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Acne 101: Educate Patients Before Topical Therapy


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LAS VEGAS – Acne patients need to know it’s a bad idea to spot-treat comedones with topical retinoids, according to Dr. Linda F. Stein Gold.

"We have to educate our patients that if they spot treat, they’re going to have acne indefinitely until their body decides it’s done having acne," she said. "You have to educate them that they have to treat the entire acne-prone area and [keep treating it] to maintain remission. Their skin may look clear, but they are not cured."

Dr. Linda F. Stein Gold

Topical retinoids remain the gold standard for acne treatment. They clear and prevent comedones, help clindamycin and other antibiotics penetrate the skin, and calm inflammation, which is probably the initial step in acne’s development, noted Dr. Stein Gold, director of dermatology research at Henry Ford Hospital, Detroit.


Microsphere and micronized tretinoin gel formulations are less irritating than generic topical tretinoin, and they’re less apt to be deactivated by benzoyl peroxide and ultraviolet light, she said at SDEF Las Vegas Dermatology Seminar.

One of the newer topicals combines benzoyl peroxide and a retinoid stable in its presence, adapalene. One study found about a 70% reduction in lesions after 4 months of use (J. Drugs Dermatol. 2007;6:899-905). With that topical combination and other acne treatments, patients should be told that it may take a while to see maximal improvements, she said.

With any retinoid treatment, patients should also expect flare-ups of redness, irritation, and dryness in the first 2 weeks. "If I’m concerned about irritation, I’ll ask them to go every other night for the first 2 weeks until they adjust to the medication, and then titrate up to every night," Dr. Stein Gold noted. "I also have them use a moisturizer and general cleanser." But she tells them not to use facial scrubs, because scrubbing does "more harm than good."

Benzoil peroxide also remains important, either alone or in combination, because Propionibacterium acnes bacteria do not develop resistance to it, and it helps prevent resistance when used with antibiotics.

"You get a nice reduction both in inflammatory and noninflammatory lesions with benzoil peroxide," she said, but patients should be warned about possible skin bleaching.

The concentration of benzoyl peroxide isn’t that important, Dr. Stein Gold explained. "We know that 2.5% and 10% gels have fairly similar efficacy," she added (Int. J. Dermatol. 1986;25:664-7).

Benzoil peroxide gels are known to work well, although foams and cleansers are available for patients who find them too irritating. Cleansers appear most effective at reducing P. acnes on the face, as long as patients wait 20 seconds before rinsing. One study found foams effective on the back when massaged into dry skin for 20 seconds and patients waited 2 minutes before showering (J. Drugs Dermatol. 2012;11:830-3).

Whatever the treatment, Dr. Stein Gold noted, "stress compliance. My first question is, ‘Did you get a chance to fill your medicine?’ and then, ‘How many times do you think you got a chance to use it?’ "

She cautioned physicians to "have no expectations" – that way, patients won’t be afraid to admit that they only used it once or twice. Whatever their usage, "you say, ‘Great. Good for you. Keep on going.’ "

In addition, "the simpler you make the regimen, the more likely it is your patients are going to" stick with it, Dr. Stein Gold explained.

Dr. Stein Gold is a consultant or researcher for Galderma, Leo, Medicis, Novartis, and Stiefel. SDEF and this news organization are owned by Frontline Medical Communications.

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