Should we still be Prescribing Topical Antibiotic Monotherapy in Acne?
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
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.
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.
- 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.
- Feneran AN, Kaufman WS, Dabade TS, Feldman SR. Retinoid plus
antimicrobial combination treatments for acne. Clin Cosmet
Investig Dermatol 2011;4:79-92.
- Hoover WD, Davis SA, Fleischer AB, Feldman SR. Topical
antibiotic monotherapy prescribing practices in acne vulgaris.
J Dermatolog Treat 2014;25:97-9.
- 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.