Therapy

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Topical therapy may be useful 1) in the management of mild acne; 2) in combination with oral therapy in moderate to severe forms, with more inflammation and a tendency to scar; and 3) as maintenance treatment (Tables 11.4 and 11.5). Choice of topical agents depends upon acne variety. For comedonal acne, anticomedogenic agents are indicated, whereas antibacterial agents are required in inflammatory acne. Retinoids, azelaic acid, salicylic acid, and benzoyl peroxide are effective for comedones. Benzoyl peroxide, azelaic acid and topical antibiotics such as erythromycin and clindamycin are most effective in reducing inflammatory lesions. Antibiotics act both as bacteriostatic/ bactericidal on P acnes and as direct antiinflammatory agents. Inhibition of P. acnes growth indirectly reduces inflammation. Anti biotics currently used are tetracyclines, macro-lides (erythromycin) and clindamycin. Topical antibiotics are indicated in the treatment of inflammatory acne, particularly milder forms and are available in a variety of vehicles such as creams, lotions, ointments, gels and solutions. Antibiotics have been formulated in combination with other anti-acne agents such as ben-zoyl peroxide and topical retinoids. The principal side-effect of topical antibiotics is the induction of bacterial resistance. Combination with benzoyl peroxide increases the bactericidal effect of the antibiotics, while reducing the risk of bacterial resistance development.

Topical retinoids acting on gene transcription regulate cell proliferation and differentia-

Table 11.4 Topical treatment

Topical drug

Main effects

Antibiotics (macrolides, clindamycin, tetracyclines)

P acnes suppression Indirect anti-inflammatory

Direct anti-inflammatory

Benzoyl peroxide Azelaic acid

P. acnes suppression Antibacterial

Table 11.5 Topicals for acne

Comedonal acne

Topical retinoids

Retinoic acid

Cream, gel, liquid

0.01%, 0.02%, 0.025%, 0.04%, 0.05%, 0.1%

o.d.

Isotretinoin

Gel, cream

0.05%

o.d

Adapalene

Cream, gel

0.1%

o.d.

Tazarotene

Cream, gel

0.05%, 0.1%

o.d.

Inflammatory acne

Antibiotics

Erythromycin

Cream, gel, solution

2%, 3%, 4%

o.d., b.i.d.

Clindamycin

Gel, lotion, solution

1%

o.d., b.i.d.

Benzoyl peroxide

Cream, gel

3%, 4%, 5%, 10%

o.d.

Azelaic acid

Cream, gel

15%, 20%

o.d., b.i.d.

Sodium sulfacetamide 10%

Lotion, gel, pads

-

o.d., b.i.d.

(+ sulfur 5%)

Hydrogen peroxide

Cream

1%

o.d, b.i.d.

Combination of topicals

Benzoyl peroxide 5%

Gel

-

o.d., b.i.d.

+ erythromycin 3%

Benzoyl peroxyde 5%

Gel

-

o.d., b.i.d.

+ clindamycin 1%

Isotretinoin 0.05%

Gel

-

o.d., b.i.d.

+ erythromycin 2%

Retinoic acid 0.025%

Gel

-

o.d, b.i.d

+ clindamycin 1%.

Retinaldehyde 0.1%

Cream

-

o.d, b.i.d.

+ glycolic acid 6%

Detergents

Benzoyl peroxide

Creamy wash

4%, 5%, 8%, 10%

o.d., b.i.d.

Salicylic acid

Solution

2%

o.d., b.i.d.

o.d.: once & day; b.i.d.: twice a day (bi in die)

o.d.: once & day; b.i.d.: twice a day (bi in die)

tion and to a lesser extent inflammation, they also prevent microcomedonal formation and resolve mature comedones leading to: a) reduced production of keratohyalin granules by follicular keratinocytes, and b) inhibition of corneocytes accumulation and cohesion, increasing in this way infundibular keratinocytes turnover. Retinoids, particularly adapalene, possess some anti-inflammatory activities, though they do not have a direct antibacterial effect. Tretinoin, the first topical retinoid used in acne, is available as a cream, gel or solution in a variety of concentrations. It has recently be come available in new formulations such as mi-crosponges or propylpolymers in order to minimize irritation. Adapalene is a naphtoic acid derivative with retinoid-like activity.Adapalene has been demonstrated to be equally effective as tretinoin, but better tolerated than the latter (Fig. 11.17a, b). It is available as gel, cream and solution. Isotretinoin is an alternative preparation with similar properties to tretinoin. It is available as cream or gel, either alone or in combination with topical antibiotic (erythrom-ycin, clindamycin). Tazarotene is a synthetic acetylenic retinoid authorized in psoriasis and

Patient with mild acne treated with topical tretinoin

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