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 Retinoids

Retinoic (vitamin A) acid is available in the form of tretinoin gel or cream (0.01–0.025%) and its isomer, isotretinoin gel (0.05%). A third-generation retinoid-like drug, adapalene (gel or cream; 0.1%) is also licensed for mild-to-moderate acne, has a significant and rapid anti-inflammatory action and is better tolerated than its predecessors.[17–19] Vitamin A and other retinoids reduce abnormal growth and development of keratinocytes within the pilosebaceous unit. Reversal of the hypercornification within the follicular canal, as well as the induction of accelerated proliferation of the follicular epithelium helps to 'unplug' the follicle.[20] This in turn inhibits development of the microcomedo and noninflammatory lesions, resulting in fewer anaerobic conditions, a reduction in P. acnes growth and a microenvironment less favorable for the development of inflammation. In addition, the newer retinoids reduce the rupture of comedones into the surrounding skin, also resulting in less inflammation.[21,22]

In terms of preference, both 0.1% adapalene and 0.025% tretinoin are shown to be equally effective against total lesion count, although adapalene has a faster onset of action with greater activity observed after 1 week of continuous daily use. By 12 weeks, both agents reduce noninflammatory lesions and inflammatory lesions by 83 and 70%, respectively.[17,18,23]

All topical retinoids can produce irritant dermatitis, but this is less problematic with second- and third-generation agents and with cream formulations rather than gels.[18] Patients should be warned that they may experience an initial flare of inflammatory lesions at the start of treatment.[15] These adverse effects can be minimized by starting at lower concentrations for a short period with incremental increases in contact time and preparation strength. Owing to potential photosensitivity, topical retinoids are best applied at night and patients should not expose themselves to excessive UV light. The link between retinoids and teratogenicity is well established but significant systemic absorption of topical retinoids has not been demonstrated.[24] Recommendations are, however, that female patients should be advised to avoid pregnancy and discontinue use immediately should they conceive while on treatment.


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