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Dr. Keller:
For many years, acne scarring was considered to be a result of severe acne, but recent research shows that scarring can affect any patient regardless of the severity.  Additionally, acne scarring can significantly reduce a patient's quality of life, which is why it's important that treatment is started early to achieve better outcomes.  So what are the assessment and treatment strategies available that can help us reach that goal? 

Welcome to DermConsult on ReachMD.  I'm Dr. Matthew Keller, and joining me today is Dr. Linda Stein Gold, Director of Dermatology Clinical Research at Henry Ford Health System in Detroit.  She's also the Division Head of Dermatology at Henry Ford Health System in West Bloomfield, Michigan. 

Dr. Stein Gold, welcome to the program. 

Dr. Stein Gold:
Thanks so much for having me today. 

Dr. Keller:
To start off with some background, we know that there is some new research on the pathophysiology of acne and acne scarring.  Can you briefly explain those findings for us, Dr. Stein Gold? 

Dr. Stein Gold:
Absolutely.  Acne scarring is probably the most important sequelae that we worry about when we're dealing with our patients with acne, and one of the things we're starting to understand is that acne scarring, as you mentioned, is something that can occur we know with those patients with nodulocystic disease, but it also occurs in those patients who have superficial inflammatory acne.  And studies have shown, actually, that when we look at atrophic scars, it turns out that it's probably the papule and especially those papules that are present for longer periods of time that tend to be the precursors to the atrophic acne scars. 

Dr. Keller:
With that in mind, which of our patients are at risk for acne scarring?  And what risk assessments can we use to determine this? 

Dr. Stein Gold:
Well, unfortunately, pretty much any acne patient is really at risk for acne scarring.  Of course, those patients who have the deep nodules and cysts, we know that those can leave acne that can be very difficult to treat, but even patients that have papules or pustules, those patients can also end up having some scarring.  And we know that there are certain risk factors associated with the development of scarring, especially those patients who have a family history of acne scarring, those patients who have kind of the worst acne that they've seen, and especially those patients who delay treatment before getting their acne under control; they are at higher risk for scarring. 

Dr. Keller:
Now if we turn our attention to treatment, what are the new options available for acne scars, and how are they different from previous methods? 

Dr. Stein Gold:
Well, what's interesting is we've always thought about treating acne scarring with a device, something that will help get the skin under control with either a deep chemical peel or a process that will help thin the skin, or decrease the scarring, but for the first time we actually have some data that a topical therapy can help either minimize the risk of scarring and in some cases actually reverse the atrophic scars. 

So, a number of years ago, the fixed combination of adapalene and benzoyl peroxide, the 0.1 and 2.5%, showed that by using this drug we could actually prevent the development of new scars in patients who had moderate inflammatory acne, and this was studied in a split-phase study.  But then more recently there was a study that looked at the higher concentration of adapalene 0.3% with the fixed combination of 2.5% benzoyl peroxide, and this was also a split-phase study where they looked at patients who had at least 12 atrophic scars on each side of their face.  On one-half they treated with the fixed combination, and in the other half they treated with just the vehicle, and what they found was not only did the active side not have the development of new atrophic scars, but we actually saw a reduction over the course of six months in the number of atrophic scars, and those on the vehicle side we actually saw an increase in scars.  So overall, there was about a four-scar difference between the treated side and the untreated side. 

And what's important here is this is the first time we can tell our patients if you treat with a really good topical agent, and in this case, it was the fixed combination of adapalene 0.3 and a 2.5% benzoyl peroxide, over time we have the possibility of actually making those scars not only less visible but actually decreasing the number of scars. 

Dr. Keller:
For those just tuning in, you're listening to DermConsult on ReachMD.  I'm Dr. Matthew Keller, and today I'm speaking with Dr. Linda Stein Gold about acne scarring. 

So Dr. Stein Gold, now that we know more about our current treatment options, let's focus on the patient.  What are the psychological and psychosocial impacts that can affect their quality of life? 

Dr. Stein Gold:
We have to remember that any defect, especially in a visible area on the skin, can have a tremendous effect on patient's quality of life, and unfortunately, this is something that we see not only in adolescents but also young adults, and it can persist even into later adulthood.  And we know that people are judged on their appearance.  It's absolutely true.  And there have been studies that look at patients who have active acne, but they also look at patients who have just acne scarring, and we find that they are judged.  They're thought of as being less successful, less outgoing, less intelligent, and so people feel like they're being discriminated against, but part of it is really true.  We are being judged by society, and that leads to a really significant negative impact on patients' overall quality of life. 

Dr. Keller:
Now what are some of the challenges of acne scar prevention you've encountered with patients? 

Dr. Stein Gold:
Patients have to understand that when we're talking about acne, inflammation under the skin actually starts before the development of a visible acne lesion, and it persists even when they think that lesion has gone away.  When you see the pink spots on the skin that look like the acne has pretty much gone away and it's just pink, we have to realize that that's still an active inflammatory spot and  can develop into atrophic scars.  So what we have to tell our patients is we have to be aggressive in getting that acne under control, we have to be aggressive in keeping it under control, and I think it's important to talk about the sequelae of acne, the dyspigmentation and the scarring, at the very first visit so the patients understand this is going to be an ongoing relationship.  They're going to have to do their part, and the physician will do their part, but it's really a team effort to keep the patient looking their best possible. 

Dr. Keller:
Now with those challenges in mind, can you share some strategies that might help us overcome those obstacles? 

Dr. Stein Gold:
Absolutely.  First of all, I think it's important to set up the expectations at the very first visit.   Our patients are surrounded by misinformation.  Everybody thinks that they can go online or they can eat something or apply something that's going to get their acne clear overnight, and the truth is that just is not going to happen.  Getting acne under control is not something that takes days or even weeks; it might take months, so we have to have a strategy that's basically, “get that acne under control.”  But unfortunately, once we get it under control, we didn't cure you, so it's going to take an ongoing active maintenance to keep the acne under control.  And you can't just stop.   Everybody wants a drug holiday, but unfortunately, getting it under control and keeping it under control can be quite a challenge, so people have to understand you have to be compliant.  You have to do the right things.  Don't manipulate the lesions.  Use your medication even when you're tired and you don't feel like it.  And  together we have the tools today to get really good success. 

Dr. Keller:
Now before we come to close, Dr. Stein Gold, is there anything else you'd like to share with our audience about how we can better treat acne scars for our patients? 

Dr. Stein Gold:
I think being sympathetic to the patient, understanding that active acne matters, the sequelae of acne matters, the dyspigmentation matters, the red spots matter and the atrophic scars matter, and so understanding that straight up and talking to the patient even at the very first visit and telling them you understand how frustrating it is, you understand how embarrassing it is, and letting them know that we can put a plan in place that will get them under control and keep them under control.  And the fact of continuing to work on it and continuing to work together will lead to a successful outcome. 

Dr. Keller:
Well those are all great takeaways when it comes to acne scar prevention.  And I want to thank my guest, Dr. Linda Stein Gold, for sharing her insights.  Dr. Stein Gold, it was great having you on the program today. 

Dr. Stein Gold:
Thanks so much, and thanks for covering this very important topic. 

Dr. Keller:
For ReachMD, I'm Dr. Matthew Keller.  To access this episode and others from this series, visit ReachMD.com/DermConsult, where you can Be Part of the Knowledge.  Thanks for listening.