Mechanism-based treatment of acne vulgaris: the value of combination therapy

Journal of Drugs in Dermatology, May-June, 2005 by Guy Webster

Table 1. Acne Treatment Guidelines. (1)

                   Mild                                Moderate
                   Comedonal         Papular/Pustular  Papular/Pustular

1st Choice (1)     Topical Retinoid  Topical Retinoid  Oral Antibiotic
                                      Topical           Topical Retinoid
                                     Antimicrobial      /-BPO
Alternatives (1)   Alt. Topical      Alt. Topical      Alt. Oral
                   Retinoid or       Antimicrobial     Antibiotic Alt.
                   Azelaic acid* or  Agent Alt.        Topical Retinoid,
                   Salicylic Acid    Topical Retinoid   /-BPO
                                     or Azelaic Acid*
Alternatives       See 1st Choice    See 1st Choice    Oral Antiandrogen
for Females (1,4)                                       Topical Retinoid
                                                       /Azelaic Acid*
                                                        /-Topical
                                                       Antimicrobial
Maintenance        Topical Retinoid
Therapy

                   Moderate                   Severe
                   Nodular (2)                Nodular/Conglobate

1st Choice (1)     Oral Antibiotic Topical    Oral Isotretinoin (3)
                   Retinoid BPO
Alternatives (1)   Oral Isotretinoin or Alt.  High-Dose Oral Antibiotic
                   Oral Antibiotic Alt.        Topical Retinoid BPO
                   Topical Retinoid,
                    /-BPO/Azelaic Acid*
Alternatives       Oral Antiandrogen          High-Dose Oral
for Females (1,4)   Topical Retinoid          Antiandrogen Topical
                    /-Oral Antibiotic,        Retinoid  /-Alt. Topical
                    /-Alt. Antimicrobial      Antimicrobial
Maintenance        Topical Retinoid  /-BPO
Therapy

(1) Consider physical removal of comedones; (2) With small nodules
(>0.5 - 1 cm); (3) Second course in case of relapse; (4) For pregnancy,
*There was no consensus on this alternative recommendation, however,
in some countries azelaic acid prescribing is appropriate practice.

Table 2. The Effect of Drug Classes Used for Acne Vulgaris on
Pathophysiologic Factors. (1,2)

Drug Class/Agents                         Inflammation

Topical retinoids (adapalene, tretinoin,
tazarotene)                               [check][check][check]
Isotretinoin                              [check][check][check][check]
Benzoyl peroxide                          [check][check]
Azelaic acid                              [check]
Antibiotics (erythromycin, tetracycline,
clindamycin)                              [check][check]

Drug Class/Agents                         Comedogenesis

Topical retinoids (adapalene, tretinoin,
tazarotene)                               [check][check][check][check]
Isotretinoin                              [check][check][check]
Benzoyl peroxide
Azelaic acid                              [check]
Antibiotics (erythromycin, tetracycline,
clindamycin)

Drug Class/Agents                         P acnes reduction

Topical retinoids (adapalene, tretinoin,
tazarotene)
Isotretinoin                              [check][check][check][check]
Benzoyl peroxide                          [check][check][check]
Azelaic acid                              [check]
Antibiotics (erythromycin, tetracycline,
clindamycin)                              [check][check][check]

Drug Class/Agents                         Sebum Production

Topical retinoids (adapalene, tretinoin,
tazarotene)
Isotretinoin                              [check][check][check][check]
Benzoyl peroxide
Azelaic acid
Antibiotics (erythromycin, tetracycline,
clindamycin)

References

1. Gollnick H, Cunliffe W, the Global Alliance to Improve Outcomes in Acne. Management of acne. A report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2003;49(1);Suppl: S1-S37.

2. Leyden, JJ. A review of the use of combination therapies for the treatment of acne vulgaris. J Am Acad Dermatol. 2003;49(3);Suppl:S200-S210.

3. Webster GF. Acne vulgaris. BMJ. 2002;325:475-479.

4. Cunliffe WJ, Holland DB, Clark SM, Stables GI. Comedogenesis: some new aetiological, clinical and therapeutic strategies. Br J Dermatol. 2000;142:1084-1091.

5. Eady EA, Cove JH. Is acne an infection of blocked pilosebaceous follicles? Implications for antimicrobial treatment. Am J Clin Dermatol. 2000;1:201-209.

6. Guy R, Kealey T. Modeling the infundibulum in acne. Dermatology. 1998;196:32-37.

7. Guy R, Green MR, Kealey T. Modeling acne in vitro. J Invest Dermatol. 1996;106:176-182.

8. Webster GF. Inflammation in acne vulgaris. J Am Acad Dermatol. 1995;33:247-253.

9. Shalita A. The integral role of topical and oral retinoids in the early treatment of acne. J Eur Acad Dermatol Venereol. 2001;15(suppl 3):43-49.

10. Millikan LE. The rationale for using a topical retinoids for inflammatory acne. Am J Clin Dermatol. 2003;4(2):75-80.