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)