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For mild comedonal acne, monotherapy with topical retinoids is the treatment of choice (strength of recommendation [SOR]: A). For moderate comedonal and mild to moderate papulopustular acne, combination therapy with either benzoyl peroxide or topical retinoids (adapalene [Differin], tazarotene [Tazorac], tretinoin [Retin-A]) plus topical antibiotics (erythromycin or clindamycin) is proven most effective (SOR: A). Six to eight weeks should be allowed for most treatments to work before altering the regimen (SOR: A).
Get patients (or parents) to agree to an adequate trial before declaring failure
Timothy Mott, MD
US Navy, Pensacola, Fla
Fortunately, we have excellent first-line therapies for mild to moderate acne. A greater challenge is getting patients (or parents) to agree to an adequate trial of these agents, and then sharing objective data on progress before hastily declaring failure.
We must remember the significant psychosocial impact that “zits” have on our adolescent patients. Validating this central concern and providing lay education on acne pathophysiology help get patients to agree to 6 weeks of therapy before judging the effectiveness of treatment. Comparative digital photographs and repeat counts of inflammatory lesions and comedones at the follow-up visit help significantly in objective progress assessment and fostering therapeutic adherence.
Evidence summary
Acne vulgaris is the most common cutaneous disorder, affecting about 45 million people in the United States. Five to 6 million acne-related visits are made to physicians in outpatient offices each year.1
For mild noninflammatory (come-donal) acne, the preferred option is monotherapy with topical retinoids. Randomized controlled trials (RCTs) have proven the efficacy of tretinoin, an older retinoid for comedonal acne.2 In one RCT, patients were randomly assigned to 1 of 3 treatment groups, each having 33 enrollees: patients in the first group received 0.1% tazarotene gel as twice daily application; the second group received 0.1% tazarotene gel in the evening and vehicle gel in the morning; the third group received vehicle gel twice daily. By 12 weeks, the first and second groups achieved significantly greater improvement in acne than the third group, based on mean percentage reduction in noninflammatory lesions (46% and 41% vs 2%; P=.002) and inflammatory lesions (38% and 34% vs 9%; P=.01).3 Another 12-week RCT of 237 patients with mild to moderate acne demonstrated superior efficacy with 0.1% adapalene cream over placebo (P<.05).4 While most studies did not compare the use of one retinoid vs another, a recent meta-analysis of placebo-controlled trials concluded that topical tazarotene is more effective in treating mild comedonal acne than adapalene or tretinoin, although it may be more likely to cause skin irritation.6,7
A systematic review evaluating the evidence for treatment of acne found that combining topical antibiotics with topical retinoids or benzoyl peroxide is effective for moderate noninflammatory (come-donal) and mild to moderate inflammatory (papulopustular) acne.7 Because of its antibacterial and anti-comedogenic properties, benzoyl peroxide is preferred to retinoids for inflammatory acne. Another benefit of using benzoyl peroxide with antibiotic cream is its potential to reduce antibiotic-associated resistance to Propionibacterium acnes.7,8
No comparative trials or meta-analyses compare efficacy of different combination therapies. A recent narrative review of clinical trials concluded that clindamycin plus benzoyl peroxide was more effective in reducing inflammatory lesions than monotherapy with either agent alone, and was similar in efficacy to benzoyl peroxide/erythromycin combination.8 Similarly, combination therapy with clindamycin and adapalene was superior to clindamycin alone in improving mild to moderate acne.9 Both 1% clindamycin and 2% erythromycin were comparable in reducing inflammatory and noninflammatory lesions for patients with moderate acne.10
Studies are ongoing for topical tetracycline, topical isotretinoin, and light and laser therapy in treatment of mild to moderate acne.
Recommendations from others
An expert review stated that treatment of acne should be individualized for best results.7 A report from the Global Alliance to Improve Outcomes in Acne states that topical retinoids are appropriate first-line therapy for all forms of acne and should be combined with topical antimicrobial therapy when inflammatory lesions are present.11
1. Stern S. Medication and medical service utilization for acne 1995-1998. J Am Acad Dermatol 2000;43:1042-1048.
2. Christiansen JV, Gadborg E, Ludvigsen K, et al. Topical tretinoin, Vitamin A acid (Airol) in acne vulgaris. A controlled clinical trial. Dermatologica 1974;148:82-89.
3. Bershad S, Kranjac Singer G, Parente JE, et al. Successful treatment of acne vulgaris using a new method: results of a randomized vehicle-controlled trial of short-contact therapy with 0.1% tazarotene gel. Arch Dermatol 2002;138:481-489.
4. Lucky A, Jorizzo JL, Rodriguez D, et al. Efficacy and tolerance of adapalene cream 0.1% compared with its cream vehicle for the treatment of acne vulgaris. Cutis 2001;68(4 Suppl):34-40.
5. Leyden JJ. Meta-analysis of topical tazarotene in treatment of mild to moderate acne. Cutis 2004;74(4 Suppl):9-15.
6. Eady EA, Bojar RA, Jones CE, Cove JH, Holland KT, Cunliffe WJ. The effects of acne treatment with a combination of benzoyl peroxide and erythromycin on skin carriage of erythromycin-resistant propionibacteria. Br J Dermatol 1996;134:107-113.
7. Haider A, Shaw JC. Treatment of acne vulgaris. JAMA 2004;292:726-735.
8. Warner GT, Plosker GL. Clindamycin/benzoyl peroxide gel: a review of its use in the management of acne. Am J Clin Dermatol 2002;3:349-360.
9. Wolf JE, Jr, Kaplan D, Kraus SJ, et al. Efficacy and tolerability of combined topical treatment of acne vulgaris with adapalene and clindamycin: a multicenter, randomized, investigator-blinded study. J Am Acad Dermatol 2003;49(3 Suppl):S211-217
10. Leyden JJ, Shalita AR, Saatjian GD, Sefton J. Erythromycin 2% gel in comparison with clindamycin phosphate 1% solution in acne vulgaris. J Am Acad Dermatol 1987;16:822-827.
11. Gollnick H, Cunliffe W, Berson D, et al. Management of acne: a report from Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol 2003;49(1 Suppl):S1-S37.
For mild comedonal acne, monotherapy with topical retinoids is the treatment of choice (strength of recommendation [SOR]: A). For moderate comedonal and mild to moderate papulopustular acne, combination therapy with either benzoyl peroxide or topical retinoids (adapalene [Differin], tazarotene [Tazorac], tretinoin [Retin-A]) plus topical antibiotics (erythromycin or clindamycin) is proven most effective (SOR: A). Six to eight weeks should be allowed for most treatments to work before altering the regimen (SOR: A).
Get patients (or parents) to agree to an adequate trial before declaring failure
Timothy Mott, MD
US Navy, Pensacola, Fla
Fortunately, we have excellent first-line therapies for mild to moderate acne. A greater challenge is getting patients (or parents) to agree to an adequate trial of these agents, and then sharing objective data on progress before hastily declaring failure.
We must remember the significant psychosocial impact that “zits” have on our adolescent patients. Validating this central concern and providing lay education on acne pathophysiology help get patients to agree to 6 weeks of therapy before judging the effectiveness of treatment. Comparative digital photographs and repeat counts of inflammatory lesions and comedones at the follow-up visit help significantly in objective progress assessment and fostering therapeutic adherence.
Evidence summary
Acne vulgaris is the most common cutaneous disorder, affecting about 45 million people in the United States. Five to 6 million acne-related visits are made to physicians in outpatient offices each year.1
For mild noninflammatory (come-donal) acne, the preferred option is monotherapy with topical retinoids. Randomized controlled trials (RCTs) have proven the efficacy of tretinoin, an older retinoid for comedonal acne.2 In one RCT, patients were randomly assigned to 1 of 3 treatment groups, each having 33 enrollees: patients in the first group received 0.1% tazarotene gel as twice daily application; the second group received 0.1% tazarotene gel in the evening and vehicle gel in the morning; the third group received vehicle gel twice daily. By 12 weeks, the first and second groups achieved significantly greater improvement in acne than the third group, based on mean percentage reduction in noninflammatory lesions (46% and 41% vs 2%; P=.002) and inflammatory lesions (38% and 34% vs 9%; P=.01).3 Another 12-week RCT of 237 patients with mild to moderate acne demonstrated superior efficacy with 0.1% adapalene cream over placebo (P<.05).4 While most studies did not compare the use of one retinoid vs another, a recent meta-analysis of placebo-controlled trials concluded that topical tazarotene is more effective in treating mild comedonal acne than adapalene or tretinoin, although it may be more likely to cause skin irritation.6,7
A systematic review evaluating the evidence for treatment of acne found that combining topical antibiotics with topical retinoids or benzoyl peroxide is effective for moderate noninflammatory (come-donal) and mild to moderate inflammatory (papulopustular) acne.7 Because of its antibacterial and anti-comedogenic properties, benzoyl peroxide is preferred to retinoids for inflammatory acne. Another benefit of using benzoyl peroxide with antibiotic cream is its potential to reduce antibiotic-associated resistance to Propionibacterium acnes.7,8
No comparative trials or meta-analyses compare efficacy of different combination therapies. A recent narrative review of clinical trials concluded that clindamycin plus benzoyl peroxide was more effective in reducing inflammatory lesions than monotherapy with either agent alone, and was similar in efficacy to benzoyl peroxide/erythromycin combination.8 Similarly, combination therapy with clindamycin and adapalene was superior to clindamycin alone in improving mild to moderate acne.9 Both 1% clindamycin and 2% erythromycin were comparable in reducing inflammatory and noninflammatory lesions for patients with moderate acne.10
Studies are ongoing for topical tetracycline, topical isotretinoin, and light and laser therapy in treatment of mild to moderate acne.
Recommendations from others
An expert review stated that treatment of acne should be individualized for best results.7 A report from the Global Alliance to Improve Outcomes in Acne states that topical retinoids are appropriate first-line therapy for all forms of acne and should be combined with topical antimicrobial therapy when inflammatory lesions are present.11
For mild comedonal acne, monotherapy with topical retinoids is the treatment of choice (strength of recommendation [SOR]: A). For moderate comedonal and mild to moderate papulopustular acne, combination therapy with either benzoyl peroxide or topical retinoids (adapalene [Differin], tazarotene [Tazorac], tretinoin [Retin-A]) plus topical antibiotics (erythromycin or clindamycin) is proven most effective (SOR: A). Six to eight weeks should be allowed for most treatments to work before altering the regimen (SOR: A).
Get patients (or parents) to agree to an adequate trial before declaring failure
Timothy Mott, MD
US Navy, Pensacola, Fla
Fortunately, we have excellent first-line therapies for mild to moderate acne. A greater challenge is getting patients (or parents) to agree to an adequate trial of these agents, and then sharing objective data on progress before hastily declaring failure.
We must remember the significant psychosocial impact that “zits” have on our adolescent patients. Validating this central concern and providing lay education on acne pathophysiology help get patients to agree to 6 weeks of therapy before judging the effectiveness of treatment. Comparative digital photographs and repeat counts of inflammatory lesions and comedones at the follow-up visit help significantly in objective progress assessment and fostering therapeutic adherence.
Evidence summary
Acne vulgaris is the most common cutaneous disorder, affecting about 45 million people in the United States. Five to 6 million acne-related visits are made to physicians in outpatient offices each year.1
For mild noninflammatory (come-donal) acne, the preferred option is monotherapy with topical retinoids. Randomized controlled trials (RCTs) have proven the efficacy of tretinoin, an older retinoid for comedonal acne.2 In one RCT, patients were randomly assigned to 1 of 3 treatment groups, each having 33 enrollees: patients in the first group received 0.1% tazarotene gel as twice daily application; the second group received 0.1% tazarotene gel in the evening and vehicle gel in the morning; the third group received vehicle gel twice daily. By 12 weeks, the first and second groups achieved significantly greater improvement in acne than the third group, based on mean percentage reduction in noninflammatory lesions (46% and 41% vs 2%; P=.002) and inflammatory lesions (38% and 34% vs 9%; P=.01).3 Another 12-week RCT of 237 patients with mild to moderate acne demonstrated superior efficacy with 0.1% adapalene cream over placebo (P<.05).4 While most studies did not compare the use of one retinoid vs another, a recent meta-analysis of placebo-controlled trials concluded that topical tazarotene is more effective in treating mild comedonal acne than adapalene or tretinoin, although it may be more likely to cause skin irritation.6,7
A systematic review evaluating the evidence for treatment of acne found that combining topical antibiotics with topical retinoids or benzoyl peroxide is effective for moderate noninflammatory (come-donal) and mild to moderate inflammatory (papulopustular) acne.7 Because of its antibacterial and anti-comedogenic properties, benzoyl peroxide is preferred to retinoids for inflammatory acne. Another benefit of using benzoyl peroxide with antibiotic cream is its potential to reduce antibiotic-associated resistance to Propionibacterium acnes.7,8
No comparative trials or meta-analyses compare efficacy of different combination therapies. A recent narrative review of clinical trials concluded that clindamycin plus benzoyl peroxide was more effective in reducing inflammatory lesions than monotherapy with either agent alone, and was similar in efficacy to benzoyl peroxide/erythromycin combination.8 Similarly, combination therapy with clindamycin and adapalene was superior to clindamycin alone in improving mild to moderate acne.9 Both 1% clindamycin and 2% erythromycin were comparable in reducing inflammatory and noninflammatory lesions for patients with moderate acne.10
Studies are ongoing for topical tetracycline, topical isotretinoin, and light and laser therapy in treatment of mild to moderate acne.
Recommendations from others
An expert review stated that treatment of acne should be individualized for best results.7 A report from the Global Alliance to Improve Outcomes in Acne states that topical retinoids are appropriate first-line therapy for all forms of acne and should be combined with topical antimicrobial therapy when inflammatory lesions are present.11
1. Stern S. Medication and medical service utilization for acne 1995-1998. J Am Acad Dermatol 2000;43:1042-1048.
2. Christiansen JV, Gadborg E, Ludvigsen K, et al. Topical tretinoin, Vitamin A acid (Airol) in acne vulgaris. A controlled clinical trial. Dermatologica 1974;148:82-89.
3. Bershad S, Kranjac Singer G, Parente JE, et al. Successful treatment of acne vulgaris using a new method: results of a randomized vehicle-controlled trial of short-contact therapy with 0.1% tazarotene gel. Arch Dermatol 2002;138:481-489.
4. Lucky A, Jorizzo JL, Rodriguez D, et al. Efficacy and tolerance of adapalene cream 0.1% compared with its cream vehicle for the treatment of acne vulgaris. Cutis 2001;68(4 Suppl):34-40.
5. Leyden JJ. Meta-analysis of topical tazarotene in treatment of mild to moderate acne. Cutis 2004;74(4 Suppl):9-15.
6. Eady EA, Bojar RA, Jones CE, Cove JH, Holland KT, Cunliffe WJ. The effects of acne treatment with a combination of benzoyl peroxide and erythromycin on skin carriage of erythromycin-resistant propionibacteria. Br J Dermatol 1996;134:107-113.
7. Haider A, Shaw JC. Treatment of acne vulgaris. JAMA 2004;292:726-735.
8. Warner GT, Plosker GL. Clindamycin/benzoyl peroxide gel: a review of its use in the management of acne. Am J Clin Dermatol 2002;3:349-360.
9. Wolf JE, Jr, Kaplan D, Kraus SJ, et al. Efficacy and tolerability of combined topical treatment of acne vulgaris with adapalene and clindamycin: a multicenter, randomized, investigator-blinded study. J Am Acad Dermatol 2003;49(3 Suppl):S211-217
10. Leyden JJ, Shalita AR, Saatjian GD, Sefton J. Erythromycin 2% gel in comparison with clindamycin phosphate 1% solution in acne vulgaris. J Am Acad Dermatol 1987;16:822-827.
11. Gollnick H, Cunliffe W, Berson D, et al. Management of acne: a report from Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol 2003;49(1 Suppl):S1-S37.
1. Stern S. Medication and medical service utilization for acne 1995-1998. J Am Acad Dermatol 2000;43:1042-1048.
2. Christiansen JV, Gadborg E, Ludvigsen K, et al. Topical tretinoin, Vitamin A acid (Airol) in acne vulgaris. A controlled clinical trial. Dermatologica 1974;148:82-89.
3. Bershad S, Kranjac Singer G, Parente JE, et al. Successful treatment of acne vulgaris using a new method: results of a randomized vehicle-controlled trial of short-contact therapy with 0.1% tazarotene gel. Arch Dermatol 2002;138:481-489.
4. Lucky A, Jorizzo JL, Rodriguez D, et al. Efficacy and tolerance of adapalene cream 0.1% compared with its cream vehicle for the treatment of acne vulgaris. Cutis 2001;68(4 Suppl):34-40.
5. Leyden JJ. Meta-analysis of topical tazarotene in treatment of mild to moderate acne. Cutis 2004;74(4 Suppl):9-15.
6. Eady EA, Bojar RA, Jones CE, Cove JH, Holland KT, Cunliffe WJ. The effects of acne treatment with a combination of benzoyl peroxide and erythromycin on skin carriage of erythromycin-resistant propionibacteria. Br J Dermatol 1996;134:107-113.
7. Haider A, Shaw JC. Treatment of acne vulgaris. JAMA 2004;292:726-735.
8. Warner GT, Plosker GL. Clindamycin/benzoyl peroxide gel: a review of its use in the management of acne. Am J Clin Dermatol 2002;3:349-360.
9. Wolf JE, Jr, Kaplan D, Kraus SJ, et al. Efficacy and tolerability of combined topical treatment of acne vulgaris with adapalene and clindamycin: a multicenter, randomized, investigator-blinded study. J Am Acad Dermatol 2003;49(3 Suppl):S211-217
10. Leyden JJ, Shalita AR, Saatjian GD, Sefton J. Erythromycin 2% gel in comparison with clindamycin phosphate 1% solution in acne vulgaris. J Am Acad Dermatol 1987;16:822-827.
11. Gollnick H, Cunliffe W, Berson D, et al. Management of acne: a report from Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol 2003;49(1 Suppl):S1-S37.
Evidence-based answers from the Family Physicians Inquiries Network