Beyond Isotretinoin: Long Term Management, Controversies, and What’s Next in Acne

(upbeat music) You're listening to The Spot Check Podcast, powered by Derm squared. Ciao ragazzi, and welcome back to the latest episode of The Spot Check Podcast, your source for clinical insights you can use in your practice the very next day. I'm your host, Jamie Restivo, board certified physician assistant, and today we are continuing our special two-part acne awareness month series with Dr. John Barbieri. In part one, we focused heavily on optimizing isotretinoan outcomes. Everything from dosing strategies and recurrence to absorption and side-effect mitigation. Today we're taking the conversation one step further and diving into some of the most commonly debated and rapidly evolving topics in acne management. Once again, I'm joined by Dr. John Barbieri, board certified dermatologist, director of the Advanced Acne Therapeutics Clinic at Brigham and Women's Hospital, associate professor of dermatology at Harvard Medical School, co-chair of the American Academy of Dermatology Acne Guidelines Work Group, and associate editor at JAMA Dermatology. That is a mouthful. Dr. Barbieri, welcome back for part two of this series. - Thanks for having me again. - It is such a delight. I can't wait to get into this with you. So we can not have a conversation about isotretinoan without addressing the elephant in the room. Psychiatric safety. How do you approach screening prior to initiation? - Yeah, so I think let's just start with the data on the really outcomes that we worry about, which are like depression, anti-depressant use, and suicidal use isotretinoan. So first off, I really do believe that isotretinoan can cause mood changes. Both anecdotally, I feel like I've seen people who have developed mood mobility, including sadness and depression, as well as irritability from it and have had improvement when they stopped it. And there's certainly these challenge studies that I think are compelling, where people take the drug, they have these symptoms, they stop, they feel better, they take it again, they recur. So I really do think that this can happen. That's the first thing, right? That being said, when you look at the observational data, so you look at these big core studies that compare people who are treated with isotretinoan versus people who get treated with other drugs, like oral antibiotics, other treatments for monitor acne, those who get treated with isotretinoan consistently have lower rates of depression, anti-depressant use, and suicidality. So if the decision is to be an isotretinoan or be on something else for acne, they are, I think, the expected values, you're actually less likely to get a psychiatric comorbidity that are complication on isotretinoan than other treatments. And that's because acne itself is associated with all of these mood symptoms. And so that's, to me, a huge caveat when making this decision-making. We do have to be thoughtful about these side effects, but from what should we do standpoint? To me, someone who's depressed and is acne, that's a reason to use isotretinoan, not to be afraid of it. Right. And I'm so glad that you touched on that. I mean, acne really impacts us in terms of just going out to being social dating, applying for a promotion, going to high school prom. It impacts people more than one might think. So we have to be really thoughtful about approaching it aggressively and taking it seriously. Sometimes just a few pimples are enough to ruin someone's day. So I do think the data is very supportive. As you said, we do have to be mindful of this. We have to counsel, we have to watch for it. Some of the volatility or liability in the mood, something we have to watch for, and then re-challenging, I think, is when we really take a step back and say, maybe this isn't the right approach for you as an individual because you've had this now on two occasions. So do you tell the families, patients, what to watch out for? And if this happens, we stop you. How do you approach that? - Yeah, so I think two things to come up for. One, if someone has pre-existing mood symptoms, do you give them this medicine? And I've seen some people who will require, I don't know, like psychiatric clearance to be on the drug. And to me, that doesn't make a ton of sense 'cause again, the expectation of this drug is improved mood. So I think someone who has baseline depression or anxiety or mental health comorbidies and 20% of people with acne have these mental health comorbidies. It speaks to the incredible impact that this condition can have on individuals. To me, that's a reason to just use it. Making them have to go find a mental health professional which can be incredibly hard to do, can be stigmatizing in and of itself, to be allowed to be on the drug. I don't think it's practical. If they have a mental health professional work with great to coordinate care to collaborate with them, but I don't think requiring them to get like approval to be on this drug makes a lot of sense to me. I think if you think it's right medicine for them, they think it's right medicine, just do it and don't make them go through the steps. That being said, I do think it's important to counsel about these things and I talk about really mood swings to be the main ones to depression sadness, but I also think ear to ability can happen. And so I talk about both of those and mentioning, if you're feeling those things, please let me know. This medicine might not be the right one for us and we can think about we have lots of other options and if they have, if they're an adolescent, working together with their parents to keep an eye out for these things too. - These are all really good points if they're connected with psychotherapy, making their parents aware that hey, be mindful of these. Let us know if these things are happening. I think that the biggest issue here is the medical legal aspect. So it's a CYA, cover your Toshy Tosh Tosh. So if they are aligned with the medical professional, maybe they're on an antidepressant getting kind of approval from their pediatrician or PCP and saying, hey, is this well managed before we started? I think a lot of clinicians will do that, but it does delay treatment. So I personally think this is a CYA issue because that just comes down to the crux of it. - Yeah, I can appreciate the medical legal concerns. Why people do it? - I'm not sure there's ever been a successful lawsuit against the dermatologist on that basis. Well, I've not seen that. I mean, there's all that gray literature of legal stuff and I will pretend to be a legal scholar, but I don't think it's a common reason for malpractice suits. And the other thing is, you know, I think if you have adequate documentation about the risks and it helps create that medical legal protection and you have a good relationship with the patient that again, that's probably the biggest predictor of medical legal things. - Yes, that is true. - I can totally appreciate that concern, but I'm not sure that it's that grounded in something that's likely to happen. And I think there is likely harm that happens from delaying things. Like we talk about the need to start it because of scarring and then we're delaying it because of this medical legal concern site. I do think we're a little bit overly cautious there by totally understanding where people come from too. - It is a very litigious aside. And I do think unfortunately that can get in the way of prescribing some of these medications. So but I appreciate your approach there. I think it's a very pragmatic approach and one that our listeners can benefit from hearing from an expert like yourself. So talk to me, we talked a little bit in segment one about IBD inflammatory bowel disease. So all sort of colitis and Crohn's disease. What is your counseling with patients in that regard? - Yeah, some people bring it up and then I'll talk about more. And people don't, I've described really briefly, which is that there have been some concerns about inflammatory bowel disease that's got health problem with this medication. Unfortunately and the data that we have, the most rigorous observational studies trying to look at does this medicine actually increase someone's risk? There doesn't seem to be any compelling evidence that it causes a meaningful increase in risk of these conditions. And front people, they're happy there. There's some people we dive into it more. - It really depends and there's no causation or causality between your own isotretino and you are therefore going to get IBD. So we have to be thoughtful about that. And then there's some recent genetic research that suggests that acne and inflammatory bowel disease, so all sort of colitis, Crohn's may actually share overlapping immune and inflammatory pathways. In other words, acne itself may reflect a broader systemic inflammatory profile rather than the relationship being driven by isotretino. And so I think it's worth mentioning that patients that have acne may be at greater risk for IBD. - Yeah, 100%. We've done some of that work too, showing that association between acne and inflammatory bowel disease, just those two conditions. And they share some inflammatory pathways like IL-17. So it totally makes sense mechanistically and then there's both some genetic data, Mendelian randomization data, it supports that, and some epidemiologic data support that association. The other thing here too is like the antibiotics that people get. - There you go. - You know, oral antibiotics, there's been some associations with inflammatory bowel disease. And so if you get oral antibiotics, and you get isotretino, and people like the blame isotretino for anything bad that happens, it's sort of just this like unfortunate. Because it has some real side effects, it kind of gets blamed for all sorts of things that it probably doesn't do too. - Yes. - And so, you know, that's the thing you see when you look at the literature on this, studies that don't really adequately consider prior antibiotic exposure are more likely to identify potential associations between isotretino and inflammatory bowel disease and studies that do. So I do think that's a really important caveat when considering this literature and also considering your choices. Like if you can be on doxycycline or isotretino and your fears inflammatory bowel disease, I would pick isotretino and every time. - And day. - Yep. And you know, there are other patients out there that are like, oh, give me more doxycycline. It's like, no, this is going to put out the fire when we take this away, that acne-causing bacteria, populations are gonna come right back. So this is just kind of the one-border topicals, give that time to work, and we are taking those antibiotics away. So I think that's a really good point. And, you know, patients in the old days, you know, when I was offered isotretino and I had to fail, you know, a bajillion things out there. Now I think clinicians are more steadfast in offering this, you know, before they normally would. So if they're scarring psychosocial impact, we're choosing this option a little bit earlier than we have maybe in the past. but those are really good points. Are you monitoring for any GI symptoms when patients are coming in for follow-up or are you asking them certain questions? And if so, walk me through that. - I actually asked if they're having any stomach pain. I won't get too much into it again, 'cause I don't think it's a really clear association. So I'm not like searching for something that I don't really expect to happen anyway. - Right. - So if they bring it up, you know, we'll look into it, but I'm not necessarily just like really trying to find a you there. I'm not like every visibly like, are you having blood in your stool? If you ain't change this here about, like I'm not going to like that kind of detail, I just like, do you have any, you know, abdominal pain? You have any belly pain? - Just kind of as an overhead bird's-eye view, just inquiring about it. - Yeah. - I think that's a good approach, because sometimes the more you talk about something, the more they think it's gonna happen, and the more they kind of bring it to fruition. So that can be a dangerous approach to. Your approach is very calm and collected, and if there's an issue, you address it. If it's not an issue, you don't go after it. So we alluded to labs in part one, and I think this is where practices here seem to vary dramatically. Historically, many of us were trained at monitor labs, very aggressively throughout isotretino. And so baseline labs, monthly labs, what is your approach? - Yeah, my kind of baseline approach is to check, really an ALT, though often I'll check in ALT and ASD, and then a triglyceride, so often I'll check a lipid panel just because of some ordering practicalities at baseline, and then again, at peak dose. So basically, I'll check ASD, ALT, and lipids at baseline in peak dose. And if those are both really acceptable, we can talk about what to me that is, which is true in about 99.7% of people, I won't check any further labs. That's sort of my baseline. There might be some individuals where we monitor things more closely, where we monitor some extended labs. There might be some people where I monitor no labs, depending on certain circumstances, and we can kind of talk about what those might look like. - Very bold, Dr. Barbier. (laughing) - But you know, you believe in this therapy. - Think about this a few years ago. - It is such a hot topic. It's so different from every clinician, from every practice, and I wish that there were something that we could hang our hat to and say, "Okay, look, this is what we're gonna do in every patient." But that's the way medicine is, we have to individualize. So to your point, when you're doing ASD, ALT, you're doing a lipid from practicality, 'cause we're really watching that triglycerides, what numbers start to freak you out and say, "Okay, we might have to stop or do a dose reduction." - Yeah, their triglycerides are going to like 400, 500 or more. That's where I start to feel like, "Okay, are we doing this really fast thing?" 'Cause sometimes that can influence it. And do we need to think about adjusting dose thing, or using other adjuvant things to try to address that? - Right. - Exactly. - And then for ASD and ALT, if they start becoming really just above normal, then we start to think about it. But, you know, we look at the data of these, so just changes in labs. Changes in ASD and ALT are just as likely before people start like having a normal lab will happen to about 1% of people. And it's just as common before they start is on treatment. So I think a lot of this is background noise, not a really meaningful impact of the drug. There's not really any clear evidence that it does anything meaningful. And there's basically zero reports ever of someone having a lasting liver injury. So like, Turbinephine, like people get their case reports of like, hepatic failure in the hospital. They're just are not those case reports that I said try to know. There's lots of like, their ASD was like 2x the upper limit of normal and then it was normal again. But there's none of this like real liver problem kind of stuff coming up. And so for checking ASD and ALT, it tried to prevent like a real meaningful liver thing. And those things don't even seem to happen. Is this a valuable practice? - Right, and what's the cost to healthcare? So it's like, why are we checking these labs? I mean, to your point, it might be an incidental finding. Maybe they took a little Tylenol or, you know, something else happened on in the background. So actually we're trying to get all kinds of things can make these mildly elevated. - Exactly. So we're doing these labs and it's like, okay, how is this actually going to impact our clinical management? And sometimes it's just kind of another burden. So, you know, maybe you can work on that, Dr. Barbier. He put out, you know, guidelines for labs that we can all follow because I think it's a really tough issue. And you know, Turbinephine, you can check labs before, during, after, it doesn't predict who's going to have an issue. That's the other thing about checking. Do you check CBC with differential? Talk to me about that. - Yeah, so I don't check CBC with differential at all. And that's because there's been a variety of studies highlighting that there's really no meaningful changes to CBC parameters I used to try and know on. There's not really clear evidence that there's any meaningful rates of, like, leukopenia and cytopinias and through what people worry about. There's certainly a couple of like case reports out there about it. But just looking at more population-based data sets, it's extraordinarily rare if it happens. And it just doesn't seem like a high-value practice. And it's unclear if it's even meaningful. - Excellent, love it. That was fantastic. So we're going to continue this rapid fire episode. I want to talk to you a little bit about your favorite supportive therapies. Because patients are always asking, what can I actually use while I'm on the medicine? We tell them upfront, you're going to have dry eyes, you're going to have dry nose, you're going to have dry skin, dry lips. And to some effect, we want that to happen because it indicates absorption. If the patient before you does not have a little bit of that going on, we wonder about are you actually taking it? Is it getting absorbed? You know, and I think the shift with skincare has really been a focus on supporting the barrier. When I was younger, it was like strip the barrier. If it doesn't sting, it doesn't burn, it's not working. And that's just not the way it is. We need to support the skin barrier. Patients tolerate their therapy better. They're more adherent and we have better results. So I'm curious as to what your approach is. Do you have any go-to cleansers that you like to recommend? - Yeah, so I mean, the first thing, a little what you're getting at, making sure they're not doing stuff that's causing a problem. 'Cause especially now, there's so much of like, I saw this product on TikTok and it's like a good product, so I'm using it. And so I think everything has to have a purpose so I tell people, if this doesn't have a role, don't do it. Don't do it because you're supposed to use a serum, do it 'cause it's trying to accomplish something. So that's the first thing is like, I basically just want people using cleanser, moisturizer, and sunscreen, and I used to trend on. And not really anything else unless it's to like address dispigmentation or something. So, cleansers, I don't think matter that much honestly. Like, just get something that's affordable, that's, you know, has a hydrating kind of cindet cleanser and there's lots of those and that you like to use. That's to me it. So like, just pick a brand that you like that you can get that isn't too expensive and that isn't something like, don't use like ivory soap on your face. But as are like, you know, Ios friend or something like that. But outside using things that are really like harsh and drying, most like cleansers are gonna be fine in my perspective. Do you send them home with samples? Do you verbalize like, hey, these are some options? Or you just kind of let the patient decide what they're going to use? I guess that's my question. I give them a list of options. I have a handout and I'm like, people often ask me about cleansers, moisturizers, and sunscreen. And here's some ones that I like. And if you have ones you like, that's awesome. But in case you're looking for suggestions here or some you can use. So that's what I do. We don't really have great samples in our office because of where we are and all that, which is a general, I think, limitation of sometimes academic practice places. So that is not as easy to do though. I do think it'd be helpful 'cause then they can try it out. They can like see the bottle or if you have those little sheets that are like here, you can check it out. I do think those things are really nice. I don't totally have access to that stuff unfortunately. So I just give them this handout. - Okay, so, but I think to your point being intentional, I mean, we see, you know, kids that are like 11 to 13, they're using vitamin C, retinoids. They have a 13 step, you know, drunk elephant routine. And it's like, oh my god, your barriers are just gonna be totally out of whack. So you basically give them a handout and just make sure that they're being intentional about the products they're using. - Yeah, have a plan, not trying to pick great products, have a great plan. - Right, exactly. What do you like for lips, key lightest? Do you have any favorites there? - Just, you know, ointment kinds of things. So, you know, Vaseline, Aquaforce, Airway Healing Ointment, pick your favorite, one of that kind of product class. - Okay, perfect. - I tend to have to use those as opposed to like a chapstick kind of thing. - Yes, oh certainly. - And then I'm prescribed them hydrocortisone, like point, 2.5% ointment sometimes, if it's more bothersome. - And do you like the Cordy Bomb? I have a lot of patients ask about that. - Yeah, I think that can be a great, like actually on my handout I have those, like if you want to try in your own, like next step thing for dry lips, you can go and buy that kind of a product. Or you can tell me and I can prescribe you something, which sometimes works a little better and a little less expensive. - Okay, perfect. And dry eye, we talked about the Omega-3 in part one of the series. What else do you like for dry eyes? Anything in particular over the counter prescription? - Yeah, I think those lubricating eyedrops and I'm no expert in ophthalmology, so I go out but some of the ophthalmology people have told me like refreshing, sustain or good. - Yeah, they're great. - But not that I have independently verified that I like science, those are the best for anything like those lines. - Yeah, I think, you know, that's common practice. So the artificial tears, there's some out there that are more of like an ointment base. So I have dry eye, these are some of the things that my eye doctors have recommended over the years. So like sustain has an ointment that you can put on at night. Gentile has an eye gel that's a little bit more, you know, thick, it's an ointment based. So this can be helpful. And nose, like nasal dryness, nose bleeds, what do you like there? - Yeah, so, you know, humidifier can be helpful and make the air and the environment less especially. I'm in the northeast of the winters here can be pretty dry. So humidifier can be something the bedroom can be helpful. There are these nasal saline moisturizers, which I think can be a little helpful to kind of like these nose spray type things. - Yeah. - I actually really like to use these sort of nasal like gel moisturizers, which are almost basically like super sergy loop in the end. And I thought that was to be incredibly, but the point of asking your nose is like yucky. These aren't, don't feel as bad. And I really do think they work quite well. I've used them a lot and had good success with them for people with dry nose and nose bleeds and even just like oxygen in the hospital dry nose kind of stuff. Oh definitely. And you like the Neal Med. Is that one that you recommend the nasal gel? That's one. I think there's lots of products similar to that. That's an easy to find one that's pretty affordable. Excellent. Those are great pearls. And do you tell patients to avoid anything if they're like, "Hey, can I do a sal acid wash, BPO wash? Are you telling them to avoid that?" Generally, so both, as we talked about in the first session, for those that will actually go check it out. But for me, I still try not to be clear on nothing because I go as long to remission. So I don't want them using products with active in it because then I don't know where they actually clear or not. I don't want them to have to keep using them long-term. So I want them to be off of that stuff for that reason. And because they're irritating, it's often that just exacerbate things. I say, "This medicine is so good at treating acne that I don't want you doing anything else because all those things are going to do is give you more side effects." Perfect. I think there's a really good clinical pearls that we can implement in the office. So post-acerotretinone protocols, it's eerie to me that there's no maintenance protocol that happens. And I think a lot of the problem with that is patients really think this is a quote-unquote cure. They're never going to have a pimple afterwards or permanently cured. And in the study that we talked about in part one, there's a meaningful subset of patients that go on to fill topical prescriptions oral medications that may even require a second course of medication. So a vizotretinone, excuse me. So we need to be putting them on some kind of maintenance therapy. I personally like to use a lot of araslo. And again, no conflict of interest there. I think it's a very effective medication. It's much better tolerated due to the formulation. And it does a great job with cleaning up any post-inflammatory hyperpigmentation, scarring, texture. What do you like? Is there certain topicals that you reach for every single time? Do you have a standard approach? Yeah. So what do you do there? Because everything I will share is my favorite topical too in terms of topical red noids. For me, again, because Michael is to have long-term mission, I will often people do nothing because a lot of them, that's their goal. I want to think about acting anymore. So if I'm using these acne products, it's still in my mind. So I want them really to be like, this is not in your life anymore. And interesting. I like to give them a chance to do that because we don't have any data that doing anything afterward prevents recurrence. We have it, you know, it can treat the recurrence. You don't notice it, but not that immediately prevents it so it doesn't happen. So for me, I encourage people to do nothing. And if things come back then, I'll add the, you know, topical red noid, whatever, you know, we think we want to do next. But there are people who are like really scared. They're like, right. Exactly. When I stop this, I'm so worried, Max, it's going to go back. And those people who are feeling that way, I'll often start them on a topical red noid. You know, pick your favorite topical red noid product. Exactly. I do think that's a good next step. And what we just don't know is is doing that change the trajectory of things. Does it make it so if they were going to have a recurrence, they don't, or is it just treating the recurrence, they were going to have anyway. So that's the thing we don't know. And that's why I encourage people to do that thing. So I have the patients that are like, Jamie, I don't want another pimple. So I, you know, I'm the type of individual who, especially, you know, like if it's an older patient, female, they're getting these undergrounders. It's been difficult to treat their acne before I used to treat noid and they've been on every topical and systemic known to man. And they're really panicked about having acne. I will say, look, you know, we should start you on this. It'll get any nuisance stuff that you could, that could arise thereafter. It can help with pigment, you know, anti-aging, scarring, texture. I mean, the benefits go on and on when we talk about red noids. So I think we have to be thoughtful. Yeah, they're an easy sound, especially people have like sequelae still like red marks or dry marks. We might want to use as like acid, red noids or different things to help address that. So totally, there's lots of things you want to add to a dress sequelae. And I agree, those people who are worried about recurrence, just giving them something and like make them feel a little extra safe, I think is helpful. Yes, busy hands are happy hands. So give them something to do. Give them, you know, one of your favorite sunscreens that you like to help declare up to Scromia, you know, you can't go wrong. You're going to help with photo-aging and patients are happy. But I think it's interesting that you kind of do like a wait and see approach because to your point, you know, you're giving them the straw because you want them to get better. So you want to see if they're getting better. But it's, it's everyone's approach is unique. So that's why I'm always just elated to have these discussions because it's interesting to see what people do out in the trenches out in the wild. So I appreciate your approach. I think both of us that comes back to the patient in the end with this, you know, it's really definitely is the patient sick of using red noids and that's why they're on ice a trend on or do they actually like to use things and be active about stuff. And I think that's the key to distinguishing factors. What is the patient's goal? Yes, we have to be very patient centric. So yes, she hit the knee on the head with that one. And as always, we are running out of time because I just want to pick your brain about everything known to manacutane. So before we wrap up, I just want to touch on a few rapidly trending acne topics. So patients, they're constantly asking about these LED light therapy devices, ads are so prominent on social media apps, you know, they're constantly popping up. What are your thoughts on these devices? Did they actually provide meaningful benefit? Or are they just type? I think they work, we just did a systematic review on this topic. And they seem to be about as effective as like benzoproxide. So like, are they ice a trend? No, no. But can they like play a role in acting regimen and they very well tolerate it? Yeah. So for someone with more mild acne or needs a little bit extra around the edges and isn't quite there or has more sense of skin, I think you need a great option. If you're going to do it, you want both red and blue light because the studies show that the two colors together work better than either alone. And what we don't know is what's the best device because almost none of the ones on the market have clinical trials. So we're basically all basing this on other studies for other devices. But I would look for something that's modestly priced like that's $50 is probably not enough flu and so work. If it's $1,000 is probably more expensive than it needs to be. And something that's red and blue, that would be the way I think about this. And something in the middle, you know, cost cost price point to. So something not exuberantly expensive, but something that's, you know, not extremely cheap that's going to burn your face off. So, you know, kind of going right in the middle there. But patients ask about it. And, you know, you're basically saying it's, it's about equivalent to one over the counter, like a BPO. Yeah, like any single Asian topical regimen, it's about that effective. As effective as retinoids? Well, retinoids are about the same as benzoproxide in, you know, network metanalysis. So I would say so. Okay, that's a good, good thing to know to tell patients. They're a little different though. Like, you know, someone that's comedones, probably not as good. Like, retinoids, if someone's like a million comedones, retinoids are amazing. But just like on average, it's about the same as any single Asian topical thing. Okay, so that's, that's a good kind of pearl to tell patients. Like, if you want to use it and make sure you're going kind of middle of the range, you know, I don't think it's going to work wonders. But if it's something that you have the time and money to invest in and you want to do it, it's not going to be harmful, right? Yeah. Is what you're saying? Exactly. Okay. And then lastly, what emerging therapies or developments are on the horizon and the acne pipeline that really have you very excited? Anything we should be watching for? I'm really excited about these fatty acid synthase inhibitors and in full disclosure, I've done some work for some of the companies that are developing them. But, you know, these are really interesting. They block some of the pathways similar to like what we're trying to do with anti-androgen therapy, but a little bit further down. So instead of rocking like the hormones that are turning on, the way we're like blocking the oil gland and they seem to end some of the clinical trials from China to work a little bit better than oral antibiotics. But you can use them in men and women. They're pretty well tolerated. They cause a little bit of dryness, but not like Isatranone kind of level dryness. So I think they'll be a really great addition to our treatment armantarium, especially for male patients where we can't use hormonal therapy and can complement hormonal therapy too. So I think a lot of times where we use oral antibiotics, these might be a great alternative. And, you know, some people see me talk about dermatologists, for example, oral antibiotics and any other specialty medicine. And also that's right. So it would be great to have some more non-anabetic options that aren't Isatranone because that's not right for everyone that work really well. Right. Exactly. Do you think it's going to be kind of Isatranone, maybe efficacy without the side effects or we're just not there? I think not quite there. I think it's like a little bit better than oral antibiotics. So not Isatranone, but really effective and quite tolerated. It seems like another tool in our toolbox. So yeah, we'll look forward to seeing more on that. And it's so exciting. We've had so many novel therapeutics for acne. I love treating acne. It's a huge part of what I do. So I'm always excited when I have a new toy to play with and then something else in the toolbox. So Dr. Barbiri, thank you again for joining me for this two-part acne awareness month series. This has been exceptional. I know that our listeners are going to benefit from both of these episodes. There's so many pearls in there. So very insightful. Such a joy to have you and we would love to have you quite possibly in the future because I know we didn't get through everything I wanted to talk to you about today. So thank you to our listeners as well for tuning in to yet another episode of the spot check podcast. If you found these conversations helpful, help us continue to grow this podcast by subscribing or following on your favorite podcast platform. Downloading the episodes for easy future reference. These are ones you're going to want to review believe me and sharing them with colleagues and trainees who may benefit from these discussions. Graziemi Liragatsi. And as always, I look forward to bringing you more clinical insights in our next episode. So stay tuned. Ciao, ciao. Looking for more conversations like this one. Don't stop here. Explore the full lineup of podcasts from Derm squared where dermatology industry leaders, innovators and experts share insights you won't hear anywhere else. Visit Derm squared dot com slash podcasts. (upbeat music)