Balancing Pathophysiology and Patient Lifestyle in Acne Management: Part 3

Conversation continued from part 2.

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 Adult Woman With Hormonal Pattern Acne and PIH

The third case across the programs involved an African American flight attendant in her mid-20s, presenting with mild to moderate acne combined with postinflammatory hyperpigmentation (PIH). She had tried tretinoin briefly but stopped due to irritation. She admitted inconsistent use of products and a tendency to abandon regimens that did not yield quick results. Her occupational environment—dry air, irregular schedules, and frequent climate changes—compounded her skin sensitivity.

This scenario brought pigmentary considerations to the forefront. Baldwin emphasized findings from multiple surveys showing that “patients with skin of color dislike their spots more than they dislike their pimples.” As such, the approach must prioritize prevention of new hyperpigmentation while treating active acne.

The panelists stressed the need for gentle, deliberate regimens for these patients. Irritation is the enemy, not only because it reduces adherence but also because it can deepen or trigger PIH. Baldwin described her strategy as “cautiously aggressive”: aggressive enough to prevent new lesions from creating additional pigmentary change, but cautious enough to avoid iatrogenic pigmentation.

Across all programs, clinicians highlighted azelaic acid, niacinamide, and lower-strength retinoids as cornerstones for sensitive skin with pigmentary risk. Combination products such as the clindamycin/adapalene/benzoyl peroxide triple gel were favored once tolerance was established, primarily because simplifying a regimen improves adherence. Baldwin noted she frequently sees patients stop treatment not because it is ineffective, but because it feels too complicated for their busy lives.

This patient population also benefits from consistent sunscreen use, even when they believe their skin tone protects them from sun-induced darkening. Adjunctive brightening agents, such as newer nonhydroquinone formulations, were acknowledged for their affordability and effectiveness without bleaching surrounding skin. Baldwin remarked that “the nice thing about the new topical brighteners…is that they’re affordable…and they work without bleaching normal skin.”

One of Baldwin’s more memorable teaching tips in this case involved instructing patients with sensitive skin to apply retinoids “consistently inconsistently”; for example, using them every other night to maintain routine without triggering irritation. This flexibility often prevents the pattern of overuse followed by a complete stop, which is common in patients with sensitive or pigment-prone skin.

Together, these cases reinforced that PIH management is inseparable from acne management. Prevention, gentle titration, consistent routines, and clear education about irritation risk remain the backbone of success.

Shared Lessons Across All Cases

Although the 3 programs were held with different expert faculty, several unifying principles emerged across all discussions.

Education is arguably the most critical determinant of success. Baldwin summarized this theme: “It all boils down to listening to your patient and educating your patient.” Patients need to understand how their medications work, how long improvement takes, and how to apply products without inducing irritation. Education also addresses common myths, such as the notion that retinoids cannot be used safely on skin of color or that moisturizers should be avoided in cases of acne.

Personalization surpassed guidelines in importance. Baldwin reminded participants that “this isn’t about right or wrong…; it’s whatever you do in your practice.” Real-world acne care must accommodate lifestyle, insurance coverage, skin type, sensitivity, emotional distress, and individual preferences. Two teens with identical lesions may require completely different regimens depending on schedules, sports commitments, or tolerance thresholds.

Therapeutic layering, rather than abrupt switching, was preferred across all cases. Clinicians tended to add or adjust medications incrementally, avoiding simultaneous additions and removals. This approach allows a more straightforward interpretation of results and minimizes patient confusion.

Retinoids remained foundational, regardless of acne type. Whether delivered as tretinoin, adapalene, or tazarotene lotion, they consistently served as the structural backbone of therapy. Clascoterone emerged as a modern complement, particularly when sebum production or hormonal influence contributed to disease persistence.

Finally, adherence—not potency—often determined outcomes. Del Rosso captured this sentiment when he noted that the clinician must not only ask how much acne bothers the patient, but also how committed they are to managing it. Motivation, clarity, and sustainable routines are just as crucial as mechanisms of action.

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.