Balancing Pathophysiology and Patient Lifestyle in Acne Management: Part 2

Conversation continued from part 1.

Acne’s profound challenge lies in its diverse clinical expression, its psychosocial burden, and the impact of both patient behaviors and scientific results. Although therapeutic innovation has expanded the clinician’s toolbox, the art of acne care still relies on clear communication, thoughtful regimen design, and an understanding of the individual behind the diagnosis.

Across 3 recent Dermatology Times Case-Based programs, Hilary Baldwin, MD, a dermatologist at Rutgers University Robert Wood Johnson Medical Center in New Brunswick, New Jersey, and medical director of the Acne Treatment and Research Center in Brooklyn, New York; and James Del Rosso, DO, dermatologist, Mohs micrographic surgeon, and research director at JDR Dermatology Research in Las Vegas, Nevada, shared patient scenarios illustrating how clinical reasoning, lifestyle considerations, psychological factors, and evolving topical agents shape real-world decisions. When examined together, these conversations present a cohesive picture of modern acne care: grounded in pathophysiology, responsive to patient preferences, and refined through education and partnership.

The Competitive Swimmer With Inflammatory Acne

A second scenario involved a competitive teenage swimmer presenting with inflammatory facial and truncal acne. Chlorine exposure had caused dryness and irritation, and tight swim caps and goggles contributed to frictional stress. Previous attempts with benzoyl peroxide wash were abandoned due to severe dryness. Social withdrawal had begun; acne had become more than a cosmetic concern.

This case prompted a deep discussion about how lifestyle can limit the effectiveness of topical therapy. Daily chemical exposure, sweat, friction, and high water contact create a perfect storm for irritation. Baldwin explained that this swimmer “is going to have a hard time tolerating topicals,” making oral therapy a reasonable starting point—not because topical mechanisms are insufficient, but because the patient’s environment compromises topical tolerability.

Del Rosso’s roundtable spent considerable time focusing on oral antibiotic options. Doxycycline, especially in modified-release formulations, offers anti-inflammatory benefits with a lower risk of resistance. Sarecycline was also discussed for its narrow-spectrum activity and improved tolerability profile. Several clinicians compared it favorably to broader tetracyclines due to its lower risk of gastrointestinal upset and photosensitivity, which can be particularly relevant for athletes training outdoors.

Systemic therapy, however, was not viewed as a standalone solution. Instead, the clinicians emphasized the importance of using it as a bridge: rapidly reducing inflammation while concurrently implementing a gentle but strategic topical base for long-term maintenance. Tazarotene lotion 0.045% was highlighted for its spreadability and favorable tolerability profile on both face and trunk. Clascoterone cream, too, was praised for its hydrating vehicle and ability to reduce sebum without inducing additional irritation in skin already stressed by chlorine.

Adherence emerged as a major theme in all 3 discussions. Athletes have demanding schedules, and teens often expect rapid results. Del Rosso reminded attendees that compassion plays an important clinical role. He encourages patients not to dwell on missed doses, telling them, “Don’t get down about yourself, because that’s the last thing you want.”

The swimmer case also illustrated when to modify therapy. At follow-up, improvement was noted; however, the use of benzoyl peroxide bleaching affected clothing and led to frustration. In such cases, the group agreed that switching from combination therapy containing benzoyl peroxide to another retinoid (such as trifarotene) is both reasonable and often welcomed by patients.

Ultimately, this case reinforced that acne care must bend to the realities of lifestyle. Understanding the physical environment in which patients live, work, and train ultimately guides therapeutic choices as much as lesion morphology does.

Conclusion: A Modern Model of Acne Care

Across these case-based discussions, a portrait of contemporary acne management emerges; one defined not by rigid protocols but by adaptable, patient-centered thinking. Acne is a chronic, multifactorial, and deeply personal condition. Effective treatment requires both scientific precision and interpersonal skill.

Baldwin summarized this philosophy aptly: “Managing acne isn’t about finding the magic molecule, it’s about matching the right drug, in the right form, for the right patient.” And as Del Rosso added, “Not everybody’s the same…but it doesn’t mean it doesn’t bother them and they wouldn’t want to get rid of acne.”

Together, these insights underscore the clinician’s evolving role: expert, educator, coach, and partner. With an ever-expanding therapeutic toolbox and a deeper appreciation of patient diversity, clinicians are better equipped than ever to deliver meaningful, sustained improvement for patients across the acne spectrum.