Newer Approaches in Topical Combination Therapy for Acne

Lisa W. Fu, BHSc; Ronald B. Vender, MD, FRCPC


Skin Therapy Letter. 2011;16(9) 

In This Article

Treatment of Acne Vulgaris

Treatment is targeted to one or multiple pathogenic element(s). 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.[1] Retinoids (e.g., adapalene, tazarotene, tretinoin) act to reduce dyskeratosis at the pilosebaceous unit, inhibit the formation of microcomedones, and have mild anti-inflammatory effects.[3] Advanced vehicle formulations in the form of emollient cream and microsphere gel reduce irritation and enhance efficacy.[4] Antimicrobials (e.g., benzoyl peroxide (BPO), clindamycin, erythromycin, sodium sulfacetamide) have bactericidal or bacteriostatic action against P. acnes. 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.[5]

Combination products (e.g., BPO + antibiotic, retinoid + antibiotic) target multiple pathogenic factors, which are complementary and synergistic in mechanisms of action. It also simplifies the treatment regimen and reduces dosing frequency.[3] BPO + clindamycin combination products have been widely studied, a recent meta-analysis showed that BPO 2.5% + clindamycin is comparable to BPO 5%+ clindamycin in reducing acne lesion counts.[6] Investigators suggest that BPO 2.5% + clindamycin may in fact be more effective in treating non-inflammatory acne lesions possibly because of decreased irritation, thereby encouraging treatment follow-through by patients.[6] Furthermore, combination preparations were found to be superior in treating acne lesions compared with using either agent alone.[6]

The addition of BPO to topical antibiotics and retinoids in managing mild to moderate acne reduces the incidence of bacterial resistance. This bacteriostatic agent is efficacious against both nonresistant and resistant P. acnes strains. BPO acts by producing free-radical oxygen that oxidizes bacterial proteins and exerting a mild keratolytic effect on comedones. In more severe acne, when oral antibiotics are necessary, BPO may contribute to suppressing the emergence of resistant P. acnes strains.[7]


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