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The Cosmetic Treatment of Acne
HILARY E. BALDWIN, M.D.-MEDICAL DIRECTOR
ACNE TREATMENT AND RESEARCH CENTER
MORRISTOWN N.J.
-CLINICAL ASSOCIATE PROFESSOR OF DERMATOLOGY
RUTGERS ROBERT WOOD JOHNSON MEDICAL SCHOOL
Disclosures
Almirall (S)
BioPharmX (I)
Botanix (I)
Dermira (I,A)
Encore (A)
EPIHealth (A)
Foamix (A)
Galderma (A,I,S)
J&J (A)
LaRoche-Posay (A, S)
Novan (I)
Ortho Dermatologics (A,I,S)
Pfizer (S)
Promius (A)
Sol-Gel (A)
Sun (A,S)
S=Speaker’s BureauA=Advisory BoardI=Investigator
The Cosmetic Treatment of Acne
Make the patient better Keep the patient better Prevent or get rid of the sequelae Improve the appearance of their skin
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Acne is our bread and butter
IT’S NOT ROCKET SCIENCEDoing it well means: *Taking your time
*Educating your patients*Knowledge of what to
use when in whom
Deciding what to use when andin whom
Type of lesions Inflammatory
Non-inflammatory
Number of lesions Size of lesions Distribution
Deciding what to use when andin whom
Seek the baggage!
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All acne patients deserve a topical retinoid
No other medication is comedolytic and anti-comedogenic BP weakly comedolytic
Good anti-inflammatory drugs
Good for both acute and maintenance therapy
Reduces hyperpigmentation
Prevents and reduces scars
Reduces fine lines and wrinkles
Microsphere formulations reduce shine
Topical retinoids alone
BaselineWeek 12
Tazarotene 0.1% Cream
Tazarotene .1% Cream Monotherapy
Baseline Week 12
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Tazarotene 1% Cream Monotherapy
Baseline Week 12
Tretinoin 0.05% Lotion (Altreno)
N=1640, moderate to severe acne
Vehicle contains hydrating agents and humectants Hyaluronic acid, soluble collagen and
glycerin
Superior tolerability
0%
-23%
-35%
-46%
0%
-16%
-24%
-30%
Baseline Week 4 Week 8 Week 12
Tretinoin 0.05% lotion (N=819) Vehicle (N=821)
Data on file Ortho Dermatologics
Patients like to glow, not shine
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Microsphere tretinoin is not degraded by BP and/or sunlight
9484
1910
0
20
40
60
80
100
Per
cen
t o
f R
emai
nin
g
Tret
ino
in
RETIN-A MICRO0.1%
8981
70
0
20
40
60
80
100
Per
cen
t o
f R
emai
nin
g
Tret
ino
in
RETIN-A MICRO 0.1% + EBPTretinoin gel 0.025% + EBP
1. Nighland M, Yusuf M, Wisniewski S, Huddleston K, Nyirady J. Cutis. 2006;77:313-316.
*In vitro exposure of tretinoin to simulated solar UV irradiation ± EBP.EBP = erythromycin-benzoyl peroxide
2 hours UV Exposure
6 hours UV Exposure
2 hours UV Exposure
6 hours UV Exposure
Microsphere formulation absorbs sebum in vitro
0
100
200
300
Perc
ent O
il A
bsor
bed
by W
eigh
t
Saxena S, and Nacht S. Polymeric Porous Delivery Systems: Poyltrap® and Microsponge®. Delivery System Handbook for Personal Care and Cosmetic Products. In Technology, Applications and Formulations, edited by MR Rosen. William Andrew Publishing, New York 2005: 334-351.
Absorbs over 2 times its own weight
1. Nyirady J, Nighland M, Payonk G, et al. Cutis. 2000;66:153-156; 2. Kaity S, Maiti S, Ghosh AK, et al. J Adv Pharm Tech Res. 2010;1:283-290; 3. Data on file. Ortho Dermatologics. 1998.
Microsphere-Assisted Shine Control
77%
46% 34%
80%72%
57%
0%
50%
100%
Baseline 3 hours 6 hours
RETIN-A MICRO0.1%
Perc
ent o
f Pat
ient
s w
ith
Mod
erat
e to
Sev
er F
acia
l Shi
ne
Significantly less facial shine at 3- and 6-hours post application*1
†P = 0.008†P = 0.001
*Baseline measurement obtained after 4 days of treatment application; †P-values are vs baseline.
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1. Data on file. P.U.M.P. Study. Ortho Dermatologics. 2007.
Before Treatment After Treatment
Real-World Shine Control
Methacrylate copolymer
Microparticles of methacrylate copolymer that imbibes and holds sebum within the molecules
Incorporates into the molecule, swells to many times original size
Once imbibed, cannot leak out
Controls oil/shine for up to 8 hours
Invisible on the skin
Thiboutot Cosmetic Dermatology 2001:45-51
Methacrylate copolymer
Thiboutot Cosmetic Dermatology 2001:45-51
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Should we wait to add a retinoid?
108 patients with mild-moderate acneClindamycin 1%/BP 5% QD X 3 moRandomized to receive:
Adapalene 0.1% Gel QD from day 1Adapalene 0.1% Gel QD from day 30
Results at month 1:Superior efficacy in adapalene groupNo significant irritation differences
Earlier improvement gave hope, did not increase irritation, improved compliance
Del Rosso J. 2007;6(6):616-22
NO!
Benzoyl Peroxide is the most effective antimicrobial
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0.5
1
1.5
2
2.5
3
3.5
Clin-BP Ery-Bp Benzoylperoxide
Clindamycin Erythromycin Azelaic acid
Harkaway KA, et al. Brit J Derm. 1992;126:586-590.
Lo
g c
m2
Ability to kill P. acnes
Benzoyl peroxide
BP kills faster and more effectively than topical antibiotics BP alone significantly reduces both inflammatory and non-
inflammatory acne BP is not associated with antimicrobial resistance BP can prevent the development of resistance to topical and oral
antibiotics BP can reverse resistance that has already occurred
Gloor M, et al. Z. Hautkr. 1982;57:867-878, Gollnick H, et al. J Am Acad Dermatol. 2003;49;S1-38, Gollnick H, Schramm M. Dermatol. 1998;196:119-125
Benzoyl Peroxide should be used whenever topical and oral antibiotics
are used
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Clindamycin should never be used as monotherapy
Cunliffe WJ, Holland KT, Bojar R, Levy SF. Clin Ther. 2002;24:1117-1133.
Compliance With Topical Benzoyl Peroxide
Yentzer BA et al. J Am Acad Dermatol. 2009;60(5):879-880.
Individual subjects’ adherence to topical benzoyl peroxide ranged from 14% to 79% for the 6 weeks. No subject was considered “adherent to
treatment” as defined by a mean adherence of ≥80%.
N=11
Adult female acne may be a different disease
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What Adult Females With Acne Expect From a Visit to Their Dermatologist
Better understanding of the condition Involvement in treatment choices
Adult Female Acne Survey
What Adult Females With Acne Expect From a Visit to Their Dermatologist
Better understanding of the condition Involvement in treatment choices
Why were you dissatisfied with some elements of your visit to your dermatologist?
Respondents(N = 128)
The examination was too quick 56%
The discussion of different treatment options was too short, not detailed enough 48%
The dermatologist did not look at my skin meticulously 44%The dermatologists did not discuss different treatment options 41%
Adult Female Acne Survey
Patient Factors to Consider when Treating Adult Female Acne
Clinical aspects: lesion type and location Long duration - maintenance therapy crucial Potential of older skin to irritation Bypass the skin?
Dreno B, et al. JEADV. 2013;27:1063-1070. Williams C, et al. Am J Clin Dermatol. 2006;7:281-290..
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Spironolactone
• Anti-androgen, androgen-blocker• Reduces masculine characteristics
• Excess hair, hair loss, acne• Not FDA approved for skin issues (hypertension)• Launched in 1950, having a renaissance • Few side effects
Breast tenderness, menstrual irregularities No need to check potassium in women younger
than 50 but…
Low-sodium processed foodsCoconut water/milk
(600 mg/cup)
Severe inflammatory acne
Therapeutic optionsIsotretinoinIsotretinoinIsotretinoin
Baseline 5 MONTHS
Isotretinoin
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Unnecessary consequences-Scarring
Layton AM, et al. Clin Exper Dermatol. 1994;19:303-308. Tan J, et al. J Cutan Med Surg. 2010;14:156-160,Dreno et al 2014 poster presented EADV
Risk factors for developing scars Brazil France USA
Time elapsed between acne onset and 1st effective treatment: ≥ 3 years vs < 3 years 1.6 [1.4 – 1.8] 2.8 [2.4 – 3.3] 2.8 [2.4 – 3.2]
Likelihood of acne scarring increases with delays in treatment
Treat EarlyTreat Aggressively
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Adapalene 0.3%/BP 2.5% vs Vehicle Scar Formation Risk in Moderate to Severe Acne
Split-face, Investigator-blinded, Vehicle Controlled Whole Face, Open-label
Part I - 24 weeks; 8 visits Part II - 24 weeks, 2 visits
A/BPO 0.3%/2.5%
Vehicle
Split Face
Week 1, 4, 8, 12, 16, 20, 24 Week 36, 48
Dreno et al. Poster, Winter Clinical,Maui HI 2018
A/BPO 0.3%/2.5%
Adapalene 0.3%/BP 2.5% vs Vehicle Scar Formation Risk in Moderate to Severe Acne
Split-face, Investigator-blinded, Vehicle Controlled
Part I - 24 weeks; 8 visits
A/BPO 0.3%/2.5%
Vehicle
Split Face
Week 1, 4, 8, 12, 16, 20, 24
Dreno et al. Poster, Winter Clinical,Maui HI 2018
67 patients 16-34IGA 3 or 4
Symmetrical distribution of:
≥25 inflammatory lesions
≥10 atrophic scars
Adapalene 0.3%/BP 2.5% vs Vehicle Percent Change From Baseline - Total Atrophic Scar Count
5.89.8 12.3
16.2 17.1 15.2 14.4
-30
-20
-10
0
10
20
30
0 4 8 12 16 20 24
Perc
ent C
hang
e (M
ean)
Week
* * ** * *
*
* P-value < .001
• The difference in the mean percent change in scars after 24 weeks was 29.9%
Dreno et al. Poster, Winter Clinical, Maui HI, 2018
VehicleA/BPO 0.3/2.5%
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Adapalene 0.3%/BP 2.5% vs Vehicle Percent Change From Baseline - Total Atrophic Scar Count
-2.5 -1.0 -4.5-7.3 -7.0 -8.7
-15.5
5.89.8 12.3
16.2 17.1 15.2 14.4
-30
-20
-10
0
10
20
30
0 4 8 12 16 20 24
Perc
ent C
hang
e (M
ean)
Week
* * ** * *
*
* P-value < .001
• The difference in the mean percent change in scars after 24 weeks was 29.9%
Dreno et al. Poster, Winter Clinical, Maui HI, 2018
VehicleA/BPO 0.3/2.5%
Tretinoin and scars
Improves existing scar cosmesis 10,11,12,13
Specifically acne scars 14
Prevents development of scars by accelerating speed of healing and reepithelialization after:
Dermabrasions 15
Chemical peels 16
Facial resurfacing procedures (the deeper the better) 17
EDC of truncal BCCs 18
10)Janssen de Limpens, BJD 1980;103:319-328, 11) Panabiere-castaings J Derm Surg Oncol 1988; 14:1274-1276, 12) Schmidt et al, Int J Dermatol 1995;34:53-57, 13) Knor Acta Dermatovenereol Coat 2004;12:84-91, 14) Schmidt et al, Int J Dermatol. 1999;38:149-53, 15) Mandy, JAAD 1986; 15:878-879, 16) Hevia et al. Arch Derm 1991;127:678-682, 18) Pariser et al. J Clin Aestett Dermatol 2009;2(5):38-42 17) Buchanan, Gilman. J Cut Aesthet Surg 2016; 9(3):139-144.
Unnecessary Consequences-Hyperpigmentation
Stop picking!Topical retinoidsHydroquinone
Chemical peelsLasers
Azelaic acid?
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Retinoids and dyspigmentation
Established treatment for existing dyspigmentation1,2
0.05% tretinoin lotion showed decreased PIH3
Reduces development of dyspigmentation 4,5,6,7
Specifically acne-induced PIH8
Synergy with HQ9,10
1) Perez-Bernal et al. Am J Clin Dermatol,2001;1:261-268, 2) Pathak JAAD 1986;15:894-897, 3) Lain E et al. J Drugs Dermatol. 2019;18(11):1128-1138. 4) Kang et al, Am J Clin Dermatol 2005;6:245-253, 5) Haddad et al, Int J Derm 2003;42:153-156, 6) Halder, Richards, Skin Ther Lett 2004;9:1-3, 7) Pagnini et al, Acta Derm Venereol, 1999;79:305-310 8) Rossi et al, JEADV, 2001;25:398-402, 9) Engasser, Maibach JAAD 1981;5:143-147, 10) Kasraee et al. Dermatol, 2003;206:289-293,
New isotretinoin data
Absorica® and Accutane®-Fasting vs fed conditions
Open-label, single-dose, randomized, 4-treatment, crossover, comparative bioavailability study1
60 patients enrolled; 57 completed the study
4 arms separated by 21 day washout period: 40 mg Absorica® or Accutane®
10 hour fast or FDA high-fat meal
Webster G, Leyden J, Gross. J Am Acad Dermatol. 2013;69(5):762-767
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Webster G, Leyden J, Gross. J Am Acad Dermatol. 2013;69(5):762-767
Sample FDA High Fat Diet
2 eggs fried in butter
2 strips of bacon
2 slices of toast with butter
4 oz hash brown potatoes
8 oz whole milk…
Sample FDA High Fat Diet
2 eggs fried in butter 2 strips of bacon 2 slices of toast with butter 4 oz hash brown potatoes 8 oz whole milk
TWICE A DAY!!
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.Webster G, Leyden J, Gross J. J Am Acad Dermatol. 2014;13(6):665-70
Lidose-formulation isotretinoin vs. food-dependent isotretinoin
Lidose formulation isotretinoin in fasting state
Open-label, single-arm 20 week (active) study, N=163 Twice daily without food Cumulative dose of 120–150 mg/kg Treatment after Week 20 was not permitted 2 year post-treatment observation phase
IGA, lesion counts, Acne-QoL
Lidose formulation isotretinoin in fasting state
IGA improved significantly from baseline to week 20 Change from baseline was maintained in the 2 year
post-therapy period (P<0.0001) Conclusion: Lidose-ISO taken without food, clinical
efficacy and improved QoL were sustained for 120 weeks
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Re-treatment rates in post-therapy phase
Historical relapse rate:10-22% at 1 mg/kg/d20-53% at 0.5 mg/kg/d 1,2,3
1) Layton A et al. Br J Dermatol 1983;129:292-296, 2) Cunliffe W, Norris J. Dermatologica. 1987;175(Suppl 1): 133-137, 3) Strauss J, et al. J Am Acad Dermatol 1984;10:490-496
Should we give treatment after successful course of isotretinoin?
Recurrence of acne requiring additional isotretinoincourses is uncommon
Occurrence of some severity of acne after isotretinoinuse is common Disturbing to patients
Unpredictable at the time if they are relapsing
Pilot study (N=20), randomized, double-blinded, vehicle-controlled of RAM .04% QD immediately after successful isotretinoin course 38.7% lower lesion count versus vehicle
Vender, Vender. Derm Res Pract 2012; doi: 10.1155/2012/736532
Spironolactone during last month of isotretinoin
Many AFA will flare after isotretinoin discontinuation Second course of isotretinoin Women with PCOS
Start spironolactone 50 mg during last month Continue indefinitely
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Beneficial Effects of Cosmetics
Used to fard1
Camouflage, contour and conceal Response to acne therapy too slow for most Chronic relapsing condition
Enhance oil control Adorn Create a sense of well-being Improve the quality of life
1) OED – to paint the face with cosmetics so as to hide blemishes
Decorative cosmetics improve QOL
23 patients with disfiguring facial conditions including acne (8) and rosacea (9)1
Taught to use cosmetics by professionals
DLQI baseline and 2 weeks
Improvement in all, acne p=0.0078
18 patients with acne treated and taught to use cosmetics2
Improvement of acne and improved QOL at 2/4 weeks
1) Boehncke et al. Eur J Dermatol 2002;12:577-80, 2) Hayashi et al. Eur J Dermatol 15;15:284-7
Concomitant procedures during acne therapy improve the quality of life
Comedone extraction Chemical peels, MDA Laser and light
Acne, PIE, PIH, Scars
Microneedling
Chilicka et al. Patient Preference and adherence. 2017, Aug 4
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