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I N T E R V I E W
Getting the Word Out about E ective Treatments: A Hurdle to
Jasper Lovoi, PharmD
Lovoi and Sons Pharmacy
One of the problems with treating acne is, pares with Benzaclin (the proprietary
quite simply, getting the word out. Market- name for a topical preparation combin-
ing of medications is now an important ing clindamycin 1% and benzoyl
aspect of health care, and compounding peroxide 5%). Unlike the antibacterial
pharmacists, who are typically on the cusp Benzaclin, niacinamide induces no
of current medical research, are still way bacterial resistance. A double-blind
behind in getting the word out to prescrib- study cited in the International Journal
ers about how effective compounded of Dermatology concluded that
treatments can be. In fact, many physicians “[n]icotinamide gel provides potent
first hear about compounding from their anti-inflammatory activity without the
patients who have heard from a family risk of inducing bacterial resistance.” 1
member or friend about the effectiveness
of a compounded preparation.
“One of the problems with
Niacinamide is a good example of this. treating acne is, quite simply,
Many doctors are unaware of niacinamide getting the word out.”
(also called nicotinamide) and how it com-
Continued on reverse
C A S E R E P O R T
Severe Acne and Excess Facial Hair in a 35-year-old Woman
Jasper Lovoi, PharmD mone, one of the causes of acne. The test
Lovoi and Sons Pharmacy did, however, measure levels of testoster-
Beaumont, Texas one and dihydroepiandosterone (DHEAS),
which both correlate with DHT level. The
In February 2004, a 35-year-old woman with results of her saliva tests showed that her
severe acne and excessive facial hair came testosterone level was sky high at 90
into our pharmacy. She had heard from a pg/mL when the normal range is 20-50.
speaker at a skincare clinic that I was having
Her DHEAS level
very good results in treating acne. Having had
was 21.1 H ng/mL,
acne since her teenage years, the patient said
she had tried “everything,” which included
3-10). Her cortisol
oral and topical antibiotics as well as Retin A.
morning score was
None of those treatments, she said, helped her
8.7 H ng/mL
acne or facial hair. She also reported symp-
(normal range, 3-8),
toms of weight gain around her waste and
and her cortisol
hips and loss of scalp hair. Although I have
night level was
recently found a lab that can measure a
within range at 1.2.
patient’s dihydrotestosterone (DHT) level
specifically, the saliva test tha t I gave this
patient did not measure the level of this hor-
ACNE: E ective Treatments COMPOUNDED MEDICATIONS
INTERVIEW CONTINUED USED IN TREATING ACNE
Since February 2004, I have been using
niacinamide 4% topical gel to treat acne Erythromycin 3% and benzoyl
with remarkable success. Of the 15 patients peroxide 10% gel: Apply daily
who have tried my niacinamide prepara-
tion, each has raved about it and refilled it,
reporting no side effects.
Before trying the niacinamide treatment, Niacinamide 4% acne gel, 30 mL:
many of my acne patients had tried Apply daily
Benzaclin and said that it worked for a little
while but then showed no results. Several
of these acne patients said they did not Niacinamide 4% in Vanicream:
want to take Acutane because of side Reference: Apply daily
effects, such as scarring. Niacinamide has 1. Shalita AR, Smith JG, Parish LC et al. Topical nicotin-
made all of my clients with acne very happy, amide compared with clindamycin gel in the treat-
especially those whose acne showed ment of inflammatory acne vulgaris. Int J Dermatol
resistance to antibiotics. 1995; 34(6): 434–437. Spironolactone 5% cream, 30 g:
Apply twice daily
What is Nicotinamide 4% t
When exposed to air and light, it may
turn brown and, at temperatures lower
than 15C, it may stratify (this can bean
Also known as niacinamide (or nicotinic Tretinoin .025% and erythro-
corrected by warming and mixing). It
acid amide), nicotinamide in a g e l form tight tainers
should be stored in airtight containers
mycin 4% gel: Apply daily
has been reported to provide potent protected from light, in a cool place.
anti-inflammatory activity in acne
without inducing bacterial resistance. In
one study, 76 patients with moderately References:
severe inflammatory acne vulgaris were
1. Allen LV Jr. Formulation: Nicotinamide
Formula What Is Acne?
divided into two groups; 38 received 4%
nicotinamide gel and the other 38 1998;
4% Topical Gel. IJPC 1998 2(4): 302. According to the American Academy of
received 1% clindamycin twice daily. Pa
2. Shalita AR, Smith JG, Parish, LC et al. Dermatology, “acne” is the term for
After 8 weeks, both treatments produced com
Topical Nicotinamide compared with plugged pores (blackheads and white-
beneficial results, as follows: 82% of the cli n t
clindamycin gel in the treatment of heads), pimples, and even deeper lumps
patients treated with nicotinamide gel l -
inflammatory acne vulgaris. Int J Derma- (cysts or nodules) that occur on the face,
and 68% treated with clindamycin had n 34–437.
tol 1995; 34: 434–437. ,
neck, chest, bac k shoulders, and even
improvement in their acne. The authorsthors the upper arms. Acne a ects most
3. McEvoy GK. AHFS Drug Information-98.
concluded that 4% nicotinamide gel is teenagers to some extent, but is not
Bethesda, MD: American Society of
comparable to 1% clindamycin gel in Health-System Pharmacists; 1998: 3002-
restricted to that age group; adults in
efficacy and that nicotinamide gel had -3003. their 20s--even their 40s--can get acne.
the advantage of not inducing bacterial While not a life-threatening condition,
4. Goskonda SR, Lee JC. Triethanolamine. In
resistance. Nicotinamide is a water acne can be upsetting and dis guring.
Kibbe AH, ed. Handbook of Pharmaceuti- -
soluble, B-complex vitamin that occurs as When severe, acne can lead to serious
cal Excipients, 3rd ed. Washington, DC:
a white, odorless or practically odorless, , American Pharmaceutical Association
and permanent scarring. Even less
crystalline powder. It has a bitter taste 2000: 572–57
572–573. severe acne can lead to scarring.
and is freely soluble in water and alcohol. References:
1. American Academy of Dermatology.
Regulatory Update Over-the-Counter Medications: DID YOU KNOW?
AcneNet. Available at: www.derminfo
Pharmacists can compound over-the-counter (OTC) products for in-store sales as long March 4, 2005.
as their state boards allow such practices. Since the state boards have primary
jurisdiction over compounding and state laws do vary, pharmacists should make
sure that OTC compounding is allowed in their state. If so, pharmacists can com-
owed Allen LV Jr. Estriol solution for iontophoresis
pound nonprescription drugs as OTC products. for acne scars. IJPC 1997; 1(6): 411.
Allen LV Jr. Formulation: Niacinamide 4% acne
CASE REPORT CONTINUED gel. IJPC 2001; 5(1): 49.
We recommended that her doctor Chu CY. The use of 1% pimecrolimus cream
prescribe niacinamide 4% gel to be for the treatment of steroid-induced rosacea.
applied to her affected skin twice daily. We Br J Dermatol 2005; 152(2): 396–399.
recommended that he prescribe spirono-
lactone 5% cream and spironolactone 25 Dreno B, Nocera T, Verriere F et al. Topical
mg orally once daily to help slow down retinaldehyde with glycolic acid: Study of
hair growth on her face. When the woman tolerance and acceptability in association
with anti-acne treatments in 1,709 patients.
returned to us 2 months later, her acne
Dermatology 2005; 210(Suppl 1): 22–29.
was almost completely gone. She was
flabbergasted that finally she had found Shalita AR, Berson DS, Thiboutot DM et al, and
an acne treatment that worked. She had the Acne Clinical Study Investigator Group.
undergone facial laser treatment during Effects of tazarotene 0.1% cream in the
that time, and her facial hair had dimin- treatment of facial acne vulgaris: Pooled
ished substantially. Although spironolac- results from two multicenter, double-blind,
tone binds immediately to the receptors, randomized, vehicle-controlled, parallel-group
the slowing of facial hair growth takes trials. Clin Ther 2004; 26(11): 1865–1873.
some time and therefore would not be
observable after 2 months. Spironolac- Shalita AR, Myers JA, Krochmal L et al. The
tone does not lower testosterone levels safety and efficacy of clindamycin phosphate
but stops testosterone from binding to
Suggested Reading: foam 1% versus clindamycin phosphate
topical gel 1% for the treatment of acne
the receptors that lead to hair loss on the Spieg by
Adebamowo CA, Spiegelman D, Danby FW et vulgaris. J Drugs Dermatol 2005; 4(1): 48–56.
scalp and rapid hair growth on the face. d take
al. High school dietary diary intake and
Spironolactone for excess facial hair teenage acne. J Am Acad Dermatol 2005; 52(2):
. [No author listed]. Treatment for severe acne
should not be recommended unless 207–214. vulgaris. IJPC RxTriad 2002; 5(1):1.
hormone levels are accurately tested.
RxTriad - A publication of the International Journal of Pharmaceutical Compounding. © 2005 IJPC. All rights reserved.