ReachMD Announcer:
You’re listening to Clinician’s Roundtable on ReachMD. On this episode, we’ll hear from Dr. John Barbieri, who’s an Associate Professor of Dermatology at Harvard Medical School and the Director of the Advanced Acne Therapeutics Clinic at the Brigham and Women’s Hospital. He’ll be discussing the role of hormonal therapy and isotretinoin in acne management. Here’s Dr. Barbieri now.
Dr. Barbieri:
Hormonal therapy, I think, sometimes gets lumped into this narrow category of adult women who have acne that’s on their lower face or jawline or have flares with their menstrual cycle, but we really should consider this broadly for our patients with acne. Whether someone’s a 12-year-old boy or a 38-year-old woman, all acne is fundamentally about hormones, and hormonal therapy can work for any patient with acne. In fact, when we look at studies of adult women with acne, about 90 percent of them have a phenotype that’s more like adolescents with acne than lower face-lying U-zone predominant acne. And in fact, that lower facial acne is not a predictor of hyperandrogenism or polycystic ovarian syndrome. That being said, there are patients who probably benefit more from hormonal therapy, so those who are having acne flaring with their menstrual cycle and those who have other signs of hyperandrogenism probably will benefit more from hormonal therapies like spironolactone, combined oral contraceptives, and clascoterone. But these treatments can work in any patient with acne. We know clascoterone is FDA approved for men and women with acne to age 12, so we can use these treatments broadly for our patients with acne, and they’re a great way for us to reduce our reliance on oral antibiotics as well.
Isotretinoin is a treatment that is not right for everyone, but it does have some special properties. It’s really our only medical therapy that can deliver long-term clearance and long-term remission of acne. About four out of five patients won’t have really much meaningful acne after completing a course of isotretinoin. Additionally, isotretinoin is one of the most effective treatments for acne, so for really severe or difficult-to-treat acne or acne causing a lot of scarring or psychosocial distress, it’s a very important treatment option.
However, it does have some important side effects, dryness being the most common one. Pretty much everyone is going to get some dryness. This is very dose dependent, so using a lower dose and omega 3 supplements can help to minimize this. But this is an important issue, and in the same way that it causes apoptosis of the sebaceous glands to give long-term clearance of acne, it can cause some more long-term meibomian gland dysfunction that can lead to eye dryness. So I do think we have to be careful about long-term skin or eye dryness when we’re using isotretinoin and really pay attention and listen to that side effect when we’re thinking about how long to treat individuals with acne.
And then the other most common side effects are things like joint pains or muscle aches, which again, typically can be improved with lower doses and usually will resolve after treatment. And then rarely there can be issues like mood changes. And I do think that isotretinoin can cause mood changes. In general, isotretinoin results in improved mood, and we’ve seen in study after study that those who are treated with isotretinoin compared to other treatments have lower rates of depression, taking an antidepressant, or even committing suicide. However, there are people who take isotretinoin who get depression symptoms, sadness symptoms, or irritability. They stop it. They feel better. They take it again. It happens again. So I do think that isotretinoin can causally result in these mood symptoms, and we have to pay attention to them and screen for them. But in general, the expectation when we’re deciding whether or not to use it is improved mood. And in fact, in my mind, someone who has depression at baseline is a reason to use isotretinoin and not to be afraid of it.
Sometimes for individuals with acne, you’ll have a plan to use isotretinoin; they’ll get a lot better. They get 90 to 95 percent better, and they’ll just get stuck. I find this sometimes happens with adult women with acne, especially who have some component of hyperandrogenism. They may have PCOS, irregular periods, or other signs of high androgens. And for these patients, I often find, even if it didn’t work before, that switching from isotretinoin to spironolactone, even at sometimes a relatively low dose, can be very effective. So for patients who are stuck on isotretinoin—they’re almost better, but not quite there—and who have some evidence that hormones are playing a particularly important role in their acne, I do find hormonal therapy like spironolactone or combined oral contraceptives can be very effective. In addition, hormonal therapy can be a nice option after isotretinoin for someone who’s acne just keeps coming back. Maybe they’ve done isotretinoin a couple of times and it just keeps recurring three to nine months after they stop. They’re not getting that long-term clearance. And then for those adult women with acne, sometimes hormonal therapy can be very effective at achieving that long-term control that we’re looking for.
We’re finally starting to get some good trials of spironolactone for acne. We really, for the past years, just had some small trials to go on. Now, we’ve had the SAFA trial from the UK—400 individuals, placebo-controlled. We’ve had the FASCE trial from France, which had a couple hundred individuals and was an active comparator study against doxycycline. And soon we’re going to have the results of the SD-ACNE trial from the United States, which is going to have 350 women with acne who are randomized either spironolactone 100 mg a day or doxycycline 100 mg a day, and it also looks at the microbiome.
So we’re going to have more and more data to guide the relative decision-making on when should we use hormonal therapy like spironolactone and combined oral contraceptives and when should we use oral antibiotics for our women patients with acne to best guide what we want to do there.
ReachMD Announcer:
That was Dr. John Barbieri talking about when hormonal therapy and isotretinoin should be used to treat patients with acne. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
