Top 5 Clinical Pearls for Acne Vulgaris Management

Five expert dermatologists recently met to discuss their strategies for treating patients with acne vulgaris (AV) and what therapies are available and efficacious. James Del Rosso, DO; Hilary Baldwin, MD; Neal Bhatia, MD; Christopher Bunick, MD, PhD; and Leon Kircik, MD, revealed their clinical pearls in Dermatology Times®’ most recent Frontline Forum series, “Expert Perspectives on the Management of Acne Vulgaris.”¹

Clinical pearl #1: The main goal of AV treatment is to prevent new lesions from developing

According to the panelists, healing previous acne lesions is important, especially to their patients, but the first focus of treating AV is preventing the development of new lesions. Bunick mentioned that sometimes, both dermatologists and patients mistakenly focus on spot treatment instead of prevention, which is not effective for long-term acne clearance. Additionally, AV management is often approached reactively rather than proactively. “You’re treating today for next month’s acne,” said Baldwin.

Clinical pearl #2: Understand the patient’s skin care routine to avoid negative interactions

Certain therapies may not be as effective when combined with others when compared to monotherapy use, according to the panelists. “Putting 2…agents one on top of [the other], even though it’s convenient for the patient, may not [yield] the same efficacy,” said Kircik. “We don’t know if they are stable together or not. Still, most of the providers don’t understand the fact that [if] you put one on top of [the other], you [may not have] 100% efficacy.” Baldwin counsels her patients on the appropriate timing and sequence of application when patients are using multiple therapies.

Clinical pearl #3: Assess the patient’s AV severity before developing a treatment strategy

The panelists agreed that they categorize patients by whether they should be treated with a topical-only regimen, combination of topical and oral medications, or isotretinoin, which the panelists generally consider for “very severe” AV. According to Del Rosso, the severity of AV can be dynamic and tends to fluctuate. Baldwin stressed the importance of asking patients during their visit if they are having a good or bad day. Based on their answer, Baldwin can understand better what a truly bad day might be like.

Clinical pearl #4: Prescribe clascoterone cream 1% in combination with fast-acting agents

Clascoterone cream 1% (Winlevi; Sun Pharma) can take 8 to 12 weeks to see results, and therefore should be used in combination with fast-acting agents such as a retinoid. According to Bunick, he has high rates of satisfaction among patients who use clascoterone with a retinoid. The panelists said that although they try to minimize antibiotic use, they may give a narrow-spectrum antibiotic in addition to clascoterone, a retinoid, and BP for a patient who wants a quick response for an upcoming event. Clascoterone can also be used with dapsone in patients who want to avoid retinoids.

Clinical pearl #5: Consider the use of new isotretinoin formulations

A new formulation of micronized isotretinoin (Absorica LD) is dispersed in a lipid carrier system, resulting in greater surface area per unit mass and thereby higher rates of dissolution and bioavailability.² According to the panelists, the higher bioavailability of the newer isotretinoin formulations raises the question of the cumulative dose to target. Despite some of the challenges and questions surrounding new formulations of isotretinoin, the panelists agreed that more bioavailable formulations of isotretinoin are advantageous for improving the likelihood of sustained remission with minimal concerns about timing the medication with a high-fat meal.

To read the full Frontline Forum series or watch additional episodes from the panelists, click here.

References

1. Battaglia G. A greater understanding of the acne vulgaris armamentarium. Dermatology Times. August 14, 2023. Accessed August 24, 2023. https://cdn.sanity.io/files/0vv8moc6/dermatologytimes/48b7d9232c92f995c02fa956b672bb69bc7d0425.pdf/DT0823supp_ezine.pdf
2. Madan S, Kumar S, Segal J. Comparative pharmacokinetic profiles of a novel low-dose micronized-isotretinoin 32 mg formulation and lidose-isotretinoin 40 mg in fed and fasted conditions: two open-label, randomized, crossover studies in healthy adult participants. Acta Derm Venereol. 2020;100(4):adv00049. doi:10.2340/00015555-3381