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Clinical Updates

Steven R. Feldman, MD, PhD

Should we still be Prescribing Topical Antibiotic Monotherapy in Acne?

Steven R. Feldman, MD, PhD

Wednesday, June 11, 2014

Typically in our Expert Opinion articles, we look forward at new treatments and their evolving role in dermatology. I want to take a look backward this time. One of the pillars of acne treatment has been the use of topical antibiotics, often as monotherapy. Are topical antibiotic monotherapy products something we should still be prescribing to patients?

Acne is a multifactorial condition. Topical antibiotics and anti-microbials, topical retinoids, oral antibiotics, hormonal treatments and systemic retinoids can be used, often in combination. When used alone, topical antibiotics can be associated with the development of resistant organisms, so typically we now think about using topical antibiotics - such as topical clindamycin - in combination with topical benzoyl peroxide, both to increase efficacy and to prevent the development of antibiotic resistance. Moreover, topical retinoids, which treat comedones, are recommended as a foundation of treatment for nearly all but the most severe acne patients (who are treated with oral retinoids). The use of these treatments in combination regimens can get pretty complicated.

The primary patient population for acne treatment is teenagers and young adults. These are not the most compliant patients. In one of our studies of teenagers using a simple regimen of daily topical benzoyl peroxide, none of the patients achieved 80% adherence to treatment and mean adherence for this study group declined significantly over a 6-week study period (Figure 1). Making treatment regimens more complicated by asking patients to put different topical treatments on their face each day further degrades adherence to treatment.


Feldman - adherence

Figure 1. Adherence to benzoyl peroxide 5% gel over a 6-week study period. The mean percent adherence to topical acne treatment decreased significantly from 82% on Day 1 to 45% on Day 43 for a study population of 13 to 18 year olds (p<0.001). Figure adapted from Yentzer BA, et al. (2009).


Use of combination approaches facilitates targeting multiple components of acne pathogenesis while minimizing the burden of treatment and thereby enhancing patients' adherence to the treatment regimen. The development of topical antibiotic-benzoyl peroxide products made it possible to prescribe both products without patients having to use separate treatments. The more recent development of a topical retinoid/benzoyl peroxide combination (adapalene/benzoyl peroxide), now permits us to give patients both a topical retinoid and a topical antimicrobial that does not promote antibiotic resistance in a single product.

If we can prescribe topical retinoid and topical benzoyl peroxide in a single product, do we even need topical antibiotic monotherapy products anymore? In a recent analysis, we found that topical antibiotic monotherapy for acne has been decreasing in the United States. It may be that it is time to give up topical antibiotic monotherapy treatment for acne entirely.



  1. Yentzer BA, Ade RA, Fountain JM, Clark AR, Taylor SL, Fleischer AB Jr, Feldman SR. Simplifying regimens promotes greater adherence and outcomes with topical acne medications: a randomized controlled trial. Cutis 2010;86:103-8.
  2. Feneran AN, Kaufman WS, Dabade TS, Feldman SR. Retinoid plus antimicrobial combination treatments for acne. Clin Cosmet Investig Dermatol 2011;4:79-92.
  3. Hoover WD, Davis SA, Fleischer AB, Feldman SR. Topical antibiotic monotherapy prescribing practices in acne vulgaris. J Dermatolog Treat 2014;25:97-9.
  4. Yentzer BA, Alikhan A, Teuschler H, Williams LL, Tusa M, Fleischer AB Jr, Kaur M, Balkrishnan R, Feldman SR. An exploratory study of adherence to topical benzoyl peroxide in patients with acne vulgaris. J Am Acad Dermatol 2009;60:879-80.