John Barbieri, MD, MBA, FAAD: Aligning Treatments With Patients' Experiences

John Barbieri, MD, MBA, FAAD, is director of the Advanced Therapeutics Acne Clinic at Brigham and Women's Hospital and an assistant professor of dermatology at Harvard Medical School.

Barbieri told Dermatology Times® about the highlights of sessions at the Society of Dermatology Physician Assistants (SDPA) Annual Summer Dermatology Conference, "Foundational Tools for Acne and Rosacea Management" and "Neutraceuticals and Cosmeceuticals: Which to Choose?"

John Barbieri, MD, MBA, FAAD: When I think about rosacea, there's really a couple of main manifestations of it, and we want to align our treatments with what the patient's experiencing. So there's redness; that can be broken blood vessels like telangiectasias on the skin, that can be flushing, that can be kind of fixed background redness on the face, there's lumps, there's papules, and pustules, just like an acne, and then some people can get what's called a phymatous changes where their nose starts to get thicker, and the sebaceous tissue becomes too big.

And really, the treatments are distinct for each of those. So for the bumps, they actually do overlap a bit like with acne. So topical anti-microbial things, we often use metronidazole or ivermectin, and now there's a benzoyl peroxide that's more gentle that can be used for rosacea-prone skin where that benzoyl peroxide is encapsulated. So bumps, there is some overlap.

For redness, we do use some of the same ideas like we talked about for acne-associated erythema using alpha agonists, like oxymetazoline. That's one of our go-tos for rosacea redness, and also, energy-based devices like pulsed dye laser or KTP laser can be helpful for redness, as well.

And then for phymatous changes, we often use stronger treatments like oral antibiotics, or isotretinoin. And for patients who have more severe papules and pustules, more inflammatory rosacea, again, we often think about antibiotics, and as well, sometimes isotretinoin for that, too.

From the standpoint of acne, I think trying to create a simple regimen that's affordable is not something that's that hard to do, and I think we often get caught up and lots of, 'The newest medicine must be the best.' There's a real lack of evidence for a lot of these products; there's not enough head-to-head data. So for me, I think about mechanisms, and I really try and pick the most affordable one that category. Topical retinoids, benzoyl peroxide, great for whiteheads and blackheads. I just pick the most affordable one, or the one that patients can access the easiest, because there's not a lot of data that other ones are better, with the one caveat being if they do have trouble tolerating a retinoid, and they really need one, some of the lotion formulations like tazarotene lotion, do have evidence that they're more tolerable and work just as well. So those can be helpful.

From the same standpoint, topical antibiotics, if they got more inflammatory acne, I usually just use clindamycin because it's easy to access. It's affordable, and there's really no evidence that dapsone or minocycline foam [are] any better. So I tend to not use those; I find dapsone gel is helpful for scalp folliculitis. That's kind of a neat case where I use it, but for run of the mill acne, I'm not sure it's particularly better on average. There's not really actually data that supports it's better for adult women. It's really kind of more of a marketing thing, and something that in my mind, that is [not] truly evidence-based. There's no head-to-head trials in adult women of different topical antibiotics, so I don't tend to use it specifically for that. I might use them if the patient does get better with clindamycin as another option, but it's not my first starting place.

And then clascoterone, I do think it has a lot of nice aspects to it, but it is somewhat hard to access. So again, it's not usually my first thing when I start. So simple, affordable, are really my key concepts there.

And then for systemic treatments, I think we probably underutilize isotretinoin a bit. It is certainly a medicine that needs to be respected and used cautiously, but it really can cause meaningful impacts for patients, improving their life. The number one thing I hear is: 'I wish I had done this sooner.' So it is something that I think we should think about; again, it's not right for everyone. We should be thoughtful. It does have important risks, but it is a very effective medicine that can cause a remission of acne, so it's something we should consider.

And for women, really hormonal therapy works incredibly well: spironolactone or combined oral contraceptives, so those are definitely things we should consider.

On the rosacea side, really just focusing on morphology. So rather than being, 'No, here are different rosacea treatments,' thinking about what does this patient have? Is it redness that bothers them? Is it bumps? Is it phymatous changes? And choosing treatments that are aligned with those specific morphologies.

Dermatology Times: What are some top considerations when choosing between neutraceuticals and cosmeceuticals for a patient?

Barbieri: I think it just depends on really their individual preferences about treatment. It really applies the whole spectrum of treatments of acne and rosacea. If you have a patient who wants to avoid topical treatments, because they're inconvenient, you might pick a pill medicine, where an average patient, you wouldn't have; you would have done topicals. You can see the opposite thing happen: Someone's really scared about side effects from some of these pill medicines, and they actually would prefer a topical medicine, even though you think the chance of working might be lower.

And they are going to be people who'd want a non-pharmacologic and non-prescription treatment option. That's where neutraceutical treatments might be really helpful, or other kinds of treatments like lasers that aren't a pill. And when you have a patient who is almost there, you're just not quite getting to where you need to be, that's again where these neutraceuticals can be a nice adjuvant treatment that might get them that last little bit that they need. I think just having some information so when they're discussing things like neutraceuticals with their patients, they're armed. If someone comes inand says, 'You know what? I'd love to take vitamin D. I think that's going to help my acne.' Well now, there's some data that you can use the guide that discussion, or often patients bring in all the things they're doing, and you might [think], 'You know what that thing you're doing? I actually think it might not be a great idea because it might have some important risks, or it might not work, and you might be better spending your time and effort elsewhere.'

So I think I really just want people to be armed with information about the data for these different neutraceutical products so that when they do have these discussions with their patient, one: They're aware that these things actually might be helpful in many ways, and also when patients come and they want to learn about it, they can have a really nice discussion about what things might work and why things might might not, and what the different risks of those options are.

[Transcript edited for clarity]