Dr. Hilary Baldwin emphasizes key points from her lecture Inflammatory Pathways in Acne and Rosacea at the 6th annual Elevate-Derm Alliance Conference at the JW Marriott Water Street in Tampa, Florida.

In this video

In conversation with Lisa Weiss, Dr. Baldwin walks through the "four pillars" of acne pathophysiology — increased and altered sebum production, follicular hyperkeratinization, C. acnes proliferation in a warm, low-oxygen follicle she likens to "the Ritz Carlton," and the resulting inflammation. She stresses that hitting all four pillars in a single patient makes for a "happy outcome," which is why isotretinoin is so effective. She also upends old teaching: subclinical inflammation, not the microcomedone, comes first, and inflammation persists even after lesions appear "burned out," so treatment must continue well beyond apparent clearance.

Dr. Baldwin calls tetracyclines "the bomb" for both acne and rosacea, tamping down every inflammatory pathway while also killing C. acnes. She pushes back on the arbitrary three-month antibiotic cutoff — a number "plucked from thin air" — arguing clinicians should treat until the patient is at least 50% better with topicals already on board, then maintain with topicals alone. She also previews a therapeutic (not preventative) acne vaccine in phase one that suppresses the CAMP virulence factor to spare type 2 C. acnes, and notes the rosacea pipeline — mast cell degranulation inhibitors, minocycline, and possibly oral sarecycline — now looks "sweeter than the acne pipeline."

  • Acne runs on four pillars — sebum, follicular hyperkeratinization, C. acnes, and inflammation — and treatments that hit all four (like isotretinoin) give the best outcomes.
  • Inflammation comes first: subclinical inflammation precedes the microcomedone and lingers even after lesions look burned out, so continue treatment past apparent clearance.
  • The three-month antibiotic rule is arbitrary; treat until the patient is at least 50% better, and make sure topicals are already on board before stopping the oral.
  • The acne vaccine in development is therapeutic, not preventative — it suppresses the CAMP virulence factor to target virulent type 1 C. acnes while sparing protective type 2.
  • The rosacea pipeline is heating up, including mast cell degranulation inhibitors and possible oral sarecycline, which is more narrow-spectrum and gentler on the gut than doxycycline or minocycline.