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Redefining Acne Vulgaris as a Chronic Disease: Implications on Improving Therapy

Authors: Diane Berson, MDFaculty and Disclosures

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Question
The Global Alliance to Improve Outcomes in Acne recently recommended that acne be defined as a chronic disease. What would be the advantages and effects of such a redefinition?

Response from Diane Berson, MD
Assistant Clinical Professor, Department of Dermatology, Weill Medical College of Cornell University, New York, NY

Acne is indeed a "chronic" disease.[1] These flares can be due to genetic predisposition, hormonal fluctuations (especially in females), or ongoing elevations in sebum production.

Although we are able to get our patients' acne under control, there can be a tendency for further flares when a patient is not given a maintenance regimen.

We usually treat acne with a topical combination regimen, usually including a topical retinoid in conjunction with a topical antimicrobial.[2] For more severe inflammatory acne, an oral antibiotic can be added to the regimen. Women susceptible to hormonal flares, such as those who flare premenstrually, can also be prescribed an oral contraceptive or spironolactone to help reduce sebum production and prevent these outbreaks.[3] For those whose acne is severe, nodulocystic, unresponsive to therapy, or has evidence of scarring, isotretinoin may be indicated. Once the acne is "clear" we prescribe medications to use as a "maintenance" regimen, to help prevent further flares. Most patients are prescribed a topical retinoid (tretinoin, adapalene, or tazarotene), which acts as a comedolytic agent and therefore helps prevent the development of new microcomedones, which are the precursor lesions of acne.[4,5] Topical retinoids may also have anti-inflammatory properties, inhibiting toll-like receptors and the development of inflammation. Patients may also be given a low-dose (sub-antimicrobial) oral antibiotic, either doxycycline or minocycline, especially for those who have inflammatory papules of acne or rosacea.

It is important for patients to understand that acne is an inflammatory condition that can continue to flare and may be characterized by exacerbations and remissions. Therefore, appropriate ongoing skin care may be necessary. Patients should also understand that although antibiotics constitute an integral part of treatment, acne is not an infection (like strep throat) that will clear after a short course of antimicrobials. It is an ongoing condition that may require maintenance treatments. It is also important for insurance carriers to understand this, as adult patients are often denied coverage for treatments, especially topical retinoids, which can also be used for the management of photodamaged skin.

This activity is supported by an independent educational grant from Medicis.