Consultant dermatologists see a lot of patients with acne and there are traditionally a few options available to us in the management of acne. For mild acne, we prescribe topical anti-acne agents.; for moderate to severe papulopustular acne (red spots and pustules), we prescribe topical anti-acne agents in combination with an oral antibiotic and for severe nodulocystic acne we have isotretinoin which is highly effective but comes with all its inherent side-effects.
As consultant dermatologists are the only doctors that can prescribe isotretinoin, we may often be in a situation where patients seek our opinions specifically to request isotretinoin therapy for their acne, irrespective of how mild it may be.
Sometimes, trying to dissuade a patient can be really tricky especially if they have known people who have been on months of different courses of antibiotics to only end up on isotretinoin which then worked.
But aren’t we trying to avoid using long term antibiotics?
Yes, that is true. By and large, it is the patients with moderate to severe papulopustular acne who don’t fulfill the criteria for or are not keen on isotretinoin therapy, that prove a real challenge as we really don’t have anything else.
So are there no other options?
Well, there have been new studies looking at what we already have to see if they can be improved upon.
Well, in this era of trying to reduce antibiotic use and preventing bacterial antibiotic resistance, the use of benzoyl peroxide (a bactericidal agent not associated with antibiotic resistance) is encouraged.
We also use topical agents containing a retinoid called adapalene in acne managment. Adapalene is comedolytic (breaks up blackheads) and has anti-inflammatory properties. It downregulates a receptor involved in the development of acne lesions.
[Tenaud I, Khammari A, Dreno B. In vitro modulation of TLR-2, CD1d and IL-10 by adapalene on normal human skin and acne inflammatory lesions. Exp Dermatol. 2007;16(6):500–6.]
Use of these two agents has been supported by the Global Alliance to Improve Outcomes in Acne guidelines and the European guidelines for acne treatment.
[Thiboutot D, Gollnick H, Bettoli V, et al. Global Alliance to Improve Outcomes in Acne. New insights into the management of acne: an update from the Global Alliance to Improve Out- comes in Acne group. J Am Acad Dermatol. 2009;60(Suppl 5):S1–50.]
[Nast A, Rosumeck S, Sammain A, Sporbeck B, Rzany B. Methods report on the development of the European S3 guide- lines for the treatment of acne. J Eur Acad Dermatol Venereol. 2012;26(Suppl 1):e1–41.]
I’m already using a gel which contains both those products.
Yes, there is a gel containing both these agents which was first available in the USA in early 2009 and arrived in the UK not long after. It contains 0.1% adapalene and 2.5% benzoyl peroxide. It’s beneficial use in mild comedonal (blackhead predominant) and early papulopustular acne has been well documented.
[Tan J, Gollnick HP, Loesche C, Ma YM, Gold LS. Synergistic efficacy of adapalene 0.1%-benzoyl peroxide 2.5% in the treatment of 3855 acne vulgaris patients. J Dermatolog Treat. 2011;22(4):197–205.]
Will it work in more severe disease?
Probably not on its own. However, there have been studies looking at whether a combination gel containing a higher concentration of adapalene might be more effective.
And what have these studies shown?
The results look promising.
A study looking at adapalene 0.3% versus adapalene 0.1% showed superiority with the stronger concentration in moderate acne.
[Thiboutot D, Pariser DM, Egan N, et al. Adapalene gel 0.3% for the treatment of acne vulgaris: a multicenter, randomized, double-blind, controlled, phase III trial. J Am Acad Dermatol. 2006;54(2):242–50.]
A more recent study looking at a new combination product containing adapalene 0.3% with benzoyl peroxide showed a statistically significant improvement in severe inflammatory acne compared to the 0.1% adapalene combination gel and was just as well tolerated.
[Stein Gold L, Weiss J, Rueda MJ et al. Moderate and Severe Inflammatory Acne Vulgaris Effectively Treated with Single-Agent Therapy by a New Fixed-Dose Combination Adapalene 0.3%/Benzoyl Peroxide 2.5% Gel: A Randomized, Double-Blind, Parallel-Group, Controlled Study. Am J Clin Dermatol. 2016;17:293-303.]
[Stein Gold L, Baldwin HE, Lin T. Management of Severe Acne Vulgaris With Topical Therapy. J Drugs Dermatol. 2017;16:1134-38.]
I’ve heard that retinoids are good at treating acne scars?
Yes, that is true and there is evidence that these combination products can not only treat acne but also improve the appearance of any acne scars present.
[Dreno B, Tan J, Rivier M et al. Adapalene 0.1%/benzoyl peroxide 2.5% gel reduces the risk of atrophic scar formation in moderate inflammatory acne: a split-face randomized controlled trial. JEADV 2017;31:737-42.]
So by revisiting what we already have, it seems as if we may finally have a solution for moderate to severe papulopustular acne without having to resort to lengthy courses of antibiotics or isotretinoin therapy.
Dr Sandy Flann, Consultant Dermatologist.