Rosacea

KAUAI, HAWAII – Should you taper or stop your acne patient’s oral antibiotic abruptly? And what are the best topical and oral antibiotics to treat chronic acne? Dr. Linda Stein Gold of the Henry Ford Hospital in Detroit addresses these concerns and discusses the latest developments in topical antibiotics at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation. Dr. Gold disclosed she has several industry ties, including with Galderma, Roche, and Stiefel. SDEF and this news organization are owed by the same parent company.

[email protected]

On Twitter @whitneymcknight

KAUAI, HAWAII – Should you taper or stop your acne patient’s oral antibiotic abruptly? And what are the best topical and oral antibiotics to treat chronic acne? Dr. Linda Stein Gold of the Henry Ford Hospital in Detroit addresses these concerns and discusses the latest developments in topical antibiotics at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation. Dr. Gold disclosed she has several industry ties, including with Galderma, Roche, and Stiefel. SDEF and this news organization are owed by the same parent company.

[email protected]

On Twitter @whitneymcknight

KAUAI, HAWAII – Should you taper or stop your acne patient’s oral antibiotic abruptly? And what are the best topical and oral antibiotics to treat chronic acne? Dr. Linda Stein Gold of the Henry Ford Hospital in Detroit addresses these concerns and discusses the latest developments in topical antibiotics at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation. Dr. Gold disclosed she has several industry ties, including with Galderma, Roche, and Stiefel. SDEF and this news organization are owed by the same parent company.

[email protected]

On Twitter @whitneymcknight

Dermatologists with a strictly medical or surgical practice may consider offering cosmetic procedures to their patients. Dr. Gary Goldenberg provides tips on how to market your practice as cosmetic by obtaining patient input, estimating start-up costs, and determining which procedures may benefit patients with medical conditions such as acne and rosacea.

Dermatologists with a strictly medical or surgical practice may consider offering cosmetic procedures to their patients. Dr. Gary Goldenberg provides tips on how to market your practice as cosmetic by obtaining patient input, estimating start-up costs, and determining which procedures may benefit patients with medical conditions such as acne and rosacea.

Dermatologists with a strictly medical or surgical practice may consider offering cosmetic procedures to their patients. Dr. Gary Goldenberg provides tips on how to market your practice as cosmetic by obtaining patient input, estimating start-up costs, and determining which procedures may benefit patients with medical conditions such as acne and rosacea.

MIAMI BEACH – The value of specific instructions for general skin care in acne patients is often underestimated, but clear guidance can improve outcomes, according to Dr. James Q. Del Rosso.

“Skin care is very important. It sounds trivial, but it is extremely important to tell patients exactly what they should be using as far as skin care,” he said at the South Beach Symposium.

Courtesy Wikimedia Commons/Kinan Ayu/Creative Commons license

Using the wrong products can reduce the efficacy of acne treatment, he said. Patients may use products that damage the stratum corneum and cause excess water loss, thereby increasing the likelihood of irritation. This sets their skin up for additional irritation or sensitization from prescribed topical medications, he explained.

“If you controlled the skin care, you wouldn’t have that problem at all,” said Dr. Del Rosso of Touro University in Henderson, Nev.

Additionally, patients may be engaging in procedures at home, such as microdermabrasion, that can increase transepidermal water loss and promote inflammation as part of the skin’s self-repair mechanism, he noted.

Such inflammation can increase skin sensitivity to medications.

“So controlling the skin care has a lot to do with what the therapeutic outcome will be,” he said.

Dr. Del Russo and colleagues found that a specific regimen consisting of a foam moisturizer and an SPF 30 moisturizer formulated with a lower dose of sunscreen (DermaControl) to reduce the potential for irritation was safe, effective, and well liked by patients when used in conjunction with daily application of a topical gel containing adapalene 1% and benzoyl peroxide 2.5% (Epiduo). Their findings appeared earlier this year (J. Clin. Aesthet. Dermatol. 2015; 8:22-30).

Further, a review of the types of patients included in the original pivotal trials for Epiduo and those in Dr. Del Rosso’s study suggests that use of the DermaControl skin care regimen lessened skin irritation caused by the prescription treatment. The same types of patients were included in both studies, and the same treatment regimen was used, he said.

Additional studies comparing various treatments used with and without specific skin care regimens are needed, and are likely in the future, he said.

Dr. Del Rosso has served as a consultant, researcher, and/or speaker for multiple companies including Allergan, Anacor Pharmaceuticals, Aqua Pharmaceuticals, Bayer HealthCare Pharmaceuticals, Celgene, Dermira, Ferndale Pharmaceuticals, Galderma, Genentech, Innocutis, LEO Pharmaceuticals, Promius Pharma, PuraCap Pharmaceutical, Quinnova Pharmaceuticals, Ranbaxy Pharmaceuticals, Sebacia, Suneva Medical, Taro Pharmaceutical Industries, Unilever, and Valeant. His spouse is employed by Novartis.

MIAMI BEACH – The value of specific instructions for general skin care in acne patients is often underestimated, but clear guidance can improve outcomes, according to Dr. James Q. Del Rosso.

“Skin care is very important. It sounds trivial, but it is extremely important to tell patients exactly what they should be using as far as skin care,” he said at the South Beach Symposium.

Courtesy Wikimedia Commons/Kinan Ayu/Creative Commons license

Using the wrong products can reduce the efficacy of acne treatment, he said. Patients may use products that damage the stratum corneum and cause excess water loss, thereby increasing the likelihood of irritation. This sets their skin up for additional irritation or sensitization from prescribed topical medications, he explained.

“If you controlled the skin care, you wouldn’t have that problem at all,” said Dr. Del Rosso of Touro University in Henderson, Nev.

Additionally, patients may be engaging in procedures at home, such as microdermabrasion, that can increase transepidermal water loss and promote inflammation as part of the skin’s self-repair mechanism, he noted.

Such inflammation can increase skin sensitivity to medications.

“So controlling the skin care has a lot to do with what the therapeutic outcome will be,” he said.

Dr. Del Russo and colleagues found that a specific regimen consisting of a foam moisturizer and an SPF 30 moisturizer formulated with a lower dose of sunscreen (DermaControl) to reduce the potential for irritation was safe, effective, and well liked by patients when used in conjunction with daily application of a topical gel containing adapalene 1% and benzoyl peroxide 2.5% (Epiduo). Their findings appeared earlier this year (J. Clin. Aesthet. Dermatol. 2015; 8:22-30).

Further, a review of the types of patients included in the original pivotal trials for Epiduo and those in Dr. Del Rosso’s study suggests that use of the DermaControl skin care regimen lessened skin irritation caused by the prescription treatment. The same types of patients were included in both studies, and the same treatment regimen was used, he said.

Additional studies comparing various treatments used with and without specific skin care regimens are needed, and are likely in the future, he said.

Dr. Del Rosso has served as a consultant, researcher, and/or speaker for multiple companies including Allergan, Anacor Pharmaceuticals, Aqua Pharmaceuticals, Bayer HealthCare Pharmaceuticals, Celgene, Dermira, Ferndale Pharmaceuticals, Galderma, Genentech, Innocutis, LEO Pharmaceuticals, Promius Pharma, PuraCap Pharmaceutical, Quinnova Pharmaceuticals, Ranbaxy Pharmaceuticals, Sebacia, Suneva Medical, Taro Pharmaceutical Industries, Unilever, and Valeant. His spouse is employed by Novartis.

MIAMI BEACH – The value of specific instructions for general skin care in acne patients is often underestimated, but clear guidance can improve outcomes, according to Dr. James Q. Del Rosso.

“Skin care is very important. It sounds trivial, but it is extremely important to tell patients exactly what they should be using as far as skin care,” he said at the South Beach Symposium.

Courtesy Wikimedia Commons/Kinan Ayu/Creative Commons license

Using the wrong products can reduce the efficacy of acne treatment, he said. Patients may use products that damage the stratum corneum and cause excess water loss, thereby increasing the likelihood of irritation. This sets their skin up for additional irritation or sensitization from prescribed topical medications, he explained.

“If you controlled the skin care, you wouldn’t have that problem at all,” said Dr. Del Rosso of Touro University in Henderson, Nev.

Additionally, patients may be engaging in procedures at home, such as microdermabrasion, that can increase transepidermal water loss and promote inflammation as part of the skin’s self-repair mechanism, he noted.

Such inflammation can increase skin sensitivity to medications.

“So controlling the skin care has a lot to do with what the therapeutic outcome will be,” he said.

Dr. Del Russo and colleagues found that a specific regimen consisting of a foam moisturizer and an SPF 30 moisturizer formulated with a lower dose of sunscreen (DermaControl) to reduce the potential for irritation was safe, effective, and well liked by patients when used in conjunction with daily application of a topical gel containing adapalene 1% and benzoyl peroxide 2.5% (Epiduo). Their findings appeared earlier this year (J. Clin. Aesthet. Dermatol. 2015; 8:22-30).

Further, a review of the types of patients included in the original pivotal trials for Epiduo and those in Dr. Del Rosso’s study suggests that use of the DermaControl skin care regimen lessened skin irritation caused by the prescription treatment. The same types of patients were included in both studies, and the same treatment regimen was used, he said.

Additional studies comparing various treatments used with and without specific skin care regimens are needed, and are likely in the future, he said.

Dr. Del Rosso has served as a consultant, researcher, and/or speaker for multiple companies including Allergan, Anacor Pharmaceuticals, Aqua Pharmaceuticals, Bayer HealthCare Pharmaceuticals, Celgene, Dermira, Ferndale Pharmaceuticals, Galderma, Genentech, Innocutis, LEO Pharmaceuticals, Promius Pharma, PuraCap Pharmaceutical, Quinnova Pharmaceuticals, Ranbaxy Pharmaceuticals, Sebacia, Suneva Medical, Taro Pharmaceutical Industries, Unilever, and Valeant. His spouse is employed by Novartis.

MIAMI BEACH – A fixed-dose adapalene/benzoyl peroxide gel is a suitable treatment for acne in adult women, according to a meta-analysis of data from three randomized, vehicle-controlled multicenter studies.

The median percent change in total lesions at 12 weeks in 130 women who were treated with the 0.1% adapalene/2.5% benzoyl peroxide gel (A-BPO) was –71%, compared with –45% in 124 treated with vehicle gel, Dr. Linda Stein Gold of Henry Ford Medical Center, Detroit, reported in a poster at the annual South Beach Symposium.

Similarly, the median percent change in inflammatory lesions was –73% vs. –41%, and the median percent change in noninflammatory lesions was –70% vs. –45% in the groups, respectively.

Response to the A-BPO treatment was rapid, with significant improvements seen at 1 week, compared with vehicle. Treatment was also well tolerated; adverse events occurring in at least 3% of those in the A-BPO treatment group were dry skin, contact dermatitis, and application site irritation, but all were mild, Dr. Gold noted.

Study participants were women aged 25 years and older. Data increasingly demonstrate that the prevalence of acne in women in this age group is increasing, with up to 54% of women affected, she said.

“Furthermore, recent data show that the mandibular form of acne traditionally associated with adult women is less prevalent than previously thought and that most acne in adult women more closely resembles adolescent acne,” she wrote.

Treatment with benzoyl peroxide in combination with a retinoid has been recommended as a first-line treatment for women with acne, and the fixed-dose A-BPO combination used in this study has been shown to be safe in patients as young as age 9 years.

The findings of this meta-analysis suggest that it is also effective and safe – with quick onset of action – in adult women, she concluded.

This study was funded by Galderma Research and Development and Galderma Laboratories.

MIAMI BEACH – A fixed-dose adapalene/benzoyl peroxide gel is a suitable treatment for acne in adult women, according to a meta-analysis of data from three randomized, vehicle-controlled multicenter studies.

The median percent change in total lesions at 12 weeks in 130 women who were treated with the 0.1% adapalene/2.5% benzoyl peroxide gel (A-BPO) was –71%, compared with –45% in 124 treated with vehicle gel, Dr. Linda Stein Gold of Henry Ford Medical Center, Detroit, reported in a poster at the annual South Beach Symposium.

Similarly, the median percent change in inflammatory lesions was –73% vs. –41%, and the median percent change in noninflammatory lesions was –70% vs. –45% in the groups, respectively.

Response to the A-BPO treatment was rapid, with significant improvements seen at 1 week, compared with vehicle. Treatment was also well tolerated; adverse events occurring in at least 3% of those in the A-BPO treatment group were dry skin, contact dermatitis, and application site irritation, but all were mild, Dr. Gold noted.

Study participants were women aged 25 years and older. Data increasingly demonstrate that the prevalence of acne in women in this age group is increasing, with up to 54% of women affected, she said.

“Furthermore, recent data show that the mandibular form of acne traditionally associated with adult women is less prevalent than previously thought and that most acne in adult women more closely resembles adolescent acne,” she wrote.

Treatment with benzoyl peroxide in combination with a retinoid has been recommended as a first-line treatment for women with acne, and the fixed-dose A-BPO combination used in this study has been shown to be safe in patients as young as age 9 years.

The findings of this meta-analysis suggest that it is also effective and safe – with quick onset of action – in adult women, she concluded.

This study was funded by Galderma Research and Development and Galderma Laboratories.

MIAMI BEACH – A fixed-dose adapalene/benzoyl peroxide gel is a suitable treatment for acne in adult women, according to a meta-analysis of data from three randomized, vehicle-controlled multicenter studies.

The median percent change in total lesions at 12 weeks in 130 women who were treated with the 0.1% adapalene/2.5% benzoyl peroxide gel (A-BPO) was –71%, compared with –45% in 124 treated with vehicle gel, Dr. Linda Stein Gold of Henry Ford Medical Center, Detroit, reported in a poster at the annual South Beach Symposium.

Similarly, the median percent change in inflammatory lesions was –73% vs. –41%, and the median percent change in noninflammatory lesions was –70% vs. –45% in the groups, respectively.

Response to the A-BPO treatment was rapid, with significant improvements seen at 1 week, compared with vehicle. Treatment was also well tolerated; adverse events occurring in at least 3% of those in the A-BPO treatment group were dry skin, contact dermatitis, and application site irritation, but all were mild, Dr. Gold noted.

Study participants were women aged 25 years and older. Data increasingly demonstrate that the prevalence of acne in women in this age group is increasing, with up to 54% of women affected, she said.

“Furthermore, recent data show that the mandibular form of acne traditionally associated with adult women is less prevalent than previously thought and that most acne in adult women more closely resembles adolescent acne,” she wrote.

Treatment with benzoyl peroxide in combination with a retinoid has been recommended as a first-line treatment for women with acne, and the fixed-dose A-BPO combination used in this study has been shown to be safe in patients as young as age 9 years.

The findings of this meta-analysis suggest that it is also effective and safe – with quick onset of action – in adult women, she concluded.

This study was funded by Galderma Research and Development and Galderma Laboratories.

NEW ORLEANS – Identifying the right treatment for each type of acne scar and using a combination of modalities can yield the best results, according to Dr. Jennifer Chwalek.

Multiple safe, effective, and cost-effective options are available for the treatment of acne scarring, Dr. Chwalek said at the annual meeting of the American Academy of Cosmetic Surgery.

“These techniques are often underutilized, but they’re very easy to put into practice,” Dr. Chwalek said. “With laser resurfacing techniques, they can add to patient improvement and better outcomes.”

Acne is the most common skin disorder in the United States, affecting an estimated 40-50 million people, and by their mid-teens, more than 40% of Americans have had acne accompanied by some scarring, said Dr. Chwalek. The appearance of these scars often worsens and becomes more prominent with aging, she added.

Acne scars are classified by their morphology as ice-pick scars, boxcar scars, and rolling scars. Different categories of scars require different approaches to minimize their appearance and maximize patient satisfaction, said Dr. Chwalek of Mount Sinai Medical Center in New York. Ice pick scars are characterized by small, deep holes in the skin with a wide opening and a narrow base. Boxcar scars present as square or U-shaped depressions in the skin. Scar morphology is a key driver of treatment options; ice pick and boxcar scars can be treated surgically through punch excisions, grafts, and elevation, and through the chemical reconstruction of skin scars technique, Dr. Chwalek said. Skin resurfacing procedures such as chemical peels, dermabrasion, and ablative and nonablative laser resurfacing can also be used to address acne scars. “However, lasers cannot always penetrate deep enough to address deep ice pick and boxcar scars; as a result, outcomes from laser treatments really fall short of our expectations,” she said.

With a punch excision, the acne scar is surgically removed through a punch matching the size of the scar (ideally 1.5-3.5 mm), and the remaining wound is sealed. Punch excision is ideal for deep ice pick scars and narrow, deep boxcar scars (<3 mm), said Dr. Chwalek. “As scars become larger, it is often better to treat with elliptical excision – otherwise you risk contour deformities,” she advised.

The punch elevation method is best for shallow and deep boxcar scars, Dr. Chwalek said. Scars treated with this method should have sharp edges, so the center of the scar can be elevated to the level of the surrounding tissue and reattached by a suture, Steri-Strips thin adhesive strips, or 2-octyl cyanoacrylate glue. Punch elevation brings scars up to the surface level of the skin, making them appear less noticeable, she said.

Punch grafting is an option to treat very deep, large, and more atrophic scars, Dr. Chwalek said. Skin that is not cosmetically sensitive is ideal for this method, and pre- or postauricular skin is typically utilized. However, there is a risk of textural or color mismatch when using this method, Dr. Chwalek noted

For deep acne scars, punch excision, elevation, and grafting are particularly effective when combined with laser resurfacing. “Combining surgical approaches with laser can really result in improvement for the patients,” said Dr. Chwalek.

Histologically, acne scars show a reduction in collagen and elastin. “Chemical reconstruction of skin scars [CROSS] is a technique of applying high concentrations of trichloroacetic acid [TCA] to atrophic ice pick scars to induce inflammation and collagen production,” Dr. Chwalek explained. The CROSS method causes coagulative epidermal necrosis and collagen necrosis in the papillary and upper reticular dermis, resulting in scar remodeling over time.

With the CROSS method, a 50%-100% concentration of TCA should be utilized. The skin should be held taut, and the acid applied directly to the scar using a toothpick or sharp wooden applicator, Dr. Chwalek emphasized. “It’s very important to keep the TCA isolated to the acne scar – if it spills out to the surrounding area, this may result in a potentially larger scar for the patient,” she explained. Higher concentrations of TCA have been shown to be more effective at modifying deeper scars, and typically result in greater patient satisfaction with no significant complications, she added.

Frosting will occur at the site of treatment within 10-15 seconds, crusting will be observed 3 days post treatment, and after a week, the site of treatment will be fully resolved. It is crucial to warn darker-skinned patients of the risk of transient postinflammatory hypopigmentation as a result of the CROSS method, although this resolves within weeks of treatment. “It is also important to make patients aware of downtime associated with CROSS,” she added. “One week after treatment, they may still have crusting.”

“Patients who come to you for acne scarring are really anxious to see improvement,” said Dr. Chwalek, so it is imperative to address patient expectations and to explain that the treatment of acne scars is a gradual process. “It is important to let patients know that it’s going to take multiple treatments to get them to where they want to be,” she added.

Dr. Chwalek reported no relevant financial disclosures.

NEW ORLEANS – Identifying the right treatment for each type of acne scar and using a combination of modalities can yield the best results, according to Dr. Jennifer Chwalek.

Multiple safe, effective, and cost-effective options are available for the treatment of acne scarring, Dr. Chwalek said at the annual meeting of the American Academy of Cosmetic Surgery.

“These techniques are often underutilized, but they’re very easy to put into practice,” Dr. Chwalek said. “With laser resurfacing techniques, they can add to patient improvement and better outcomes.”

Acne is the most common skin disorder in the United States, affecting an estimated 40-50 million people, and by their mid-teens, more than 40% of Americans have had acne accompanied by some scarring, said Dr. Chwalek. The appearance of these scars often worsens and becomes more prominent with aging, she added.

Acne scars are classified by their morphology as ice-pick scars, boxcar scars, and rolling scars. Different categories of scars require different approaches to minimize their appearance and maximize patient satisfaction, said Dr. Chwalek of Mount Sinai Medical Center in New York. Ice pick scars are characterized by small, deep holes in the skin with a wide opening and a narrow base. Boxcar scars present as square or U-shaped depressions in the skin. Scar morphology is a key driver of treatment options; ice pick and boxcar scars can be treated surgically through punch excisions, grafts, and elevation, and through the chemical reconstruction of skin scars technique, Dr. Chwalek said. Skin resurfacing procedures such as chemical peels, dermabrasion, and ablative and nonablative laser resurfacing can also be used to address acne scars. “However, lasers cannot always penetrate deep enough to address deep ice pick and boxcar scars; as a result, outcomes from laser treatments really fall short of our expectations,” she said.

With a punch excision, the acne scar is surgically removed through a punch matching the size of the scar (ideally 1.5-3.5 mm), and the remaining wound is sealed. Punch excision is ideal for deep ice pick scars and narrow, deep boxcar scars (<3 mm), said Dr. Chwalek. “As scars become larger, it is often better to treat with elliptical excision – otherwise you risk contour deformities,” she advised.

The punch elevation method is best for shallow and deep boxcar scars, Dr. Chwalek said. Scars treated with this method should have sharp edges, so the center of the scar can be elevated to the level of the surrounding tissue and reattached by a suture, Steri-Strips thin adhesive strips, or 2-octyl cyanoacrylate glue. Punch elevation brings scars up to the surface level of the skin, making them appear less noticeable, she said.

Punch grafting is an option to treat very deep, large, and more atrophic scars, Dr. Chwalek said. Skin that is not cosmetically sensitive is ideal for this method, and pre- or postauricular skin is typically utilized. However, there is a risk of textural or color mismatch when using this method, Dr. Chwalek noted

For deep acne scars, punch excision, elevation, and grafting are particularly effective when combined with laser resurfacing. “Combining surgical approaches with laser can really result in improvement for the patients,” said Dr. Chwalek.

Histologically, acne scars show a reduction in collagen and elastin. “Chemical reconstruction of skin scars [CROSS] is a technique of applying high concentrations of trichloroacetic acid [TCA] to atrophic ice pick scars to induce inflammation and collagen production,” Dr. Chwalek explained. The CROSS method causes coagulative epidermal necrosis and collagen necrosis in the papillary and upper reticular dermis, resulting in scar remodeling over time.

With the CROSS method, a 50%-100% concentration of TCA should be utilized. The skin should be held taut, and the acid applied directly to the scar using a toothpick or sharp wooden applicator, Dr. Chwalek emphasized. “It’s very important to keep the TCA isolated to the acne scar – if it spills out to the surrounding area, this may result in a potentially larger scar for the patient,” she explained. Higher concentrations of TCA have been shown to be more effective at modifying deeper scars, and typically result in greater patient satisfaction with no significant complications, she added.

Frosting will occur at the site of treatment within 10-15 seconds, crusting will be observed 3 days post treatment, and after a week, the site of treatment will be fully resolved. It is crucial to warn darker-skinned patients of the risk of transient postinflammatory hypopigmentation as a result of the CROSS method, although this resolves within weeks of treatment. “It is also important to make patients aware of downtime associated with CROSS,” she added. “One week after treatment, they may still have crusting.”

“Patients who come to you for acne scarring are really anxious to see improvement,” said Dr. Chwalek, so it is imperative to address patient expectations and to explain that the treatment of acne scars is a gradual process. “It is important to let patients know that it’s going to take multiple treatments to get them to where they want to be,” she added.

Dr. Chwalek reported no relevant financial disclosures.

NEW ORLEANS – Identifying the right treatment for each type of acne scar and using a combination of modalities can yield the best results, according to Dr. Jennifer Chwalek.

Multiple safe, effective, and cost-effective options are available for the treatment of acne scarring, Dr. Chwalek said at the annual meeting of the American Academy of Cosmetic Surgery.

“These techniques are often underutilized, but they’re very easy to put into practice,” Dr. Chwalek said. “With laser resurfacing techniques, they can add to patient improvement and better outcomes.”

Acne is the most common skin disorder in the United States, affecting an estimated 40-50 million people, and by their mid-teens, more than 40% of Americans have had acne accompanied by some scarring, said Dr. Chwalek. The appearance of these scars often worsens and becomes more prominent with aging, she added.

Acne scars are classified by their morphology as ice-pick scars, boxcar scars, and rolling scars. Different categories of scars require different approaches to minimize their appearance and maximize patient satisfaction, said Dr. Chwalek of Mount Sinai Medical Center in New York. Ice pick scars are characterized by small, deep holes in the skin with a wide opening and a narrow base. Boxcar scars present as square or U-shaped depressions in the skin. Scar morphology is a key driver of treatment options; ice pick and boxcar scars can be treated surgically through punch excisions, grafts, and elevation, and through the chemical reconstruction of skin scars technique, Dr. Chwalek said. Skin resurfacing procedures such as chemical peels, dermabrasion, and ablative and nonablative laser resurfacing can also be used to address acne scars. “However, lasers cannot always penetrate deep enough to address deep ice pick and boxcar scars; as a result, outcomes from laser treatments really fall short of our expectations,” she said.

With a punch excision, the acne scar is surgically removed through a punch matching the size of the scar (ideally 1.5-3.5 mm), and the remaining wound is sealed. Punch excision is ideal for deep ice pick scars and narrow, deep boxcar scars (<3 mm), said Dr. Chwalek. “As scars become larger, it is often better to treat with elliptical excision – otherwise you risk contour deformities,” she advised.

The punch elevation method is best for shallow and deep boxcar scars, Dr. Chwalek said. Scars treated with this method should have sharp edges, so the center of the scar can be elevated to the level of the surrounding tissue and reattached by a suture, Steri-Strips thin adhesive strips, or 2-octyl cyanoacrylate glue. Punch elevation brings scars up to the surface level of the skin, making them appear less noticeable, she said.

Punch grafting is an option to treat very deep, large, and more atrophic scars, Dr. Chwalek said. Skin that is not cosmetically sensitive is ideal for this method, and pre- or postauricular skin is typically utilized. However, there is a risk of textural or color mismatch when using this method, Dr. Chwalek noted

For deep acne scars, punch excision, elevation, and grafting are particularly effective when combined with laser resurfacing. “Combining surgical approaches with laser can really result in improvement for the patients,” said Dr. Chwalek.

Histologically, acne scars show a reduction in collagen and elastin. “Chemical reconstruction of skin scars [CROSS] is a technique of applying high concentrations of trichloroacetic acid [TCA] to atrophic ice pick scars to induce inflammation and collagen production,” Dr. Chwalek explained. The CROSS method causes coagulative epidermal necrosis and collagen necrosis in the papillary and upper reticular dermis, resulting in scar remodeling over time.

With the CROSS method, a 50%-100% concentration of TCA should be utilized. The skin should be held taut, and the acid applied directly to the scar using a toothpick or sharp wooden applicator, Dr. Chwalek emphasized. “It’s very important to keep the TCA isolated to the acne scar – if it spills out to the surrounding area, this may result in a potentially larger scar for the patient,” she explained. Higher concentrations of TCA have been shown to be more effective at modifying deeper scars, and typically result in greater patient satisfaction with no significant complications, she added.

Frosting will occur at the site of treatment within 10-15 seconds, crusting will be observed 3 days post treatment, and after a week, the site of treatment will be fully resolved. It is crucial to warn darker-skinned patients of the risk of transient postinflammatory hypopigmentation as a result of the CROSS method, although this resolves within weeks of treatment. “It is also important to make patients aware of downtime associated with CROSS,” she added. “One week after treatment, they may still have crusting.”

“Patients who come to you for acne scarring are really anxious to see improvement,” said Dr. Chwalek, so it is imperative to address patient expectations and to explain that the treatment of acne scars is a gradual process. “It is important to let patients know that it’s going to take multiple treatments to get them to where they want to be,” she added.

Dr. Chwalek reported no relevant financial disclosures.

MIAMI BEACH – Acne on the face and trunk in adolescents could be associated with the use of whey protein supplements, according to Dr. Jonette E. Keri.

Teenage boys, especially, may use whey protein supplements in an effort to increase muscle mass or gain weight, Dr. Keri of the University of Miami said at the South Beach Symposium.

She cited a 2012 case series of five male teenage athletes aged 14-18 years who were using whey protein shakes or reconstituted powder. The teens presented with moderate to severe acne that responded poorly to standard treatment, but four of the five experienced clearing of the acne upon discontinuation of the whey protein supplement.

marekuliasz/Thinkstock.com

All five had been treated unsuccessfully with traditional therapies, including oral antibiotics, topical retinoids, and benzoyl peroxide. One teen stopped using the whey protein immediately after being counseled to do so, and he experienced improvement. Two teens didn’t stop using whey protein immediately but experienced improvement in their acne when they did discontinue it. Another teen experienced clearing after discontinuing the whey protein during a second course of isotretinoin therapy, and the fifth was lost to follow-up (Cutis 2012;90:70-2).

One of the teens who cleared after discontinuing the whey protein experienced a flare of the acne when he reinitiated supplementation, Dr. Keri said.

Three of the boys were trying to build muscle for football and two were trying to gain weight, which underscores the importance of asking teens about supplement use, she noted, adding that, importantly, it’s not just boys who are affected.

In fact, a Brazilian study of 30 patients showed a very strong association between the onset or exacerbation of acne and initiation of whey protein use – and the finding was more pronounced among women than men, and among those without a personal or family history of acne (An. Bras. Dermatol. 2013;88:907-12).

In that study, subjects were examined on three occasions and followed for 60 days.

“They went the gym, wanted to work out a little bit and get bigger, took some whey, and broke out in acne,” Dr. Keri said.

Although acne breakouts won’t happen to everyone who uses whey protein, it’s something worth considering in teens, particularly if they fail to respond to standard therapies, she said.

Although the reason for the association hasn’t yet been “teased out,” whey protein is derived from cow’s milk, and it appears to be related to activation of the insulin cascade, explained Dr. Keri.

Dr. Nanette B. Silverberg of the Mount Sinai Health System, New York, author of the case series involving the five male athletes, noted that milk is known to be associated with acne and suggested that whey protein may be the fraction of dairy products that promote acne formation.

Similarly, based on findings from a study of five adult male bodybuilders who developed moderate to severe facial or truncal acne after consuming whey protein, Dr. Thierry Simonart of Brussels noted that the observations are “in line with biochemical and epidemiological data supporting the effects of milk and dairy products as enhancers of insulin/insulin-like growth factor 1 signaling and acne aggravation” (Dermatology 2012;225:256-8).

Dr. Kerri reported having no relevant disclosures.

MIAMI BEACH – Acne on the face and trunk in adolescents could be associated with the use of whey protein supplements, according to Dr. Jonette E. Keri.

Teenage boys, especially, may use whey protein supplements in an effort to increase muscle mass or gain weight, Dr. Keri of the University of Miami said at the South Beach Symposium.

She cited a 2012 case series of five male teenage athletes aged 14-18 years who were using whey protein shakes or reconstituted powder. The teens presented with moderate to severe acne that responded poorly to standard treatment, but four of the five experienced clearing of the acne upon discontinuation of the whey protein supplement.

marekuliasz/Thinkstock.com

All five had been treated unsuccessfully with traditional therapies, including oral antibiotics, topical retinoids, and benzoyl peroxide. One teen stopped using the whey protein immediately after being counseled to do so, and he experienced improvement. Two teens didn’t stop using whey protein immediately but experienced improvement in their acne when they did discontinue it. Another teen experienced clearing after discontinuing the whey protein during a second course of isotretinoin therapy, and the fifth was lost to follow-up (Cutis 2012;90:70-2).

One of the teens who cleared after discontinuing the whey protein experienced a flare of the acne when he reinitiated supplementation, Dr. Keri said.

Three of the boys were trying to build muscle for football and two were trying to gain weight, which underscores the importance of asking teens about supplement use, she noted, adding that, importantly, it’s not just boys who are affected.

In fact, a Brazilian study of 30 patients showed a very strong association between the onset or exacerbation of acne and initiation of whey protein use – and the finding was more pronounced among women than men, and among those without a personal or family history of acne (An. Bras. Dermatol. 2013;88:907-12).

In that study, subjects were examined on three occasions and followed for 60 days.

“They went the gym, wanted to work out a little bit and get bigger, took some whey, and broke out in acne,” Dr. Keri said.

Although acne breakouts won’t happen to everyone who uses whey protein, it’s something worth considering in teens, particularly if they fail to respond to standard therapies, she said.

Although the reason for the association hasn’t yet been “teased out,” whey protein is derived from cow’s milk, and it appears to be related to activation of the insulin cascade, explained Dr. Keri.

Dr. Nanette B. Silverberg of the Mount Sinai Health System, New York, author of the case series involving the five male athletes, noted that milk is known to be associated with acne and suggested that whey protein may be the fraction of dairy products that promote acne formation.

Similarly, based on findings from a study of five adult male bodybuilders who developed moderate to severe facial or truncal acne after consuming whey protein, Dr. Thierry Simonart of Brussels noted that the observations are “in line with biochemical and epidemiological data supporting the effects of milk and dairy products as enhancers of insulin/insulin-like growth factor 1 signaling and acne aggravation” (Dermatology 2012;225:256-8).

Dr. Kerri reported having no relevant disclosures.

MIAMI BEACH – Acne on the face and trunk in adolescents could be associated with the use of whey protein supplements, according to Dr. Jonette E. Keri.

Teenage boys, especially, may use whey protein supplements in an effort to increase muscle mass or gain weight, Dr. Keri of the University of Miami said at the South Beach Symposium.

She cited a 2012 case series of five male teenage athletes aged 14-18 years who were using whey protein shakes or reconstituted powder. The teens presented with moderate to severe acne that responded poorly to standard treatment, but four of the five experienced clearing of the acne upon discontinuation of the whey protein supplement.

marekuliasz/Thinkstock.com

All five had been treated unsuccessfully with traditional therapies, including oral antibiotics, topical retinoids, and benzoyl peroxide. One teen stopped using the whey protein immediately after being counseled to do so, and he experienced improvement. Two teens didn’t stop using whey protein immediately but experienced improvement in their acne when they did discontinue it. Another teen experienced clearing after discontinuing the whey protein during a second course of isotretinoin therapy, and the fifth was lost to follow-up (Cutis 2012;90:70-2).

One of the teens who cleared after discontinuing the whey protein experienced a flare of the acne when he reinitiated supplementation, Dr. Keri said.

Three of the boys were trying to build muscle for football and two were trying to gain weight, which underscores the importance of asking teens about supplement use, she noted, adding that, importantly, it’s not just boys who are affected.

In fact, a Brazilian study of 30 patients showed a very strong association between the onset or exacerbation of acne and initiation of whey protein use – and the finding was more pronounced among women than men, and among those without a personal or family history of acne (An. Bras. Dermatol. 2013;88:907-12).

In that study, subjects were examined on three occasions and followed for 60 days.

“They went the gym, wanted to work out a little bit and get bigger, took some whey, and broke out in acne,” Dr. Keri said.

Although acne breakouts won’t happen to everyone who uses whey protein, it’s something worth considering in teens, particularly if they fail to respond to standard therapies, she said.

Although the reason for the association hasn’t yet been “teased out,” whey protein is derived from cow’s milk, and it appears to be related to activation of the insulin cascade, explained Dr. Keri.

Dr. Nanette B. Silverberg of the Mount Sinai Health System, New York, author of the case series involving the five male athletes, noted that milk is known to be associated with acne and suggested that whey protein may be the fraction of dairy products that promote acne formation.

Similarly, based on findings from a study of five adult male bodybuilders who developed moderate to severe facial or truncal acne after consuming whey protein, Dr. Thierry Simonart of Brussels noted that the observations are “in line with biochemical and epidemiological data supporting the effects of milk and dairy products as enhancers of insulin/insulin-like growth factor 1 signaling and acne aggravation” (Dermatology 2012;225:256-8).

Dr. Kerri reported having no relevant disclosures.

MIAMI BEACH – Acne flares on the chin can usually be managed in women with oral contraceptive therapy and spironolactone, according to Dr. Diane Berson.

These acne breakouts may be just a few pimples and are often related to the menstrual cycle, Dr. Berson of Cornell University and New York Presbyterian Hospital, both in New York, said at the South Beach Symposium.

“We know that women do develop premenstrual acne,” she said, citing a 2014 survey in which 65% of 105 respondents reported worsening of acne with their menstrual cycles, and 56% of those women reported acne in the week preceding menses (J. Clin. Aesthet. Dermatol. 2014;7:30-4).

Stress also seems to play a role, with another recent study showing that various stress factors including noise, socioeconomic pressures, light stimuli, and sleep deprivation also contribute to acne breakouts – again, often on the chin, she noted.

Oral contraceptives decrease testosterone, thereby reducing sebum production and, hopefully, acne breakouts, she said. With the traditional 21-day active/7-day inactive oral contraceptives, women tend to have acne flares during the 7-day inactive part of the treatment cycle, so increasing the active treatment cycle to 24 days of active therapy and 4 days of “blanks” can limit premenstrual syndrome and acne breakouts.

Contraceptive patches and rings provide a more continuous release of estrogen, so these products may also be helpful for women with hormonally induced acne, she added.

“Spironolactone is a great adjunct,” she said, noting that “it is inexpensive, really has minimal side effects, and women notice they get fewer hormonal breakouts when they are on it.”

A dose of 25-50 mg of spironolactone is usually sufficient, she said. “I have gone up to 100 mg, but my average patient is on 50 mg.” Patients also taking a drospirenone-containing oral contraceptive such as Yaz or Yasmin, get 25 mg of spironolactone, because they are already getting the equivalent of 25 mg in the oral contraceptive.

In another study, adding spironolactone to topical retinoid treatment led to a superior response to retinoids alone in the treatment of female adult cyclical acne (J. Drugs Dermatol. 2014;13:126-9), she noted.

“For our women patients with acne, a big part of our management is maintenance therapy,” she concluded. With hormonal flares, “I find that the best maintenance is a topical retinoid paired with either an oral contraceptive pill or spironolactone. That way you are giving them a topical comedolytic to decrease their clogging, and the hormonal treatment to decrease their hormonally induced flares.”

Dr. Berson is a consultant for Allergan, Galderma, Kythera Biopharmaceuticals, La Roche-Posay, Procter & Gamble, and Valeant Pharmaceuticals International.

MIAMI BEACH – Acne flares on the chin can usually be managed in women with oral contraceptive therapy and spironolactone, according to Dr. Diane Berson.

These acne breakouts may be just a few pimples and are often related to the menstrual cycle, Dr. Berson of Cornell University and New York Presbyterian Hospital, both in New York, said at the South Beach Symposium.

“We know that women do develop premenstrual acne,” she said, citing a 2014 survey in which 65% of 105 respondents reported worsening of acne with their menstrual cycles, and 56% of those women reported acne in the week preceding menses (J. Clin. Aesthet. Dermatol. 2014;7:30-4).

Stress also seems to play a role, with another recent study showing that various stress factors including noise, socioeconomic pressures, light stimuli, and sleep deprivation also contribute to acne breakouts – again, often on the chin, she noted.

Oral contraceptives decrease testosterone, thereby reducing sebum production and, hopefully, acne breakouts, she said. With the traditional 21-day active/7-day inactive oral contraceptives, women tend to have acne flares during the 7-day inactive part of the treatment cycle, so increasing the active treatment cycle to 24 days of active therapy and 4 days of “blanks” can limit premenstrual syndrome and acne breakouts.

Contraceptive patches and rings provide a more continuous release of estrogen, so these products may also be helpful for women with hormonally induced acne, she added.

“Spironolactone is a great adjunct,” she said, noting that “it is inexpensive, really has minimal side effects, and women notice they get fewer hormonal breakouts when they are on it.”

A dose of 25-50 mg of spironolactone is usually sufficient, she said. “I have gone up to 100 mg, but my average patient is on 50 mg.” Patients also taking a drospirenone-containing oral contraceptive such as Yaz or Yasmin, get 25 mg of spironolactone, because they are already getting the equivalent of 25 mg in the oral contraceptive.

In another study, adding spironolactone to topical retinoid treatment led to a superior response to retinoids alone in the treatment of female adult cyclical acne (J. Drugs Dermatol. 2014;13:126-9), she noted.

“For our women patients with acne, a big part of our management is maintenance therapy,” she concluded. With hormonal flares, “I find that the best maintenance is a topical retinoid paired with either an oral contraceptive pill or spironolactone. That way you are giving them a topical comedolytic to decrease their clogging, and the hormonal treatment to decrease their hormonally induced flares.”

Dr. Berson is a consultant for Allergan, Galderma, Kythera Biopharmaceuticals, La Roche-Posay, Procter & Gamble, and Valeant Pharmaceuticals International.

MIAMI BEACH – Acne flares on the chin can usually be managed in women with oral contraceptive therapy and spironolactone, according to Dr. Diane Berson.

These acne breakouts may be just a few pimples and are often related to the menstrual cycle, Dr. Berson of Cornell University and New York Presbyterian Hospital, both in New York, said at the South Beach Symposium.

“We know that women do develop premenstrual acne,” she said, citing a 2014 survey in which 65% of 105 respondents reported worsening of acne with their menstrual cycles, and 56% of those women reported acne in the week preceding menses (J. Clin. Aesthet. Dermatol. 2014;7:30-4).

Stress also seems to play a role, with another recent study showing that various stress factors including noise, socioeconomic pressures, light stimuli, and sleep deprivation also contribute to acne breakouts – again, often on the chin, she noted.

Oral contraceptives decrease testosterone, thereby reducing sebum production and, hopefully, acne breakouts, she said. With the traditional 21-day active/7-day inactive oral contraceptives, women tend to have acne flares during the 7-day inactive part of the treatment cycle, so increasing the active treatment cycle to 24 days of active therapy and 4 days of “blanks” can limit premenstrual syndrome and acne breakouts.

Contraceptive patches and rings provide a more continuous release of estrogen, so these products may also be helpful for women with hormonally induced acne, she added.

“Spironolactone is a great adjunct,” she said, noting that “it is inexpensive, really has minimal side effects, and women notice they get fewer hormonal breakouts when they are on it.”

A dose of 25-50 mg of spironolactone is usually sufficient, she said. “I have gone up to 100 mg, but my average patient is on 50 mg.” Patients also taking a drospirenone-containing oral contraceptive such as Yaz or Yasmin, get 25 mg of spironolactone, because they are already getting the equivalent of 25 mg in the oral contraceptive.

In another study, adding spironolactone to topical retinoid treatment led to a superior response to retinoids alone in the treatment of female adult cyclical acne (J. Drugs Dermatol. 2014;13:126-9), she noted.

“For our women patients with acne, a big part of our management is maintenance therapy,” she concluded. With hormonal flares, “I find that the best maintenance is a topical retinoid paired with either an oral contraceptive pill or spironolactone. That way you are giving them a topical comedolytic to decrease their clogging, and the hormonal treatment to decrease their hormonally induced flares.”

Dr. Berson is a consultant for Allergan, Galderma, Kythera Biopharmaceuticals, La Roche-Posay, Procter & Gamble, and Valeant Pharmaceuticals International.

A collagen dermal filler already on the market has been approved for improving the appearance of acne scars in people aged 21 years and older.

The filler, made of bovine collagen and nonabsorbable polymethylmethacrylate beads (PMMA microspheres), with a small amount of lidocaine, was approved for the correction of “moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over the age of 21 years,” according to the Food and Drug Administration’s approval letter, dated Dec. 23, 2014.

The filler is marketed as Bellafill by Suneva Medical; it was formerly marketed as ArteFill. In December, the brand name was changed to Bellafill, according to the company. The filler was approved in 2006 for the correction of nasolabial folds and is the first permanent filler approved by the FDA for treating acne scars, an FDA spokesperson said.

In a clinical trial, one or two injections were needed to improve the appearance of acne scars, and the effect lasted more than 1 year, according to the FDA’s summary of approval-related information. Side effects included lumps at the injection site, redness, swelling, pain, tenderness, and itching. Contraindications included severe allergies, a positive response to the Bellafill skin test (which is required), allergies to lidocaine or cow tissue products, and bleeding disorders.

Approval was based on the multicenter U.S. study of patients aged 21 years and older with moderate to severe atrophic distensible facial acne scars on the cheek. The patients were randomized to Bellafill or sterile saline injections. Their mean age was 45 years, and about 60% were women.

At 6 months, 56 of 87 patients (64%) treated with Bellafill had at least a 2-point improvement on the 4-point Acne Scar Rating Scale for at least half of the treated scars (as assessed by a blinded evaluator), the primary endpoint. Of the 46 controls, 15 (33%) met this endpoint, and this difference was statistically significant.

Patient responses were among the endpoints evaluated in the study. At 6 months, 77% of those treated with Bellafill thought the appearance of scars had “improved” or had “much improved,” based on the Subject Global Aesthetic Improvement Scale ( a secondary endpoint), compared with 41% of controls.

Information on the approval is available on the FDA website at www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfTopic/pma/pma.cfm?num=P020012S009.

Adverse events for this product or other drugs and devices should be reported to the FDA’s MedWatch program at 800-332-1088 or www.fda.gov/Safety/MedWatch/.

[email protected]

A collagen dermal filler already on the market has been approved for improving the appearance of acne scars in people aged 21 years and older.

The filler, made of bovine collagen and nonabsorbable polymethylmethacrylate beads (PMMA microspheres), with a small amount of lidocaine, was approved for the correction of “moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over the age of 21 years,” according to the Food and Drug Administration’s approval letter, dated Dec. 23, 2014.

The filler is marketed as Bellafill by Suneva Medical; it was formerly marketed as ArteFill. In December, the brand name was changed to Bellafill, according to the company. The filler was approved in 2006 for the correction of nasolabial folds and is the first permanent filler approved by the FDA for treating acne scars, an FDA spokesperson said.

In a clinical trial, one or two injections were needed to improve the appearance of acne scars, and the effect lasted more than 1 year, according to the FDA’s summary of approval-related information. Side effects included lumps at the injection site, redness, swelling, pain, tenderness, and itching. Contraindications included severe allergies, a positive response to the Bellafill skin test (which is required), allergies to lidocaine or cow tissue products, and bleeding disorders.

Approval was based on the multicenter U.S. study of patients aged 21 years and older with moderate to severe atrophic distensible facial acne scars on the cheek. The patients were randomized to Bellafill or sterile saline injections. Their mean age was 45 years, and about 60% were women.

At 6 months, 56 of 87 patients (64%) treated with Bellafill had at least a 2-point improvement on the 4-point Acne Scar Rating Scale for at least half of the treated scars (as assessed by a blinded evaluator), the primary endpoint. Of the 46 controls, 15 (33%) met this endpoint, and this difference was statistically significant.

Patient responses were among the endpoints evaluated in the study. At 6 months, 77% of those treated with Bellafill thought the appearance of scars had “improved” or had “much improved,” based on the Subject Global Aesthetic Improvement Scale ( a secondary endpoint), compared with 41% of controls.

Information on the approval is available on the FDA website at www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfTopic/pma/pma.cfm?num=P020012S009.

Adverse events for this product or other drugs and devices should be reported to the FDA’s MedWatch program at 800-332-1088 or www.fda.gov/Safety/MedWatch/.

[email protected]

A collagen dermal filler already on the market has been approved for improving the appearance of acne scars in people aged 21 years and older.

The filler, made of bovine collagen and nonabsorbable polymethylmethacrylate beads (PMMA microspheres), with a small amount of lidocaine, was approved for the correction of “moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over the age of 21 years,” according to the Food and Drug Administration’s approval letter, dated Dec. 23, 2014.

The filler is marketed as Bellafill by Suneva Medical; it was formerly marketed as ArteFill. In December, the brand name was changed to Bellafill, according to the company. The filler was approved in 2006 for the correction of nasolabial folds and is the first permanent filler approved by the FDA for treating acne scars, an FDA spokesperson said.

In a clinical trial, one or two injections were needed to improve the appearance of acne scars, and the effect lasted more than 1 year, according to the FDA’s summary of approval-related information. Side effects included lumps at the injection site, redness, swelling, pain, tenderness, and itching. Contraindications included severe allergies, a positive response to the Bellafill skin test (which is required), allergies to lidocaine or cow tissue products, and bleeding disorders.

Approval was based on the multicenter U.S. study of patients aged 21 years and older with moderate to severe atrophic distensible facial acne scars on the cheek. The patients were randomized to Bellafill or sterile saline injections. Their mean age was 45 years, and about 60% were women.

At 6 months, 56 of 87 patients (64%) treated with Bellafill had at least a 2-point improvement on the 4-point Acne Scar Rating Scale for at least half of the treated scars (as assessed by a blinded evaluator), the primary endpoint. Of the 46 controls, 15 (33%) met this endpoint, and this difference was statistically significant.

Patient responses were among the endpoints evaluated in the study. At 6 months, 77% of those treated with Bellafill thought the appearance of scars had “improved” or had “much improved,” based on the Subject Global Aesthetic Improvement Scale ( a secondary endpoint), compared with 41% of controls.

Information on the approval is available on the FDA website at www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfTopic/pma/pma.cfm?num=P020012S009.

Adverse events for this product or other drugs and devices should be reported to the FDA’s MedWatch program at 800-332-1088 or www.fda.gov/Safety/MedWatch/.

[email protected]

Tanghetti et al (J Drugs Dermatol. 2015;14:33-40) discuss the use of topical brimonidine for the redness associated with rosacea. Brimonidine is the newest therapeutic to combat the erythema associated with rosacea of all subtypes. It is a topical α₂-adrenergic agonist that causes peripheral vasoconstriction via a direct effect on smooth muscle receptors. The authors describe 2 large studies that studied the safety and efficacy of topical brimonidine and also give consensus recommendations regarding optimal utilization while minimizing adverse effects, such as the “rebound” phenomena described. It is important to note that it is not a traditional rebound effect, as it does not occur once the medication has stopped; however, it is a worsening of the erythema during active treatment with brimonidine. The authors discuss the various cases reported to the manufacturer after the medication was released. The most frequently associated side effects reported were erythema in almost all cases, flushing, feeling of heat or burning sensation, and rarely pain. Other issues such as dermatitis, pruritus, facial swelling, and pallor were seen in less than 10% of reports each.

These rebound effects were most likely to occur in the first 15 days after initiation of therapy, mainly in the first week. They also were noticed at 2 other time points—3 to 6 hours and 10 to 12 hours after application—which allowed the identification of 2 types of reactions based on the time to onset postapplication: appearing within 3 to 6 hours and observed after 10 to 12 hours. These events have been given new names. “Paradoxical erythema” is the redness appearing within 3 to 6 hours after application, which can be worse than baseline. “Exaggerated recurrence of erythema” is the redness that is greater than baseline and occurs as therapy wears off, approximately 10 to 12 hours after application. Allergic contact dermatitis also has been associated with the medication and can therefore be a source of redness 3 to 4 months after initiation.

What’s the issue?

The erythema associated with rosacea can be a distressing symptom for both the patient and the dermatologist. It can be difficult to treat and quite often recalcitrant to multiple treatments. Although pulsed dye laser is an effective therapy for treating telangiectases and dilated blood vessels, it can be expensive for many patients. Topical brimonidine represents a novel therapeutic to combat one of the most remarkable symptoms of rosacea. However, because of the possibility of this increased redness after use, Tanghetti et al suggest the following treatment algorithm:

• “Assess” the patient and rule out other causes of redness or associated conditions, such as seborrheic dermatitis or lupus.
• “Educate” the patient regarding the known triggers of rosacea flair and how they can be best avoided. Also educate that brimonidine only treats redness and not the papules, pustules, or other symptoms of rosacea.
• “Inhibit” inflammation that is currently present using gentle skin care practices, mild cleansers, and barrier-restoring emollients.
• “Optimize” the application of brimonidine. Instruct how to apply a pea-sized amount in the morning or how patients can best time the application to coincide with daily events or social events.
• “Understand” that worsening redness may occur, which can be key to patient satisfaction. Patients should be made aware that there is a risk for worsening redness in 10% to 20% of patients. It usually occurs within the first 2 weeks of starting the medication and it may be seen soon after application (3–6 hours) or after treatment has subsided (10–12 hours). Generally this worsening will subside within 12 to 24 hours after discontinuation. Also symptoms can be treated throughout with the use of nonsteroidal anti-inflammatory medications, antihistamines, topical calcineurin inhibitors, and topical steroids, if necessary.

What has been your experience with brimonidine gel and how do you manage these patients?

We want to know your views! Tell us what you think.

Tanghetti et al (J Drugs Dermatol. 2015;14:33-40) discuss the use of topical brimonidine for the redness associated with rosacea. Brimonidine is the newest therapeutic to combat the erythema associated with rosacea of all subtypes. It is a topical α₂-adrenergic agonist that causes peripheral vasoconstriction via a direct effect on smooth muscle receptors. The authors describe 2 large studies that studied the safety and efficacy of topical brimonidine and also give consensus recommendations regarding optimal utilization while minimizing adverse effects, such as the “rebound” phenomena described. It is important to note that it is not a traditional rebound effect, as it does not occur once the medication has stopped; however, it is a worsening of the erythema during active treatment with brimonidine. The authors discuss the various cases reported to the manufacturer after the medication was released. The most frequently associated side effects reported were erythema in almost all cases, flushing, feeling of heat or burning sensation, and rarely pain. Other issues such as dermatitis, pruritus, facial swelling, and pallor were seen in less than 10% of reports each.

These rebound effects were most likely to occur in the first 15 days after initiation of therapy, mainly in the first week. They also were noticed at 2 other time points—3 to 6 hours and 10 to 12 hours after application—which allowed the identification of 2 types of reactions based on the time to onset postapplication: appearing within 3 to 6 hours and observed after 10 to 12 hours. These events have been given new names. “Paradoxical erythema” is the redness appearing within 3 to 6 hours after application, which can be worse than baseline. “Exaggerated recurrence of erythema” is the redness that is greater than baseline and occurs as therapy wears off, approximately 10 to 12 hours after application. Allergic contact dermatitis also has been associated with the medication and can therefore be a source of redness 3 to 4 months after initiation.

What’s the issue?

The erythema associated with rosacea can be a distressing symptom for both the patient and the dermatologist. It can be difficult to treat and quite often recalcitrant to multiple treatments. Although pulsed dye laser is an effective therapy for treating telangiectases and dilated blood vessels, it can be expensive for many patients. Topical brimonidine represents a novel therapeutic to combat one of the most remarkable symptoms of rosacea. However, because of the possibility of this increased redness after use, Tanghetti et al suggest the following treatment algorithm:

• “Assess” the patient and rule out other causes of redness or associated conditions, such as seborrheic dermatitis or lupus.
• “Educate” the patient regarding the known triggers of rosacea flair and how they can be best avoided. Also educate that brimonidine only treats redness and not the papules, pustules, or other symptoms of rosacea.
• “Inhibit” inflammation that is currently present using gentle skin care practices, mild cleansers, and barrier-restoring emollients.
• “Optimize” the application of brimonidine. Instruct how to apply a pea-sized amount in the morning or how patients can best time the application to coincide with daily events or social events.
• “Understand” that worsening redness may occur, which can be key to patient satisfaction. Patients should be made aware that there is a risk for worsening redness in 10% to 20% of patients. It usually occurs within the first 2 weeks of starting the medication and it may be seen soon after application (3–6 hours) or after treatment has subsided (10–12 hours). Generally this worsening will subside within 12 to 24 hours after discontinuation. Also symptoms can be treated throughout with the use of nonsteroidal anti-inflammatory medications, antihistamines, topical calcineurin inhibitors, and topical steroids, if necessary.

What has been your experience with brimonidine gel and how do you manage these patients?

We want to know your views! Tell us what you think.

Tanghetti et al (J Drugs Dermatol. 2015;14:33-40) discuss the use of topical brimonidine for the redness associated with rosacea. Brimonidine is the newest therapeutic to combat the erythema associated with rosacea of all subtypes. It is a topical α₂-adrenergic agonist that causes peripheral vasoconstriction via a direct effect on smooth muscle receptors. The authors describe 2 large studies that studied the safety and efficacy of topical brimonidine and also give consensus recommendations regarding optimal utilization while minimizing adverse effects, such as the “rebound” phenomena described. It is important to note that it is not a traditional rebound effect, as it does not occur once the medication has stopped; however, it is a worsening of the erythema during active treatment with brimonidine. The authors discuss the various cases reported to the manufacturer after the medication was released. The most frequently associated side effects reported were erythema in almost all cases, flushing, feeling of heat or burning sensation, and rarely pain. Other issues such as dermatitis, pruritus, facial swelling, and pallor were seen in less than 10% of reports each.

These rebound effects were most likely to occur in the first 15 days after initiation of therapy, mainly in the first week. They also were noticed at 2 other time points—3 to 6 hours and 10 to 12 hours after application—which allowed the identification of 2 types of reactions based on the time to onset postapplication: appearing within 3 to 6 hours and observed after 10 to 12 hours. These events have been given new names. “Paradoxical erythema” is the redness appearing within 3 to 6 hours after application, which can be worse than baseline. “Exaggerated recurrence of erythema” is the redness that is greater than baseline and occurs as therapy wears off, approximately 10 to 12 hours after application. Allergic contact dermatitis also has been associated with the medication and can therefore be a source of redness 3 to 4 months after initiation.

What’s the issue?

The erythema associated with rosacea can be a distressing symptom for both the patient and the dermatologist. It can be difficult to treat and quite often recalcitrant to multiple treatments. Although pulsed dye laser is an effective therapy for treating telangiectases and dilated blood vessels, it can be expensive for many patients. Topical brimonidine represents a novel therapeutic to combat one of the most remarkable symptoms of rosacea. However, because of the possibility of this increased redness after use, Tanghetti et al suggest the following treatment algorithm:

• “Assess” the patient and rule out other causes of redness or associated conditions, such as seborrheic dermatitis or lupus.
• “Educate” the patient regarding the known triggers of rosacea flair and how they can be best avoided. Also educate that brimonidine only treats redness and not the papules, pustules, or other symptoms of rosacea.
• “Inhibit” inflammation that is currently present using gentle skin care practices, mild cleansers, and barrier-restoring emollients.
• “Optimize” the application of brimonidine. Instruct how to apply a pea-sized amount in the morning or how patients can best time the application to coincide with daily events or social events.
• “Understand” that worsening redness may occur, which can be key to patient satisfaction. Patients should be made aware that there is a risk for worsening redness in 10% to 20% of patients. It usually occurs within the first 2 weeks of starting the medication and it may be seen soon after application (3–6 hours) or after treatment has subsided (10–12 hours). Generally this worsening will subside within 12 to 24 hours after discontinuation. Also symptoms can be treated throughout with the use of nonsteroidal anti-inflammatory medications, antihistamines, topical calcineurin inhibitors, and topical steroids, if necessary.

What has been your experience with brimonidine gel and how do you manage these patients?

We want to know your views! Tell us what you think.

For more information, access Dr. Feldman's article from the January 2015 issue, "The Rosacea Patient Journey: A Novel Approach to Conceptualizing Patient Experiences."

For more information, access Dr. Feldman's article from the January 2015 issue, "The Rosacea Patient Journey: A Novel Approach to Conceptualizing Patient Experiences."

For more information, access Dr. Feldman's article from the January 2015 issue, "The Rosacea Patient Journey: A Novel Approach to Conceptualizing Patient Experiences."