Treatment of acne in the aesthetic patient: A round table update

The popularity of social media appears to be increasing the acceptance of cosmetic treatments, prompting more consumers to seek cosmetic treatments. As the estimated prevalence of acne vulgaris among adult women may be as high as 54%, acne is commonly observed among patients presenting for cosmetic treatments. Concomitant treatment of acne in the aesthetic patient population will improve overall clinical outcomes.

I-IV 9 and displays significant diversity in presentation, including lesion shape, size 10 and severity. 7 The estimated prevalence rates of adult female acne varies widely but may be as high as 54%. 11 Not surprisingly, acne is commonly observed among patients presenting for cosmetic treatments. As there are no guidelines for the treatment of acne in aesthetic patients, the objective of this report was to review the literature and propose suitable treatments for acne in this patient population.

| ME THODS
A literature search performed on PubMed (https://pubmed.ncbi. nlm.nih.gov/) using the search terms "acne vulgaris" and "topical medications" or "systemic medications" or "chemical peels", or "energy-based therapies" during the past 5 years limited to English language revealed no information about the concomitant treatment of acne in patients undergoing aesthetic procedures. A subsequent roundtable discussion was held by several notable experts in their field during a special addition of the Thriving in Diversity web conference on February 18, 2023 (https://thriv ingin aesth etics.com/). This program began with a review of popular acne therapies followed by a discussion of the treatment of acne in aesthetic patients.

| Acne in the aesthetic patient
Many patients presenting for aesthetic injectable treatments have concomitant acne vulgaris, rosacea and/or melasma. A greater than 50% prevalence of acne has been found among 20 year olds, 33% among 30 year olds and 25% among 40 year olds. This age group is also the demographic that presents for injectable neuromodulators and filler treatments. Skin quality is a collection of attributes that encompasses how skin looks and feels and has become a current beauty trend. Good skin quality conveys good health and well-being, fitness, psychological balance, and youthfulness. [12][13][14] This trend is being driven in large part due to the popularity of social media filters that give the appearance of flawless skin. 15 The goal is to look filtered and pore-free without having to use filters or make-up.
The popularity of social media filters is increasing the acceptance of cosmetic treatments, 16 and prompting more consumers to seek cosmetic treatments. 17 Social media platforms, such as Tiktok (https://www.tiktok. com/), are also a significant source of information about acne. In one 2020 Tiktok survey, the top 100 videos tagged with "#acne" had over 13 million likes and 64 thousand comments during a 7.6 month period. 18 Unfortunately, the available information is not always reliable as only nine videos were produced by board-certified physicians.
Some of the major shortcomings were failures to cite information sources and include discussions of treatment risks; however, this provides an excellent educational opportunity for physicians to discuss and correct misinformation and misconceptions about acne and its treatment among patients.

| Approach to treating acne in the aesthetic patient
Patients may present with a specific cosmetic goal, such as lip enhancement or frown lines without concerns about existing acne; however, as cosmetic providers, it is important to think of the skin holistically to optimize treatment outcomes. 19 For aesthetic patients with acne, offering acne treatments will enhance their overall aesthetic outcomes by improving the appearance and quality of their skin. Advise patients that treating acne is important for improving skin quality and avoiding the risk of scarring and hyperpigmentation.
If treating skin disorders is not an area of expertise, consider referring the patient to an appropriate practice.
Consider the following points when discussing acne.
• How long have you had acne?
• Is today a good day or bad day for your acne?
• What are you currently using to treat acne?
• Are you taking any kind of hormonal therapy?
• Have you used prescription medications to treat your acne? Did it work? Any side effects?
• What is your skincare routine? Sunscreen? Moisturizer?
• Does your acne worsen during menstrual cycles?
• Is your acne bothersome for you?
If your patient does not already have a satisfactory skin care routine, recommend skin cleansing and products to encourage barrier repair that are noncomedogenic and oil-free with humectants (ceramides, lipids and hyaluronic acid [HA], and moisturizers). 20 Also recommended are topical anti-inflammatories and antioxidant products containing vitamins C and niacinamide; however, products containing vitamin E are sometimes comedogenic, and not recommended.
Hydrating serums and moisturizers combined with prescription topicals enhance tolerability and cosmetic acceptability while maintaining efficacy. Silymarin is the active component of milk thistle, which has antioxidant properties by scavenging free radicals. 21 It is a useful adjuvant for treating mild-to-moderate acne vulgaris as a silymarinloaded antioxidant serum. 22,23 Silymarin also prevents melanin production without affecting cell viability and decreases the expression of tyrosinase protein, which aids in preventing postinflammatory hyperpigmentation associated with acne. 24 Dietary changes might also be considered as part of the holistic treatment of acne. A high glycemic index and increased daily glycemic intake are associated with a greater incidence and severity of acne while intake of dairy products may be influenced by other factors such as sex and ethnicity. 25 As described below, additional acne treatments target one or more acne-related factors, such as follicular hyperkeratinization, the presence of Cutibacterium acnes, increased sebum production, and inflammation. 26,27

| Topical medications for treating acne
Retinoids should be first-line treatment for treating active acne and also for maintenance and prevention. Retinoids provide relief of postinflammatory hyperpigmentation, early scarring and can provide cosmetic benefits. Tretinoin is a topical retinoid indicated for the treatment of acne vulgaris 28 and is the most potent and widely used retinoid. Disadvantages include the potential for severe skin irritation and sensitivity to ultraviolet light. 28 Lighter tretinoins such as tretinoin 0.025% can be used to start to avoid severe irritation. 29 Adapalene is a second-generation topical retinoid indicated for the topical treatment of acne vulgaris in patients 12 years of age and older. 30 Adapalene is less irritating than tretinoin but patients should similarly avoid exposure to ultraviolet light. 30 The retinoid prodrug tazarotene is also indicated for treating patients with acne vulgaris. 31 Tazarotene may be more effective in improving the noninflammatory acne lesions, such as open and closed comedones. It may be slightly more irritating when treatment is first started but it is more stable to light than other retinoids. Tazarotene has recently been formulated as a patented polymeric emulsion to improve skin barrier function 32 with decreased irritation, and good patient acceptance. 33 Trifarotene is a novel fourth-generation retinoid with strong anti-comedogenic, anti-pigmenting, and anti-inflammatory properties, 34 indicated for the topical treatment of acne vulgaris in patients 9 years of age and older and approved for use on the face and trunk. 35 In a large Phase 3 trial, trifarotene was efficacious and welltolerated. Common facial adverse events were mild pruritus (4.6%), irritation (4.2%), and sunburn (1.8%). 36 In general, retinoids should be applied in the evening with a moisturizer to minimize irritation.
Effective sunscreens should be used by all patients being treated with retinoids.
Clascoterone is a novel androgen receptor inhibitor indicated for the treatment of acne vulgaris in patients 12 years old or older although its mechanism of action is unknown. 37 The results of two Phase 3 randomized clinical trials demonstrated subjects with acne treated with clascoterone cream achieved considerable reductions in absolute noninflammatory and inflammatory lesion counts (ILC).
Adverse events were predominantly mild and similar to those of the vehicle control. 38 Benzoyl peroxide is an effective acne treatment recommended as monotherapy for mild acne, or in conjunction with a topical retinoid, or systemic antibiotic therapy for moderate to severe acne. 3 Benzoyl peroxide is effective for preventing bacterial resistance and is recommended for patients on topical or systemic antibiotic therapy. 3 It is available in various formulation and prescription and overthe-counter concentrations.
Dapsone is a sulfone indicated for the topical treatment of acne vulgaris in patients 12 years of age and older. 39 While the mechanism of action of dapsone for treating acne vulgaris is not known, topical dapsone 5% gel is recommended for inflammatory acne, particularly in adult women with acne. 3 In clinical trials, topical dapsone showed modest to moderate efficacy, primarily in the reduction of inflammatory lesions. 40 Azelaic acid is indicated for topical treatment of the inflammatory papules and pustules of mild to moderate rosacea 41 ; however, it is a useful as an adjunctive acne treatment and is recommended for treating postinflammatory dyspigmentation. 3 Adapalene and benzoyl peroxide have been combined in a single formulation, indicated for the topical treatment of acne vulgaris. 42 In a 6-month clinical trial, this combination significantly reduced inflammatory acne lesions and reduced atrophic scar formation. 43 The most common treatment-related adverse events were skin irritation (14.9%) and skin pain (3.0%). Another topical product combines microencapsulated tretinoin and benzoyl peroxide, permitting inclusion of both agents in a unique, stable formulation that prevents benzoyl peroxide from deactivating tretinoin while in the bottle. 44 When applied, this technology gradually releases each agent onto the skin to treat acne. In two 12-week, phase 3, randomized, vehicle-controlled clinical trials, tretinoin/benzoyl peroxide cream significantly reduced inflammatory and noninflammatory facial acne lesions and significantly improved Investigator Global Assessment rating to clear or almost clear. 45 Long-term data on efficacy and tolerability are not yet available.

| Systemic medications for treating acne
Systemic antibiotics are recommended for treating moderate and severe acne and inflammatory acne that is resistant to topical treatments. 3 Sarecycline is specifically indicated for the treatment of inflammatory lesions of non-nodular moderate to severe acne vulgaris in patients as young as 9 years old. 46 Doxycycline and minocycline are equally effective with one another and are the most frequently prescribed antibiotics for acne. 47 Erythromycin and azithromycin can also be effective, but their use should be limited to patients for whom tetracyclines are contraindicated, such as children and pregnant women. 48 Erythromycin also increases the risk of bacterial resistance. 49 All oral antibiotics should be limited to the shortest possible duration and treatment should be periodically reassessed.
Antibiotics should be used together with benzoyl peroxide or a retinoid to prevent bacterial resistance. All tetracyclines can cause photosensitivity. 48 Hormonal agents for acne include combination oral contraceptives are effective for treating inflammatory acne in women due to antiandrogenic effects. The currently available FDA-approved combination oral contraceptives for treating acne are ethinyl estradiol/norgestimate, ethinyl estradiol/norethindrone, acetate/ferrous fumarate, ethinyl estradiol/drospirenone, and ethinyl estradiol/ drospirenone/levomefolate. 3 Oral contraceptives are a known risk factor for venous thromboembolic and other cardiovascular events and their use must be weight against the risks associated with acne vulgaris. 50 Spironolactone is an aldosterone receptor antagonist that also exhibits potent antiandrogen activity; however, its use for the treatment of acne is not FDA-approved. 51 A large long-term retrospective case series of 403 adult women treated for acne reported spironolactone improved clinical outcomes and was well-tolerated. 52 Oral isotretinoin is indicated for the treatment of severe recalcitrant nodular acne in patients 12 years of age and older. 53 Due to the risk of major congenital malformations, spontaneous abortions, and premature births in pregnant women, oral isotretinoin may only be administered to patients enrolled in the iPLEDGE® program, is a computer-based risk management program designed to prevent fetal exposure to isotretinoin through a special restricted distribution program approved by the FDA. 54 Unfortunately, the administrative burden of the program is deterring many dermatologists from prescribing oral isotretinoin for their patients with severe recalcitrant nodular acne. 55

| Chemical peels for treating acne
Chemical peeling, also known as chemical exfoliation, is a procedure where a chemical substance applied to the skin causes controlled destruction of the epidermis with or without part of the dermis, leading to skin regeneration and remodeling. Chemical peels can be used to treat various skin conditions, such as acne vulgaris, photodamage, pigmentary disorders, uneven tone and texture, and scars. 56 When used for the treatment of acne, chemical peels can significantly improve patient self-esteem. 57 Chemical peels are generally classified by their depth of skin penetration into superficial, medium, and deep peels. 58 Superficial or light peels remove the outer layer of skin (epidermis). It is used to treat fine wrinkles, acne, uneven skin tone, and dryness. Superficial Complications from chemical peels are generally related to the depth of the procedure, with deeper peels associated with higher rates of complications. 59 Other factors affecting the actions of peeling agents include concentration, pH of solution, application technique, duration of procedure (unless self-neutralizing), skin type, and skin thickness. Characteristics of available peeling agents are summarized in Table 1. With respect to acne, chemical peels are best for preventing acne by keeping pores clear and treating early comedonal acne and shortening the period of postinflammatory hyperpigmentation. Chemical peels are less useful for pustular or cystic/nodular acne.

| Energy-based devices for acne
Microdermabrasion activates a dermal remodeling/wound healing cascade with minimal epidermal disruption. 60 It is a procedure that can produce changes in dermal matrix constituents and improve skin TA B L E 1 Types and characteristics of chemical peels. contour irregularities. It may also be beneficial in improving transepidermal delivery of certain medications; however, its role in the treatment of dyschromias and acne vulgaris is limited. 61  The safety and efficacy of IPL for treating mild to moderate facial papulopustular acne has been demonstrated clinically. 75 One IPL device initially uses blue light to eliminate acne-causing bacteria located in skin pores followed by yellow light to reduce inflammation, acne-related redness, and prevent further breakouts. 76 Another device combines vacuum with pulsed broadband light delivered through a liquid-cooled handheld delivery system to treat mild-to-moderate acne, including comedonal, pustular, and inflammatory acne vulgaris. 77 This device removes C. acnes mechanically and thermally from the pilosebaceous unit and reduces sebum production. In the experience of one of the authors, this device also known as photopneumatic therapy, is best used together with traditional oral and topical acne regimens. 78 Lower energy settings and longer breaks between treatments may be needed for darker skin tones. Maintenance therapy while remaining on a topical prescription regimen may be performed every few months or when flares occur.
Laser devices have also been used for treating acne, including pulsed dye laser, potassium titanyl phosphate (KTP) laser, fractionated and nonfractionated infrared lasers, and fractionated CO 2 lasers. 3

| Acne scars
A combination of treatment modalities is usually required for treating acne scars. 84 The treatment goal is generally reducing scar severity but not complete removal. In a study involving subjects with moderate or severe acne scars, treatment with HA gel effectively reduced acne scar severity and improved facial aesthetic appearance. 85 Based on investigator assessment, 100% of subjects had improved acne scarring and skin quality after two treatment sessions at Week 8, and that 92% were still improved at Week 36. The percentage of subjects who were assessed to have much or very much improved acne scarring and skin quality increased from 0% at Week 4 to 50% at Week 12 and then further increased to 83% at Week 36. 85 A benefit of using HA-based fillers for treating acne scars is recovery of skin radiance in post-inflammation acne. Poly-L-lactic acid is an injectable collagen builder that has been shown to yield excellent results for treating acne scars. 86-92

| Acne and injectables
The use of neurotoxins may be used in patients with mild or moderate acne but should be avoided in areas of cystic acne. In these cases, the acne should be treated first. Caution should be taken when botulinum toxin is used in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. 93 The use of toxins may actually be beneficial for the acne patient.
Due to its effect on acetylcholine, botulinum neurotoxins may reduce sebum production and reduce pore size. [94][95][96] The use of dermal filler may be acceptable in nonreactive areas; however, some manufacturers suggest deferring their use of at specific sites where an active inflammatory process, such as skin eruptions such as cysts, pimples, rashes, or hives or infection is present until the process has been controlled. 97

| Acne and chemical peels
Contraindication to the use of a chemical peels for treating acne include active bacterial or viral skin infection or dermatitis in the area, known allergy to chemical peel ingredients, pregnancy or breastfeeding (depending on the active ingredients of the chemical peel).

| Energy-based devices and acne
Patients on isotretinoin or who have been treated with isotretinoin in the previous 6 months are generally considered poor candidates for dermabrasion. Active acne is a relative contraindication to dermabrasion as it may predispose to postoperative infection. 100 There are relatively few contraindications for the use of therapeutic laser and many of them are relative rather than absolute. The recent use of oral isotretinoin within the previous 6-12 months may lead to delayed wound healing or undesirable scarring. 101

| CON CLUS ION
The growth of social media as raised awareness of aesthetic procedures and appears to be increasing the number of patients seeking aesthetic treatment. While the presence of acne may not be a patient concern, educating patients about the importance of treating acne vulgaris can improve overall treatment outcomes. In most instances, the presence of acne is not a barrier to aesthetic care.

AUTH O R CO NTR I B UTI O N S
Each author made substantial contributions to conception and design, or acquisition of data, was involved in drafting and critically reviewing the manuscript for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.

ACK N OWLED G M ENTS
The authors acknowledge the editorial assistance of Dr. Carl S.
Hornfeldt, Apothekon, Inc., during the preparation of this manuscript. This activity was sponsored by Galderma Laboratories LP, Fort Worth, TX.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing not applicable no new were data generated.

E TH I C A L A PPROVA L
This material has not been published in whole or in part elsewhere.
The manuscript is not currently being considered for publication in another journal. All authors have been personally and actively involved in substantive work leading to the manuscript, and will hold themselves jointly and individually responsible for its content.