The Treatment Gap in Acne Care: Guidelines versus Treatment Practices

Dr. Shannon Humphrey,¹ Dr. Joseph Brioux,² Dr. D'Arcy Little,³

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Abstract: Do dermatologists and GPs approach acne care differently? How do these two groups of clinicians approach acne treatment, keep abreast of the latest guidelines, and manage maintenance therapy? How will the availability of a new retinoid combination product in Canada for acne change the way acne is currently treated? To address these questions, a roundtable discussion was convened, featuring clinicians with a significant number of acne patients in their practices. Dr. Shannon Humphrey, a dermatologist, and Dr. Joseph Brioux, a family physician, and moderator Dr. D'Arcy Little, himself a family physician and radiologist, offered a candid take on guideline-based acne treatment and the effort to improve treatment outcomes among patients. The discussants addressed how each professional has tended to view acne, pursues acne care differently, and why. They also discussed the latest acne treatment guidelines as well as the depth of the gap between the generalist's versus the specialist's treatment approach.

Key Words: acne, treatment gap, antibiotic resistance, treatment adherence.

Antiobiotic resistance is a key factor to consider when establishing maintenance and treatment regimens.

Combination retinoid-based therapies are first-line treatments for acne; evidence suggests that such regimens achieve faster and more complete clearance, while addressing multiple pathogenic factors simultaneously.

Patients are often prescribed legitimate, evidence-based therapies but may abandon them after a short trial because of lack of perceived, efficacy or side effects. Address patient expectations and advise on the necessity of pursuing a sufficient course of topical therapy (e.g., 12 weeks) before drawing conclusions.

It is advisable to see patients on maintenance therapy for follow-up—attempt at least two office visits per year, and more if there is an increase in flares.

Convey to patients that acne is a chronic condition and that a sound treatment maintenance regimen is essential.

Do not give samples to patients unless supply is sufficient to pursue a 12-week trial of medication.

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New Developments in the Topical Management of Acne

Publication of THE LATEST IN ACNE CARE supplement was made possible by an unrestricted educational grant from Galderma Canada Inc.

Jerry Tan, MD, FRCPC,

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Abstract: Adapalene 0.1%/BPO 2.5% (adapalene/BPO) gel is a novel agent for acne therapy that has recently become available in Canada. This fixed-dose combination of a topical retinoid and benzoyl peroxide is efficacious in mild-moderate inflammatory acne and as an adjunct to oral antibiotics for severe acne. Adapalene 0.1%/BPO 2.5% (adapalene/BPO) gel provides synergistic efficacy, whereby efficacy of the combination exceeds the summed efficacy of individual components. Furthermore, adapalene/BPO with oral doxycycline for severe acne increases the rate of global treatment success four-fold beyond that with doxycycline alone. Practical means to abrogate the development of local intolerability have been shown to be effective.

Key Words: acne, adapalene, benzoyl peroxide, fixed-dose gel, combination, topical acne medication, retinoids.

Three of five pathogenic factors involved in acne can be addressed by topical medications: follicular hyperkeratinization, Proprionibacterium acnes proliferation, and inflammation.

The combination of retinoid and BPO in the form of adapalene 0.1%/BPO 2.5% has recently been approved in Canada, and has been advocated by an international acne expert group as a rational standard for treating mild-moderate acne as it offers complementary mechanisms of action.

An adapalene/BPO formulation provides greater proportions of global success and reduction in acne lesion counts compared to the vehicle or either agent alone.

As topical retinoids and benzoyl peroxide can be irritating, their combination may potentiate this factor. Measures to minimize intolerability include every other night application and daily moisturizer use.

For the treatment of mild-moderate acne, the fixed-dose adapalene and BPO gel combination may enhance treatment efficacy and adherence through improved ease of use.

Benzoyl peroxide does not induce bacterial resistance.

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Hyperhidrosis: A Common Problem

Christian A. Murray MD, FRCPC, Assistant Professor, Division of Dermatology, University of Toronto, Women's College Hospital, Toronto, ON,
Nowell Solish MD, FRCPC, Assistant Professor, Division of Dermatology, University of Toronto, Women's College Hospital, Toronto, ON

Abstract
Focal hyperhidrosis is a disorder of idiopathic excessive sweating that typically affects the axillae, soles, palms, and face. This common problem may be associated with considerable physical, psychosocial, and occupational impairments. Current therapeutic strategies include topical aluminum salts, tap-water iontophoresis, oral anticholinergic agents, local surgical approaches, and sympathectomies. Although non-surgical treatment complications are typically transient, surgical adverse events may be permanent and significant. Considerable evidence suggests that botulinum toxin type A (BTX-A) injections into hyperhidrotic areas can considerably reduce focal sweating in multiple areas without major side effects. BTX-A has therefore shown promise as a potential replacement for more invasive treatments if topical options have failed.
Keywords: hyperhidrosis, botulinum toxin, axilla.

Psoriasis in Older Adults

Carrie Lynde, MD, Dermatology PGY-1, University of Toronto, Toronto, ON.
John Kraft, MD, Dermatology PGY-4, University of Toronto, Toronto, ON.
Charles Lynde, MD, FRCPC, Assistant Professor, Division of Dermatology, University of Toronto; Dermatology consultant for Metropolitan Homes for the Aged, Toronto; Markham Stouffville Hospital; Scarborough Grace Hospital, Toronto, ON.

Psoriasis is a chronic relapsing skin disease. Age of onset is bimodal with a peak in second to third decades and the sixth decade. Individuals affected by psoriasis usually complain of lower self-esteem. Choice of therapy depends on many factors, including areas affected, extent of disease, patient’s lifestyle, other health problems, and medications. Many effective therapies exist, including topicals, phototherapy, systemics, and biologicals.
Key words: psoriasis, comorbidities, topical steroids, phototherapy, biologics.

Skin Manifestations of Internal Disease in Older Adults

William Lear, MD, FRCPC, FAAD, Dermatologist, Silver Falls Dermatology PC, Salem, OR, USA.
Jennifer Akeroyd, RN, PhD student, Oregon Health & Science University, Portland, OR, USA.

In this article, we discuss skin findings affecting older adults, with a focus on pruritus, flushing, dermatitis, and ulcers, and consider related internal diseases. Our goal is to make this information readily transferable to the clinical setting for the non-dermatologist.
Key words: dermatology, skin manifestations, older adults, pruritus, flushing, dermatitis, ulcers.

Beauty Is Skin Deep

The skin is our largest organ and is the “face” that we show the world, yet it seems to be held in relatively low esteem by some medical practitioners. This is clearly not a logical position, as dermatological diseases can at times be lethal and may frequently result in severe impairment of quality of life. One only has to watch television ads or read magazines to realize that the general public has a very high regard for things dermatological. Dermatological medical practice rewards bedside clinical acumen more than many other specialties. Although high tech diagnosis is available in dermatology, most diagnoses are based predominantly on history and physical. I suspect that this makes dermatological practice particularly satisfying. Certainly, the dermatologists I know seem to love their practice.

Our focus articles this month are, of course, concerned with dermatology. For family doctors and internists, the skin can be an important source of information about other types of disease. This area is addressed in this month’s CME article “Skin Manifestations of Internal Disease in Older Adults” by Dr. William Lear and Jennifer Akroyd. Psoriasis is extraordinarily common in the general population, and is clearly more than just a skin disorder, although that is its most important manifestation. Like all chronic disorders, management can be quite tricky. This topic is covered in the article “Psoriasis in Older Adults” by Dr. Carrie Lynde, Dr. John Kraft and Dr. Charles Lynde.

Of course, we have our usual array of articles on diverse topics related to health care of the older adult. The management of hypertension, regardless of age, seems to be under constant evolution, and that is certainly very true of hypertension after the age of 80. This topic is ably reviewed in the article “Treating Hypertension in the Very Elderly Reduces Death and Disability: New Information from the HYVET Trial” by Drs. M. Faisal Jhandir, Robert J. Herman, and Norm R.C. Campbell. One of the major duties of a physician is to relieve suffering, particularly from pain. However, survey after survey shows that we do a poor job in pain management for those people with cognitive impairment. This shortcoming is addressed in the article “Pain Management in Moderate and Advanced Dementias” by Drs. Eric Widera and Dr. Alex Smith. The complicated issue of neuropathic pain and how we can reduce the suffering of those patients experiencing it is discussed by Dr. Jackie Gardner-Nix in her article “Neuropathic Pain in Older Adults.” I have a fondness for information developed at my own university, and progressive supranuclear palsy is a disorder first described at Toronto General Hospital and the University of Toronto. It is fitting that U of T has an internationally acclaimed Movement Disorders Program (now based at Toronto Western Hospital) and we are very proud to regularly publish articles from that group. This month’s contribution is “Diagnosis and Management of Progressive Supranuclear Palsy” by Dr. Amitabh Gupta and Dr. Susan Fox.

Enjoy this issue,
Barry Goldlist

Facial Rejuvenation in the Aging Population

Jeffrey A. Fialkov, MD, MSc, FRCSC, Assistant Professor, Division of Plastic Surgery, Department of Surgery, University of Toronto; Staff Plastic Surgeon, Sunnybrook Health Sciences Centre, Toronto, ON.

This article reviews surgical and nonsurgical rejuvenation techniques as they relate to the anatomic changes that occur with facial aging. An understanding of the changes that occur to the facial soft tissues and their support structures over time and with exposure to the elements facilitates individualized treatment optimization for older adults seeking facial rejuvenation. In addition, treatment optimization must take into account the patient’s underlying medical status and personal psychosocial concerns.
Key words: facial rejuvenation, cosmetic surgery, facial aging, noninvasive rejuvenation, photoaging.

Older Adults and Burns

Kristen Davidge, MD, Plastic Surgery Resident; Candidate, Master of Surgical Science, Department of Surgery, University of Toronto, ON.
Joel Fish, MD, MSc, FRCS(C), Burn Surgeon, Ross Tilley Burn Unit, Sunnybrook Health Sciences Centre; Chief Medical Officer, St. Johns Rehab Hospital; Associate Professor, Department of Surgery, University of Toronto; Director of Research, Division of Plastic Surgery, University of Toronto, Toronto, ON.

Burn injury among older adults will result in significant morbidity and mortality despite the many advances in burn treatment. Many adult burn units in North America admit and treat a significant number of older adults so understanding the issues and problems specific to this age group is important. Older adults experience specific problems with wound care, and if the injury is large, they will require critical care interventions during the course of treatment. Despite the advances in wound care and critical care that have occurred, the mortality rates of older adults with burn injuries remain quite high. This article reviews the literature on specific issues for older adults that need to be considered when treating older adults with burn injury.
Key words: burn injury, burn depth, older adults, geriatric, mortality.

Common Skin Conditions among Older Adults in Long-Term Care

Foy White-Chu, MD, Geriatric Fellow, Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Madhuri Reddy, MD, MSc, Department of Medicine, Director of the Chronic Wound Healing Program, Hebrew Rehabilitation Center; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA; Director, Wound Healing Clinic, Lahey Clinic, Burlington, MA, USA.

The skin of older adults undergoes intrinsic aging and is susceptible to multiple ailments. Both comorbidities and environmental issues increase the risk for particular skin diseases among older adults who live in long-term care facilities. This article looks at four common skin conditions frequently found among older adults living in long-term care facilities, and reviews methods of treatment and prevention.
Key words: skin, wound, skin tear, scabies, incontinence dermatitis.

Maintaining Health of the Largest Human Organ: Focus on Skin

The focus of this issue is on our largest and most visible organ, the skin. In this era of preventive medicine, it seems easy to tell our patients how to prevent skin problems: just stay out of the sun! However, the importance of sun exposure and vitamin D levels is becoming more and more apparent. Epidemiological evidence showing inverse relationships between multiple sclerosis and sun exposure has been available for years, and more recent evidence suggests that sun exposure may protect against juvenile (type I) diabetes mellitus. In adult populations, vitamin D may be important in preventing various neoplasias, and among older adults, it is protective against falls. It seems that once again, the more I learn the less I seem to know for sure. In any event, this month’s issue will provide lots of opportunity for useful learning. Our CME article this month is on “Common Skin Conditions among Older Adults in Long-Term Care” by Dr. Foy White-Chu and Dr. Madhuri Reddy. We have an article on “Older Adults and Burns” by Dr. Joel Fish and Dr. Kristen Davidge, and then in recognition of how much we value our looks, we have an article on “Facial Rejuvenation in the Aging Population” by Dr. Jeffrey Fialkov. As well, our cancer column this month is on a cutaneous malignancy, namely “Malignant Melanoma among Older Adults” by Drs. Wey Leong, Alexandra Easson and Michael Reedijk.

As well, we have our usual collection of articles on other important topics concerning older adults. “The Role of Peripheral Arterial Disease in the Pathogenesis of Diabetic Foot Disease: When to Refer for Vascular Surger” is by Dr. Robert Hinchcliffe and Dr. William Jeffcoate and provides practical advice to the primary care physician. Our Dementia column this month looks at “Dementia Related to Alcohol and Other Drugs” and is by Dr. Kiran Rabheru. Decubitus ulcers are a major health care problem among older adults, with multiple factors involved in their etiology and pathogenesis. A major factor is discussed in the article “The Role of Nutrition in the Prevention and Management of Pressure Ulcers” by Zena Moore and Dr. Seamus Cowman. As our population of patients with end-stage renal disease ages, the population undergoing transplantation is also aging. Combined with the prolonged survival that many patients currently experience after transplantation, we are seeing many more older renal transplant recipients. Some of the issues these patients present with are discussed in the article “Primary Care Issues in Renal Transplant Recipients” by Dr. Jeffery Schiff.

Enjoy this issue,
Barry Goldlist