the cosmetic treatment of acne · • the mean number of scars decreased over time witha/bpo...
TRANSCRIPT
The Cosmetic Treatment of Acne
HILARY E. BALDWIN, M.D.-MEDICAL DIRECTOR
ACNE TREATMENT AND RESEARCH CENTER
MORRISTOWN N.J.
-CLINICAL ASSOCIATE PROFESSOR OF DERMATOLOGY
RUTGERS ROBERT WOOD JOHNSON MEDICAL SCHOOL
Disclosures
Almirall (S)
BioPharmX (I)
Botanix (I)
Dermira (I,A)
Encore (A)
EPIHealth (A)
Foamix (A)
Galderma (A,I,S)
J&J (A)
LaRoche-Posay (A, S)
Novan (I)
Ortho Dermatologics (A,I,S)
Pfizer (S)
Promius (A)
Sol-Gel (A)
Sun (A,S)
S=Speaker’s BureauA=Advisory BoardI=Investigator
The Cosmetic Treatment of Acne
Make the patient better Keep the patient better Get rid of the sequelae Improve the appearance of their skin
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Acne is our bread and butter
IT’S NOT ROCKET SCIENCEDoing it well means: *Taking your time
*Educating your patients*Knowledge of what to
use when in whom
Deciding what to use when andin whom
Type of lesions Inflammatory
Non-inflammatory
Number of lesions Size of lesions Distribution
Acne treatment based on pathogenesis
Increased sebum production
Increased P. acnes
Follicular hyperkeratosis
Inflammation
Hormonal TherapyIsotretinoin
AntibioticsIsotretinoin
AntibioticsRetinoids
Clindamycin?
Topical retinoidsBenzoyl peroxide
Isotretinoin
Topical retinoidsBenzoyl peroxide
Isotretinoin
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Mild inflammatory acne treatment optionsTopical retinoids aloneBenzoyl peroxide alone
Topical dapsoneCombination product
Oral antibiotic
Topical retinoids alone
BaselineWeek 12
Tazarotene 0.1% Cream
Tazarotene .1% Cream Monotherapy
Baseline Week 12
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Tazarotene 1% Cream Monotherapy
Baseline Week 12
Benzoyl Peroxide is the most effective antimicrobial
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0.5
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1.5
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2.5
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3.5
Clin-BP Ery-Bp Benzoylperoxide
Clindamycin Erythromycin Azelaic acid
Harkaway KA, et al. Brit J Derm. 1992;126:586-590.
Lo
g c
m2
Ability to kill P. acnes
Benzoyl peroxide
BP kills faster and more effectively than topical antibiotics
BP alone significantly reduces both inflammatory and non-inflammatory acne
BP is not associated with antimicrobial resistance
BP can prevent the development of resistance to topical and oral antibiotics
BP can reverse resistance that has already occurred
Gloor M, et al. Z. Hautkr. 1982;57:867-878, Gollnick H, et al. J Am Acad Dermatol. 2003;49;S1-38, Gollnick H, Schramm M. Dermatol. 1998;196:119-125
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BPO/Clindamycin vs. Clindamycin Monotherapy
Cunliffe WJ, Holland KT, Bojar R, Levy SF. Clin Ther. 2002;24:1117-1133.
Compliance With Topical Benzoyl Peroxide
Yentzer BA et al. J Am Acad Dermatol. 2009;60(5):879-880.
Individual subjects’ adherence to topical benzoyl peroxide ranged from 14% to 79% for the 6 weeks. No subject was considered “adherent to
treatment” as defined by a mean adherence of ≥80%.
N=11
Baseline: Severe (IGA=4)
Week 12: Mild (IGA=2)
IL: 12 | NIL: 17Subject 8423-007
IL: 80 | NIL: 112Subject 8423-
007
Treatment failure!
BP 2.5%/Adapalene .3% Gel
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Dapsone 7.5% Phase III results
Baseline Week 12
Moderate-severe inflammatory acne
Topical therapy alone unlikely to work well enough or fast enough
Oral antibiotics with topicalsHormonal therapy with topicals
Isotretinoin
Acne is a chronic disease
Chronic, relapsing course over many years Severe psychosocial overlay Acute and maintenance therapy necessary Need for maintenance leads to frustration
Delicate balance of: Efficacy Tolerability Acceptability
Need for maintenance adds urgency to bacterial resistance problem
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40 mg modified-release doxycycline for acne
662 patients with mod-severe acne Randomized in 1:1:1 ratio to receive QD X 16
weeks: 100 mg doxycyline 40 mg modified-release doxycycline Placebo
At all time points comparable speed of improvement, efficacy and superior safety
Moore et al. JDD 2015;14(6):581-6
Sarecycline (Seysara®)
Sarecycline – a new tetracycline-class antibiotic
Once a day, weight-based dosing
9 and above
Narrow spectrum antibiotic Less effect on GI organisms than mino/doxy
IL reduction of 35%
Well tolerated with low GI complaints
Adult female acne – different?
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Spironolactone
• Anti-androgen, androgen-blocker• Reduces masculine characteristics
• Excess hair, hair loss, acne• Not FDA approved for skin issues (hypertension)• Launched in 1950, having a renaissance • Few side effects
Breast tenderness, menstrual irregularities Contraindicated in pregnancy – use in
combination with birth control pills
Severe inflammatory acne
Therapeutic optionsIsotretinoinIsotretinoinIsotretinoin
Baseline 5 MONTHS
Isotretinoin
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Unnecessary consequence
Hyperpigmentation
Stop picking!Topical retinoidsHydroquinone
Chemical peelsLasers
Azelaic acid?
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Patients like to glow, not shine
Oil control
Sebum: triglycerides, phospholipids, esterified cholesterol
Normal amounts: lubrication for hair and skin In some, excessive
solo or in combination with AV
Commonly used products not intended for oil control Topical retinoids, salicylic and glycolic acid, alcohol-
based washes and foundations to conceal
Thiboutot Cosmetic Dermatology 2001:45-51
Topical sebum inhibitor (Drm01)Olumacostat glasaretil
Inhibits acetyl coenzyme A carboxylase
Reduces saturated and monounsaturated fatty acyl chains in sebaceous lipids
Dose-dependent reduction in sebaceous gland size in animal model
Melnik B. J Invest Dermatol 2017;137(7):1405-1408
Phase IIIFailed both co-primary endpoints:
IGA 2 grade and C/NCPercent reduction of IL/NIL
Did not surpass vehicle
Company has announced intention to discontinue pursuit
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Steroidal anti-androgen
Strong topical anti-androgenic activity
Mild anti-inflammatory properties
Easily penetrates human skin
Metabolized in skin into cortexolone (no androgenic effect)
Pilot study vs. placebo and tretinoin microsphere 0.05% (active control)
Cortexolone 17𝛼-propionate 1% cream
Cortexolone 17𝛼-propionate 1% cream Phase IIb study in 363 patients
www.cassiopea.com
Cortexolone 17𝛼-propionate 1% cream Phase IIb study in 363 patients
www.cassiopea.com
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Methacrylate copolymer
Microparticles of methacrylate copolymer that imbibes and holds sebum within the molecules
Incorporates into the molecule, swells to many times original size
Once imbibed, cannot leak out
Controls oil/shine for up to 8 hours
Invisible on the skin
Thiboutot Cosmetic Dermatology 2001:45-51
Methacrylate copolymer
Thiboutot Cosmetic Dermatology 2001:45-51
SCARS
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Natural History of Atrophic Acne Scar Development: Duration
Scars form continuously
36% of scars are transient (arose and resolved within the 6-month study)
Transient scars had a mean duration of 41 ± 38.4 days
The remaining 64% of scars did not resolve by study end
Scars
Closed Comedones: 1%
Pustules: 1%
Post-inflammatory Lesions: 82%
Papules: 16%
Papule
70%
OSCAR Study
A/BPO 0.3%/2.5% vs VehicleScar Formation Risk
Split-face, Investigator-blinded, Vehicle Controlled Whole Face, Open-label
Part I - 24 weeks; 8 visits Part II - 24 weeks, 2 visits
A/BPO 0.3%/2.5%
Vehicle
Split Face
Week 1, 4, 8, 12, 16, 20, 24 Week 36, 48
OSCAR Study
A/BPO 0.3%/2.5%67 patients 16-34IGA 3 or 4
Symmetrical distribution of:
≥25 inflammatory lesions≥10 atrophic scars
A/BPO 0.3%/2.5% vs Vehicle Percent Change From Baseline - Total Atrophic Scar Count
-2.5 -1.0 -4.5-7.3 -7.0 -8.7
-15.5
5.89.8 12.3
16.2 17.1 15.2 14.4
-30
-20
-10
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0 4 8 12 16 20 24
Perc
ent C
hang
e (M
ean)
Week
* * ** * *
*
* P-value < .001
• A/BPO 0.3%/2.5% was significantly superior to vehicle at all study visits and as early as week 1
• The mean number of scars decreased over time with A/BPO 0.3%/2.5%
• The mean number of scars increased over time with the vehicle
• The difference in the mean percent change in scars (A/BPO 0.3%/2.5% vs vehicle) after 24 weeks was 29.9%
Dreno et al. Poster, Winter Clinical, Maui HI, 2018
VehicleA/BPO 0.3/2.5%
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Beneficial Effects of Cosmetics
Used to fard1
Camouflage, contour and conceal Response to acne therapy too slow for most Chronic relapsing condition
Enhance oil control Adorn
Improve quality of life Create a sense of well-being
1) OED – to paint the face with cosmetics so as to hide blemishes
Decorative cosmetics improve QOL
23 patients with disfiguring facial conditions including acne (8) and rosacea (9)1
Taught to use cosmetics by professionals
DLQI baseline and 2 weeks
Improvement in all, acne p=0.0078
18 patients with acne treated and taught to use cosmetics2
Improvement of acne and improved QOL at 2/4 weeks
1) Boehncke et al. Eur J Dermatol 2002;12:577-80, 2) Hayashi et al. Eur J Dermatol 15;15:284-7
Cosmetic procedures in acne patients
Laser, peels, MDA, Microneedling
Improved QOL
Chilicka et al. Patient Preference and adherence. 2017, Aug 4
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Moisturizers in acne
200 subjects enrolled in Internet-based survey study
15-40 yo - used clindamycin-BP (5%) in past 6 months
Side effects caused sub-optimal use: Spot application
Use only when flaring
Infrequent use
Discontinuation
Feldman and Chen. JDD 2011;10:605-608
Moisturizers in acne
31% Called doctors office to complain
23% physician didn’t understand SE potential
21% loss of confidence in doctor
11% less likely to see doctor again
41% used moisturizer to combat dryness/redness – perhaps the wrong one?
Feldman and Chen. JDD 2011;10:605-608
No acne visit is complete
without discussion of skin
care
Thank You!
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