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. 

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. 

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.