Narrator:
0:01
Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased evidence, proven facts powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.
Dr. Michael Koren:
0:17
Hello, I'm Dr. Michael Koren and I'm very excited to lead another session of Two Docs Talk, which is part of our MedEvidence platform. I'm particularly excited today because I have a great guest Dr. Michael Bernhardt is here with me.
Dr. Michael Bernhardt:
0:32
Thank you.
Dr. Michael Koren:
0:33
Michael and I have known each other for a few years now. Michael is an amazing dermatologist. I trust my own skin to him.
Dr. Michael Bernhardt:
0:40
Thank you.
Dr. Michael Koren:
0:41
And he's also a great researcher and I've worked with him in the research realm here at Jacksonville Center for Clinical Research. So we're going to talk about an area that is probably the bread and butter of dermatologists and is something that is now getting a very high tech spin, and that's the treatment of acne.
Dr. Michael Bernhardt:
0:58
Correct.
Dr. Michael Koren:
0:59
So what I'm going to do is we're going to walk through what is acne, who does it affect all the basics, and then we'll eventually get to the elements that are really exciting, which is, new ways of treating it that may be more effective than what we have now.
Dr. Michael Bernhardt:
1:14
What's interesting is that as a dermatologist, the stage we're at in terms of treating acne is kind of similar, in my opinion, to where we were in terms of treating psoriasis back in 2005, 2003. Before the biologics had the big impact and, of course, we did some of the studies here Taltz, Cosentyx, all these drugs were huge game changers for psoriasis and I still think that in a way, we're still in kind of a early phase of understanding, even though this is ubiquitous problem. According to the people that are promoting the study. I think that the target range is over 230 million people that globally with acne and it creates a lot of morbidity more than people realize the physical impact in terms of scarring, psychological impact in terms of state of being, state of mind, particularly in vulnerable teenagers who have self-esteem issues as a rule to begin with. So if something could be done to bring acne care to the 21st century, that would be great.
Dr. Michael Koren:
2:23
Yeah, exciting, so let's break it down for our audience. So let's start with the definition of acne and what is the cause of acne.
Dr. Michael Bernhardt:
2:31
So acne is inflammatory condition that affects the sebaceous glands and the first step is comedone formation and the analogy.
Dr. Michael Koren:
2:41
Before you get to that, so does it just affect the face or is acne everywhere?
Dr. Michael Bernhardt:
2:43
It could be the trunk, it could be face back chest, it could be small. Just sun exposed or any place, doesn't really matter? A nywhere it goes anywhere, there's a follicles is at risk, and so the first step is a plug into the pore.
Dr. Michael Bernhardt:
2:57
The analogy that I make in the office is I tell people to kind of close their eyes and visualize a Coca-Cola bottle that's about three quarters full of soda. Because, just like a soda bottle has a tapering, we screw the cap on, the follicle has a tapering and that area is called the isthmus, and where the isthmus of the follicle is, the cells will proliferate, choke off. The follicle prevents that fluid, which is not soda but it's semi-liquid wax or sebum, from coming out of the follicle, lubricating the skin,
Dr. Michael Koren:
3:30
Right so, and we talk about bacteria being an important part of it. So can you explain that a little bit to folks?
Dr. Michael Bernhardt:
3:38
So you know, the skin is not a sterile envelope, which is something I explain to patients all the time. There are fungi, there are viruses, there are bacteria that are normal inhabitants on the human skin, and one of the key players in acne is a bacterium called Propionibacterium acne, or P acne, f or short. There are several different strains of this organism, and it's been found that one or two strains are particularly pro-inflammatory, and there are particulates of the organism, what they call cell surface markers, as well as what's called opsonizing particles, which are clumping particles, and those are the parts that are the target of this vaccine that we're looking at.
Dr. Michael Koren:
4:15
So just a little bit more about the epidemiology. We think of acne as something that teenagers get, but it's more than that. So explain why it's teenagers. Explain a little bit more about other times in life when you're prone to acne and maybe explain why you are prone to that problem at that time. So why, are teenagers more prone, or why are other people more prone?
Dr. Michael Bernhardt:
4:34
Well, I mean, first, off the myth that it's only a teenager disease, right, and 40% of people that are new onset acting patients, women between the ages of 24 and 64. So in almost half the patients it's an adult onset. It is common in teenagers, right? So what plays a role?
Dr. Michael Bernhardt:
4:51
Obviously the hormone flux plays a role and certainly we know that, acting like an hydrodinitis subrataeva, we know that the cells that line the follicular epithelial cells, are particularly sensitive to the presence of testosterone or progesterone in those, you know, proto hormones. Why? Certain, there's different reasons that are speculated. We know that in hydrodinitis, for example right, we know that which is almost a cousin of acne, a more severe cousin of acne, we know that those cells are exquisitely sensitive to testosterone. We know that in that population there's a high incidence of hyperinsulinemia and insulin resistance. We know that in women, for example, there are certain sexually-based differences in terms of immune response, killer cells versus T-cell-driven responses. How that plays an acne, that it hasn't really been translated over yet, but at the gut level I think some of that plays a role. So in the teenage years, when those kids are growing and hormone levels are in a state of flux, sensitivity to the presence of hormones or a state of flux causes changes Interesting.
Dr. Michael Koren:
5:59
Interesting and you said sometimes women at later stages in life are prone to this. How about men? Any time in their life in particular, where you see that they're more or less prone?
Dr. Michael Bernhardt:
6:10
Mostly teenage in my experience, but I do get older, you know, people post 20.
Dr. Michael Koren:
6:15
So there's no men-o-pause that causes acne.
Dr. Michael Bernhardt:
6:18
Why is it menopause, it should be girlopaust, right?
Dr. Michael Koren:
6:23
Yeah, that should be the opposite, right? Yeah, right, interesting.
Dr. Michael Bernhardt:
6:28
When I was out, when I practiced for a yard in Arizona, big market out there everybody's on testosterone supplementation for quote unquote overall health. So a lot of nodulocystic acting. Even the women nuance at men. So definitely testosterone plays a role.
Dr. Michael Koren:
6:42
So guys that may take extra testosterone to live forever or to build their muscle mass, they would be prone to acne.
Dr. Michael Bernhardt:
6:48
Yeah, and it could be really tough to treat. Interesting, especially if they don't want to come off the testosterone.
Dr. Michael Koren:
6:53
Okay. So let's pivot a little bit to the treatment elements and we're going to get much more into that, but just from a general sense. So as a general physician, I have knowledge that you use topical things and then eventually you use antibiotics if it gets bad. So just walk us through that in a very fundamental way.
Dr. Michael Bernhardt:
7:10
Sure. So treatment is kind of based on what you're seeing, no different than in your field, cardiology. So what's the reality in front of you? So if someone has maybe five to 10 small plug pores, what we call closed colonones, right, we're not going to go on systemic therapy for that. So that's the kind of person where you want to exfoliate the skin and modify the lining of the pores. So that's where things like retinol A, adapylene, all these retinoids retinoids are derivatives of vitamin A that are designed to modify the texture and the quality of the follicles.
Dr. Michael Koren:
7:45
And that has a big following. Now, for other reasons, retinol A, I know a lot of people think it helps with wrinkles.
Dr. Michael Bernhardt:
7:50
It works.
Dr. Michael Koren:
7:52
Does it work? I've heard it's been evidence-based to prove that it works for wrinkles as well as acne.
Dr. Michael Bernhardt:
7:59
I haven't read the evidence-based date on it. I've just been using it for 40 years and I've seen it. It definitely works. You can tell who's using it and who's not using it and it's really a pretty benign drug when you think of all the drugs that are out there. But it definitely works, smooths out wrinkle lines, but it also exfoliates, kind of modifies the follicle, which I think is probably gut level. I think it's having an effect on fiber blasts. I don't know if there's been any research into that, but I think that's what's driving a lot of the youthful approach to it. So that's usually step one is a retinoid to topical antibiotics and the topical clindamycin which drives down the P-actin's population and also acts as an anti-inflammatory. If someone has a more advanced condition where they start getting little lumpy bumps, we call endermatology nodular cystic lesions, which in plain English translates into lumpy bumps.
Dr. Michael Koren:
8:52
Those are the kinds of In teenage speak. Is that pizza face?
Dr. Michael Bernhardt:
8:58
Sure, sure, yeah, and it could be tough, though it could be tough on those kids. So when they come in with the nodular cystic lesions and the excessive oil secretion, which is what's been called pizza face, that's when oral antibiotics come into play, because for non-inflammatory lesions antibiotics don't work. I mean, antibiotics work A by driving down the propionic bacteria, but a lot of these drugs block metalloproteinases. That's one of the things that doxycycline does. That's why we use it in rosacea a lot. It's because it downregulates metalloproteinase 8, 9, and 10, which are pro-inflammatory collagenolytic molecules.
Dr. Michael Bernhardt:
9:39
So we're using it as much for anti-inflammatory basis as we are for bacteria kill. So that's when we use it for the nodular cystic lesions. And if they don't respond to that, that's when you start getting into the world of isotretinoin. Now the other drug that we're using a lot, particularly in our female population, is spurnolactone, aldosterone. It is a great hormone blocker and I started using it a lot more the year I was in Arizona because it was a big treatment out there and I brought it back and we use it as a mainstay in our practice and probably I have as many young ladies on Spyro as I do on Doxy.
Dr. Michael Koren:
10:17
That's just fascinating from a sort of historical perspective and how drugs develop. So something that was really built as a hypertension drug is now being used by you for acne and being used for me for congestive heart failure and it works great for acne. It works great. It's a pretty safe drug. It raises your potassium level. You have to watch for that.
Dr. Michael Bernhardt:
10:35
You've got to keep an eye on that, yeah, but a pretty safe drug. It's like monoxidil.
Dr. Michael Koren:
10:39
Yeah.
Dr. Michael Bernhardt:
10:40
Right, it meant that it was a blood pressure drug, and now we're using it at 1.25 or 2.5 milligrams for hair restoration.
Dr. Michael Koren:
10:46
Interesting benign drug. Yeah, so we're going to end this session with one last question. Actually, we'll do two questions. The serious question is that if we have pretty good treatments, do we need something new or are there some limitations of the current treatments?
Dr. Michael Bernhardt:
11:02
Well, I can't say them before. I really think that we're 20 years behind what we need to be in terms of acne treatment. I think we could be doing better and I think we owe it to our patients to do better. I don't think kids should have to be in a situation where they have to try five or six or seven different regimens before we get to the sweet spot.
Dr. Michael Bernhardt:
11:21
They should be able to walk in and we should be able to have an immediate slam dunk. And the fact I was having a discussion with another DERM about this at the investigators meeting for the injection and I was making the point that I think we're doing the best we can. But, in all honesty, for our patient population, if we're doing the best that was out there, patients would not have to go on isotretin. No, patients would not have to be on a spurnal loctam. We should be able to have an easy slam dunk, like we do now in the psoriasis world and the topic dermatitis world.
Dr. Michael Koren:
11:52
Interesting, and so the not so serious question is when we started this session, you were telling me that you hadn't done a podcast before. I'm a first-time podder. Right, and that you needed to be poddy trained. I've been poddy trained, so do you feel poddy trained at this point? I feel very relieved. With that, we're going to end this session and we look forward to you sticking with us for our next discussion on this really interesting topic.
Narrator:
12:12
Thanks for joining the MedEvidence podcast. To learn more, head over to MedEvidence. com or subscribe to our podcast on your favorite podcast platform.
