from Ludwig Maximilian University in Munich, and colleagues examined the clinical effects associated with increasing EPA/DHA levels in patients with acne. Sixty participants without prescription medication (23 with acne comedonica [AC] and 37 with acne papulopustulosa [AP]) adhered to a Mediterranean diet, incorporating omega-3 fatty acid supplementation. Blood EPA/DHA levels were tracked at four visits (V1 to V4) using the HS-omega 3 index (EPA/DHA [percent] of total identified fatty acids in erythrocytes: target, 8 to 11 percent; deficit, &lt;8 percent; severe deficit, &lt;4 percent).The researchers found that 98.3 percent of patients had an EPA/DHA deficit at baseline, with the mean HS-omega 3 index increasing from 4.9 to 8.3 percent at V1 to V4. At V4, significantly higher indices were seen for AC than AP. In both inflammatory and noninflammatory lesions, there were objective improvements observed. Four patients self-reported worsened appearance, but overall quality of life improved, especially in AP. Compared with beneficial foods, dietary triggers were more clearly defined. Cow's milk and dairy product intake was reduced. A high rate of compliance was observed, and there were no reports of adverse events. "Lifestyle interventions, including dietary recommendations, should not be considered in opposition to prescription medications, but rather as a valuable adjunct to any modern acne treatment plan," Guertler said in a statement.Omegametrix® GmbH performed the analysis of the HS-omega-3 Index® free of charge. Queisser Pharma GmbH &amp; Co. KG offered omega-3 supplements free of charge.<a target="_blank" rel="noopener noreferrer" href="https://onlinelibrary.wiley.com/doi/10.1111/jocd.16434">Abstract/Full Text (subscription or payment may be required)</a>

Reduction seen in inflammatory and noninflammatory lesions, improvement seen in overall quality of life with EPA/DHA

Adherence to Mediterranean Diet, Omega-3 Fatty Acids Beneficial in Acne

WEDNESDAY, May 8, 2024 (HealthDay News) -- Trifarotene plus skin care is beneficial for patients with moderate acne vulgaris (AV) and acne-induced hyperpigmentation (AIH), according to a study published online April 29 in the International Journal of Dermatology.Andrew Alexis, M.D., M.P.H., from Weill Cornell Medical College in New York City, and colleagues conducted a phase IV, double-blind, parallel-group study of patients aged 13 to 35 years with moderate AV and AIH who were treated with trifarotene or vehicle (63 and 60 patients, respectively), plus a skin care regimen of moisturizer, cleanser, and sunscreen for 24 weeks.The researchers found that compared with vehicle, trifarotene 50 µg/g cream significantly improved the AIH overall disease severity score from baseline (−1.6 versus −1.1) at week 12, but at week 24, scores were comparable. At week 24, there was a better reduction in the post-AV hyperpigmentation index score with trifarotene (−18.9 versus −11.3 percent). At weeks 12 and 24, lesion count reductions were higher with trifarotene than vehicle, as were Investigator Global Assessment success rates. The skin care regimen contributed to less irritation, making adherence to treatment easier. Across all skin types, photography showed improvements in pigmentation and erythema. The vehicle group experienced more adverse events than the trifarotene group (30.2 versus 16.7 percent)."This study shows that trifarotene cream has a favorable efficacy and safety profile for treating AV and AIH in subjects with all skin types, which likely will translate to overall improved outcomes for AV patients," the authors write.Several authors disclosed ties to pharmaceutical companies, including Galderma, which manufactures trifarotene and funded the study.<a target="_blank" rel="noopener noreferrer" href="https://onlinelibrary.wiley.com/doi/10.1111/ijd.17189">Abstract/Full Text</a>

Improvement seen in acne-induced hyperpigmentation overall disease severity score at week 12, but not week 24

Trifarotene Plus Skin Care Beneficial for Acne Vulgaris

WEDNESDAY, April 10, 2024 (HealthDay News) -- Multiple salient factors affect long-term antibiotic prescribing practices for acne, according to a study published online April 3 in JAMA Dermatology.Ronnie A. Festok, from the Emory University School of Medicine in Atlanta, and colleagues conducted a qualitative study assessing data collected from stakeholders (dermatologists, infectious disease physicians, dermatology resident physicians, and nonphysician clinicians) via an online survey and semistructured video interviews to identify salient barriers and facilitators to long-term antibiotic prescriptions for acne treatment. Thirty participants were included in the analysis.The researchers found that knowledge of antibiotic guideline recommendations was high among participants in the study, and antibiotic stewardship was considered to be a professional responsibility. Perceived lack of evidence to justify change in dermatologic practice, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, iPLEDGE-related barriers, and the absence of an effective system to measure progress on antibiotic stewardship were the five salient themes that affected long-term antibiotic prescriptions. "The findings of this qualitative study indicate that while clinicians consider antibiotic stewardship a professional responsibility and they are aware of antibiotic stewardship guidelines in acne treatment, future interventions must address the need for robust evidence-based knowledge on the clinical implications of long-term antibiotic prescriptions for acne and clearly disseminate this information to clinicians and patients," the authors write.Several authors disclosed ties to the pharmaceutical industry.<a target="_blank" rel="noopener noreferrer" href="https://jamanetwork.com/journals/jamadermatology/article-abstract/2817136">Abstract/Full Text (subscription or payment may be required)</a>

Five themes affect long-term prescribing, including perceived lack of evidence to justify change, discomfort discussing contraception

Study Identifies Factors That Affect Antibiotic Prescribing for Acne

FRIDAY, March 15, 2024 (HealthDay News) -- Short-term exposure to wildfire-related air pollution is associated with an increase in clinic visits for acne vulgaris among adults, according to a study presented at the annual meeting of the American Academy of Dermatology, held from March 8 to 12 in San Diego.Alex Ha, from the University of California, San Francisco, and colleagues conducted a retrospective cohort study to determine environmental triggers and factors for acne vulgaris. Dermatology clinic visits for acne vulgaris at an academic tertiary care center in San Francisco before, during, and after the 2018 California Camp Fire were compared to patient visits during the same period in 2015 and 2016 when there were no wildfires. A total of 2,054 visits for 1,549 patients were analyzed. Three metrics of wildfire-associated air pollution were assessed: PM2.5 concentration, fire status, and satellite-based smoke plume density scores.The researchers found that an increase in weekly PM2.5 concentration of 10 µg/m3 was associated with a 2.3 percent increase in adult acne clinic visits at lag week 0 (95 percent confidence interval, 0.17 to 4.6 percent). When adjusting for temperature, humidity, age, and clinic volume, the rate of adult acne clinic visits during the California Camp Fire was 1.2-fold higher (95 percent confidence interval, 1.02 to 1.42) than the rate of visits during nonfire weeks at lag 0. For smoke plume density, the adjusted rate ratio was 1.14 (95 percent confidence interval, 1.01 to 1.28) at lag 0. No significant associations were observed for pediatric patients across the exposure metrics."With the worldwide increasing frequency and intensity of wildfires, these findings can inform patient counseling and management," the authors write.<a target="_blank" rel="noopener noreferrer" href="https://eposters.aad.org/abstracts/52052">Abstract</a><a target="_blank" rel="noopener noreferrer" href="https://www.aad.org/member/meetings-education/am24">More Information</a>

Rate of adult acne clinic visits 1.2-fold higher during 2018 California Camp Fire compared with nonfire weeks in 2015 and 2016

AAD: Adult Acne Clinic Visits Increase With Exposure to Wildfire-Related Air Pollution

THURSDAY, March 7, 2024 (HealthDay News) -- Some acne treatments may banish blemishes but carry hidden dangers: A new report reveals high levels of the carcinogen benzene can form in products that contain the zit-fighting ingredient benzoyl peroxide.According to the new <a target="_blank" rel="noopener noreferrer" href="https://www.valisure.com/valisure-newsroom/valisure-detects-benzene-in-benzoyl-peroxide">report</a> from the independent laboratory Valisure, benzene “can form at unacceptably high levels” in both prescription and over-the-counter benzoyl peroxide products.Some tests showed that certain products had more than 800 times the concentration limit for benzene that the U.S. Food and Drug Administration allows.What triggers the formation of benzene in these treatments?Tests showed that when stored or handled at high temperatures -- such as when left in a hot car for days -- they can generate high levels of benzene.In one test, an acne product was stored at 158 degrees Fahrenheit for nearly 17 hours. The lab not only detected benzene inside the product, but benzene gas found in the air around it was more than 1,200 times the threshold that the U.S. Environmental Protection Agency allows for long-term exposure.Other types of acne treatment products that were tested, such as those containing salicylic acid or adapalene, did not have that issue, according to the lab.Valisure also sent a <a target="_blank" rel="noopener noreferrer" href="https://assets-global.website-files.com/6215052733f8bb8fea016220/65e8560962ed23f744902a7b_Valisure%20Citizen%20Petition%20on%20Benzene%20in%20Benzoyl%20Peroxide%20Drug%20Products.pdf">citizen petition</a> to the FDA in which it described an initial analysis of 175 acne treatment products, finding that 99 of them contained benzoyl peroxide, with benzene detected in 94 of those products.The petition urges the FDA to “request recalls and a suspension of sales for products containing the active pharmaceutical ingredient benzoyl peroxide.”An FDA spokesperson said in a statement Wednesday that it has received the citizen petition, CNN reported.“The agency acts on information provided from a variety of sources, such as that provided by Valisure, but such data must be verified as accurate and reproducible before it can be utilized to make regulatory decisions such as recommending product sale suspensions and recalls,” the statement said.Benzene is one of the 20 most widely used chemicals in the United States, and people are exposed “mainly by breathing in air containing benzene,” according to the <a target="_blank" rel="noopener noreferrer" href="https://www.cancer.org/cancer/risk-prevention/chemicals/benzene.html">American Cancer Society.</a>Benzene is also used in a variety of products including lubricants, dyes, detergents and drugs.This isn’t the first time Valisure has sent a citizen petition letter to the FDA regarding concerns about benzene. In 2022, the lab found <a target="_blank" rel="noopener noreferrer" href="https://www.valisure.com/valisure-newsroom/valisure-detects-benzene-in-dry-shampoo">benzene in dry shampoo products</a> and urged the FDA to request recalls, and the lab detected <a target="_blank" rel="noopener noreferrer" href="https://www.valisure.com/valisure-newsroom/valisure-detects-benzene-in-sunscreen">benzene in sunscreen</a> in 2021.But this latest report differs in significant ways, Valisure officials noted.“This discovery of benzoyl peroxide’s fundamental instability and formation of benzene is substantially different than Valisure’s previous findings of benzene in sunscreens, hand sanitizers and other consumer products,” Valisure co-founder and President <a target="_blank" rel="noopener noreferrer" href="https://www.valisure.com/team/david-light">David Light</a> said in a <a target="_blank" rel="noopener noreferrer" href="https://www.valisure.com/valisure-newsroom/valisure-detects-benzene-in-benzoyl-peroxide">statement </a>Wednesday.“The benzene we found in sunscreens and other consumer products were impurities that came from contaminated ingredients; however, the benzene in benzoyl peroxide products is coming from the benzoyl peroxide itself, sometimes at hundreds of times the conditional FDA limit,” he said. “This means the problem broadly affects benzoyl peroxide products, both prescription and over-the-counter, and necessitates urgent action.”More informationVisit the National Cancer Institute for more on <a target="_blank" rel="noopener noreferrer" href="https://www.cancer.gov/about-cancer/causes-prevention/risk/substances/benzene">benzene</a>.SOURCE: Valisure, news release, March 6, 2024; CNN

A new report finds high levels of the carcinogen benzene in acne treatments that contain benzoyl peroxide.

Carcinogen Benzene Can Form in Some Acne Treatments: Report

MONDAY, Feb. 5, 2024 (HealthDay News) -- In guidelines issued by the American Academy of Dermatology and published online Jan. 30 in the Journal of the American Academy of Dermatology, updated recommendations are presented for the management of acne vulgaris.Rachel V. Reynolds, M.D., from Beth Israel Deaconess Medical Center in Boston, and colleagues conducted a systematic review to provide evidence-based recommendations for the management of acne to update the 2016 American Academy of Dermatology guidelines.The authors presented 18 evidence-based recommendations and five good practice statements. Benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline were strongly recommended. For acne that is severe, causing psychological burden or scarring, or failing standard oral or topical therapy, oral isotretinoin is strongly recommended. Topical clascoterone, salicylic acid, and azelaic acid, as well as oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone were conditionally recommended. Good practice statements included combining topical therapies with varied mechanisms of action; limiting use of systemic antibiotics; combining systemic antibiotics with topical therapies; and adding intralesional corticosteroid injections for larger acne lesions.&nbsp;"Board-certified dermatologists are on the forefront of new and exciting advances in the treatment of acne," coauthor John S. Barbieri, M.D., from Brigham and Women's Hospital in Boston, said in a statement. "We are able to offer our patients with acne more options than ever before as we work to address their concerns and determine the most effective treatment plan possible. Just as important, dermatologists must have access to all available therapeutic options."Several authors disclosed ties to the biopharmaceutical industry.<a target="_blank" rel="noopener noreferrer" href="https://www.jaad.org/article/S0190-9622(23)03389-3/fulltext">Abstract/Full Text</a>

Strong recommendations made for benzoyl peroxide, topical retinoids, topical antibiotics, oral doxycycline

AAD Updates Guidelines for Management of Acne Vulgaris

WEDNESDAY, Jan. 3, 2024 (HealthDay News) -- Transgender and gender-diverse individuals report experiencing acne-related stigma, according to a study published online Jan. 3 in JAMA Dermatology.Sarah Gold, from the Emory University School of Medicine in Atlanta, and colleagues conducted a mixed-methods analysis at a multidisciplinary gender center using semistructured interviews and surveys to examine the lived experiences of acne and acne treatment in transgender and gender-diverse participants. Thirty-two individuals were included in the study: 17 transgender men, 11 transgender women, and four nonbinary participants.The researchers found that 10, 11, and 11 participants self-rated their skin as currently clear or almost clear, with mild acne, or with moderate-to-severe acne (31, 34, and 34 percent, respectively). Experiences of rejection and bullying related to acne were described, and participants admitted avoiding social interactions in which they expected acne-related discrimination, which led to depression and anxiety. Body appearance dissatisfaction was worsened with acne. Transgender women reported that acne interfered with feminine gender expression, while transgender men frequently normalized acne development, perceiving it as a sign of testosterone action. Most of the participants tried over-the-counter treatments for acne; acne treatment advice was commonly sought from physicians, peers, online forums, and social media. Cost, lack of multidisciplinary care, mistrust toward the health care system, and lack of transgender-specific acne care education were barriers to acne treatment."Clinicians should proactively inquire, monitor, and treat acne to take the onus off the patient and facilitate acne care and should develop further research to guide evidence-based hormonal acne treatment," the authors write.One author disclosed ties to Epidemiologic Research &amp; Methods LLC.<a target="_blank" rel="noopener noreferrer" href="https://jamanetwork.com/journals/jamadermatology/article-abstract/2813277">Abstract/Full Text (subscription or payment may be required)</a>

Barriers to acne treatment include cost, lack of multidisciplinary care, mistrust toward health care system

Transgender, Gender-Diverse Individuals Report Acne-Related Stigma

WEDNESDAY, Jan. 3, 2024 -- For patients with acne vulgaris, maintenance therapy with adapalene/benzoyl peroxide gel and benzoyl peroxide gel is effective for preventing worsening of scars, according to a study published in the December issue of the Journal of Dermatology.Hideaki Tanizaki, M.D., Ph.D., from Kansai Medical University Hospital in Osaka, Japan, and colleagues examined the efficacy of maintenance therapy using adapalene 0.1 percent/benzoyl peroxide 2.5 percent gel and benzoyl peroxide 2.5 percent gel and their effects on atrophic scarring in a randomized trial involving 126 patients with acne vulgaris. Participants were randomly assigned to receive adapalene/benzoyl peroxide, benzoyl peroxide, and control (without maintenance treatment drugs; 40, 44, and 42 patients, respectively); 111 completed the 24-week trial.The researchers found that the treatment success rate (percentage of patients in whom the number of inflammatory lesions was maintained at ≤10) was 89.2, 87.5, and 47.4 percent in the adapalene/benzoyl peroxide, benzoyl peroxide, and control groups, respectively. The success rates were significantly higher in the adapalene/benzoyl peroxide and benzoyl peroxide groups versus the control group. There was a significant improvement observed in the rate of change in the number of atrophic scars from baseline in the adapalene/benzoyl peroxide and benzoyl peroxide groups at week 24. Significant worsening was seen in the control group in the three-dimensional image analysis parameters, while no change was seen in the adapalene/benzoyl peroxide and benzoyl peroxide groups at week 24."These findings may serve as new therapeutic evidence in maintenance therapy using adapalene/benzoyl peroxide gel and benzoyl peroxide gel, and may be useful in daily medical practice," the authors write.Several authors disclosed ties to Maruho, which funded the study.

Maintenance therapy with adapalene/benzoyl peroxide gel and benzoyl peroxide gel effective in acne vulgaris

Does Adapalene/Benzoyl Peroxide Gel Prevent Scar Worsening in Acne?

THURSDAY, Dec. 7, 2023 (HealthDay News) -- Stigmatizing attitudes toward individuals with acne are observed across a range of social and professional scenarios, according to a study published online Dec. 6 in JAMA Dermatology.Ali Shields, from Drexel University College of Medicine in Philadelphia, and colleagues conducted a cross-sectional internet survey study to explore the degree of stigma toward individuals with acne. Four stock portraits of adults that varied in sex (male/female) and skin tone (light/dark) were digitally enhanced to have acne (mild/severe); survey participants answered questions regarding stigmatizing attitudes with respect to the image with which they were randomly presented.&nbsp;A total of 1,357 respondents completed the survey. The researchers found that participants reported less comfort being friends with, hiring, having physical contact with, dating, and posting a photograph together on social media with those with severe acne compared with those with no acne. Participants were more likely to rate those with severe acne as having poor hygiene and being unattractive, unintelligent, unlikable, immature, and untrustworthy compared with those with no acne. For individuals with dark skin, there was evidence that the effect size of the association of acne with desire to social distance was greater."These findings highlight the need to identify approaches to reduce stigmatizing attitudes in the community and for adequate access to care, which might prevent negative downstream effects related to these stigmatizing attitudes," the authors write.&nbsp;Two authors disclosed ties to the pharmaceutical industry.

Participants reported less comfort being friends with, hiring, having physical contact, dating someone with severe acne

Stigmatizing Attitudes Identified Toward Individuals With Acne

MONDAY, Dec. 4, 2023 (HealthDay News) -- Isotretinoin users do not have an increased risk for suicide or psychiatric disorders and may have a lower risk for suicide attempts, according to a review published online Nov. 29 in JAMA Dermatology.Nicole Kye Wen Tan, from the National University of Singapore School of Medicine, and colleagues clarified the absolute and relative risks and risk factors associated with suicide and psychiatric disorders among isotretinoin users in a systematic review of randomized trials and observational studies. Twenty-five studies, with 1,625,891 participants, were included in the review; the meta-analysis included 24 studies.&nbsp;The researchers found that the one-year pooled absolute risk of completed suicide, suicide attempt, suicide ideation, and self-harm were each less than 0.5 percent in two to eight studies, while that of depression was 3.83 percent in 11 studies. The likelihood of attempting suicide at two, three, and four years following treatment was lower among isotretinoin users versus nonusers (risk ratios [95 percent confidence intervals], 0.92 [0.84 to 1.00], 0.86 [0.77 to 0.95], and 0.85 [0.72 to 1.00], respectively). No association was seen for isotretinoin with the risk for all psychiatric disorders. Studies with participants of older age showed a lower one-year absolute risk for depression, while a higher one-year absolute risk for completed suicide was seen in studies with a higher percentage of male participants."While our findings are reassuring, clinicians should continue to practice holistic psychodermatologic care and monitor patients for signs of mental distress during isotretinoin treatment," the authors write.&nbsp;One author disclosed financial ties to pharmaceutical companies.

Likelihood of attempting suicide lower at two, three, and four years following treatment in isotretinoin users

No Increased Suicide Risk Observed for Isotretinoin Users

MONDAY, Nov. 20, 2023 -- Modified 5-aminolevulinic acid photodynamic therapy (M-PDT) is effective for moderate-to-severe acne vulgaris and results in quicker responses than low-dose isotretinoin (ISO) therapy, according to a study published in the December issue of the Journal of the American Academy of Dermatology.Linglin Zhang, M.D., from the Tongji University School of Medicine in Shanghai, and colleagues conducted a multicenter randomized clinical trial involving participants with moderate-to-severe acne vulgaris. A total of 152 participants were randomly assigned to M-PDT (up to five weekly sessions following manual comedone extraction) or ISO (0.5 mg/kg/day for six months) and were followed for up to six months after treatment.The researchers found that the overall effective rates were significantly higher in the M-PDT group versus the ISO group at one month (67.74 versus 10.26 percent), but after one month, rates were higher in the ISO group (75.81 versus 97.44 percent). The time to achieve 50 percent lesion improvement was significantly lower in the M-PDT group than the ISO group (one versus eight weeks). Systemic side effects such as hepatotoxicity were experienced by 70.67 percent of patients in the ISO group, while side effects in the M-PDT group were skin-limited."Compared with low-dose ISO, M-PDT showed a rapid onset of effect with tolerable topical adverse effects and comparable outcomes at six months after therapy," the authors write.

More rapid onset of improvement, comparable efficacy, and good tolerability seen for M-PDT versus low-dose isotretinoin

Can Modified Photodynamic Therapy Offer Rapid Improvement of Acne?

FRIDAY, Oct. 20, 2023 (HealthDay News) -- Acne patterns significantly influence how individuals are perceived in social settings, according to a study presented at the annual meeting of the European Academy of Dermatology and Venereology, held from Oct. 11 to 14 in Berlin.Marek Jankowski, M.D., Ph.D., and Agnieszka Goroncy, Ph.D., from Nicolaus Copernicus University in Toruń, Poland, investigated the effect of anatomic variants of acne on natural gaze patterns and the resulting impact on social perception of acne patients. The analysis included tracked eye movements from 245 adults viewing neutral and emotional faces with clinically relevant anatomical variants of acne, as well as survey responses from 205 participants.The researchers found that faces with acne were perceived as significantly less attractive (difference, 1.1593), trustworthy (difference, 0.3549), confident (difference, 0.9573), successful (difference, 0.6220), and dominant (difference, 0.9086). Mid-facial acne showed the smallest perceived differences from healthy faces. T-zone and generalized acne showed the least significant difference in respondents' gaze behavior pattern. There was no significant difference noted in respondents' grading of acne visual disturbance and ratings for attractiveness, successfulness, and trustworthiness. Ratings for most visually disturbing and lowest scores for attractiveness were seen for adult female acne. Compared with clear-skin faces, happy faces with adult female acne were rated as less happy."With over a decade of experience in the field, I've consistently seen that adult female acne leads to more social challenges compared to adolescent acne. The findings therefore reaffirm this," Jankowski said in a statement. "However, what was truly surprising was images depicting generalized acne, covering a larger area with more lesions, received more positive ratings than images featuring adult female acne occurring in the 'U-zone.'"

Faces with acne rated as less attractive, trustworthy, confident, successful, dominant, and happy

Social Stigma Associated With Adult Facial Acne

WEDNESDAY, Oct. 25, 2023 -- Nutraceutical supplements may be useful for the treatment of acne, with potential benefits seen for vitamins B5 and D, botanical extracts (green tea), probiotics, and ω-3 fatty acids, according to a systematic review published online Oct. 25 in JAMA Dermatology.Ali Shields, from Brigham and Women's Hospital in Boston, and colleagues examined the evidence for oral nutraceuticals in the treatment of acne in a systematic review. Randomized clinical trials evaluating oral nutraceutical interventions in individuals with acne were identified; 42 studies, with 3,346 participants, were included.The researchers found that for the treatment of acne, the potential benefit of vitamins B5 and D, botanical extracts (green tea), probiotics, and ω-3 fatty acids was demonstrated in studies of fair or good quality. The most frequent associations for these interventions were with reduced lesion counts or improved investigator global assessment scores. For most of the therapies assessed, adverse effects were rare, but gastrointestinal tract adverse events were reported for zinc therapy."Available evidence is limited, and larger trials are needed to better understand the efficacy of these treatments," the authors write. "Physicians should be prepared to discuss the evidence for nutraceuticals with patients."Several authors disclosed ties to the biopharmaceutical industry.

Studies demonstrate potential benefit of vitamins B5 and D, botanical extracts (green tea), probiotics, and ω-3 fatty acids

Do Nutraceutical Supplements Have Beneficial Role in Acne Treatment?

<div class="raw-html-embed"><mux-player playback-id="UmG3YwoTCNtNMf01bQC601028vkv01z00USAfzq5wCPFWylA" env-key="ENV_KEY" metadata-video-title="IDP-126 Launch Alert" controls=""></mux-player></div>Dr James Q Del Rosso announces the launch of IDP-126 gel, discussing its unique mechanism of action, efficacy, tolerability profile, and dosing&nbsp;Bausch Health Companies Inc. and Ortho Dermatologics have announced FDA approval for IDP-126 (clindamycin 1.2%/adapalene 0.15%/benzoyl peroxide 3.1%) topical gel, indicated for the treatment of acne vulgaris in patients 12 years and older. This approval marks the only FDA-approved fixed-dose, triple-combination topical treatment for acne.&nbsp;IDP-126 topical gel was studied in two Phase 3 multicenter, randomized, placebo-controlled clinical trials, both meeting all coprimary efficacy endpoints. In Study 1, participants treated with IDP-126 saw a mean percent reduction for inflammatory lesions of 75.7% vs 59.6% vs those treated with vehicle and a mean percent reduction for noninflammatory lesions of 72.7% vs 47.6% with vehicle.&nbsp;In Study 2, participants treated with IDP-126 saw a mean percent reduction of 80.1% for inflammatory lesions vs 56.2% for those treated with vehicle and a mean percent reduction of 73.3% for noninflammatory lesions vs 49.0 with vehicle.&nbsp;The most common adverse reactions (&gt;1%) were application site reactions, pain, erythema, dryness, irritation, exfoliation, and dermatitis.&nbsp;IDP-126 topical gel works by combining 3 mechanisms of action via an antibiotic, retinoid, and antibacterial. It is expected to be available to patients in Q1 2024

The once-daily triple-combination topical acne treatment is approved for use in patients 12 years and older

LAUNCH ALERT: FDA Approves IDP-126 Gel for Acne Vulgaris

TUESDAY, Aug. 22, 2023 &nbsp;-- For patients aged 12 years and older with moderate-to-severe acne, clascoterone cream 1 percent has favorable long-term safety and efficacy, according to a study published in the August issue of the Journal of Drugs in Dermatology.Lawrence F. Eichenfield, M.D., from the University of California San Diego School of Medicine in La Jolla, and colleagues examined the safety and efficacy of clascoterone in patients aged 12 years and older with moderate-to-severe acne from an open-label, long-term extension study. Enrolled patients applied clascoterone cream 1 percent twice daily to the entire face and/or truncal area for up to nine months. Of 600 patients (311 originally randomly assigned to clascoterone; 289 to vehicle), 343 (177 clascoterone; 166 vehicle) completed the extension study.The researchers found that 187 treatment-emergent adverse events occurred in 18.1 percent of all clascoterone-treated patients, including 18.0 and 18.1 percent originally randomly assigned to clascoterone and vehicle, respectively. The most common local skin reactions were erythema (face, 8.0 and 7.7 percent; trunk, 6.1 and 7.3 percent) and scaling/dryness (face, 10.0 and 7.3 percent; trunk, 3.5 and 4.5 percent) for patients originally randomly assigned to clascoterone and vehicle, respectively. At study end, the percentage of per-protocol patients with facial and truncal Investigator's Global Assessment Score of 0 or 1 increased to 48.9 and 52.4 percent, respectively."The findings from this and previous studies support clascoterone as an option for long-term treatment of acne vulgaris," the authors write.Several authors disclosed ties to the pharmaceutical industry, including Cassiopea S.p.A., which funded the study.

Long-term safety and efficacy favorable during treatment in patients aged 12 years and older with moderate-to-severe acne

 Clascoterone Cream Safe, Efficacious for Moderate-to-Severe Acne

WEDNESDAY, Aug. 16, 2023 -- Trends in prescribing for acne include an increase in spironolactone prescribing, which was prescribed at about the same frequency as oral antibiotics in 2020, according to a research letter published online Aug. 16 in JAMA Dermatology.John S. Barbieri, M.D., from Brigham and Women's Hospital in Boston, conducted a repeated cross-sectional study to examine recent trends in prescriptions of oral tetracycline antibiotics (doxycycline, minocycline), other commonly prescribed oral antibiotics (trimethoprim-sulfamethoxazole, amoxicillin, cephalexin), spironolactone, and isotretinoin for individuals with acne.Barbieri found that during 2017 through 2020, there was an approximately threefold to fourfold increase in prescribing of spironolactone among dermatologists, nurse practitioners (NPs) or physician assistants (PAs), and nondermatology physicians. In 2017, oral antibiotics were prescribed about twofold to threefold more often than spironolactone, while in 2020, they were prescribed at about the same frequency; nondermatology physicians and NPs or PAs prescribed oral antibiotics slightly more frequently in 2020. During the study period, isotretinoin prescribing decreased slightly across both male and female patients. While overall prescribing increased across all antibiotic types, the rate of increase was higher for doxycycline versus minocycline, especially among dermatology physicians and NPs or PAs."Oral antibiotics continued to be frequently prescribed by both dermatologists and nondermatologists, which emphasizes the need for continued efforts to identify nonantibiotic treatment options for acne, particularly as many patients are interested in these options," Barbieri writes.Barbieri disclosed receiving consulting fees from Dexcel Pharma.

Oral antibiotics and spironolactone prescribed at about the same frequency in 2020 compared with more antibiotics in 2017

Has There Been a Change in Spironolactone Prescribing for Acne?

THURSDAY, July 27, 2023 (HealthDay News) -- The most effective treatment for acne is oral isotretinoin, according to a review published in the July/August issue of the Annals of Family Medicine.Chung-Yen Huang, M.D., from the National Taiwan University Hospital in Taipei, and colleagues conducted a systematic literature review to identify randomized controlled trials comparing the efficacy of pharmacological therapies for acne vulgaris in patients of any age and sex and with a treatment duration of two or more weeks.Based on 221 included trials (37 interventions and 65,601 patients), the researchers found the most effective treatment was oral isotretinoin (mean difference, 48.41), followed by triple therapy containing a topical antibiotic, a topical retinoid, and benzoyl peroxide (mean difference, 38.15) and by triple therapy containing an oral antibiotic, a topical retinoid, and benzoyl peroxide (mean difference, 34.83). Oral or topical antibiotics or topical retinoids, as monotherapies, have comparable efficacy for inflammatory lesions. However, oral or topical antibiotics have less effect on noninflammatory lesions."Acne is an extremely common skin disease with an estimated global prevalence of 9.4 percent and an annual cost of 3 billion dollars in the United States. Measured by disability-adjusted life years, the global burden from acne is ranked the second highest among all cutaneous diseases worldwide," the authors write. "Our study provides the most comprehensive evidence to date about common pharmacological interventions for acne vulgaris with analyses of both percentage and absolute reduction in lesion counts and detailed comparisons for each intervention."

Meta-analysis reveals triple therapies containing topical retinoid, benzoyl peroxide, and antibiotic are next best

Review: Oral Isotretinoin Is Best Treatment for Acne

<p style="-webkit-text-stroke-width:0px;background-color:rgb(255, 255, 255);color:rgb(90, 88, 88);font-family:&quot;Source Sans Pro&quot;, sans-serif;font-size:18px;font-style:normal;font-variant-caps:normal;font-variant-ligatures:normal;font-weight:100;letter-spacing:normal;margin-left:auto;margin-right:auto;margin-top:0px;max-width:980px;orphans:2;text-align:start;text-decoration-color:initial;text-decoration-style:initial;text-decoration-thickness:initial;text-indent:0px;text-transform:none;white-space:normal;widows:2;word-spacing:0px;">WEDNESDAY, July 19, 2023 -- For patients with acne, especially those with moderate-to-severe acne, lymecycline is superior to doxycycline, according to a study published online in the July issue of SKIN.<p style="-webkit-text-stroke-width:0px;background-color:rgb(255, 255, 255);color:rgb(90, 88, 88);font-family:&quot;Source Sans Pro&quot;, sans-serif;font-size:18px;font-style:normal;font-variant-caps:normal;font-variant-ligatures:normal;font-weight:100;letter-spacing:normal;margin-left:auto;margin-right:auto;margin-top:0px;max-width:980px;orphans:2;text-align:start;text-decoration-color:initial;text-decoration-style:initial;text-decoration-thickness:initial;text-indent:0px;text-transform:none;white-space:normal;widows:2;word-spacing:0px;">Rekha Gurunatham Ponnurangam, M.D., from Tagore Medical College Hospital in Rathinamangalam, India, and colleagues compared the efficacy of topical 2.5 percent benzoyl peroxide gel with oral doxycycline versus topical 2.5 percent benzoyl peroxide gel with oral lymecycline for treatment of acne vulgaris in a study involving 100 patients. Participants were divided into two groups: benzoyl peroxide gel applied once daily at night and oral doxycycline 100 mg twice a day (group A; 50 patients) and benzoyl peroxide gel applied once daily at night and oral lymecycline 408 mg once a day (group B; 50 patients) for 12 weeks. The Indian Association of Acne was used for grading at baseline and every two weeks for 12 weeks. After completion of the study, patients were followed for another 12 weeks.<p style="-webkit-text-stroke-width:0px;background-color:rgb(255, 255, 255);color:rgb(90, 88, 88);font-family:&quot;Source Sans Pro&quot;, sans-serif;font-size:18px;font-style:normal;font-variant-caps:normal;font-variant-ligatures:normal;font-weight:100;letter-spacing:normal;margin-left:auto;margin-right:auto;margin-top:0px;max-width:980px;orphans:2;text-align:start;text-decoration-color:initial;text-decoration-style:initial;text-decoration-thickness:initial;text-indent:0px;text-transform:none;white-space:normal;widows:2;word-spacing:0px;">The researchers found that patients in group B had significant improvement at two, eight, and 10 weeks, with reduction seen in both the number of lesions and the severity of acne. Rapid initiation of improvement was seen for patients in group B among the severe grades of acne, with results within eight weeks compared with about 12 weeks for group A. Similar efficacy was seen for both drugs for less severe grades of acne.<p style="-webkit-text-stroke-width:0px;background-color:rgb(255, 255, 255);color:rgb(90, 88, 88);font-family:&quot;Source Sans Pro&quot;, sans-serif;font-size:18px;font-style:normal;font-variant-caps:normal;font-variant-ligatures:normal;font-weight:100;letter-spacing:normal;margin-left:auto;margin-right:auto;margin-top:0px;max-width:980px;orphans:2;text-align:start;text-decoration-color:initial;text-decoration-style:initial;text-decoration-thickness:initial;text-indent:0px;text-transform:none;white-space:normal;widows:2;word-spacing:0px;">"From our study it is evident that lymecycline is superior to doxycycline, with much statistical significance among moderate-to-severe acne," the authors write. "There was earlier reduction in lesions and the duration of therapy needed was also less than that needed for doxycycline."

Lymecycline led to earlier reduction in number of lesions and severity of acne; shorter duration of therapy needed with lymecycline

 Is Lymecycline Superior to Doxycycline for Moderate-to-Severe Acne?

WEDNESDAY, July 5, 2023 -- Microencapsulated benzoyl peroxide (BPO)/encapsulated tretinoin (E-BPO/T) cream is efficacious for moderate-to-severe acne, according to a study published online May 25 in the Journal of the American Academy of Dermatology.James Del Rosso, D.O., from JDR Dermatology Research in Las Vegas, and colleagues examined the efficacy, safety, and tolerability of E-BPO/T cream 3.0 or 0.1 percent in two multicenter, double-blind, vehicle-controlled trials. Participants aged 9 years or older with moderate-to-severe acne were enrolled and randomly assigned to 12 weeks of E-BPO/T or vehicle cream (571 and 287 participants, respectively).The researchers found that in both studies, E-BPO/T was significantly superior to vehicle, with Investigator Global Assessment (IGA) success achieved by more subjects receiving E-BPO/T (38.5/25.4 percent) than vehicle (11.5/14.7 percent). In studies one and two, the change from baseline in inflammatory lesion count for E-BPO/T versus vehicle was −21.6 versus −14.8 and −16.2 versus −14.1, respectively. In studies one and two, the changes from baseline in noninflammatory lesions were −29.7 versus −19.8 and −24.2 versus −17.4 for E-BPO/T versus placebo. In both studies, E-BPO/T was well tolerated."Both identically designed phase 3 clinical trials demonstrated the safety and efficacy of E-BPO/T in treating acne vulgaris," the authors write. "These results will allow clinicians to administer two efficacious compounds as a single, once-daily product with a favorable tolerability profile."Two authors disclosed employment with Sol-Gel Technologies, which provided study funding.

Two studies show significant improvement in achieving Investigator Global Assessment success and change in inflammatory lesion count from baseline

 How Efficacious Is Microencapsulated BPO/Tretinoin for Acne?

<p style="-webkit-text-stroke-width:0px;background-color:rgb(255, 255, 255);color:rgb(90, 88, 88);font-family:&quot;Source Sans Pro&quot;, sans-serif;font-size:18px;font-style:normal;font-variant-caps:normal;font-variant-ligatures:normal;font-weight:100;letter-spacing:normal;margin-left:auto;margin-right:auto;margin-top:0px;max-width:980px;orphans:2;text-align:start;text-decoration-color:initial;text-decoration-style:initial;text-decoration-thickness:initial;text-indent:0px;text-transform:none;white-space:normal;widows:2;word-spacing:0px;">WEDNESDAY, June 21, 2023 -- For patients with moderate-to-severe acne, the novel 1,726 nm laser is well tolerated and offers durable improvement across skin types, according to a study published online June 14 in the Journal of the American Academy of Dermatology.<p style="-webkit-text-stroke-width:0px;background-color:rgb(255, 255, 255);color:rgb(90, 88, 88);font-family:&quot;Source Sans Pro&quot;, sans-serif;font-size:18px;font-style:normal;font-variant-caps:normal;font-variant-ligatures:normal;font-weight:100;letter-spacing:normal;margin-left:auto;margin-right:auto;margin-top:0px;max-width:980px;orphans:2;text-align:start;text-decoration-color:initial;text-decoration-style:initial;text-decoration-thickness:initial;text-indent:0px;text-transform:none;white-space:normal;widows:2;word-spacing:0px;">Macrene Alexiades, M.D., Ph.D., from the Dermatology &amp; Laser Surgery Center of New York in New York City, and colleagues examined the tolerability and therapeutic outcomes of a novel 1,726 nm laser treatment of moderate-to-severe acne across skin types in a prospective study. A total of 104 individuals with moderate-to-severe facial acne and Fitzpatrick Skin Types ranging from II to VI were included; participants received three laser treatments.<p style="-webkit-text-stroke-width:0px;background-color:rgb(255, 255, 255);color:rgb(90, 88, 88);font-family:&quot;Source Sans Pro&quot;, sans-serif;font-size:18px;font-style:normal;font-variant-caps:normal;font-variant-ligatures:normal;font-weight:100;letter-spacing:normal;margin-left:auto;margin-right:auto;margin-top:0px;max-width:980px;orphans:2;text-align:start;text-decoration-color:initial;text-decoration-style:initial;text-decoration-thickness:initial;text-indent:0px;text-transform:none;white-space:normal;widows:2;word-spacing:0px;">The researchers observed a ≥50 percent reduction in active acne inflammatory lesions in 32.6 percent of participants at four-week follow-up following final treatment; this number increased to 79.8 and 87.3 percent at 12 and 26 weeks, respectively. From baseline to four-, 12-, and 26-week follow-up, the percentage of participants who were clear or almost clear increased from 0 to 9, 36.0, and 41.8 percent, respectively. No device or protocol-related serious adverse events were reported; treatments were tolerated well and did not require anesthetic. Across all skin types, therapeutic outcomes and discomfort were similar.<p style="-webkit-text-stroke-width:0px;background-color:rgb(255, 255, 255);color:rgb(90, 88, 88);font-family:&quot;Source Sans Pro&quot;, sans-serif;font-size:18px;font-style:normal;font-variant-caps:normal;font-variant-ligatures:normal;font-weight:100;letter-spacing:normal;margin-left:auto;margin-right:auto;margin-top:0px;max-width:980px;orphans:2;text-align:start;text-decoration-color:initial;text-decoration-style:initial;text-decoration-thickness:initial;text-indent:0px;text-transform:none;white-space:normal;widows:2;word-spacing:0px;">"The laser described here resulted in clinically meaningful progressive posttreatment improvement to at least 26-week follow-up and may alter the natural history of the disease, inducing a durable amelioration in moderate-to-severe acne across skin phototypes," the authors write.<p style="-webkit-text-stroke-width:0px;background-color:rgb(255, 255, 255);color:rgb(90, 88, 88);font-family:&quot;Source Sans Pro&quot;, sans-serif;font-size:18px;font-style:normal;font-variant-caps:normal;font-variant-ligatures:normal;font-weight:100;letter-spacing:normal;margin-left:auto;margin-right:auto;margin-top:0px;max-width:980px;orphans:2;text-align:start;text-decoration-color:initial;text-decoration-style:initial;text-decoration-thickness:initial;text-indent:0px;text-transform:none;white-space:normal;widows:2;word-spacing:0px;">Several authors disclosed ties to Cutera.

Laser well tolerated with durable posttreatment improvement through 26 weeks across skin types

Is Novel 1,726 nm Laser Treatment Tolerated for Moderate-to-Severe Acne?

WEDNESDAY, June 7, 2023 (HealthDay News) -- Spironolactone improves acne compared with placebo, with greater differences seen at week 24 than week 12, according to a study published online May 17 in The BMJ.Miriam Santer, M.B., B.Chir., from the University of Southampton in the United Kingdom, and colleagues conducted a multicenter, phase 3 trial to examine the effectiveness of oral spironolactone for acne vulgaris in adult women with facial acne for at least six months, judged to warrant oral antibiotics. Participants were randomly assigned to 50 mg/day spironolactone or matched placebo until week 6, increasing to 100 mg/day spironolactone or placebo until week 24. The primary analysis included 342 women (176 in the spironolactone group and 166 in the placebo group).The researchers found that at baseline and week 12, respectively, the mean acne quality-of-life symptom scores were 13.2 and 19.2 for the spironolactone group and 12.9 and 17.8 for the control group (difference, 1.27 favoring spironolactone). At week 24, scores were 21.2 and 17.4 for spironolactone and placebo, respectively (difference, 3.45). More participants in the spironolactone versus placebo group reported acne improvement, with a significant difference seen at week 24 (82 versus 63 percent; odds ratio, 2.72). Treatment success was 19 and 6 percent for spironolactone and placebo, respectively, at week 12 (odds ratio, 5.18). The spironolactone group had adverse reactions slightly more often (20 versus 12 percent)."Adopting a combined approach using oral spironolactone and topical agents has the potential to reduce the long-term prescribing of oral antibiotics and therefore to reduce the likelihood of emerging bacterial resistance," the authors write.One author disclosed ties to the pharmaceutical industry.

Mean quality-of-life symptoms favor spironolactone at 12 and 24 weeks; more participants report acne improvement with spironolactone

Spironolactone Found to Improve Acne in Adult Women

To slug or not to slug? That's the
 
 
 question for millions of TikTok users, who turn to the social media giant for tips and information on what amounts to a DIY
 <a class="rm-stats-tracked" href="https://www.aad.org/public/everyday-care/skin-care-basics" target="_blank">
 skin care
 </a>
 phenomenon.




 <a class="rm-stats-tracked" href="https://health.clevelandclinic.org/slugging/" target="_blank">
 Slugging
 </a>
 involves slathering some sort of sealing agent -- like Vaseline or another petroleum-based ointment -- onto the skin.




 What's the problem with that? New research warns that the majority of TikTok posts focused on the wrinkle-reducing practice are medically unreliable, hyping the benefits while downplaying the risks.




 The goal of slugging, explained study lead author Kyla Pagani, is "to help moisturize and strengthen the skin barrier," for those battling dryness, irritation or inflammation.




 The idea is not medically unsound, stressed Pagani, who conducted her research while a medical student in the Department of Dermatology at the Beth Israel Deaconess Medical Center in Boston.




 "I've heard some dermatologists speak very highly about it, most often for addressing
 <a class="rm-stats-tracked" href="https://nationaleczema.org/eczema/" target="_blank">
 eczema
 </a>
 on the hands," she added. "It definitely does have benefits."




 But it also has potential downsides, said Pagani, such as boosting the odds for acne. And with social media sites like TikTok exerting such a "strong influence on the younger population," she and her colleagues wanted to see if that platform's more than 1 billion users are likely to get the full picture of what slugging really involves.




 To do that, the study team analyzed the content found in the top 49 English-language TikTok videos on slugging. When the investigation was launched, those posts had collectively amassed more than 26.5 million views and nearly 3.3 million "likes."




 But in the end, only 37% of the videos were classified by investigators as educational. That meant that they offered a reasonably full discussion of both the potential pros of slugging -- such as smoother and more hydrated skin -- and the potential cons, including the blocking of skin pores and
 <a class="rm-stats-tracked" href="https://www.aad.org/public/diseases/acne" target="_blank">
 acne
 </a>
 .




 The posting sources mattered a lot. For example, the team found that nearly 88% of videos uploaded by health care providers were found to be educational and balanced. But that figure plummeted to just only about 43% for posts shared by "influencers" focused on beauty.




 Overall, the study authors found that about 6 in 10 posts highlighted only the upside of slugging, while only 2 in 10 mentioned possible risks.




 "What we found was not necessarily misinformation, but often a lack of information," Pagani said. "A lot of the time, there was just no inclusion of risks."




 Beyond a heightened risk for facial acne among acne-prone patients, Pagani said there is also the risk that any topical skin medication applied before slugging would essentially become trapped underneath petroleum ointments, and therefore potentially absorbed more deeply -- and for longer periods of time -- than originally intended.




 "Now, slugging is one of the relatively harmless things that can be found on TikTok," Pagani acknowledged. "But even in the case of mostly benign beauty trends, the hope is that viewers are going to get accurate information from reliable sources, information backed by science based on data and research. Because other trends or beauty products may certainly be more potentially harmful than something like slugging."




 The findings were published recently in the journal
 
 <a class="rm-stats-tracked" href="https://www.sciencedirect.com/science/article/abs/pii/S0738081X22001092" target="_blank">
 Clinics in Dermatology
 </a>
 .
 




 It's that broader issue that concerns Kelly Garrett, director of the School of Communication at Ohio State University.




 "It is no wonder that people end up looking for health information in these digital spaces," said Garrett, who pointed out that social media is familiar, easy to use and can be an empowering way to do research.




 And medical professionals are not the sole purveyors of useful health information. "For example, someone who is living with a cancer diagnosis can have important insights, too," Garrett said.




 But the problem, he noted, is that "on social media, content creators' goals are not always obvious.




 "Posts by health care providers are often intended to inform, but other creators may be more interested in providing entertainment, persuading consumers to buy something, or just generating traffic to their content," Garrett said. "Consumers who misunderstand the creators' goals can end up being misled about the content, too."




 All of which means it's critical that social media users be aware of the risks involved when searching for health information online, said Garrett, who was not involved in the study.




 "
 <a class="rm-stats-tracked" href="https://literacy.ala.org/information-literacy/" target="_blank">
 Information literacy
 </a>
 " is what it's all about, he noted, meaning that those who turn to social media for health information know that they have to distinguish "between those making a good faith effort to help others navigate complex health issues and those who are more concerned about getting attention than about being right."




 
 More information
 




 There's more on slugging at the
 <a class="rm-stats-tracked" href="https://health.clevelandclinic.org/slugging/" target="_blank">
 Cleveland Clinic
 </a>
 .








 <a href="https://consumer.healthday.com/u/physiciansbriefingstaff">
 <img alt="HealthDay" src="https://assets.rbl.ms/23636171/origin.png" style="max-width: 150px;"/>
 </a>

TikTok 'Slugging' Trend Has People Coating Their Faces With Grease

For patients with Fitzpatrick Skin Phototype IV to VI with atrophic acne scars, microneedling provides better treatment outcomes than 35 percent glycolic acid chemical peels, according to a study recently published in the
 
 Journal of Clinical and Aesthetic Dermatology
 
 .




 Fatima Ishfaq, M.D., from Benazir Bhutto Hospital in Rawalpindi, Pakistan, and colleagues compared the efficacy of microneedling versus 35 percent glycolic acid chemical peels in 60 patients with Fitzpatrick Skin Phototype IV to VI with atrophic acne scars. Participants were randomly assigned to microneedling every two weeks for 12 weeks or chemical peeling every two weeks for 12 weeks (groups A and B, respectively).




 The researchers found that compared with group B, group A demonstrated more improved outcomes in acne scar treatment, with 73.33 and 33.33 percent of patients in groups A and B, respectively, achieving treatment efficacy, represented by an improvement greater than one grade from baseline according to the Goodman and Baron Scarring Grading System, measured two weeks after completion of the last treatment session. Furthermore, 26.67 and 66.67 percent of patients in groups A and B, respectively, showed no efficacy after treatment.




 "Based on our study's findings, we envision either using microneedling as a first line option followed by chemical peels if limited improvement is witnessed, or using them in combination with one another," the authors write.




 <a class="rm-stats-tracked" href="https://jcadonline.com/microneedling-acid-peel-acne-scarring/" target="_blank">
 Abstract/Full Text
 </a>

Treatment efficacy superior for patients receiving microneedling versus 35 percent glycolic acid peels every two weeks

How Does Microneedling Compare to Chemical Peeling for Acne Scars?

In a consensus statement published online June 15 in
 
 JAMA Dermatology,
 
 data is provided for optimizing laboratory monitoring of acne patients treated with isotretinoin.




 Eric Xia, from Harvard Medical School in Boston, and colleagues established a consensus for isotretinoin laboratory monitoring among clinical and research experts in acne. Four rounds of electronic surveys were administered from 2021 to 2022 using a modified electronic Delphi process. For laboratory tests reaching consensus (≥70 percent agreement) for inclusion, in subsequent rounds, questions regarding more time-specific monitoring throughout isotretinoin therapy were asked. The 22 experts had a mean of 23.7 years in practice, and represented a variety of practice settings.




 The researchers found that consensus about testing or not testing was achieved for checking alanine aminotransferase within a month prior to initiation (89.5 percent) and at peak dose (89.5 percent), but not monthly (76.2 percent) or after treatment completion (73.7 percent), and for checking triglycerides within a month prior to initiation and at peak dose (89.5 and 78.9 percent, respectively), but not monthly or after treatment completion (84.2 and 73.7 percent, respectively). Consensus was also achieved for not checking complete blood cell count or basic metabolic panel parameters at any point during isotretinoin treatment (all &gt;70 percent), and for not checking gamma-glutamyl transferase, bilirubin, albumin, total protein, low-density lipoprotein, high-density lipoprotein, or C-reactive protein (78.9, 81.0, 72.7, 72.7, 73.7, 73.7, and 77.3 percent, respectively).




 "Reducing unnecessary laboratory monitoring may help decrease the pain, fear, and direct and indirect costs experienced by patients being treated with isotretinoin for acne," the authors write.




 Several authors disclosed financial ties to the pharmaceutical industry.




 <a class="rm-stats-tracked" href="https://jamanetwork.com/journals/jamadermatology/fullarticle/2793099" target="_blank">
 Abstract/Full Text (subscription or payment may be required)
 </a>




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 </a>

Consensus reached on recommendations to test alanine aminotransferase, triglycerides within a month prior to initiation and at peak dose

Experts Address Lab Monitoring of Isotretinoin for Treating Acne

The Acne-Q and CompAQ can be used for measuring acne-associated quality of life, according to a review published online June 22 in
 
 JAMA Dermatology.
 




 Zachary H. Hopkins, M.D., from Broward Health Dermatology in Fort Lauderdale, Florida, and colleagues conducted a systematic review of patient-reported outcome measures (PROMs) for health-related quality of life (HRQoL) in adults or adolescents with acne. A total of 54 acne PROM development or validation studies were identified for 10 acne-specific PROMs, six dermatology-specific PROMs, and five generic PROMs.




 The researchers found that few of the PROMs had studies for responsiveness. The CompAQ and Acne-Q were the only acne-specific PROMs with sufficient evidence for content validity. These PROMs can be recommended for use in acne clinical studies, based on the available evidence.




 "The Acne-Q and CompAQ were found to be validated to a sufficient standard to support recommendation for measuring acne-associated quality of life," the authors write. "Further research is needed to better define content validity, other measurement properties such as responsiveness, and interpretability of PROMs used to assess HRQoL in patients with acne."




 Several authors disclosed financial ties to CompAQ, including one who reported holding a patent licensed to CompAQ.




 <a class="rm-stats-tracked" href="https://jamanetwork.com/journals/jamadermatology/fullarticle/2793182" target="_blank">
 Abstract/Full Text (subscription or payment may be required)
 </a>

Systematic review finds that Acne-Q and CompAQ can be used for measuring acne-associated quality of life

Two Patient-Reported Outcome Measures Useful for Determining QoL With Acne

For patients with acne vulgaris, concomitant treatment using intense pulsed light (IPL) and minocycline demonstrates better clinical efficacy than minocycline alone, according to a study published online May 5 in the
 
 Journal of Cosmetic Dermatology
 
 .




 Huanhuan Qu, from The Fourth Military Medical University in Xi'an, China, and colleagues examined the safety and efficiency of IPL combined with minocycline for the treatment of acne vulgaris. Forty patients were randomly assigned to receive minocycline for eight weeks with IPL treatments three times (at weeks 0, 4, and 8) or minocycline only at the same dose. Before treatment and at weeks 4, 8, and 16, evaluations for inflammatory lesion count, Investigator Global Assessment of Acne (IGA), erythema, and purpura indexes were conducted.




 The researchers found that compared with baseline, at week 16, there were significant improvements in inflammatory lesion count, IGA scores, and purpura index in both groups. Significant improvement was seen in the erythema index at the 16th week compared with baseline for concomitant therapy, but not minocycline only. Compared with the group given minocycline only, the group receiving combination treatment had significant improvements in inflammatory lesion counts and IGA scores at weeks 4, 8, and 16. During the trial, there were no severe adverse effects reported.




 "Our data demonstrate that minocycline IPL treatment for patients with moderate-to-severe facial acne vulgaris is effective and safe," the authors write.




 <a class="rm-stats-tracked" href="https://onlinelibrary.wiley.com/doi/10.1111/jocd.15046" target="_blank">
 Abstract/Full Text (subscription or payment may be required)
 </a>

Combination treatment has better clinical efficacy than minocycline alone for patients with acne vulgaris

Does Intense Pulsed Light Augment Minocycline Therapy for Acne Vulgaris?

As many as 50 million Americans deal with acne. The blemishes can be painful and, for some, embarrassing.

 Now, researchers may have found a new weapon to fight acne — one without harsh side effects.




 A study in Germany has pinpointed omega-3 fatty acids — found in fish oil, wild salmon, nuts and seeds — as a nutrient helpful for reducing acne.




 Among 100 participants with acne, about 94% had low levels of the fatty acid in their blood, the study discovered. Many also had higher levels of a hormone known to stimulate acne production.




 "As someone who loves to treat acne and someone who performs clinical trials, this is a very interesting study," said Dr. Sandra Johnson, a dermatologist in Fort Smith, Ark. Johnson was not involved in the study.




 "We have great
 <a class="rm-stats-tracked" href="https://www.aad.org/public/diseases/acne/derm-treat/treat" target="_blank">
 treatments for acne
 </a>
 , but they come at a financial cost as well as potential side effects," Johnson said. "It would be more natural, and less risky and less expensive to modify diet to treat acne."




 The study findings were released at last week's meeting of the European Academy of Dermatology and Venereology. Research presented at medical meetings should be considered preliminary until published in a peer-reviewed journal.




 <a class="rm-stats-tracked" href="https://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/fats-and-cholesterol/types-of-fat/omega-3-fats/" target="_blank">
 Omega-3 fatty acids
 </a>
 are commonly found in non-farmed fish, algae and other plant-based foods, including legumes, nuts and seeds.




 The researchers said these fatty acids reduce inflammation by stimulating the body to produce anti-inflammatory prostaglandins E1 and E3 and leukotriene B5, and lowering levels of IGF-1 (insulin-like growth factor). IGF-1 is known to induce acne.




 Lead study author Dr. Anne Gürtler said clinicians should provide patients with information on dietary choices as part of a modern treatment approach for acne. She is in the department of dermatology and allergy at Ludwig-Maximilian University in Munich, Germany.




 When her team analyzed participants' blood samples, they found most had levels of omega-3 fatty acids below the recommended amounts of 8% to 11%.




 Looking at individual diets, the team found those who regularly ate chickpeas and lentils, while abstaining from sunflower oil, had higher levels of omega-3s. Sunflower oil has been found in past research to aggravate acne.




 The study patients who had lower levels of omega-3 fatty acids also had higher levels of IGF-1. Those with severe deficits in omega-3s, lower than 4%, had even more IGF-1 hormone.




 Researchers have been looking at dietary influence on acne for many years, Johnson said. Yet, the research has not been of high quality because there has not been much funding for it.




 Some think foods like donuts that are
 <a class="rm-stats-tracked" href="https://www.health.harvard.edu/healthbeat/a-good-guide-to-good-carbs-the-glycemic-index" target="_blank">
 high in glycemic index
 </a>
 , nuts, hormonally influenced meats and high iodine foods can worsen acne, she said.




 Dairy and sugar are among the other dietary culprits that have been blamed for increasing acne.




 Dr. Debra Jaliman, a dermatologist in New York City, said she always discusses diet with her patients, in addition to reviewing the products they use on their skin. Jaliman was also not involved in this study.




 "Omega-3 seems to be a very important element in our diet in many ways," Jaliman said, noting its link to other health benefits.




 "I notice in my patients, when we change people's diets, I feel like it really has an effect on their acne, but it could also be that, of course, I'm changing their habits, I'm adding medication. We do a lot of things at once. It's not like here where it's a controlled study, but I do think it does have an effect," Jaliman said.




 <a class="rm-stats-tracked" href="https://www.aad.org/public/diseases/acne/derm-treat/hormonal-therapy" target="_blank">
 Topical hormone blockers
 </a>
 , a new treatment, are another change that's revolutionizing the field of acne treatment. The cream blocks excess male hormones on the skin, without requiring consuming harsh, internal medications, Jaliman said. She called it the biggest breakthrough in 30 years.




 It's too early to say whether an omega-3 supplement created to reduce acne according to blood serum levels would improve skin, according to the researchers. Additional study is needed first.




 Johnson said she'd like to know about any potential side effects and what the optimal dose of omega-3 fatty acids might be.




 "Although there are not a lot of clinical trials to support their use, one can consider eating foods high in omega-3 as well as supplements as an adjunct or a natural alternative for the treatment of acne," Johnson said.




 Although Jaliman said she would like to see research with a larger sample, she also said it wouldn't hurt for someone living with acne to add some more omega-3 foods to their diet.




 "I think the skin is impacted by everything. It's impacted by stress. It's impacted by exercise. People who exercise have better skin," Jaliman said. "I think it's a reflection of your whole body."




 
 More information
 




 The U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases has more on
 <a class="rm-stats-tracked" href="https://www.niams.nih.gov/health-topics/acne" target="_blank">
 acne
 </a>
 .




 <a href="https://consumer.healthday.com/u/physiciansbriefingstaff">
 <img alt="HealthDay" src="https://assets.rbl.ms/23636171/origin.png" style="max-width: 150px;"/>
 </a>

Could Omega-3 Fatty Acids Fight Acne?

For patients with atrophic postacne scars, microneedling combined with topical insulin or vitamin C achieves comparable significant improvement, according to a study published online Feb. 12 in
 
 Dermatologic Therapy
 
 .




 Mohamed Ali Mahmoud Abbas, from Al-Azhar University in Cairo, and colleagues assessed microneedling by dermapen with topical vitamin C versus microneedling with topical insulin for treatment of atrophic postacne scars in a split-face comparative study involving 30 individuals. Human insulin was topically applied to the left side of the face, and vitamin C serum was applied to the right side.




 The researchers observed a statistically significant mean improvement in the Acne Scar Assessment Scale (ASAS) value on both sides of the face (2.13 and 1.83) after one month of four treatments compared with baseline (3.03 and 2.93). The mean ASAS value improved significantly when compared with baseline, with slightly more improvement noted on the vitamin C-treated side. Patient satisfaction was significantly higher with vitamin C versus insulin treatment. There were no reports of serious adverse events; edema was the most common side effect reported, followed by erythema. The side effects did not differ between the sides.




 "Both topical vitamin C and topical insulin combined with microneedling may achieve comparable significant improvement," the authors write. "The good safety profile, easy accessibility, low cost, and noninvasive nature merits the use of both topical medications."

Acne Scar Assessment Scale value significantly improved in split-face study of atrophic postacne scars with both treatments

Does Microneedling With Vitamin C Serum or Insulin Aid Postacne Scarring?

Spironolactone use is not associated with an increased risk for cancer, according to a systematic review and meta-analysis published online Feb. 9 in
 
 JAMA Dermatology
 
 .




 Kanthi Bommareddy, M.D., from the University of Miami Miller School of Medicine in Fort Lauderdale, Florida, and colleagues conducted a systematic review to examine the pooled occurrence of cancers, particularly breast and prostate cancers, among individuals treated with spironolactone. Data were included for seven studies, with a total population of 4,528,332 individuals (mean age, 62.6 to 72.0 years).




 The studies were all considered to have a low risk for bias. The researchers observed no association between spironolactone use and risk for breast cancer (risk ratio, 1.04; 95 percent confidence interval, 0.86 to 1.22). Spironolactone use was associated with a reduced risk for prostate cancer (risk ratio, 0.79; 95 percent confidence interval, 0.68 to 0.90). No significant associations were observed between use of spironolactone and risks for ovarian cancer, bladder cancer, kidney cancer, gastric cancer, or esophageal cancer.




 "This systematic review and meta-analysis provides reassuring data that use of spironolactone, an important treatment for patients with acne, hidradenitis, androgenetic alopecia, and hirsutism, is unlikely to be associated with a substantial increased risk of cancer," the authors write. "However, the certainty of the evidence was low. Future studies are needed, particularly among diverse populations such as younger individuals and those with acne or hirsutism.
 
 "
 




 <a class="rm-stats-tracked" href="https://jamanetwork.com/journals/jamadermatology/article-abstract/2788624" target="_blank">
 Abstract/Full Text (subscription or payment may be required)
 </a>




 <a href="https://consumer.healthday.com/u/physiciansbriefingstaff">
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 </a>

No significant associations seen for spironolactone with risk for breast, ovarian, bladder, kidney, gastric, esophageal cancers

Spironolactone Use Not Linked to Increased Risk for Cancer

Twenty-nine novel significant loci for acne have been identified, according to a study published online Feb. 7 in
 
 Nature Communications
 
 .




 Brittany L. Mitchell, Ph.D., from the QIMR Berghofer Medical Research Institute in Brisbane, Australia, and colleagues performed the largest meta-analysis of genome-wide association studies to date, which included 20,165 individuals with acne from nine cohorts.




 The researchers identified 29 novel genome-wide significant loci and replicated 14 of 17 previously identified risk loci. At several acne susceptibility loci, which have previously been implicated in Mendelian hair and skin disorders such as pustular psoriasis, putative causal genes were identified. Shared genetic etiology was identified between acne, hormone levels, hormone-sensitive cancers, and psychiatric traits. In an independent cohort, up to 5.6 percent of the variance in acne liability was explained by a polygenic risk score calculated from these results.




 "Our results highlight the substantial influence on genetic risk harbored by other, as yet undiscovered loci and motivate future studies to both identify additional risk loci and establish the biological processes through which genetic risk is mediated," the authors write.




 <a class="rm-stats-tracked" href="https://www.nature.com/articles/s41467-022-28252-5" target="_blank">
 Abstract/Full Text
 </a>




 <a href="https://consumer.healthday.com/u/physiciansbriefingstaff">
 <img alt="HealthDay" src="https://assets.rbl.ms/23636171/origin.png" style="max-width: 150px;"/>
 </a>

Meta-analysis of genome-wide association studies adds to knowledge of genetic contribution to acne susceptibility

Twenty-Nine Novel Loci Identified for Acne Susceptibility

In this 2-part special edition of Derms and Conditions, host James Q Del Rosso, DO, sits down with David Light, cofounder and president of Valisure, and Christopher Bunick, associate professor of dermatology and translational medicine at Yale University and medical and dermatologic advisor for Valisure, to shed light on Valisure’s recent Citizen Petition to the US Food and Drug Administration regarding findings of high levels of benzene in benzoyl peroxide-containing products.&nbsp;

In this 2-part special edition of Derms and Conditions, host James Q Del Rosso, DO, sits down with David Light, cofounder and president of Valisure, and Christopher Bunick, associate professor of dermatology and translational medicine at Yale University and medical and dermatologic advisor for Valisure, to shed light on Valisure’s recent Citizen Petition to the US Food and Drug Administration regarding findings of high levels of benzene in benzoyl peroxide-containing products.&nbsp;In Part 1, Dr Del Rosso interviews David Light, cofounder and president of Valisure, an independent quality assurance company that aims to address a critical gap in the health care supply chain. Dr Del Rosso and Mr Light delve into the details regarding how a product review gets initiated, the financial source of such reviews, and the important differences between Valisure’s work and that of Good Manufacturing Practice (GMP) testing facilities. Finally, they address the impact that manufacturing issues have on the increasing incidences of drug shortages in the United States.<a target="_blank" rel="noopener noreferrer" href="https://dermsquared.com/podcasts/derms-and-conditions/season-4-podcast-episode-75">Click here to listen to Part 2.</a>

David Light

Christopher Bunick, MD, PhD

Derms and Conditions Podcast

Special Edition on Recent Reports of Benzene Found in Benzoyl Peroxide Products: Part 1

In this 2-part special edition of Derms and Conditions, host James Q Del Rosso, DO, sits down with David Light, cofounder and president of Valisure, and Christopher Bunick, associate professor of dermatology and translational medicine at Yale University and medical and dermatologic advisor for Valisure, to shed light on Valisure’s recent Citizen Petition to the US Food and Drug Administration regarding findings of high levels of benzene in benzoyl peroxide-containing products.&nbsp;In Part 2, Dr Del Rosso continues his conversation with David Light to discuss stability testing—what it is, why it’s important, and how Valisure undertook stability testing on products containing benzoyl peroxide. Mr Light details the rationale for conducting accelerated stability testing at elevated temperatures to evaluate the safety of the products across their entire lifecycles. Dr Bunick also joins the conversation to comment on the misperceptions about FDA-allowable limits of benzene in consumer products and the urgent need for change in how products are evaluated and formulated to ensure patient safety first and foremost. Lastly, Dr Del Rosso and Dr Bunick discuss how dermatologists should counsel patients in the short term on minimizing the risk of benzene exposure while we await further testing, external validation, and regulatory guidance.Missed Part 1? Listen <a target="_blank" rel="noopener noreferrer" href="https://dermsquared.com/podcasts/derms-and-conditions/season-4-podcast-episode-74">here</a>.

Special Edition on Recent Reports of Benzene Found in Benzoyl Peroxide Products: Part 2

In episode 58 of Derms and Conditions, our host, Dr James Q. Del Rosso, presents a self-made episode where he discusses some clarifications regarding commonly misunderstood therapies in dermatology.&nbsp;

In episode 58 of Derms and Conditions, our host, Dr James Q. Del Rosso, presents a self-made episode where he discusses some clarifications regarding commonly misunderstood therapies in dermatology. Dr Del Rosso begins by discussing the use of benzoyl peroxide (BPO) for papulopustular rosacea and notes that many providers are hesitant to use this treatment given the perceived irritant effects. He notes that the microencapsulated BPO 5% cream (FDA approved EPSOLAY®), specifically formulated to allow for the slow release of the drug in the skin, is the only formulation proven to be efficacious, safe, and tolerable in rosacea. He summarizes a 12-week study of patients with moderate to severe papulopustular rosacea in which 25% of patients were clear or almost clear at 4 weeks with total inflammation reduced by 70% at 12 weeks. In addition, he notes that the tolerability was favorable with no differences noted between the active and vehicle groups.Next, Dr Del Rosso discusses clascoterone 1% cream, FDA approved for twice daily use for acne in patients aged 12 years and older with no limitations on duration of use. He explains findings from a recently published study that show even with the maximum use of clascoterone, 4 to 6 times greater than the normal 1-gram dose, there were no clinically significant hyperkalemia readings, adverse events, or EKG changes in any participant in the control or experimental groups. Given its topical use, negligible systemic absorption especially when used as recommended, and the findings of this study, Dr Del Rosso agrees that clinicians should be reassured about the lack of risk of hyperkalemia with clascoterone use.Lastly, Dr Del Rosso switches focus to Janus kinase (JAK) inhibitors and biologics. He discusses where the boxed warnings for JAK inhibitors originated and why they are not as concerning overall with oral JAK inhibitors used for dermatologic indications in younger populations who exhibit fewer comorbidities and/or concomitant therapies. In addition, he notes that the risk of several side effects of special interest, such as lymphopenia, malignancy, and thromboembolic events are quite low. He also emphasizes that not all monoclonal antibodies with similar modes of action exhibit the same pharmacologic and therapeutic profiles. In a selected case where a patient with AD has an inadequate response or adverse event such as persistent conjunctivitis caused by dupilumab (which inhibits IL-13 and IL-4), case reports have shown that changing to another monoclonal antibody that inhibits IL-13 (ie, tralokinumab) can exhibit relevant efficacy without associated conjunctivitis. Ultimately, it is good for clinicians to have options and &nbsp;as much data as possible to differentiate their use. He concludes that although certain drugs are part of the same category or class, they all have differences in pharmacokinetics, and the benefits and differences of each drug must be understood to optimize treatment selection for individual patients. Tune in to this episode to learn all the valuable clinical pearls surrounding many commonly confused therapies!&nbsp;

Removing the Confusion Surrounding Some Commonly Used Therapies

You're listening to the Derms and Conditions podcast. Well, I'm Dr. Jim del Rosso and I'm bringing you a self made episode of Derms and Conditions Podcast, which I really hope you're enjoying. The series that we put together. We're now on our third season, and I thought it was important to discuss what I think are some misunderstood therapies, or therapies that are easily confused based on a lot of the information that's out there. So I'm picking a few selected areas that I'll bring to light from my perspective, areas that I've done work on, clinical research, studies, advising, consulting, a lot of data evaluation that will hopefully be relevant to you clinically. And the first area I want to talk about is the area of benzoil peroxide used to treat Rosacea, specifically patients that have papules and pustules that have Rosacea. This is very confusing, and not a week goes by that I don't get questioned about this from a clinician in dermatology, whether it be a dermatologist, physician assistant, nurse practitioner, or even other individuals from companies. Benzel peroxide for Rosacea benzel peroxide is going to be too irritating and they know about it for acne, but they just can't wrap their head around it with Rosacea even if they've seen some of the data. I think it's really important here to emphasize that the studies that were done with benzoil peroxide for rosacea specifically used encapsulated benzoil peroxide, what's also been called microencapsulated benzoil peroxide that is a specific formulation of benzoil peroxide. And there only one branded formulation of benzoyl peroxide incorporated of 5%. For rosacea, there is benzoyl peroxide microencapsulated along with microencapsulated tretinoin that is FDA approved for acne vulgaris, a combination formulation. The microencapsulation separates those active ingredients in the formulation and allows the benzoil peroxide and the tretinoin to be applied together in the same single formulation. Right first time that's been done that it could be done in the same vehicle because benzo peroxide had always degraded tretinoin and they were applied separately and couldn't be put in the same formulation. But the benzel peroxide 5% encapsulated in the cream formulation was specifically evaluated for patients that had moderate to severe rosacea with papules and pustules and the average number of the range I should say of papules and pustules in the actively treated patients in the two studies, and in the vehicle. Patients that had the same vehicle but without the encapsulated 5% benzel peroxide was anywhere from 26 to 30 lesions. So these patients had a pretty robust number of papules and pushules at baseline, and they were treated over a twelve week period with one Staley application of the active versus the vehicle in a double blind, placebo controlled, or vehicle controlled fashion randomized study, just the way it needs to be done to get approval by the FDA. Important to recognize that this is the only formulation that's been evaluated to show efficacy, safety and very importantly, tolerability for rosacea. So if you're going to think about utilizing benzoil peroxide for rosacea, regardless of whether it's over the counter or prescription, this is the only formulation you should utilize, or you should anticipate that you will get irritation from benzoil peroxide in many cases because it's being immediately released and not in the slow release that you get from the encapsulation. So the encapsulation is a special technique used in the manufacturer with a silicon dioxide shell that creates a shell that encapsulates the benzoil peroxide, that has some small micro channels that allows the benzoil peroxide to be released slowly. So you're not getting that quick dump into the skin, but with the slow release over time, you get the therapeutic effect and there's data to show how that actually happens. Right. So let's move on to what we can expect from encapsulated benzoil peroxide. Importantly, that the patient gets this specific brand formulation, not because we're promoting it for one particular company, but because it's the only one that the studies have actually been done that shows that you can get this benefit and where the efficacy was actually evaluated. But I think what's really important that we learned is that there is a very fast onset of clinical effect. Right. You see about 25% of the patients getting to clear, almost clear by four weeks of use, with the encapsulated 5% benzoil peroxide cream applied once a day. So that's impressive. We also see that by the end of twelve weeks, there's a 70% reduction in inflammatory lesions. Right. We don't have head to head, but that's very impressive and probably the highest number that we've seen in any particular study. Keeping in mind that we have 26 to 30 papules and pustules at baseline which is a robust number of baseline lesions. Also about 40% inflammatory lesion reduction. That's papules and postules. By week two, which was also a very impressive quick onset, the tolerability was very favorable. It was just about the same in the active group as the vehicle group when you're looking at local tolerability reactions. So, yes, it's possible you may get some stinging, some erythema, but not much different than the vehicle that does not have the encapsulated bencible peroxide. So this data is out there, it's available, and the drug is FDA approved under the brand name of Epsila. So if you don't believe Jim Dolaso, look at it for yourself, and I think you will find this to be a very helpful topical formulation for patients with papillopustular rosacea. We have several others. We obviously have metronidosol, azalaic acid. We have brands and generics. Of those. We have brand generic topical ivomectin. All of these have been very helpful for papillopustrial lesions of rosacea, minocycline foam, 1.5% foam. All of these FDA approved. This is a new agent, but I would encourage you not to get stuck on. It's benzol peroxide. It's not benzoyl peroxide, it's encapsulated benzo peroxide. So now I want to move on to another agent. It's topical clascodone. It's a 1% cream FDA approved twice a day for patients twelve years of age and older with acne vulgaris. Right. Male or female, doesn't matter the severity, the site, and no limitations on duration of use. It was studied on the face and also in long term extension on the trunk. A couple of caveats. There was a recent article published by Hannah Peterson and also with Leon Kursick and April Armstrong in the Journal of Drugs and Dermatology, which is a review on the efficacy safety mechanism of action of this particular agent, hot off the press in June of 2023. There's a lot of other publications that are out there, but this is a very good one. Also in the Journal of Clinical and Aesthetic Dermatology this month, there is a review where I was the lead author, but we also had Lindestine gold, Diane Tibetot and Nick Squateri, these other physicians that assisted on the hyperkalemia data with topical quescoderone. Right. And this does show, first of all, hyperkalemia. It was looked at because of issues that surrounded spironalactone. Right. And these drugs are structurally different. Right. But because spironalactone can cause hyperkalemia as an oral agent, with clascodorone being topically applied and having negligible systemic exposure, quite frankly, if you use it as recommended, approximately 1 gram twice a day to acne vulgaris in patients twelve years of age and older. Right. You have really, based on maximum use data, negligible concern about systemic exposure and issues such as clinically relevant hyperkalemia. But that being said, in the patients that were evaluated in twelve years of age and older in maximum use, which was four to six times the amount that you would typically use, there was no evidence that there was any clinically relevant. Meaning alert signals with hyperkalemia in the active versus the vehicle control group. And that is good news. The drug is FDA approved, twelve years of age and older. The bottom line was looking at exposure response analysis, looking at the levels of hyperkalemia. Hyperkalemia not meaning that it was high, that there was an alert, that there was an adverse event, because there were no EKG changes, no adverse events, or no alert levels that led to discontinuation in any of the patients, whether they be the vehicle, meaning they weren't exposed to the closcoderone or the closcoderone group. Importantly, these were just levels that may have been slightly above the limit of normal. So that could certainly happen in anyone, and it certainly happened in almost the same number of patients treated with vehicle as in the active. The denominator was a higher number in the active versus the vehicle because the randomization was two to one. But the bottom line is evaluated through phase two. And after that point, there was no recommendation by the FDA to evaluate in phase three or post marketing surveillance, and no laboratory monitoring recommendations in the product monograph. So I think you can feel comfortable with that. And the publication is available in the Journal of Clinical Anesthetic Dermatology. If you search it in Pubmed under my name, you can download an individual pDF of the article for use by yourself for review. If you want to look at it further. The next area I want to discuss is one that I've talked a lot about and many other people have talked about, and I think it can get somewhat confusing, and it has to do with monitoring guidelines with Janus kinase inhibitors. And I'm going to specifically focus on the drugs abracitinib and upaticitinib for atopic dermatitis. They're available orally. The package inserts recommend that you start with the lower dose and then step up to the higher dose if the patient does not get an adequate response within an appropriate amount of time to evaluate that patient. It's a little bit different in how it's written with each of the package inserts. But when we look at the box warnings, we have to recognize that some of the statements, a lot of what's in the box warning, and you've likely heard this from many people, is based on another Janus kinase inhibitor, which inhibits januskinase one, two and three. Abrasitinib and upaticitinib are primarily Janus kinase one, and they can have some Janus kinase two. Right inhibition. But the important thing being that tophacitinib, which is one that a lot of the statements are based on, looked at a comparison in a population of patients that were over the age of 60 that often had rheumatoid arthritis and other indicated comorbid diseases and were not just the atopic dermis population. So they had comorbidities that can predispose them to some of those adverse events of special interest, like tuberculosis, venous thromboembolism, arterial thromboembolism, major cardiovascular events, serious infections, et cetera. And in that population of patients, compared to tumor necrosis factor alpha inhibitors that are used in many of those patients that also be receiving methotrexate, many of these patients are receiving other therapies. It was higher with the tofacitinib that got transferred over to the other oral Janus kinase inhibitors. But looking at those only in the population of atopic dermatitis patients with upaticitinib and abracitinib, the age average is younger and the associated comorbidities are significantly less. But it doesn't mean that patients were not included that had comorbidities. For example, in the upatacitinib studies, they did include patients that were smokers, right? About 30% were smokers, about 20% were chronic smokers, 10% were past smokers. About 20% of the female population were utilizing oral contraceptives. And there were some patients that may have had some of the other comorbidities. But they did certainly exclude patients that had certain significant comorbidities from the study based on the inclusion criteria of those studies. But nevertheless, when we look at those population of patients, we have to factor in what is the risk of these adverse events of special interest and those we think about with Janus kinase inhibitors in this specific population. When we're talking to our patients that we believe need either abrasit, nib or eupatocitinib for the aratopic dermatitis based on the severity of the disease, based on whether or not they've had difficulties or not adequate response with previous treatments, including other systemic therapies, corticosteroids, classic immunosuppressives like cyclosporin and methotrexate, and even biologic agents like dupliumab, betrala, kenyumab. Right. We know that these monoclonal antibodies are very effective, and many patients are not going to need to think about utilizing another therapy. But in some of them, these oral Janus kinase inhibitors are certainly something that can provide them additional benefit if they need a better response, if they're not responding as well as they like, have difficulty sleeping, their disease has progressed or gotten worse. Whatever the case may be, your judgment as a clinician and the patient's interest is to look at another therapy. So we know that with upaticitinib and abracitinib, that switching to them in patients that had previously used the piliumab can get incremental benefit. Right. But also you have to factor in the blood monitoring that's required and the potential safety risks to discuss with the patient so you have a proper risk benefit. Discussion, joint decision making, which to me is always implicit, but is commonly talked about now, and making sure there's a full discussion on what they can anticipate in terms of benefit, certainly the benefit is there. So, for example, I'm going to use upatacitinib, for example, because I have that there's actually data on this drug going out to five years. There's longer data than one year also with abracitinib, and there's collections of data with both that support what I'm saying right now. But, for example, if you look at the one year data with upaticitinib, looking at 30 milligrams a day, which is the higher dose, and if you had 100 patients treated for a year in this population of patients with atopic dermatitis that were in pivotal trials, you would have less than two cases of anemia, less than one case of lymphopenia, less than four cases of serious infections, less than six cases of herpes oster, less than one case of active tuberculosis, less than one case of malignancy in general, less than one case of mace, and less than one case of venous thromboembolism. That's if you treated 100 patients for one year. So, yes, these can occur, right. And these cases may or may not been related to the upatacitinib, but they occurred in patients that were receiving upatacitinib. So, yes, we could not guarantee that these adverse events are not going to happen. And we do need to follow the monitoring guidelines, both clinical patient assessments, history, understanding their medication history and their medical background, and updating it each time we see them and looking at the blood test monitoring, that is recommended. Right. And it's pretty well worked out. I just published on LinkedIn. You could look up under my name a slide that has my recommendations. Based on what's published and the package inserts that are out there, you're certainly welcome to use that. But as long as we're doing that, we're treating patients with systemic therapies that can help them significantly with their disease, that are changing the lives dramatically of patients that are suffering from a very significant disease. Itching, difficulty sleeping. Whatever the case may be, we all know it. We just don't want to harm our patients. Well, this is not much different than when we first learned how to use isotretinoin or. Okay, I'll pick a chronic disease. Atopic dermatitis, psoriasis with cyclosporin, methotrexate, mycophenylate, mafatil, hydroxychloroquine. Whatever drug had some associated testing that we had to do or blood testing. It was a learning curve then. It's a similar learning curve now. So I don't want to sound like I'm on a soapbox, but I do want to encourage you to take into account the realities of what the risks are and feel comfortable having those conversations with your patients. So I try to bring forward three areas that I think are important. I do want to end with another factor. Remember that the monoclonal antibodies are not all the same. You can get conjunctivitis with topiliumab. You can get it with the anti IL 13 agents. Traloquinumab is available now. Lebricizumab will likely be available coming up. But just because a patient has conjunctivitis with topiliumab doesn't mean they're going to have it. If you treat them with tralicanumab or you switch them with tralicinumab, which in some cases may be helpful in patients that had conjunctivitis where you had to take them off topiliumab or didn't respond for some other reason, there are case reports on this. So the bottom line here is, just because drugs are in the same chemical class, like antial 13, stramab and lebricizumab, or are very similar, like monoclonal antibodies to pilumab being il four and il 13, where tralokinumab and leprechizumab being anti l 13. We may make assumptions of similar activities or similar adverse events. We truly cannot do that because there are many differences between these drugs, where they bind, their pharmacokinetic profiles, their activities are different, even drugs within the same chemical class. So I think that's a take home point. Learn each agent, regardless, topical or oral, individually, what its merits are and what its risks are, and then I think you'll feel very comfortable utilizing them in your clinical practice to help a lot of our patients. I hope this is helpful to you. This is some of the things I've gleaned through my own reading, teaching, and through many of the people that I talk to on derms and petition derms and conditions podcasts. I've mispronounced my own show, but it's been a long day. But I hope this was helpful to you. Thank you. Thank you for listening to this episode of Derms and Conditions. If you have any questions, please email us at podcast@dermsquared.com that's podcast at D-E-R-M-S-Q-U-A-R-E D.com. Podcast@dermsquared.com.

In episode 57 of Derms and Conditions, our host, James Q. Del Rosso, DO, sits down with Christopher Bunick, MD, PHD, an associate professor of dermatology at Yale University School of Medicine who performs specialized dermatologic research utilizing x-ray crystallography and other novel techniques.&nbsp;

In episode 57 of Derms and Conditions, our host, James Q. Del Rosso, DO, sits down with Christopher Bunick, MD, PHD, an associate professor of dermatology at Yale University School of Medicine who performs specialized dermatologic research utilizing x-ray crystallography and other novel techniques. The 2 discuss research findings surrounding new information on properties that differentiate the activity of antibiotics, with specific data on how narrow spectrum activity with sarecycline differs from the broad-spectrum tetracyclines we use in dermatology. There are new data described by Dr Bunick and his team on how the unique molecular structure of sarecycline targets Cutibacterium acnes (C. acnes) through multiple mechanisms of action, making it less vulnerable to antibiotic resistance.&nbsp; Dr Del Rosso begins by introducing sarecycline, a major new antibiotic in dermatology, and has Dr Bunick discuss some of his research on the medication. Dr Bunick explains how the recent scientific findings on the biochemistry of sarecycline translate clinically and have allowed us to not only advance our understanding of sarecycline but also other tetracyclines, including minocycline and doxycycline. Drs Del Rosso and Bunick follow this up by agreeing on the importance of dermatologists having a strong understanding of tetracyclines given their prevalence and frequency of use in clinical practice. Next, they switch focus to C. acnes, and Dr Bunick discusses his new findings on the ribosomal structure of C. acnes through the use of cryo-electron microscopy and how tetracyclines interact with it. Dr Bunick’s research group found that sarecycline binds C. acnes at both the 30S ribosomal subunit and a new additional ribosomal binding site, which had not previously been discovered. In addition, Dr Bunick notes how these variations in the mechanism of action can explain why tetracycline antibiotics have different properties, such as side effect profiles, despite being in the same chemical class. Drs Bunick and Del Rosso further solidify this point by explaining how similar research has established differences between PDE4 inhibitors such as roflumilast. Finally, they discuss antibiotic resistance in acne and how clinicians can better select therapies. Dr Bunick explains that sarecycline has the lowest rate of antibiotic resistance amongst tetracyclines because it targets C. acnes through 2 ribosomal binding sites and has an mRNA interfering carbon side chain that no other tetracycline possesses. Overall, Drs Bunick and Del Rosso agree that there is substantial scientific evidence on the effectiveness of sarecycline that supports its use by clinicians. Tune in to this episode to learn more about the new developments on antibiotics being discovered at a molecular level in the treatment of acne!

Improving Our Understanding of How New and Established Drugs Work: Let's Start With Our Most Often Used Antibiotic Class

In Episode 55 of Derms and Conditions, our host James Q. Del Rosso, DO, sits down with Guy Webster, MD, PhD, FAAD, a Clinical Professor of Dermatology at Jefferson Medical College. The two discuss new developments in the pathophysiology and management of acne as well as key pearls and pitfalls when using topicals, antibiotics, and isotretinoin.&nbsp;

In episode 55 of Derms and Conditions, our host James Q. Del Rosso, DO, sits down with Guy Webster, MD, PhD, FAAD, a clinical professor of dermatology at Jefferson Medical College. The 2 discuss new developments in the pathophysiology and management of acne as well as key pearls and pitfalls when using topicals, antibiotics, and isotretinoin.Dr. Del Rosso begins by asking Dr. Webster about any major changes to acne dogma over the last few decades. Dr. Webster points out that while our knowledge is constantly evolving, our understanding of acne hasn’t changed as drastically as it has for diseases such as psoriasis. We know the 4 common pillars for acne pathophysiology, and we know the immune system is involved. The main mistake we have made is placing too much weight on newer data and ignoring older, equally robust data.Next, they switch focus to antibiotics and Dr. Del Rosso asks about their role in acne management. Dr. Webster finds topical antibiotics such as erythromycin and clindamycin ineffective as monotherapy due to drug resistance. However, benzoyl peroxide has not been shown to create resistance and therefore remains very effective. They also discuss oral antibiotics and some of the newer narrow-spectrum options like sarecycline.Dr. Del Rosso then asks Dr. Webster about a hypothetical but very common case of a patient with moderate acne and how he would approach treatment. Dr. Webster states that he disagrees with stepwise therapy and believes you should use your clinical experience to start with the right medication, right away. You should also identify what the patient’s goals are and recognize what they are willing to tolerate with regard to treatments. He notes that after about 4-6 weeks of treatment he can tell if a therapy is having a beneficial effect or if he needs to recommend a stronger option. Finally, they discuss isotretinoin and key considerations surrounding its usage. Tune in to this episode to learn more!&nbsp;

Guy Webster, MD, PhD, FAAD

The Right "Guy" For the Job to Bring Us Up to Date: Important Observations About Acne and Beyond

In episode 9 of&nbsp;Derms and Conditions, James Del Rosso, DO speaks with Emmy Graber, MD, MBA regarding acne and rosacea. Dr. Graber provides tips on how to manage persistent erythema associated with acne using a pulsed-dye laser.

In Episode 9 of&nbsp;Derms and Conditions, James Del Rosso, DO speaks with Emmy Graber, MD, MBA regarding acne and rosacea. Dr. Graber provides tips on how to manage persistent erythema associated with acne using a pulsed-dye laser.Treatment for acne scarring is also discussed and Dr. Graber shares some tips and tricks for treating sequelae of acne. Dr. Del Rosso asks Dr. Graber how she integrates physical and medical treatments for rosacea and residual erythema associated with rosacea. Finally, Dr. Graber shares an in office pearl which involves the use of a hair dryer and a pulsed dye laser. Financial Disclosures James Del Rosso, DO CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo). Emmy Graber, MD, MBA CONSULTANT/ADVISOR Digital Diagnostics, Almirall, Hovione, Keratin Biosciences, Sebacia, SolGel, Verrica, WebMD RESEARCH INVESTIGATOR Hovione, Ortho Dermatologics, Sebacia SPEAKER Almirall ROYALTIES WoltersKluwer Health &nbsp;

How to Avoid "Getting Red in the Face" When Treating Persistent Erythema Associated with Acne and Rosacea

A Roadmap for Clear Skin: Pathways to Put Acne in the Rearview Mirror 

In this session, James Del Rosso, DO, and Karan Lal, DO, provided insights into management of patients with acne.&nbsp;The presentation started with emphasis on patient-centered and collaborative care that sets the stage for successful acne treatment, emphasizing patient education, collaborative review of treatment options, joint-decision making, and compliance and follow-up. The presentation highlighted the need for combination therapy to address the 4 major factors involved in acne pathogenesis (ie, excess sebum production, follicular hyperkeratinization, cutibacterium acnes colonization and proliferation, and inflammation). Clascoterone is a competitive antagonist to the DHT-receptor that can reduce the effect of downstream androgen effects in skin for both genders above 12 years old. It has been shown to be effective and tolerable when used as a monotherapy but is recommended as an additional treatment in a combination regimen.&nbsp;Beyond the tried-and-true monotherapies that can be combined in a multistep regimen, there are double- and triple-combination topical acne products that include benzoyl peroxide (BPO), retinoids, and antibiotics to reduce treatment regimen steps. Clindamycin 1.2% + BPO + adapalene 0.15% gel has been shown to be effective in moderate-to-severe inflammatory and noninflammatory acne.&nbsp;They discuss further the various nuances in the art of acne treatment. When comparing topical antibiotic treatments, clindamycin showed longer-term efficacy and anti-inflammatory properties than erythromycin. Just as the type of antibiotic chosen can make a difference, delivery can also change efficacy. It was emphasized that the formulation of products and vehicles matter—polymeric emulsion formulation has been shown to better stabilize and deliver active ingredients while increasing tolerability.&nbsp;Rosso and Lal conclude with an interactive discussion and case presentations that present a stepwise approach to patients with acne. Cases start with the patient-centered approach mentioned above and critical thinking about compliance, motivation, tolerability, and severity of lesions. They then recommend selecting from a wide range of topical regimens first while keeping those patient-specific factors and goals in mind.

Evaluating Benzene Concerns in Benzoyl Peroxide Products 

In this episode of Topical Conversations, John Barbieri, MD, MBA, FAAD, shares his updated thoughts on the Valisure report findings from March 2024, which identified potentially harmful levels of benzene in benzoyl peroxide-containing products, particularly those exposed to high temperatures.&nbsp;Call for transparency and FDA input&nbsp;Dr Barbieri expressed the medical community's need for more detailed information from Valisure and guidance from the FDA. He highlighted the importance of updated data to determine whether benzoyl peroxide products remain safe for consumer use. The lack of conclusive data has left health care professionals seeking clarity to make informed decisions for their patients.&nbsp;Approach to patient care&nbsp;In the absence of more comprehensive data from Valisure and definitive input from the FDA, Dr Barbieri shared his approach to managing the potential risks in clinical practice. He referenced 2 recent studies that provide some reassurance regarding the safety of benzoyl peroxide products: <a target="_blank" rel="noopener noreferrer" href="https://www.jaad.org/article/S0190-9622(24)00980-0/abstract">One study analyzing blood benzene levels</a> demonstrated that individuals using benzoyl peroxide-containing products do not exhibit elevated benzene levels in their blood compared to nonusers. <a target="_blank" rel="noopener noreferrer" href="https://www.sciencedirect.com/science/article/abs/pii/S019096222401051X">Another cohort study on cancer risk</a> found no increased risk of leukemia, lymphoma, or other cancers among users of benzoyl peroxide products compared to those who do not use these products.&nbsp;Dr Barbieri found these results reassuring, indicating that routine use of benzoyl peroxide-containing products does not appear to pose the risks of cancer or elevated benzene levels that might be expected.&nbsp;Understanding benzene exposure risks&nbsp;Dr Barbieri explained the general principles of toxicology, noting that "the dose makes the poison." Benzene, a known carcinogen, is not significantly absorbed through the skin, making topical exposure unlikely to cause major risks such as skin cancer. He provided a comparative analysis of benzene exposure, explaining that even the worst-case scenario product tested by Valisure, with 10 parts per million of benzene, would result in about 10 micrograms of exposure from a typical 1-gram application. He compared this to the everyday benzene exposure from a gas stove, which emits about 5 micrograms of benzene per minute. This comparison suggests that the theoretical risk from benzoyl peroxide products is minimal compared to common everyday exposures.&nbsp;Practical advice and continued use in clinical practice&nbsp;Dr Barbieri continues to use benzoyl peroxide products in his practice. He advises patients to store these products properly and emphasizes the importance of considering the supply chain to minimize heat exposure during transit.&nbsp;Awaiting further guidance&nbsp;Dr Barbieri concluded by expressing a need for ongoing input from the FDA to provide clearer guidelines on the safety of benzoyl peroxide products. In the meantime, he believes that with appropriate storage and usage, these products can be used safely, supported by current data and practical considerations.

Examining Benzene in Benzoyl Peroxide: Insights into the Latest Research 

In this episode of Topical Conversations, John Barbieri, MD, MBA, FAAD, examines the safety concerns surrounding benzoyl peroxide, a common ingredient in acne treatment products. He reviews 2 new research studies that investigate the risks associated with benzoyl peroxide use, providing insights into its safety for routine clinical practice.&nbsp;Concerns raised by Valisure report on benzoyl peroxide&nbsp;In March 2024, Valisure released a report indicating that benzoyl peroxide products may contain benzene, a potential carcinogen, due to thermal decomposition under high temperatures. This raised concerns about the safety of benzoyl peroxide in clinical practice. Dr John Barbieri addresses these concerns by discussing 2 new research studies that explore the risks associated with benzoyl peroxide use.&nbsp;Analysis of blood benzene levels in benzoyl peroxide users&nbsp;<a target="_blank" rel="noopener noreferrer" href="https://www.jaad.org/article/S0190-9622(24)00980-0/abstract">The first study</a> analyzed data from the National Health and Nutrition Examination Survey (NHANES), comparing blood benzene levels in individuals using benzoyl peroxide products with those who did not. The study matched participants on various risk factors for benzene exposure and found no detectable differences in benzene levels between the 2 groups. Additionally, for those with detectable benzene, the average levels were similar in both groups. Dr Barbieri notes that these findings suggest that benzoyl peroxide use does not lead to increased benzene levels in the body, providing reassurance about its safety in routine clinical use.&nbsp;Long-term cancer risk assessment in benzoyl peroxide users&nbsp;<a target="_blank" rel="noopener noreferrer" href="https://www.sciencedirect.com/science/article/abs/pii/S019096222401051X">The second study</a> utilized data from TriNetX, examining a cohort of over 50,000 individuals. The study matched benzoyl peroxide users with nonusers and monitored them for 10 years. The research did not identify any increased risk of malignancy, including leukemia, lymphoma, or solid organ tumors, among benzoyl peroxide users. Dr Barbieri comments that these results further support the safety of benzoyl peroxide in clinical practice, indicating no heightened cancer risk from its routine use.&nbsp;Overall safety of benzoyl peroxide in clinical practice&nbsp;Dr Barbieri concludes by commenting that together, these studies provide valuable data, suggesting that the routine use of benzoyl peroxide products for acne and other skin conditions appears to be relatively safe. He suggests that, based on these findings, patients and clinicians can feel reassured about the continued use of benzoyl peroxide in their treatment regimens.

Exploring a Triple-Combination Therapy for Acne Management 

In this episode of Topical Conversations, John Barbieri, MD, MBA, FAAD, gives an overview of a triple-combination topical therapy for acne comprising clindamycin, adapalene, and benzoyl peroxide, highlighting its efficacy, safety, and tolerability and how this formulation may impact patient adherence.&nbsp;Efficacy&nbsp;In phase 3 clinical trials, the success rates, as measured by the Investigator’s Global Assessment (IGA) of achieving clear or almost clear skin, were 50% for those using the treatment, compared to 20% for those using the vehicle. For context, most single-ingredient topical therapies show a delta of about 10% between the treatment and the vehicle. Fixed-dose combination treatments with 2 ingredients generally show a delta of around 20%. Therefore, the 30% delta observed with clindamycin/adapalene/benzoyl peroxide underscores its potential as a powerful option in acne therapy.&nbsp;Meta-analysis findings&nbsp;A meta-analysis that reviewed over 221 randomized controlled trials found that clindamycin/adapalene/benzoyl peroxide had the highest rates of effectiveness among all acne treatments evaluated. Earlier studies also demonstrated that this triple-combination therapy outperformed any of the dual-ingredient combinations.&nbsp;Tolerability and safety profile&nbsp;In addition to its efficacy, clindamycin/adapalene/benzoyl peroxide demonstrates a favorable tolerability profile. The phase 3 trials reported a discontinuation rate due to adverse effects of just 2.5%. For comparison, phase 3 studies of adapalene-benzoyl peroxide combinations reported discontinuation rates of about 2%, while tretinoin-benzoyl peroxide combinations had a rate of approximately 3.2%. The meta-analysis also indicated that this new treatment is relatively well-tolerated, on par with other topical retinoid or fixed-dose combination treatments.&nbsp;Implications for patient adherence&nbsp;This triple-combination therapy not only shows high efficacy and good tolerability but also has the potential to improve patient adherence. Studies have consistently shown that patients are more likely to adhere to fixed-dose combination products compared to using individual components separately. Improved adherence often leads to better outcomes in acne management, making this therapy a promising option for patients.

Dermbusters: Cheri Frey, MD

In this episode of Dermbusters, host Nicholas Brownstone, MD, chats with Cheri Frey, MD, about some common misperceptions they often hear from their patients.Dr Frey shares some suggestions on how to counsel patients on 2 significant topics: retinol use for patients with sensitive skin and moisturizing for patients with acne.Myth 1: Patients with sensitive skin can’t use retinol for acne.Dr Frey addresses a common myth that dermatologists often hear from their patients: that they shouldn’t use retinol to treat acne if they have sensitive skin. She offers a few suggestions for dispelling this misperception when speaking with patients.Tips for counseling your patients:<ul><li>Advise eligible patients to try an over-the-counter retinol that’s not as strong or harsh as prescription-strength retinoids</li><li>Explain application strategies such as the sandwich method, which involves applying retinol between 2 layers of moisturizer, and short-contact application, where retinol sits on the skin for a few minutes before being washed off</li><li>Express the importance of retinol as a cornerstone of acne treatment and reassure patients there is always a way to incorporate it as a therapy</li></ul>Myth 2: Patients with acne can’t moisturize their skin.Dr Brownstone and Dr Frey next cover another common myth often heard from patients: that moisturizing can exacerbate acne.Dr Frey stresses the importance of moisturization for patients with acne and serves up a few tips to use in patient conversations when addressing this topic.Tips for counseling your patients:<ul><li>Explain the barrier disruption that occurs in patients with acne and how it can cause more irritation and inflammation; advise patients that moisturizing can mitigate this disruption to the top layer of skin</li><li>Educate patients on the drying nature of retinols and other acne-fighting ingredients; emphasize the importance of keeping skin hydrated so patients can tolerate their acne medications</li></ul>

Updated AAD Guidelines for Acne Vulgaris: A Summary of Key Points  

In this episode of Topical Conversations, join John Barbieri, MD, MBA, FAAD as he summarizes some key points from the American Academy of Dermatology’s <a target="_blank" rel="noopener noreferrer" href="https://dermsquared.com/news-research/aad-updates-guidelines-for-management-of-acne-vulgaris">updated guidelines for the management of acne vulgaris</a>. These evidence-based recommendations were last updated in 2016.&nbsp;Topical treatments&nbsp;Several new treatments have emerged since the prior guidelines were released, including the antiandrogen clascoterone, the first topical treatment that addresses the fundamental hormonal causes of acne. Clascoterone, which is safe for both men and women and approved for patients 12 years and older, received a conditional recommendation for use in the new guidelines. Clascoterone demonstrates a high certainty of benefits over risks; however, a conditional recommendation was issued due to the current high cost of treatment that may impact equitable access.&nbsp;Oral antibiotics&nbsp;Sarecycline&nbsp;Sarecycline, a narrow-spectrum tetracycline, received a conditional recommendation in the updated guidelines. Sarecycline, while effective at treating acne, can have a negative impact on the gut microbiome. As an oral antibiotic, it comes with the limitations and challenges of using antibiotics in the treatment of acne; however, it poses some theoretical advantages to other antibiotics currently in use for acne treatment. The high cost of sarecycline treatment was also a factor in issuing a conditional recommendation for this treatment.&nbsp;Doxycycline and minocycline&nbsp;Notably, doxycycline received a strong recommendation in the updated guidelines while minocycline received a conditional recommendation. The conditional recommendation is supported by the potential for side effects that are unique to minocycline, including severe cutaneous adverse reactions and vestibular dysfunction. Considering this, the guidelines recommend doxycycline over minocycline for the typical patient with acne.&nbsp;This represents a departure from current practice, where both drugs tend to be used equally.&nbsp;Trimethoprim-sulfamethoxazole&nbsp;The guidelines also discuss limiting the use of antibiotics like trimethoprim-sulfamethoxazole, as these can be associated with serious cutaneous adverse reactions and acute respiratory failure. Isotretinoin The guidelines also discuss the use of isotretinoin, one of the most effective treatments currently available for acne. The updated guidelines discuss recommendations for lab monitoring and notable adverse effects like inflammatory bowel disease and neuropsychiatric symptoms.&nbsp;Spironolactone&nbsp;The guidelines also detail recommended lab monitoring for spironolactone. For healthy patients who do not have other risk factors for hyperkalemia, the guidelines advise that routine potassium monitoring is likely a low-value practice. This determination may help clinicians feel more comfortable with patients who would prefer to pursue less lab monitoring while undergoing treatment for acne vulgaris.&nbsp;Key points&nbsp;<ul><li>Clascoterone and sarecycline received conditional recommendations for use in the updated guidelines, with high cost of treatment and potential impact on equitable access contributing to the recommendation&nbsp;</li><li>Doxycycline received a strong recommendation&nbsp;</li><li>Minocycline received a conditional recommendation supported by potential for adverse effects unique to minocycline&nbsp;</li><li>Doxycycline is recommended over minocycline for the typical patient, representing a departure from current practice&nbsp;</li><li>The guidelines recommend limiting the use of trimethoprim-sulfamethoxazole&nbsp;</li><li>The guidelines advise that routine potassium monitoring for most patients on spironolactone is likely a low-value practice</li></ul>

What's New and Hot in Acne and Rosacea

Major developments in the treatment of acne and rosacea in the past year have changed the face of these two common clinical conditions. In this relevant update, Hilary Baldwin, MD started by refreshing us on a consensus shift in literature to phenotypes of rosacea rather than distinct subtypes, all of which maintain centrofacial erythema as the key diagnostic feature. Other features of rosacea such as telangectasias, flushing, papules, and ocular manifestations are not diagnostic in and of themselves but useful to assess severity when considered all together. The shift from subtypes to phenotypes is particularly important, Dr. Baldwin assured us, when considering treatment options and algorithms.&nbsp;Specifically, for papules and pustules, treatments remain focused on topical antimicrobials including ivermectin 1% cream, minocycline 1.5% foam, and microencapsulated benzoyl peroxide 5% with or without the addition of an oral tetracycline or isotretinoin. Oral options include sarecycline, which has narrower antimicrobial activity compared to other tetracyclines, and low-dose extended-release minocycline which showed superiority at all timepoints to the customary 40mg doxycycline. For persistent facial erythema, Dr. Baldwin recommended alpha agonists like brimonidine and oxymetazoline, beta blockers for flushing, and vascular lasers for telangiectasias. While the potent vasoconstriction by alpha agonists makes them a clear choice for any erythema acutely, a more recent study showed that the efficacy of oxymetazoline cream increased overtime as patients had improvement in even pre-application erythema severity scores at 52 weeks with consistent application. One clinical pearl is to target perilesional erythema by treating papules and pustules rather than targeting the erythema itself. She concluded the rosacea portion by reviewing some atypical treatments such as mast cell stabilizers and botulinum toxin, which also inhibits mast cell degranulation as well as decreasing substance P release and calcitonin gene-related peptide to decrease erythema.&nbsp; Acne, one of the most common conditions seen in the clinic, affects a wide range of ages and Fitzpatrick skin types. Dr. Baldwin reviewed some accessible topicals that have emerged for acne including microencapsulated benzoyl peroxide 3%/tretinoin 0.1%, which was more efficacious than either component alone without an increase in adverse events, and clascoterone 1% cream, a promising new androgen receptor inhibitor. Due to rapid metabolism in the skin into cortexelone, which has no anti-androgenic activity, it is considered safe for men, and results from a RCT demonstrated significant efficacy with about 20% of patients achieving an IGA score of 0 or 1 by week 12. Perhaps the most exciting novel treatment for acne vulgaris is the 1726nm Nd:YAG laser which destroys sebocytes and is safe for use in darker skin types. Dr. Baldwin concluded by presenting data in over 100 subjects with mostly moderate acne vulgaris who were treated with 3 total 30 minute monthly laser treatments. 80% of patients obtained a greater than 50% reduction in inflammatory lesion count 3 months after their final treatment. Overall, this session reviewed some practice-changing therapeutics for rosacea and acne vulgaris, which have taken center-stage of innovation in inflammatory skin disease.&nbsp;

Breaking Down the FDA-Mandated Changes to the iPLEDGE Program for Isotretinoin 

The FDA has recently mandated significant modifications to the iPLEDGE program, which is designed to manage the risks associated with isotretinoin use. In this video, Dr John Barbieri of Brigham and Women’s Hospital and Harvard Medical School breaks down the details of the key updates.&nbsp;<h6>Streamlined Counseling for Individuals not of Childbearing Potential&nbsp;</h6>One of the most noteworthy changes is the elimination of monthly counseling documentation for individuals not of childbearing potential. Previously, this requirement added an unnecessary burden for both patients and clinicians. Under the new guidelines, counseling documentation will only be required at enrollment, potentially providing a substantial reduction in the frequency of patient visits. Dr Barbieri underscores how this change can enhance flexibility for clinicians, making it easier to prescribe isotretinoin and subsequently improve access to this crucial acne treatment.&nbsp;<h6>Removal of the 19-Day Lockout Period&nbsp;</h6>A second pivotal change involves the removal of the 19-day lockout period. Currently, patients face a stringent 7-day window to pick up their prescription; if missed, patients are required to wait 19 days before taking another pregnancy test. This measure, sometimes considered overly punitive to patients, is now being eliminated, aligning the iPLEDGE program with other similar programs. Under the new requirements, patients who miss the initial 7-day window can repeat a pregnancy test, granting them eligibility to receive the drug. This modification addresses issues related to pharmacy stock and prior authorization hurdles, ensuring patients can access the medication without unnecessary delays.&nbsp;<h6>Shift Towards Home Pregnancy Testing&nbsp;</h6>Another substantial update involves a shift from requiring CLIA-certified pregnancy tests to allowing home pregnancy testing for patients of childbearing potential. While the first 2 tests, to enroll the patient and after the 30-day waiting period, still need to occur in an office-based setting, subsequent tests after the initiation of isotretinoin can be conducted either in a medical setting or using a home pregnancy test. Dr Barbieri suggests steps to minimize falsification, such as having patients write their names and dates on the test, ensuring accuracy and convenience for patients.&nbsp;<h6>Anticipated Implementation&nbsp;</h6>These transformative changes are eagerly anticipated, and isotretinoin manufacturers have been given a 6-month window to respond to the FDA's recommendations. Dr Barbieri expresses hope that collaboration with stakeholders, including dermatologists, patients, and pharmacists, will be key to implementing changes that prioritize patient safety while ensuring continued and accessible isotretinoin treatment.

Therapeutic Hotline: Acne, Rosacea, AKs, Eczema, and Others

Hi, I'm Gary Goldenberg, dermatologist in New York City. In my therapeutic hotline presentation, I reviewed multiple new medications that we can use to improve the lives of our patients. There's so many new therapies available for us in dermatology. It's a very exciting time. From acne to rosacea to psoriasis, eczema, skin cancer diagnosed prognosis treatment, viral skin infections, there's really a plethora of new treatments that we can use to improve our patients conditions. As dermatologists, it's our job to bring the latest and greatest treatments to our patients. And the therapeutic hotline presentation reviewed all of these new developments that we have in dermatology.

In this session, Gary Goldenberg, MD, took the audience on a whirlwind tour through the latest in treatment updates for common dermatologic conditions. Starting off with acne and rosacea, Dr Goldenberg reviewed efficacy data for a new fixed-dose combination product currently in clinical trials: clindamycin 1.2% + benzoyl peroxide 3.1% + adapalene 0.15% gel (IDP-126). In a Phase 2 study, IDP-126 gel showed superior efficacy in reducing inflammatory and noninflammatory lesions than other fixed-dose combination products (CLIN/BPO, BPO/ADAP, CLIN/ADAP). Dr Goldenberg also reviewed data for clascoterone 1% cream, a novel 1726 nm laser recently approved for mild, moderate, and severe acne and a photopneumatic acne therapy system.&nbsp;Moving on to atopic dermatitis, Dr Goldenberg discussed the impressive efficacy of both upadacitinib and abrocitinib before introducing tapinarof cream 1%, which is currently under investigation for use in atopic dermatitis. Transitioning to new nonsteroidal topical treatments of psoriasis, tapinarof cream 1% daily led to 64% of patients achieving PASI-75 responses at any time point in a pooled Phase 3 trial analysis. Apremilast appears to be safe and efficacious for pediatric patients with moderate-to-severe plaque psoriasis, with 45.4% achieving PASI-75 at Week 16 compared to 16.1% of those on placebo. Dr Goldenberg concluded the discussion on psoriasis with an overview of recently released data for several biologic medications, including secukinumab, ixekizumab, and risankizumab.&nbsp;Transitioning to medications currently under investigation, roflumilast foam 0.3% was shown to be effective for seborrheic dermatitis in Phase 2 trials. Monotherapy with nemolizumab, an IL-31R inhibitor, led to statistically significant improvements in itch scores compared to placebo in patients with prurigo nodularis in Phase 3 trials, and secukinumab was statistically superior to placebo in reducing abscesses and inflammatory nodules in hidradenitis suppurativa compared to placebo in Phase 3 trials. Dr Goldenberg concluded this action-packed session with an update on useful technology for dermatologists, including a pigmented lesion assay and electrical impedance spectroscopy machine to assist in melanoma diagnosis, as well as gene expression profiling tests to assist with risk stratification for patients with melanoma and cutaneous squamous cell carcinoma. With all of these new medications and technologies, it is certainly a great time to be a dermatologist!

Dermbusters: Elizabeth Swanson, MD

Welcome to Derm busters, where we discuss common misperceptions in the practice of dermatology. I'm Dr. Nick Brownstone, here with Dr. Lisa Swanson, dermatologist. Lisa, nice to have you here. Thanks. I want to ask you about a disease that I really never see, which is acne. That's funny. Just kidding. I see acne all day, every day. And obviously a medication network. Everyone's so familiar with accutane. Lot of misperceptions about amongst our colleagues and amongst our patients, too. So first thing I want to ask Lisa is monthly labs for Accutane. Are they needed for safety? So I would say in a short answer, no. And I've been in practice a little over twelve years. And back when I was in training, we did do labs every month. We did liver function tests. We did a lipid panel. Some providers did a CBC as well. And during my years of practice, that monitoring guideline rules have gotten less and less and less. And there was just a really great article in the jamaderm in August saying that actually we just need to check alt and triglycerides, and we just need to check them at baseline and then after two months or when the peak dose is reached. And so we really only have to check twice, and we really only have to check two things, which is great news for our patients. Yeah, I read that article, too. Really great article. So more of a myth, you would say? Yes, I would say that's a myth. And what do you tell your patients about this? When they say, oh, I want labs, I want to make sure this medication is not causing any side effects. I don't have any patients like that. Okay. My patients are very excited when they hear that. It's just two times that they have to have their blood drawn if they say less needles, that they like that. Yes, they do. Okay, that's great to hear. Next question about accutane. Does it increase risk of suicidal behavior or depression? This is very controversial. There has been a lot of stuff swirling about this for years and years and years. What I tell patients and their families, I say that there were some initial concerns about the risk of depression and suicidal ideation with patients on accutane. And because of these concerns, it has been extensively studied. Looking at studies of tens of thousands of patients that were studied on accutane. And what they've actually found in most of them is that people who go on accutane actually notice an improvement in their mood. Their skin is clearer, they're looking better, they're feeling better, their self esteem improves, their confidence improves, and so their happiness improves. And so if you look at tens of thousands of patients, you would say there is no association with suicidal ideation or depression. I do also tell my patients and their families that in my twelve plus years of practice, I have had six patients who've become depressed and had to stop the medicine. So I prescribe accutane every day. I'm a pediatric dermatologist, so six patients in twelve plus years is a pretty teeny number. I do think it does happen rarely. But if you look at all the studies, it says that most patients note an improvement in their mood. Great. Accutane, common medication. We discussed two myths, and I learned a lot. Thank you for speaking with me. Of course. Thanks for having me. Bye.

Join Dr Nick Brownstone in this episode of Dermbusters, where he chats with Dr Elizabeth Swanson to address some common misperceptions surrounding the use of Accutane that they often hear from both colleagues and patients.&nbsp;<h5>Are monthly labs for Accutane needed for safety?&nbsp;</h5>No. Dr Swanson notes that she has been in practice for over 12 years, and when she was in training, providers did do labs every month for patients taking Accutane, including a liver function test, a lipid panel, and sometimes a CBC. Since she’s been practicing, the guidelines for Accutane have recommended less and less monitoring over time.&nbsp;She references an article published in JAMA Dermatology that recommended testing only for alanine aminotransferase (ALT) and triglycerides at baseline and again at 2 months or after peak dose is reached. Dr Swanson comments that testing only twice for 2 things is great news for patients.&nbsp;Dr Brownstone asks Dr Swanson how she counsels patients when they want additional labs performed to ensure the medication isn’t causing side effects. She remarks that her patients never request that, and she generally finds they are very pleased to only need minimal blood draws for monitoring.&nbsp;<h5>Does Accutane increase the risk of suicidal behavior or depression?&nbsp;</h5>Dr Swanson notes that this is a very controversial topic. When she addresses this with her patients and their families, she explains that there were some initial concerns about suicidal behavior and depression in patients with Accutane, but because of these concerns, it has been extensively studied in tens of thousands of patients. Those studies found that most patients actually notice an improvement in their mood due to clearer skin and improved self-esteem and confidence.&nbsp;As a pediatric dermatologist, Dr Swanson prescribes Accutane daily; she reassures her patients and their families that in her years of practice, she has had only 6 patients who exhibited signs of depression and had to stop the medication. She concludes by noting that while these side effects do occur rarely, the studies support patients seeing an improvement in their mood.

If a patient is on oral spironolactone and is trying to conceive, how long before that should they stop the spironolactone?

You. So in general, it's not advisable to have a patient on oral spironalactone while they're pregnant. We want to avoid that, but there really doesn't need to be a large washout period beforehand. The half life of oral spiron lactone is very short. It's less than 24 hours. So usually what I tell patients is when you stop your contraception, when you stop your birth control pill, or when you're actively trying to become pregnant, that's when you should stop your spiralactone. If you have a patient who should inadvertently become pregnant on spironalactone, it's always good to consult with your local gynecologist or your patient's gynecologist. Quite frankly, I've had other gynecologists tell me that they aren't concerned and that they'll even use spironalactone in some cases for preeclampsia, which is a condition that they treat during pregnancy. So although I try to, my best to have patients avoid pregnancy while they're on spironalactone, they don't need to stop the spiron lactone for weeks or days or months before they try to conceive. Just really, I tell them when you're going to try to conceive, stop your spironalactone.

What are the pros and cons of the different topical azelaic acid formulations?

You. So the prescription topical azalaic acid formulations that we have available are the 15% gel, the 15% foam and the 20% cream. Now, one thing I used to think was that, well, stronger or higher number must be better, but that may not necessarily be the case. The 20% is not necessarily better than the 15%. There are some in vitro studies that show that there's actually greater cutaneous penetration with the 15% gel versus the 20% cream. When we look about tolerability amongst the 15% products, the foam actually has reduced side effect profile or cutaneous adverse events compared to the 15% gel. There are no head to head studies. However, in the phase three studies of the foam, there were fewer incidence of cutaneous pain and paritis as compared to the 15% gel. So.

Do you suggest checking potassium on patients on drospirenone containing OCP with concurrent use of spironolactone on healthy patients?

You. I personally don't routinely check potassium levels in patients on spironalactone unless they're on a medication that may also cause hyperkalemia or if they're over the age of 45, or if they're on a really high dose such as 100 milligrams bid. So if they're on 200 milligrams a day or higher, or they have a preexisting condition that might make them more likely to develop hyperkalemia or they're over 45, then I will occasionally check potassium. Now, the issue with the drospirinone containing oral contraceptive pills is that drospirinone in itself acts similarly to about 25 milligrams of spironalactone. Now. So in general, in patients who are both on drospironone and spironalactone, I'm not concerned, except if we're getting up into those higher doses where we're pushing close to 200 milligrams a day total, and they're on a drospironone containing oral contraceptive, then I may check a potassium. If they're on, say, 50 milligrams a day of spironalactone or 100 milligrams a day of spironalactone plus drospirinone, I'm not concerned unless they're over 45 or unless they have another preexisting condition or another or medication that also causes hyperkalemia.

What dose of spironolactone do you typically use in your acne patients?

You. So when I start a patient on oral spironalactone, I do tend to start on the lower end because we can always go up. Especially I might start patients a little bit lower. If they're a patient that doesn't intake a lot of fluids, like water during the day, or if it's somebody who does a lot of cardio exercise and they're sweating a lot during the day, then I might be more worried read about the additive diuretic effect of the spironalactone, and I might be more concerned about them developing perhaps some orthostatic hypotension. So in my patients who tell me they're not great water drinkers or they are running a lot during the day, I might start them on the lower end, even sometimes as low as 25 milligrams a day, although my usual dose for those patients is 25 milligrams bid. Do have some patients that I start at 50 milligrams bid. It just depends on their level of comfort, also with the medication and also if they do a lot of cardiovascular exercise, are sweating a lot, don't have a lot of water intake. I might start them on the lower end and then reassess in a few months and potentially increase.

Can you integrate hormonal therapy with sarecycline?

You. I get this question a lot about using oral spironalactone with oral seracycline. Can I do both? Do I have to do one or the other? I do both all the time, or a lot of the time, I should say, just because the onset of action is so different between these two therapeutics, oral seracycline, the study show you can see improvement as early as three weeks in inflammatory lesions, whereas with spironalactone, it might take at least three months. And so sometimes if I have a patient in my office who I think has hormonal acne and she's very upset about it and really doesn't want to wait the three months to get it better, I'll also start at the same time, seracycline, so that we can get some initial improvement within that first month. And then once the spironalactone has kicked in a few months later, then I may stop the oral seracycline.

Why does clascoterone work for acne and not minoxidil since they are both anti-androgens?

I've got a question here about classicodarone, which is a new topical medication that's coming out that's actually been approved for acne and has completed trials for use in male pattern hair loss. And the question is, why does minoxidil not work for acne and closcorone does? And the question was around those medications, both being antiandrogens. Well, the first issue is that minoxidil is not an antiandrogen. Minoxidil is actually in its own class. It's nothing to do with hormones. It just happens to prolong the antigen phase. We think that it has to do with potassium, inhibition of receptors in the follicle. And so there's no antiandrogen effect from minoxidil. So it's a totally different class from classcodorone. So it would not make sense for minoxidil to work in its current form. It is typically a little bit of an irritat to the skin, so we don't typically have patients apply it to their face or if they do very sparingly to eyebrows in patients with alopecia of the eyebrows, potentially a few times a week. So we wouldn't want to try to think about using minoxidil for acne because that would not be a good use of that medication.

Are there any differences in the side effect profiles between ABSORICA LD and traditional isotretinoin?

So with the advent of isotretinoin formulations that are presolubilized in the lipid matrix. So you don't need a fatty meal like you do with branded generics or accutane, which was the original brand, which is now available from a company. Those original agents, the branded generics like amnestine, Clarivis, xenotane, myoricin and Accutane. To get optimal absorption, you need to give a high fat meal, and they were studied with 50 grams of fat, which would be needed with each dose. With the presolubilized formulations Absorica and Absorica LD. Absorica LD is micronized. It's absorbed even better. Even with water, you don't need a fatty meal. We have to recognize that that correlates with a lower risk of relapse because they get greater systemic exposure. But the side effect profiles are the same. The formulations like Absorica and absoric LD do not have any additional safety signals as compared to any oral isotretretinoin. So the monitoring and the side effect profiles are the same.

Do you see WINLEVI replacing ACZONE?

You. We now have available a topical androgen receptor inhibitor, which is topical cliscodorone. It's FDA approved as a 1% cream applied twice a day in patients with acne that are at least twelve years of age. This is the first time we actually have an FDA approved androgen receptor inhibitor. It's available topically. So the data showed that it can be used in males and females with oral spironalactone, which is an androgen inhibitor that we use off label. It's utilized only in females, but it's important to recognize that topical clascodorone was studied in males and females and can be safely used in both. It's a unique mechanism of action. So a lot of people ask, is this going to replace topical dapsone or topical benzero peroxide or retinoids? It doesn't technically replace anything because it's working on a different pathophysiological pathway. So there's no immediate replacement of any other agent, whether it be topical or oral antibiotic for that matter, it doesn't replace any other therapies. It targets a specific pathophysiology, which is inhibition of androgen activity.

Can AMZEEQ be combined with benzoyl peroxide?

You. So with the advance, with topical minocycline being available, and there's a 4% foam that's available once a day for the treatment of acne. There's a 1.5% topical minocycline foam approved for the treatment of papilla plush lesions of rosacea. But we're typically going to get into a situation where we want to use topical minocycline 4% foam in a patient with acne, where we also want to use benzo peroxide. We have to recognize that benzel peroxide is an oxidizing agent and it can actually break down or degrade certain other agents that we use for acne. We've known about that for years with tretinoin. So we separate benzoil peroxide from most of the formulations of tretinoin with topical minocycline foam. Benzoil peroxide degrades the topical minocycline foam, so we expect it to be less active or inactive, and it also is going to create a discoloration. So it is recommended, and actually, it's in the labeling that you separate by at least 8 hours application of benzo peroxide from when they apply a topical cycling foam.

When do you restart retinoids and azelaic acid after a chemical peel?

You. So restarting topicals after a chemical peel procedure is really important in terms of timing and treatment outcome, especially for your skin of color patients. Typically, if it's a retinoid, I will wait a minimum of 72 hours post peel to restart azalaic acid and sunscreen and cosmeceuticals. I'm a little bit more open to starting those sooner if the patient would really like. Honestly, it's very treatment dependent depending on your depth of your peel and how the patient is reacting. A good rule of thumb is five to seven days as a blanket rule and then adjust accordingly for dependent on the ingredient subtype.

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