Proceedings of the Fifth SKIN SPECTRUM SUMMIT

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to] 34.4 per cent of men.” Dr.
Ahluwalia also stated that this product
works on both inflammatory and noninflammatory
lesions and patients are
sustaining treatment results for over a
year.
A Canadian study on topical
dapsone 5% treatment in 101 female
patients showed very effective
results. Using the global acne grading
score as a measuring tool, 69%
of patients achieved success.
After three months of the topical
combination regimen, Dr.
Ahluwalia's patient had noticeably
improved skin but was not completely
clear of acne. It was to further
target the hormonal
component of her patient’s acne
that Dr. Ahluwalia prescribed 100
mg daily of spironolactone.
“When there is a hormonal component,
we have to address that.”
Dr. Ahluwalia’s presentation was
supported through an unrestricted
educational grant from Bausch
Health.
Dr. Renita Ahluwalia
Conveying the rationale of acne Tx to patients
Dr. Andrew F. Alexis
Explaining the rationale behind
choices in a therapeutic
regimen for acne can help
patients be more confident in a
doctor’s recommendations and
encourage better adherence to
treatment, said Dr. Andrew F.
Alexis in a presentation at Skin
Spectrum Summit in Montreal.
“It helps to very briefly tell the
patient that acne is caused by four
key factors, including overproduction
of sebum — oil, in layman’s
terms for the patient; follicular hyperkeratinization,
which to the patient
you can describe as blocked
follicles; overgrowth of bacteria —
P. acnes or the new name, C.
acnes; and inflammation,” said Dr.
Alexis.
That then allows a practitioner
to explain to patients how their particular
presentation of acne is being
driven by those factors and how the
combination of recommended treatments
works to correct the situation.
He noted that benzoyl peroxide
(BPO) is frequently used in acne
treatments because not only is it antimicrobial
— without encouraging
antimicrobial resistance — it also
has some comedolytic effects. BPO
also works well in conjunction with
other agents, allowing for fixed-dose
combination products that simplify
administration while addressing multiple
pathogenic factors of acne at
the same time.
“Topical dapsone, one of the recent
additions to our topical acne armamentarium,
has a range of
anti-inflammatory effects and is
available as an aqueous gel. It tends
to be very well tolerated,” Dr. Alexis
said. He noted that studies have
looked at the efficacy of combining
topical dapsone with BPO or with a
fixed-dose combination of BPO and
the retinoid adapalene.
“When we do it like this, we use
[topical dapsone] once a day — offlabel
instead of … twice a day — and
use the retinoid formulation in the
evening, typically,” he said.
“One word of caution is when
you combine topical dapsone directly
with a benzoyl peroxide,” Dr.
Alexis said. “You want to do that at
separate times, not in the same
place and time. Otherwise, you can
get a tan-brown discolouration.”
Topical retinoids are one of the
most important classes of medication
in managing acne, said Dr.
Alexis. “They help to normalize follicular
desquamation but also have the
added benefit of reducing hyperpigmentation,
which, of course, is very
relevant to patients with skin of
colour.”
This class of medications is also
valuable as a maintenance therapy,
used in conjunction with another
therapy, such as an oral antibiotic, to
bring acne under control and then
used alone after the antibiotic is
stopped to prevent acne flares, he
said.
Antibiotics, although they are
effective at reducing microbial
overgrowth and have anti-inflammatory
properties, should not be
used as monotherapy due to the
risk of encouraging antimicrobial
resistance, he said. As well, the
choice of antibiotic — based on efficacy,
safety and cost — should be
explained to the patient. Minocycline,
for example, is extremely efficacious
and has a low risk of
inducing photosensitivity but can
potentially induce some unusual
side effects, including drug hypersensitivity
syndrome and pigmentation
of scars and mucous
membranes.
“There is even evidence from a
French study that patients of African
ancestry were more likely to develop
this drug hypersensitivity syndrome
from minocycline,” Dr. Alexis said.
“So when thinking about patients of
colour, this, coupled with the pigmentation
concern, makes this a
second-line agent. So we depend
more on doxycycline [in darkerskinned
patients].”
6 • Proceedings of 2019 SKIN SPECTRUM SUMMIT