LAS VEGAS – New combination drugs have given clinicians powerful weapons against acne, according to Dr. Lawrence F. Eichenfield, assistant chief of pediatric and adolescent dermatology at the University of California, San Diego.
Dr. Lawrence F. Eichenfield
"I can wipe out virtually anyone’s acne," Dr. Eichenfield said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. "We are capable of doing it with the broad range of medications we have."
The condition varies widely in the number of lesions, the amount of scarring, and the patient’s perception. "There are some teenagers who might have one pimple, but to them it’s like a volcano," he said.
Retinoids are now considered the base therapy for any significant acne because they target microcomedos, the precursors to acne lesions. Topical retinoids are usually enough for comedonal acne. Benzoyl peroxide can be used as an alternative. For more moderate cases, a topical antibiotic may be needed.
The bacterium implicated in acne, Propionibacterium acnes, can develop resistance to topical antibiotics. But combining antibiotics with benzoyl peroxide minimizes this resistance. So some of the new gels combine benzoyl peroxide with clindamycin. There are also tretinoin-clindamycin and adapalene–benzoyl peroxide combinations.
"These are excellent products," said Dr. Eichenfield. "Probably the only negative is the cost." Some can run as much as $160 a tube, he noted. He encourages patients to look for coupons on the Internet.
If these treatments fail or if the acne is very severe, an oral antibiotic may be needed. Oral antibiotics should be used only in combination with topical retinoids. Finally, if these fail, Dr. Eichenfield said, you can prescribe isotretinoin.
Once the acne is under control, the medication can be scaled back and should be predominantly topical. In older adolescent females, hormonal therapy may be an alternative. "We try to minimize the use of systemic antibiotics," said Dr. Eichenfield. "Get control over 2-3 months, and then try to back down."
No medication is approved for acne in patients under age 12 years, he said. But acne vulgaris is reported in more than three-quarters of children in this age range, so it’s not unreasonable to think about treating them with a topical retinoid.
Dr. Eichenfield and his colleagues investigated this possibility in an open-label study of 40 patients 8-12 years of age with mild-to-moderate acne (Pediatrics 2010;125:e1316-23). After 12 weeks of treatment with 0.04% tretinoin microsphere gel supplied in a pump, 75% of cases were graded as almost clear or mild.
The total lesion count decreased 49.8%, and there were significant improvements in both the Evaluator’s Global Severity Score and the Alternative Evaluator’s Global Severity Score.
Patients experienced only mild adverse reactions, mostly mild skin irritation in the first 3 weeks of therapy. Only one patient discontinued use of the medication.
Such data have made Dr. Eichenfield an advocate of taking acne seriously. "It’s much easier to prevent scarring than to get rid of it later," he concluded.
Dr. Eichenfield disclosed that he has served as an investigator without personal compensation, a consultant, or an adviser for the following companies: Astellas Pharma, Coria Laboratories, Galderma, Ortho Dermatologics, GlaxoSmithKline (Stiefel), Sanofi-Aventis, and Johnson & Johnson.