Recognizing the ongoing value of benzoyl peroxide, educating patients about the role of antibiotics, and embracing spironolactone are among the acne treatment pearls provided by Hilary Baldwin, MD, during a virtual presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar.
Courtesy Wikimedia Commons/Kinan Ayu/Creative Commons license
Benzoyl peroxide celebrates its 60th birthday and is still going strong as an acne treatment, said Dr. Baldwin, of the department of dermatology, Rutgers Robert Wood Johnston Medical Center, New Brunswick, N.J. Benzoyl peroxide can be used as a stand-alone and has the added benefit of not being associated with antimicrobial resistance. In addition, “benzoyl peroxide is the heavy lifter in combinations,” she said. In fact, benzoyl peroxide can prevent the development of resistance to topical and oral antibiotics such as clindamycin, and can reverse resistance that has occurred, she noted.
However, patient compliance can be an issue. Benzoyl peroxide often is underused because of its tendency to bleach fabric, noted Dr. Baldwin, who is also medical director of The Acne Treatment and Research Center in New York. To help combat this problem and improve compliance, she advises patients to establish a dosing schedule for benzoyl peroxide, such as using it first thing in the morning, or applying in the afternoon and using a paper towel first, or a white towel, to wash their faces at bedtime, she said. When dealing with teenagers, “it sounds like a lot of work, but it makes the mothers much happier not to have their towels bleached.”
Although clinicians want to reduce unnecessary antibiotic use in acne, there is a place for antibiotics, but not as monotherapy, Dr. Baldwin said. Instead, initiate topical therapy, such as a retinoid or benzoyl peroxide, simultaneously with antibiotics and evaluate the response in 6-8 weeks, she advised. At that point, the antibiotics can be stopped, even if 100% clearing has not been achieved, and “the topicals can carry you on for months and months,” she noted.
Also, in female patients, consider oral contraceptive pills or spironolactone at the same time as oral antibiotics, then discontinue the antibiotics and continue with the hormonal therapy, she added. “Plan your exit strategy early,” she said. Explain to patients that you will stop the oral antibiotics after 2 months, so they must continue with the topicals.
“Embrace spironolactone if you haven’t already,” said Dr. Baldwin, who noted that spironolactone has been underused in recent years. Spironolactone use for acne has not been well studied, “but consensus groups and expert opinions certainly favor its use,” she added.
Dr. Hilary E. Baldwin
Spironolactone takes 3-6 months to reach its full effect, so Dr. Baldwin recommends beginning the therapy in combination with other strategies. “I begin in combination with oral antibiotics,” she said. Also, be sure to check hormone levels before initiating therapy if appropriate. Potential side effects include menstrual irregularities and breast tenderness, but they tend to decrease over time, Dr. Baldwin noted. Other side effects such as CNS symptoms (fatigue, dizziness, and headache) can be eased by paying attention to proper hydration and starting with a lower dose, she added. Studies in younger adults show no reason for concern about potassium levels, but potassium should be checked at baseline in older patients, after the first month, and after a dose increase, she said.
Dr. Baldwin was enthusiastic about the recent introduction of several new treatments for acne: Sarecycline, now approved by the Food and Drug Administration for use in patients as young as 9 years; trifarotene 0.005% cream, the first 4th generation retinoid, with truncal acne data; tazarotene 0.045% lotion , with improved tolerability; minocycline 4% foam , with high cutaneous levels and minimal systemic absorption; and clascoterone 1% cream , “the first topical antiandrogen and safe for use in males,” she said.
Relevant to her presentation, Dr. Baldwin disclosed relationships as an adviser, speaker, and/or investigator for Almirall, EPI Health, Foamix, Galderma, Johnson & Johnson, LaRoche-Posay, Menlo Therapeutics, Ortho Dermatologics, Sol-Gel, and Sun.
MedscapeLive and this news organization are owned by the same parent company.