Five years of innovation and research have created many knowledge gaps in the American Academy of Dermatology (AAD) guidelines for acne care and management.first A working group recently established by the academy to update the guidelines will provide best practice recommendations and safety precautions for therapies, treatments, and devices developed to Treatment of acne. Originally published in 2016, the new guidelines will be released in 2023 or 2024.

“The two main concerns are appropriate isotretinoin dosing and in-room monitoring,” says Jonette Keri, MD, PhD, FAAD, associate professor of dermatology and skin surgery at the University of Miami Miller School of Medicine in Florida. experiments with spironolactone and isotretinoin. at the Miami VA Medical Center, and was a member of the working group. “The updates will also provide guidance on new antibiotics and antibiotic management, as well as a broader knowledge of lasers and other light devices used to treat acne.”

She provided details on upcoming revisions to the AAD acne guidelines as forum director for a proof-of-concept interpretation of current acne guidelines and beyond. more at the American Academy of Dermatology Virtual Meeting Experience 2021 (AAD VMX) in April.2

Other speakers included Arun L. Pathy, MD, FAAD, a dermatologist with Colorado Permanente Medical Group in Centennial and a partner in the working group that revised the AAD acne guidelines.3; Rachel Sabbag Reynolds, MD, vice president, Department of Dermatology, and assistant professor of dermatology, Harvard Medical School, in Boston, Massachusetts4; Jonathan S. Weiss, MD, dermatologist with Georgia Partners in Dermatology and Gwinnett Clinical Research Center in Snellville, Georgia5; and Andrea Zaenglein, MD, FAAD, professor of dermatology and pediatric dermatology at the Milton S. Hershey Medical Center at Penn State University in Hershey, Pennsylvania.6

“In developing these new guidelines, we recruited not only acne specialists from around the country, but also an internist, a pediatrician and an advocate,” says Keri. patient. “In fact, more than 51% of workgroups don’t have any pharmaceutical-related concerns. This is important because acne isn’t just treated by a dermatologist. Primary care plays an active role, so we need to consider their perspective, as well as the patient’s perspective.”

Keri tells Dermatology Times® that there is always the potential to improve acne treatment. “At least [for now], we don’t have a magic bullet that can get rid of acne 100% of a person’s life 100%,” she says.

However, the pipeline of treatment options continues to flow, focusing on care until a cure becomes a reality. New to the list of topical formulations are minocycline foam (Amzeeq; Foamix Pharmaceuticals) and the retinoid, trifarotene (Aklief; Galderma).

“There are also new formulations of older, already evaluated retinoids [and found] to be useful,” Keri said. “Also, clascoterone [Winlevi; Cassiopea] is a topical antiandrogen that is newly approved by the FDA but has not yet been published for use. The drug will be on the market soon.”

Sarecycline (Seysara; Almirall) is the first new oral antibiotic approved by the FDA in more than 40 years. One of its added benefits is that this tetracycline-derived small-molecule drug is “less likely to induce resistance,” Keri says. “This is exciting because of the goal of antibiotic stewardship around the world.”

Patients should also be educated about new weight-based oral antibiotics. “We have this for some antibiotics, but not all of them,” Keri said. “Antibiotic management ensures that you have the right antibiotic and the correct dose at the right time for the correct condition. You want to make sure you don’t give too much or not enough.”

In Keri’s view, the dermatology community is working to reduce dependence on antibiotics. “When we have new mechanisms to treat acne, perhaps we can use fewer antibiotics,” she said.

The forum included a review of approved oral contraceptives for the treatment of acne, as well as highlighting some of the controversies over side effects, including thromboembolic events with certain oral contraceptives. oral pregnancy and their safety.

“Currently, there are four types of birth control pills approved by the FDA to treat acne, but there are many birth control pills that are not FDA approved to treat acne. [that] can help,” Keri said.

Most oral contraceptives, whether or not they are approved to treat acne, are a combination of estrogen and progesterone. “Doctors need to understand the difference between these two ingredients so they can make informed decisions about prescribing acne medications to their patients,” says Keri. “There is an oral contraceptive that treats acne very well; however, these companies have not pursued approval for the treatment of acne. ”

Keri tends to prescribe FDA-approved birth control pills that contain drospirenone (Yaz; Beyaz; Bayer) because the synthetic progestin acts as a potent anti-androgen. “However, there is a bit of controversy about [adverse] effect profiles, specifically thromboembolic events,” she said. “But the risk is slight.”

Spironolactone is also an antiandrogen used in adult women. “It has been adopted by a lot of people over the years as a treatment for acne, in part because of celebrity endorsements,” says Keri. “One of the [adverse] The effect of spironolactone in men is gynaecomastia, so it is not used to treat acne in men.”

Keri says excellent results are achieved with spironolactone, with long-term treatment for many years. However, laboratory monitoring may be required because the drug may cause hyperkalemia, hyperkalemia.

Isotretinoin is a vitamin A derivative that treats severe scarring with nodular cystic acne or acne that has a heavy psychological impact on the patient. However, systemic drugs are still controversial because of serious side effects, including malformations in the fetus.

“That [adverse] effect [teratogenicity] Keri said. “In the past, I believed that people were simply cautious about prescribing isotretinoin. However, now, thanks to good epidemiological studies, dermatologists feel more and more comfortable prescribing the drug.”

In Keri’s practice, isotretinoin dosing is preferred by patients, although she advocates a typical cumulative dose of 150 mg/kg. “But there are patients who need more or less,” says Keri. “There is variation in the amount of isotretinoin that a patient will need and we are working to determine the optimal dose for the patient.”

Diet is becoming increasingly important in the treatment of acne. “There is some evidence that dairy aggravates acne,” says Keri. “While some data suggest skim milk is more relevant, recent data do not support this. The jury is still out on the link between dairy and acne. “

High-glycemic “white” foods, such as white bread, rice, and pasta, have also been strongly linked to worsening acne. “My patients tend to be too diet-focused, even though diet can be a contributing factor in acne,” says Keri. “Diet is of more concern for female patients with PCOS. Diet interventions [watching the glycemic load/index] has been shown to specifically help these patients. ”

The advantages of light-based devices over traditional pharmaceutical therapies are also changing the paradigm of acne treatment. Traditional treatments still tend to be the first choice, but laser and light-based therapies can be used for patients who don’t want traditional treatments or have failed with conventional treatments. traditional therapy and may be at your own expense – that’s Theo Keri, which is generally not covered by insurance.

Other research gaps in acne include treating patients with skin color and pregnant patients, as well as exploring the molecular and cellular mechanisms underlying acne.

“A lot of work goes into formulating the motto,” says Keri. “That’s why it takes two to three years. We try to evaluate the validity of the evidence and try to make it user-friendly so that the guidelines can be a reference for the busy practitioner. ”

Disclosure:

Keri is a member of VYNE Therapeutics’ speaker office and an advisor to Almirall.

Pathy, Sabbag and Reynolds made no financial statements or related disclosures.

Zaenglein is a consultant for Pfizer; advisory board member for Dermata, Sol-Gel, Regeneron, Verrica Pharmaceuticals, and Cassiopea; and a contracted researcher for AbbVie, Arcutis, and Pfizer.

Presenter:

1. Zaenglein AL, Pathy AL, Schlosser BJ, et al. A care guide to acne control. J Am Acad Dermatol. 2016; 74 (5): 945-73.e33. doi: 10.1016 / j.jaad.2015.12,037

2. Keri J, Pathy A, Weiss JS et al. Turning evidence into practice, current acne guidelines and more. American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX); April 23-25, 2021; virtual. Retrieved May 4, 2021.

3. Pathy A. Clinical Pearl and Developmental Guidelines. American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX); April 23-25, 2021; virtual. Retrieved May 4, 2021.

4. Sabbag Reynolds. Spironolactone for the treatment of acne. American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX); April 23-25, 2021; virtual. Retrieved May 4, 2021.

5. Instructions by Weiss J. Isotretinoin. American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX); April 23-25, 2021; virtual. Retrieved May 4, 2021.

6. Zaenglein A. Diet and acne. American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX); April 23-25, 2021; virtual. Retrieved May 4, 2021.

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