A Method for Educating on the Categories and Usage of Acne Medications

The commonality of acne vulgaris belies its complicated nature, a feature familiar to dermatologists, yet often misunderstood by non-specialists and the lay public. The diverse and variable pathogenesis of acne accounts for the wide range of clinical presentations, chronic fluctuating courses, and need for polypharmacy. This “perfect storm” sets the stage for poor treatment design, non-compliance, and resignation, with lifelong physical and psychological consequences. Deterrents to management are multiple, from misunderstanding the disease to a myriad of medication issues. Drug companies are helping by developing better tolerated and combination drug products. Nevertheless, adequate patient education remains the cornerstone for ensuring compliance to treatment regimens, appropriate expectations, and good outcomes. The “Acne Care PyramidTM” and “Algorithms for Acne CareTM” are teaching tools for busy medical personnel to enhance their patients’ understanding of acne treatment and expectations in a visually pleasing and engaging manner.

Acne is extremely common, affecting over 80% of adolescents (). Persistence or de novo onset well past the teenaged years is common however; Collier recently documented the presence of acne in 26% of women, and 12% of men, aged 40-49 years old (). The psychological and social effects of acne cannot be underestimated, and the impact of this disease on quality of life and self esteem has been repeatedly documented (). Importantly, the psychological impact of the disease does not correlate with clinical disease severity, and the consequences of not treating early and appropriately may have a lifelong impact (). A whole industry has burgeoned around treating the physical stigmata of acne (lasers, microdermabrasion, chemical .peels, cosmeceuticals, etc); yet the impact of these non-insurance covered procedures on the psychological burden of the disease remains unclear (). Consequently, modern medicine no longer regards acne as a cosmetic issue, but rather supports treatment early, appropriately and aggressively ().

The myths and misunderstandings surrounding the management of acne vulgaris are rampant, and may be inadvertently perpetuated by non-specialized practitioners unfamiliar with the particular nuances of managing acne (). The changing landscape of managed care may amplify this occurrence if barriers to accessing specialty care become more challenging in the future. Further confusion regarding patient expectations is heightened by widely advertized over-the-counter products promising acne cures through facial cleansing and/or quick-fix monotherapies ().

Acne patients make up a sizeable portion of most medical dermatology practices, and appointments for these patients are generally scheduled only a few minutes. Given the sheer volume of these patients, as well as the brevity of the typical encounter, little time may be allotted to discuss the diverse nature of acne and its treatment variables with patients. Traditional patient handouts or quick in-office verbal discussions may or may not be engaging enough for patients to retain key points about their disease. Nevertheless experts agree that dispelling the myths and emphasizing some of the key features regarding acne and its treatment are fundamental to ensuing good outcomes ().

We have devised a visual aide poster and handout set to highlight the major categories of acne medications, along with key bullet points about acne and acne management. Several clinical categories of the disease highlighted, along with accompanying examples of typical treatment regimens and algorithms showing modifications over time. Using this overview format, a quick impression of the complexity and chronicity of the disease are laid out and patients get a better sense of “the big picture” for their management right from the start of therapy.

Methods: The “Acne Care PyramidTM” and accompanying “Algorithms for Acne CareTM” are educational tools for busy practioners interested in providing in-office visuals and take home literature to their acne patients of any age. This simple framework categorizes and describes seven basic groupings of acne therapies in a visually pleasing rainbow colored “pyramid structure” with an accompanying brief explanation of the pharmacological action of each therapeutic grouping. Because retinoids as a therapeutic group hold fundamental significance for acne management, this category is intentionally placed as the foundation of the pyramid. To the left of the pyramid are 10 bulleted “take home” points for the patient to retain about this complex disease (see below enlarged). (Figure 1).

The 10 key learning points:

1- Acne is slow to respond to medication- be patient!
2- Acne responds best to combination therapy using several medications from different treatment groupings initially; followed by a simpler program over time (some products come pre-made as combination medications from 2 or more groupings).
3- Different forms of acne need different medication programs. Different people may respond differently to different medications.
4- Acne responds best when medications are taken consistently and monitored with regular medical visits.
5- Acne may change forms over time naturally; sudden worsening needs medical attention.
6- Stress regularly aggravates acne.
7- Hormonal changes at any age can aggravate acne.
8- Irritation to acne medication can occur; if persistent, speak with your doctor- there are many different product formulas available.
9- Acne is not caused by dirty skin; use a gentle skin cleanser, and strive to use non-comedogenic skin products (moisturizers, sunscreen, makeup).
10- Certain foods may aggravate some individual’s acne- however diet alone does not cause acne.

On the flip side of this handout (or in a second poster), the “Algorithms for Acne CareTM” chart briefly defines “inflammatory” and “comedonal” acne terminology and lays out six major clinical subtypes of acne. Sample therapeutic programs and durations are provided for each subtype. The “take home” message of the algorithm poster is two fold: 1) to emphasize broadly the fact that acne regimens are often complicated initially but become simpler over time (culminating with a retinoid-only program) and 2) acne treatment is monitored over the course of many months. The regimens chosen for the algorithms are examples only, and can be tailored to the preferences of the educating physician or nurse. (Figure 2).

Discussion:
Although medically and therapeutically complicated, acne is treatable and today’s medications are very effective when taken properly. The burden of reducing lifelong stigmata of this disease rests with practitioners overcoming the various challenges to successful treatment. Fundamental hurdles involve 1) instilling a basic understanding of the complexity of the disease to support the diversity of clinical appearances, the need for polytherapy, and the chronic nature of the disease, 2) encouraging regular medical monitoring, and 3) overcoming medication tolerance and compliance issues.

Highlighting the chronicity of the disease is essential to provide appropriate expectations. Nearly half of patients with acne think the disease is readily curable, with typical expectations for cure being 1-2 months (). Unfortunately, it can be difficult for the clinician to predict which patients will have a chronic course (). The concept of acne as a chronic disease is becoming more widely recognized and is recommended among experts as a critical teaching point ().

Devising an effective acne regimen can be challenging and international consensus is regularly sought to provide guidelines. In 2003, the Global Alliance recommended that patients with mild to moderate acne should be managed with agents that treat several different aspects of acne pathogenesis simultaneously (). Retinoids hold particular prominence in both acute and chronic acne management owing to this class’ ability to be anticomedogenic, comedolytic and anti-inflammatory simultaneously. Currently, combination therapy is the recommended standard of care for all forms of acne other than the most extreme mild or severe variants.

It has been well documented that poorly designed monotherapy regimens (particularly with topical or oral antibiotics), or poorly adhered to polytherapy (which essentially becomes monotherapy or “no therapy”), can lead to poor outcomes and antibiotic resistance to p. acnes as well as other more pathogenic bacteria (). Combining retinoids with either antibiotics or benzoyl peroxides work more effectively in combination than when used separately, and importantly serve to reduce the incidence of antibiotic resistance (). As the disease transitions over time to milder forms, the treatment regimens should become simpler, culminating in a retinoid only maintenance program.

Recently a number of innovative combination polypharmacy acne products have come on the market (). These products have greatly simplified the acne therapeutic programs, and have been shown to both increase compliance as well as improve clinical outcomes (). Many of these drugs not only combine different therapeutic molecules, but are also developed to be significantly less irritating and more effective than older formulas, leading to better compliance, less frequent dosing, and fewer drug tubes (). Nevertheless, single drug topicals, particularly newer formulations with enhanced tolerability, still have an important role to play in acne management as the clinical presentation diminishes and chronic maintenance therapy becomes appropriate.

Despite new advances in polypharmacy and enhanced formulation efficacy, most acne products still take several weeks to produce results, and treatment regimens for acne are expected to change over time. Not only does the prescribing practitioner need understand these basics and how best to combine drugs for different clinical scenarios, but the patient needs to understand this so they will stay the course. These facts place education at the forefront of managing acne patients if optimal outcomes are expected to be achieved, and written handouts or verbal discussions are advocated by most acne experts ().

Traditional pamphlets showing pictures of severe acne or quick discussions conducted in a busy clinic may be intimidating, uninteresting, or poorly retained. The “Acne Care PyramidTM” and accompanying “Algorithms for Acne CareTM” were designed using patient and staff input, to be educational tools to quickly impress upon patients several key features of the disease, its therapeutic and clinical diversity, and treatment durations and expectations over time in a broad overview fashion. Summarizing information in a concise, colorful and visually pleasing/playful manner may offer a more engaging educational tool for patients to gain a healthy respect for the complexity of the disease while simultaneously providing confidence that their provider has the many tools and in-depth knowledge to help them maneuver the course.

Importantly, the two part poster or handout set may be modified by the treating doctor to reflect his/her preferences regarding acne management over time, and can be on display in waiting areas where acne patients or their family members can learn while they wait for their appointment. Ideally, versions of the teaching set would be updated periodically by dermatologists for use by primary care physicians, who may serve as the first echelon of caretakers for those suffering from acne vulgaris.

Conclusion

Using the “Acne Care PyramidTM” and “Algorithms for Acne CareTM” concepts, the clinician can provide to his/her patients an aesthetically engaging educational overview of the medical basis of acne therapy and treatment expectations over time. Both the pyramid and algorithm charts are designed to be individually tailored to the prescribing physician’s preferences, with the doctor able to modify the “10 key points to remember about acne”, and therapeutic ladders to fit their own practice style.
Once individually tailored, the pyramid and algorithm charts can be produced in poster size for patients to read while waiting in the office, and provided as take home literature when finished with their exam. We have found patient satisfaction improved greatly since implementing this educational program, and are in the process of acquiring objective data via patient surveys to support this impression.

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