Acne Challenges: October 2024 Supplement Recap

The October Case-Based Peer Perspective supplement of Dermatology Times includes a collection of thought-provoking discussions and strategies surrounding tips for managing complex acne cases from Hilary Baldwin, MD; James Del Rosso, DO; and Heather Woolery-Lloyd, MD. Be sure to read the highlights from the supplement below. Also, don’t miss a moment of Dermatology Times by signing up for our eNewsletters and subscribing to receive the free print issue and supplement each month.

Part 1

In a series of Dermatology Times Case-Based Roundtable® events, leading dermatologists and their local peers tackled some of the most challenging cases of acne. These gatherings provided an invaluable platform for collaborative discussion, innovative problem-solving, and the exchange of cutting-edge treatment strategies. Each session featured in-depth case presentations, allowing participants to delve into the complexities of acne presentations and explore various diagnostic and therapeutic approaches for diverse patient populations. These clinical insights from New York, Nevada, and Florida showcased the dermatology community’s collective expertise and dedication to improving patient care.

Hilary Baldwin, MD, medical director of the Acne Treatment and Research Center in Morristown, New Jersey, led a team of local colleagues in a detailed discussion about 2 particularly challenging cases of acne in younger patients. These cases emphasized the importance of combination therapies, adherence, and flexibility.

Diet Considerations for Drug Absorption

The first case presented was that of a 12-year-old boy with moderate acne on both his face and back. Baldwin described the patient as “quite overweight” and noted that his mother mentioned he was “a very picky eater,” implying a diet high in junk food and low in nutritional value. This was the patient’s first visit to a dermatologist, having only used some over-the-counter spot treatments before this consultation.

“This is his first time visiting a dermatologist. He’s used some over the counter stuff before, but it’s mostly just spot treatments—some of those spot pads, for example. No medications, not even any bona fide over the counter acne medications,” Baldwin explained. She highlighted that the acne was affecting his self-esteem, social interactions, and performance in school.

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Part 2

Tackling Persistent Acne in Adolescence

Del Rosso introduced the case of a 14-year-old girl with persistent acne. “This patient had been treated with conventional therapies but remained dissatisfied with her progress,” he explained. Initially, she had been using various over the counter topical treatments without success. When she sought medical intervention, she was prescribed topical clindamycin combined with benzoyl peroxide and, subsequently, oral doxycycline.

“From the start, she disliked benzoyl peroxide,” Del Rosso noted. “She had a strong aversion to it even as an over the counter medication, so we had to discontinue its use.” The patient’s acne primarily consisted of closed comedones, open comedones, and superficial inflammatory papules and pustules scattered across her face. Despite not having nodular acne, her condition was persistent and did not improve to her satisfaction over several months of treatment.

Navigating Diet and Preference Challenges in Treatment

The patient’s dislike for benzoyl peroxide posed a significant challenge. “We had to respect her preferences and not push her to use something she was uncomfortable with,” Del Rosso emphasized. Instead, the patient was treated with clindamycin and tretinoin, and oral doxycycline was added because of insufficient improvement. However, concerns about antibiotic resistance and the patient’s strict vegan, low-fat diet added layers of complexity to her treatment.

“When discussing options, we considered different topical therapies,” said Del Rosso. “But she was adamant about not using benzoyl peroxide, even in potentially less irritating formulations.” The team had to navigate these preferences while aiming to optimize her treatment outcomes.

Introducing Isotretinoin With Contraceptive Considerations

Given the patient’s lack of response to initial treatments and her consistent use of an intrauterine device that released levonorgestrel, the decision was made to start her on oral isotretinoin. “She was motivated and already had contraceptive protection, which made her a suitable candidate for isotretinoin,” Del Rosso explained. “We used a branded generic formulation based on the original Accutane, which requires high-fat intake for optimal absorption.”

Despite the challenge of her low-fat diet, the patient initially responded well to isotretinoin, achieving clear skin for nearly 1.5 years. However, her acne recurred, necessitating further treatment. A second course of isotretinoin at a higher dose provided another period of remission, but the acne returned after 2 years.

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Part 3

Addressing Diet and Psychological Impact

Woolery-Lloyd introduced the first case involving a 12-year-old overweight boy with moderate facial and chest acne that began 2 years ago. The patient’s mother expressed concerns about his diet and the psychological impact of acne on his self-esteem and academic performance.” Because this patient had moderate to severe acne affecting both the face and trunk, one of the first things that the participants thought would be a good option was isotretinoin,” said Woolery-Lloyd. “We discussed the risks and benefits, but many felt that starting isotretinoin right off the bat was appropriate.”

Half of the participants were willing to consider isotretinoin at the first visit, whereas others preferred trying topical treatments or oral antibiotics first. They acknowledged the challenge of adherence to a complicated skincare routine, especially for a young patient. “Typically for this type of patient with moderate to severe acne, they may need to use a treatment in the morning, a treatment at night, certain skincare products, moisturizers, and maybe an oral antibiotic. This can be very complicated for a young male who may not be interested in such a routine,” Woolery-Lloyd explained.

During a follow-up visit, the patient admitted difficulty adhering to the prescribed combination therapy of topical benzoyl peroxide and clindamycin due to its complexity. The mother’s concern about long-term antibiotic use also emerged. “We discussed the issue of antibiotic resistance, which is a hot topic. Participants recommended probiotics to support the gut microbiome and emphasized limiting the use of long-term antibiotics,” Woolery-Lloyd noted.

Given these challenges, the dermatologists decided that isotretinoin was a more viableoption. They addressed the practicalities of isotretinoin, including the need to take it with fatty meals, which can be difficult for patients adhering to a low-fat diet. “Many participants suggested options like almond butter or peanut butter to ensure the medication is absorbed properly,” Woolery-Lloyd added. “However, the modern diet has changed, and people generally don’t consume fatty meals twice daily.” The patient was ultimately prescribed a micronized version of isotretinoin, which does not require consumption with fatty meals, significantly improving adherence. “This micronized version was considered a good option for improving adherence and outcomes, especially in young patients,” Woolery-Lloyd stated.

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