1. health and fitness
2. therapy

VOL 1 • NO 2
ACNEBRIEFS
1999
™
Published under an unrestricted educational grant from
COMBINATION THERAPY IS THE BEST APPROACH
FOR MILD TO MODERATE ACNE
In this issue of Acne Briefs, Gary M. White, MD, chief of dermatology at Kaiser
Permanente in San Diego, shares his experience treating acne with what he calls the
“two pillars of conventional therapy”: a comedolytic agent to open the pores and an
antimicrobial to kill the bacterium Propionibacterium acnes, which infects the follicles of
acne patients. Recent advances in acne therapy, including the development of new, less
irritating topical retinoids that successfully resolve and prevent comedones, have given
this two-pillared approach an extra punch. Dr White explains how best to integrate these
drugs into effective acne therapy for patients of any age or skin type.
Q. Can you review the various types of acne therapies available, and delineate which part of the pathogenesis of acne they
each affect?
Dr White: One of the two pillars of conventional therapy is
killing the bacterium P acnes with antimicrobials (Table 1, page
2). We have both topical and
oral agents. There is topical benzoyl peroxide, which is probably the best topical agent to kill
P acnes, and then we have topical erythromycin and clindamycin. In the past, tetracycline was
used topically, but that’s not
really used much anymore. We
have combination therapies, like
Benzamycin®, which is a combination of 5% benzoyl peroxide and 3% erythromycin. There
are also some products that contain sodium sulfacetamide, like
Klaron®, that can be used to kill
P acnes.
I like Differin® (adapalene) gel, which is excellent for almost
any patient, but in particular those with a little oilier complexion or maybe during the summertime. I also like Avita® (tretinoin) cream for patients with sensitive skin or during the wintertime, when the air can be a little drying. I find both of those
very effective. Retin-A Micro® (tretinoin) is another one you
might consider. Tazorac ®
(tazarotene) tends to be a little
more irritating and more costly,
and so I usually don’t use
tazarotene.
Azelex® (azelaic acid) has been
marketed to have both P acnes–
reducing and comedolytic effects, but I think the data don’t
support its effectiveness in killing P acnes, and its comedolytic
effect is not quite as good as that
of the retinoids.
So, in general, to open up those
pores, the retinoids are really the
best.
In terms of oral antibiotics, I
usually use tetracycline, at a
Q. Are there any drawbacks with
the drugs used in this “two-pildose of 500 mg twice a day,
Gary M. White, MD
doxycycline, 50 to 100 mg
lar” approach?
twice a day, and minocycline, 50 to 100 mg once or twice a
Dr White: Benzoyl peroxide is very effective in killing
day. Those are the drugs that kill P acnes.
P acnes, but the main drawback is the drying effect. Some
patients don’t tolerate it well, especially if you go to 10%.
As the second pillar, to open up the follicle, to get rid of those
We modulate that by trying to go with the 5% preparations.
comedones, I rely on the retinoids. Retinoids are just fabulous
Patients can even use it every other day, if they need to. If
topical agents to do that, and the newer, less irritating retinoids
that still doesn’t work, Benzamycin is an excellent product
are definitely my favorite.
that reduces the irritation of benzoyl peroxide and has, perhaps, even greater efficacy. The one downside to Benzamycin is it’s a little more expensive than an over-the-counter
drug or even many of the prescription benzoyl peroxides.
In terms of sodium sulfacetamide, it probably doesn’t kill
P acnes as well as benzoyl peroxide, but it may be appropriate
for patients with really sensitive skin.
Clindamycin is an excellent
topical product, though it
doesn’t kill the P acnes quite as
well as benzoyl peroxide. Also,
the bacterium can develop resistance to both topical clindamycin and erythromycin, but
we still use a lot of that.
tory acne with some nodules, I’ll add an oral antibiotic, either
tetracycline or doxycycline, to that topical regimen. If they are
resistant to that treatment, I’ll switch the oral antibiotic to
minocycline and give that another 6 weeks. If that doesn’t work,
then I put them on isotretinoin (Accutane®).
Q. What prompts you to change therapies?
Dr White: I usually like to see patients back in about a month
to 6 weeks, to see how any regimen they’re on is doing. If they
improved significantly, by
One of the two pillars of conventional therapy have
maybe 40% to 60%, I’ll stay on
it and see them back in another
is killing the bacterium P acnes with
to 6 weeks. If they
antimicrobials…. As the second pillar, to open month
haven’t budged one bit after a
up the follicle, to get rid of those comedones, month to 6 weeks, then I usually
think it’s time to switch to someI rely on the retinoids.
thing different.
Oral antibiotics: Tetracycline is
a good first-line agent for moderate inflammatory acne. It can
Q. What can the dermatologist
cause a yeast infection in about
do to reduce the risk for the
3% of women, so we always
patient’s P acnes developing rehave to let them know about
sistance when using antibiotics?
that. There’s a theoretical interaction with birth control pills,
Dr White: The resistance of the
so as doctors, we always feel
bacterium P acnes to various anANTIMICROBIALS
COMEDOLYTICS
obligated to mention that, but
tibiotics is on a significant rise,
®
Benzoyl peroxide
Differin gel
it’s not been proven.
and I think it will continue to go
®
Erythromycin
Avita cream
Doxycycline is very effective
in that direction and be a prob®
®
Benzamycin
Retin-A Micro
and can be taken with food, but
lem for our patients. But the
Clindamycin
Tazorac®*
it has quite a bit of photosensigood news is that benzoyl perTetracycline†
tivity, so we don’t like
oxide is not subject to that;
Minocycline‡
doxycycline in the summertime.
P acnes will not develop resisMinocycline is probably the
tance to benzoyl peroxide, plus
Klaron®
most effective of all our oral anthere’s no resistance in any way
Doxycycline
tibiotics, but it has some longto the retinoids and their action.
* May cause irritation
term side effects that you have
Therapy with adapalene gel and
† Contradinicated in children less than 8 years
‡ May stain the teeth, skin, and eyes blue
to think about, like blue patches
benzoyl peroxide, for example,
on the skin and even blue teeth.
is not at all subject to any
And sometimes, early on,
P acnes resistance problems. And
women can get vertigo or dizziness with the first couple of doses.
when you add an oral antibiotic, such as tetracycline, you still have
It is also more expensive than tetracycline and doxycycline.
that benzoyl peroxide on board to help kill the P acnes. A strain of
P acnes that’s fully resistant to tetracycline will be just as easily
With regard to the retinoids, there are very few drawbacks to
killed by benzoyl peroxide as one that’s not resistant to tetracyeither the Differin® (adapalene) gel or Avita® (tretinoin) cream.
cline. So this topical regimen of benzoyl peroxide and retinoids is
not going to be affected by any P acnes resistance.
I find those products to be very well tolerated by patients.
Tazarotene, as I mentioned, is more irritating.
Q. Should two different antibiotics ever be used simultaneously?
Q. What is the normal therapeutic regimen you prescribe for
Dr White: That question, I think, would apply to a regimen of,
the average patient with acne?
perhaps, tetracycline orally and clindamycin topically, along with
a retinoid. I don’t use that as much, because you get into the issue
Dr White: The average paof P acnes resistance. That’s why I like an oral antibiotic, such as a
tient with acne gets topical
™
tetracycline, with benzoyl peroxide, because you don’t have that
therapy as a fundamental
problem, and if irritation is a problem, I’ll use Benzamycin. But
starting point. So, they alEditorial Director ........... Leo Orris, MD
Managing Editor ............. Alison Marek
there are some patients who just don’t tolerate a benzoyl peroxide,
ways get a topical retinoid
Graphic Design ............... Candy Hayes
but they had used clindamycin or erythromycin in the past and
and a topical antimicrobial.
Production Manager ........... Laura Lynn
Publisher .......................... Murray Stern
they had liked it. So I do, sometimes, have a very small percentage
My favorite is Differin gel
Acne Briefs is published under an unrestricted
of my patients on an oral tetracycline and a topical antibiotic, but
or
the
Avita
cream,
along
educational grant from Galderma. Editorial content
does not necessarily reflect the opinions of the
it’s not my first choice.
with
a
benzoyl
peroxide–
sponsor or the publisher.
containing product. That’s
A publication of
Academy Professional Information Services, Inc.
Q. How many times in your practice have you used a single
my foundation.
116 West 32nd Street, New York, NY 10001
agent for acne therapy and obtained good results?
© Copyright 1999
Academy Professional Information Services, Inc.
If in addition to that they
Dr White: The only time we use monotherapy is with the syshave moderate inflamma-
Table 1. The Two Pillars of
Combination Acne Therapy
ACNEBRIEFS
PAGE 2 • ACNEBRIEFS
temic retinoid isotretinoin. If you exclude that and look just at
conventional therapy, I use one medication just 2% or 3% of the
time; 97% or 98% of the time, I use multiple medications.
Q. Why do you need to use more than one drug?
Dr White: The whole reason we use combination therapy is
because acne, probably fundamentally, has two problems that
we try to address: one is the closing up of the pore, the comedone
formation, and the second is the growth of the bacterium P acnes.
We don’t have any topical agents that fight both.
Sometimes, if a patient is very young and the main thing that
bothers him or her is the inflammatory papules and pustules,
benzoyl peroxide would be very appropriate. The patient can
get that over the counter and do pretty well. Sometimes
adult women in their 20s or 30s who are mainly bothered
by the inflammatory papules
do pretty well with nightly
benzoyl peroxide.
If I want to get rid of comedones, I use the topical retinoids
almost exclusively. It’s interesting that almost anything that reduces P acnes will also reduce comedones to some extent, so
when you use benzoyl peroxide, when you give oral antibiotics,
the reduction of P acnes actually will help to a small extent to
reduce the comedones. So that’s one benefit of combination
therapy.
Also, acne surgery can be an adjunct to retinoid therapy. We
have patients see our nurse for acne surgery, to take out some
comedones.
Q. What about azelaic acid and the α-hydroxy acids?
Dr White: Azelaic acid probably has some comedolytic effect,
though it is not nearly as effective as the retinoids. It might be a
good adjunct in a patient with darker skin who has some
postinflammatory hyperpigmented macules.
The α-hydroxy acids continue to
be agents that people would like
to use for acne, but the data are
really quite sparse. The best
study, published in Cosmetic
Dermatology, used glycolic acid
with or without tretinoin, and the
tretinoin was far superior to the
glycolic acid. We need more
studies in the area of α-hydroxy
acids, but I continue to think that
retinoids are clearly superior in
their comedolytic effect.
If a young patient has mainly
comedones and hasn’t started to
develop the inflammatory acne
phase, then a topical retinoid
might be good. Those are the
kinds of situations where I
might use a single agent.
Q. Why is it important to include
an agent that corrects keratinization defects when treating
acne?
Dr White: The follicular opening, the pore, closes up or gets
clogged because of a variety
factors, but one of the key ones
is the thickening of the follicular lining, which results from
abnormal keratinization. That,
together with the oil and the debris from the P acnes, forms the
plug. Anything that can improve
the keratinization and normalize the follicular opening will
help unclog that pore.
Q. Are there any combination
treatments for acne that do not
work and shouldn’t be used?
Dr White: Absolutely. Obviously, we have only a certain
number of interventions we can
expect our patients to use. I think
three medications is getting to
be about the limit.
If you focus all your efforts on
either killing P acnes or opening up the pore, and not both,
then you’re missing the boat. So,
for example, I don’t like tetracycline plus benzoyl peroxide.
That therapy kills P acnes, but
it doesn’t open up the pore. I
don’t like a topical retinoid therapy plus salicylic acid as the
only approach. It doesn’t do anything for P acnes. Azelaic acid,
as I’ve mentioned, is only a little better in its comedolytic effect, so I wouldn’t combine it with a retinoid.
Although acne is popularly thought of as a disease that strikes
only during the teenage years, many women in their 20s, 30s,
or 40s will develop comedonal and/or inflammatory lesions. In
addition to standard therapy with a topical retinoid and an antimicrobial, or systemic therapy with an oral retinoid, some women
may need hormone therapy with norgestimate or another oral
contraceptive.
There is some benefit to using
keratolytics, such as salicylic
acid, that peel the skin, but those
are not nearly as effective as the
topical retinoids, which act
through the retinoic acid receptors to normalize that follicular
opening. We don’t fully understand why retinoids normalize the
opening, but we do know they do that very well.
Q. Is there anything else that can help eliminate or prevent
comedones?
Dr White: Whenever I encounter patients with a lot of
comedones, the first thing I want to know is whether they are
putting anything on their face that’s greasy or comedogenic. I
always go through a quick question-and-answer session about
what they put on their face, and then try to eliminate any greasy
substances that might be causing the comedones to occur.
Q. Have the newer, less irritating retinoids changed the way
you treat acne, and if so, how?
Dr White: The newer retinoids, like adapalene (Differin), and
the newer packaging of tretinoin, like Avita, have definitely
changed the way I practice dermatology in the area of treating
acne by making it much easier for me. I am more willing to
give the retinoids to almost every patient with acne. In the past,
ACNEBRIEFS • PAGE 3
because Retin-A was fairly irritating, I would sometimes try to
get by with not giving a retinoid to some patients who didn’t
have as many comedones, whereas now I’m able to give retinoids
to almost any patient.
Q. What about the patient with sensitive skin? Do you have any
patients who still have problems with irritation?
can use Differin much more easily.
Q. What kind of daily regimen do you recommend to maximize
the efficacy of using topical retinoids and antimicrobials in the
two-pillared approach to acne therapy?
Dr White: In general, we like the patients to wash their face
twice a day: morning and night (Table 2). We want them to be
careful about what they put on their face and use products from
Dr White: In the past, we often had a significant percentage of
reputable, well-known companies, like Clinique, Estée Lauder,
patients whom we couldn’t get to stay on a daily regimen of
or any of the major companies.
retinoids. But now, with the
We like products that say “nonnewer, less irritating retinoids,
comedogenic” or “nonacnegealmost every patient will stay on
The average patient with acne gets topical
nic” — something that shows
retinoid therapy and do very
therapy as a fundamental starting point…. My that the company thinks they’re
well.
okay for acne skin. I discourage
favorite is Differin gel or the Avita cream,
a lot of moisturizers if the paIn the past, we used to have the
along with a benzoyl peroxide–containing
tient has acne. In the morning,
patients wash their face and wait
they may want to use a light
20 minutes before they put the
product. That’s my foundation.
moisturizer with sunscreen, or
retinoids on; we don’t have to do
they may want to use a light
that anymore. The new retinoids
moisturizer if they’re getting
have simplified the approach for
some drying or peeling from the
our patients. They just wash their
Table 2. Dr White's Recommended
regimen.
face, put the medication on, and
Regimen for Acne Care
go do their thing.
Other than that, the key points that
I go over with patients for their
Q. Do you ever encounter pa➊ Wash the face twice a day, morning and night
regimen is that we’re trying to
tients who have tried a retinoid
prevent acne. Probably the numbefore and don’t want to try one
➋ Then apply topical acne medication, such as
ber-one mistake that patients
again?
Differin® gel or benzoyl peroxide
make with their topical therapies
is trying to “spot treat.” They want
Dr White: It’s interesting how
➌ Next, if desired, a light noncomedogenic
to put a little something here, a
educated many of our patients
moisturizer with a sunscreen can be used
little something there on the acne
are. Many of the lay publicathat’s already broken out. I tell pations have correctly encouraged
➍ For those who play or work in the sun, a
tients that’s like closing the barn
patients to see their doctors for
sunscreen with an SPF of 30 is recommended
door after the cow got out. It
these newer retinoids. Everyone
doesn’t prevent acne; they need
knows that Retin-A can be very
➎ Noncomedogenic cosmetics from a reputable
to put the medications all over to
irritating, and these new medicompany may be applied as usual
prevent acne.
cations are really a nice advance. I do have some patients
Benzoyl peroxide can bleach
that I have to tell about the new
carpets and clothing, so that’s important for patients to know.
retinoids, but many patients come to me knowing that there’s
Many patients do better with benzoyl peroxide at nighttime,
something different, something new, and maybe they don’t have
especially women, because sometimes it leaves a visible white
to use that old Retin-A.
residue that doesn’t look good at school or work.
Q. What do you tell those few patients who require persuasion?
Although it’s not in the package insert, Differin gel does very
nicely in the morning. Many women like to put Differin on in
Dr White: I just tell them, “Medical science has made an adthe morning and then put makeup on afterwards, as needed. It’s
vance here. Retin-A was the old product. We’ve got some newer,
very light and goes well with makeup.
improved medications. They really are better. If you’ll just try
them, I think you’ll do very well and you won’t get the irritaI work in San Diego, and we’ve used Differin gel on thousands
tion that you used to get with Retin-A.”
of patients. I have not seen a single case of photosensitivity
from it. I do confess that I usually like patients to use some
Q. How do these new retinoids compare in efficacy with allmoisturizer with a little sunscreen in the summertime, but I’d
trans-retinoic acid (Retin-A)?
say that this regimen works very well.
Dr White: In the largest multicenter trial comparing Differin
Q. What kind of sunscreens should acne patients use when they
gel with Retin-A .025% gel, Differin gel was actually more
are at the beach or in the sun for prolonged periods of time?
effective than Retin-A. There were some other studies that
showed that they were equally effective. The bottom line, I
Dr White: Sun-protection factor (SPF) 15 is probably not suffithink, that most dermatologists should take away from the
cient for several hours out in the sun. I recommend at least an
studies with retinoids is that in general, either Differin or
SPF 30 for my patients with acne who will be outside for proRetin-A will get you to the same point at 12 weeks. It’s very
longed periods of time. Many of the sunscreens with SPF 30
hard to prove any significant difference in terms of efficacy.
claim to be noncomedogenic, or okay for acne, but I have found
The main benefit is the reduction in irritation. The patients
PAGE 4 • ACNEBRIEFS
in general that a patient just has to go and try them. If you use
something for a week, and your acne flares up, even if the product says “nonacnegenic,” it’s not good for you. I tell the patient
to get two or three different sunscreens and try them for a week
in the summertime. I’ve never had a patient who couldn’t figure out which ones flare up their acne and which ones don’t.
Q. Do you recommend any special acne cleansers or soaps?
rocomedones underneath the skin, despite otherwise successful
acne therapy?
Dr White: The macrocomedones are an interesting variant of
the comedone. They’re these 1- to 2-mm white balls right under
the skin that you can see best by stretching the skin (Figure).
They often become apparent during isotretinoin therapy, but you
may notice them in patients on conventional therapy as well.
Oftentimes, the tried-and-true method of acne surgery is best at
eliminating these. You take a number 11 blade, make a small
incision, and then use a comedone extractor to remove them.
Dr White: I’m not really into spending money on a whole regimen that’s not nearly as effective as benzoyl peroxide and a
topical retinoid. There are, in general, two types of cleansers:
the salicylic acid–containing
cleanser and the benzoyl peroxide–containing cleanser.
If you focus all your efforts on either killing
The benzoyl peroxide–containing cleanser is not nearly
P acnes or opening up the pore, and not both,
as effective at killing P acnes
then you’re missing the boat.
as the benzoyl peroxide that
you put on and leave on. But
if patients are on a topical
retinoid and an antimicrobial,
and they still have some inflammatory lesions, then you
could add a cleanser with
benzoyl peroxide. Or, if they
have a few more comedones,
you could add a salicylic
acid–containing cleanser.
In the United Kingdom, they
have reported using EMLA
cream applied first, and then
electrocautery if there are
maybe 50 to 100 lesions. I
myself haven’t done that, but
Dr Cunliffe and others recommend that approach for
treating multiple lesions.
Q. How often do you use acne
surgery as an adjunct to acne
therapy?
Dr White: I think we have a
duty to do what’s best for our
patients. If you can get them
on a topical retinoid that
keeps their pores clear, they
Q. How can patients be eduprobably won’t have to return
cated to maximize the value
to you month after month for
of their acne therapy?
extractions; that’s a service
we do for our patients. But
Dr White: In terms of eduin those few patients on a
cating patients about acne
therapy, there are a few things Macrocomedones, which are 1- to 2-mm whiteheads that underlie the topical retinoid who are not
I always try to do in the time surface of the skin of some acne patients, may not be visible at first fully clear of comedones —
glance (left). After the skin is stretched, however, the lesions become
blackheads and whiteheads
that I have them in my office. apparent (right).
— then I utilize my acne surThe first is to stress that if a
gery nurse to clear out those
regimen works, we have got
pores, and have the patients come back as often as they need.
to stay on it. If it works for 6 weeks, then we stay on it for 3
So I use it as an adjunct to topical retinoid therapy.
months, 6 months, etc; we don’t wait until it improves and then
stop. That’s one of the key things.
Q. What role do hormones play in acne, and do you take that
into account when prescribing therapies?
The second is that we use combination therapy in acne for a
reason. We are trying to affect at least two different causes of
Dr White: We know that hormones are a significant part of the
acne, so we’re using medications with two different purposes.
process of acne, because it only occurs when the pubertal horMany times, if you don’t prepare patients appropriately, if you
mones start to increase. But that’s a normal process.
give them two medications, they’ll try to figure out which one
works better. And I’ve never understood how patients can think
It’s in the area of young adult women with acne that we rethey’ve figured out that one works and the other one doesn’t.
ally think that hormones are related, although we’re not quite
But invariably, they will, and they’ll stop one medication and
sure of all the details. We see a lot of young adult women
come back to you and they’re just on one topical.
who have acne that flares with their menstrual cycle, and
that is benefited by hormonal therapy. It’s interesting, but in
I prep them by saying “We’ve got to use these medications daily
this group of patients, the hormone levels are usually norfor a prolonged period of time. I want you to use them both;
mal. If you take 100 young adult women with acne, their
don’t stop just one, use them both. And if you have any side
average hormone levels might be slightly higher than those
effects or problems, call me.” You want to head off the patient
in a normal group, but for the individual patient, you don’t
who’s going to come back to your office who used the medicafind a specific abnormality. Oftentimes, for young adult
tion for 1 week, had some sort of problem, and then just stopped.
women — especially those who have relapsed after AccuThen you’ve wasted that whole period of time, and you’ve got
tane — we’ll want them to go on birth control pills, such as
to get him or her back on the regimen. Those are the things that
Ortho-Tri-Cyclen®. If a woman has a relapse after a second
I tell patients as a kind of preemptive strike.
course of Accutane, I’ll give spironolactone therapy, which
Q. How do you manage the patient who continues to have macI've found to be effective in this subset of patients with acne.
ACNEBRIEFS • PAGE 5
Q. Are there any precautions that pregnant or nursing women
who are being treated for acne should take?
use it. The oral antibiotics — tetracycline and doxycycline —
are very inexpensive, and of course Accutane is very expensive.
Dr White: We have a greatly limited armamentarium for pregnant women with acne. Erythromycin is okay topically, as is
benzoyl peroxide. That allows them to use Benzamycin, benzoyl peroxide, topical erythromycin, or even oral erythromycin, although I must say that I always have the patient or myself
check with the obstetrician before I start any oral medications.
Q. How long after their acne clears should patients remain on
their regimen?
Azelex (azelaic acid) is pregnancy category B, and even though
it’s not as comedolytic as the retinoids, we in general don’t use
topical retinoids in our pregnant patients. Azelex is also appropriate for nursing mothers. So, in general, a lot of women just
have to wait until they’re done with their pregnancy.
Dr White: If a patient is on this topical regimen of a retinoid
plus benzoyl peroxide or an antimicrobial and an oral antibiotic, then I’ll usually give the oral antibiotic for a 3- to 6-month
period and then tell the patient to stop it and see if the topical
regimen will do. I usually see the topical program as something
for long-term maintenance, but I try to get patients off antibiotics orally if I can.
If they have gone a long time with the topical regimen, then
invariably I don’t have to tell patients. On their own, they
will stop one agent and see how they do. If they ask me first,
Many times, the acne will improve with pregnancy, but someif they have more inflammatory lesions, I’ll say, “Stop the
times it will worsen, and for those patients, they just have to
retinoid and just go with the
wait.
topical antimicrobial.” If
they have more comedonal
Q. What about treating the
Everyone knows that Retin-A can be very
disease, I’ll say, “Stay on
pediatric patient? Is it safe to
the retinoids, stop the antiuse your normal combination
irritating, and these new medications
microbial, and just see how
of benzoyl peroxide and
are really a nice advance…. In the largest
you do over time.”
retinoids, or topical antibiotics and retinoids?
multicenter trial comparing Differin gel with
Q. What are some of the
Retin-A .025% gel, Differin gel was actually
changes in lifestyle and selfDr White: The child with
image that people experience
acne can be treated with all
more effective than Retin-A.
after being on successful
of these regimens. There’s
combination acne therapy?
certainly no problem with
benzoyl peroxide with all of
Dr White: A lot has been
the topical retinoids. The
said about the psychological
main concern that we think
problems, concerns, or issues
about is with tetracycline, bethat patients have when they
cause it can damage the
have a face full of acne, and
teeth.You shouldn’t use tetI think that’s absolutely warracycline in kids 8 years or
ranted. These poor kids —
younger. It’s rare to need tetthey’re trying to become
racyclines in patients until
adults and create their own
they’re 12, 13, or 14. So
personality and life, and if
there’s rarely any problem
they’re plagued with a face
with kids and using these sort
full of acne, it really causes
of therapies.
them a lot of harm.
Q. How does the cost of
You’ll see patients when they
therapies influence the regiWith the new acne treatments now available — either standard therapy first come in with bad acne:
mens you prescribe?
using a topical retinoid and an antimicrobial, or systemic therapy for they’re not talking, they’re
Dr White: In a perfect world, fulminant disease — Dr White is confident that he can take a “face full not looking at you in the eye,
of acne” (left) and help the patient achieve a clear complexion (right).
they’re looking down at the
I would like to ignore costs
floor, they let Mom do most
in treating patients. I would
of the talking, etc. You get a sense that their self-esteem is low,
like to give them the absolute best therapy possible. Sometimes
they don’t feel good about themselves. And then, when you do
the cost is very important to the patient, especially if they’re
treat them effectively, and their face is clear, they come in,
paying for it, and so they want to know how much it’s going to
they’re smiling, they’re looking at you, they’re interacting much
cost; if it’s too expensive, they can’t afford it. But if a health
more. And that is one of the rewards that I have in treating acne.
plan is paying for the medication, then I think the doctor is
When the patients get better, you can just see, psychologically,
more free to give what’s absolutely best for the patient.
how much better they feel.
Now, having said that, I think that the good news is that many
Q. Do you ever have to recommend adjunctive psychologic
of the most effective therapies that I recommend are relatively
counseling?
inexpensive, compared with alternatives. For example, benzoyl
peroxide is very inexpensive, and yet it’s a great topical mediDr White: You know, I never have. The acne therapy that we
cation for acne. In the area of retinoids, Differin gel is also a
have available is so good — the topical retinoids, the Accutane
good drug for its cost. Avita is the least expensive. Tazarotene is
— we have such good therapy these days, that if a patient has a
more expensive and it’s also more irritating, so I don’t usually
PAGE 6 • ACNEBRIEFS
HOW WOULD YOU TREAT THIS PATIENT?
Case 1
Case 3
A 12-year-old girl presents with multiple comedones but no inflammatory lesions. Her mother is concerned that she will soon
have a full-fledged case of acne. The girl, however, thinks it’s
boring to “mess with her face” and doesn’t want to use medication that will make her skin look “funny.”
A 15-year-old boy presents with severe inflammatory acne with
multiple cysts, papules, pustules, and scarring on his face, neck,
and back. He has never tried any type of acne therapy before.
Adapalene gel is a great choice here. It’s good for comedones
and has a low level of irritation.
I would first start him on an oral tetracycline plus Differin gel or
another topical retinoid to decrease acne, but would simultaneously start the laboratory work necessary to decide whether
to put him on Accutane.
Case 2
Case 4
A 30-year-old African-American woman is experiencing her first
flare of acne since her teenage years. She has a small number
of comedones and pustules, mostly around her chin. She also
has some hyperpigmented areas from healed acne lesions. She
has noticed that her acne flares just before the onset of menstruation. She is not currently using oral contraceptives.
A 17-year-old girl with moderate acne has used many over-thecounter acne treatments with only limited success. She is wearing heavy makeup, including foundation. She is confused by the
condition of her skin, because she uses an astringent several
times a day to “help unclog my pores.”
Many options are available for this patient. I might combine
Differin gel or Avita cream with benzoyl peroxide or Benzamycin. Azelex might also be helpful here to decrease hyperpigmentation from healed lesions.
face full of acne, then it’s almost always because he or she is
not seeing a doctor. The old story is told about the psychologist
who is treating a patient who is standing out in the rain and the
psychologist is trying to help him to accept all the problems
associated with standing in the rain, and another psychologist
comes by and just says, “Come in out of the rain!” So, we could
try to treat all of these psychological issues, or we could just fix
the acne. And that’s really what I focus on.
Q. So you never use psychotropic drugs in your practice?
Major education is needed for this patient because she uses
excessive astringents and heavy makeup. She should switch to
a well-known brand of cosmetics that is noncomedogenic. I would
begin her on one of the newer, less irritating topical retinoids
plus a benzoyl peroxide–containing product.
what he’s willing to do. And if he’s willing to use only one
therapy, which is a retinoid or benzoyl peroxide, then that’s what
you do.
If you don’t find out that a patient has a summer job that requires
work outdoors, you might give doxycycline, which would have
too many side effects. Or, if you don’t find out that patients have
really sensitive skin, or they’re allergic to benzoyl peroxide, then
you may give benzoyl peroxide and have it not work.
It’s really important to try to find
out what patients have used, the
characteristics of their skin,
their activities, etc, so you can
tailor something that’s just right
for them.
Dr White: I never do. I tell the
Differin is so good that I can’t imagine
patients, and I can be very hontreating acne without it.
est about it, “If you’ll stick with
me, if you’ll do what I recommend, if you come to see me
every 4 to 6 weeks, we will fix your acne, one way or the other.”
Q. Will the newer retinoids continue to be a part of your
armamentarium?
Q. How important for effective therapy is the relationship of
trust that you establish with the patient?
Dr White: Differin is so good that I can’t imagine treating acne
without it. At the current time, I can’t imagine not having the
Dr White: The most important thing for effective therapy is
topical retinoids in my therapy.
that patients use what you give them. And this applies not just
for acne, but for any skin disease.
Q. Do you have any advice for new dermatologists who are just
starting to treat acne?
You have to have a certain bonding with patients so that they
know that you have personalized your therapy for them, that
Dr White: For the medical student, or the new dermatology
you know their concerns, and you address them appropriately.
resident, or the new dermatologist who has not really thought
If you don’t do that, then you get into a situation where the
much about acne therapy, I would say it’s different from other
patient ends up not using what you recommend. For example, if
therapies, in the sense that we try to treat two things. We try to
the patient is there only because Mom wants him to be there,
open the pore and kill the bacteria. So think about combination
and you don’t sense that and pick up on that, then he’s probably
therapy when you treat acne, and just get very comfortable with
not going to use what you recommend. In that situation, you
these topical retinoids and benzoyl peroxide, because they’ll be
have to talk to the patient, have Mom be quiet, and find out
very beneficial in your practice.
ACNEBRIEFS • PAGE 7
ACNE BRIEFS REVIEW:
COMBINATION THERAPY IS THE BEST APPROACH
Summarized here are the key points made by Gary M. White, MD,
in his discussion of why most patients with mild to moderate acne
will need more than one acne agent to clear their skin.
The “Two-Pillared Approach” to Acne Treatment
• The first pillar of conventional therapy is killing the bacterium Propionibacterium acnes with antimicrobials. Topical
antimicrobials include benzoyl peroxide, erythromycin, clindamycin, tetracycline (rarely used), sodium sulfacetamide,
and Benzamycin®. Effective oral antibiotics are tetracycline,
doxycycline, and minocycline.
• The second pillar is opening the follicles. Retinoids, such as
Differin® (adapalene) gel, are excellent for almost any patient. Other topical retinoids include Avita® (tretinoin) cream
for patients with sensitive skin, Retin-A Micro® (tretinoin),
and Tazorac® (tazarotene).
Combining Agents for Effective Therapy
• The average patient with acne should be given a topical
retinoid and a topical antimicrobial, such as Differin gel with
benzoyl peroxide.
• Patients with moderate inflammatory acne and nodules should
have an oral antibiotic added to the standard regimen of a
topical retinoid and a topical antimicrobial.
• Monotherapy is usually reserved for isotretinoin, but if a
patient has only comedones, a topical retinoid should be sufficient. If only inflammatory lesions are apparent, an antimicrobial alone might be effective.
Avoiding Resistance With Combination Therapy
• The resistance of the bacterium P acnes to various antibiotics continues to rise.
• Benzoyl peroxide kills P acnes without instigating resistance.
• Therapy with topical retinoids and benzoyl peroxide is not
subject to any P acnes resistance problems.
• Two oral antibiotics should not be used together except in
rare instances.
Improving Keratinization Defects
• Pores become clogged because of a thickening of the follicular lining as well as oil and debris from P acnes.
• Topical retinoids act through the retinoic acid receptors to
normalize the follicular lining.
• Keratolytics, such as salicylic acid, are not as effective at
unclogging pores as comedolytics, such as the topical
retinoids.
• Azelaic acid and the α-hydroxy acids are less comedolytic
than the topical retinoids, such as Differin.
• To minimize clogging, patients should avoid using heavy or
greasy moisturizers, sunscreens, and cosmetics. All skin products used should be from well-known manufacturers and be
labeled “noncomedogenic.”
PAGE 8 • ACNEBRIEFS
New, Less Irritating Retinoids
Have Revolutionized Acne Treatment
• All patients can use products such as Differin gel without
experiencing the irritation associated with Retin-A.
• Many patients already know about the new retinoids and are
eager to try them.
• Differin and other new-generation retinoids are just as effective as Retin-A, but are considerably better tolerated.
Prevention Is the Way to Clear Skin
• Patients must remain on “two-pillared” therapy to maintain
clear skin.
• They should be instructed not to “spot treat” inflammatory
lesions; topical retinoids and antimicrobials should be applied all over the face and other affected regions of their
body.
• Encourage patients to call if they have questions about their
therapy.
Successful Acne Therapy Improves Lives
• Teenagers often suffer low self-esteem when they have acne.
• Acne therapy is so effective that Dr White has never had to
recommend adjunctive psychological counseling or psychotropic drugs, unless depression that might be related to use
of isotretinoin develops. Clearing acne is usually sufficient.
Advice to the New Practitioner
• Open the pore and kill the bacteria with topical retinoids and
antimicrobials.
• Get comfortable with topical retinoids and benzoyl peroxide, because they’ll be very beneficial in your practice.
ACNEBRIEFS
™
116 WEST 32ND STREET
NEW YORK NY 10001
BULK RATE
US POSTAGE
PAID
STATEN ISLAND NY
PERMIT 391