- Jennifer Middleton, MD, MPH
The October 15 issue of AFP includes an article on "Acne Vulgaris: Diagnosis and Treatment;" for many types of acne (Figure 4), a topical retinoid medication is the first line of treatment. Although topical retinoids are highly effective, many physicians don't prescribe them, follow-up appointments often don't happen, and adherence to these sometimes irritating treatments can be spotty at best.
For acne primarily composed of comedones and/or mild inflammatory papules and pustules, a topical retinoid is first-line treatment; even moderate severity acne regimens should include a topical retinoid. Only severe, nodular acne regimens begin with a different treatment (isotretinoin) and, even then, once clinical improvement is noted, transitioning to a topical retinoid is often appropriate. Despite the near-ubiquity of topical retinoids in these recommendations, though, physicians are not consistently prescribing them first-line. A study of prescribing practices in the United Kingdom found that only 38% of patients receiving a topical antibiotic prescription for acne also received a topical retinoid.
Patients also struggle with adherence to topical retinoids. In one study, 65.7% of adolescents and young adults self-discontinued their topical retinoid medication due to side effects such as irritation, redness, and scaling. They also found, however, that patients who were instructed to use their topical retinoid every other night had much lower discontinuation rates, possibly because their side effects were less bothersome.
The challenges of adhering to a topical retinoid regimen may explain poor follow-up and refill rates. A large database study of acne medication prescribing practices found that 66.1% of patients with new diagnosis of acne had no subsequent visit with that diagnosis for the year following, and 60.1% of patients did not have a documented refill for their medication within 90 days of their initial visit (despite most prescriptions being written for no more than 2 months' supply/refills).
Given the evidence in the above AFP article supporting retinoids' efficacy, these data present opportunities for both prescribers and patients to improve the use of this class of medications. Prescribing topical retinoids to be used every other night - or even every third night - may minimize irritation. Scheduling follow-ups a bit sooner may help patients and physicians problem-solve any challenges with adherence or side effects. Family physicians already prescribe generics and less-expensive acne treatments more often than other specialists, which can hopefully help any adherence issues related to cost.
There's an AFP By Topic on Skin Conditions which includes STEPS (Safety, Tolerability, Effectiveness, Price, Simplicity) articles on several acne treatments as well as this editorial on prescribing isotretinoin as a family physician if you'd like to read more.