Clinical Pearls and Therapeutic Wisdom in Acne and Rosacea

Joshua Zeichner, MD, kick-started this expert panel on acne and rosacea with a recommendation to use combination topical therapies from the beginning. Phase 3 results of a triple-combination fixed-dose clindamycin 1.2%, adapalene 0.15%, benzoyl peroxide 3.1% gel demonstrated half of patients treated with the triple-combination gel achieved treatment success at Week 12 compared with 22% of vehicle-treated patients, and the triple-combination gel led to a 70% decrease in inflammation and noninflammatory acne lesions. Dr Zeichner presented data from several review articles showing treatment adherence is increased for patients on once-daily fixed-dose combination treatments than multiple separate generics that need to be applied twice daily. Dr Zeichner concluded with tips on how to adjust isotretinoin dosing at each visit based on the patient’s skin and lip dryness.

James Q. Del Rosso, DO, continued the discussion with a review of the complex pathophysiology of rosacea, which includes increased immune responses, angiogenesis, neurovascular dysregulation, and dermal matrix degradation. Dr Del Rosso reminded the audience that while patients with rosacea may experience flushing and perilesional erythema, central facial erythema is the primary diagnostic feature of rosacea and is persistent between flares. Dr Del Rosso discussed recent data indicating that the IL-17 pathway may be involved in rosacea pathogenesis and provided case-study evidence that oral JAK inhibitors may be the newest treatment option for severe, recalcitrant rosacea.

Linda F. Stein Gold, MD, was our next expert panelist and posed the question, “do antihistamines improve isotretinoin therapy?” Dr Stein Gold presented data from a recent study suggesting that they do. One small study showed combination isotretinoin and levocetirizine showed greater clearance of acne lesions and scars compared to isotretinoin alone as well as minimized side effects of isotretinoin. Another study of isotretinoin plus desloratadine found that patient satisfaction was increased in the isotretinoin + desloratadine group compared to isotretinoin alone (53.6% vs 36.6%). Dr Stein Gold concluded with a tip that omega 3 fatty acid supplements can help to improve the mucocutaneous side effects of isotretinoin.

Julie C. Harper, MD, wrapped up the session on acne and rosacea with a few clinical pearls on using combined oral contraceptives (OCP) for the treatment of acne in females. Dr Harper reminded the audience that it frequently takes at least three cycles of OCP to see a meaningful reduction in acne. She recommends obtaining a thorough medical history and blood pressure measurement before prescribing OCPs. Important contraindications to OCPs include pregnancy, breastfeeding, age greater than 35 years, heavy smoking, hypertension, and migraine with aura. While OCPs do increase the risk of venous thromboembolism from baseline, the increase is minimal and less than the increase in venous thromboembolism risk during pregnancy.