Acne vulgaris is a diagnosis common to all primary care physicians, and the No. 1 concern for most adolescents. Referral wait times to a dermatologist can be anywhere from 3 to 6 months; if you’re lucky, dermatologists have a physician assistant or nurse practitioner who can see patients sooner. But the majority of acne cases – even complex ones – can successfully be treated by a primary care physician. Not only would you be improving patient satisfaction because the patient can be treated immediately, you also would increase your revenue.
Acne care is a billion dollar industry. Prescription medications are a $2 billion industry, and nonprescription medications are three to four times that (Semin. Cutan. Med. Surg. 2008;27:170). Yet, the average primary care physician will start treatment, then refer to the dermatologist.
The scope of acne care is not that broad; this should decrease your anxiety about being more aggressive with the treatment. Acne begins when there is follicular hyperproliferation, which leads to the obstruction of the follicle. This is followed by an increase in the sebum, by inflammation, and then by colonization with bacteria. Topical retinoids (tretinoin, adapalene, and tazarotene) normalize the follicular hyperproliferation and decrease inflammation. Antibiotics kill the bacteria. So, with implementation of topical retinoids, antibiotics, and a good home regimen, the vast majority of acne cases can be successfully treated without a referral.
When a patient presents with either concerns about acne or obvious full-blown acne, an assessment of the condition should be done. Realizing that there is gender gap in the treatment of acne is crucial. Males are much less likely to admit that they are bothered by their acne or adhere to treatment because they think it’s “girly” to use products on the face or follow a cleansing regimen. But, it is well documented that acne is associated with lower self-esteem, being bullied, depression, and anxiety. The patient assessment should identify acne type (comedonal, inflammatory, nodular), severity, scarring, menstrual history in girls, and the psychological impact on the patient.
Also review past treatments and what worked, what didn’t work, and why. Most patients upon presentation have used the over-the-counter preparations, which usually consist of benzoyl peroxide and salicylic acid.
Managing patients’ expectations is another key component to successful treatment. Most of the topical treatments have undesirable side effects like drying and reddening and hyperpigmentation of the skin. Informing them that irritations will lessen and will improve over time can aid in adherence to the regimen.
If a patient has dry skin, cream formulations will be less irritating; more oily skin will respond better to gels that tend to be more drying. The percentage of benzoyl peroxide also contributes to the discomfort. One study showed that the 2.5% was as effective as the 10% formulation, but resulted in less irritation (Br. J. Dermatol .2014;170:557). Salicylic acid is a good alternative if benzoyl peroxide is not tolerated.
Antibiotics are an essential part of acne treatment. Topicals such as erythromycin, clindamycin, and dapsone reduce Propionibacterium acnes, which also reduces inflammation. Oral antibiotics have similar efficacy, but are associated with more rapid clinical improvement. Another consideration in using oral antibiotics is the side effects. Photosensitivity and gastrointestinal upset are significant issues that arise with their use. Doxycycline monohydrate tends to have fewer GI side effects and is preferred over doxycycline hyclate. Minocycline has fewer GI effects and less photosensitivity, but tends to be more expensive and is associated with vertigo and serum sickness (Arch. Dermatol. 1982;118:989-92). Prolonged use of either topical or oral antibiotics increases the risk of resistant strains of P. acnes. Other antibiotics are available for use, such as trimethoprim-sulfamethoxazole, clindamycin, and erythromycin, but all have either significant side effects associated with them or higher levels of resistance.
Combination therapy is superior to monotherapy. Whether combining benzoyl peroxide with a topical retinoid, antibiotic, or both, improved outcomes have been shown. Studies also confirm that use of benzoyl peroxide with antibiotics lowers the risk of P. acne’s resistance (Dermatol. Clin. 2009;27:25-31).
Now, how do you make acne care work for your business model? It’s easier than you may think. Other highly effective, inexpensive, and efficient treatments can be implemented with little investment.
Establishing and marketing an acne program and dedicating a few hours a week to an acne clinic can add significant revenue to your practice. Educate the patient on cleansing and diet; information can be found at www.acne.com. Beyond using the traditional acne treatments, consider adding peels and a light-based therapy to the regimen. Salicylic acid peels are easy to apply and give great results. Treatments are done monthly for five to six treatments at a cost of $140-$250 per treatment. The application process takes 15-20 minutes.