Acne is a complex, multidimensional disease that is best treated by formulating a comprehensive treatment plan on the first visit (See the first article in this series “Optimizing Acne Treatment,” available online at PracticalDermatology.com, for detailed instruction on how to do this). The first follow-up is just as important. This is the time to measure efficacy and compliance and to reinforce key messages. It is also the time to make adjustments to the regimen and to discuss acne sequela, if necessary (scars, post-inflammatory hyperpigmentation, and post-inflammatory erythema). This seems like a lot of information to cover, and it is, but with proper planning it can easily be done.
So many questions need to be answered at the first follow-up visit that a checklist, administered either by the provider or the medical assistant is extremely helpful. This organized and efficient approach saves time and provides much more information than you could otherwise obtain. It also gives the patients the confidence that you are an expert with a plan and encourages compliance. The sections below follow the order of the first follow-up checklist with explanations following each checklist question.
1. Were you able obtain all of your medications?
○ Yes ○ No
If no why?_____________________
Were any “generics” substituted for brand names?
○ Yes ○ No
In today’s complicated insurance/prescribing environment with prior authorizations, prescription drug deductibles, rising costs, and restrictive formularies, you cannot take for granted that the patient got everything you prescribed. Simply ask the question, “Were you able to get all of your medications?” and then double check the medication names to make sure they did indeed get them all. Often patients won’t contact you when they hit obstacles at the pharmacy. For example, if I prescribe three medications and only two are covered, many patients think that those two are good enough and will only tell me they didn’t get the third medication if I ask. Asking the patient if any substitutions were made at the pharmacy is a good idea, too, and ensures your medication list is accurate.
2. What medications you are using and when?
Recollection Score: 1 2 3 4 5 6 7 8 9 10
○ Yes ○ No
Obviously we know what we prescribed and what the instructions were, but does the patient? If you are seeing them for a one month follow-up, for example, and the patient has been using these medications consistently, they should be able to clearly recollect their regimen. If they can’t, it is a sign of poor compliance (on the scale 1 = very poor recollection and 10 = excellent recollection). The answer to this question allows you to correct any discrepancies in how they are using the products. One common mistake is I find is patients using their twice a day topicals only once a day.
The most common mistake patients make is to spot treat. Ask, “Where are you applying your topical medications?” If the answer is “wherever I have pimples,” it is time to review why spot treatment is a losing strategy. I tell patients that each pimple they have started about a month ago and that the medications work by stopping their formation. That’s why they should be applied to the whole acne-prone area because you never know where a new pimple will appear.
3. Any side effects from your medications?
Asking about side effects is important because patients don’t always volunteer this information and it greatly affects adherence. Side effects of medications include cutaneous reactions like dryness and irritation. Side effects from oral antibiotics, such as nausea from tetracyclines, need to be identified as well. If you determine that the patient is using appropriate skincare products and still experiencing dryness and irritation beyond what they can tolerate, it is time to make a change.
With retinoids, advising patients with too much dryness to apply the retinoid every-other-day is impractical and will have poor adherence. It is better to simply lower the dose and continue with daily dosing. Tretinoin is available in 0.01% (gel only) and 0.025% strengths. Adapalene is available in 0.01%. Alternatively, if the patient wants to finish the retinoid that they have, they can use only half a pea sized amount and dilute it with moisturizer until they finish the tube. If the patient is experiencing nausea with doxycycline hyclate, for example, minocycline, doxycycline monohydrate, doxycycline hyclate enteric coated/time released (now generic), or a different class of antibiotic can be substituted.
4. How long after the last visit did you get
your medication : _____________________
How many days have you missed using your medication?
Topicals: none a few many
Pills: none a few many
We also tend to assume that the patient has been using the medications since we prescribed them. Many times this is not the case, due to delays in the patient picking up the medication or other reasons. It is essential to know how many days the patient has used a medication to know how much improvement you should expect. You have already asked them to recall their acne regimen—the second step to measure their compliance is to specifically ask them to estimate how many days of each type of medication (oral and topical) they have missed. Beyond measuring compliance, this information allows you to get to know which forms of medications are easier for patients to use. For example, if the patient has poor compliance with topicals but washes their face twice daily, it would make sense to add a medicated face wash. Since acne medications, on average, take about a month to work (most actually work sooner but the difference is too small for patients to notice), it is crucial to know exactly how long they have used it and how compliant they have been, as this will greatly alter your expectations for their improvement.
5. How much improvement have you seen? (Expressed as a percent: ____%)
Asking the patiensa to quantify their own improvement is important to find out their perception. However, as the experts, we have to be able to quantify a patient’s improvement as well. I have found that a combination of photos and a lesion count to be most helpful. At the first follow-up, the patient needs to know that post-inflammatory hyperpigmentation and post-inflammatory erythema will initially show little signs of improvement as they are the consequence of past pimples and take months to fade (some can be permanent). We are looking for fewer new pimples, which a lesion count can pick up quite well. Pictures help to supplement the lesion count. When patients can see improvement when they compare their acne to previous pictures it is very gratifying and motivating to them.
6. Last month’s lesion count _________________
As explained in my previous article “Optimizing Acne Treatment” (read it online at PracticalDermatology.com), the complete lesion count employed in studies is too time consuming for clinical practice. A modified lesion count is better suited to the time constraints of real practice. If there is symmetrical distribution of acne lesions, count time can be reduced by half by counting only one side of the face or body. Still, this may be too time consuming for clinical practice. A modified lesion count can be done in a few ways. If the patient has a dominant problem area like the forehead, with the dominant lesion being pustules, count only the pustules on the forehead. If the person has one dominant lesion across an entire region, for example cysts on the face, count only those. The idea is to quantify the dominant feature of their acne and use that count for future comparison.
This method works quite well and can be done in less than a minute during the skin exam. Taking the time to do the lesion count also increases patient satisfaction. A common patient complaint is that their provider didn’t take a close look at their acne. Often patients report little to no improvement. However, when lesion counts are compared, there is often a 25-50 percent improvement, a very good result for a first follow-up.
We may think in lesion counts but a patient looks at their face in the mirror every day and good photographs can be indispensable. Photographs, however, are limited by technical difficulties like consistent positioning and lighting. In addition, the work of transferring digital photos from camera to computer to chart can be time prohibitive for those without electronic medical records with a good photography function. An elegant solution for this problem is an iPhone/iPad app for medical photography called “Appworx.” Photos are stored in the cloud on a HIPPA compliant server so no file transfers are required. The proper positioning problem is solved as well. You select which body part to be photographed and helpful templates appear on screen as positional guides. When you are taking the second photo on a follow-up visit, there is a “ghosting” feature available that puts a translucent image of the last photo on the screen, so the current photo can be taken to match the position and angle of the previous photo. This feature makes taking consistent photo’s much easier. The two photos can then be compared side by side on the iPad for you and the patient to view together. A side-by-side photo showing a 50 percent improvement is much more powerful than telling a patient they have a 50 percent decrease in lesions. As most of us don’t have a room dedicated to photography like some plastic surgeons do, lighting can be an issue. I have found that every treatment room is different and try to find the sweet spot in each room and even mark it on the floor for patients to stand on for best results.
Sometimes the patient has had good improvement according to our pictures and lesion counts but still states that he or she is not improving and is not satisfied with treatment. At this point you need ask the patient specifically (I have them use a hand held mirror to show me) the features of their acne that are bothering them most. Many times acne scars, post-inflammatory hyperpigmentation, and post-inflammatory erythema are the patient’s main concern, and these need to be discussed in detail. If the level of improvement is on track, the patient may just need assurance that the treatment is on track and s/he just needs to stay the course.
Often times even this is not enough and changes need to be made to keep patients motivated. In this situation tell patients, “You are right on track with the amount of improvement that I expected to see at this point. Your improvement is right on track and should continue, however there are some changes we can make to speed things up.” At this point I may talk about adding another topical or medicated wash, adding an oral antibiotic, or increasing retinoid strength if they are not experiencing dryness. This is also a great time to talk about moisturizers and cleansers, as well.
What’s Plan B? The hard truth about acne treatment with topical and oral medications (besides isotretinoin) is that there are many “treatment failures.” While we may feel that a 50-75 percent improvement is good and in-line with what the best these medications can do, most patients are expecting better results. In the questionnaire I administer in the first visit I ask patients the minimum amount of improvement they would need to see to consider the treatment a success. Almost everyone says 70-100 percent. Of course, there is only one medication that can predictably meet these expectations in nearly every patient: isotretinoin.
On the first visit, if the patient has severe nodulocystic acne and may be a candidate for isotretinoin but has never used any prescription medications before, I articulate my plans in the following manner: “The good news is we have medications that can get your acne a lot better. I have a great plan A that most people respond well to. If you are one of the people who doesn’t, there is a very effective plan B with a stronger but still very safe medication.” This is a positive, realistic, and informative way to answer the patients’ main questions of “Will I get better?” Letting patients know there is a great plan B minimizes the risk of having them drop out if they don’t see results the first month. Patients respond very positively when their treatment plan is explained this way.
○ QD ○ BID Moisturizer__________________________
○ QD ○ BID
Most of the initial visit is consumed by talking about prescription medications, expectations, and the treatment plan. The first follow-up is the perfect time to talk about cleansers and moisturizers. The first step is to find out what patients are using. With so many products on the market, it is impossible to know the properties and ingredients of all of them. A 30-minute trip to the local chain drug store to record the names and active ingredients of common OTC acne products is a great idea. A spreadsheet can easily be made and kept in the treatment room for quick reference. If you have no information on the cleanser or moisturizer the patient is using, just ask them about the properties of the product (for oily skin, sensitive skin, etc.) and make sure it is appropriate for their skin type.
There are three ways to recommend skin care products to your patients, each having pros and cons.
1. Having a product line in your office ensures that you have high quality skin care products that you are familiar with and about which you have received good feedback. It also is a convenience for patients to be able to get products right in your office. The major drawback is that if you present these products in the wrong way, patients may feel you are trying to sell them things rather than trying to help them. (More details about recommending products while ensuring that you are perceived as a medical professional and not a salesperson can be found in my previous article “Strategies to Integrate Skin Care Dispensing” available at PracticalDermatology.com) Although products dispensed from the office are usually higher quality than those available over the counter and have unique formulations, they are usually more expensive. Any of the above reasons can lead to patients not purchasing your products. When this happens, they will be on their own to figure out what to use, possibly with adverse effects to their skin.
2. Another option is to recommend product lines that are found over the counter. These products tend to be less expensive, and many patients prefer to buy something over the counter. Just be sure to write down exactly what product in the product line you are recommending (the printed tear sheets provided by the manufacturer are helpful here). The downside is that the patient may not get the products at all it they are unable to find them at the store or may simply never get around to buying them.
3. The third option is to prescribe a moisturizer or cleanser. Sulfacetamide/sulfur and benzoyl peroxide cleansers and moisturizers are available but with limited coverage, resulting in a lot of call backs from the pharmacy. If the products are covered and the copay is low, patients are very happy. But this doesn’t always happen. A recent innovation in obtaining moisturizers and cleansers comes from generic drug manufacturer Prugen Pharmaceuticals. They currently have multiple cleansers and moisturizers suitable for acne patients (in addition to other acne medications). When ordered from their affiliated pharmacy with PPO insurance, the co-pay is zero. Cash patients pay $25 per product. Products are shipped overnight at no additional charge, so patients can start using them immediately. The advantage of this is that these medications are easy to obtain and inexpensive. Since they are prescription, they may be held in higher regard by patients than over-the-counter products, which may improve compliance. The only possible downside is that it takes a little time to explain the ordering process.
Ways to Make Immediate Improvement
While we are familiar and comfortable with the concept of acne taking over a month or more to improve, patients are not. They want immediate results. While we cannot make medications work faster, we do have two procedures that can give patients immediate results, extractions and intralesional corticosteroid injections.
Most acne patients have open comedones and milia that can be treated successfully with extractions. On close inspection many lesions that at first glance were thought to be acne are actually milia and patients are thrilled to have them removed. Intralesional corticosteroid injections can be recommended to any patients with inflamed cysts. Although not everyone is open to the idea of an injection, once they see how well it works, injections become a powerful tool to reduce large inflamed lesions and reduce scarring. Many patients will present between regular follow-ups just for injections.
Post-inflammatory hyperpigmentation, post-inflammatory erythema and scarring are subjects not usually explored in depth in the first visit, but for many patients, these acne sequela are just as important to resolve as are the active lesions. A complete exploration of all available treatments for acne sequela is beyond the scope of this article. What follows is advice on how to explain these sequela and a general outline to guide your decision about when to begin to treat them.
Regardless of the type of acne sequela, the first thing is to get the acne under control. Post-inflammatory hyperpigmentation and post-inflammatory erythema will most likely decrease over time if acne decreases. Many patients are content to follow a plan to control their acne and then wait several months and reevaluate post-inflammatory hyperpigmentation and post-inflammatory erythema then.
Scars. Patients have only one word for all three acne sequela: “scars.” It is our job to break down exactly the composition of the patient’s “scars” and to decide when and how they should be treated. Each patient is different as far as the urgency to treat acne sequela. Once the relationship between the acne and acne sequela is explained most patients are content stabilizing the acne first and focusing on the sequela later. However it is important to acknowledge the presence of the acne sequela and to educate the patient about when and how they can be treated.
Clinicians may tend to focus just on active lesions and consider the treatment a success if they are reduced. Patients often have a different view. Hold a mirror up and discuss with the patient what you see as well as what they are concerned about. This will allow a more detailed discussion and permit you to focus on what particular aspects of the patient’s acne and appearance bothers them most.
Post-inflammatory hyperpigmentation. Hydroquinone can be added to most topical regimens as can sunblock. It is important to warn patients about possible skin irritation from hydroquinone, as they may already be using products and prescriptions that are drying or irritating their skin. The retail price of a 28-gram tube of 4% hydroquinone can average $100 which is unaffordable for many patients. Patient may also have just a few areas to treat and not need such a large amount. Many dermatology practices use compounding pharmacies as sources for hydroquinone blends at lower prices.
A Methodical Approach
The first follow-up visit is not just a time to check on progress but a time to verify that the patient obtained all medications and has been using them as prescribed, to discuss proper skincare, to do extractions and injections, and to hone in on which aspects of a patient’s acne and acne sequela are bothering them the most. I have found that using this checklist streamlines the office visit saving time and allowing me to direct my attention where it is needed most. A multidimensional disease like acne requires a methodical and organized approach not only at the first visit but at the first follow up as well to achieve optimum results. n
Steven Leon, MS, PA-C is a dermatology physician assistant in southern Los Angeles.