Treatment of Acne Developing Behind the Ears from Vtama (Tapinarof) Use
Treat this localized acne with adapalene 0.1% gel combined with benzoyl peroxide 2.5% applied once nightly to the affected area behind the ears, while continuing Vtama for psoriasis management on the same area. 1
Understanding the Clinical Scenario
This represents a localized adverse effect where tapinarof (Vtama), a novel aryl hydrocarbon receptor agonist used for psoriasis, has triggered acne formation in the treatment area. 2 Folliculitis is the most common adverse event with tapinarof, occurring in clinical trials but typically mild to moderate. 2 The acne developing behind the ears likely represents either folliculitis or true acneiform eruption secondary to the medication.
First-Line Treatment Approach
The American Academy of Dermatology recommends topical retinoids combined with benzoyl peroxide as the foundation for acne treatment, which is directly applicable here. 1
Start with adapalene 0.1% gel applied once nightly to completely dry skin in the affected area behind the ears. 1, 3 Adapalene is preferred because it can be safely combined with benzoyl peroxide without oxidation concerns and lacks photolability restrictions. 1
Add benzoyl peroxide 2.5% gel applied once daily in the morning to the same area. 1, 3 Lower concentrations (2.5%) are equally effective as higher concentrations but cause significantly less irritation. 3
Continue Vtama application for psoriasis management as prescribed, since discontinuing effective psoriasis therapy is not warranted for this manageable side effect. 2
Alternative Single-Product Option
- Consider using a fixed-combination product of adapalene 0.1%/benzoyl peroxide 2.5% gel applied once nightly to enhance compliance and simplify the regimen. 1, 3 This provides both agents in a single application.
Application Technique to Minimize Irritation
Apply adapalene only after the skin is completely dry (wait 20-30 minutes after washing) to minimize irritation, especially important in this sensitive area. 3
Start with every-other-night application if irritation develops, then advance to nightly as tolerated. 4
Apply a thin layer covering the entire affected area behind the ears where acne has developed. 5
Critical Pitfall to Avoid
Never use topical antibiotics as monotherapy for this acne, as resistance develops rapidly without concurrent benzoyl peroxide. 1, 3 If inflammatory lesions are prominent and you consider adding a topical antibiotic (clindamycin 1%), it must always be combined with benzoyl peroxide. 1
Escalation Strategy if First-Line Fails
If the acne does not improve after 8-12 weeks of topical combination therapy, consider adding oral doxycycline 100 mg daily for no more than 3-4 months, always with concurrent benzoyl peroxide to prevent resistance. 1, 4
Alternatively, consider switching to azelaic acid 15-20% gel applied twice daily if retinoid irritation is problematic in this sensitive area. 1, 3
Monitoring and Maintenance
Reassess at 4-6 weeks to evaluate response and adjust therapy if needed. 1
Once acne clears, continue adapalene indefinitely as maintenance to prevent recurrence, even if Vtama is eventually discontinued. 1, 3
The folliculitis/acne from tapinarof typically remains mild to moderate and resulted in low discontinuation rates (≤1.8%) in clinical trials, suggesting this approach should be effective without requiring cessation of psoriasis therapy. 2