Managing adult patients with acne can sometimes be frustrating for dermatologists. For Annie Chiu, MD, founder of The Derm Institute in Redondo Beach, CA, achieving best outcomes is a matter of understanding patients’ treatment goals, realistically outlining the effects of treatment, and empowering patients to be active in their care. “Establishing long-term expectations is really important,” says Dr. Chiu. “Compliance is key. Patients must be committed.”
To improve outcomes for adult patients with acne, Dr. Chiu has devised a new approach to patient care, based on a cash-pay model (Self-pay patients tend to be more committed, she says). The approach integrates traditional medical therapies with supportive skincare and elective cosmetic interventions to optimize outcomes. She describes her approach and shares tips that can help others better manage adult acne patients.
Target Three Months
Dr. Chiu’s program is called “Three Months to Clear.” “I explain to patients that the FDA studies don’t evaluate the full range of results from topical acne therapies until the end of three months.” Patients, therefore, should not expect optimal therapeutic outcomes until completing eight to 12 weeks of treatment. Dr. Chiu discusses with patients the pathogenesis of acne and the ways that topical therapies work, so that they understand treatment is primarily aimed at preventing the emergence of new acne lesions. “If they are interested, we can jumpstart treatment,” she says, pointing to the range of supportive interventions available.
As part of the “Three Months to Clear” program, patients return to the office every three weeks. “The more engagement with the patient, the better,” Dr. Chiu maintains. Every other visit is with Dr. Chiu to review and adjust the prescription regimen, if needed, and assess compliance.
Intralesional cortisone injections are available to patients for more cystic lesions to lessen scarring and to encourage patients to come in frequently. This also helps build confidence in eradicating the longer lasting lesions. Patients may receive physician-administered procedures, such as deep chemical peels. The alternating visits are with an MA or aesthetician who can talk to the patient about skincare and provide treatments like light chemical peels or extractions under Dr. Chiu’s direction.
Compared to adolescents, adults are more open to procedures, Dr. Chiu finds. She finds that both men and women are interested in procedures/interventions beyond conventional prescription therapies (See chart).
Devise and Discuss Combinations
Patients tend to be more adherent to acne therapies when they understand how they work, know what to expect, and are aware of treatment benefits, Dr. Chiu says. For example, she discusses with patients that topical retinoids will improve acne, while also providing a rejuvenating effect.
SOME SUPPORTIVE INTERVENTIONS FOR ADULT ACNE PATIENTS
• Microneedling: Minimizes enlarged pores; Improves existing acne scars
• IPL: Optimizes cosmesis; Helps improve skin texture and tone, helps even pigmentation
• Clear and Brilliant: Optimizes cosmesis; Helps improve skin texture and tone, helps even pigmentation
• PDT: Most helpful for nodulocystic acne
• Chemical peels (salycilic acid): Targets acne lesions, improves skin texture and tone, may have mild anti-inflammatory effects.
• Intralesional Kenalog: For painful cysts
Since adult patients with acne—especially women—may have sensitive skin, supportive skincare in important. Gentle cleansers with glycolic acid can be useful. Moisturizers are recommended, especially for those using retinoids.
Some treatments are better tolerated than others. For example, Dr. Chiu uses topical dapsone for many of her female patients because of its good tolerability. The new 7.5% gel formulation (Aczone, Allergan) is a once-daily treatment, which is considered more convenient on its own, and less irritating even when paired with a retinoid.
Patients also require instruction on the regular use of sunscreens. Broad spectrum, high SPF formulations are best. For patients with oily skin, Dr. Chiu recommends a mattifying sunscreen for an aesthetic benefit in addition to skin protection.
Treat Aggressively When Necessary
For women and men with nodulocystic acne and for women with hormonally-influenced acne, Dr. Chiu recommends systemic treatment as appropriate. Isotretinoin remains an important tool, especially since she has tried to decrease the use of oral antibiotics. A few weeks after the completion of an isotretinoin course, Dr. Chiu introduces topicals. Topical dapsone’s anti-inflammatory effects can be beneficial post-isotretinoin and can help diminish the mild, pink erythema some patients develop with treatment, she notes.
For patients who cannot or will not use isotretinoin, photodynamic therapy is a worthwhile option, Dr. Chiu says. Some women with hormonal or U shaped distribution of acne around the chin and jawline may be candidates for therapies like spironolactone with topical dapsone.
Give Patients Control
Patients—especially adults—want to take control of acne. Many patients ask about diet, Dr. Chiu observes. “I tell them that diet has been shown to possibly influence acne in some patients but is not considered a major contributor,” she says. She adds that patients need not avoid specific foods but can be encouraged to eat a healthy diet and avoid foods they think may influence their outbreaks. Dr. Chiu educates on the recent association of dairy and high glycemic diets with acne, noting this is a minor contributor, and compliance with treatment is key.
Focusing on the individual is key. “It’s important to customize a regimen for each patient,” Dr. Chiu stresses. Adult acne patients who feel that they are using a personalized treatment plan, understand the rationale for interventions, have proper expectations, and know they have a range of treatment options are most likely to be active participants in their own care. That means better results in the long-term. n
Addressing the Psychological Impact of Acne Scars
Acne scarring can have a negative effect on QoL. If your peers are not treating scars, why should they?
Amy Forman Taub, MD: I have been impressed with how much emotional difference a significant improvement in acne scars can make. Patients have told me their stories of how they had devised ways to avoid looking at themselves in a mirror or in a window reflection. They tell me how much more confident they feel. Interestingly, they don’t share these stories unless they achieve a very significant improvement with their scars. It seems like after the relief of putting the feelings in the past, they discuss them as a way of putting more distance between their “old self” and “new self.”
There are now a few options available to improve the appearance of acne scars. When and how do you opt for Bellafill over laser or other treatments?
Dr. Taub: For mild scarring, go right to Bellafill. In some patient cases, it also makes economic sense to start with Bellafill for moderate scarring, or if there are particular areas the patient really is upset about. While lasers can efface the upper layers of the skin and require multiple sessions over several months, Bellafill provides immediate correction for indicated facial acne scars with minimal downtime. Regarding combination regimens, for very severe scarring, I like to start with either CO2 resurfacing, non-ablative infrared resurfacing or RF sublative or microneedling, and then finish with Bellafill. However, combination therapies have not been studied.
Are you at all concerned about the use of a “long-lasting” filler to treat acne scars?
Dr. Taub: Yes, of course, safety is a paramount concern. Suneva has done an extremely thorough job in studying more than 1,000 patients for their acne scar study. The five-year nasolabial fold study which shows a one percent incidence of granulomas that did not require surgical removal and were treatable is reassuring. I consider myself a careful physician and do have reservations; however, this filler has produced such clinically outstanding results that I feel strongly that I should offer it to my patients who suffer from facial acne scarring. Their tears of joy, hugs and big smiles when they come for follow up lets me know I have made the right choice.