Advancing Acne Care: Pathophysiology-Based Treatments and Emerging Therapies

Sarah B.W. Patton, PA-C, MSHS
she/her/hers
MaineHealth Dermatology, Portland
Acne Insights with Hilary Baldwin, MD & Shanna Miranti, MPAS, PA-C

Founding member and past president of the American Acne and Rosacea society and this year’s CME conference medical director Hilary Baldwin, MD, joined PA Shanna Miranti for a collaborative lecture reviewing acne. Dr. Baldwin reviewed the pathogenesis of acne with the increase of androgen production at puberty increasing sebum production, follicular hyperkeratosis, increased C.acnes and inflammation.  She reports “no sebum, no acne, therefore all treatments should address sebum production”. Dr. Baldwin communicated that treatment of acne should be based on the pathophysiology of the acne with combination therapy as “the name of the game”. Studies reveal that patients need an average of 2.53 products for treatment success.  

Topical retinoids are the mainstay for all patients due to it targeting all four targets of the pathophysiology of acne.  The side effects of topical tretinoin are concentration and vehicle dependent with maximum irritation at 1-2 weeks, therefore educating the patient regarding expectations is important to help patients comply with use of tretinoin.   PA Miranti noted topical tretinoin is not FDA approved for patients under 12 years of age. Next, oral antibiotics were discussed including the newest tetracycline, Sarecycline, for which prescribing is weight based. One of the benefits of Sarecycline is that it’s absorption is not impacted with food, it has low photosensitivity and spares the microbiome. Further, Shanna Miranti conveyed the only topical treatment which targets sebum production is topical clascoterone. Clascoterone is superior when used twice daily, with maximum efficacy later in treatment with success achieved between 8- 12 weeks.

Additional treatment options discussed included the three FDA approved oral contraceptives for acne treatment in women, oral isotretinoin and spironolactone. Spironolactone is an excellent choice for women with acne at a dose of 50-100 twice daily. It is important to note that it is not FDA approved for the treatment of acne and it should not be used in men. There is a black box warning for spironolactone due to benign liver tumors in male rats.  Lastly, a new medication which targets three of the pathophysiology targets of acne was highlighted by PA Miranti. This combination medication contains clindamycin, adapalene, and benzoyl peroxide (BPO). It is FDA approved for patients 12 years and older and in trials, this combination outperformed all other dyad products (e.g  clindamycin  bpo combo products). Additionally, this is a once a day dosing product which makes this an ideal product for teenagers. The main side effect of this product is that it is drying.