Treatment of Facial Acne

Journal Watch. 2005;4(2) 

Investigators in the U.K. conducted a large, observer-masked comparison of the efficacy, tolerability, safety, cost-effectiveness, and effects of propionibacterium resistance in five acne treatment regimens. They randomized 649 patients with mild-to-moderate facial acne (at least 15 inflammatory and 15 noninflammatory facial lesions) to receive:

  • twice-daily oral oxytetracycline (500 mg) with topical placebo,

  • daily oral minocycline (100 mg) with topical placebo,

  • twice-daily topical 5% benzoyl peroxide (bp) with oral placebo,

  • twice-daily topical 5% bp plus topical 3% erythromycin with oral placebo, or

  • topical 2% erythromycin in the AM and 5% bp gel in the PM with oral placebo.

All regimens produced moderate improvement or better in at least 50% of subjects and decreased by about 30% the number of inflamed lesions at 18 weeks. Results were significantly better in the two bp/erythromycin groups than in the other three groups. Viable Propionibacterium acnes were identified in almost all subjects: erythromycin resistance was seen in 47%, clindamycin resistance in 41%, and tetracycline resistance in 18%. Resistance decreased the efficacy of both tetracyclines. The authors conclude that topical bp, with or without erythromycin, is as effective as oral tetracycline without being affected by antibiotic resistance.

These findings reinforce concerns about emerging antibiotic resistance in acne patients. Topical benzoyl peroxide works well, alone or in combination, but it has more local side effects and is not as useful as systemic therapy for truncal disease. Broadening the assessment to include topical retinoids would have been useful, because they have many benefits that can improve outcomes. Also, higher doses of minocycline might work better than those used here. Clinicians now recognize that antibiotic-only therapy can increase resistance and has lower efficacy than combined regimens that include bp or retinoids.

— Neil H. Shear, MD, FRCPC

Ozolins M et al. Comparison of five antimicrobial regimens for treatment of mild to moderate inflammatory facial acne vulgaris in the community: Randomised controlled trial.   Lancet   2004 Dec 18; 364:2188-95.

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