Physician Spotlight: Judith Hellman, MD

June is Acne Awareness Month, and new guidelines from the American Academy of Dermatology plus an influx of new treatments are changing the way doctors address acne. An expert weighs in.

What has been the most exciting development in acne treatment in the past decade?

“The emergence of various laser, light, and radiofrequency (RF) devices has added a significant number of new options to our repertoire of treatments. The use of in-office and now at-home blue light devices was the first large step. The use of intense pulsed light (IPL) and pulsed dye laser (PDL) followed, aiming at reducing erythematous lesions, with success.

Recently, RF devices turned out to be an effective option for both the inflammatory as well as the scarring components of acne in the same treatment setting.

Energy-based devices are a highly successful and desirable treatment. Unlike isotretinoin, there are no potential systemic side effect to the treatments. Unlike antibiotics and other oral medications like spironolactone, there is no problem of flare-ups once the medication is stopped (and many practitioners keep young patients on them for prolonged periods). Knowing the devices well and using them safely can get rid of even severe cystic, inflammatory acne in about six monthly treatments or so. For mild cases, home devices with blue light with or without infrared light can be utilized. This will cut down on flare ups and frequent visits to the dermatologist. 

In terms of topical treatments, my favorite in the past few years has been Aczone (topical dapsone), now available in 7.5% for once-a-day use. Recent scientific evidence points to the fact that acne is a condition of subclinical inflammation not only in the effected areas but also in normal appearing skin. Hence, the use of topicals and the extension of treatments to an entire area (not just spots) makes a lot of sense.”

How do you devise a treatment protocol?

“There are different approaches for mild, moderate, or severe acne. I always aim to use the least amount of topicals with the most therapeutic effect. For mild acne, a retinoid with or without added benzoyl peroxide (like Epiduo) is helpful. For more extensive cases, adding Aczone helps both the red lesions, and as recently evidenced in clinical trials for the 7.5% gel, also the comedonal lesions. At times, I couple it with tazarotene or tretinoin for added benefit.  I try not to have patients use more than two agents daily. I do advise them not to moisturize too aggressively as acne prone skin makes excess oil as it is.”

Is compliance the main barrier to successful acne treatment?

“Compliance is certainly an issue. Trying to create easy-to-follow treatment protocols is key. I explain to my patients that they should think of acne topicals the same way that they think of brushing their teeth—both are a part of their daily routine. I also preach patience as a virtue and emphasize that they must give the treatment some time to work.”

Do you prescribe isotretonin?

“I used to prescribe isotretinoin a lot. Over the years, I have realized that my laser patients have experienced no recurrences of acne once done with the series of treatments. This was not the case for isotretinoin, where patients often relapsed and ended up with a second, and at times, even a third course of the medication. I still talk to my patients with severe acne about isotretinoin, and if they prefer to pursue that course, I refer them to a dermatologist who prescribes it.” n

Judith Hellman, MD is a dermatologist in private practice in New York City. She is currently an associate professor in the Department of Dermatology at Mount Sinai Medical Center.