Online Extra: Let’s Talk About Truncal Acne
A look at the burden of truncal acne and current treatment options.
While often trivialized as a cosmetic skin disease, acne is in fact an inflammatory skin condition with a complex pathogenesis associated with a significant physical and psychological burden. Approximately 50% of people with facial acne also have truncal acne manifesting on the back, shoulders, and/or chest, while more than 3% of persons suffering from acne present with truncal acne only.1 The focus of patients on facial acne means that, generally, during consultations only a quarter of the patients suffering from truncal acne bring it up,2 and it is often overlooked by dermatologists.3
When treating acne, oral antibiotics are widely prescribed for truncal acne due to the challenges of applying topical therapy to such an extensive body surface area; however, the challenge remains that oral antibiotics should only be used for short durations to limit the potential for antibiotic resistance. Furthermore, compared with topical formulations, systemic treatments may cause wider-reaching side effects that could potentially require additional treatment. Retinoid vehicles, like foams and lotions, have been developed to theoretically improve ease of use on a larger surface area; however, there is little to no evidence that they are effective and well-tolerated on truncal acne. To date, Aklief® (trifarotene, Galderma) Cream, 0.005% has been the first and only single-agent topical retinoid robustly studied on both the face and trunk in large-scale trials.4-6
While truncal acne is common and burdensome, there is a paucity of evidence to guide the management of truncal acne. Recommendations recently published in JAAD International suggest dermatology specialists take a proactive approach with patients who may be embarrassed to report truncal acne and personalize the treatment approach to suit the patient’s needs and extent of truncal acne.7
Effective truncal acne management is pivotal to alleviate the significant physical and emotional toll of the condition.7,8 The emotional burden of acne can be potentiated by external influences, and around 60% of patients with both facial and truncal acne have been bullied and/or verbally or physically abused for their acne. Even more patients (74%) voiced that their acne holds them back from doing the things they enjoy, like swimming, getting their picture taken, or participating in social events.2 Personal experience has shown that patients are concerned about truncal acne showing in their cheer or dance uniforms or worry about being unable to wear tank tops when going to the pool. Patients with truncal acne can feel uncomfortable, with three-quarters of patients considering their acne to be serious.9 Despite the fact that truncal acne can be easier concealed with clothing, patients with combined facial and truncal acne are almost twice as likely to report a very large or extremely large impact on quality of life than those with facial acne alone.8,9 Another prominent feature that contributes to social withdrawal is that patients often feel ugly, ashamed, embarrassed, and isolated.9
RETINOIDS AS THE CORNERSTONE OF TRUNCAL ACNE TREATMENT
Since the FDA approval of tretinoin in 1971, retinoids alone or in combination with other agents have become the mainstay of acne treatment. These treatments target retinoic acid receptors (RAR) in the skin, which have been identified as a key modulator of skin health and have been a target for acne treatments for many years. One of the most recent developments is the fourth-generation retinoid trifarotene, a first-of-its-kind, topical retinoid molecule designed to specifically target RAR-&gamma, the most common RAR in the skin.10 Compared with other retinoids, trifarotene selectively binds RAR-γ and has 20 times greater affinity to the RAR-γ than other available topical retinoids.10
Trifarotene is the active component of Aklief® which has been approved by the FDA and is the first and only topical retinoid studied for moderate and severe facial and moderate truncal acne. Aklief® is an innovative topical retinoid cream proven to be safe and effective for acne on the face, shoulders, chest, and/or back (truncal acne).4-6 The formulation has demonstrated rapid reduction in inflammatory and noninflammatory acne lesions in two pivotal trials, where significant (p<0.0001) improvement in inflammatory and non-inflammatory truncal lesions were observed with trifarotene as early as Week 4. These improvements continued through Week 12 compared with vehicle (Galderma DoF); at Week 12, reductions of 52.3% and 59.9% in total lesions were reported with trifarotene compared with 43.6% and 46.6% for the vehicle (Galderma DoF).
The RAR-γ target specificity of trifarotene permits low concentration formulation and application to larger body areas while maintaining low systemic absorption, which is reflected in a favorable safety profile and addresses one of the main challenges of truncal acne treatment. Reported key adverse events including erythema, dryness, scaling and stinging were mild and improved over a 12-week study period with around 90% of patients completing the trial.6,11 A similar safety profile was maintained over one year of treatment,11 and patient satisfaction and adherence rates were very high as demonstrated by the 76.5% of patients who remained on monotherapy after one year of therapy and the 91.7% who completed the trial (Galderma DoF). Similarly, a high proportion of patients (92.5%) completed a combination study of trifarotene and oral doxycycline as dual therapy for three months (Galderma DoF).
WHAT DOES THE FUTURE HOLD FOR PATIENTS WITH TRUNCAL ACNE?
Truncal acne has taken a backseat in terms of diagnosis and treatment for many years. It is a debilitating condition and both patients and physicians need to recognize it as a treatable skin disorder that warrants attention. Studies have shown that trifarotene cream (0.005%) proved to be as effective, worked as quickly, and was well-tolerated when used on larger body areas as it is on the face. These results are encouraging, and, although additional research is needed to support use of acne treatments for truncal acne, the approval of Aklief® (trifarotene) Cream, 0.005% is starting to pave the way to providing improved care to patients with truncal acne and help alleviate some of their physical and psychological pressures.
Dr. Harper is a consultant, advisor and speaker for Galderma L.P.
Julie Harper, MD is a board-certified dermatologist in private practice at the Dermatology and Skin Care Center of Birmingham in Birmingham, AL. She is a Fellow of the American Academy of Dermatology and recently served on the AAD’s Acne Work Group, tasked with writing acne treatment guidelines. Dr. Harper is Founding Director and past-President of the American Acne and Rosacea Society, and a former President of the Alabama Dermatological Society.
1. Del Rosso JQ, et al. A closer look at truncal acne vulgaris: prevalence, severity, and clinical significance. J Drugs Dermatol. 2007;6:597–600.
2. Galderma Laboratories, L.P. Burden Summary Report: Combined Facial and Truncal Acne. March 2021.
3. Poli F, et al. Truncal acne, what do we know? J Eur Acad Dermatol Venereol. 2020;34(10):2241-2246. doi: 10.1111/jdv.16634.
4. AKLIEF press release. FDA approval, 2019.
5. AKLIEF® (trifarotene) Cream, 0.005% [prescribing information], 2019.
6. Tan J, et al. Randomized phase 3 evaluation of trifarotene 50 μg/g cream treatment of moderate facial and truncal acne. J Am Acad Dermatol. 2019;80:1691–1699
7. Tan J, et al. Gaps and recommendations for clinical management of truncal acne from the Personalising Acne: Consensus of Experts panel. JAAD Int. 2021;5:33-40. doi: 10.1016/j.jdin.2021.06.00
8. Tan J, et al. Impact of facial and truncal acne on quality of life: A multi-country population-based survey. JAAD Int. 2021;3:102-110. doi: 10.1016/j.jdin.2021.03.002.
9. Kantar on behalf of Galderma. Burden survey, combined facial and truncal acne qualitative and quantitative report. March 2020.
10. Aubert J, et al, Nonclinical and human pharmacology of the potent and selective topical retinoic acid receptor-y agonist trifarotene. Br J Dermatol. 2018;179:442–456.
11. Blume-Peytavi U, et al. Long-term safety and efficacy of trifarotene 50 lg/g cream, a first-in-class RAR-c selective topical retinoid, in patients with moderate facial and truncal acne. J Eur Acad Dermatol Venereol. 2020;34(1):166-173. doi: 10.1111/jdv.15794.