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Selecting Treatment Based on Pathophysiology of Acne


Key opinion leaders in dermatology discuss approaches to selecting treatment based on the pathophysiology of acne.

Hilary E. Baldwin, MD: Jim, let me start with you. Briefly, how do we tie in the medications that we’re going to pick to treat these patients based on what we know about the pathophysiology of acne?

James Q. Del Rosso, DO: We always want to target as many of the pathways in the pathophysiology as we can. I like to see all patients on a topical retinoid. I like to utilize benzoyl peroxide as often as I can. We have some good formulations of benzoyl peroxide that are well tolerated.

Topical antibiotics, as long as benzoyl peroxide is there and being applied at the same time, not separately because they don’t always get them on. These can both help, but benzoyl peroxide and retinoids are still fundamental. We have other agents. We have dapsone and others that are helpful. We now have clascoterone, and it is going to be interesting to see where it fits in.

We have a topical minocycline, and I might utilize that before I put the patient on an oral antibiotic, if I thought they need an oral antibiotic, to see what type of an effect I’m going to get. If it’s not enough, then I could always change. I like the old fundamentals from the beginning: a topical retinoid, even if you have to build it up because of tolerability issues, and benzoyl peroxide. I like both of those a lot.

Hilary E. Baldwin, MD: You’re attacking the problem from multiple directions. Is your eye on the pathophysiology? Are you thinking, “I’m going to use this for the follicular hyperkeratinization? I’m going to use this to kill C-acnes [cutibacterium acne].”

James Q. Del Rosso, DO: Yes. I’m trying to target most of those things, but I also think that it’s more conceptual. These are not static: I’m a big believer that the inflammation is there before you see the lesions.

Hilary E. Baldwin, MD: Right.

James Q. Del Rosso, DO: It lasts longer, even when the papules and the pustules flatten out, and you just have an area of discoloration. You know that C-acnes is sitting there, even if it’s dead, and it’s still promoting inflammation. That’s why we have a persistent inflammatory erythema and pigmentation. It’s not immediately post-inflammatory: the inflammation doesn’t shut off overnight. You have to treat more aggressively up front and go longer than you might think you need to, with a good combination approach.

Fran E. Cook-Bolden, MD: Jim, that’s a great point. Many years ago, [Rebat] Halder, [MD] did a study looking at post-inflammatory hyperpigmentation that was a result of acne and skin of color. I’m sure you’re all familiar with the study.

James Q. Del Rosso, DO: I remember the histology.

Fran E. Cook-Bolden, MD: Absolutely. We think that, with post-inflammatory hyperpigmentation, there’s no active disease going on, but when they did the biopsies, there was tons of inflammation in those lesions. You’re right, we definitely have inflammation going on well before we can see it. Even as you have precursor lesions, microcomedone, and comedone, there can be some inflammation associated with those, and we see that. We’ve learned how to understand that process clinically and apply it to what we’re seeing, as well as the post-inflammatory hyperpigmentation. It’s not so surprising with the post-inflammatory erythema.

Hilary E. Baldwin, MD: In general, what we’re talking about here, getting back to the pathophysiology of acne and the 4 pivotal factors in the pathophysiology of acne, we’re talking about grabbing medications, 1 from column A, and 1 from column B, trying to make sure that we’re attacking acne from different directions. We use something to decrease inflammation, something to unclog the pores, something to kill C acnes, and something to reduce sebum. We know that, with the average dermatologist, the average successfully treated patient with acne is on 2.53 medications for Pete’s sake. Something that you will all agree with is this: when we see patients who come in out of the dermatology specialty, let’s say, they are often on multiple medications that influence only 1 of the pathophysiologic factors of acne. I see patients coming in on topical clindamycin and oral minocycline, ignoring all the rest of the pathophysiology of acne.

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