Patients’ preferences, timeline drive acne treatments

June 1, 2013

Even though patients may present with clinically similar acne, says an expert, their expectations and preferences for particular treatments may differ vastly.

Miami Beach, Fla. - Even though patients may present with clinically similar acne, says an expert, their expectations and preferences for particular treatments may differ vastly.

Accordingly, says Whitney P. Bowe, M.D., “We must tailor our treatment recommendations based on the patient’s acceptance of certain interventions, as well as their timeline.” Dr. Bowe is a dermatologist in New York City and Westchester, N.Y., and is a clinical assistant professor of dermatology at the State University of New York Downstate Medical Center. “We can achieve very dramatic, similar results using completely different methods. But it’s important to be flexible and listen to your patient’s needs.”

One case that illustrates this point involved a 27-year-old female patient who had suffered from severe acne since college. She presented with inflammatory papules and multiple cysts, says Dr. Bowe, who spoke at the annual meeting of the American Academy of Dermatology. As such, “Her acne was severely affecting their quality of life. Specifically, she said that it was putting a heavy strain on her ability to get close to her boyfriend.” Additionally, the patient had a very specific goal: to look and feel better within one month, so she could attend New Year’s Eve festivities with her boyfriend.

Clinically, Dr. Bowe says, “It’s very challenging to have a dramatic impact on acne within one month. I told her, ‘I can’t make the acne go away in one month. But I can try to flatten out the lesions - especially the lumpy, bumpy appearance of the cystic ones - so that you can cover them very effectively with makeup.’ She said that would be great.”

Although the patient’s acne affected her upper face, chest and back, it appeared most prominently on her chin and jawline. This suggested to Dr. Bowe that the patient might respond well to a hormonal intervention such as spironolactone. However, the patient rejected this treatment because she was already taking an oral contraceptive and didn’t like the idea of adding another medication that could affect her hormones.

Instead, “I put her on a combination of an extended-release minocycline tablet at 1 mg/kg dosing, and a topical formulation that combined adapalene and benzoyl peroxide.” Initially the patient applied the topical medication every other night. Then, after 10 days, the patient switched to every night because she was not experiencing dryness or irritation.

“To speed up the resolution of her acne, I added photopneumatic treatments,” performed once weekly for four weeks with the Acleara Acne Clearing System (Palomar). “It’s a non-painful treatment that involves broad-spectrum light and a vacuum apparatus that sucks out the contents of the pore and physically breaks up the biofilm within the pore.”

Additionally, Dr. Bowe says, the combination of red and blue light targets porphyrins naturally present in Propionibacterium acnes (without using a photosensitizer such as aminolevulinic acid), and has been shown to decrease the release of inflammatory cytokines in the skin.

Skincare regimens

Simultaneously, Dr. Bowe recommended a daily skincare regimen that met the patient’s desire for simplicity while also calming and moisturizing her skin to help it withstand aggressive treatment. Specifically, “I gave her a morning moisturizer with a sun protection factor of 30 and a soy complex. The soy is a natural brightener that can even out skin tone and texture.” The patient also used gentle cleansers and an evening moisturizer containing ceramides.

Finally, Dr. Bowe recommended that the patient minimize her consumption of foods with a high glycemic index, such as white bread. “She was also drinking a lot of skim milk, which we replaced with almond milk, because skim milk has been known to exacerbate acne.”

Based on other evidence, Dr. Bowe added a daily probiotic supplement and fish oil (its high omega-3 content provides anti-inflammatory action). The patient also maximized her antioxidant ingestion by adding more deeply colored fruits and vegetables.

“One month later, the active acne had almost completely resolved. She was left with just postinflammatory erythematous macules that she could easily cover up with a light foundation. She was ecstatic, and she has remained clear since then,” Dr. Bowe says.

The patient discontinued the oral antibiotics after three months, but continues using the topical medication and dietary and skincare regimens, she says.

In contrast, Dr. Bowe treated a young woman who presented with similar symptoms but much different expectations using a different approach. “She was open to trying spironolactone, and she was not in such a rush to achieve results.” In addition to the spironolactone, Dr. Bowe prescribed a topical retinoid (tazarotene) and implemented the dietary modifications above. “Her skin was perfectly clear in 3.5 months.”

Disclosures: Dr. Bowe has been a consultant for Galderma and Johnson & Johnson Consumer Products.