Acne and Rosacea Insights: Experts Offer Pearls and Novel Approaches

The early Tuesday morning line up for a presentation of pearls on managing acne and rosacea placed Josh Zeisner, MD, Julie Harper, MD, Jim Del Rosso, MD, and Linda Stein Gold, MD, on the dais at the 2025 Midwinter Clinical Hawaii Dermatology Conference, February 15-29, 2025, on the Big Island, Waikoloa Village, HI.

Their insights highlighted both foundational and emerging therapeutic strategies for these common dermatologic conditions.

Julie Harper, MD: Hormonal Approaches in Acne Management

Dr. Harper emphasized the importance of understanding the role of oral contraceptives (OCPs) in treating acne. "Spironolactone is not even FDA-approved for acne," she pointed out, "but four oral contraceptive pills are." She offered the following key insights on OCP use for acne.

• Combination matters: Only combination OCPs (estrogen + progestin) are effective; progestin-only pills can exacerbate acne due to androgenic effects.
• Generational differences: Newer progestins (third and fourth generation) are less androgenic but may carry an increased thrombotic risk.
• Risk considerations: For healthy young women, the absolute risk of venous thromboembolism (VTE) remains low:
  • Baseline risk: 3 per 10,000 women/year
  • ICP use: 6 per 10,000 women/year
  • Fourth-generation progestins: 9 per 10,000 women/year
  • Third-trimester pregnancy: 12 per 10,000 women/year
  • Postpartum: 30 per 10,000 women/year
• Contraindications: Pregnancy, breastfeeding, smoking, and migraine remain significant contraindications.
• Patient counseling: Emphasize a 3-cycle trial period for efficacy. While pelvic exams are unnecessary, obtaining a thorough medical history and checking blood pressure is essential.

Linda Stein Gold, MD: Optimizing Isotretinoin Therapy

Gold addressed the potential benefits of combining antihistamines and omega-3 fatty acids with isotretinoin to mitigate side effects and enhance efficacy.

Antihistamines

• Levocetirizine adjunctive therapy improved tolerability and slightly enhanced efficacy in a small study; 50 participants treated with isotretinoin and 50 with levocetirizine + isotretinoin; levocetirizine group showed statistically significant decrease in score of global acne grading system (51.0 vs. 38.5%) and acne lesion counts (non-inflammatory lesion: 63.2 vs. 44.5%; inflammatory lesions: 75.9 vs. 62.7%; total lesions: 66.07 vs. 48.7%; all P <.05).
• Desloratadine (5 mg/day) added to low-dose isotretinoin (0.3 mg/kg/day) did not affect efficacy but reduced patient dropout due to improved tolerability. Dropout rates noted were 8.8% in the study group and 33% in the control group. Participant satisfaction was 53.66% in the study group vs 36.67% in the control group, and statistically significant.

Omega-3 fatty acids

• In a 16-week trial, 1 g/day of omega-3 with isotretinoin vs isotretinoin alone significantly reduced early-stage dry nose and dry skin (weeks 0–16,
  P <.05; statistically nonsignificant in weeks 4–16)
• Benefits were most notable during the first 2 months of isotretinoin therapy suggesting it may be most helpful in early therapy.

Joshua Zeichner, MD: Acne Treatment Strategies

Zeichner emphasized a multimodal approach to acne treatment targeting all four key pathogenic factors: hyperkeratinization, inflammation, sebum production, and C. acnes proliferation.

Use combination therapy from the beginning

• Using a benzoyl peroxide (BPO) and clindamycin fixed-dose combination with adapalene from the outset yields faster and more robust outcomes.
• A novel triple combination (BPO, clindamycin, adapalene) demonstrated rapid and significant improvement in clinical trials.
• For additional sebum reduction, combine topical agents with clascoterone

Simplified regimens improve adherence

• Fixed-dose combinations lead to greater adherence and superior outcomes. Primary nonadherence has been reported by >30% of patients with ≥2 prescriptions to be used in combination

Acne is not a 12-week disease—keep treating

• Pivotal clinical trials only provide data for 12 weeks of treatment. New data showing improvement out to 12 months supports staying on course beyond the initial 3 months; encourage patients to persist with effective therapies for 6-8 months if they are on the right trajectory.

Shared Decision-Making

• Engage patients in treatment decisions early to avoid misalignment and enhance adherence. Ask what the patient is looking for in therapy; spend the time even if you don’t have it. You may be able to make the diagnosis from the doorway, but it’s all about the interaction.

James Del Rosso, MD: Innovations in Rosacea Management

Rosacea remains challenging, particularly the persistent erythema subtype. Del Rosso highlighted emerging therapies, including off-label use of Janus kinase (JAK) inhibitors.

Clinical presentations

• Central facial erythema, with or without papules and pustules.
• Fixed background erythema may persist despite resolving inflammatory lesions.

Conventional treatments

• Papulopustular rosacea responds to topical agents (eg, metronidazole, ivermectin, azelaic acid) and sub-antimicrobial dose doxycycline.

JAK inhibitors in refractory cases

• The presentation that has caused the most difficulty in treatment, Del Rosso noted, is erythematotelangiectatic rosacea, without papules and pustules.
• Case reports indicate efficacy of low-dose upadacitinib (15 mg/day) in severe erythematotelangiectatic rosacea.
• After 8-12 weeks of treatment, dose tapering to every 3 days maintained remission without flares.

"JAK inhibitors are not first-line," he cautioned, "and this use is off-label, but they may be an option when conventional therapies fail."

The panel underscored the importance of individualized, evidence-based approaches for managing acne and rosacea. By combining established protocols with emerging therapies, clinicians can offer more comprehensive, patient-centered care.

Key takeaways

• Use combination OCPs for hormonal acne management, avoiding progestin-only pills due to their androgenic effects.
• Consider adjunctive therapies like antihistamines or omega-3 fatty acids to improve isotretinoin tolerability.
• Maximize adherence with simplified, fixed-dose regimens and educate patients to maintain therapy beyond 12 weeks.
• For refractory rosacea cases, JAK inhibitors may offer a novel therapeutic avenue when standard treatments fail.
• Clascoterone is a promising topical option for reducing sebum production in acne management.