Feedback EADV 2018

Conference summaries

Acne

Treatment Algorithms

Presented by: Alison Layton, MD
Harrogate and District NHS Foundation Trust, Harrogate, and Hull York Medical School, UK

Treatment algorithms are much different than traditional guidelines in that they are precise and detailed plans for a regimen over time, where guidelines review evidence over a study period in a well-defined population. Algorithms are practical as they provide dermatologists information that can be used every day to deliver evidence-based care consistently and in a standardized fashion.

Many algorithms for acne are published within or alongside the context of guidelines. However, there are two main limitations that must be considered: 1) they are based on severity and/or lesion type, and are not reflective of specific patient features and 2) patients’ perspectives not reflected.

In 2016, 17 acne experts reviewed existing highly cited evidence-based guidelines and developed three acne-specific algorithms based on the following types of acne:1

  • Comedonal
  • Papulopustular
  • Nodular/conglobate.

This approach was very useful for dermatologists as it provided a sense of how to address a complicated patient as well as provided checklists and a global evaluation scale.1

There are 5 principal reasons why treatment responses may fail. These include:

  • Non-drug-related reasons
  • Drug-related reasons
  • Poor adherence
  • Adverse events
  • Disease progression.

The development of checklists to determine the causes for a lack of treatment response are a useful tool to optimize acne management (Table)1.

The Global Alliance to Improve Outcomes in Acne recently published a therapeutic algorithm that provided practical management information over time for treating mild, moderate, severe, and very severe acne.2 This algorithm also provides reasons for lack of response as well as considerations for treatment amendment.

The importance of skin care regimens is a strong consideration and is discussed in the acne algorithm by Bagastin et al. as these regimens are commonly overlooked by dermatologists and patients alike.3

Items Not Included in Algorithms

Patients themselves are not frequently represented in algorithms. Often times they may have questions related to cosmeceuticals or over-the-counter preparations and how they may fit into a regimen.

There are a number of suggestions that have shown efficacy in the management of patients with acne.

  • Many of the algorithms agree that a topical retinoid is a first-line approach for comedonal acne and subsequent maintenance.
  • Topical product combinations/fixed dose topical combinations are central to acne management as they provide:
    • An effective first-line therapy for mild-to-moderate papulopustular disease
    • An increased efficacy, improved rate of lesion resolution, and minimized potential for antibiotic resistance
    • A further benefit of increased convenience and potential to improve adherence
  • Therapy comprising various combinations of topical retinoids, benzoyl peroxide, antibiotics (topical or oral), and hormonal therapy for women is now considered the primary best standard of care.
  • The use of topical and systemic antibiotics should be optimized by using appropriate combinations to reduce the development of antibiotic resistance. This includes use for a predefined duration
  • Patient education is of vital importance to ensure:
    • Patients are aware of how to use the treatment
    • Apply medication to affected areas
    • Aware of adverse events
    • This is also a time to discuss skin care regimes and review the multifactorial/chronic nature of acne.
  • For best results, patients should be seen within 6 to 8 weeks to assess response/lack of response and adjust treatment as necessary.

With funding from a National Institutes of Health grant, the Acne Core Outcomes Research Network sought to develop a universal set of core outcome measures for use in clinical trials:4

  • Satisfaction with appearance
  • Satisfaction with treatment received
  • Signs and symptom of acne
  • Extent of scars and dark marks
  • Long-term control of acne
  • Health-related quality-of-life.

Patient’s should be included in the deciding factors for their treatment. This allows patients to be more involved, increase knowledge, reduce passivity, and improve patient/practitioner communication. There are a number of patient decision tool aids available on the internet, some with videos, checklists, and other programs. It is important to encourage patients to play a more active role in their acne treatment decision-making.

Key messages

  • Algorithms based on current evidence have improved patient care.
  • Further work is needed to place patient perspectives in clinical care.
  • Patients should be encouraged to play a vital role in their decision.


REFERENCES

Present disclosure: The presenter disclosed that she completed research and received unrestricted educational grants or consulted for Galderma, GSK, La Roche Posay, Proctor & Gamble, MEDA.

Written by: Debbie Anderson, PhD

Reviewed by: Victor Desmond Mandel, MD



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