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Newer Agents in Treatment Algorithms


Discussion on treatment algorithms as well as the impact of sebum in acne patients.

Casey Butrus, PharmD: I know we’ve been talking a lot about these newer agents. Hilary, how have you adopted them into your clinical practice and how are they working into your treatment algorithms?

Hilary Baldwin, MD: When we talk about algorithms, we have 2 types. We have the printed ones, which we’ve already said are woefully behind the times. And then we have our mental algorithms, especially those of us who treat lots of acne patients. So the 3 new medications that we just mentioned have figured substantially into my algorithm. I mentioned before that I consider sebum production to be foundational for acne. We all do certainly. Again, no sebum, no acne. So people often ask me, what is the niche patient for clascoterone? And my answer back is, what isn’t the niche patient? Sebum drives acne, period. So I find it to be very useful as one of my foundational treatments. Additionally, of course, you can use it in men. And it has truncal data. We haven’t harped on that enough, I think. We always said that acne was acne. And if you have a drug that you saw was good on the face, of course, it was going to work on the trunk, but the trunk is very different. Sebaceous glands are smaller. They’re more spread out. There’s some evidence that we need to leave the medications in place for a much longer period of time than we actually do. And we have very little in the way of truncal data. So clascoterone is one of the drugs during the long-term safety trial. They started putting it on the trunk as well and they saw excellent efficacy there. It’s very tolerable, doesn’t stain and doesn’t bleach—all those sorts of nice things that we would like from a truncal medication. For minocycline, as was mentioned, it took 50 years to figure out how to make this persnickety molecule something that could be used topically. And it turned out that the secret sauce was mineral oil. As a result, it’s got virtually no cutaneous adverse effects. And it is kind of greasy to touch, but it sure as heck doesn’t cause any irritation. And I like to use it under topical retinoids sometimes to help with tolerability, for example. Also, I’m less concerned about antibiotic resistance, as you mentioned. [There is] virtually no systemic absorption and a ton of drug in the skin. So it’s really not just tickling the bacteria; it’s clobbering them, and I feel much safer about it. Additionally, minocycline has been around for 50 years, and we see very little in the way of resistance to that particular tetracycline.…It has completely replaced erythromycin….It’s actually one of my managed care pet peeves when you require me to use erythromycin. It doesn’t work anymore in the United States to kill acne and we should be taking it off of the plate. Also replacing, to a large extent, clindamycin use as a stand-alone drug because of antibiotic resistance concerns. And then there’s trifarotene, able to be compounded at 0.005%, which decreases absorption. I’m not as worried about using it on the face and chest and back and arms. It’s the only retinoid that actually has phase 3 truncal data as part of the study. And then the last 2 things just came out…2 new studies that show that trifarotene can reduce the development of acne scars as well as help eradicate some existing scars and also reduce postinflammatory hyperpigmentation much more rapidly than waiting for it to happen naturally. So they play a very important role in my acne algorithm and they’re right up at the top.

Casey Butrus, PharmD: As you mentioned with erythromycin and having that in- step therapy, I think from the health plan perspective it’s always important to listen to provider opinion and expert opinion in this space as treatments are constantly changing and newer therapies are evolving. Maybe the more outdated options aren’t the best options for patients to step through as well. Steve, what are your thoughts on these newer therapies and how do you view them?

Steven Feldman, MD, PhD: I think they’re useful to a degree. I think the big problem with the older therapies is that patients aren’t using them very well so a lot of my focus is on getting people to use their medicines better if they’re not getting well. I’ve read philosophies from older dermatologists that oh, you’ve got to always have 1 more. I think Dr Shelly said, ‘You always have to have 1 more treatment that you could use.’ I think we often just need 1 more, better way to get people to use their medicines than necessarily having a newer drug to use.

Casey Butrus, PharmD: And with potentially fewer adverse effects or simplified dosage forms that allow for better tolerability, maybe that’s a way for the innovation to allow for better adherence if patients are having as many adverse effects or even like you mentioned before with combination products. I agree that innovation is definitely important for making sure people take their meds as well.

Steven Feldman, MD, PhD: Adverse effects are such an interesting issue. In trials, I guess they probably do very careful assessments of whether adverse effects are occurring. In my real-life practice, I’m just asking patients if they’re happy. I’m not using formal assessments of efficacy or adverse effects. But I think there’s a belief that irritation will stop people from using their medicines. And that may be true for some people. But if you tell patients you may experience some dryness and irritation—in my experience, that’s a sign the medicine is working—then it turns things around. It takes a potential hurdle and it turns it into an advantage. Patients may actually be more willing to use medicine when they’re getting some irritation. The best adherence I ever found to any topical in any of our studies was adherence to topical fluorouracil, which was far and away probably the most irritating thing we’re regularly prescribing. And the best example of this, take the hurdle and turn it into an opportunity. As a dermatologist in Texas once told me, when she prescribed spironolactone for acne, she tells people, ‘Now, unfortunately, this drug is also a diuretic and you may notice some weight loss while you’re on it.’

Transcript edited for clarity.

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