Topical Conversations

In this episode of Topical Conversations, Dr John Barbieri of Brigham and Women’s Hospital in Boston provides an overview of the exciting developments in acne treatment in 2024 and shares key innovations to look forward to in 2025. 2024: a year of breakthroughs in acne care Fixed-dose combination therapy One of the standout advancements of 2024 was the introduction of a fixed-dose combination therapy comprising clindamycin, adapalene, and benzoyl peroxide. Dr. Barbieri highlights this as the most efficacious single-agent topical treatment currently available for acne. Optimized vehicle: Unlike other products, this combination utilizes an advanced formulation to minimize irritation and improve patient comfort. Enhanced adherence and outcomes: Studies comparing fixed-dose combinations to separately used components have demonstrated improved adherence rates and superior clinical outcomes. Comprehensive mechanism of action: Pairing this fixed-dose therapy with another agent, such as clascoterone, addresses all major acne pathways, offering a robust, well-tolerated treatment option. 1726 nm lasers: targeted sebaceous gland therapy Another significant development in 2024 is the emergence of 1726 nanometer lasers, including devices like AviClear and Accure. Precision treatment: These lasers directly target sebaceous glands, providing a focused alternative to systemic therapies like isotretinoin, which often carry off-target side effects such as eye dryness and systemic impacts. Clinical efficacy: Clinical trials show promising results: Around 40% of patients with moderate to severe acne achieve clear or almost clear skin for up to 6 months post-treatment. Eighty to 90% of patients experience at least a 50% reduction in inflammatory lesions. Well-tolerated option: While transient acne worsening can occur, the overall side effect profile is favorable, offering a new avenue for patients who cannot or prefer not to use systemic treatments. Looking ahead: innovations in 2025 and beyond Spongilla lacustris extract mask A topical treatment derived from Spongilla lacustris extract is under development as a once-weekly mask with dual anti-inflammatory and antimicrobial properties. Phase 2 success: Early trials have shown promise, paving the way for this novel therapy to become an accessible option for patients with acne N-acetyl-GED Another exciting candidate is a topical treatment targeting the sebaceous glands. Direct Action on Sebaceous Glands: This innovation offers a rare mechanism of action for topical therapies, focusing on reducing sebum production, oiliness, and acne-promoting factors like C. acnes bacteria Potential for Impact: With few existing treatments addressing sebaceous gland activity directly, this agent holds potential to reshape acne management The Road Ahead in Acne Treatment As we look ahead to 2025, the landscape of acne treatment is set to evolve with a mix of innovative therapies and technologies. Fixed-dose combination topicals, advanced laser technologies, and novel agents in development offer new options to address the complex mechanisms of acne. These advancements provide dermatologists with more tools to tailor treatments to individual patient needs. By staying informed and incorporating these developments into practice, dermatologists can continue to refine their approach to managing acne and improve overall outcomes.

In this episode of Topical Conversations, Dr Stephen Lewellis provides an insightful overview of the evolving landscape of dermatology devices and treatments to watch in 2025. Sharing his personal insights and experiences, Dr Lewellis highlights how these innovations can enhance patient outcomes and help dermatologists distinguish their practice by offering unique and forward-thinking options that patients may not encounter elsewhere. AviClear for acne Dr Lewellis begins by discussing AviClear, a 1726-nanometer laser device FDA cleared for treating acne of all severities. He highlights its best use cases, including moderate to severe inflammatory acne and patients who cannot or do not wish to take isotretinoin. Treatment overview: Three treatments over 2 months with optimal results typically appearing 6 to 12 months post-treatment Patient counseling: Emphasize patience and realistic expectations for long-term improvement Cost consideration: Though not covered by insurance, it may be more affordable than isotretinoin in some cases Dr Lewellis advises dermatologists to consider AviClear as part of their practice or refer patients to trusted colleagues who offer this treatment to provide comprehensive care. excel V+ Plus for versatile needs The excel V+ device features the Laser Genesis treatment mode, which uses 532- or 1064-nanometer lasers to induce dermal heating. Treatment benefits: Improved complexion, reduced pore size, and some acne improvement with minimal downtime Expectations: While optimal results require 6 to 8 treatments, even 1 to 2 sessions can provide improvement Applications: Beyond aesthetics, excel V+ can treat rosacea, inflammatory acne, and more, making it a versatile addition to a dermatology practice Swift for refractory warts Swift uses focused microwave energy to treat warts, especially plantar warts, by inducing a heat response that stimulates an immune reaction against the virus. Advantages: Less painful than cryosurgery with no post-treatment wound formation Key use case: Can be effective for refractory warts across the body Dr Lewellis notes that Swift is a niche offering that can help dermatologists stand out in their communities. YCANTH for molluscum contagiosum While not a device, YCANTH is a standardized form of cantharidin for molluscum contagiosum. Treatment highlights: Reliable, controlled results with treatments every 3 weeks as needed Controversy: While compounded cantharidin remains an option, consistency and robust data make YCANTH worth considering for patients Setting your practice apart Dr Lewellis concludes by advising that incorporating innovative devices and treatments such as AviClear, excel V+, and Swift, along with in-office options like YCANTH, represents an opportunity for dermatologists to differentiate their practices in 2025. These technologies offer cutting-edge solutions that can improve patient outcomes and expand treatment options. Exploring and integrating these advancements can help establish a practice as a leader in forward-thinking dermatologic care, enhancing both patient satisfaction and professional reputation within the community.

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. Call for transparency and FDA input 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. Approach to patient care 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: One study analyzing blood benzene levels demonstrated that individuals using benzoyl peroxide-containing products do not exhibit elevated benzene levels in their blood compared to nonusers. Another cohort study on cancer risk 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. 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. Understanding benzene exposure risks 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. Practical advice and continued use in clinical practice 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. Awaiting further guidance 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.

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. Concerns raised by Valisure report on benzoyl peroxide 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. Analysis of blood benzene levels in benzoyl peroxide users The first study 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. Long-term cancer risk assessment in benzoyl peroxide users The second study 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. Overall safety of benzoyl peroxide in clinical practice 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.

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. Efficacy 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. Meta-analysis findings 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. Tolerability and safety profile 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. Implications for patient adherence 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.

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 updated guidelines for the management of acne vulgaris. These evidence-based recommendations were last updated in 2016. Topical treatments 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. Oral antibiotics Sarecycline 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. Doxycycline and minocycline 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. This represents a departure from current practice, where both drugs tend to be used equally. Trimethoprim-sulfamethoxazole 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. Spironolactone 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. Key points 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 Doxycycline received a strong recommendation Minocycline received a conditional recommendation supported by potential for adverse effects unique to minocycline Doxycycline is recommended over minocycline for the typical patient, representing a departure from current practice The guidelines recommend limiting the use of trimethoprim-sulfamethoxazole The guidelines advise that routine potassium monitoring for most patients on spironolactone is likely a low-value practice

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. Streamlined Counseling for Individuals not of Childbearing Potential 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. Removal of the 19-Day Lockout Period 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. Shift Towards Home Pregnancy Testing 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. Anticipated Implementation 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.