Main Issue June 2011

Effective Strategies to Manage Acne on the Chest and Back

Acne can be particularly challenging when it presents on the trunk.

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There is no question that acne can have a strong psychosocial impact on affected patients1 and that effective treatment of acne is associated with improvement in self-esteem, body image, and self-confidence and reduction in shame, embarrassment, and other psychosocial measures.1 For these reasons, dermatologists recognize the importance of early initiation of effective therapy for patients with acne. Yet, despite a wide range of treatment options available, there are some common instances in which management of acne remains challenging, and, despite the clinician’s desire to implement an effective therapy, efficient treatment is difficult. One particular presentation that comes to mind: the treatment of truncal acne.

Back Acne

Back and chest acne are estimated to occur in 61 percent and 45 percent of acne patients, respectively. 2,3 In one study, half of patients with facial acne were found to also have truncal involvement, while three percent of patients had only truncal involvement. There is, surprisingly, some evidence that patients with truncal acne may not recognize that they have truncal involvement,4 suggesting that clinicians should be more attentive to truncal acne and specifically question patients about any evidence of acne on the chest, shoulders, or back.

Pathophysiologically, truncal acne is no different from acne on the face, although the chest, back, and shoulders may be more prone to “acne mechanica.”4 The effects of pressure, occlusion, friction, and heat produced by shoulder pads and other sports equipment may contribute to exacerbation of acne. In addition to targeted anti-acne therapies, strategies to minimize the mechanical forces of equipment should be instituted.

Acne on the back and chest is expected to respond to therapy just as acne on the face would. Yet, evidence suggests that clinicians tend to emphasize oral therapies over topical interventions for truncal acne.5 Likely, this reality is a reflection of the common assumption that it is more convenient to take an oral medication than to apply topical applications to large and potentially hard-toreach body areas. The challenges of topical application of medication to the trunk, particularly the back, are obvious. Nonetheless, several topical therapies may be appropriate for application to the trunk.

Topical clindamycin has been a mainstay of acne therapy. One attempt to ease application to the back and improve compliance with topical antibiotic therapy is the ClindaReach (DUSA Pharmaceuticals) system, designed to aid application of clindamycin solution 1% via pledgets. Acne patients may purchase other implements from home-health catalogs that are intended to facilitate application of topical agents to hard-to-reach body sites (usually they are marketed to older patient for bathing or application of lotions).

Clindamycin phosphate foam 1% (Evoclin, Stiefel) is specifically formulated for use on the trunk. In clinical studies clindamycin foam was superior to clindamycin gel or the foam vehicle in reduction in total, inflammatory, and non-inflammatory acne lesion counts6

Antimicrobial washes, specifically those containing benzoyl peroxide, have been a convenient option to treat truncal acne for some time. They can be used alone or in combination with topical clindamycin or oral antibiotics. Two benzoyl peroxide emollient foam formulations are now available (5.4%, BenzeFoam and 9.8%, BenzeFoam Ultra; Onset Dermatologics) and well suited to use on the trunk, especially hair-bearing areas.

In previous studies, benzoyl peroxide 5.4% emollient foam was shown to produce a 100-fold reduction in P. acnes colonization after two weeks of use.7 The newer 9.8% foam formulation, also significantly reduced P. acnes counts, even when it was used as a short-contact therapy. A two-week open-label, single center study of short contact therapy involved 20 healthy subjects (>18 years old) all confirmed to be colonized with P. acnes on their backs (>10,000 colonies per cm2).8 For two weeks, each subject applied BPO 9.8% foam to the dry back once daily and left it in place for two minutes before rinsing if off with water and wiping the area with a cloth. This protocol was performed under supervision at the study center during the week and unsupervised at home on the weekends.

Mean reduction of P. acnes counts on the back was 0.91 log per cm2 after one week of treatment, and 1.66 log per cm2 after two weeks of treatment with BPO 9.8% foam (p<0.0001)—equivalent to a 98.3 percent reduction in P. acnes counts. The twominute contact time is longer than with a BPO wash applied to the back and rinsed off immediately, as is done conventionally. Emollient characteristics of the foam coupled with short duration of contact are expected to minimize BPO irritation while providing adequate antimicrobial effect.

Know the Options

Data continue to confirm the detrimental impact of acne on patients’ quality of life. Managing acne of the trunk is often challenging. However, effective treatment options exist. Foam-based benzoyl-peroxide with or without clindamycin represents a patient friendly-treatment option. Foam vehicles are associated with improved usability, better adherence and, consequently, improved therapeutic results.9

Dr. Bikowski has served on the advisory board, served as a consultant, received honoraria, and/or served on the speaker’s bureau for Allergan, Barrier, CollaGenex, Coria, Galderma, Intendis, Medicis, Onset Dermatologics, OrthoNeutrogena, PharmaDerm, Quinnova, Ranbaxy, Sanofi-Aventis, SkinMedica, Stiefel, UCB, and Warner Chilcott.

Joseph Bikowski, MD, FAAD is Clinical Assistant Professor of Dermatology, Ohio State University, Columbus, OH and Director, Bikowski Skin Care Center in Sewickley, PA.

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