Frontline Forum Part 3: Exploring Expert Perspectives on the Management of Acne Vulgaris

Continued from part 2

Androgen Cascade

Panel members agreed that looking at patients’ androgen level in relation to acne can be difficult. Webster said it has been done indirectly looking at a population of women with polycystic ovary disease and observing how many also had acne, which was around 30%. He noted that suppressing the women’s androgens with oral steroids only helped relieve symptoms in a small percentage of the population.

Stein Gold’s practice does not routinely check androgen levels in patients with acne. However, she said they do so for patients who have severe acne and have not responded to typically prescribed treatments because that could indicate a hormonal abnormality (which could lead to a diagnosis of polycystic ovary disease).

“When I see very untreatable acne, a lot of the time [it is in] patients who are [receiving] exogenous testosterone,” added Dawn Eichenfield.

The Issue of Scarring

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The panel also explored the leading causes of acne scarring. According to Stein Gold, one cause could be lack of absorption with isotretinoin, which is often patient-induced. For instance, the patient may have failed to take their medication while eating. She said another potential reason is that patients have severe comedones that simply do not respond well to treatments.

Webster added that patients with severe acne may have lesions that are not retinoid responsive, such as a keloid or epidermal cyst, and that he focuses on clearing their acne first before coming back to address keloids or cysts.

“You kind of have to get into who’s been undertreated, who’s a picker, and who’s just not responding. And why…they get scars. …You…have to approach it from what was the issue in the first place,” Bhatia commented.

Lawrence Eichenfield added, “I regularly will now have patients with what I call micro scars continue on retinoids even when they have good clinical response, both as a mixture of maintenance and [to] see what we can get out of it for those micro scars.”

Adherence and Monitoring

Clinicians have several treatment options to guide each patient to a plan that works for their lifestyle and needs. When it comes to determining the success of a treatment, Dawn Eichenfield said she usually waits 2 months to judge a clinical response to any therapy.

Stein Gold sees her isotretinoin patients monthly but will wait 3 months in between visits for patients to whom she has given topical therapies.

For Bhatia, the co-pays dictate the frequency of patient visits. “If patients need to pay $75, they are not going to want to do that,” he said. “So I schedule 6 weeks out if the patient is on orals and topicals. But if the patient is just on topicals, [I schedule them at] 3 months, if at all.”

Webster said he worries about less frequent visits because it decreases adherence.

Bhatia does not have many patient adherence challenges with isotretinoin as patients are usually motivated to have their skin cleared up. Topicals can be tough, he noted, because if there are too many steps, the patient will not always follow through. However, Bhatia addresses that issue by giving a patient one topical therapy to spread on the overall affected surface area and another for specific acne. Once a patient’s acne is cleared, Bhatia recommends they maintain themselves with retinoids 2 or 3 times a week; Stein Gold recommends 3 times a week.

The therapy must match the patient, Webster noted. “When you give a topical to a teenage boy, you better have a long discussion about whether he’s going to use it or not,” he said.

Continued in part 4 coming soon.

Disclosure

This Frontline Forum is supported by Sun Pharmaceutical Industries Ltd.