Finding the right acne treatment for your patients

With so many drugs and cosmeceuticals on the market, it can sometimes be difficult to determine the best treatment regimen for your acne patients. However, Shanna M. Miranti, MPAS, PA-C, Riverchase Dermatology, Naples, Florida, comes to the rescue by revealing how to best optimize an acne treatment regimen for different patients during her presentation at the Society for Dermatology. Physician Assistants Annual Summer 2022 Meeting held June 16-19, 2022 in Austin, Texas.1

In her presentation, Miranti discussed current acne treatment guidelines, new therapies on the market, differences between different treatment options for specific acne subcategories, why each patient should not receive tretinoin and why clinicians should continue to prescribe Accutane.

Guidelines

Regarding the guidelines for the treatment of acne, Miranti says that patients are divided into 3 categories: mild, moderate and severe. For patients with mild disease, benzoyl peroxide (BPO), a topical retinoid, or combination therapy is recommended. For moderate disease, start with a topical combination of BPO and an antibiotic, a retinoid and BPO, or a retinoid, BPO and an antibiotic. Miranti says you can also swap the antibiotic or oral topic. The same diet guideline applies to patients with critical illness; however, oral isotretinoin can also be used in this patient population.

New treatments

Miranti also showcased some of the latest drugs on the acne market since 2019, including:

  • Aklief (trifarotene; Galderma)
    • Approved by the United States Food and Drug Administration (FDA) in 2019
    • Fourth generation retinoid
    • Approved for ages 9 and up
  • Amzeeq (minocycline; Journey Medical)
    • FDA approved in 2019
    • Topical foam
    • Very low systemic absorption
    • Approved for ages 9 and up
  • Arazlo (tazarotene 0.045%: Ortho Dermatologics)
    • FDA approved in 2019
    • Third generation retinoid
    • Topical photostable retinoid
    • Approved for ages 9 and up
  • Seysara (sarecycline; Almirall)
    • FDA approved in 2019
    • Oral antibiotic
    • Part of a class of tetracycline based on weight
    • Approved for ages 9 and up
  • Winlevi (clascoterone; sun dermatology)
    • FDA approved in 2020
    • First in class
    • Topical anti-androgen
    • Approved for ages 12 and up
  • Twyneo (1% tretinoin and 3% BPO; Galderma)
    • FDA approved in 2021
    • Microencapsulation of ingredients
    • Approved for ages 9 and up

Treat different acne subtypes

With all of these new drugs in the clinicians’ toolbox, Miranti dove into how these therapies can be used on different subtypes of acne such as tweens, comedonal acne, oily and inflammatory teens, l female hormonal acne, skin-colored (SOC) patients who are prone to post-inflammatory hyperpigmentation (PIH) and inflammatory/cystic/scar acne.

For tweens (9-12 years old), Miranti suggests keeping the regimen simple and choosing a vehicle that’s tolerable for the sensitive skin of this patient population. She reminded that generic tretinoin cannot be prescribed for this age group as it is only approved for patients 12 years and older. Miranti also notes that acne at age 9 is no longer considered precocious puberty; however, a workup should be done for precocious puberty if acne begins before age 7.

In Comedonal Acne, she emphasized the importance of befriending a good beautician who can perform extractions and teen facials. Miranti also recommends AHA or BHA washes, pads or scrubs to help break up pilosebaceous congestions and use tolerable retinoid vehicles to prevent the formation of micro-comedones. When it comes to treatment, Amzeeq, Aklief, Twyneo, Fabior, and Arazlo have all been shown to be effective in treating this subtype of acne.

For oily and inflammatory acne in adolescents, Miranti recommends BPO if the patient can tolerate it and looks for products with good data on reducing inflammatory and non-inflammatory lesions. A simple diet is also suggested for this age group to promote better adherence to treatment. She also noted to remember that sebum production and inflammation can be caused by androgens. For treatments, Winlevi and Aklief are recommended for this subtype.

In female hormonal acne, Miranti says to focus on androgens. She added that adult women are more motivated to perform more complex regimens and will add recommended serums, antioxidants and cleansers to their skincare routine. As for treatments, Miranti suggests prescribing spironolactone to patients 18 and older starting at 50 mg. Additionally, Winlevi has been shown to be effective as a twice-daily treatment, retinoids have both acne and anti-aging benefits, and Aczone has shown specific female hormone data.

For SOC patients, this patient population is often more bothered by IPH than by active acne, so treat this symptom early, according to Miranti. She also said to urge those patients to use sunscreen. Hydroquinone, especially in combination treatments like Tri-luma (Fluocinolone/Hydroquinone/Tretinoin; Galderma), can be very effective in SOC patients, but Miranti cautioned to be aware of over-bleaching/haloing and l ochronosis in high percentage compounds. Cysteamine/cyspera is also now available without a prescription and helps regulate melanin synthesis. Other treatments available include Aklief, Arazlo, Finacea/Azelaic Acid and antioxidants such as Heliocare and Skinceuticals: Phloretin, Discoloration Defense.

Finally, in patients with inflammatory, cystic, and scarring acne, Miranti says Accutane (isotretinoin) is still the gold standard for nodulocystic/scarring acne. Oral antibiotics/non-antimicrobial dose oral antibiotics may be effective in reducing inflammation. However, she stressed that clinicians should never prescribe antibiotics as monotherapy. Instead, always add a BPO wash, topical or combination therapy to reduce the risk of bacterial resistance. Other treatments that have shown efficacy for the acne subtype include retinoids, lasers, radio frequency devices, microneedling, and platelet-rich plasma (PRP).

Disclosure

Miranti is a speaker for EPI Health, Galderma, Incyte, Ortho Dermatologics, Verrica and Soarsa. She is also a consultant for Verrica and Soarsa, and a member of the advisory board of Galderma and Incyte.

Reference

  1. Miranti S. Not your mom’s acne/rosacea diets. Presented at the Society for Dermatology Physician Assistants Annual Summer Meeting. June 16-19, 2022. Austin, TX.

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