Addressing Challenging Cases of Acne: Part 1

In a series of Dermatology Times Case-Based Roundtable® events, leading dermatologists and their local peers tackled some of the most challenging cases of acne. These gatherings provided an invaluable platform for collaborative discussion, innovative problem-solving, and the exchange of cutting-edge treatment strategies. Each session featured in-depth case presentations, allowing participants to delve into the complexities of acne presentations and explore various diagnostic and therapeutic approaches for diverse patient populations. These clinical insights from New York, Nevada, and Florida showcased the dermatology community’s collective expertise and dedication to improving patient care.

Hilary Baldwin, MD, medical director of the Acne Treatment and Research Center in Morristown, New Jersey, led a team of local colleagues in a detailed discussion about 2 particularly challenging cases of acne in younger patients. These cases emphasized the importance of combination therapies, adherence, and flexibility.

Diet Considerations for Drug Absorption

The first case presented was that of a 12-year-old boy with moderate acne on both his face and back. Baldwin described the patient as “quite overweight” and noted that his mother mentioned he was “a very picky eater,” implying a diet high in junk food and low in nutritional value. This was the patient’s first visit to a dermatologist, having only used some over-the-counter spot treatments before this consultation.

“This is his first time visiting a dermatologist. He’s used some over the counter stuff before, but it’s mostly just spot treatments—some of those spot pads, for example. No medications, not even any bona fide over the counter acne medications,” Baldwin explained. She highlighted that the acne was affecting his self-esteem, social interactions, and performance in school.

The team noted that it was unusual for someone so young to have such extensive acne, leading them to predict that he might eventually need isotretinoin. However, given his age, they aimed to try alternative treatments first to potentially postpone the use of isotretinoin, knowing that “the younger you start isotretinoin, the more likely patients are to relapse,” Baldwin explained.

The treatment plan involved a combination of benzoyl peroxide and adapalene (0.3%) to be applied every other day initially, then gradually increased to once daily. Baldwin stressed the importance of gradual introduction to minimize irritation. “We came up with a combination of benzoyl peroxide and adapalene 0.3%...starting out every other day and then gradually increasing to once a day, hoping that that slow onset of use would reduce any irritation that he might experience.”

The patient was advised to return in 6 weeks. Upon his return, his acne showed no significant improvement, largely due to questionable adherence to the medication regimen. Consequently, the team decided to prescribe 100 mg of doxycycline twice daily as a more effective and easier-to-use treatment. “We decided that it was time to put him on a medication that was a little bit easier to use and would be a little bit more effective and perhaps work more rapidly, and we started him on doxycycline 100 mg twice a day,” Baldwin said, adding that they also addressed concerns about antibiotic resistance with the patient’s mother.

When the patient returned 6 weeks later with little improvement, they opted to start him on isotretinoin, despite his young age. This decision was made after discussing the proper dosing and ensuring that he took the medication with a fatty meal to improve absorption. “Knowing that the younger you start isotretinoin, the more likely patients are to relapse,” Baldwin noted, they agreed on a starting dose of 0.5 mg/kg/day to prevent potential adverse events like pseudoacne fulminans. Despite these efforts, the patient’s condition did not improve significantly, leading to the realization that his low-fat diet was impairing drug absorption. The team switched him to a food-independent formulation of isotretinoin, which proved to be successful.

TikTok and the Urgent Countdown to Prom

The second case involved a 17-year-old girl with moderate acne on her face and back, who was particularly concerned about clearing her skin in time for prom and graduation. This patient had been using makeup and TikTok remedies, such as toothpaste, to manage her acne, but had not tried prescription medications. Baldwin emphasized the importance of using non-comedogenic products, especially for young girls who experiment with various skin care products. “We want to make sure that our patients are using only topical products that actually say non-comedogenic on it,” she advised.

The patient’s treatment plan included a triple combination of clindamycin, adapalene, and benzoyl peroxide.

Baldwin noted the importance of setting realistic expectations for improvement, typically around 8 weeks, to prevent patient frustration and discontinuation of treatment.

Given the need for rapid improvement before prom, the team considered adding clascoterone to the regimen to address sebum production. “The key takeaways here were that we felt that with the triple combination, we were taking care of killing Cutibacterium acnes, helping to reduce follicular hyperkeratinization, and helping to reduce inflammation, but what we were lacking was a reduction in sebum production,” Baldwin explained.

When the patient reported no significant improvement after 4 weeks, despite good adherence, the team decided to add clascoterone twice a day. This addition aimed to provide comprehensive treatment covering all aspects of acne pathogenesis. “One of the key takeaways here was that it is very important to be using this drug twice a day,” Baldwin said, emphasizing the importance of patient education on the mechanisms of action of drugs and the need for consistent use.

The team also considered starting an oral antibiotic for the patient’s back acne but decided to give clascoterone more time to work before adding another medication. They highlighted the importance of continuous follow-up and patient education to ensure adherence and avoid treatment discontinuation.