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AcneManagementintoday’steens:Factsvs.Fads
IngridPolcariMDAssistantProfessorofDermatologyandPediatrics
UniversityofMinnesotaFridayMay3,2019
Disclosures
• Ihavenorelevantfinancialrelationshipswiththemanufacturer(s)ofanycommercialproduct(s)and/orprovider(s)ofcommercialservicesdiscussedinthisCMEactivity• Iwillmentionoff-labeluse
Learningobjectives
• Understandtrendsinacnetreatment• Reviewtheevidencebehind“alternative”therapies• Knowthegoldstandardtreatmentsforacne
Acnetrends
• Gettinghardertokeepupwithteenagetrends• Teensaregettingadvicefromeachother andfromsocialmedia• Virtualacnetreatmentbecomingmoreavailable
• Lotsofacnesystemsonthemarket• Dothesework?
• Lotsof“natural”treatmentscirculating• Whicharehelpfulandwhichmightbeharmful?
• Thepublichasimplicateddietasanunderlyingfactorinmanyconditions
FactorFad:OTCacnesystems?
• Firstwell-knownacnesystemcameontothemarketin1995• createdby2youngdermatologists:KatieRodan andKathyFields• catchyname• celebrityendorsements
• Subscriptionswithmonthlyshipments• Countlessmimicsnowavailable
FactorFad:OTCacnesystems?
• Tendtobecostly• MostarecombinationsofBenzoylPeroxideandSalicylicacid• Somehavesulfur• Washes• Leave-onproducts• Toners/astringents
• Tossthese!Norolefortheseinacnecare
• Bottomline:Theymayworkformildacne!Butconsiderteachingyourpatientsaboutlesscostlyversionsofthesameproducts
Benzoylperoxide
• Antibacterial• Nopacnesresistance
• Mildlycomedolytic• Availablein2.5-10%strengths• Washorleave-onproducts• Canbeirritating,canbleachtowelsandclothing
• Canbemonotherapyformildacne• Studiesshowthatthiscanrivaloralantibiotics• Bottomline:agreatproductasmonotherapyorcombinationtherapy
SalicylicAcid
• Keratolytic• LessevidencetosupportusethanBPO• Tendstobelessirritating• Avoidharshscrubs:overscrubbingcanworsenacne
• Bottomline:• Useinpatientswhodon’ttolerateBPO• Considerasa“firststep”forverymildacneinyoungerpatients
Topicalantibiotics
• Antiinflammatory andantibacterialeffects• P.acnesisnowresistanttotopicalerythromycinsolesspreferred• Clindamycin1%gelorsolutionispreferred• Butneedtocombinewithbenzoylperoxidewashortopicaltoreduceriskofantibioticresistance• Canprescribeseparatelyorasacombinationagent
• Clinda 1%/BP5%orClinda 1%/BP3.5%
• Bottomline:Don’tusetopicalantibioticsasmonotherapy
Updateonantibiotics
• Oralantibiotics:• Tetracyclineclassstillfirstline(doxycyclineandminocycline)• Formoderatetosevereacneorthoserecalcitranttotopicaltherapy• Limitdurationto3monthsifpossible• UseatopicalBPOproductatthesametimetodecreaseantibioticresistance
• Proceedtohormonaltreatmentsorisotretinoinifneeded
FactorFad:theroleofdietinacne
• Emergingdata(RTC)suggeststhathighglycemicindexdietsmaybeassociatedwithacne• Limitedretrospectivedatasuggeststhatsometypesofdairymayinfluenceacne• Skimmilkinparticular
• Antioxidants:oralzinc,fishoil:evidencenotstrongenough
Bottomline:dietmayplayaverylimitedroleinacne
Factorfad:probioticsinacne
• Hottopic,staytuned• Currentstudiesfailtoshowbenefit• Bottomline:Existingevidenceisnotstrongenoughtosupportrecommendationforthisindication
Whichofthefollowingalternativetherapieshassomeevidencesuggestingefficacyforacnetreatment?
A)acupunctureB)cuppingC)teatreeoilD)lavenderoil
“natural”treatmentsforacne
• Bydefinition,theseare“alternative”becausetheylackhighqualityevidencetobecomemainstream
CharcoalsoapandmasksEssentialoils(teatree,others)ApplecidervinegarAloeVera
Alternativetherapies
• Mostlyfad!• Littletonoevidencethattheyworkinacne• Essentialoilsarevolatilecompoundsthatshouldn’tbeputdirectlyontotheskin• Lowqualityevidenceshowsthatteatreeoilcanloweracnelesioncount
• Patientstendtobeproudoftheirroutinessobecarefulnottocriticize• Mystrategy:“setasidefornow”
• Bottomline:otherthanteatreeoil,alternativetherapieslackevidencetosupportuse
FactorFad:lighttherapymaskforacne?
Fact.
• RedandBluelightreduceinflammationandp.acnes• Attachedactivatorhaslimitednumberofusessothereisongoingcostforthedeviceandplasticwaste• Bottomline:canberecommendedformildacne
FactorFad:OTCretinoids?• Anti-wrinklecreamscontainRetinol• notasstrongasretinoids
• Asof2016,adapalene0.1%gelavailableoverthecounter• Costabout$20• Coveredbysomeinsurances• Moredryingthanthecream
Bottomline:adapalene0.1%gelisacost-effectivealternativetoprescriptionretinoidsbutmaynotbestrongenoughforsomepatients
TopicalRetinoids• VitaminAderivatives:adapalene,tretinoin,tazarotene• Thecoretreatmentforacne!MostFDAapproved12andolder• Antiinflammatory,comedolyticandpreventmicrocomedone precursors• Startlowstrengthandworkyourwayup• Choosevehiclecarefully:
• gelsmoredryingthancreams• Lotionsandfoamsmorecostly
• Takeafewminutestocounselre:use:• Peasizefortheface• Notaspottreatment• Starteveryothernight• WearlotionwithSPF
Treatmentofsevereacne
• Systemicmedication• Oralantibiotics• Oralcontraceptivepills• Isotretinoin
Acne:OCPs• Typicallyreservedforfemales>2yearspostmenarche• OCPswithFDAapprovalforacne:• Ortho-Tri-Cyclin• Estrostep• Yaz• Beyaz
• Consider”continuoususe”tokeephormonesatasteadystate• Progesterone-onlybirthcontrolcanworsenacne
Whichistrueaboutisotretinoin?
• A)newdatasuggestslongertreatmentcoursesresultinlessreboundacne• B)ithasbeenconclusivelylinkedtodevelopmentofinflammatoryboweldisease• C)patientsshouldbecounseledthathe/shemaynotreachfullpotentialheight• D)depressionisanabsolutecontraindicationtoitsuse
Isotretinoin
• Veryeffectivemedicationforacne• Usedforseverenodularacne,treatment-resistantmoderateacne,oracnecausingscarringand/orpsychosocialdistress• Requiresperiodiclabmonitoring• PatientsandprovidermustadheretoiPLEDGEprogramrequirements• Femalesofchild-bearingageneedcontraceptivecounseling
Isotretinoin
• Veryeffectivemedicationforacne• Usedforseverenodularacne,treatment-resistantmoderateacne,oracnecausingscarringand/orpsychosocialdistress• Requiresperiodiclabmonitoring• PatientsandprovidermustadheretoiPLEDGEprogramrequirements• Femalesofchild-bearingageneedcontraceptivecounseling
Isotretinoin:lengthoftherapy
• Previouslyweaimedforagoaldoseof120-150whichisa4-6monthcourse• Newdatasuggeststhatahighergoaldose/longercoursemayresultinlessrebound• largerstudiesneeded
Isotretinoinandinflammatoryboweldisease
• EarlierstudiessuggestedalinkbetweenisotretinoinandIBD• Butoralantibioticusealsoassociated• CouldsevereacnebeamarkerfordevelopmentofIBD?
• 2016meta-analysis:noincreasedriskofIBD
Isotretinoin:Bonyeffects?
• TheoreticalrisksbasedonfindingsofChronicVit Atoxicity:diffuseskeletalhyperostosis,osteophyteformation,prematureepiphysealclosure• Potentialwithretinoids dependsondoseandduration• JAAD2004:singlecourseofisotretinoinhadnoeffectonbonemineraldensityordevelopmentofcervicalhyperostosis• 2casereportsofprematureepiphysealclosure• Carefullyconsiderrisksandbenefitsifstartinginapreadolescent• Noroleforxrays orDEXAinabsenceofsymptomsorprolongedtreatmentcourse
Isotretinoinanddepression• Literatureshowsanxietyimproves,suggestivethatdepressivesymptomsimprovetoo• Sporadicreportsofdepression,suicidalideationandsuicide
• Mediaattention:2000suicideofa17yearoldsonofaCongressman
• Nostudiestosuggestanevidence-basedlink• Considergettingclearancefrompsychiatristpriortotreatingapatientwithknowndepression
Conclusions
• Benzoylperoxideandsalicylicacidusefulformildacne• Don’tusetopicalororalantibioticsasmonotherapy• Topicalretinoidsareagoldstandardtreatment• Mostalternativetherapieslackevidencetosupportuseinacne• Teatreeoilandred/bluelighteffectiveinmildacne
• Dietplaysalimitedroleinacne• Noevidencetoproveprobioticshelpacne• Oralcontraceptivepillscanbeeffectiveforacne• Isotretinoinissafeandeffectiveforsevereacne
Thanksforyourattention!
References
• Blasiak RC,Stamey CR,BurkhartCN,Lugo-Somolinos A,MorrellDS.High-doseisotretinointreatmentandtherateofretrial,relapse,andadverseeffectsinpatientswithacnevulgaris. JAMADermatol. 2013;149:1392-1398.• Luthi F,Eggel Y,Theumann N.Prematureepiphysealclosureinanadolescenttreatedbyretinoidsforacne:anunusualcauseofanteriorkneepain. JointBoneSpine. 2012;79:314-316.• SteeleRG,LuggP,RichardsonM.Prematureepiphysealclosuresecondarytosingle-coursevitaminAtherapy. Aust NZJSurg. 1999;69:825-827.• LeeSY1,JamalMM,NguyenET,BechtoldML,NguyenDL.Doesexposureto isotretinoin increasetheriskforthedevelopmentof inflammatory boweldisease?Ameta-analysis.Eur JGastroenterolHepatol.2016Feb;28(2):210-6.
• SmithRN,MannNJ,Braue A,Makelainen H,Varigos GA.Theeffectofahigh-protein,lowglycemic-loaddietversusaconventional,highglycemic-loaddietonbiochemicalparametersassociatedwithacnevulgaris:arandomized,investigator-masked,controlledtrial. JAmAcadDermatol. 2007;57:247-256.• JungGW,Tse JE,Guiha I,RaoJ.Prospective,randomized,open-labeltrialcomparingthesafety,efficacy,andtolerabilityofanacnetreatmentregimenwithandwithoutaprobioticsupplementandminocyclineinsubjectswithmildtomoderateacne. JCutan MedSurg. 2013;17:114-122.
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