Finding the Right Acne Regimen for Your Patients

With so many medications and cosmeceuticals on the market, it can sometimes be difficult to determine the best treatment regimen for your acne patients. However, Shanna M. Miranti, MPAS, PA-C, Riverchase Dermatology, Naples, Florida, comes to the rescue by revealing how to best optimize an acne treatment regimen for different patients during her presentation at the 2022 Society for Dermatology Physician Assistants Annual Summer Meeting held June 16-19, 2022, in Austin, Texas.¹

In her presentation, Miranti discussed the current acne treatment guidelines, new therapies on the market, how various treatment options differ for specific acne subcategories, why every patient should not be given tretinoin, and why clinicians should continue to prescribe Accutane.

Guidelines

Regarding guidelines for acne treatment, Miranti says patients are divided into 3 categories: mild, moderate, and severe. For patients with mild disease, benzoyl peroxide (BPO), a topical retinoid, or combination therapy is recommended. For moderate disease, start with topical combination therapy of BPO and an antibiotic, a retinoid and BPO, or a retinoid, BPO, and antibiotic. Miranti says you could also swap out the topic antibiotic or an oral one. The same regimen guideline goes for patients with severe disease; however, oral isotretinoin can also be used among this patient population.

New Treatments

Miranti also featured some of the latest medications to hit the market for acne since 2019, including:

• Aklief (trifarotene; Galderma)
  • Approved by the US Food and Drug Administration (FDA) in 2019
  • Fourth-generation retinoid
  • Approved for 9 years old and up
• Amzeeq (minocycline; Journey Medical)
  • FDA-approved in 2019
  • Topical foam
  • Very low systemic absorption
  • Approved for 9 years old and up
• Arazlo (tazarotene 0.045%: Ortho Dermatologics)
  • FDA-approved in 2019
  • Third generation retinoid
  • Topical photostable retinoid
  • Approved for 9 years old and up
• Seysara (sarecycline; Almirall)
  • FDA-approved in 2019
  • Oral antibiotic
  • A part of a weight-based tetracycline class
  • Approved for 9 years old and up
• Winlevi (clascoterone; Sun Dermatology)
  • FDA-approved in 2020
  • First in class
  • Topical anti-androgen
  • Approved for 12 years old and up
• Twyneo (tretinoin 1% and BPO 3%; Galderma)
  • FDA-approved in 2021
  • Microencapsulation of ingredients
  • Approved for 9 years old and up

Treating Different Acne Subtypes

With all of these new medications in clinicians’ toolbox, Miranti dove into how these therapies can be used on different acne subtypes such as preteens, comedonal acne, oily and inflammatory teens, female hormonal acne, skin of color (SOC) patients who are prone to postinflammatory hyperpigmentation (PIH), and inflammatory/cystic/scarring acne.

For preteens (9 to 12 years old), Miranti suggests keeping the regimen simple and selecting a tolerable vehicle for this patient population’s tender skin. She reminded that generic tretinoin cannot be prescribed for this age group as it is only approved for patients 12 years old and up. Miranti also notes that acne at 9 years old is no longer considered precocious puberty; however, work up needs to be done for precocious puberty if acne starts prior to age 7.

In comedonal acne, she emphasized the importance of befriending a good esthetician who can perform extractions and teen facials. Miranti also recommends an AHA or BHA washes, pads, or scrubs to aid in breaking up the pilosebaceous congestions and to utilize tolerable retinoid vehicles to prevent micro-comedo formation. Regarding treatment, Amzeeq, Aklief, Twyneo, Fabior, and Arazlo have all shown efficacy and treating this acne subtype.

For oily and inflammatory acne in teens, Miranti recommends BPO if the patient can tolerate it and look for products with good data on inflammatory and noninflammatory lesion reduction. A simple regimen is also suggested for this age group to promote better treatment compliance. She also noted to remember both sebum production and inflammation can be driven by androgens. For treatments, Winlevi and Aklief are recommended for this subtype.

In female hormonal acne, Miranti says to focus on the androgens. She added that adult females are more motivated to perform more complex regimes and will add recommended serums, antioxidants, and washes to their skin care routine. Regarding treatments, Miranti suggests prescribing spironolactone for patients 18 years and older starting at 50 mg. Also, Winlevi has been shown to be effective as a twice-daily treatment, retinoids have both acne and antiaging benefits, and Aczone has displayed specific female hormonal data.

For SOC patients, this patient population is often bothered by PIH more than active acne, so address this symptom early, according to Miranti. She also said to urge these patients to use sunblock. Hydroquinone, especially in combination treatment like Tri-luma (Fluocinolone/Hydroquinone/Tretinoin; Galderma), can be very effective in SOC patients, but Miranti warned to be aware of over-whitening/halo and ochronosis in high percentage compounds. Cysteamine/cyspera is also now available without a prescription and helps regulate melanin synthesis. Other available treatments include Aklief, Arazlo, Finacea/azelaic acid, and antioxidants such as Heliocare and Skinceuticals: Phloretin, Discoloration Defense.

Finally, in patients with Inflammatory, cystic, and scarring acne, Miranti says Accutane (isotretinoin) is still the gold standard for nodulocystic/scarring acne. Oral antibiotics/oral nonantimicrobial dose antibiotics can be effective in reducing inflammation. However, she emphasized that clinicians should never prescribe antibiotics as monotherapy. Instead, always add a BPO wash, topical, or combination therapy to reduce the risk of bacterial resistance. Other treatments that have shown efficacy for the acne subtype include retinoids, lasers, radio frequency devices, microneedling, and platelet-rich plasma (PRP).

Disclosure

Miranti is a speaker for EPI Health, Galderma, Incyte, Ortho Dermatologics, Verrica, and Soarsa. Also, she is a consultant for Verrica and Soarsa, and an advisory board member for Galderma and Incyte.

Reference

1. Miranti S. Not your mama’s acne/rosacea regimens. Presented at: The Society for Dermatology Physician Assistants Annual Summer Meeting. June 16-19, 2022. Austin, Texas.