Moderate Acne Vulgaris Management

Aka: Moderate Acne Vulgaris Management, Acne Vulgaris Pharmacologic Management, Topical Acne Vulgaris Management, Comedolytics in Acne Vulgaris, Topical Antibiotics in Acne Vulgaris

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II. Indication

  1. Mild to moderate Inflammatory Acne Vulgaris
  2. Comedonal Acne Vulgaris

III. Management: Step 1 - OTC Topical Medications (Self-directed treatment)

  1. Approach
    1. Patient typically presents already using Benzoyl Peroxide
    2. Most providers start at step 2
  2. Indications
    1. Comedones
  3. Preparations
    1. Acne wash (e.g. Cetaphil) daily
    2. Topical Benzoyl Peroxide 2.5% gel in morning
      1. Benzoyl Peroxide 2.5% is as effective as 5-10%
        1. Lower strength is much less irritating than 5-10%
      2. Benzoyl Peroxide is effective against P. acnes
        1. Continue with each step of acne management
  4. Follow-up
    1. Return in 6 weeks

IV. Management: Step 2 - Comedolytics

  1. Indications
    1. Comedones
    2. Mild inflammatory Papules and Pustules
  2. Preparations
    1. Continue topical Benzoyl Peroxide in morning (from step 1)
    2. Add Comedolytic at night
      1. First-line options
        1. Topical Tretinoin (Retin A)
          1. Start with 0.025% cream at bedtime
          2. Also available as microsphere gel
        2. Adapalene (Differin)
          1. Start with 0.1% gel at bedtime
          2. Also available combined with Benzoyl Peroxide as Epiduo gel (0.1%/2.5%)
          3. Best tolerated topical Retinoid
      2. Warn regarding redness and irritation
        1. Use only pea size amount per triangle of face
        2. Use only at night-time
  3. Follow-up
    1. Return in 12 weeks

V. Management: Step 3 - Topical Antibiotics

  1. Indications
    1. Moderate inflammatory Papules and Pustules
  2. Precautions
    1. Topical Antibiotic Resistance is increasing (resistance approaches 50%)
      1. Use Topical Antibiotics with Benzoyl Peroxide to prevent resistance
      2. Limit Topical Antibiotic use to12 weeks
    2. Consider using oral Antibiotic instead
      1. See Severe Acne Vulgaris Management
      2. Indicated for Inflammatory Nodules (deep lesions)
  3. Protocol
    1. Morning
      1. Continue Benzoyl Peroxide AND
      2. Add Topical Antibiotic (e.g. topical Clindamycin such as Cleocin-T)
        1. See preparations below
        2. Consider a combination product with Benzoyl Peroxide (e.g. Benzaclin)
    2. Bedtime
      1. Continue Comedolytic (e.g. Tretinoin or Adapalene) OR
      2. Combine Adapalene with Benzoyl Peroxide (Epiduo) OR
      3. Consider Tazarotene (Tazorac) 0.05% gel or cream
        1. More irritating than Retin A, but more effective
        2. Indicated if no Tretinoin or Adapalene response
        3. Pregnancy Category X
  4. Preparations
    1. Antibiotics Half lives
      1. Clindamycin (longest half life)
      2. Erythromycin (mid range half life)
      3. Tetracycline (shortest half life)
    2. Topical Antibiotic Preparations
      1. Clindamycin HCl (Cleocin-T, Evoclin)
      2. Erythromycin (Akne-mycin, Erygel) Lotion (1.5% 2%)
      3. Tetracycline HCl (Topicycline) Lotion 2.2 mg/ml
      4. Azelaic Acid (Azelex)
        1. Consider if Postinflammatory Hyperpigmentation
      5. Consider sulfa agents if intollerance to other meds
        1. Sulfur (Acne lotion 10, Liquimat, Sulpho-Lac)
        2. Sulfur 5% and Sodium sulfacetamide 10% (Novacet)
      6. Amzeeq (Minocycline foam)
        1. Topical Minocycline preparation released in 2020 and very expensive (30 g for $490)
          1. Not recommend (consider Clindamycin with benzyol peroxide instead)
          2. (2020) Presc Lett 27(2): 8
    3. Combination agents (Comedolytic with Antibiotic)
      1. Refrigeration required
        1. Erythromycin with Benzoyl Peroxide (Benzamycin)
      2. Refrigeration not required
        1. Benzoyl Peroxide, Glycolic Acid, Zinc (Triaz)
        2. Clindamycin 1%/Benzoyl Peroxide 5% Gel (Benzaclin, Neuac)
          1. More effective than Clindamycin alone

VI. Management: Step 4 - Systemic Agents

  1. See Systemic Acne Vulgaris Management
  2. Indications
    1. Inflammatory Nodules
    2. Moderate to severe inflammatory Papules and Pustules
  3. Preparations
    1. Consider Adjunctive Acne Vulgaris Management
    2. Oral Antibiotics (e.g. Doxycycline)
      1. As with topical Antibiotic Resistance in acne, oral Antibiotic Resistance is also increasing
      2. Stop oral Antibiotics after acne improves (after 3-4 months) and continue topical agents
    3. Isotretinoin (Accutane)

VII. Management: Step 5 - Miscellaneous

  1. See Adjunctive Acne Vulgaris Management
  2. Topical Preparations
    1. Benzoyl Peroxide
      1. Available as a 2.5% to 10% formulations in various bases
      2. First-line agent for all forms of acne and especially in concert with topical and systemic Antibiotics
      3. Pregnancy Category C
    2. Azelaic Acid (Finacea, Azelex)
      1. Finacea 15% gel has better Bioavailability and is preferred over the Azelex 20% cream
      2. Pregnancy category B
    3. Dapsone (Aczone 5% Gel)
      1. Pregnancy Category C
      2. Variable efficacy in inflammatory acne, but more effective in adult women
    4. Salicylic acid
      1. Available as 0.5% to 3% formulations in various bases
      2. Not recommended in acne (used in Wart Management)
      3. Pregnancy Category C
    5. Tea tree oil
      1. Not typically used in Acne Vulgaris
      2. Appears to reduce total number of Papules, Pustules and comedones
  3. Other interventions
    1. Intralesional Corticosteroid Injection (intralesional Triamcinolone)
      1. Consider for nodular acne or special occasions (e.g. graduation pictures)

VIII. References

  1. Habif (2004) Dermatology, Mosby, p. 162-94
  2. Parker in Noble (2001) Primary Care p. 758-60
  3. Feldman (2004) Am Fam Physician 69:2123-56 [PubMed]
  4. Gollnick (2003) J Am Acad Dermatol 49:S1-37 [PubMed]
  5. James (2005) N Engl J Med 352(14):1463-72 [PubMed]
  6. Strauss (2007) J Am Acad Dermatol 56(4): 651-63 [PubMed]
  7. Titus (2012) Am Fam Physician 86(8): 734-40 [PubMed]

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