Acne and Rosacea: Dr. Harper

Dr. Julie Harper:
Hi, I'm Dr. Julie Harper. I'm a dermatologist, and I'm here at Maui Derm on beautiful Maui in Hawaii.

I presented on hormonal treatments in acne, and I really focused on three things: spironolactone, oral contraceptives, and topical clascoterone. So with spironolactone, I have three tips that I'd like to share with you, three tips that I shared with the audience, and that is, number one, what is the right dosing of spironolactone? And we looked at the package insert, we know spironolactone is not FDA-approved for really anything dermatologic, but for any of its indications, the dosing range is kind of that comfort zone for us, 25 milligrams to 200 milligrams a day, so I think we found our sweet spot. We do know that higher doses probably work better, but we also know that higher doses are associated with more side effects, so we've got to find that middle ground. The side effects that we worry about with spironolactone include menstrual irregularities, breast tenderness, fatigue, dizziness, so the higher you push that daily dose, the more likely you are to deal with some of those.

The second tip that we talked about with spironolactone is do we have to worry about clotting? And we talk about that because we know we do have to worry about that with birth control pills. But I can tell you, we can set spironolactone free with that one. We have a study that shows the risk of DVT and pulmonary embolism does not appear to be any higher with spironolactone than it is, for example, with oral tetracyclines.

The third tip with spironolactone is talking about, Do we check potassium? And we've had the same answer now since 2015, and that is if your patients are 45 years of age and younger, if they're healthy, you really don't need to be checking potassium. But if they're older than 45, and certainly if they have any risk factors or if they're on other medications that could increase potassium, then we should be checking potassium. When do we check it? We have no idea. The package insert says check within one week. None of us are doing that, I'm not doing that, and I don't plan to do that. So right now, what I do is I check after about two or three months, and then annually, as long as people are tolerating the product well.

I also talked about birth control pills. I don't want people to forget birth control pills. Four of them are FDA-approved to treat acne, and we can learn in dermatology how to use these safely and effectively, they are free for most of our patients. So learn what the contraindications are. But we don't have to do pap smears, we don't have to do bimanual pelvic exams. We do need to make sure people are safe candidates, so no migraines, no smoking, no history of a clot, for example, and document blood pressure, put it in the chart. Give those time to work, they also take three to six months for them to really start having their impact.

And then, lastly, clascoterone. We have a topical anti-androgen, and what's really, I think, most remarkable about that, in my opinion, is that it gives men an opportunity to benefit from hormonal treatments too. We have a tendency, I think, because we've only had drugs that target this systemically, to think of acne in women as being the hormonal acne. But really, all acne is hormonal. It's hormonal in men too. So having a topical anti-androgen that gives the anti-androgen effect in the skin, without giving a systemic anti-androgen effect, is a real win for our patients.