How aligned are Redditor-driven recommendations with the current AAD acne guidelines?
Clinical Applications
Dr. Schwarzenberger is the former physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, FAAD, October 1, 2024
In this month’s Clinical Applications column, DermWorld Physician Editor Kathryn Schwarzenberger, MD, FAAD, talks with Justin Marson, MD, about his International Journal of Dermatology paper ‘Reddit dermatology: a cross-sectional analysis of the r/acne forum.’
DermWorld: By now, most of us are quite aware that for good or bad, dermatology advice is readily available on social media. You and your colleagues recently published an analysis of acne advice posted on the news/social content discussion platform Reddit. For those of us who might not be familiar with Reddit, can you briefly explain the platform and tell us how dermatology fits in?
Given the challenges patients face accessing health care (especially dermatologic care), it is unsurprising that many would turn to the internet for advice or to compare experiences. We were interested to see how aligned Redditor-driven discussion and advice is with the current AAD acne guidelines to better understand the mindset (and misconceptions) some patients may have before ever setting foot in a dermatologists’ office and where improvement in skin care education and awareness can be made.
DermWorld: What did you study and how did you do it?
Dr. Marson: We looked at and categorized the posts requesting “Help” made within a one-year period (May 4, 2022, through May 4, 2023) in the most popular acne subreddit (r/acne) into four buckets: “requests for diagnosis,” “follow-up guidance,” “product-specific content,” and other, and then assessed user sentiment (i.e., upvotes and downvotes). Comments from the top 10 “diagnosis” and “follow-up” posts were assessed in a similar fashion.
We then compared user-sentiment for these posts and comments to “dermatologist sentiment” using the (at the time most-current) AAD guidelines as a proxy. Of note, soon after our study was published, the AAD released updates guidelines using an alternate system to grade strengths of their recommendations.
DermWorld: What did your study conclude?
Dr. Marson: Overall, we found 64-69% of Redditor comments and posts were aligned with grade A and B recommendations from the AAD acne guidelines. Furthermore, grade A and B aligned comments received more positive sentiment from the r/acne community than grade C comments (as measured by “upvotes”). While positive, it does leave a wide margin of error as grade B recommendations can be “inconsistent or limited quality patient-oriented evidence.” At worst this may suggest that there is some level of misinformation that is being woven into the narrative on r/acne; this could be compounded by the fact that Redditors post anonymously and do not have to qualify their comments with any form of experience or expertise. Also, despite 60% of screened posts requesting “follow-up” guidance (i.e., advice following initial [self-]diagnosis and/or treatment), only 24% of the included 100 posts had comments recommending (re-)consultation with a dermatologist.
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DermWorld: Were there any unexpected topics of discussion or recommendations provided? Are there areas of interest or concern that we are failing to address? I noticed, for example, that “purging” is listed as a sub-topic.
Dr. Marson: Of the top 15 sub-topics (created by categorizing posts into related groups), the most frequently mentioned topic was skin care (n=16) and further down the list skin barrier (n=4). For me, this highlights the importance of discussing a gentle skin care regimen with all our acne patients, especially given data that suggests acne-prone skin inherently has an epidermal barrier deficiency that traditional first-line agents such as retinoids and benzoyl peroxide can transiently exacerbate. Taking the time to discuss best practices and recommend gentle non-comedogenic moisturizers and cleansers with our acne patients can both improve adherence to individualized regimens, but also prevent our patients from latching onto the latest in skincare trends that may very well worsen their acne.
Another interesting topic is “purging” — this idea of retinoid-induced flare of acne. It is a very common and trendy topic across much of social media. Interestingly, to my knowledge, there is not a lot in the way of primary literature supporting this notion. While acne fulminans arising after initiating isotretinoin is well documented, the same has not been consistently reported for topical retinoids. One review looking at clinical trial data from 1996 to 2007 found at most one trial wherein 10% of participants treated with topical tretinoin 0.025% gel had a ≥20% increase in inflammatory lesion count within the first two weeks of usage that did not consistently affect individuals in the trial with moderate-severe acne (J Drugs Dermatol. 2009;8(9):799-801).
The authors here suggest that these “flares” may be misinterpreted side effects from retinoid dermatitis and/or poor adherence (due to adverse effects) leading to “drug holiday” associated flares. Nevertheless, this may also be an opportunity to counsel patients on expectations with new (topical) therapies, especially since questions regarding retinoids (n=10), benzoyl peroxide (n=10), and isotretinoin (n=8) were commonly asked, on the use of adjunctive gentle skin care products to mitigate adverse effects.
There were multiple posts highlighting different “types” of acne [hormonal acne (n=14), cystic acne (n=12), truncal acne (n=11), and fungal acne (n=3)]. The two that I found interesting were the idea of “hormonal” acne and fungal acne. To me, this suggests we may not be taking the time to adequately explain our current understanding of acne pathogenesis. That is to say that hormones play a part in all acne, not just adult female acne, and may also help explain why we recommend combined oral contraceptive agents, spironolactone, and clascoterone as part of an individual’s regimen. While we might consider “fungal acne” to be pityrosporum folliculitis, I have noticed this term being co-opted to explain acne that didn’t (immediately) improve with therapy. This presents an opportunity for dermatologists to set expectations, encourage adherence, and counsel patients on gentle skin care tips to maximize long-term efficacy.
DermWorld: Your study clearly shows a great deal of public interest in skin care, but less interest in seeking that advice from a dermatologist. How do you recommend that we address this as a specialty?
Dr. Marson: I believe to some degree there is a misconception among some of the public that acne, because it is so common and for some goes away with age, isn’t a true medical problem. More broadly, there are some that are not aware of dermatologists’ expertise in conditions of the skin, hair, and nails. Taken together with all the voices on social media and old wives’ tales and home remedies for skin care and acne, it’s hard not to try a “quick” fix if it may save time and a trip to the doctor’s office.
I believe the Academy and many individual dermatologists have created a framework for meeting our patients where they are online and providing and/or directing patients to free, readily available literature. While it may not be everyone’s cup of tea, I believe taking to social media platforms to increase awareness about dermatologists and our medical, surgical, and procedural expertise and offer evidence-based skin care recommendations is increasingly important for the specialty, especially as other “skin-fluencers” vie for the public’s attention (and sponsorships for potentially questionable product placement).
Justin Marson, MD, is chief resident in the Department of Dermatology at SUNY Downstate Health Sciences University. Dr. Marson has served as an advisory board member for La Roche-Posay and as a consultant for Cerave and Blair & Jack. His paper appeared in the International Journal of Dermatology.
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DermWorld.
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