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TUESDAY, Aug. 1, 2023 – Millions of people live with acne, and it can take a dramatic toll on their quality of life, but is any one treatment better than the rest?
Isotretinoin is a high-dose vitamin A that targets the main causes of acne by shrinking oil-producing sebaceous glands, killing bacteria that can cause breakouts, preventing clogged pores and cooling inflammation.
The study results are in line with what acne experts see every day in their practices.
“Isotretinoin is the most predictably effective drug we have for the treatment of acne,” said Birmingham, Ala.-based dermatologist Dr. Julie Harper. She is the founding director and past president of the American Acne and Rosacea Society.
“Not only does it clear acne, it also yields a long-lasting clearance in the majority of people who take it,” said Harper, who wasn't involved in the study.
Not everyone can or will take isotretinoin due to its potential side effects, she noted. While highly effective, isotretinoin does confer its fair share of side effects, namely a risk for severe birth defects and concern about liver problems and depression.
“When treating acne without isotretinoin, we have to rely on combinations of agents with different modes of action,” she said. “Combining antibiotics [oral or topical], retinoids, and benzoyl peroxide is probably the second-best option for most patients. “
For the study, researchers led by Dr. Chung-Yen Huang of the National Taiwan University Hospital in Taipei, Taiwan, reviewed 221 studies comprising around 65,600 people with acne (average age: 20). The researchers compared 37 acne treatments based on how well they reduced the percentage and number of inflammatory or noninflammatory pimples.
Oral isotretinoin was the most effective acne treatment, followed by triple therapy with topical antibiotics, benzoyl peroxide and retinoids, the study showed.
Retinoids unclog pores and reduce inflammation, while benzoyl peroxide can kill the bacteria that cause acne, and antibiotics reduce the redness, swelling and inflammation of acne.
For single therapies, antibiotics or topical retinoids showed similar effects for inflammatory lesions, while antibiotics have less effect on non-inflammatory lesions, the study showed.
The research was published in the July/August issue of the Annals of Family Medicine.
Certain effective acne treatments were not included in this new study. “Our female patients can benefit greatly from oral hormonal treatments, including spironolactone and combination oral contraceptives, but these are not acceptable for our male patients,” Harper said.
Spironolactone slows down the production of hormones that can lead to clogged pores and breakouts.
“We also now have a topical androgen receptor inhibitor that can be used in men or women, but it should be used in combination with other agents like topical retinoids and benzoyl peroxide,” Harper said. That drug is called Winlevi (clascoterone) cream 1%.
Energy-based devices are also showing some early promise in acne treatment, she said. “These devices don't replace our current treatments, but they do give patients and providers an alternative.”
Acne treatment is not one-size-fits-all, she said. “It is helpful to have a wide range of treatment alternatives for patients.”
Dr. Emmy Graber agreed. She is a dermatologist in Boston. “We know isotretinoin is the gold standard,” she said.
People who take part in research studies are more likely to comply with treatment regimens including triple therapy with topical antibiotics, benzoyl peroxide and retinoids. “In the real world, it's hard to get people to use several different topical treatments several times a day,” Graber said.
“You can get great results even with topical agents, but the key is compliance and using things in combination,” she said.
“Using an oral acne treatment as part of triple therapy is more effective than topical triple therapy,” she said.
The study does have its share of limitations, said Dr. Hilary Baldwin. She is the medical director of the Acne Treatment & Research Center in New York City, and a past president of the American Acne and Rosacea Society.
For starters, not all topical retinoids are created equally, but they were all grouped together in the new study. “It is impossible to evaluate the strength of topical retinoids as a whole,” she said.
In addition, the study did not tease out the doses of antibiotics, which is also an important factor to consider when treating acne.
There's also more to assessing acne than counting lesions, Baldwin said. “Acne severity is a composite of both lesion count and lesion size [redness], as 25 tiny red papules are not the same thing as 25 large red papules/nodules.”
The dermatologist's assessment also matters in addition to lesion counts, she said.
“Individual patient parameters … differ greatly and treatment outcomes are determined by many factors including adherence to medications, skin sensitivity, lifestyle features,” Baldwin explained.
SOURCES: Julie Harper, MD, dermatologist, Birmingham, Ala., and founding director, past president, American Acne and Rosacea Society; Emmy Graber, MD, dermatologist, Boston; Hilary Baldwin, MD, medical director, Acne Treatment & Research Center, New York City, and past president, American Acne and Rosacea Society; Annals of Family Medicine; July/August 2023
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