Topicals, Lasers, and Oral Agents: New Developments in the Treatment of Acne and Rosacea

The treatment landscape for acne and rosacea is vast and constantly evolving. From lasers and light therapy to topicals to oral medications, clinicians have a lot of choices.

Emmy Graber, MD, MBA, president of The Dermatology Institute of Boston and affiliate clinical instructor at Northeastern University, delivered a talk at Winter Clinical Miami, held February 17-20, 2023, in Miami, Florida, reviewing some of the newest developments for acne and rosacea.¹

She began with an overview of the 1726-nanometer laser, which, Graber claims, is not just a trend.

“They work by targeting sebum,” she told attendees. “This is a novel wavelength; there are no lasers like it. They specifically target the sebaceous glands to selectively damage those sebaceous glands without damaging the epidermis.”

These 1726-nm lasers can significantly reduce papules and pustules in treated areas compared with untreated areas, and they have highly controlled air-cooling features, as well as real-time temperature safety features. Some require topical or injectable anesthesia prior to application, while others do not, and erythema subsides with some in minutes while with others, it may take 24-72 hours for the redness and swelling to clear.

Two systems currently hold FDA clearance: the Accure Laser System² and Cutera’s AviClear Acne Device.

There is a photopneumatic device that also holds FDA clearance for mild to moderate acne. It combines a vacuum with broadband lighting technology, Graber explained.

“This is a slight variation to some predicate devices that were on the market years ago,” she said. “The company recommends 4 to 6 treatments done 1 to 2 weeks apart. Patients get some erythema…after treatment.”

Moving on to sarecycline, which, while not new, is a medication that is highly potent against Cutibacterium acnes. Graber pointed to new data that detail acne burden in patients as measured by an expert panel questionnaire that asked patients questions such as how often they filter social media photos or how often they feel angry about their acne. Over the course of 12 weeks on sarecycline plus perhaps topicals, patients’ acne symptoms, as well as emotional and physical functioning all improved.

Next up is clascoterone 1% cream, which was approved by the FDA for the treatment of acne in patients 12 years of age and older in August 2020. The approval marked the first for a topical androgen receptor inhibitor. Although the exact mechanism of action (MOA) is unknown, Graber explained that clascoterone effectively inhibits sebum production, reduces secretion of inflammatory cytokines, and inhibits inflammatory pathways. It carried no safety concerns in its 2 phase 3 studies and was well-tolerated.

Graber shared that, although it has not been studied, she uses clascoterone in practice in combination with other topicals that have other MOAs, such as topical retinoids like tazarotene lotion.

The “clinical pearl of the day” for attendees was Graber’s note on isotretinoin. She pointed to a study from a few years ago of 100 patients, which that sought to evaluate whether adding the over-the-counter antihistamine levocetirizine would enhance the effect of isotretinoin. In the study, patients who received the combination experienced far greater improvements in their acne and also reported reduced mucocutaneous side effects.

Graber concluded with a few slides on benzoyl peroxide for rosacea and the triple combination acne treatment IDP-126³ currently in development.

Graber spoke with Dermatology Times® in an exclusive video interview about her presentation and offered more details about how she weighs treatment decisions.

This transcript has been edited for clarity and length.

Dermatology Times: What factors do you consider when determining which treatment to use for your patients with acne and rosacea?

Graber: That's a great question. There are so many treatments we have available now and a lot of it depends on what the patient wants, to be honest. Because if they're not going to be compliant with a certain type of treatment, it's never going to work. I usually try to get some feedback from the patient. Are they looking to just use a topical routine? Do they want an oral agent? Some of them come in asking for a laser or a device treatment. I also try to get a sense from a patient how much it's bothering them, because if it's very psychologically bothering to them, we may be more prone to [try] more treatments or to [turn to] oral agents.

Dermatology Times: Your lecture referenced 2 recently FDA-cleared 1726 nm lasers. When do you turn to devices to treat acne?

Graber: Devices in acne is a really hot topic. I have some patients who come in wanting a device because either they can't tolerate pills or they're sick of using creams, or maybe all those things were ineffective for them. And I have some patients who just want to stay away from pharmaceuticals, so I will talk to all patients really about the option of adding in a laser or device and some of them will add it in in combination with other treatments and some will just do a laser device as monotherapy.

Dermatology Times: Your talk also mentioned a case in which you used isotretinoin in combination with an OTC oral antihistamine. Can you talk a bit more about that?

Graber: There was a recent study of 100 patients and they were randomized to receive isotretinoin alone or isotretinoin plus levocetirizine, which is an over-the-counter antihistamine. The group that received the combination therapy for acne got better, moreso than the group that used isotretinoin alone. Also, the group that used the combination therapy had fewer mucocutaneous side effects, so less dryness, and the group that use the combination treatment had fewer acne flares upon initiation of isotretinoin. That study in particular, like I said, looked at levocetirizine at 5 milligrams a day and so, a lot of times, I will start my isotretinoin patients concomitantly on levocetirizine.

References:

1. Graber E. New developments in the treatment of acne and rosacea. Presented at Winter Clinical Miami 2023; February 17-20, 2023; Miami, FL.
2. Bader K. FDA clears Accure laser system for acne treatment. Dermatology Times. Published November 28, 2022. Accessed February 18, 2023. https://www.dermatologytimes.com/view/fda-clears-accure-laser-system-for-acne-treatment
3. Stocum L. IDP-126 meets endpoints in second phase 3 study. Dermatology Times. Published June 16, 2021. Accessed February 18, 2023. https://www.dermatologytimes.com/view/idp-126-meets-endpoints-in-second-phase-3-study