Who Is Accountable When Patients Do Not Achieve Successful Treatment for Their Acne?

James Q. Del Rosso DO Acne vulgaris (AV) is a very common inflammatory facial disorder that is complex in its pathophysiology, heterogenous in clinical presentation, and affects children and adults of all ethnicities, races, and skin types.^1,2 Although it appears that dermatologists are seeing more adult and pre-teen patients with AV, the time between follow up visits for patients with chronic disorders like AV are increasing, likely due to cost factors, unrealistic expectations regarding response to therapy, and/or searching for alternative options, including via the internet.³ Unlike other disease states such as psoriasis and atopic dermatitis, where new advances have become available or are emerging with biologic therapies and other systemic agents, AV continues to be managed with combinations of topical agents, oral antibiotics, and oral isotretinoin. Both topical and oral formulation advances have been very helpful in AV management, especially with topical vehicles that improve skin tolerability, provide stability with topical combination products, allow for oral formulations that reduce adverse effects and/or allow for administration without food. So why do challenges continue to be present with AV management? We have several effective and safe topical and oral therapies that should be able to control AV in most patients if used consistently, and in most cases, in appropriate combination.⁴ Unfortunately, assuming reasonable patient adherence, the most common “modern day” reason I have observed for inadequate treatment of AV has been that the patient encounters signi cant barriers when trying to obtain the medications prescribed by their dermatologist. This is not a problem unique to AV, however, what does occur with AV treatment is that patients only get part of their combination regimen. For example, they may be able to get access to one topical medication, but not a second topical agent which targets a different pathophysiologic component of AV. Another common example is that the patient obtains the topical therapy but the oral agent is not covered or access is signi cantly delayed. Except for use of oral isotretinoin for severe AV, or topical monotherapy for mild AV, successful AV management is highly dependent on the patient utilizing the full combination regimen, with anything less compromising what the dermatologist has designed in their case to achieve therapeutic success. So, who is accountable when the patient returns and their AV response in not adequate? At face value, it appears that the clinician is accountable as they were supposed to choose an effective regimen based on their clinical assessment. In fact, successful AV management is often compromised by incomplete therapy due to coverage issues, barriers encountered at the pharmacy level, formulary access, and/or cost factors. There is also the “fatigue factor” encountered by patients or their parents in trying to obtain their prescribed medications as they battle through the maze of pharmacy coverage. Over the past six months, in anticipation of writing this editorial, I have kept track of patients I have seen in follow-up for AV, looking at whether or not they were able to get the medications that were prescribed for them at their last visit. In approximately 30% of cases, the patient was not able to obtain the medications that were prescribed, with this number increasing to around 50% when brand name medications were prescribed. It is time that all of the parties who “meddle” into prescribing of therapy for patients with AV, as well as other therapies, take responsibility for altering the prescribed management plan. Accountability needs to include all who are involved. So far, I have not seen enough attention placed on parties other than the clinician in taking responsibility for poor treatment outcomes. Hopefully, action will be taken to improve access to treatment for our patients with AV. I know the American Acne and Rosacea Society has been carrying out a treatment access initiative. It will take a very large consistent effort from a large number of individuals to make a difference. May the force be with us. Enjoy this issue of the Journal of Drugs in Dermatology! James Q. Del Rosso DO JDR Dermatology Research, Las Vegas, NV Private Dermatology Practice,Thomas Dermatology, LasVegas, NV Touro University Nevada, Henderson, NV References