Five years of innovation and research have created many knowledge gaps in the American Academy of Dermatology (AAD) care guidelines for the management of acne vulgaris.1 A task force recently formed by the academy to update its guidelines will offer recommendations on best practices and safety precautions for therapies, treatments and devices developed to treat acne. Originally published in 2016, the new guidelines will be published in 2023 or 2024.
“Two major concerns are the appropriate dosage of isotretinoin and the laboratory monitoring of spironolactone and isotretinoin,” said Jonette Keri, MD, PhD, FAAD, associate professor of dermatology and skin surgery at the University. of Miami Miller School of Medicine in Florida, chief of dermatology at Miami VA Medical Center, and member of the task force. “The updates will also provide advice on new antibiotics and antibiotic management, as well as broader knowledge of lasers and other light devices used for the treatment of acne.”
She provided an overview of upcoming revisions to the AAD’s acne guidelines as the forum director for a session on translating evidence into practice of current acne guidelines and beyond at the American Academy of Dermatology Virtual Meeting Experience 2021 (AAD VMX) in April.2
Other speakers included Arun L. Pathy, MD, FAAD, dermatologist from Colorado Permanente Medical Group at Centennial and co-chair of the AAD Acne Guidelines Review Task Force.3; Rachel Sabbag Reynolds, MD, vice president, Department of Dermatology, and Assistant Professor of Dermatology, Harvard Medical School, Boston, Massachusetts4; Jonathan S. Weiss, MD, dermatologist with Georgia Dermatology Partners and Gwinnett Clinical Research Center in Snellville, GA5; and Andrea Zaenglein, MD, FAAD, professor of dermatology and pediatric dermatology at Milton S. Hershey Medical Center at Penn State University in Hershey, Pennsylvania.6
“In developing these new guidelines, not only have we recruited acne experts from across the country, but we also have an internal medicine physician, pediatrician and patient advocate,” said Keri. “In fact, over 51% of the working group has no relevant pharmaceutical interest. This is important because acne is not only treated by dermatologists. Primary care plays an active role, so we need to consider their perspective, as well as that of the patients. “
Keri told Dermatology Times® that there will always be room for improvement in the treatment of acne. “At least [for now], we don’t have a quick fix for 100% acne elimination for 100% of a person’s life, ”she said.
However, the pipeline of treatment options continues to flow, focusing on care until a cure is a reality. New to the list of topical formulations are a minocycline foam (Amzeeq; Foamix Pharmaceuticals) and a retinoid, trifarotene (Aklief; Galderma).
“There are also new formulations of older retinoids, which have been evaluated [and found] be helpful, ”Keri said. “In addition, clascoterone [Winlevi; Cassiopea] is a new topical antiandrogen that is approved by the FDA but has not yet been released to the market. This drug should be available soon.
Sarecycline (Seysara; Almirall) is the first new oral antibiotic approved by the FDA in over 40 years. One of its added advantages is that this small molecule drug derived from tetracycline is “less likely to generate resistance,” Keri said. “It’s exciting because of the goal of managing antibiotics around the world.”
Patients should also be informed about new oral antibiotics based on weight. “We have this stipulation with some antibiotics, but not all,” Keri said. “Antibiotic management ensures that you have the right antibiotic and the right dose at the right time for the right condition. You want to make sure that you aren’t giving too much or too little.
In Keri’s opinion, the dermatology community is working diligently to reduce her dependence on antibiotics. “As we get new mechanisms to treat acne, maybe we can use less antibiotics,” she said.
The forum included a review of oral contraceptives approved for the treatment of acne, as well as highlights of some of the controversies regarding side effects, including thromboembolic events with certain oral contraceptive pills and their safety.
“Currently, there are 4 oral contraceptive pills approved by the FDA for the treatment of acne, but there are many birth control pills that are not approved by the FDA for the treatment of acne. [that] can help, ”Keri said.
Most oral contraceptive pills, whether or not approved for the treatment of acne, are a combination of estrogen and progesterone. “Clinicians need to understand the difference of these 2 components, so that they can make an informed decision about prescribing their patients for acne,” said Keri. “There are oral contraceptive pills that are good for acne; however, these companies have not sought approval for the treatment of acne.
Keri tends to prescribe FDA approved oral contraceptives that contain drospirenone (Yaz; Beyaz; Bayer) because the synthetic progestin acts as a strong antiandrogen. “However, there is a little controversy about their [adverse] effect profile, especially thromboembolic events, ”she said. “But the risk is low.”
Spironolactone is also an antiandrogen used in adult women. “It has gained a lot of acceptance over the years for the acne treatment, in part thanks to celebrity endorsement,” Keri said. “One of the [adverse] effects of spironolactone in men is gynecomastia, so it is not used in the treatment of acne in men.
According to Keri, great results are obtained with spironolactone, with long-term treatment that lasts for years. Laboratory monitoring may be necessary, however, as the drug can cause hyperkalemia, an increase in potassium.
Isotretinoin is a derivative of vitamin A for severe scars with nodular cystic acne or for acne which has serious psychological implications for the patient. However, the systemic drug is surrounded by controversy over serious side effects, including malformations in the fetus.
“This [adverse] effect [teratogenicity] is undisputed, unlike concerns about depression and inflammatory bowel disease, ”Keri said. “In the past, I think people were just cautious about prescribing isotretinoin. Today, however, thanks to good epidemiological studies, dermatologists are feeling more and more comfortable in prescribing the drug.
At Keri’s office, isotretinoin dosage is the patient’s preference, although she prefers a typical cumulative dosage of 150 mg / kg. “But there are patients who need more or less of the medicine,” Keri said. “There is variability in the amount of isotretinoin that patients will need, and we are working to define the optimal dose for patients. “
Diet has also become increasingly important in the treatment of acne. “There is some evidence that milk makes acne worse,” Keri said. “While some data suggests skim milk was more involved, recent data does not support this. The jury is still out on the association between milk and acne.
“White” foods with a high glycemic load, such as white bread, rice and pasta, have also been heavily implicated in the exacerbation of acne. “My patients tend to overemphasize diet, although diet can contribute to acne,” Keri said. “Diet is of greater concern for the patient with polycystic ovarian disease. Dietary intervention [watching the glycemic load/index] has been shown to specifically help these patients.
The advantages of light-based devices over traditional pharmaceutical therapies are also changing the paradigm of acne treatment. Traditional treatments still tend to be the first line of choice, but light and laser therapy can be used for the patient who does not want traditional treatment or who has failed traditional therapy and is able to pay direct expenses – it’s usually not covered by insurance, according to Keri.
Other gaps in acne research include the treatment of patients with colored skin and pregnant patients, as well as the exploration of the molecular and cellular mechanisms underlying acne.
“A lot of work goes into developing the guidelines,” Keri said. “That’s why it takes 2 to 3 years. We try to assess the validity of the evidence and try to make it user friendly so that the guidelines can be a reference for the practitioner who is in a busy practice.
Keri is on the VYNE Therapeutics Speakers Bureau and Consultant for Almirall.
Pathy, Sabbag and Reynolds did not report any financial or relevant disclosures.
Zaenglein is a consultant for Pfizer; member of the advisory board of Dermata, Sol-Gel, Regeneron, Verrica Pharmaceuticals and Cassiopea; and contract researcher for AbbVie, Arcutis and Pfizer.
1. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Care guidelines for the management of acne vulgaris. J Am Acad Dermatol. 2016; 74 (5): 945-73.e33. doi: 10.1016 / j.jaad.2015.12.037
2. Keri J, Pathy A, Weiss JS et al. Translate the evidence into practice, current acne guidelines and beyond. American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX); April 23-25, 2021; virtual. Accessed May 4, 2021.
3. Pathy A. Development guide and clinical pearls. American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX); April 23-25, 2021; virtual. Accessed May 4, 2021.
4. Sabbag Reynolds. Spironolactone for the treatment of acne. American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX); April 23-25, 2021; virtual. Accessed May 4, 2021.
5. Guidelines Weiss J. Isotretinoin. American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX); April 23-25, 2021; virtual. Accessed May 4, 2021.
6. Zaenglein A. Diet and acne. American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX); April 23-25, 2021; virtual. Accessed May 4, 2021.