Therapies for acne are varied and include proper cleaning regimens, topical agents, oral antibiotics, oral retinoids, and oral hormonal therapies. Available treatments are outlined in Table 2.
The skin of patients with acne can be easily irritated by topical agents that are used to treat the condition. The use of mild, non-drying cleaning products and non-comedogenic moisturizers may help reduce this irritation.
All topical medications dry the skin to some extent, and patients should be warned about this. They should be advised to use the medications as tolerated.
For example, the topical medication can be used for 15 minutes at a time and then washed off. The time can be increased as tolerated, or the agent can be used every other day or every third day, with the frequency to be increased as tolerated.
The use of a topical agent is usually the best place to start treatment. The simplest and most cost-effective agent is benzoyl peroxide if it is tolerated. Bacterial resistance to has not been noted. This agent can be used as a leave-on product or as a wash. It is available over the counter and by prescription in various topical forms, including pledgets, soaps, washes, lotions, creams, and gels. It is also available as part of combination products that also contain (e.g., BenzaClin) or erythromycin (e.g., Benzamycin). It ranges in strength from 2.5% to 10%. However, more so than other topical acne treatments, benzoyl peroxide can induce allergic contact dermatitis.
Table 2 Therapies for Acne
|Topical Antibiotics||Topical Non-antibioticsand Non-retinoids||Oral Antibiotics||Topical Retinoids||OralNon-antibiotics||Herbals, Vitamins, Minerals|
|Clindamycin 1% lotion,gel, sol, pad||Azelaic acid 20%cream (Azelex); Azelaic acid 15% gel|
|b.i.d.||Tazarotene cream gel (Tazorac, Avage)||Oral contraceptives (Ortho Tri-Cyclen)||Nicotinamide 1.5 g q.d. divided in two or three doses (Nicomide)|
|ointment 2% (Akne-Mycin)||Sodium sulfacetamide 10%/sulfur 5% combination lotion, cream, pads, short contact preparation, cleanser (Novacet, Sulface)||Doxycycline 100 mg b.i.d. Doxycycline, sub-microbial dose, 20 mg b.i.d. or 40 mg q.d.||Tretinoin cream, gel, solution (Retin-A)||kg q.d. for 5-12 months; 10 or 20 mg for six months (Accutane drug)||Combination of nicotinamide 750 mg, zinc 25 mg, copper 1.5 mg, and folic acid 0.5 mgb.i.d.|
|Benzoyl peroxide 5%/clindamycin 2% combination gel, pad (BenzaClin)||Sodium sulfa-cetamide 10% lotion||Minocycline 50 mg b.i.d. Extended-release minocycline HCl (Solodyn) 45,90, or 135 q.d.||Adapalene cream, gel (Differin)||Oral zinc gluconate200 mg q.d.-b.i.d.|
|Benzoyl peroxide 5%/erythromycin 3% combination gel, pad (Benzamycin)||Benzoyl peroxide gel, wash q.d.-b.i.d. (Benzagel)||Sulfamethoxazole/ trimethoprim double-strength b.i.d.||Tretinoin 0.025%/clindamycin phosphate 1% gel (Velac: not yet approved)||Ocimum gratissimum oil (basil) (topical)|
|Topical dapsone 5% gel (Aczone)||t.i.w.-q.d.||Tretinoin 0.025%/clindamycin phosphate 1.2% gel (Ziana)||Melaleuca alternifolia (tea tree oil) (topical)|
|Clarithromycin 250 mg, 333 mg, 500 mg b.i.d.-q.d. (Biaxin canadian)|
Proactiv is an FDA-approved, OTC brand of benzoyl peroxide that has achieved prominence because of aggressive direct-to-consumer marketing. This benzoyl peroxide/sulfur combination can be more soothing for patients than traditional benzoyl peroxide products. It is available as a cleanser, toner, and repairing solution. The possibility of increased tolerability, its advertising campaign, and the basic effectiveness of benzoyl peroxide against acne have made Proactiv one of the most successful acne treatments ever, in terms of dollar volume.
Other acne medications include topical antibiotics whose active agent is erythromycin or clindamycin. Topical metron-idazole, which is commonly used to treat rosacea, is not indicated for treating acne. These agents, like their oral counterparts, are particularly effective against inflammatory acne and acne related to P. acnes responds to topical or oral antibiotics.
The FDA has approved dapsone 5% gel (Aczone, QLT USA) to treat acne after glucose-6-phosphate dehydrogenase (G6PD) levels are assessed, as required in the product’s boxed warning. A phase 4 post-approval trial is currently ongoing with the goal of having the restriction removed. In a study of patients with G6PD deficiency, the gel was found to be safe and effective in substantially decreasing inflammatory acneiform lesions.
Antibiotics do not abate comedones, and bacterial resistance to antibiotics may develop. The development of resistance is reduced if topical antibiotics are used in combination with benzoyl peroxide.
For mild acne, it is best to start with topical medications, which should be given for six to eight weeks. A first-line treatment for comedonal, non-inflammatory acne involves the use of topical retinoids (e.g., Retin-A) , such as tretinoin, adapalene (Differin, Galderma), and tazarotene (e.g., Allergan’s Tazoracand Avage).
Topical retinoids have comedolytic and anti-inflammatory properties. They increase epidermal differentiation and help normalize and abate follicular hyperproliferation and hyper-keratinization. Topical retinoids are the only medications that abate open and closed comedones; they decrease the quantity of micro-comedones, comedones, and inflammatory papules and pustules.
Retinoids are effective as monotherapy, or they can be combined with topical regimens that include antibiotics and ben-zoyl peroxide. Topical retinoids can also be used in conjunction with oral antibiotics.
Topical retinoids should be applied to clean, dry skin once daily. If they cause irritation, they can be applied every other day or every third day if irritation occurs with daily use. Some physicians have advocated the use of short-contact regimens with tazarotene, which is applied to the face for 5 to 20 minutes and is then removed by washing. Skin irritation, skin flaking and peeling, and redness of the skin can be linked to the use of topical retinoids.
Mild, non-drying skin cleaners and non-comedogenic moisturizers may help reduce this irritation. Alternate-day dosing may be used if irritation persists. Topical retinoids thin the stratum corneum, and they can be associated with sun sensitivity.
New developments in retinoids include a combination product of tretinoin 0.025% and clindamycin phosphate 1.2% in a gel (Ziana, Medicis). Ziana is indicated for the topical treatment of acne in patients 12 years of age and older.
According to trials, adapalene 0.3% gel (Differin) might be superior to its 0.1% gel predecessor.
A product combining tretinoin 0.025% and clindamycin phosphate 1% in a hydrogel base (Velac, Connetics) has not yet come to market.
Additional Topical Agents
Other topical agents include azelaic acid, either as a cream (Azelex, Allergan) or a gel (Finacea, Intendis), used once a day. Products that contain sulfur in different forms are soothing and somewhat effective for treating acne, rosacea, and seborrheic dermatitis.