Advances in the topical treatment of acne and rosacea

Journal of Drugs in Dermatology, Sept-Oct, 2004 by Roger I. Ceilley

Sodium sulfacetamide 10%/sulfur 5% combinations have been recommended for more than 40 years. This combination is approved for treatment of acne, seborrheic dermatitis and rosacea. Sulfonamides act as competitive antagonists to para-aminobenzoic acid (PABA) which is essential for bacterial growth (40). It is therefore useful as an antibiotic-sparing strategy, and there is no limitation on its duration of therapy. Sodium sulfacetamide 10%/sulfur 5% combinations also have comedolytic and keratolytic activity which makes it an appropriate adjunct for rosacea with an overlap of acne and/or seborrheic dermatitis. Sodium sulfacetamide 10%/sulfur 5% combinations are not generally regarded as effective monotherapy except in mild cases of rosacea, although studies have shown 78% and 81% reductions in inflammatory lesions and an 83% decrease in facial erythema at 8 weeks of treatment (41,42). In an 8-week study comparing sodium sulfacetamide 10%/sulfur 5% to metronidazole 0.75% gel, papule/pustule scores, erythema ratings and overall severity were lower in the sodium sulfacetamide 10%/sulfur 5% group. Patient global evaluations of improvement were similar and tolerability was favorable and similar for both agents (43).

A sodium sulfacetamide 10%/sulfur 5% cleanser is available and has been shown to be useful in rosacea management. When the cleanser was used alone or in combination with metronidazole 0.75% twice daily in an 8-week, investigator-blinded trial, the cleanser alone was found to be efficacious as monotherapy for reducing papule counts and erythema. However, when used in combination with metronidazole, better results were obtained in reducing papule counts and overall rosacea severity (44).

The use of the sodium sulfacetamide 10%/sulfur 5% cleanser is advantageous for the treatment of rosacea, acne and seborrheic dermatitis or combinations thereof. The product is applied to moistened skin and massaged for 10-20 seconds and rinsed twice daily. It may be used in both the active treatment phase and in maintenance. The only contraindication is for patients with a known hypersensitivity to sulfonamides, sulfur or other components. In a recent trial comparing 5 topical products for the treatment of rosacea (sodium sulfacetamide 10%/sulfur 5% cream with sunscreens, sodium sulfacetamide 10%/sulfur 5% suspension without sunscreens, metronidazole 0.75% cream and gel and metronidazole 1% cream) all products were found to produce little irritation following a 21-day cumulative irritation patch test. However, the sodium sulfacetamide 10%/sulfur 5% product with sunscreen produced significantly less irritation than a comparative product without sunscreens (p<0.001) (45).

Azelaic acid is a naturally-occurring dicarboxylic acid that has been used in the treatment of acne and melasma. Its anti-inflammatory activity has led to investigation of its use in roseacea. An 8-week multicenter, double-blind, randomized, parallel group study comparing 15% azelaic acid gel to 0.75% metronidazole gel found the azelaic acid to be superior in reducing mean nominal lesion count and mean inflammatory lesion percent. Erythema severity was improved in 56% of azelaic acid-treated patients versus 42% of metronidazole-treated patients. Neither treatment produced notable improvements in telangiectasias (46). Azelaic acid is available as a 15% gel [Finacea[TM]] or 20% azelaic acid creams [Finevin[R], Azelex[R]].