Acne: therapeutic updates and our most challenging cases

Markus Boos, MD, associate professor of Pediatrics, Seattle Children's Hospital in Washington; Jim Treat, MD, professor of Clinical Pediatrics and Dermatology, Children's Hospital of Philadelphia in Pennsylvania; and Andrea L. Zaenglein, MD, professor of Dermatology and Pediatrics, Penn State/Hershey Medical Center in Pennsylvania, shared highlights of what they have learned from some of their most challenging cases in dermatology.

Zaenglein began her presentation with a look at one of her patients, a 13-year old female with moderate acne, unresponsive to 3 months of doxycycline, tretinoin, and a benzoyl peroxide (BP) wash. She began menarche at 11.5 years, with irregular periods, had mild hirsutism, and an increased BMI. Questions asked: which hormonal therapies would be appropriate for this girl? Combined oral contraceptive pills, spironolactone, clascoterone, and, do you, as a clinician do a polycystic ovary syndrome (PCOS) work-up?

The best conditions for testing adolescents with PCOS, Zaenglein said, include, but are not limited to, irregular periods; common acne, and when normal levels of testosterone are not established. Additionally, noted Zaenglein, combination oral contraceptives (COCs) such as drospirenone have been shown to be effective for moderate truncal acne, yet only 55% of dermatologists in the United States prescribe contraceptives for treating acne.

Looking at prescribing a variety of treatments for acne, trends in this country between 2004 to 2013 included an increase of oral antibiotics (which increased from 19.99 to 22.48, per 100 patients with acne); spironolactone (increasing from 2.08 to 8.13); and combined oral contraceptives (increasing from 31.70 to 32.13). (During this period, the use of isotretinoin decreased, from 2.24 to 1.45).

Boos shared risk factors for the development of acne in transgender youth (TGD), which can include smoking, weight/BMI, and use of chest binders. "For transmasculine patients, spironolactone is not a rational choice," Boos remarked, citing such issues as hypotension, fatigue, polyuria, and the possible promotion of breast tissue. COCs on the other hand, do not prevent masculinization, but Boos questions efficacy and effects on bone mineral density: "I would not prescribe COCs for transfeminine patients," said Boos.

Treat looked at what a clinician might consider if isotretinoin for acne fails. For initial treatment for moderate acne, besides combination therapies, such as an oral antibiotic, topical retinoid, topical antibiotic and benzoyl peroxide, Treat reminded clinicians to manage expectations of patients when it comes to results and side effects, note the psychosocial impact of the condition, active scarring, and regiment complexity. For his patient, who failed to see improvement on doxycycline, amoxicillin, isotretinoin, adalimumab, and oral dapsone, the patient was maintained on ustekinumab, monthly, at 45 mg.

Conclusively, Treat said, "Isotretinoin can fail for a variety of reasons, such as genetics, skin picking, exogenous medications,or if taken with fatty foods."

Reference

Treat J, Boos M, Zaenglein A. Acne: therapeutics update. SPD 2022 47th Annual Meeting. July 8, 2022. Indianapolis, Indiana.