Topical Treatments in Acne Vulgaris: Guidance for the Busy Dermatologist
June 2015 | Volume 14 | Issue 6 | Original Article | 567 | Copyright © 2015
Linda Stein Gold MD
Henry Ford Hospital, Detroit, MI
Acne is a very common skin disease; frequently seen in adolescents and often persisting or occurring into adulthood. Topical therapy is very effective in mild to moderate disease, and is used as maintenance therapy. Fixed combination products have been studied in moderately severe disease. Combinations of benzoyl peroxide and either clindamycin or adapalene appear very effective. When utilizing a topical retinoid alone or in combination, it is essential to incorporate an appropriate skin care regimen to minimize local irritation. In the absence of direct comparative clinical trials, this review provides timely guidance for clinicians on the use of these agents, and their benefits in special populations.
J Drugs Dermatol. 2015;14(6):567-572.
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Acne vulgaris (acne) remains commonplace in dermatology practice. Lifetime prevalence estimates range from 73.3% to almost 100%.1,2 Although acne most frequently occurs in adolescence, over 40% of men and women experience acne in their 20s, and a significant percentage of patients, especially women continue to be affected well into adulthood.1 Duration of acne has been shown to vary from 3 months to 40 years.3
A number of factors need to be considered when selecting therapy, including severity of lesions, duration of disease, past and present response to treatment, and any tendency for scarring or postinflammatory pigmentation. Acne therapy is best tailored to an individual patient based on nature and severity of disease.4
Effective treatment of acne is extremely important to reduce both severity and potential recurrence of the disease. Topical therapies remain the most common and effective treatment option for mild to moderate acne, and also for maintenance therapy for all levels of acne severity.5 In addition, fixed combinations have been studied in moderately severe disease.
Treatment options include retinoids, antimicrobials and anti-inflammatory agents. Retinoids (eg, adapalene, tazarotene, tretinoin) act to reduce dyskeratosis at the pilosebaceous unit, inhibit the formation of microcomedones, and have mild anti-inflammatory effects.6 Antimicrobials (eg, benzoyl peroxide (BP), clindamycin, and erythromycin) have bactericidal or bacteriostatic action against Propionibacterium acnes (P acnes). Advanced cream and gel vehicle formulations in the form of emollient cream and microsphere gel reduce irritation and enhance efficacy.7 Anti-inflammatory agents such as dapsone act through direct inhibition of leukocyte trafficking and the generation of chemical mediators of inflammation by leukocytes and/or potential interference with bacterial synthesis, thereby altering the levels and activity of P acnes.7 Advances in formulation technology have provided us with products with enhanced efficacy and reduced irritation.8
Acne is a chronic disease and poor medication adherence is a major contributor to treatment unresponsiveness.9 Patients most commonly attribute frustration with the therapeutic regimen and forgetfulness as reasons for failure to use medication as prescribed. 10 As a result, combination therapy (eg, BP and antibiotic, retinoid and antibiotic, or BP) is now considered standard of care for patients with both comedonal and inflammatory acne, simplifying treatment regimen and reducing dosing frequency.6 In addition, clinical studies have consistently shown faster and better clearing of inflammatory lesions and comedones with such combinations when compared with monotherapy alone.11
The objective of this review is to analyze clinical data on the most common topical treatment approaches and provide up-to-date guidance for the busy dermatologist. Although it has been recognized that therapy is best tailored to individual patient circumstance, it is also becoming clear through post hoc analyses and practical experience that certain products may be more effective in certain patient populations, such as male/female, adolescent/post adolescent and those with skin of color.
Fixed Combination Products
The use of fixed combinations with BP and either a retinoid such as adapalene, or antibacterial such as clindamycin are commonplace.Clindamycin 1.0%-BP 2.5%, 3.75% and 5% Gel
Early clinical trials demonstrated that twice-daily use of clindamycin 1%–BP 5% gel for 10 to 16 weeks was more effective in reducing inflammatory lesion counts than individual active ingredients or vehicle in mild to moderately severe acne.12,13