PracticeUpdate: Dermatology & Rheumatology

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EDITORIAL
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PracticeUpdate Dermatology Editorial and Advisory Boardmembers
Dr Eliot Mostow and Dr Jane Grant-Kels, as well as Dr Robert Brodell of
the University of Mississippi Medical Centre, discuss their top stories
in dermatology for 2016, focusing on topical retinoids, shared care to
optimise patient outcomes, and exciting advances inmelamona.
Dr Robert Brodell on the use of
topical retinoids
Robert Brodell MD, FAAD, is Professor and Chair of the Department of Dermatology
at the University of Mississippi Medical Center.
While there were many articles involving new treatments, new tech-
nologies, and even new diseases, my favourite articles are those that
highlight gaps in care for common diseases. The article by Barbieri
et al is just such an article (J Am Acad Dermatol 2016;75:1142-1150.e1). This
English study demonstrated that 62% of practitioners did not use a topical
retinoid as part of their acne regimen. It validates the work of a team using data
from the United States (J Am Acad Dermatol 2016;74:1252-1254). In 40% of
acne patients treated by dermatologists and 70% treated by other physicians,
no topical retinoid was used.
This represents a significant gap in patient care. Experts agree that patients
with acne should be treated with topical retinoids. Guidelines from the
American Acne and Rosacea Society, the American Academy of Pediatrics,
and the Global Alliance to Improve Outcomes in Acne support the use of
topical retinoids as first-line therapy for acne. Attacking the pathophysiology
of acne with strong comedolytics should decrease the length of time systemic
and topical antibiotics are needed and minimise the potential for recurrence
because the microcomedone is the source of acne infection. If retinoids were
used immediately when systemic antibiotics are used to treat acne, the need
for prolonged systemic antibiotic use would be reduced, with obvious benefits
to society with regard to the development of resistance.
Of course, there is an explanation for this behaviour. Topical retinoids are hard
for patients to use! They can be drying, irritating, cause redness, and both
post-inflammatory hyper- and hypopigmentation. The physician should initiate
topical retinoid therapy using milder products (lower concentrations, creams
instead of gels, and products with special vehicles to decrease irritation) and
prescribing them for use every other night or twice weekly initially for patients
with dry skin. Patients develop tolerance to these products and can often
increase the frequency of use over time. Using team-based care techniques,
the physician and his/her nurse or medical assistant must take the time to
educate patients about other approaches to increase the tolerability of topical
retinoids. These include application of the topical retinoid at bedtime to a dry
face, using a non-comedogenic moisturising lotion in the morning, and using
mild soapless cleansers instead of harsher soaps. Finally, patients should avoid
other topical products that might be drying.
My experience has been that, by using all of these techniques, the vast majority
of patients can tolerate a topical retinoid and benefit from its comedolytic and
anti-inflammatory effects. This results in acne clearing faster, minimising the
time systemic antibiotics are required, and minimising acne recurrences after
patients are clear.
2016 Top Stories
in Dermatology