Rethinking C. acnes: Not All Bacteria Are the Enemy
Buchi Neita, PA-C, and Shanna Miranti, PA-C, opened the panel by revisiting the four pillars of acne pathogenesis that Dr. Hilary Baldwin has long championed: follicular hyperkeratinization, excessive sebum production, C. acnes, and inflammation. But the conversation quickly turned to a nuance Baldwin raised earlier that day: not all C. acnes bacteria are 'evil.'
Baldwin walked through the three subtypes. Type one is associated with acne, type two is associated with healthy skin, and type three isn't associated with the skin at all. Patients with acne carry more type one, while patients without acne carry more type two. Her aspiration for the field: figure out how to make the healthy strains even healthier and let the bad actors die off individually, so the beneficial roles of C. acnes — like acidifying the skin and helping reduce staph aureus colonization — are preserved.
Why the Triple Combination Was a 20-Year Wish
Baldwin explained that clinicians had wanted a triple combination of benzoyl peroxide, clindamycin, and adapalene for roughly two decades. The barrier was never the science — it was that patients balked at using three separate products, or even a duo plus a singleton. Given the choice between two products, she said, patients often do one and not the other, or nothing at all.
The goal was a single topical that fulfills three of the four pillars of acne pathophysiology, with tolerability as the hoped-for bonus. When Baldwin first heard the phase two design used only 150 patients per arm across a five-arm study — and that the adapalene concentration had been halved while benzoyl peroxide went up slightly — she and colleagues worried the triple might not beat the adapalene/benzoyl peroxide dyad. They were, in her words, 'completely wrong.' The triple came out 'head and shoulders' above each of the dyads, with 53% success and roughly 40% reduction by four weeks. A longer-term study showed continued efficacy beyond the phase three window.
Who's a Candidate, and How to Coach on Tolerability
Asked about the ideal patient profile, Baldwin's answer was blunt: her niche patient is everyone who walks in with acne. The only contraindications she could think of were pregnancy or a true allergy to one of the components. With both efficacy and tolerability delivered, she saw no reason not to reach for it in patients needing a topical.
On tolerability, Baldwin described herself as 'a little old school.' She still tells patients not to apply retinoids on freshly washed skin, preferring the face to be fully dry first. Irritation can be reduced with a well-made moisturizer under or over the product — but if it goes underneath, she wants it light and lotiony, not greasy, so it doesn't block penetration. Every-other-day starts are an option, but her bigger message is not to over-emphasize irritation. Talk about it too much, she warned, and a patient who gets a little dry will quit the product. Her mantra: 'gut it out ‘; the irritation is mild and typically gone within two weeks.
Antibiotic Stewardship and the Compounding Soapbox
Miranti raised antibiotic stewardship, a topic pushing many APPs away from oral antibiotics. Baldwin's biggest frustration is the patient arriving on minocycline plus topical clindamycin from a family practitioner and wondering why they never improved. In her view, topical clindamycin should never be a standalone—it belongs in the same bottle as benzoyl peroxide, which treats acne and prevents the emergence of clindamycin-resistant organisms. She noted that when clinicians prescribe clindamycin and simply send patients to buy benzoyl peroxide separately, studies show they often don't, or they abandon the cheap benzoyl peroxide because of irritation and fabric bleaching.
That led to a passionate stance against compounding. Benzoyl peroxide is a potent oxidizing agent that can wreak havoc on co-applied ingredients, and Baldwin argued compounders offer no studies, no proof of vehicle compatibility, and no stability data. She credited the triple combination's vehicle — the 'special sauce' — with a true synergy that makes it more effective than its individual agents, something she doesn't believe a compounded product can replicate. The small savings, she said, aren’t worth the tolerability and efficacy trade-offs.
Adherence, the Pipeline, and the Biggest Surprise
On adherence, Baldwin pointed to data showing patients prefer one product over three — and that the higher compliance rate with the single triple combination translated into improved efficacy. She framed the two failure points clinicians see constantly: primary non-adherence (never buying it) and secondary non-adherence (buying it but not using it). The more products you prescribe, she said, the less likely patients are to use anything.
Looking at the pipeline — vaccines, bacteriophages, spongilla, oral sebum inhibitors — Baldwin was candidly measured. She thinks an acne vaccine is far off and complicated, and even if it arrives, would only help prevent moderate patients from becoming severe. She found the once-weekly spongilla concept interesting and leaned toward a topical sebum inhibitor over an oral one. Her most unexpected clinical benefit from the triple combination: nine times out of ten, patients she'd have reflexively started on doxycycline no longer need oral antibiotics. The speed of improvement now leads her to wait four weeks before adding anything.