PracticalDermatology

Based on a roundtable discussion with leading dermatologists and pediatric dermatologists about acne treatment challenges, the importance of early treatment, and the potential benefits of over-the-counter treatment options. The roundtable was chaired by Zoe Draelos, MD. Participants included Crystal Agu, MD; Julie Harper, MD; Adelaide A. Hebert, MD; Peter Lio, MD; Kalyani Marathe, MD; and Anthony Rossi, MD

Acne is one of the most common skin conditions in the US, affecting 40-50 million Americans. It is estimated that 80 percent of people between 11-30 years old develop acne, and it can persist for years. If left untreated, acne can cause acne scarring and pigmentation problems and potential psychosocial issues, including low self-esteem.

Acne arises from the interaction of alterations in follicular hyperkeratinization, inflammation, Cutibacterium acne (C acnes, formerly Propionibacterium acnes) proliferation, and excessive sebum production.¹ Faulty follicular keratinization leads to pore obstruction. Androgen-influenced increases in sebum production, in combination with pore obstruction, form the microcomedone, the precursor lesion for acne. The lipid-rich interior of the microcomedo provides an excellent environment for C acnes colonization, and proliferation of C acnes contributes additional inflammation. Inflammation and alteration of normal dermal architecture then contribute to scarring. Pores become obstructed with a thick material composed of sebum and keratinous debris to form a microcomedone. Further accumulation of this dense material can lead to the formation of open and closed comedones.²

A number of factors may contribute to follicular hyperkeratinization and obstruction of pores, including increased androgen production, increased interleukin-1 (IL-1) activity, and linoleic acid deficiency.¹ Additional research is still needed to determine exactly how these factors interact to cause follicular hyperkeratinization.

Ideally, acne therapies should eradicate C acnes, normalize follicular keratinization, and prevent the formation of new lesions.³ Treatment with more than one therapeutic agent often is necessary to attain these treatment goals.

Acne is a medical condition that requires treatment. Early treatment of acne, even when the presentation is mild in severity, is essential in order to prevent negative consequences, such as scarring and adverse psychologic effects.⁴ The oral and topical treatments most frequently prescribed for the management of acne include retinoids, benzoyl peroxide, topical and/or systemic antibiotics, salicylic acid, isotretinoin, and hormone therapy.

Overcoming Barriers to Treatment

Unfortunately, patients and physicians often encounter barriers to accessing prescription treatments, including potential long wait times for an appointment, high drug costs, insurance coverage limitations, medication substitutions, etc. Problems filling a prescription can delay the start of treatment—and often physicians aren’t alerted to the problem immediately. Identifying barriers is difficult and time-consuming for physicians and staff, and many access challenges go unresolved, despite a significant amount of paperwork and phone calls. Some insurance companies require proof that a patient has failed on an over-the-counter (OTC) regimen before any prescription will be covered.

Due to recent changes in the therapeutic landscape, OTC options for acne management have expanded. For many patients, an OTC regimen may provide an effective and safe alternative to prescription drugs or allow patients to start treatment sooner, an important consideration in an overall acne treatment plan, especially in order to avoid potential scarring.

For pediatric patients who first present to their pediatrician for acne diagnosis and management, OTC recommendations may be an appropriate first step in a treatment plan or a reasonable place to start while the patient is waiting for an appointment with a dermatologist, if necessary. Retinoids are a cornerstone of acne management for a wide range of patients. In fact, when systemic treatments, including antibiotics or hormonal treatments, are recommended, many patients remain on a topical retinoid also.

The American Academy of Dermatology’s acne treatment guidelines, which are endorsed by the American Academy of Pediatrics, recommend benzoyl peroxide and a topical retinoid as first-line treatment for mild to moderate acne vulgaris.

Topical retinoids have been used to effectively treat acne for almost three decades and have been shown to decrease the formation of microcomedones, help to clear preexisting comedones, and decrease papulopustular lesions. The result is a marked decrease in inflammation. As such, retinoids have been recommended as a first-line therapy for active acne, as well as for maintenance therapy.⁵

Historical barriers to treatment adherence with retinoids include tolerability and irritation factors. Newer prescription formulations have introduced innovations, such as elegant vehicles, to help reduce these side effects. It is widely accepted that second-generation topical retinoids, such as adapalene, have reduced incidence of irritation compared to tretinoin.

In the past, OTC acne treatments were limited to only a few active ingredients, primarily benzoyl peroxide and salicylic acid. However, in 2016 prescription-strength adapalene was approved as the first new OTC acne treatment in 30 years. Over-the-counter prescription-strength acne treatment options, including adapalene, allow earlier access to treatment; education, compliance, and the guidance of a health care practitioner may also help prevent the psycho-social side effects of acne.

Potential to Improve Access

Physicians can now recommend a name-brand OTC product to their acne patients. They can tell patient the exact cost of the topical formulation, and know that patients will be able to immediately access and begin treatment. Doctors can also recommend these products to parents who ask for advice for their adolescent child who is just starting to see the first signs of acne or who may want to try to avoid breakouts.

1. Thiboutot D. Acne: 1991-2001. J Am Acad Dermatol. 2002;47:109-117.

2. Berson DS, Shalita AR. Treatment of acne: the role of combination therapies. J Am Acad Dermatol. 1995;32:S31-S41.

3. Leyden JJ. Current issues in antimicrobial therapy for the treatment of acne. J Eur Acad Dermatol Venereol. 2001;15(suppl 3):51-55.

4. Layton AM. Optimal management of acne to prevent scarring and psychological sequelae. Am J Clin Dermatol. 2001;2:135-141.

5. Piskin S, Uzunali E. A review of the use of adapalene for the treatment of acne vulgaris. Ther Clin Risk Manag. 2007 Aug; 3(4): 621–624.