One of the world’s foremost experts on acne management, Dr. James Leyden, recently conducted an interview with Practical Dermatology (May 2017, Vol. 14, No. 5, Pages 32 – 35), in which he spoke about the evolving acne treatment landscape and suggested we begin having a very serious and meaningful discussion about “decreased sensitivity” going beyond widely accepted theories of “antibiotic resistance” as a significant block in the foundation for current and future treatments. Treatment resistance, desire for increased efficacy and patient compliance are all drivers for the evolution of new treatment options. For example, Foamix Pharmaceuticals has entered their 3rd phase 3 trial for a foaming topical minocycline (FMX101) on moderate to severe acne. Pending positive results, this new trial is expected to form the basis for a New Drug Application, which the company plans to submit in the second half of 2018. BioPharmX Corporation has achieved its primary endpoint in phase 2b clinical trials of a topical minocycline gel (BPX-01). Outlined in a paper presented at the 2017 Alabama Dermatology Society Summer Symposium, they showed statistically significant results in the reduction of non-nodular inflammatory acne lesions when compared to vehicle in both 1 and 2 percent doses of BPX-01. They will progress toward phase 3. Paratek Pharmaceuticals, Inc. (in collaboration with Allergan) has announced positive results from two phase 3 studies on sarecycline, also being developed for the treatment of moderate to severe acne. Galderma recently launched Differin (a topical retinoid containing adapalene 0.1% or 0.3%) as an OTC product improving accessibility for many patients. These don’t even begin to speak to new laser protocol developments or multi-modality treatment options. For a frank discussion on the state of acne treatments, you’ll want to be sure to attend this year’s Cosmetic Surgery Forum panel, but in the meantime, we asked a few of our esteemed faculty for their current go-to when it comes to acne care for their patients. Board-certified physicians, Drs. Suneel Chilukuri, Joel Cohen, Jeanine Downie, Hassan Galadari, Neil Sadick, Joel Schlessinger and Mark B. Taylor share their thoughts.
Treatment resistance, desire for increased efficacy and patient compliance are all drivers for the evolution of new treatment options.
CSF: Do you have any acne go-to products or treatments, or is there a particular regimen you prefer for really tough acne cases?Dr. Neil Sadick of New York has a few items that qualify as go-tos. He likes the results he sees from the Venus Versa, Omnilux Blue Light and Red Light. “My most preferred treatment for tough cases is the Versa and/or PDT IPL,” says Dr. Sadick. Also a fan of how well devices can help treat tough acne is Dr. Suneel Chilukuri, of Houston, TX. “One of my favorite ‘go-to’ devices for acne is the Aerolase LightPod Neo, a 1064 nm laser with a 600-millisecond pulse. It quickly clears resistant acne and, in some cases, has shown very long-term clearance results. Another favorite device is the TheraClear IPL device. This particular device has a suction handpiece that can remove the sebum that is often ‘stuck’ inside a blocked follicular subunit. It also allows treatment of cystic acne due to the disposable 27-gauge needle tip that will painlessly penetrate the cyst while the suction clears the sebaceous material.” Outside of the use of device treatments, Dr. Joel Cohen, of the Denver, CO, area, says that both he and his patients “really like the PRESCRIBEDsolutions Starting Up/Face Glycolic Antioxidant Cleanser“. This cleanser is really flexible as a base for all types of patient concerns as it is made to be used with a PRESCRIBEDsolutions Booster for customization. Patients can add one of these booster formulas to the bottle of face wash to deal with a specific issue, such as inflammation, rosacea, dryness or scarring among others. When used together, the cleanser and booster provide quicker and more advanced results. With regard to acne flares, Dr. Cohen says, “We have had a lot of luck doing Acleara for acne flares. In fact, sometimes folks schedule it around the times of anticipated stressful events, after having successfully used it for flares in the past.” Glycolic acid is obviously a favorite when fighting acne and for Dr. Jeanine Downie of Montclair, NJ, that means aczone and Tazorac. “I like aczone 7.5%, Tazorac .05%, and glycolic acid washes and scrubs. And, I find that patients need to be reminded that a key factor in the success of treatment is consistency.” She goes on to share that she does not like toners and has an obvious preference for oil-free sunscreens. Two favorites come from the SkinMedica cosmeceutical line. “Essential Defense and Total Defense and Repair (both available in a variety of SPF values and in tinted and non-tinted versions) are among my favorite sunscreens for the face. I always stress to patients the importance of reapplication of sunscreen and remind them not to pick.” Lastly, “I recommend chemical peels once a month,” Dr. Downie says. Dr. Mark Taylor of Salt Lake City, UT, has developed his own line of acne products that he recommends. COSMION is an iontophoretic skin care regimen developed to deliver products deeply into the skin through microcurrent technology. For his toughest cases, Taylor turns to laser treatments coupled either with COSMION or isotretinoin. In Dubai, UAE, Dr. Hassan Galadari sees fantastic results with retinoids for mild to moderate acne. “A retinoid is key,” he says. “My choice would be adapalene, and I like the combination between it and benzoyl peroxide.” For the really difficult cases, “I have a low threshold for using isotretinoin. If I see scarring, I really try talking the patient into using it.”
CSF: What is your best patient tip for prevention of acne during the summer months?Dr. Galadari says, “A great cleanser, preferably with a bit of salicylic acid.” For Dr. Sadick, “astringents and glycolic acid pads.” Dr. Chilukuri shares, “I make sure that patients are using a gentle, non-drying antiseptic cleanser and a retinoid product, as well.” His top picks: “A great product from a small company (A-cute Derm) called Antisepation Cleansing Gel. It kills off MRSA in addition to acne-causing bacteria. My go-to retinoid is PCA SKIN’s Intensive Clarity Treatment®: 0.5% pure retinol night. The retinoid uses Omnisome technology to allow better penetration of the retinol, preventing irritation and dryness. In addition, this delivery system stabilizes the retinol to allow the addition of salicylic acid and other ingredients.” “My best patient tip for prevention of acne on the chest and back during those exposed summer months is to use azalaic acid or tazarotene foam,” says Dr. Downie. “I like Finacea foam and Fabior foam. And of course, patients should also wash more often and be sure to reapply a skin-friendly sunscreen.” Dr. Joel Schlessinger of Omaha, NE, reminds us that the warmer weather brings not only acne, but acne-like skin conditions. “Summer months can bring a yeast folliculitis on the face. These are noted as small papules that are approximately 1-2 mm in diameter. Our approach is to use fluconazole, 100 mg twice weekly, until it clears. Usually, it clears almost magically within a day or so.” For easy-to-use summer treatment application, Dr. Taylor recommends COSMION Acnion Pads, made available to patients in their laser clinic and online.
CSF: Lastly, is there anything new that has your attention or anything ‘old’ that is proving itself to be a workhorse?“Yes,” says Dr. Sadick. “PRP and the Enlighten/Pico Genesis.” “My workhorse,” says Dr. Galadari, “is a salicylic acid chemical peel. I start with 20% and progress to 30% in about 2-3 weeks and continue those in addition to the daily regular regimen at home of a retinoid and BP.” “For me,” says Dr. Taylor, “the new Q-Switched and picosecond lasers.” In addition, “our COSMION Acnion products have delivered great results.” “I recently discovered Microcyn (Intraderm Pharmaceuticals),” says Dr. Chilukuri. “It is a low-cost, effective way of removing acne-causing bacteria. The product is very well tolerated and patients have been pleased with the results.” “I am incorporating blue light therapy with handheld units into my practice more now,” says Dr. Schlessinger. The reason for this is that the science is evolving and clearly there are benefits.” He goes on to explain, “many of our patients are seeking a non-antibiotic and more natural approach to treatment of acne and this fits with that concept. Additionally, we are encountering more patients with restrictions for antibiotics due to conditions such as IBS/Crohn’s/Ulcerative colitis. This is a great addition to any regimen for these individuals.”
Let us know your best tips and protocols for treating acne and we look forward to continuing the conversation in Las Vegas!