Treating Acne Vulgaris: Systemic, Local and Combination Therapy

Laura J Savage; Alison M Layton


Expert Rev Clin Pharmacol. 2010;13(4):563-580. 

In This Article

Topical Therapies

Patients with mild acne usually require topical treatment alone.[15] Those with more extensive acne should be prescribed topical agents in conjunction with appropriate oral therapy. Many topical preparations are available and the choice of preparation will depend on the type of lesions seen on clinical examination. Patients with mixed lesions should be prescribed therapy that is active against microcomedones, comedones and inflammatory lesions from the outset.[14] No single topical agent is able to impact on all of the etiological factors implicated in acne pathogenesis and a combination of preparations may be needed for a successful outcome. Table 1 summarizes the actions of topical agents on each etiological factor. Response to topical agents can be slow, and it is important that patients have realistic expectations of their response to therapy. The patient should also be informed that topical therapy should be applied to all areas of skin within the active site and not just to the visible lesions, as normal skin in an acne prone site is likely to have many evolving microcomedones.[15]

Given the central role of the microcomedo as the precursor of inflammatory and noninflammatory lesions, topical retinoids are now recommended as first-line therapy as they impact on the microcomedo and have some anti-inflammatory activity.[14] Topical benzoyl peroxide (BPO), antibiotics and azelaic acid have predominantly anti-inflammatory activity in acne and can be used safely in combination with topical retinoids. However, topical antibiotics should not be used as monotherapy without an anti-resistant agent such as BPO or zinc in combination. BPO inactivates tretinoin so the two agents should not be administered simultaneously, and if used in a combination regimen, use should be alternated between morning and evening.[15] The active anticomedogenic, comedolytic and anti-inflammatory effects of topical retinoids support their use in more moderate-to-severe acne, ideally in combination with topical or oral antimicrobial agents, thus targeting a broader range of contributory etiological factors.


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