Elena B. Hawryluk, MD, PhD: Detailing Acne Vulgaris Management

Elena B. Hawryluk, MD, PhD, FAAD, FAAP

Acne is one of the most common dermatological conditions in the world, and though it affects children and adults alike the implications of this condition on pediatric groups has always been of particular concern.

Elena B. Hawryluk, MD, PhD, FAAD, FAAP, Massachusetts General Hospital Dermatology, detailed some of the burdens of acne on younger populations in her session "What's New in Acne Vulgaris Management?", which was presented at the American Academy of Pediatrics 2021 Virtual Conference.

In an interview with HCPLive, Hawryluk spoke of some of the data presented in her session this weekend.

HCPLive: Acne Vulgaris affects roughly 9% of the world’s population, but what is its prevalence in pediatric populations? What are some of the complications that younger patients face with this skin disease?

Elena B. Hawryluk, MD, PhD: Acne is estimated to affect approximately 85% of the population at some point in their lives. In pediatric patients, the prevalence of acne is 35-95%. Adolescence is a time when children are forming a more concrete sense of self and social structures and peer relationships begin to play an increasingly important role in their lives. Acne during this time can have significant psychosocial impacts, severely affect self-confidence and quality of life.

HCPLive: What are some of the acne management or treatment guidelines expressed by institutions such as the American Academy of Dermatology that clinicians generally adhere to? What are some reliable treatment methods, and how have these guidelines evolved over time to better treat pediatric patients with atopic diseases?

Hawryluk, MD, PhD: The American Academy of Dermatology published an updated evidence-based management guideline in the Journal of the American Academy of Dermatology (JAAD) in 2016 and there was an additional “practical” management update published in JAAD by a consensus work group in 2018. First-line treatment with topical retinoids and benzoyl peroxide is recommended for most patients, and isotretinoin for patients with very severe cystic or conglobate acne. Antibiotic stewardship is increasingly important and oral antibiotic monotherapy should be avoided – the topic of antibiotic stewardship has prompted evolution of guidelines in recent years.There is an increasingly appreciated role for hormonal therapies, such as oral contraceptives and spironolactone, even in the pediatric population.

HCPLive: Can you touch on some of the types of acne a young patient might encounter, and how the severity of these types of acne may differ in individual cases? What are some complications and treatments for each type of acne discussed in your session?

Hawryluk, MD, PhD: There is a 4-point classification system based on European evidence-based guidelines that can be used to classify acne type and severity and can help meaningfully guide treatment. Class I (mild) is comedonal acne, class II (moderate) is mild to moderate papulopustular acne, class III (severe) is severe papulopustular and moderate nodular acne, and class IV (very severe) is severe nodular/cystic acne and conglobate acne.

Scarring, whether atrophic or hypertrophic, and pigmentary changes can present as more long-term issues as a result of under- or untreated severe acne.

Some other forms of “acne” include “fungal acne” which is caused by a yeast (Malassezia) and presents a bit differently (i.e., itchy and monomorphic along the hairline/forehead/chest/back) and can be treated with an antifungal shampoo.

Lastly, there are rare instances when acne may be a good sign – as is the case with acneiform eruptions secondary to EGFR inhibitors. When children are on these medications, acneiform eruptions have been associated with positive outcomes and strongly correlate with survival.

HCPLive: What role do patients, caregivers, and clinicians play in establishing an effective treatment plan? What can be done by all parties involved in the management of a skin disease such as acne vulgaris?

Hawryluk, MD, PhD: Children may be hesitant to bring up their acne with clinicians out of embarrassment or lack of knowledge of treatment options. A recent survey study showed that when acne is discussed, patients are overwhelmingly dissatisfied with the information they receive (Tan et al, J Drugs Dermatol ,2021). It is important to discuss acne and treatment options routinely as acne can have profound effects on mental, emotional, and social well-being, particularly in children. Setting realistic expectations can improve adherence to treatment and the simpler the routine, the more likely the patient is to adhere to it.

Treating acne requires patients to be diligent about their skin care routine, so nonadherence is a major barrier to successful treatment. Caregivers can help by using positive reinforcement at home to encourage using medications as prescribed.Prescribers may incorporate patient preferences when developing the plan so maximize compliance.

HCPLive: Can you touch on some of the novel therapies that are detailed in your session?

Hawryluk, MD, PhD: There are several emerging therapies on the horizon, including new formulations of existing medications and novel modalities as well. During this talk I provide an overview of a new narrow narrow-spectrum tetracycline with anti-inflammatory properties with a narrow side effect profile.There are novel formulations of antibiotics as foam, topical hormonal therapies, and a 4th generation topical retinoid.nAll of these medications are new and cost, accessibility and lack of direct comparison with other acne treatment modalities should be taken into consideration.

HCPLive: How do you devise effective treatment plans for affected patients? What can be done to better treat this patient population in the coming years, and how would you like this area of research to evolve over time?

Hawryluk, MD, PhD: It is important to first consider what type of acne your patients have (comedonal, inflammatory, both) and determine the severity. There are many algorithms available online to help aid in appropriate medication selection. The 2018 practical management guidelines that were published in the Journal of the American Academy of Dermatology have a nice summary table with associated pictures to help make this decision.

As always, close follow-up with re-evaluation of your treatment plan is necessary - if it's not working then change it! Attention to treating acne effectively and early would be beneficial in the coming years to reduce the amount of scarring and more permanent changes that are difficult to treat. Research efforts focusing on improving tolerability of existing therapies also be helpful.