Sandra Fyfe

The Centers for Disease Control and Prevention’s (CDC) November 28 update for influenza shows the predictions of a difficult flu season based on the southern hemisphere’s experience are coming to fruition. In addition, children’s hospitals continue to be overwhelmed with respiratory syncytial virus, and COVID-19 is slowly rising.

The latest flu update reports that so far, the season has tallied 2900 total deaths, 53,000 hospitalizations, and at least 6.2 million illnesses from influenza.

Only 6 states or territories report low flu activity: Vermont, New Hampshire, the North Mariana Islands, Alaska, Michigan, and South Dakota. Thirty-five states report high or very high rates of influenza, with Texas, New Mexico, and Tennessee reporting the highest levels for the past week. Rates of influenza are going down in southeastern states and plateauing in the south-central region.

Lab samples have risen from a 14.7% to an 18.2% positivity rate , with A(H3N2) being the most frequently reported virus.

 “Of influenza A viruses detected and subtyped this season, 78% have been influenza A(H3N2) and 22% have been influenza A(H1N1),” the CDC reports. All pediatric deaths have been from influenza A.

 Two deaths were subtyped, with 1 being classified as A(H1N1)pdm09 and the second as an A(H3) type.

The FluSurv-NET system reported the cumulative hospitalization rate is 11.3 per 100,000, “higher than the rate observed in week 46 during every previous season since 2010-2011.” The CDC said that 11,269 patients were admitted to a hospital for lab-confirmed flu.

There have been 12 total pediatric deaths, of which 41% (5) occurred in the past week. Pediatric deaths for previous flu seasons were 2019-2020 (199 deaths); 2020-2021 (1 death); 2021-2022 (44 deaths). The CDC reported a total of 1861 pneumonia, influenza, and/or COVID related deaths for the previous week, accounting for 9.4% of total mortality. Of these, 66 were classified as influenza, and the CDC noted that “while current PIC mortality is due primarily to COVID-19, the proportion due to influenza remains small but is increasing.”

In a CDC media telebriefing about circulating respiratory diseases given on November 4th, Jose Romero, MD, FAAP, FIDSA, FPIDS, FAAAS, director of the National Center for Immunization and Respiratory Diseases said that the H3N2 strains are known for being more severe in children and the elderly, and that “there are also early signs of influenza causing severe illness in precisely these 2 groups of individuals this season.”

 However, this season’s flu vaccine continues to be a good match for circulating strains.

 “The majority of influenza viruses tested are in the same genetic subclade as and antigenically similar to the influenza viruses included in this season’s influenza vaccine,” the CDC reported.

Vaccination is highly recommended for everyone 6 months of age and older, and it is not too late to get vaccinated. Pharmacists can help fight flu this season by checking in with patients to see if they have received their annual flu shot. In particular, they can look out for young and elderly patients by prioritizing asking parents and seniors if they need a flu shot when visiting the pharmacy. In addition, pharmacists can recommend antivirals for patients infected to reduce the risk of negative outcomes.

Weekly US influenza surveillance report. Report. CDC. Updated November 28, 2022. Accessed November 29, 2022. 

CDC media telebriefing: update on respiratory disease circulation transcript. Transcript. CDC. November 4, 2022. Accessed November 29, 2022. https://www.cdc.gov/media/releases/2022/t1104-update-respiratory-disease-circulation.html.

Articles

Flanked by RSV and COVID-19, flu season started early and rates of transmission are high throughout the country.

Early and Intense Flu Season Revs Up

There are good reasons to co-administer the shingles and influenza vaccines: patients get protection from 2 viruses in a single trip, and pharmacists get a chance to increase vaccine uptake. However, co-administration has a possible pitfall that pharmacists need to be aware of.

The CDC strongly recommends adults aged 50 years and older get 2 doses of recombinant zoster vaccine (RZV) (Shingrix), in addition to immunocompromised adults aged 19 years and older.

 They note that this vaccine, which is more than 90% effective, is the only way to prevent shingles and accompanying postherpetic neuralgia.

The Advisory Committee on Immunization Practices (ACIP) says co-administration is safe and recommended, and advises that both recombinant and adjuvanted shingles vaccines can be given with the flu shot, in different arms.

 “Concomitant administration of RZV with Fluarix Quadrivalent (influenza vaccine) (QIV) has been studied, and there was no evidence for interference in the immune response to either vaccine or safety concerns,” ACIP reports.

There is a catch, revealed by a study by Benjamin M Rome, MD, MPH, of the division of pharmacoepidemiology and pharmacoeconomics in the department of medicine at Brigham and Women’s Hospital and of Harvard Medical School, in Boston, Massachusetts, and colleagues. The researchers reported that less than 50% of adults get the flu shot, and side effects play a major factor in patients avoiding vaccinations. Between August 1, 2018, and March 31, 2019, Rome and colleagues studied a cohort of 89,237 patients aged 50 years and older who either received the shingles and flu shot at the same time or separately for the 2018-2019 flu season. Women made up 58.3% of the group; 85.7% had at least 1 comorbidity; and 70.1% were white. They then tracked the number of flu vaccinations for the following flu season and found “uptake in 2019-2020 was lower among 27,161 individuals who received concurrent influenza and zoster vaccines compared with the 62,076 individuals who received the vaccines on separate days (87.3% vs 91.3%; adjusted odds ratio, 0.74; 95% CI, 0.71-0.78; 

< .001). Results were similar across subgroups.”

Brigid Groves PharmD, MS, senior director of practice and professional affairs at the American Pharmacists Association (APhA) in Washington, DC, spoke with 

® on the reduction of flu vaccination the year following the co-administration of shingles and flu shots. Pharmacists can prevent the drop-off in flu vaccine uptake the following year by counseling patients on expected side effects from each type of vaccine before administering shots, Groves said. “Flu vaccines reactions are typically localized to the injection site and consist of pain, redness, or swelling. Shingles vaccine reactions can be more systemic in nature, including fatigue, headache, or muscle aches,” she noted.

Groves advised clarifying these side effects with patients. “Explain that the shingles vaccine is known to have a greater likelihood of systemic reaction, which is less likely to happen with a flu shot. The patient may notice a greater reaction when getting both together. Emphasize that it is safe and recommended to get the flu and shingles vaccines together.” Groves added that if a patient prefers it, pharmacists may consider administering the flu and shingles vaccines on separate visits to accurately relate reaction, if any, to the specific vaccine.

“Consider giving the flu shot in the patient’s left arm (using L alliteration) and the shingles vaccine in the right arm to separate location and easily remember which side,” Groves advised. “Deliver a strong recommendation and endorsement for getting an annual flu shot,” she said.

1. What everyone should know about the shingles vaccine (Shingrix). Reference. CDC. Updated May 24, 2022. Accessed November 20, 2022. 

https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html

2.Dooling KL, Guo A, Patel M, et al. Recommendations of the advisory committee on immunization practices for use of herpes zoster vaccines. 

. 2018;67(3):103-108.doi:10.15585/mmwr.mm6703a5.

3. Rome BN, Feldman WB, Fischer MA, Desai RJ, Avorn J. Influenza vaccine uptake in the year after concurrent vs separate influenza and zoster immunization. 

. 2021;4(11):e2135362. doi:10.1001/jamanetworkopen.2021.35362.

Although it’s safe and recommended to co-administer these shots, research finds a reduction in flu vaccine uptake the following year.

Co-Administering Influenza and Shingles Vaccines May Reduce Vaccine Uptake for the Next Flu Season

Sara Rodríguez-Martín, PharmD, PhD, of the department of biomedical sciences pharmacology sector in the school of medicine at the University of Alcalá (IRYCIS) and the clinical pharmacology unit at University Hospital Príncipe de Asturias, both in Alcalá de Henares, Madrid, Spain and colleagues conducted the research on the flu shot and ischemic stroke (IS) risk.

Between 2001-2015, researchers used a Spanish primary care database to gather information about adults who had been in the registry for at least a year and were between the ages of 40-99 years. Study participants had no history of cancer or stroke. A total 3.8 million people met the criteria for the study; of these, researchers found 14,322 cases of IS, in addition to selecting 71,610 controls.

Researchers classified IS cases as non-cardioembolic (9542/41.4% vaccinated) or cardioembolic (4780/40.5% vaccinated). “Five controls per case were randomly selected, individually matched with cases for exact age, sex and date of stroke diagnosis (index date). A patient was considered vaccinated when he/she had a recorded influenza vaccination at least 14 days before the index date within the same season,” researchers wrote.

 They used pneumococcal vaccination as a negative control.

More vascular risk factors, vascular disease, and co-medication were found in vaccinated study participants, the researchers said. “After full adjustment, the association of influenza vaccination with IS yielded an AOR of 0.88 (95% CI: 0.84-0.92) was found, appearing early (AOR 15-30 days= 0.79;9 5% CI: 0.69-0.92) and slightly declining over time (AOR >150 days= 0.92; 95% CI: 0.87-0.98),” the researchers wrote.

 They added that the risk was similar for both types of IS cases in all the subgroups: subjects with medium or high vascular risk, men, women, and those over the age of 65 years during pre-epidemic flu, epidemic flu, and post-epidemic flu periods. Researchers reported no associated reduction of IS risk with the pneumococcal vaccine.

Researchers said the results, “are consistent with a moderate protective effect of influenza vaccine on IS in the general population, which is consistent with other published studies. The fact that a reduced risk was also observed during pre-epidemic periods is, however, intriguing and suggests that other mechanisms different from the prevention of influenza infection may play a role,” They emphasized that the rate of flu vaccination is still too low and should be encouraged.

William Schaffner, MD, professor of preventive medicine in the department of health policy and professor of medicine in the division of infectious diseases at the Vanderbilt University School of Medicine in Nashville, Tennessee and who is unaffiliated with the study spoke with 

 about the study’s results and its impact.

Schaffner said over the past decade information has accumulated that influenza infection invokes an inflammatory response. “After patients recover from acute infection this response lingers, which affects the small blood vessels that go to the heart and brain and put older patients at increased risk for heart attacks and strokes. This is new information – physicians were not taught this in medical school,” he said.

Schaffner added that it has been postulated that vaccines can prevent cardiovascular events. “This is a study that shows the statistical significance that influenza vaccinations indeed prevent post-influenza stroke in middle-aged and older people. We are just beginning to understand these post-infectious complications. The inflammation response takes longer to wind down post-infection than previously thought,” he explained.

“This adds to the imperative for patients to get vaccinated for influenza each year. Pharmacists can share this information with older patients as another way to encourage them to get the shot,’ Schaffner said.

1. Rodríguez-Martín S, Barreira-Hernández D, Gil M, García-Lledó A, Izquierdo-Esteban L, De Abajo FJ. Influenza vaccination and risk of ischemic stroke: a population-based case-control study [published online ahead of print, 2022 Sep 7]. 

. 2022;10.1212/WNL.0000000000201123. doi:10.1212/WNL.0000000000201123.

Recently published research reveals an important benefit for middle-aged and older adults: a reduction in ischemic stroke risk.

Flu Shots and Ischemic Stroke Risk in Older Adults

Sebastian Hamilton, MBA, PharmD, RPh, chief pharmacy officer of operations and community & ambulatory partnerships and PGY-1/PGY-2 health system pharmacy administration and leadership + MBA residency program director president at Boston Medical Center and Massachusetts Board of Registration in Pharmacy spoke with 

on administering a double vaccination for COVID-19 and influenza.

How can pharmacists reassure or encourage patients that getting both shots at once is safe?

Hamilton recommended having a quick conversation with patients to see how comfortable they are with vaccinations in general, and to discover why they are considering getting both vaccines, such as for a job requirement or being a responsible family member. “From here you will be better prepared with the appropriate response to underscore reassurance or encouragement that getting both vaccinations are safe and effective when taken together,” he said.

Specifically, he noted that pharmacists can explain to patients that:

Although flu and COVID-19 are both respiratory illnesses, each is caused by a different virus. Immunity can be obtained from each illness quicker by receiving these vaccines at the same time.

Both vaccines are proven to be safe and effective protection against each illness even when administered together. This is supported and recommended by the CDC.

The vaccines have either been approved (influenza vaccines) or authorized for emergency use (COVID-19 vaccines) by the FDA.

It’s convenient to get both together. He recommended phrasing it to patients as, “life happens and you may delay getting the other vaccination, so get it while you are here now.”

Have additional side effects from getting both shots been reported? What should pharmacists tell patients to watch for?

Hamilton said it’s important to explain to patients what side effects are to be expected from vaccination for transparency. “Tell patients that it’s normal to experience mild symptoms after receiving either vaccination alone, so both vaccinations at the same time will be no different,” he said. He added that pharmacists should be specific about side effects, which include symptoms like tiredness, body aches and pains, low-grade fever, headaches, and a sore arm at the injection site, which is almost a certainty in all cases,.

“Share that while these may cause a level of discomfort, they are self-limiting – and that patients should contact their doctor if they persist beyond 72 hours. Reassure patients that these symptoms are just an indication that their immune system is working as expected to create protection from the viruses if and when they are exposed to them,” he advised. He added that if a patient has a history of these symptoms when receiving vaccinations, it’s encouraged to be proactive by planning for a day or so of rest after getting the shots.

Is it better for the vaccines to be administered in the same arm or one in each arm? Why?

Hamilton explained that there is no difference in immune response or better protection afforded whether the vaccines are received in the same arm versus one in each arm. “The key difference here comes down to one’s personal preference and comfort level,” Hamilton told 

. “However, the most frequently reported side effect experienced by patients when receiving vaccinations is soreness at the injection site. If patients are vaccinated with both vaccines in the same arm at the same time, this is likely to cause more discomfort in that arm versus if 1 vaccine is administered in each arm. Due to the likeliness of this, it is fine for the pharmacists to recommend one shot in each arm,” Hamilton said.

What are some reasons patients may resist getting both shots at once? How can pharmacists persuade patients to get both vaccines?

Hamilton said the biggest reason patients may resist getting both shots is because of anticipatory anxiety about side effects they may have previously had, or heard about from others. “Pharmacists can help ease anxiety by listening to the patient share concerns. Tell them that the sooner they get vaccinated with both vaccines, the quicker their body develops antibodies to protect them if and when they are exposed,” he advised. Hamilton said patients can be reassured by telling them that the discomfort from the shot will be less impactful than catching the actual virus without being vaccinated.

“Patients can be encouraged to decrease this window of opportunity by getting both vaccines now,” he said.

Patients who are still concerned and do not want to get both vaccines should have this decision treated as a valid choice by pharmacists, Hamilton said. “If the patient is considering passing on getting both at the same time, let them know that they can also space the vaccinations apart, as long as they follow through and get both vaccinations at the earliest convenience.”

Other than obvious reasons, such as a bad reaction to a previous vaccine, there are no reasons for patients not to be offered both the flu and COVID booster at the same time, Hamilton explained

He added that children can also get both vaccines at the same time. Pharmacists should be mindful of the side effects that may be experienced that are similar to adults, such as arm pain. “Pharmacists should make sure the child has a positive experience in general and also so they can brag to their friends that getting their vaccines was relatively uneventful,” Hamilton noted.

He stressed that pharmacists should be aware of the child’s age as a consideration for receiving the COVID-19 vaccine as it stands today. “For ages 6 and over, flu vaccination co-administered with the COVID-19 booster is recommended,” he said.

1. Centers for Disease Control and Prevention (CDC). Frequently asked influenza (flu) questions: 2022-2023 season. 

https://www.cdc.gov/flu/season/faq-flu-season-2022-2023.htm

. Updated October 17, 2022. Accessed October 25, 2022.

Help protect patients by giving them the facts about getting both shots at once to save them a trip and increase rates of vaccination.

Breaking Down the Benefits and Risk of Co-Administration of COVID-19 and Flu Vaccines

On July 15, 2022, the World Health Organization (WHO) reported the largest decrease in routine vaccinations in 30 years. In 2021, 25 million infants worldwide missed routine vaccinations and 2.6 million children in the United States were unvaccinated or not up to date on their vaccines.

The steep decline has health officials on alert. In the news release, the WHO said the DTP3 (diphtheria tetanus toxoid and pertussis) vaccination rate, a touchstone for vaccination coverage rates, fell 5% between 2019 and 2021 to 81%, resulting in 25 million children missing 1 or more doses. In the Americas—where reported rates of routine vaccinations for rubella, measles, polio, and diphtheria have been steadily declining over the past 10 years—the pandemic has only made things worse. Human papillomavirus (HPV) vaccination has also steeply declined: More than 25% of the coverage of HPV vaccines achieved in 2019 has been lost.

The causes for the historic decrease in vaccination rates, according to the WHO, included COVID-19 containment measures that blocked access to health care services, supply chain issues, resource diversion, vaccine misinformation, service disruptions, and more children residing in conflict or fragile zones where vaccines could not reach them.

Brigid Groves, PharmD, MS, senior director of practice and professional affairs at the American Pharmacists Association (APhA) in Washington, DC, spoke with 

® to explain how pharmacists can help close the vaccination gap exacerbated by the COVID-19 pandemic. Closing this gap, she said, is essential because in addition to lower rates of routine vaccinations causing a resurgence in diseases, “there is a particular danger to immunocompromised patients who rely on herd immunity for coverage.”

Pharmacists are well positioned to help improve vaccination rates, but barriers do exist, Groves noted. “Depending on the state, there are different protocols and legislation in place regarding the administration of vaccines,” she said. “There are inconsistencies among which vaccines can be given to which age groups, where, and by whom.” Pharmacists should confirm local rules and regulations with their state pharmacy practice acts to ensure training and compliance, she said.

Another barrier is vaccine hesitancy among patients. According to Groves, a major contributor to hesitancy has been misinformation that was already circulating before the pandemic and then became worse over the past 2 years.

How Pharmacists Can Increase Vaccination Rates

Groves shared several ways that pharmacists can assist in closing gaps in vaccination. She said some states allow pharmacists to access immunization records, and having that information readily available is one way to assess immunization gaps for individual patients.

Another way pharmacists can increase rates of vaccination is to connect and collaborate with local communities, Groves said. “Pharmacists can be especially helpful in communities that don’t have other health care providers or locations nearby to get the vaccinations they need,” she explained. This includes public health entities and other providers, especially for pediatric and adolescent patients. “Pharmacists are extenders of care to make services more accessible to families when they connect with health care providers,” she said.

Groves also suggested that pharmacists think outside the box and coordinate to offer vaccinations in a local facility space where other providers such as pediatricians can be invited to attend. “Pharmacists can then create a fun and engaging atmosphere, using stickers or other novelty items to encourage children to feel comfortable,” she said.

Pharmacists can also discuss vaccines with patients when they pick up prescriptions. This point-of-care technique prevents patients from having to make an appointment and additional trip, Groves said. That contact in the pharmacy also provides an opportunity to fight misinformation. “Having conversations with families, caregivers, and patients can reduce misinformation and increase rates of vaccination,” she noted. “Scientific studies can be overwhelming for patients. Pharmacists can distill data into patient-friendly, understandable language to educate patients on the importance of being up-to-date on vaccinations.

“Pharmacists know the appropriateness of the vaccine for the patient, the timing of doses, and any contraindications that would preclude the patient from being eligible for that particular vaccine,” Groves continued, adding that pharmacists also are excellent at counseling patients and making sure they have opportunities to ask questions, which is especially important for concerned parents of pediatric patients.

1. COVID-19 pandemic fuels largest continued backslide in vaccinations in three decades. News release. World Health Organization. July 15, 2022. Accessed August 1, 2022. 

https://www.paho.org/en/news/15-7-2022-covid-19-pandemic-fuels-largest-continued-backslide-vaccinations-three-decades

Pharmacists can play a key role in helping to improve backsliding vaccination rates. 

Closing the Historic Routine-Vaccination Gap

Adult acne in women has increased 10% worldwide over the past 10 years, according to a 2022 review of adult acne conducted by Brigitte Dreno, MD, PhD, head of the Department of Dermatology at Nantes University Hospital in France, and colleagues. The review was published in the 

“In adults, acne has serious consequences, including a psychological impact, low self-esteem, social isolation, and depression,” the authors wrote. The condition affects more than 640 million people across the globe, with the biggest risk factor being heredity.

However, there are factors under patient control, such as diet, that can reduce acne risk.

Treatment approaches vary by gender, and newer treatments are in the pipeline, including skin microbiome modulation, which would be helpful in reducing antibiotic use and preventing microbial resistance.

Anais Aurora Badia, MD, DO, an adult and pediatric dermatologist and founder of the Florida Skin Center, now part of Advanced Dermatology and Cosmetic Surgery in Fort Myers and Lehigh Acres, Florida, spoke with Dermatology Times® on the increasing rates of adult acne and how to treat it.

Badia said that adult acne and adolescent acne share similar causes and that acne is mostly caused by sebum production, inflammation, and bacteria. “Stress, hormones and diet can increase inflammation,” she said. “When our stress levels rise, we produce higher levels of acne-causing androgens, which can stimulate oil glands and hair follicles that contribute to acne.”

In addition to stress—which has been considerably higher these past few years due to the pandemic—Badia said that masks worn to protect against COVID-19 increased acne rates because they trap dirt and bacteria on the skin, which contributes to an increase of the acne-causing bacteria 

Badia also noted gender differences in acne prevalence. “Increased hormone levels contribute to acne in both men and women. However, the types of hormones causing acne are different for each,” she explained. “Women tend to see more fluctuations in hormones than men due to medications, menstrual cycles, and menopause,” which is why women get more acne than men.

Diet also plays a role in developing acne. “Some small studies have shown a link between dairy consumption causing an increased risk for acne,” Badia said. “Other studies have linked high glycemic index foods to acne [because] these foods spike our blood sugars rapidly, causing inflammation, which in turn leads to an increase in acne.” The review by Dreno and colleagues also found that milk, sugar, sugary drinks, and fatty foods were associated with acne in adults.

Badia added that skin and hair products can also cause acne. She said that dermatologists should advise patients to read labels and look for products that say noncomedogenic or oil free.

“It is also important they be advised to use products with physical sunscreens, such as zinc oxide or titanium dioxide,” she said.

Badia noted that each patient should be treated based on their individual needs and concerns. The adult acne review by Dreno and colleagues contained a summary of the 2018 international consensus treatment recommendations from the Global Alliance to Improve Outcomes in Acne Group. The recommendations are as follows

Retinoids play an essential role in acne treatment, with a topical retinoid and benzoyl peroxide as first-line treatment for inflammatory acne and/or comedonal acne.

Systemic and topical antibiotics should be avoided as monotherapy.

Very severe (cystic and conglobata) acne should be treated with oral isotretinoin.

Patients should take oral isotretinoin until their acne clears. Total cumulative dosage to keep acne in remission needs more studies.

Use low-dose oral isotretinoin to minimize acne flares.

Maintenance therapy with a topical retinoid combined or not with benzoyl peroxide should be used for most patients. Avoid topical antibiotics for maintenance therapy.

Pregnant women and patients with acne and postinflammatory hyperpigmentation should be prescribed azelaic acid cream 20% or gel 15%.

Do not use devices (laser, intense pulsed light, photodynamic therapy) as first-line treatments for inflammatory acne.

In a small number of women 25 years and older, only the lower face is affected by acne. Topical retinoids with or without benzoyl peroxide should be used.

Starting treatment early minimizes the risk of scarring.

Badia noted that acne therapies have come a long way.

“With concerns about antibacterial resistance on the rise, a new topical minocycline [Amzeeq] is the first of its kind to deliver antibiotic therapy with minimal systemic absorption,” she noted. “Another novel medication for acne is clascoterone cream 1% [Winlevi]. This medication is an antagonist of dihydrotestosterone and prohibits the production of sebum.” She explained that clascoterone is similar in structure to spironolactone but has minimal systemic antiandrogen effects and is safe for both men and women.

She added that topical retinoids continue to be “the gold standard in acne treatment” and that “many new formulations...have come out recently with age indications as young as 9 years old.”

Badia recommended advising patients of the following:

Protect their skin by using a daily SPF with zinc oxide and by not actively tanning.

Clean their faces daily with a gentle cleanser.

Avoid products that contain alcohol, harsh exfoliants, and astringents that can irritate the skin and make acne worse.

Avoid popping or picking acne lesions because this could lead to more acne and scarring.

This article originally appeared on Dermatology Times. 

Dagnelie MA, Poinas A, Dréno B. What is new in adult acne for the last 2 years: focus on acne pathophysiology and treatments. 

 2022;61(10):1205-1212. doi:10.1111/ijd.16220

Tanghetti EA, Kawata AK, Daniels SR, Yeomans K, Burk CT, Callender VD. Understanding the burden of adult female acne. 2014;7(2):22-30. Accessed September 29, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935648/

Thiboutot DM, Dréno B, Abanmi A, et al. Practical management of acne for clinicians: an international consensus from the Global Alliance to Improve Outcomes in Acne. 

 2018;78(suppl 1):S1-S23.e1. doi:10.1016/j.jaad.2017.09.078

Understanding the main causes and staying current on recommendations and treatments will help reduce patient rates of the condition.