Main Issue June 2011

Education and Skin Care: Key Components in Management of Mild to Moderate Acne Vulgaris

By Joseph Bikowski, MD, FAAD

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Topical interventions are appropriate for the majority of pediatric and adolescent acne presentations, yet some individuals experience suboptimal treatment responses to standard topical regimens. Patient nonadherence with topical therapy is one significant cause of poor therapeutic response.1 Intuitively prescribers have recognized that poor tolerability of therapy, high prescription costs, and inconvenience have all influenced nonadherence. With that in mind, the importance of selecting a therapy that offers good tolerability, efficacy, and convenience has become increasingly clear. But if appropriate therapeutic selection is the cornerstone of effective acne therapy, then patient education and proper skin care are the necessary elements that buttress that foundation.

During the summer months, dermatology practices see an increase in school-age patients who now have time for dermatology visits or who wish to address a skin condition like acne or eczema before the start of the new school year. Demand for acne treatment will be high. While clinicians cannot promise to clear a patient’s acne by the first school bell, they can help pediatric and adolescent patients gain control of acne and minimize recurrence.

The Patient’s Perspective: Ask Questions

Data offer some insight into the general attitudes and experiences of young acne vulgaris patients. Of note, studies suggest that a significant proportion of affected adolescents do not seek medical care for the disease. According to responses to anonymous surveys administered to 1,214 students ages 10–19 years, 83 percent of those with acne had not seen a physician for the condition.2 Other studies show an underrepresentation of adolescents among those seeking medical treatment for acne.3

It has also been shown (and addressed in past issues of DermPerspectives, available online at PracticalDermatologyPA.com) that poor adherence with acne therapy correlates with age, the occurrence of side effects, lack of improvement as evaluated by a dermatologist, previous systemic therapy, lack of knowledge about acne treatment, consultation with a primary care physician, and lack of patient satisfaction with treatment. By contrast, use of skin care (moisturizers, cleansers), use of either topical therapy alone or isotretinoin, good clinical improvement as evaluated by the dermatologist, patient satisfaction with therapy, and knowledge of acne treatment all increased adherence.4

While the clinician should bear these general thoughts in mind as he or she assesses each adolescent acne patient, it is important to understand the individual’s concerns, experiences, and therapeutic desires. This is accomplished through both targeted questioning and active listening. For example, given that only a relatively small proportion of the estimated population affected by acne seeks treatment from a physician, it seems reasonable to assume that a majority of patients have tried over-the-counter therapies. 5 Had non-prescription remedies provided benefit, the patient would not be in the office, therefore, he or she should be willing to abandon those therapies. Nonetheless, the prescriber should ascertain what the patient has used and what sort of response he/she had. Without explicit instruction from you, the patient may continue using an OTC agent that may ultimately interfere with the prescription therapy or cause irritation. Similarly, ask patients what skin care products they use. Do not limit the question to acne skin care, as you need to understand all the products the patient applies. You may wish to question the patient about any home remedies he or she may use, as well as dietary supplements, as some “anti-acne supplements” are now sold OTC. Question patients about any “patterns” of outbreaks. Anatomic distribution may indicate unique presentations of acne such as acne mechanica or “pomade acne” (See Table 1). It also may be appropriate to question the patient about the impact of acne on his/her quality of life. Understanding the individual’s context enables the prescriber to focus patient education strategies and devise an optimal treatment regimen for the individual.

Patient Education: Provide Answers

Inform patients that although acne cannot be cured (i.e., taken away so that it never comes back), it certainly can be controlled. Setting appropriate expectations is important, including how long it will take treatment to take effect and the likely duration of treatment. Note that the typical patient may anticipate needing just six months of treatment or less, which is not realistic. Treatment must be used on a consistent basis, despite a common perception among teens that acne is a transient disease.6 Initial results from therapies can be expected in about four to six weeks. To achieve best results with any regimen will require eight to 16 weeks.

Advise patients to discontinue all overthe- counter skincare programs and therapies: No soaps, astringents, cleansers, fresheners, toners, scrubs, facial masks or cosmetic skin care programs.

Dispel common myths related to the role of dirt, hygiene, and diet in causing acne. If a patient insists that particular fatty foods exacerbate acne, suggest that the patient attempt to eat a healthier diet, as there is no known detriment to the avoidance of highfat snacks.

Questions frequently arise regarding cosmetics and acne. In the past, researchers used animal models to test the comedogenic potential of raw materials used in cosmetics, and the term “acne cosmetica” was coined to describe acne suspected to be caused by cosmetic products. However, new evidence suggests that finished products formulated with “comedogenic” ingredients may not actually induce acne.7 Patients may, therefore, continue to use foundation, setting powder, blush, eye color, lip color, and any other cosmetics they wish. Despite the rarity of acne cosmetica, patients may feel more confident choosing cosmetics labeled as non-comedogenic/ non-acnegenic.

The Regimen: Skin Care and Topical Prescriptions

Proper skin care is essential to support therapeutic outcomes and help minimize possible side effects of topical acne therapy. Moisturizers are known to provide benefits in the management of inflammatory skin diseases and have been recognized as important adjuncts to therapy.8,9 Specifically, studies show that concomitant use of effective moisturizers, mild cleansers and daily sunscreens enhances skin tolerance and comfort among individuals using topical retinoids.10 It should be noted that newer retinoid formulations have been designed in efforts to minimize therapy-associated irritation. For example, the inclusion of humectant and moisturizing ingredients in the vehicle base of tretinoin gel 0.05% (Atralin, Coria Laboratories), has resulted in a significantly reduced rate of irritation. 11 Nonetheless, gentle supportive skin care will only enhance patient comfort early in the treatment phase and may establish important long-term healthy skin care habits.

Patients should not use soap to cleanse the face or, in the case of truncal acne, the chest and back. To wash the face each morning and evening, a mild, soap-free cleanser, such as CeraVe Hydrating Cleanser (Coria Laboratories), should be applied with the fingertips and rinsed with water. A gentle moisturizer (such as CeraVe Moisturizing Cream, Coria) should be applied after cleansing.

Sun protection is essential. Patients should apply a broad-spectrum (UVA and UVB) sunscreen minimum SPF 15 to 30 to the face and all sun-exposed skin each morning. Rather than recommend a specific product, encourage patients to select the product of their choice; if they like the look, feel and smell of the formulation, they will be more inclined to use it regularly.

Optimal treatment of acne depends on the initiation of therapy aimed at multiple pathogenic features of the disease, and the majority of patients with mild to moderate acne are best treated with a combination of topical therapies.1,12 The emphasis of this article is not on therapy selection, but some key considerations bear discussion. Given the importance of topical retinoids in the management of acne and their ability to prevent the formation of the early microcomedo, most patients with mild to moderate acne vulgaris should be started on a topical retinoid each evening. Treatment is optimized with the addition of a topical antimicrobial— either topical benzoyl peroxide or benzoyl peroxide/antibiotic combination— each morning.

Get Personal

There is no “typical” acne patient, although there may be some commonalities among affected individuals. Importantly, clinicians should recognize the importance of effective therapy to improve the patient’s quality of life—and by extension long-term adherence. The establishment of realistic treatment expectations is crucial. Simplified regimens built upon formulations with good tolerability and supported by gentle skin care are expected to improve adherence.

Ongoing dialogue with patients is critical to long-term therapeutic success. Patient questioning remains important during all subsequent office visits to understand the patient’s experience of treatment and his/her use of medications. Consider that one recent survey of acne patients found that those who experienced irritation with a clindamycin- benzoyl peroxide 5% formulation reduced their use of medication without physician direction (32 percent applied less frequently than recommended, 32 percent stopped use for brief periods, and 10 percent discontinued altogether), while others switched to spot-treatment or used medication only during “flares.”14

If a patient complains of notable therapyassociated irritation, clinicians must offer reasonable and effective alternatives rather than urge patience. Assuming the patient has been adhering to the recommended skin care regimen and avoiding any additional irritants, it may be necessary to switch to a different drug formulation. For example, Clindamycin Phosphate 1.2% and Benzoyl Peroxide 2.5% gel (Acanya Gel, Coria Laboratories), which features the lowest concentration of BPO available in a fixed combination formulation, has demonstrated favorable tolerability, comparable to vehicle. Though not optimal because they may complicate adherence and delay therapeutic response, alternative dosing regimens, such as every-other-day application, may be employed for patients with very sensitive skin.

Joseph Bikowski, MD, FAAD founded DermEdOnline.com, which offers a core curriculum designed to provide medical professionals with a comprehensive dermatology learning experience including unique interactive learning tools, case histories, lectures (audio / video), study guides, supplemental projects and pre and post assessments. He is Clinical Assistant Professor of Dermatology, Ohio State University, Columbus, OH and Director of Bikowski Skin Care Center in Sewickley, PA

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