Julie Harper, MD: Real-World Experience With IDP-126 and the Rise of ‘JAKne’

The October 2023 FDA approval of a triple fixed-dose combination acne treatment was really a gamechanger when it comes to prescribing habits, according to Julie Harper, MD, a dermatologist in Birmingham, Alabama. With efficacy rivaling or better than antibiotics, it has led to less prescriptions for oral medications, she said.

Harper, along with Hilary Baldwin, MD, and James Del Rosso, MD, delivered a joint session on acne and rosacea at Maui Derm NP+PA Fall 2024, held September 15-18, 2024, in Nashville, Tennessee. In addition to commentary on the new triple combination treatment, Harper also discussed non-laser treatment options for patient with acne scarring and the rise of JAKne, acne associated with use of JAK inhibitors.

This transcript has been edited for clarity

Dermatology Times: Tell us about your session on acne and rosacea presented at Maui Derm NP+PA Fall, and why it’s important to provide this education to an audience of advanced practice providers?

Julie Harper, MD: My talk encompassed … 5 main points today. The first [thing] that I started off with was just to review the data of our new triple fixed-dose combination product. That's a product that we've all been very excited about for a long time because we haven't had a 3-in-1. So we have the beauty of a combination treatment and yet the ease of monotherapy. [But] that's not enough, though, if it doesn't work. So when you look back at the data that goes with that, the efficacy numbers are really impressive. We're getting 50% of people clear or almost clear at week 12, and more than 70% lesion count reduction. And I can tell you, because I've looked at studies for a long time, that's really unprecedented, not just in the topical acne world, but in the acne world in general. So we reviewed that.

The second thing I talked about is oral contraceptives and acne. We're used to talking about the oral contraceptives that are FDA approved to treat acne, and really, probably all combinations of estrogen and progestin together, they actually improve acne. But there [are] contraceptives out there that are progestin-only, and they have a very different impact. They can actually make acne worse, and this would include progestin-only, many pills, and also IUDs that contain progestin. Also the new over-the-counter birth control pill that is progestin-only. So just being aware of that, because our female acne patients frequently are going to be on contraception, and some of it may be helping, and some of it may be hurting.

The third thing that I talked about was acne scarring and, in particular, the fact that all of us can treat acne scarring. Hopefully we're treating it by preventing acne scarring first of all, but we all have access to things like topical trifarotene, and they have a great new study that was a split-based study that showed that they can not only improve acne, but reduce scarring over that 6-month study. And the results were really impressive, cutting acne scarring numbers in half in 6 months.

The fourth thing that I talked about was, do we need to rethink how hands off we are with isotretinoin, in particular for procedural treatments and wound healing? So we had a nice little review. That article that was published in 2017 reminded us that for most everything out there, we don't really have to delay treatment because somebody's on isotretinoin. So you don't have to delay laser hair removal. You don't have to delay superficial chemical peels. You don't even have to delay fractional ablative lasers, or non-ablative lasers. What you're still going to delay on are fully ablative and then dermabrasion with a diamond tip. But other than that, we can set that drug free a little bit. We even have a study that shows the use of a fractional, ablative CO2 laser while people are on isotretinoin. So that's really a game changer.

And then lastly, I just mentioned “JAKne,” which probably is not acne vulgaris, but it is an acne, a form eruption, and we should recognize it, and we should treat it when we see it.

DT: How has the approval of IDP-126 (triple combination acne treatment) changed your practice?

JH: I think the triple has changed my practice a lot, and I was thinking about that over the last few days. I think, over time, I am prescribing fewer oral antibiotics, and I guess that's in part about just wanting to be a responsible prescriber. If I don't have to use oral antibiotics, I don't want to use them, but I have a drug in this triple that I think is superior in efficacy, and I do think it's well-tolerated. That's probably the given the take of the topicals. You know, even if we have a topical that's very effective, if people can't tolerate it and can't use it, well, then we don't get the efficacy. But this one seems to be good on both fronts. We're getting efficacy that is better than the oral antibiotics, to be honest. And it's not a head-to-head study, but that's what we've seen looking at the clinical trials. So I think it has shifted my practice and my prescribing habits.

DT: What are some of the alternative treatments for acne scarring that providers can perform even if they don’t own a laser?

JH: There are lots of them … We all have access to prescribing and so topical retinoids, the ones that have been studied the best are topical trifarotene, but also topical adapalene. So those both not only help with active acne, but they can help with scarring.

When you're talking about procedures, I would talk about superficial chemical peels or microneedling. These are things that don't cost a lot to do. You can use your punch tool that you have in the practice and do punch excision of scars, or punch elevation of a scar, or even punch grafting of a scar. You can do subcision, where you make an incision and then go under the scars that are tethered down and try to loosen up those tethers. You could use filler, for example. You can use [trichloroacetic acid], where you go right down into some of the individual ice-pick scars. And all of these things can be done even if you don't have a laser in your practice

DT: Let’s talk about “JAKne.” What is it and what do providers need to know?

JH: I don't think we have it completely figured out, but there is precedence here, because we have other drugs that cause an acneiform eruption. Probably the one that we think about the most is steroid-induced acne, and it can have a little bit different look. It's very monomorphous, so JAKne may not look exactly like traditional acne. The cases I've seen are definitely more inflammatory papules and even little pustules, more than they are comedones. Maybe if it persists longer, you're going to see those 2, so it can have a little bit different presentation.

It is mostly on the face. And, in my experience, it does appear pretty early. I had somebody whose developed within a week or 2 of using the product. And so I don't think that's uncommon. If you look at reports that kind of review the literature on this, it looks like most of the time it's going to happen within the first 6 months of treatment. So think about face. Think about early in treatment, probably dose-related, most common in people who are being treated for atopic dermatitis, moreso than the other conditions. And that may just be a selection bias, but we should treat it.

It does bother me a little bit that we say, “Oh, it's just mild-to-moderate. Maybe we don't even need to treat it.” Well, in my practice, I treat mild-to-moderate acne all the time, and one of my take-homes on this is just because it's JAKne doesn't mean that we brush it under the rug. We treat it and we would treat it like we would any other acne.

DT: What are some of the areas of unmet need that still exist in acne?

JH: We haven't cured it yet, so there certainly are unmet needs. I do like the idea of the procedural treatments for acne. We don't have that completely figured out yet, though. So I like the idea of something that you would only have to do a few times and at an easy interval, like every 4 weeks. But I would want to have predictability that that product was going to give a long-lasting, durable response. A product that worked as well as isotretinoin, but that wasn't a teratogen, and we didn't have to worry about that … that would be excellent. Anything that gives us ease for the patient, things that really could be used weekly, once a week, something like that, and would still give efficacy.

I wish we had better treatments for scarring because even when we use all those combinations of treatments for scarring, we have to look at people and say, “Now we may make you 60% better. We never say we're going to make you 100% better.”

Reference:

Baldwin H, Harper J, Del Rosso J. Acne and rosacea update 2024 – new interactive format. Presented at: Maui Derm NP+PA Fall; September 15-18, 2024; Nashville, Tennessee.