The panel on acne guidelines, presented at the 2019 American Academy of Dermatology Summer Meeting, included reviews of the latest evidence for isotretinoin, hormonal agents, and physical modalities. Julie C. Harper, MD, Bethanee Jean Schlosser, MD, and Emmy M. Graber, MD, discussed these options as alternatives to antibiotics and potential options for patients whose acne is not responding to topicals alone. Highlights from their presentation included:
According to Dr Harper, isotretinoin should be used more frequently in dermatology and implemented faster to help patients achieve clear skin. There are still some barriers, but these are slowly being addressed by new research. For example, Dr Harper explained how she changed laboratory monitoring for patients on isotretinoin in her own practice. She performs tests at baseline and 2 months, at which point if everything looks okay and there is no dose escalation, she stops monitoring. The most likely abnormal laboratory measurement is triglyceride levels, with about 50% risk of hypertriglyceridemia while receiving isotretinoin, although incidence is low.
According to a 2016 study, said Dr Harper, changes in lipids happen early, which was already known. She recommended performing lipid assessments at baseline and 2 months, and only conducting more frequent lab testing based on these measurements and medical comorbidities.
The relationship between isotretinoin and inflammatory bowel disease (IBD) is “dead,” said Dr Harper. There is no support in data from current studies. Studies on depression with isotretinoin use suggest that susceptibility cannot be ruled out in patients, but that they can be safely treated without increased risk, she added.
Oral anti-androgen therapy is indicated for moderate to severe acne in combination with topical or other agents, said Dr Schlosser. Patients to consider include those with:
- hyperandrogenism, such as polycystic ovarian syndrome
- late-onset or persistent acne
- prominence of acne at lower face and/or neck
- perimenstrual flare
- comedonal acne with seborrhea (scalp, ears, and or face)
- resistant to conventional treatment for acne
- Alternative to repeated isotretinoin therapy
All acne is hormonally sensitive, said Dr Schlosser. The official indication for oral contraceptives for acne is patients with moderate inflammatory acne, who have achieved menarche, who are aged 15 years or older, wants contraception, and failed topical therapy. Patients do not need a pelvic exam or pap smear to receive oral contraceptives, said Dr Schlosser.
Oral contraceptives outperform placebo and require at least 3 months, or 3 cycles, to assess efficacy, she stated. However, there is no difference in acne reduction between each contraceptive agent. In addition, a meta-analysis showed oral contraceptives had similar efficacy as antibiotics at 6 months, although antibiotics outperformed oral contraceptives at 3 months.
One concern is the risk of venous thrombosis with hormonal therapies. This risk is greater in older patients, smokers, and in the first 6 to 12 months of use. However, this normalizes after discontinuing therapy, said Dr Schlosser. All oral contraceptives have this increased risk, but some have a higher risk than others, she added.
Dr Schlosser also discussed the role of spironolactone for acne, which has some support for its utility, although not FDA-approved for this indication. It is contraindicated for patients with renal insufficiency, hyperkalemia, pregnancy category C, abnormal uterine bleeding, and it is banned for athletes because it is a diuretic. Adverse effects associated with this therapy are dose-dependent. In addition, there is a black box warning for malignancy, which was observed in rats, but there is no data yet for humans.
Dr Graber discussed some physical modalities for acne, but noted she prefers topical and oral agents over these options.
Chemical peels showed mild improvement in comedonal lesions, but lack large studies. In addition, these require multiple treatments, and the effects are not long-lasting, Dr Graber said. Salicylic acid appears to be superior to glycolic acid. If patients ask about using salicylic acid chemical peels, Dr Graber recommended telling them it could be useful as an add-on therapy to prescription topicals, but not as a first-line treatment option.
KTP lasers are well-tolerated, but not very efficacious. There is limited evidence for pulse-dye lasers for active acne, which require multiple treatments, with about 6 needed to achieve similar efficacy as topical agents. In addition, these results are only sustained for a few months.
Some evidence shows infra-red lasers, which are good for atrophic acne scarring, demonstrated about 50% improvement for up to 12 months. However, it is difficult to predict results, and these lasers are known to cause acne flares. IPL also requires multiple treatment sessions and is more effective if utilized as part of photodynamic therapy (PDT). CO2 lasers were not found considered helpful for acne. Additionally, radiofrequency devices have limited data, require multiple treatments, and achieve short-term results, with about a 42% reduction.
PDT demonstrated the best evidence, but it is difficult to summarize because of different variables, such as duration, light source, and incubator, said Dr Graber. What to recommend is currently unclear, and improvement is more often seen with inflammatory lesions, such as pustules and papules. PDT also requires multiple treatments, and the results are temporary.
Home handheld devices show some improvement, but not clearance, with reduction in active lesions by about a day, but results are not great and are temporary, said Dr Graber.
For all physical modalities, more rigorous studies are needed to determine the efficacy and safety, and to develop best practices for their use in treating acne.
1. Harper JC. Isotretinoin. Present at: the 2019 American Academy of Dermatology Summer Meeting; July 25-28, 2019; New York, NY.
2. Schlosser BJ. Hormonal management of acne. Present at: the 2019 American Academy of Dermatology Summer Meeting; July 25-28, 2019; New York, NY.
3. Graber EM. Lasers and lights in acne. Present at: the 2019 American Academy of Dermatology Summer Meeting; July 25-28, 2019; New York, NY.