Enhancing the success of acne vulgaris therapy
Current concepts of acne therapy date to the mid-20th century with the introduction of broad-spectrum antibiotics, notably the tetracyclines, and estrogen, in the form of oral contraceptives. This was followed by enhanced topical therapy with the introduction of benzoyl peroxide in the 1950s, topical tretinoin in the early 1970s, and, a short time later, by topical antibiotics. Topical acne therapy was augmented further by improved formulations for all available agents, and the introduction of adapalene and tazarotene in the mid-1990s.
Estrogen therapy for acne was enhanced by combination with antiandrogens, cyproterone in other countries, and drospirenone, a spironolactone derivative, in the United States. The introduction of oral isotretinoin in 1982 was a monumental step forward, revolutionizing the treatment of severe, refractory acne. More recently, combi-nations of benzoyl peroxide with antibiotics or retinoids and retinoids with antibiotics have simplified compliance with treatment programs. All of these will be covered in this section.
The issue of compliance, however, remains a principle concern in all forms of acne treatment. Acne can have devastating physical as well as emotional effects, and thus it is critical that the patient be made aware of the nature of the disease process and what is to be expected from the treatment regimen pre-scribed. Failure to take the time to do this is a “key to the highway” of therapeutic failure in many patients. There are, of course, other factors that can affect compliance with acne treatment. The reluctant child with the dominant parent often leads to a lack of adherence to the prescribed treatment and provides a source of increased friction between parents and children, particularly in teenage acne. Some young, teenage boys are not yet concerned about their acne, yet their parents insist on dragging them to the dermatologist.
The physician needs to deftly “connect” with both the patient and parent, explaining in an understand-able manner how acne can continue to worsen the potential benefits of “staying on top of it” with treatment, and the importance of working the use of their medication into their daily routine. Overprescribing is another common reason for poor compliance. I have seen many patients who have been prescribed topical medication morning and evening with oral antibiotics and then sold cleansers, moisturizers and/or heating instruments, cleansing brushes, etc. It is much better to begin simply, albeit with a regimen tailored to the severity of acne, and add medication as necessary, all the time explaining the treatment program, the anticipated time course of response, and gaining the trust of the patient with sincere “eye–to–eye” contact.
Above all, anticipate and explain the common side effects, and arrange the treatment to minimize unwanted effects in the beginning to allow the patient to gradually accommodate. Finally, it is useful to use examples the patient can relate to, in order to explain proper use of medication. For example, we usually tell our patients to apply an amount of medication equivalent to a small green pea for each cheek and spread it out evenly. For oral isotretinoin, we not only tell the patient that it is a fat-soluble vitamin, best absorbed with food, but also use the illustration of a cheeseburger with a milkshake, for illustration purposes and not as a recommended “diet for life.” Ultimately, success occurs not only with their consistency but also with yours.