In their Fall Clinical 2022 in-depth seminar, “Topical Therapies for Acne Management: Evolving Skin One Patient at a Time,” Hilary Baldwin, MD, and James Q. Del Rosso, DO, identified patients who would benefit from topical acne treatments and described strategies to talk with patients about topical therapies to help improve adherence and outcomes.

Dr Baldwin started off by saying, “I often wonder how we do what we do so quickly when we see an acne patient. How many seconds do you think it takes you when you walk into the room and see the patient sitting there to decide what, all the things being equal, you would do for this patient? Maybe 5 seconds? Maybe 10 at most? The rest of the time is talking to the patient, trying to figure out how you’re going to need to change what you want to do to meet with their insurance, to meet with their lives, to meet with their expectations.” She commented that she is looking at what type of lesions the patient has and then within that framework, asking herself is it a mild, moderate, or severe case? Is the trunk involved? Is there scarring? Is there evidence of psychological impairment? The answers help her decide how she is going to get the patient to the end point of clear or near clear by choosing the appropriate regimen from the “rich acne toolbox” of topical therapies.

She discussed how combination therapy is the most important thing for most patients with acne. The average successfully treated patient is on 2.53 medications. Dr Baldwin observed, “That’s what makes dermatology providers different from everybody else who attempts to treat this disease with monotherapy.” However, she raised the question of how dermatologists can convince patients to trust that they need to use multiple products. “We need to educate. We need to set expectations and we need to tailor our regimen to our patient’s lifestyle. People who can’t deal with mornings should not be given medication in the mornings. Whenever possible, use fixed combinations to improve compliance,” she suggested.

Dr Baldwin highlighted the new medication clascoterone cream 1%, an androgen receptor inhibitor with the first new mechanism of action in acne for many years. Importantly, it is safe for male patients to use. She noted that she rarely uses this medication as a standalone and it should be used twice daily. She also reviewed another new drug, microencapsulated benzoyl peroxide 3% with tretinoin 0.1%. Both agents are individually microencapsulated in a silicone shell. She remarked, “You’re saying to yourself, wait, you can’t put tretinoin and benzoyl peroxide on the skin together, much less in a bottle together. Yes, you can if you segregate them inside the bottle.” The advantage is the ability to coapply previously uncombinable agents.

Dr Del Rosso then added how to break the ice with patients to improve treatment adherence, “I want to make sure I connect with them…letting them know I’m personalizing management for them that includes skin care. Why, what, and when to use different things…they want to know exactly what to do.” He continued, “I make sure they know that I need to see them again [in 8 weeks] to make sure they’re doing okay and to assess their improvement. And I need them to do exactly what I’m telling them to do.”

Drs Baldwin and Del Rosso finished their session with a lively discussion on the “dot” method, in which the patient applies the medication in dots on their face, and what constitutes “pea sized.” Dr Baldwin indicated that it takes her only 45 seconds to physically demonstrate the dot method to patients, and she keeps a handful of frozen peas in her desk to show patients exactly what a pea-sized amount is. She concluded, “I open up the desk and I say, this is a pea. And I show it to them. They laugh. Teenage boys laugh. It’s awesome.”

Reference

Baldwin H, Del Rosso JQ. Topical therapies for acne management: evolving skin one patient at a time. Presented at: Fall Clinical Dermatology Conference 2022; October 20–23, 2022; Las Vegas, NV.