Topical Treatment

Topical treatments alone may be effective in patients with mild to moderate acne, especially when the condition is limited to the face. Treatments made with more alcohol (i.e. solutions and some gels) are often preferred by patients with oily skin; patients with dry skin may prefer a cream, lotion, or ointment which offers more moisturization. A variety of over-the-counter and prescription products are available for mild to moderate acne. Most OTC products contain benzoyl peroxide, glycolic acid, or salicylic acid.

Benzoyl Peroxide

• Most frequently used topical treatment for acne
• Has antimicrobial effects to reduce colonization of P acnes on the skin surface
• Decreases free-fatty-acid concentrations, which may decrease the development or retention hyperderatosis and microcomedones.
• Has an anti-inflammatory effect by reducing the number of oxygen-free radicals.
• Active against inflammatory and noninflammatory lesions and may be useful solely for mild acne.
• Comes in a variety of formulations: gels, lotions, washes, and creams
• Generally used once or twice daily
• Is very effective in combination with either topical antibiotics (i.e. erythromycin) or tretinoin (described below).
• Side Effect: skin irritation, which can be eliminated gradually by increasing the frequency of application.

Topical retinoids

• Extremely effective type of medication for acne.
• Creates strong comedolytic and anticomedogenic activity
• Has indirect antibacterial effects
• Tretinoin is the prototype drug (all-trans-reinoic acid, Retin-A, Avita), an acid of Vitamin A. This drug has shown to normalize desquamation of the follicular epithelium, promote drainage of comedones, and inhibit new comedone formation.
• Tretinoin comes in cream, liquid, and gels and has been used effectively in combination with either topical antibiotics, benzoyl peroxide, or systemic antibiotics.
• Tazarotene and adapalene- newer topical retinoid or retinoid-like compounds .
  Topical retinoids are usually applied once daily at night to decrease the risk of phototoxicity, a rare side effect.
• Common side effects: dryness and burning which can be minimized by applying the medication to completely dried skin after washing and applying only the minimum amount of medication necessary.

Topical antibiotics

• Reduce the population of P acnes on the surface of skin and within hair follicles.
• May have anti-inflammatory effects.
• Clindamycin, erythromycin, salicylic acid and sulfonamides are the most commonly used topical antibiotics.
• Do not have comedolytic effects and therefore work best as part of a combination regimen for mixed inflammatory and comedonal acne.
• Usually applied once or twice daily to affected areas.
• Types

  
  Topical Clindamyci

  • Available as a solution, ointment, gel, pads, or pledgets
  • There is also a liquid form with zinc acetate which: helps reduce P acne counts; helps decrease free fatty acids in surface lipids.

  Benzaclin

  • A combination gel of topical clidamycin and benzoyl peroxide
  • Found to be more effective than either commponent alone
  • Applied once or twice daily
  • Side effects include occasional irritation, dryness, and a “white film” can be visible on the skin after application.
  • Does not requires refrigeration

  Sulfonamides

  • Contains sodium sulfacetamide
  • Available in lotions with and without 5% sulfur (sulfur may be useful in treatment because of it’s keratolytic effects)
  • Can be used safely used in combination therapy with BPO, retinoids, oral antibiotics, or hormonal therapies.

  Azelaic Acid (Azelex 20%)

  • A naturally occurring dicarboxylic acid
  • Demonstrates activity against P acnes and the ability to decrease microcomedo formation.
  • May be effective used as a solo treatment for mild acne but has been shown to be quite effective with systemic antibiotic therapy for moderate to severe inflammatory acne.
  • Can be continued as maintenance therapy after an oral antibiotic is tapered.
  • Applied twice daily.