The nodular acne therapy has been a staple treatment for 3 decades, yet new AAD data showed it could still be better utilized in patients.
James Q. Del Rosso, DO
There is not much therapeutic depth in the field of acne care, and there’s not even many potential new drugs that could soon change that. But the newest developments in the field, focused on a decades-long therapy, show advances could be made in dermatologist’s traditional prescribing strategies that would compensate for a slow market.
In an interview with MD Magazine® following the American Academy of Dermatology (AAD) 2019 Meeting in Washington, DC, James Q. Del Rosso, DO, research director of JDR Dermatology Research in Las Vegas, NV, spoke on how some of the biggest AAD news this year centered on the potential absorption strength and sustained benefit of isotretinoin capsule (Absorica). Though the meeting’s discussions centered on the same old drugs, it was their recently-found additional benefits that Del Rosso expressed excitement for.
MD Mag: What was your role with the Acne Boot Camp hosted at AAD this year?
Del Rosso: The acne boot camp was a session that I spoke at. I wasn’t one of the directors this year, but I was one of the additional presenters. We had started that at the American Acne and Rosacea Society (AARS) years ago, but a lot of us decided to use that title for AAD, in order to go over the basics of acne.
What’s the significance of a session like that being held at AAD?
I think that, in any given time, it’s worthwhile to have an acne boot camp—just to go over the fundamentals of whether it’s acne or rosacea, because we make assumptions that people understand things as well as we understand. I understand a certain amount about acne because I treat it, I write about it, and I research it. And I easily assume there are things that are basic to me that aren’t basic to other people. They’re not up-to-date, even on older medications—just because something’s not new doesn’t mean it could have updated information involving a new compound or new product.
It brings the information together to get everybody up to speed and on the same page as to where acne is right now, at least with the core information. I really think the purpose of it is to just give an update on whether it’s acne or rosacea every year.
Regarding treatments, isotretinoin being assessed in use both with and without food parameters—as well as a sustained therapy—were interesting discussions at AAD. What’s your perspective on the treatment now?
There are many forms of oral isotretinoin that are based on the original pharmacokinetic studies involving Acutane. The absorption of that drug from the stomach was based on having a high-fat, high-calorie meal. And we’re talking very high-fat—each time it was administered, the person ingested 50 g of fat, and about 1000 calories. So if you were taking it twice per day, you went and had a Grand Slam at Denny’s in the morning, then a Triple Whopper or whatever for dinner at Burger King. That’s what the pharmacokinetics were based on, for optimal absorption of the drug.
And if you compared that to just taking it with a glass of water, the difference in absorption, on the average, was about 60%. In the clinical studies, when patients were actually taking it to see if they would get better over 16 or 20 weeks, you would tell them to do that, without knowing if they would.
Over the years, we’ve come to realize people getting isotretinoin in practice is very much like 100 different Italian grandmothers making spaghetti sauce. They all make it a little differently, but they’re all good. They all have different ways of doing it, and it works regardless. It’s a very forgiving drug, in terms of getting people clear skin, regardless of how it’s dosed. They’re getting a certain minimal amount, they’re taking it at certain times, but it’s still a fantastic drug in getting patients clear.
The difference, potentially—and we have data that supports this now—is when you stop it, they can get cleared from acne without needing to use anything else for several years. And many of them do. And if they get any recurring acne, it’s usually very minimal to the severe form that they used to have. We don’t like to say isotretinoin is the cure, but it’s the closest we’re going to get.
The problem was, “How long can you keep people clear after they finish?” It was theorized, based on all the data before, that the more a person took or internally absorbed, the longer they could stay clear. There are some researchers who formulated Absorica, a pre-solubilized form, mostly in the fat. The patient didn’t need to take the high-fat diet—which most patients weren’t already doing. That drug was based on the hypothetical that you could sustain the clearance longer after you stop. And we now have two-year data that, in the first formal study of lidose isotretinoin on an empty stomach, the relapse rates are very impressive. Less than 5% of the patients ever had to go back on a second dose.
How important is the difference in absorption rate among competing isotretinoin therapies?
I think there’s a definite impact, that it could affect the outcome for the patient. The branded generics, based on the original Acutane—they work. There’s no doubt patients can have prolonged clearance with those drugs. But I think Absorica gives you the best chance of getting long-term outcomes for maintaining cleared skin. It’s like a batting average—the generic might be batting .280, Absorica might be batting .320. Either one of them could hit a home run, but you’ve got a better chance that the higher batting average will come through for you.
What’s your thought process during treatment selection for nodular acne?
This just happened yesterday with a patient. It was a teenager present with her parent. I let them know that this would be my preferred choice, we’ll work through the access systems and see if we can get this for them, to see what the price presented to them would be out-of-pocket after insurance, then they decide whether what it is per month is agreeable. If so, great—they’ll get Absorica. If not, they’ll get another branded generic, but they’re never sitting there thinking, “Great, I’m not going to get better.” They are going to get better—we’re just trying to give them the best chance of staying clear for the longest period of time.
I try to stay positive regardless. I want them to be coming in to this on a positive note. I can’t guarantee what their coverage will be.
What will the field of nodular acne care advance in the coming years?
There are people working on physical device therapies—different kinds of lasers and light systems which we have at our own center, but I’m not involved with. There are people working on alternative methods to treat acne other than antibiotics. There’s a big push to get away from antibiotics, and that’s a valid goal.
But in the arena of medical therapies for nodular acne, I don’t see very much. I keep hearing about vaccines, but that’s a long way off, and for nodular acne specifically, I think it’s more about isotretinoin. I haven’t seen anything, from a therapeutic standpoint, that is anywhere close, or getting closer to that direction.
There is also more information coming out about how to utilize some of the “hormonal” treatments we use in adult women with acne, who are still dealing with a lot of inflammatory acne—such as those interested in taking birth control while treating their acne. Not all women want to be on oral contraceptives. There’s emphasis in trying to keep people on oral antibiotics for a long period of time, but there’s no new options. It’s easy to say, “Don’t do that,” but there are not many other options instead of it.
Isotretinoin is an extremely good drug. If it’s not number 1, it’s in the top 3 of the greatest advances in dermatology, in the entire time I’ve been in my career.