Our panel of experts in the field of Acne and Rosacea presented interesting case studies and new data that may help the practicing dermatologist improve the overall outcomes of patients in their practice.

Isotretinoin Issues

Guy Webster, MD, PhD

What are the reasons that 20% of patients do not respond to isotretinoin?

• Inadequate dosing
• Virilization
• Taken on an empty stomach
•  Young patient with bad disease

Dr Webster feels that the most common cause of isotretinoin resistance is due to patients taking the drug on an empty stomach. Data exist that demonstrate that high-fat meals enhance the absorption of the drug. A new isotretinoin, 4-oxo-isotretinoin, (brand name Absorica) demonstrated 2 times greater absorption on an empty stomach (83%) that that of the standard isotretinoin in the absence of food.

Adverse Events

Common AEs include dry skin, dry lips, high TGs, acne flare. Uncommon AEs include elevated CK, elevated AST and ALT, dry eyes, decreased night vision, depression and acne fulminans.   Acne fulminans is uncommon yet, devastating. This is most often seen early in treatment in patients with moderate to severe chest acne. To avoid this you can start with low dose, (e.g. 10mg/day or 20 mg/day) and give prednisone 20 mg/day for the first month.

Bowel disease has also been talked about in association with isotretinoin for the last thirty years. Studies found that the bowel disease was as common in the isotretinoin group as in the antibiotic group, yet both groups were higher than placebo. This could be related to the acne itself, not necessarily the medication.

Data shows that twenty-week acne therapy with isotretinoin does not affect bone. Regarding depression, there was identical risk for suicide and depression on isotretinoin as seen in that of patients on antibiotics in a very large well-powered study.

Rosacea

Hillary Baldwin, MD

We know that facial diseases cause a great deal of emotional distress. Rosacea is linked to depression and suicide and an improvement in rosacea is linked to improvement in quality of life (QOL). While teaching camouflaging/make-up techniques takes time, it does result positive effects. Many brands are available and also are accessible and affordable and in reality, minimal training is required.

Why then is it that some patients do not use makeup?

• 53% don’t know how to use makeup
• 29% fear it will get worse
•  9% didn’t feel they needed it

After the use of makeup:

•  99% made noticeable improvement
•  99% continued to use it
• 75% felt that it contributed to relationship with others
• Overall improvement of QOL

Dr. Baldwin’s take home point….get familiar with a someone who knows how to do makeup and send your patients to them. It will certainly improve their QOL.

Why isotretinoin in rosacea?

It’s efficacy was first noted in 1981. There are numerous doses from 0.1-1.0 mg/kg/day. Isotretinoin improves papules, pustules, ocular disease, halts the progression of developing rhinophymas, and can lead to a reduction in erythema.

Continuous low-dose isotretinoin (10-20mg/day)

This may provide long-term control and is an alternative to antibiotics; however, appropriate monitoring necessary. Patients still have to follow iPLEDGE rules which can be difficult because they have to return monthly.

In a study with 573 patients with moderate PPR or rosacea that compared isotretinoin to doxycycline, the isotretinoin 0.3mg/kg/day dosing was found not to be inferior to doxycycline (100mg) and both were found to be superior to placebo.

Conclusions

• In severe, refractory or recalcitrant patients, dermatologists should consider the use of isotretinoin
• Cosmetic camouflage/makeup does work and has shown to improve patient QOL

Interesting Cases

Alan Shalita, MD

In this presentation, Dr Shalita reviewed interesting cases of acne and possible management strategies to overcome these challenging patients.

The Patient with Sandpaper Comedones

This is a rare condition that is often times difficult to treat. Dermatologists can try compounded tretinoin solution (0.05%), which can be very, very irritating but effective and possibly TCA peels, with the right concentration. Laser abrasion may be effective if you have access to a CO₂ laser. Another technique that can provide some relief is what Dr Shalita refers to as “vacuum suction.”

What about chin acne?

Chin acne is typically found in young adult women and may involve the mandible and adjacent neck. Chin acne may or may not be hormonal, but frequently improves with the use of a combination of  both oral contraception and spironolactone. Oral antibiotics can also be helpful. Topical therapy is often times too irritating for patients.

Patients with Nodulopustular Acne

Many dermatologists withhold isotretinoin treatment for too long. If this is the case, you may occasionally need I&D. It is recommended to start on low isotretinoin (target: total dose 120-150 mg/kg) and you may need to culture if the patient is not responding.

Primary Irritant Reaction

This is more common in fair skin, but can occur in all skin types. In many cases, it was a common reaction to topical retinoids; however, it can also result from peels and cryotherapy. Dr Shalita finds that topical tretinoin is effective.

Summary

• Take time with your patients
• Topical retinoids should be used in all but he most severe forms of acne
• Benzoyl peroxide reduces or eliminates less sensitive organisms
• Antibiotics: Minocycline>Doxycycline>Tetracycline- (forget erythromycin)
• Isotretinoin: Start low; consider adding steroids to avoid acne fulminans
• Don’t be afraid to use hormonal therapy