Acne at the AAD: Updates for 2015

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At the recent 73rd Annual Meeting of the American Academy of Dermatology (AAD) in San Francisco, California, acne was once again a hot topic. Considerably more attention was paid to the role of androgens and, by default, antihormonal therapy as compared to prior years. Here are some of the highlights.

Spironolactone for Acne

Although not US Food and Drug Administration approved for the treatment of acne, spironolactone can be quite effective in the treatment of adult female acne due to its ability to block androgen receptors, decrease androgen production, inhibit 5α-reductase, and increase sexual hormone–binding protein. The question that often comes up is, how frequently do you need to check serum potassium levels, given that this drug is a potassium-sparing diuretic? According to both a poster at the AAD (P1296) and a study (the largest of its kind) published online on March 22 by Plovanich et al in JAMA Dermatology, the answer is not often or possibly not at all in young, otherwise-healthy women. Who should be checked then? Patients who have known cardiac and renal disease or impaired hepatic functioning as well as patients taking angiotensin-converting enzyme inhibitors, aldosterone blockers, angiotensin II antagonists, nonsteroidal anti-inflammatory drugs, or potassium supplementation. Be cautious with patients on digoxin and lithium, as spironolactone can increase their serum concentration and half-life.

Isotretinoin Risk

During a symposium (Acne Treatment Controversies), Dr. Diane M. Thiboutot discussed what’s new in the world of isotretinoin safety myths as well as useful tips to improve outcomes. The most recent data do not support a link between isotretinoin and inflammatory bowel disease. Prednisone and lower doses of isotretinoin can be used when initiating in a patient with severe inflammatory acne. Isotretinoin use also can be considered in patients with prior history of pseudotumor from tetracycline antibiotics with appropriate consultation. No significant issues regarding wound healing have been demonstrated or reported with isotretinoin, so the need to stop before cutaneous surgery is unlikely. Additionally, there are limited reports of complications with rhinoplasty, a possible slight increased risk for dry socket, and few cases of keloidal scarring with dermabrasion.

Updates in Pathophysiology

New immunologic targets for therapy and a better understanding of the role of the sebocyte in acne pathogenesis dominated the discussions at the AAD. In a workshop (Translating Evidence Into Practice: Acne Guidelines), Dr. Rachel V. Reynolds discussed the many hats worn by the sebocyte from an endocrine organ responsive to melanocortins, vitamin D, and corticotropin-releasing hormone to an immune cell responsible for secreting antimicrobial peptides and a broad array of inflammatory mediators implicated in the pathogenesis of acne. Fitting in with the recent excitement surrounding the identification of a key inflammasome (NLRP3 [NOD-like receptor family, pyrin domain containing 3]) in the IL-1β-induced subclinical inflammation in acne (Qin et al. J Invest Dermatol. 2014;134:381-388), it also was found that the sebocyte can participate in the same pathway. Propionibacterium acnes–induced NLRP3-derived IL-1β activation in sebocytes also has a role in acne pathogenesis (Li et al. J Invest Dermatol. 2014;134:2747-2756).

With respect to targeting elements of the inflammasome, during a forum (Treating Tumors and Inflammatory Skin Diseases With Immunomodulators and Biologics) I had the opportunity to discuss my collaboration with Dr. Jenny Kim of the University of California, Los Angeles, using nitric oxide–releasing nanoparticles (P1691). We found that not only do nitric oxide–releasing nanoparticles prevent the release of inflammatory cytokines from P acnes–stimulated human keratinocytes and monocytes, but even more importantly, this nanotechnology can inhibit multiple elements of the inflammasome cascade at the gene level. For example, caspase-1 and IL-1β suggests a mechanism(s) by which this technology could serve as not only a treatment of acne but of other inflammatory dermatoses.

That’s all for now! Stay tuned for more updates and hot topics in the world of acne.

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