Download Managing Two Challenging Presentations of Acne

Clinical Focus: Acne
Managing Two Challenging
Presentations of Acne
Acne can be particularly challenging when it presents on the trunk or develops during pregnancy,
but effective therapeutic approaches exist.
By Joseph Bikowski, MD
T
here is no question that acne can have a strong
psychosocial impact on affected patients1 and that
effective treatment of acne is associated with
improvement in self-esteem, body image, and
self-confidence and reduction in shame, embarrassment, and other psychosocial measures.1 For these reasons, dermatologists recognize the importance of early
initiation of effective therapy for patients with acne.
Yet, despite a wide range of treatment options available, there are some common instances in which management of acne remains challenging, and, despite the
clinician’s desire to implement an effective therapy,
efficient treatment is difficult. Two cases in particular
come to mind: the treatment of truncal acne and the
treatment of acne in pregnancy.
Back Acne
Back and chest acne are estimated to occur in 61 percent and 45 percent of acne patients, respectively.2,3 In
one study, half of patients with facial acne also had
truncal involvement, while three percent of patients
had only truncal involvement. There is, surprisingly,
some evidence that patients with truncal acne may not
recognize that they have truncal involvement,4 suggesting that clinicians should be more attentive to truncal
acne and specifically question patients about any evidence of acne on the chest, shoulders, or back.
Pathophysiologically, truncal acne is no different
from acne on the face, although the chest, back, and
shoulders may be more prone to “acne mechanica.”4
The effects of pressure, occlusion, friction, and heat
produced by shoulder pads and other sports equipment may contribute to exacerbation of acne. In addition to targeted anti-acne therapies, strategies to mini-
mize the mechanical forces of equipment should be
instituted.
Acne on the back and chest is expected to respond
to therapy just as acne on the face would. Yet, evidence suggests that dermatologists tend to emphasize
oral therapies over topical interventions for truncal
acne.5 Likely this reality is a reflection of the common
assumption that it is more convenient to take an oral
medication than to apply topical mediations to large
and potentially hard-to-reach body areas. The challenges of topical application of medication to the
trunk, particularly the back, are obvious. Nonetheless,
several topical therapies may be appropriate for application to the trunk.
Topical clindamycin has been a mainstay of acne
therapy. One attempt to ease application to the back
and improve compliance with topical antibiotic therapy is the ClindaReach (DUSA Pharmaceuticals) system, designed to aid application of clindamycin solution 1% via pledgets. Acne patients may purchase
other implements from home-health catalogs that are
intended to facilitate application of topical agents to
hard-to-reach body sites (usually they are marketed to
older patient for bathing or application of lotions).
Clindamycin phosphate foam 1% (Evoclin, Stiefel)
is suitable for use on the trunk and hair-bearing skin.
In clinical studies, clindamycin foam was superior to
clindamycin gel or foam vehicle in reduction of total,
inflammatory, and non-inflammatory acne lesion
counts.6
Antimicrobial washes, specifically those containing
benzoyl peroxide, have been a convenient option to
treat truncal acne for some time. They can be used
alone or in combination with topical clindamycin or
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Practical Dermatology | 63
Clinical Focus: Acne
oral antibiotics. Two benzoyl peroxide emollient foam
formulations now available (5.3%, BenzeFoam and
9.8%, BenzeFoam Ultra; Onset Dermatologics) are
suited to use on the trunk, especially hair-bearing
areas.
In previous studies, benzoyl peroxide 5.3% emollient foam was shown to produce a 100-fold reduction
in P. acnes colonization after two weeks of use.7 The
newer 9.8% foam formulation also significantly
reduced P. acnes counts, even when used as a shortcontact therapy. A two-week open-label, single center
study of short contact therapy involved 20 healthy
subjects (>18 years old) all confirmed to be colonized
with P. acnes on their backs (>10,000 colonies per
cm2).8 For two weeks, each subject applied BPO 9.8%
foam to the dry back once daily and left it in place for
two minutes before rinsing if off with water and wiping the area with a cloth. This protocol was performed
under supervision at the study center during the week
and unsupervised at home on the weekends.
Mean reduction of P. acnes counts on the back was
0.91 log per cm2 after one week of treatment, and 1.66
log per cm2 after two weeks of treatment with BPO
9.8% foam (p<0.0001)—equivalent to a 98.3 percent
reduction in P. acnes counts. The two-minute contact
time is longer than with a BPO wash applied to the
back and rinsed off immediately, as is done conventionally. Emollient characteristics of the foam coupled
with short duration of contact are expected to minimize BPO irritation while providing adequate antimicrobial effect.
Acne in Pregnancy
Many women develop acne during pregnancy,
although prevalence data are lacking. For some, acne
is mild and a temporary nuisance. Others develop conspicuous lesions that diminish self-confidence, and in
some cases painful nodules occur. Given the need to
ensure the safety of the developing fetus, treatment
must proceed cautiously.
All oral contraceptive pills (OCPs), including lowestrogen formulations, are classified as pregnancy category X by the FDA and are contraindicated for use by
pregnant women. Isotretinoin is also category X, and
obviously, is also strictly contraindicated in pregnancy.
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| May 2011
Among oral antibiotics, tetracyline is a category D
drug and should not be taken by women after the sixteenth week of gestation or during lactation because of
its potential for suppressing fetal and neonatal calcification and bone growth. Oral clindamycin and erythromycin are considered relatively safe during pregnancy (category B). However, they typically are used for
moderate to severe inflammatory acne, which may not
account for a majority of pregnant patients with acne.
Because of the anticipated low rate of systemic
absorption and associated reduction of risks, topical
agents would seem to be preferred for treatment of
acne in pregnant women. However, it is essential to
recognize that topical agents are not all appropriate for
use by pregnant women. Tazarotene is rated category
X and should never be used in this population.
Similarly, tretinoin and adapalane are rated category C
and should not be prescribed to pregnant women.
Of note, if a pregnant woman is inadvertently
exposed to tretinoin—that is, if she uses tretinoin without realizing she is pregnant—dermatologists can
assure the patient that there appears to be minimal, if
any, risk. Even when alltrans-retinoic acid is applied
daily, the absorbed dose is below 0.015mg/kg—more
than 30-fold lower than the lowest teratogenic dose of
isotretinoin in the human. Furthermore, topical alltrans-retinoic acid does not appreciably alter endogenous plasma retinoid levels.9
Two publications in the Lancet actually showed a
lower rate of fetal abnormalities among women
exposed to tretinoin during the first trimester of pregnancy compared to non-exposed women.10.11 In one of
these publications, a prospective study, the relative
risk estimate for having a baby with a major congenital anomaly for exposed versus nonexposed women
was 0.7 (95% CI 0.2-2.3).10
High doses of oral salicylic acid have been associated with birth defects,12 but topical salicylic acid is generally considered safe for acne treatment in pregnant
women. Benzoyl peroxide is rated Category C but is
nonetheless prescribed by some dermatologists for
pregnant women. Other women may obtain the agent
over-the-counter without seeking physician guidance.
The apparent safety of topical erythromycin and
clindamycin, both rated category B, make them attrac-
Clinical Focus: Acne
tive options for pregnant women, but they are not
optimal treatments. Their benefit is limited by the fact
that current guidelines suggest that, in order to reduce
the risk of bacterial resistance, these agents should be
used only in conjunction with topical benzoyl
peroxide13—which, as noted above, is questionable for
use by pregnant women.
Azelaic acid (AzA) has emerged as a worthwhile
treatment option for pregnant women. A saturated
dicarboxylic acid found naturally in wheat, rye, and
barley, azaleic acid is present in foods and has no
known fetal effects. It is rated Category B. It has
antimicrobial, anti-inflammatory, and antikeratinizing
properties. A 20% cream formulation (Azelex,
Allergan) is indicated in the US for the treatment of
acne; the 15% gel formulation (Finacea, Intendis) is
indicated in the US for treatment of rosacea but is
approved in many European countries to treat acne.
One benefit of the gel formulation over the cream
appears to be enhanced absorption into the skin. In in
vitro studies, 25.3 percent of azelaic acid in the gel
vehicle penetrated into viable skin as compared with
only 3.4 percent in the cream vehicle.14 Controlled
clinical trials in Europe have found AzA 15% gel to be
as effective as benzoyl peroxide and topical clindamycin in reducing facial papules and pustules and
significantly more effective than clindamycin in reducing closed and open comedones (P=0.031).15 It appears
to reduce comedonal and papulopustular lesions of
acne with similar efficacy to oral tetracycline.15
AzA is bacteriostatic against S. epidermidis and P.
acnes, and does not appear to promote bacterial resistance.15 It appears to have antioxidant and anti-inflamatory effects, as it decreases the generation of reactive
oxygen species by neutrophils.
Twice-daily application of topical azelaic acid,
though off-label, is a safe and effective treatment for
acne vulgaris in pregnant women.
Know the Options
Data continue to confirm the detrimental impact of
acne on patients’ quality of life. Recent evidence suggests that the impact increases as the patient ages.
Regardless of site of involvement, acne has been
shown to have a more significant impact on the self-
consciousness of individuals age 20 or older compared
to those age 16 to 19.16 Given that most cases of acne
in pregnancy involve women in their 20s and 30s, this
may influence the presentation’s significant impact.
Managing acne of the trunk or acne in pregnancy is
challenging. However, effective treatment options
exist. Foam-based benzoyl-peroxide with or without
clindamycin represents a patient friendly-treatment
option. Foam vehicles are associated with improved
usability, better adherence and, consequently,
improved therapeutic results.17 For the pregnant
woman with acne, topical azelaic acid offers good efficacy and safety. ■
Joseph Bikowski, MD, FAAD is Clinical
Assistant Professor of Dermatology,
Ohio State University, Columbus, OH and
Director, Bikowski Skin Care Center in Sewickley,
PA.
Dr. Bikowski has served on the advisory board, served as a consultant, received honoraria, and/or served on the speaker’s
bureau for Allergan, Barrier, CollaGenex, Coria, Galderma,
Intendis, Medicis, Onset Dermatologics, OrthoNeutrogena,
PharmaDerm, Quinnova, Ranbaxy, Sanofi-Aventis, SkinMedica,
Stiefel, UCB, and Warner Chilcott.
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Drugs Dermatol. 2008 Jun;7(6):551-6.
3. Del Rosso JQ, Bikowski JB, Baum E, et al. A closer look at truncal acne vulgaris: prevalence, severity,
and clinical significance. J Drugs Dermatol. 2007 Jun;6(6):597-600.
4. Basler RS. Acne mechanica in athletes. Cutis. 1992 Aug;50(2):125-8.
5. Del Rosso JQ.Truncal acne vulgaris: the relative roles of topical and systemic antibiotic therapy. J
Drugs Dermatol. 2007 Feb;6(2):148-51.
6. Shalita AR, Myers JA, Krochmal L, et al. The safety and efficacy of clindamycin phosphate foam 1%
versus clindamycin phosphate topical gel 1% for the treatment of acne vulgaris. J Drugs Dermatol.
2005 Jan-Feb;4(1):48-56.
7. Data on file, Onset Therapeutics.
8. Leyden, J. Fall Clinical Dermatology Conference, November 2010.
9. McAdams M, Staffa JA, Dal Pan GJ. The concomitant prescribing of ethinyl estradiol/drospirenone
and potentially interacting drugs. Contraception. Oct;76(4):278-81.
10. Shapiro L, Pastuszak A, Curto G, Koren G. Safety of first-trimester exposure to topical tretinoin:
prospective cohort study. Lancet. 1997 Oct 18;350(9085):1143-4.
11. Jick SS, Terris BZ, Jick H. First trimester topical tretinoin and congenital disorders. Lancet. 1993
May 8;341(8854):1181-2.
12. Joschko MA, Dreosti IE, Tulsi RS. The teratogenic effects of salicylic acid on the developing nervous
system in rats in vitro. Teratology. 1993 Aug;48(2):105-14.
13. Thiboutot D, Gollnick H, Bettoli V, et al. New insights into the management of acne: an update
from the Global Alliance to Improve Outcomes in Acne group. J Am Acad Dermatol. 2009 May;60(5
Suppl):S1-50.
14. Data on file, Intendis
15. Thiboutot D. Versatility of azelaic acid 15% gel in treatment of inflammatory acne vulgaris. J Drugs
Dermatol. 2008 Jan;7(1):13-6.15.
16. Hassan J, Grogan S, Clark-Carter D, et al.The individual health burden of acne: appearance-related
distress in male and female adolescents and adults with back, chest and facial acne. J Health
Psychol;14(8):1105-18.
17. Tamarkin D, Friedman D, Shemer A. Emollient foam in topical drug delivery. Expert Opin Drug Deliv.
2006 Nov;3(6):799-807.
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