Casey Butrus, PharmD: I know you mentioned for clascoterone, spironolactone was historically used as 1 of the androgen products. I know that had its plethora of [adverse] effects being used previously for blood pressure with gynecomastia, things of that nature, blood pressure lowering. Do you see any of those concerns also for the topicals or is that more just an oral adverse effect that we’re concerned about?

Arash Mostaghimi, MD, MPH, FAAD: The good news is that the adverse effect profile is very good for these medications. For all of them, topical irritation is the main adverse effect. For clascoterone, there was a little bit of evidence maybe in an earlier study that in large amounts it could have some adrenal suppression that wasn’t symptomatic and really didn’t bear out in future trials, but something to consider with regards to how much you put it on. But certainly, none of the blood pressure or other types of adverse effects that you’re talking about. For minocycline, minocycline is often well tolerated, but there’s a long list of weird and unusual adverse effects. You can get weird drug reactions, you can generate autoimmune phenomena, these types of things where anybody who’s used enough has seen patients with this. Also with long-term use, you can get discoloration and pigmenting of the skin. None of those were identified with the topical version. So I think they have captured a lot of the efficacy with a much better adverse effect profile.

Casey Butrus, PharmD: With acne being a topical dermatological condition, I think most patients and probably providers, too, prefer to use topicals when they are available if the disease can be treated by a topical since it has a more localized effect rather than a systemic effect associated with its length of adverse effects.

Steven Feldman, MD, PhD: That’s true. An issue we face with those topicals though is that it’s harder to get people to use a topical than it is to get them to use a pill. And when Arash says, we see some people, as I heard you, have home runs with the topical clascoterone, I wonder if those are the ones where androgens are really driving the process, if those are the patients who are actually using the medicine really well.

Arash Mostaghimi, MD, MPH, FAAD: I think it’s hard to separate that. And I think real-world data are different from what’s in the trials for it’s actually getting slightly less motivated. If you’re motivated to go into a clinical trial, it would be unusual for you to sign up for a clinical trial then refuse to use the medicines in it. You’re a different type of person at that point. But I agree with both of you. I think the ideal is a topical treatment. In reality, some people prefer a pill. But I think at least now we have options to meet the patients where they are.

Hilary Baldwin, MD: In my practice, I find it to be very Venus vs Mars. I don’t remember which one is which, but the men tend to prefer pills, and the women tend to prefer topicals, in general. Do you find that to be true, Steve? Has that ever been demonstrated? I mean, if it has been, it was demonstrated by you. So I’ll go to the source.

Steven Feldman, MD, PhD: I don’t think I’ve ever looked at that, but I’ll take notes and have my minions work on that.

Transcript edited for clarity.