Acne: taking into account pigmentation and medicine hypersensitivity for patients of colour
An expert talks about conveying the treatment rationale behind acne therapy to patients (1,785 words, reading time: 6 mins)
Pigmentation concerns and drug hypersensitivity are among concerns when prescribing acne medications to patients of African ancestry, according to Dr. Andrew F. Alexis.
Explaining the rationale behind choices in a therapeutic regimen for acne can help patients be more confident in a doctor’s recommendations and encourage better adherence to treatment, said Dr. Andrew F. Alexis in a presentation at Skin Spectrum Summit in Montreal.
“It helps to very briefly tell the patient that acne is caused by four key factors, including overproduction of sebum — oil, in layman’s terms for the patient; follicular hyperkeratinization, which to the patient you can describe as blocked follicles; overgrowth of bacteria — P. acnes or the new name, C. acnes; and inflammation,” said Dr. Alexis.
That then allows a practitioner to explain to patients how their particular presentation of acne is being driven by those factors and how the combination of recommended treatments works to correct the situation.
He noted that benzoyl peroxide (BPO) is frequently used in acne treatments because not only is it antimicrobial — without encouraging antimicrobial resistance — it also has some comedolytic effects. BPO also works well in conjunction with other agents, allowing for fixed-dose combination products that simplify administration while addressing multiple pathogenic factors of acne at the same time.
“Topical dapsone, one of the recent additions to our topical acne armamentarium, has a range of anti-inflammatory effects and is available as an aqueous gel. It tends to be very well-tolerated,” Dr. Alexis said. He noted that studies have looked at the efficacy of combining topical dapsone with BPO or with a fixed-dose combination of BPO and the retinoid adapalene.
When we do it like this, we use [topical dapsone] once a day—off-label instead of ... twice a day—and use the retinoid formulation in the evening, typically,” he said.
“One word of caution is when you combine topical dapsone directly with a benzoyl peroxide,” Dr. Alexis said. “You want to do that at separate times, not in the same place and time. Otherwise, you can get a tan-brown discolouration.”
Topical retinoids are one of the most important classes of medication in managing acne, said Dr. Alexis. “They help to normalize follicular desquamation but also have the added benefit of reducing hyperpigmentation, which, of course, is very relevant to patients with skin of colour.”
This class of medications is also valuable as maintenance therapy, used in conjunction with another therapy, such as an oral antibiotic, to bring acne under control and then used alone after the antibiotic is stopped to prevent acne flares, he said.
Antibiotics, although they are effective at reducing microbial overgrowth and have anti-inflammatory properties, should not be used as monotherapy due to the risk of encouraging antimicrobial resistance, he said. As well, the choice of antibiotic — based on efficacy, safety and cost — should be explained to the patient. Minocycline, for example, is extremely efficacious and has a low risk of inducing photosensitivity but can potentially induce some unusual side effects, including drug hypersensitivity syndrome and pigmentation of scars and mucous membranes.
“There is even evidence from a French study that patients of African ancestry were more likely to develop this drug hypersensitivity syndrome from minocycline,” Dr. Alexis said. “So when thinking about patients of colour, this, coupled with the pigmentation concern, makes this a second-line agent. So we depend more on doxycycline [in darker- skinned patients].”
The takeaway: Choosing the right therapy for the right patient may mean taking into account their skin pigmentation as well as explaining the rationale behind choices to patients. This will help to ensure adherence.
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FROM THE LITERATURE ON ACNE
The efficacy of topical hydrolyzed psoralea corylifolia extract in treating postinflammatory hyperpigmentation
A prospective, single-blinded, non-randomized trial study of 20 subjects with skin phototypes IV-VI, found some improvement of acne-induced post-inflammatory hyperpigmentation when treated with hydrolyzed psoralea corylifolia extract.
An advanced, physician-strength retinol peel improves signs of aging and acne across a range of skin types including melasma and skin of color
Researchers have found evidence that 3% retinol superficial peel was effective in treating skin damage from acne and other skin conditions in patients with Fitzpatrick skin types IV-VI after two to four sessions.
Conventional versus daylight photodynamic therapy for acne vulgaris: A randomized and prospective clinical study in China
In a head-to-head comparison, researchers in China have deemed daylight photodynamic therapy as an effective and well-tolerated therapy for moderate-to-severe acne as compared to conventional photodynamic therapy.
Treatment of post‐inflammatory hyperpigmentation in patients with darker skin types using a low energy 1,927 nm non‐ablative fractional laser: a retrospective photographic review analysis
For patients with skin of colour, researchers have found that low energy low density non‐ablative fractional 1927 nm wavelength laser is a safe and effective for treating post inflammatory hyperpigmentation caused by acne and other sources.
VIDEO: Study finds racial disparity in acne medication prescribing
AT THE INTERSECTION OF SKIN & SOCIETY
In a recent article published by the New York Times, a number of Black physicians, including Dr. Onyeka Otugo (pictured below) talked about the microaggressions and racism they have faced while working in emergency rooms, hospitals, and clinics. According to the article, only five per cent of U.S. physicians are Black, while only two per cent are Black women. In Canada, the numbers are likely similar, according to a 2015 report, though medical organizations in Canada typically do not track statistics on demographics in medicine as closely. Read the full story here.
THIS WEEK
Monday, Aug. 24 2020: Canadian Medial Protective Association Annual Meeting and Education Session
Friday, Aug. 28-Sunday, Aug. 30: Internal Medicine for Primary Care: Derm/Neuro/Rheum
Monday, Aug. 24 & Tuesday, Aug. 25: Healthcare and Hospital Management Conference
Something to think about during the week ahead:
NEXT WEEK
A report by Dr. Danielle Marcoux on atopic dermatitis in children with skin of colour. Subscribe to Skin Spectrum Weekly and have each issue sent directly to your phone or inbox.
Don’t forget to register now for the Skin Spectrum Summit 2020 Webinar Series, beginning October 1, 2020. Sign up here