Credited as the most common skin disease and a perennial presentation in the dermatology clinic, acne vulgaris continues to be a focus of study and is still yielding new findings. Practical Dermatology® magazine had the opportunity to sit down with Linda Stein Gold, MD, Director of Dermatology Clinical Research at Henry Ford Health System in Detroit and the Division Head of Dermatology at Henry Ford Health System in West Bloomfield, MI in late 2016 to discuss the changing way we think about acne. Fittingly, the meeting took place at the Nestle Skin Health SHIELD (Skin Health Investigation, Education and Longevity Development) Center in Manhattan, a sleek and shiny idea incubator that aims to advance skin health for tomorrow.
We are connecting the dots between inflammation and psoriasis, vitiligo and rosacea. What about acne?
Linda Stein Gold, MD: We are learning more and more about the role inflammation may play in the pathogenesis of acne. As a result, we may have to reevaluate our thoughts and understand that inflammation may be the first step in the development of lesions. We always thought the microcomedone was the first step, but if all acne lesions are technically inflammatory lesions, we have to think about them differently. In addition, we used to think that once the lesion is resolved with either a red or brown mark, it was over, but if the inflammatory process continues, we should continue therapy even after the lesion appears to be gone.
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What does this mean for treatment?
Dr. Stein Gold: Some studies suggest that an anti-inflammatory dose of an antibiotic may help treat acne. This suggests that the anti-inflammatory effects may be just as important as the anti-bacterial effects. In the world of bacterial resistance, which has become a major problem, using anti-inflammatory vs. antibiotic treatment may represent a healthier way to approach acne patients. Topical retinoids and the combination of the retinoid adapalene and benzoyl peroxide in Epiduo Forte are important in treating comedones and have do anti-inflammatory properties as well. Generally patients need combination therapy to get the best results.
What questions about acne treatment remain?
Dr. Stein Gold: : We would like to know if there is a way to predict in advance who will have more severe acne. We know family history plays a role before the acne even develops. In addition, we want to know if there is a way to predict who will respond to different treatment options before we start therapy. This personalized medicine approach can help eliminate trial and error and get patients clear faster with fewer side effects.
What does the acne treatment pipeline look like today?
Dr. Stein Gold: Sebum inhibitors are very promising and we have several under development. Until now we haven’t been able to decrease excess sebum with a topical, but there are a few such agents in late stage development that appear to work including Dermira’s DRM01 and Novan’s topical nitric oxide drug candidate SB204. I’m looking forward to research on new molecules. There is a lot that we don’t know in the pathogenesis of acne and there are a lot of potential targets that we can formulate drugs against once we learn more.
What is the current thinking about acne and diet?
Dr. Stein Gold: Food and acne has been a very controversial issue. It does appear that food can influence acne, and the best evidence exists regarding foods with a high GI index and skim milk. The latest acne guidelines from the American Academy of Dermatology acknowledge these link but state that there is not enough data to recommend dietary changes for acne patients. That said, we do tell all of our patients to eat more fruits, vegetables, and whole grains
What is the best advice for healthy acne-free skin?
Dr. Stein Gold: It’s pretty simple: Use a gentle cleanser, gentle moisturizer and sunscreen every day. Combination therapy targeting multiple areas in the pathogenesis of acne is the best approach while minimizing exposure to antibiotics.