Main Issue June 2012

Insights in Treating Acne Vulgaris

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Given the prevalence of acne vulgaris and its importance to Physician Assistants (PAs) who specialize in dermatology, these panelists discuss their approaches to managing acne and emphasize the importance of education and establishing realistic patient expectations.

Q: In your daily practice, how much time is devoted to managing patients with acne?

A: About 30 percent of the panelists’ patients have acne (10-12 patients a day); most are teenagers, but there are increasing numbers of adult females. Acne patients require a lot of handholding, and managing expectations is critical to treatment success. Panelists spend about 15 minutes per patient, depending on acne severity. Jeff Johnson suggests, “In mild comedonal (noninflammatory) acne where you are going to prescribe a cream, it is fairly straightforward, but if the patient has cystic acne and you are adding an oral agent, there has to be discussion on side effects, length of treatment, and potential resistance.” Randy Banks sees patients back sooner than he used to (within three to four weeks). He has concerns about adherence and has found that some patients don’t fill every prescription, especially if he prescribed two or more products they cannot afford. Risha Bellomo manages having her patients come back within six to eight weeks, but spends more time with them on their first visit. Most panelists assess their patients’ treatment at 12 weeks.

Sandy Snyder emphasizes the importance of patient expectations: “They expect a magic bullet, and to be better quickly.” Risha Bellomo highlights a survey suggesting adult females, “expect results within a week.” Randy Banks finds he is taking more pictures, especially of his severe patients: “It helps to show them how their treatment is progressing.” “It is important patients see objective evidence of your treatment plan,” Sandy Snyder concurs.

Although everyone agrees that spending time with acne patients is important, CaSondra Soto makes the point that with experience it is possible to reduce this time and focus on those who really need help. “You can see it in their face as you are talking to them. I ask whether their acne bothers them and whether they really want to be treated. Sometimes they are only there because Mom sent them...In these situations I often start with a BPO wash to get them a little bit better and talk to the parent about what is important. Acne may not be high on their list.” All of Ms. Soto’s patients get written instructions.

Q: What do patients tell you that motivate them to seek professional medical care for their acne?

A: Sandy Snyder believes it could be the greater drive for perfection: greater peer pressure and way more advertising. Randy Banks suggests frustration with things they have already tried; “everyone I see has already tried four to six different things, sometimes all at once.” Sandy Snyder adds that upcoming events, such as prom, graduation, and homecoming, bring in new or established acne patients that want a quick fix.

“Adult females are very motivated; they don’t understand why they are getting acne at their age and are very self-conscious especially in the workplace,” says CaSondra Soto. Risha Bellomo likes to use a regimen that includes a retinoid to help treat fine lines and wrinkles in this age group as well as their acne, but it is a challenge to get coverage of a retinoid when patients are over 20 to 25 years of age.

Q: What aspects of patient management are the most important considerations in your successful treatment of acne?

A: “A lot of patients come in knowing exactly what they want,” mentions Sandy Snyder. “They have read up on the Internet, making our job more challenging.” Risha Bellomo hears patients, “Say their best friend has used it and it worked for them. They don’t understand it may not work for them.” Acne is one condition where Jeff Johnson and others spend an inordinate amount of time explaining why certain medications are being used, and others not. Sandy Snyder adds, “There are so many parameters that have to be considered: acne severity, likely adherence, patient and parent’s expectations and involvement, and their occupation—are they out in the sun a lot or play sports?”

“Taking a detailed history determines my treatment plan,” says Risha Bellomo. “I had a patient with mild acne and even with a mild treatment regimen his skin still burnt as he had very sensitive skin. It is a bigger challenge if they have moderate to severe acne. What do you do?” She adds, “Over the last five years I am more confident treating acne, I do much more self-educating, I am more honest with my experience, lucky to be around a lot of opinion leaders (both PA peers and physicians) and learn a lot. I read more journals, something I think is increasingly important, look at clinical data, and compare to my own experience.”

CaSondra Soto comments on some of the recent clinical data, “I have plenty of adult women come in wanting something for oiliness and I think some tretinoin products might help.” Risha Bellomo adds, “They don’t like to be shiny in general, I agree.” The panelists also discuss some of the data on relative retinoid photostability and lack of degradation when used in combination with BPO products.1,2 Sandy Snyder comments, “ I would like to try a 2.5% BPO-clindamycin fixed combination and retinoid together. I am always afraid to put on anything with BPO during the day in case it messes up clothing, so switching is attractive, having them put the fixed combination on at night and one of the retinoids that is not photodegraded during the day.” Risha Bellomo adds that using the two products at the same time is also a realistic option. “I have good experience putting one on then the other,” she comments. CaSondra Soto also thinks this is a good idea: “Any time you can do things once a day improves compliance.” Sandy Snyder agrees, “It is nice to have choices for the non-compliant acne patient or the typical adolescent male who doesn’t like to do much.”

Q: Has the role of the PA in managing acne changed and do you see more change in the future? What about the role of the dermatologist?

A: “Most certainly yes,” says CaSondra Soto. “Many dermatologists have moved into surgery and cosmetic dermatology, leaving acne patients to the PA. This works just great as we take the time to get a good history, prior authorization, and the phone call when the patient calls back. It has definitely improved patient outcomes.” “PAs are inherently teachers anyway,” Sandy Snyder adds. Randy Banks feels that dermatologists have given their PAs the role of taking care of the acne patients. Risha Bellomo notes that PAs are seeing more acne patients. This allows the dermatologist time to concentrate on more detailed procedures and complex cases. “It is also easier for patients to see the PA,” Jeff Johnson reminds the group; “if they have an acne problem they don’t want to be waiting three months to see someone.” All panelists see the PA’s role increasing, especially as there are fewer dermatologists amidst a growing population. There is another important trend with some nurse practitioners moving forward to practice more independently from doctors —maybe the dermatologists will see the need to hire more PAs as PAs work with them as part of the healthcare team as their supervising physicians. “PAs are dependent practitioners; with more patients seeking dermatology care, there is a growing need to take the load off of our physicians,” Risha Bellomo adds.

Q: How do you keep up-to-date with acne best practice?

A: CaSondra Soto comments on the importance of local PA groups. The Florida Society of Dermatology Physician Assistant’s Board of Directors puts on CME events to educate new graduates and those new to the field. “There are so many nuances in acne,” Jeff Johnson adds, “and a great need for the frontline practitioner to keep up-to-date.” Sandy Snyder reminds the group of the importance of reading journals regularly. “Learning in our field is imperative,” she adds, “whether this is talking with peers, quizzing drug reps, trying samples, or attending promotional dinners and roundtables.” All the panelists like roundtables as a way of learning, and they see networking as important. Some had found webcasts a great way of learning, although few would sit through the whole session and many preferred one-on-one peer interaction.

Q: How common are ‘call-backs’ and why do these occur? How can they be minimized?

A: Prior Authorization is the main issue all face. In some cases callbacks seemed to be going down, but Jeff Johnson wonders whether this is because they were being handled by nursing staff. “Callbacks for side effects are rare,” he adds. Sandy Snyder emphasizes how important it is for PAs to understand the insurance- provider process. “We also need to educate our patients on the benefits of branded products,” says CaSondra Soto. “This is so important in acne where formulation can make the difference.”

“I spend a lot of time talking with PAs and have found that many new ones coming through don’t understand the importance of vehicles,” advises Randy Banks. Sandy Snyder feels this is another reason to spend time with the patient, as they might need to convince the pharmacist. “Samples are also important,” says CaSondra Soto. “Patients get the chance to try for two to three days so when they like the brand they are more committed to discuss with the pharmacist.” All the panelists are concerned about insurance companies dictating what the PA can and cannot do, putting patient care at risk.

Q: In your experience, how good is adherence with acne treatment and what are the key influencing factors?

A: ”The patient has to come first,” says CaSondra Soto, “if your adolescent acne patient tells you that their acne doesn’t bother them then you are probably best giving them a BPO wash.” However, the panelists recognize the problems managing patient-parent dynamics that often get quite charged in the exam room. “The parent wants perfection for their child,” comments Risha Bellomo. “But if the child is not committed it is really tough. Sometimes you have to be more direct; ask them if it is affecting their self-esteem, tell them that they have to be careful because chronic inflammation can cause permanent scarring if not treated. They need to be aware of the serious long-term implications.” “This is another reason I take pictures; when I talk to them about scarring,” adds Randy Banks.

Sandy Snyder adds that often when you first start you may have to be more aggressive with treatment; three to six months down the road you may transition to more maintenance therapy. “One of the tricks I use,” says Jeff Johnson, “is I always ask, ‘Is this day a good day or a bad day?’ It certainly helps you gauge treatment.”

Q: What are the most common reasons why fixedcombination products are used in your practice to treat acne?

A: The panelists list a number of reasons including ease of use, once-daily application, synergy with the individual active ingredients, and adherence. This is the way acne therapy is going, they add. Jeff Johnson is pleasantly surprised with the results he has seen recently with the 2.5% BPO-clindamycin fixed combination and would like to see more data. “Samples and the relationship with the representative are also important considerations,” adds CaSondra Soto. Sometimes the answer is in the labeling (for example, only one tretinoin preparation is indicated in children as young as 10 years) or new information (for example, not all tretinoins have the same photostability1 and not all BPO-clindamycin fixed combinations are effective in noninflammatory lesions3). “Tolerability is an important point,” adds Randy Banks. “Acne patients are often looking for fast results and are bothered so they are going to get frustrated very quickly if they run into issues with the treatment and irritability would be the main one.” They are often red when they come in as a result of trying things at home, “So you don’t want to give them something that is going to make them worse than they already are,” he adds. “If they can’t tolerate the product they (and you) are going to know about it in a week or two.”

Q: When selecting an acne regimen, how often do you start with a topical retinoid? How often do you add a topical retinoid?

A: “I like to calm people down as quickly as possible, perhaps with a lower potency retinoid,” says Risha Bellomo. Randy Banks adds that he would usually start off 80 to 100 of his acne patients with a retinoid. “If it is just mild inflammatory acne I sometimes start them with dapsone and have them back in eight weeks to see how they are doing,” Ms. Bellomo adds. “I always start with a retinoid,” says Sandy Snyder, “but if you start with a retinoid/BPO fixed combination where do you go from there, what do you add, do you start all over again? At least by starting with retinoid monotherapy you can add a second agent more easily.”

Risha Bellomo wonders if PAs had considered a BPO/ clindamycin fixed combination compared to a retinoid. She sees them as complementary—doing two different things. Combination treatment is more important in moderate to severe acne patients.

Q: When you start a patient (mild or moderate) on a topical retinoid, what is the most common regimen used?

A: Sandy Snyder uses a ceramide-based moisturizer and retinoid at bedtime and finds very few people who can’t tolerate the regimen. CaSondra Soto has tried a tretinoin/ clindamycin fixed combination but did not find it particularly effective. The panelists have mixed views on applying medication on dry or wet skin. Jeff Johnson emphasizes the importance of drying the face after washing. “Sometimes patients don’t dry properly, especially the creases around the bottom of the nose, and this is where they get flaking,” he adds. CaSondra Soto has a patient handout that states, “Apply to damp skin.” “If you try to put any cream on dry skin it sucks it up so there is not enough to spread over the face.” Risha Bellomo adds that if she has a patient who was more irritated she would tell them to apply the medication onto damp skin, even using a little bit of mist. “And yet recommendations say to put on a clean dry face,” Randy Banks points out.

“What about moisturizers?” asks Risha Bellomo. “When patients get more dry they produce more oil, the body over compensates for the dryness.” Jeff Johnson says that this is probably true, but it is not why he recommends moisturizers (mostly for the irritation of the retinoid). He recommends a morning moisturizer (unless a male patient, then “whenever” is good—they don’t like moisturizers). “Before our discussions today,” says CaSondra Soto, “my philosophy was you don’t give then a BPO that stays on the skin, you give it to them in a wash because it only takes a couple of minutes for it to be effective. So you don’t need to put something on the skin and leave it. After today I might be a little more flexible...If I am not writing a BPO wash, then I would use ceramide-based moisturizer wash. Americans love washes that foam,” she adds, “if it doesn’t foam they are going to call you.”

“What influences your choice of retinoid?” asks Risha Bellomo. “They definitely have to be able to tolerate it, otherwise they won’t use it,” replies CaSondra Soto. “Especially in skin of color patients you need something as gentle as possible even though they tell you ‘oh I am oily,’ which would normally steer me towards something more aggressive. I would prefer to start gentle and after they have run out of the first month’s script then move them up into something a little more aggressive.”

Randy Banks always starts slow and gets aggressive based on his experience in treating acne. “Once you get a patient irritated they are not going to trust you,” adds Sandy Snyder. Jeff Johnson feels it might be more of an issue when patients are paying for their medication and have to buy something else; It almost forces you to go milder, more tolerable. Some colleagues try giving medication every other night, but this can be a significant compliance problem, and we don’t know what sort of efficacy we are going to get. Some patients come in who are using their retinoid once a week. This is a good indication to step down the dose or switch to something else.

Q: When do you see the need to use an oral antibiotic to treat acne and why?

A: “When patients have a lot of pustules and you think there is a bacterial component most of us use oral antibiotics for a month or two,” says Randy Banks. Not all the panelists culture patients when they come in, and resistance can be a problem. “I look at antibiotics as a vehicle to get the inflammatory component down until you can get the topicals in place and effective, then wean them off,” adds Sandy Snyder.

Q: How important is patient access (formulary, coupons) in your prescribing choice?

A: “This is a huge issue,” says Sandy Snyder, “access is all.” The problem with acne is that you can’t look at a patient and have any idea how they are going to respond to a medication, adds Jeff Johnson. Also it bothers people so differently: some people come in with the one pimple on their face and want a note for school and products I would only use on severe acne, others come in and you say, “wow,” but they are not there for their acne, they are in for a mole check or something else.

Q: What is the single most important thing you think will make the most difference to the successful management of acne in the future?

A: The panelists feel the biggest hurdle is the pharmacist and were glad more and more specialty pharmacies are cropping up, working very well with the PAs. “I don’t think we understand the pressure each of us is under and it is easy to blame each other,” says Risha Bellomo. “They are held accountable to their peers with performance-based on generic substitution which is why they actively look to switch,” she adds. “I think specialty pharmacies will play a bigger role in dermatology as they are not under that pressure,” says CaSondra Soto.

“Pharmacists tell me that patients often yell at them when they hear the cost of the medicine or they just turn around and walk out. If a patient comes back to see us I assume they got their medication and things are going well. I don’t get a call back, but you wonder how many patients just don’t pick up their medication?” adds Jeff Johnson. “It seems about only 30 do and then there is compliance to worry about.” “I believe,” says Risha Bellomo, that if the co-pay is $50 or more it is 15 abandonment, and if it is $11 or more it is 10.” “Parents often have other priorities,” adds Jeff Johnson. “For my self-pay patients I do try to be aware where is the free drug (samples, coupons) as I want to help all I can,” says Sandy Snyder.

In concluding the discussion, Risha Bellomo emphasizes that education is critical (peer-to-peer and patient) and treating the whole patient, not just their acne. The PA is so important in acne management as they are committed to putting the time in to get it right. It is vital they keep up-todate with the latest data and information from key thought leaders in the acne arena.

Risha Bellomo, with over 15 years of healthcare experience is a Physician’s Assistant at Advanced Dermatology and Cosmetic Surgery in Orlando, FL. Over the last nine years she has specialized in dermatology and the development of medical educational programs.

Jeff Johnson is senior Physician Assistant at Water’s Edge Dermatology in Stuart, FL with over 20 years’ experience, both as a Diplomat of the SDPA and Distinguished Fellow.

Randy Banks is Physician Assistant at Academic Alliance in Dermatology in Tampa, FL and has been working in dermatology in Florida for over 10 years. He is a Past President of the Florida Society of Dermatology Physician Assistants (FSDPA).

CaSondra Soto is Physician Assistant at Advanced Dermatology in Florida, current President of the FSDPA and Past-Vice President of the SDPA with almost 15 years’ experience in dermatology.

Sandy Snyder is Physician Assistant at Florida West Coast Skin & Cancer Center in Tampa, FL. All panelists are Board Members of the FSDPA.

  1. Tretinoin photostability: comparison of micronized tretinoin (0.05%) gel and tretinoin (0.025%) gel following exposure to UV-A light. Del Rosso J et al. J Clin Aesthet Dermatol 2012;5(1) 27-29.
  2. Absence of Degradation of Tretinoin when Benzoyl Peroxide is Combined with an Optimized Formulation of Tretinoin Gel (0.05%). Del Rosso J et al. J Clin Aethet Dermatol. 2010;3(10):26-28. 3. Optimizing topical combination therapy for the treatment of acne vulgaris. Zeichner J Drugs Dermatoil. 2012;11(3):313- 317.

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