Acne vulgaris is a chronic disease of the pilosebacous unit that presents with cutaneous comedones, papules,
pustules, and nodules of varying severity. Early intervention is the key to avoid permanent scarring. Optimal treatment strategies continue to evolve along with a greater understanding of the pathogenesis of acne.1 Current consensus guidelines recommend the use of combination therapy, simultaneously
targeting multiple pathogenic factors.2 The combination
of a topical retinoid plus an antimicrobial and a benzoyl peroxide (BPO) product is first-line therapy for most patients with acne.3 A rapid improvement may lead to greater patient adherence, less antibiotic exposure, and lower Propionibacterium
acnes (P. acnes) resistance.3 Moreover, early intervention with an efficacious combination therapy can prevent scarring and postinflammatory hyperpigmentation.4
Topical retinoids are recommended as part of first-line therapy for most cases of acne, as well as for maintenance therapy.3 Retinoids influence cellular differentiation and proliferation
and normalize abnormal follicular desquamation.5,6 Normalization of keratinization helps to inhibit the formation of microcomedones.7 Furthermore, retinoids have been shown to reduce inflammation through a number of pathways, including
downregulating toll-like receptors,8 cytokines,9 and nitric oxide.10 However, topical retinoids are irritating to the skin and commonly cause dryness, erythema, and burning/stinging.11 Irritation, especially during the first few weeks of treatment, can be a limiting factor for treatment adherence in many patients.12 For sensitive patients, it is recommended to start at a low strength and increase as needed to minimize the potential for irritation.13
Antimicrobial treatments, including topical antibiotics and BPO, reduce skin colonization of P. acnes and its subsequent proinflammatory
effects. In the 1980s, clindamycin and erythromycin were found to be equally effective in the reduction of acne lesions.14 However, concern about resistant forms of P. acnes has limited the use of antibiotics. BPO reduces the number of P. acnes by suppressing growth15,16 without the risk for resistance selection; thus, it is used in combination with topical antibiotics to prevent development of resistance.17-19 Moreover, the combination
of BPO with a topical antibiotic has been shown to be a more effective therapy for acne than either as monotherapy.20 Like topical retinoids, BPO can cause skin irritation, peeling, dryness, and erythema.21
The optimal acne regimen offers patients quick, efficacious results, maximizing patient satisfaction and reducing the risk for scarring.22 Since two of the most commonly used acne medications (retinoids and BPO) are potentially irritating, their
