During the Society of Dermatology Physician Assistants 19th Annual Fall Dermatology Conference, John Barbieri, MD, MBA, opened his session “Acne Vulgaris” with the following question: why does cost-effective acne care matter for patients?

He highlighted how, despite the tremendous advancements in acne treatments that physicians can offer patients, many of them cannot access them because of the costs.

“In dermatology, especially with generics, we have to deal with these dramatic price increases that some of us have probably experienced over the past few years,” Dr Barbieri stated.

He emphasized the importance of improving patient adherence by making it convenient to pick up their medication, adding that it could even reduce administrative burden on physicians by not having to do so many prior authorizations, which means less phone calls from patients asking for a less expensive alternative. 

When moving onto topical regimens, Dr Barbieri stated, “As we get to like our fourth, fifth, sixth topical topical retinoids, I don’t need to know does it work—I need to know is it better than the thing I was using yesterday."

For this, he introduced meta-analysis, a network that can help physicians consider topical treatments through a cross-trial comparison.

When discussing these cross comparisons, Dr Barbieri introduced a new treatment released just 4 days ago as of November 6—clascoterone—an anti-androgen that competes with androgens to bind to the androgen receptor. He shared that this new treatment can not only be used by women but also men.

He continued onto trifarotene, a fourth generation retinoid that is highly potent against RAR-ᵧ receptor that has shown a great improvement in Investigator Global Assessment success, and even shows great response against truncal acne.

Next, he presented two top brands that came out recently, tazarotene and tretinoin lotion. These treatments were aimed to disperse more evenly on the skin by changing the vehicle around. While tazarotene displayed great tolerability in phase 2 and 3 trials, tretinoin only potentially becomes more tolerable.

Dr Barbieri then went on to discuss minocycline foam, which is a response to the growing challenge of antibiotic resistance to topicals. It has been shown to have great tolerability, but there are no data so far on its long-term resistance despite being high concentration.

Dr Barbieri continued onto hormonal therapy and new oral antibiotics by beginning to share that dermatologists—over any other provider—prescribe the most antibiotics.

When discussing the potential harm from antibiotics, Dr Barbieri lists:

• Inflammatory bowel disease
• Higher risks of colon cancer and breast cancer
• Strep throat
• Pharyngitis

“These are all complications that patients can get from oral antibiotics, and we probably don’t even really understand all the changes to the microbiome that happen, “Dr Barbieri added.

With the rise of use in hormonal treatments, Dr Barbieri stated that this may present a new opportunity for dermatologists to decrease a need for antibiotics. He notes that oftentimes hormonal treatments are considered second-line options for moderate-severe acne. However, he noted a past study had shown that, while patients initially start on oral antibiotics, they almost always ending up shifting to combined oral contraceptives.

“So, this raises the questions for me like, one, should we be starting with those if they’re going to end up there anyway? Why not do it from the beginning? And two, how well do these work when compared with each other,” said Dr Barbieri.

Summarizing his discussion on hormonal therapies and antibiotics, Dr Barbieri encourages physicians to:

• Consider hormonal options for all female patients with acne
• Consider an earlier initiation of isotretinoin
• Try to limit the number of patients treated with antibiotics rather than by duration
• Consider using doxycycline due to its similar efficacy and increased safety compared to minocycline—in addition to being inexpensive
• Consider using sarecycline for patients with limited options, comorbidities, and for long-term use.

The final topic Dr Barbieri touched on was updates to managing isotretinoin side effects and monitoring. Dr Barbieri encouraged physicians to consider utilizing omega-3s to reduce mucocutaneous side effects from isotretinoin and to lower dosages in order to manage most side effects. He also warned that “we’re probably consistently overmonitoring and overtesting, causing unnecessary pain, fear, and cost for our patients.”

At the conclusion of his session, Dr Barbieri shared how the new “low-dose” lidose isotretinoin has not proven to have any advantages over the current formulations available.

Reference
Barbieri J. Acne vulgaris. Presented at: Society of Dermatology Physician Assistants 19th Annual Fall Dermatology Conference; November 4-7, 2021; Los Angeles, CA.