Topical therapies: Recommendations

What is the effectiveness and what are the potential side effects of topical agents in the treatment of adult acne and acne vulgaris in adolescents to adults including:

  • Retinoids and retinoid-like drugs
  • Benzoyl peroxide
  • Topical antibiotics
  • Salicylic/azelaic acids
  • Sulfur and resorcinol
  • Aluminum chloride
  • Zinc
  • Combinations of topical agents

  • Benzoyl peroxide and/ or combinations with erythromycin or clindamycin are effective acne treatments and are recommended as monotherapy for mild acne, or in conjunction with a topical retinoid, or systemic antibiotic therapy for moderate to severe acne.
  • Benzoyl peroxide is effective in the prevention of bacterial resistance and is recommended for patients on topical or systemic antibiotic therapy.
  • Topical antibiotics (e.g., erythromycin and clindamycin) are effective acne treatments but are not recommended as monotherapy due risk of bacterial resistance.
  • Topical retinoids are important in addressing the development and maintenance of acne and are recommended as monotherapy in primarily comedonal acne, or in combination with topical or oral antimicrobials in patients with mixed or primarily inflammatory acne lesions.
  • Employing multiple topical agents that affect different aspects of acne pathogenesis can be useful. Combination therapy should be used in the majority of patients with acne.
    Topical adapalene, tretinoin and benzoyl peroxide can be safely used in the management of preadolescent acne in children.
  • Azelaic acid is a useful adjunctive acne treatment and is recommended in the treatment of postinflammatory dyspigmentation.
  • Topical dapsone 5% gel is recommended for inflammatory acne, particularly in adult females with acne. 
    There is limited evidence to support recommendations for sulfur, nicotinamide, resorcinol, sodium sulfacetamide, aluminum chloride, and zinc in the treatment of acne.
  Strength of Recommendation  Level of Evidence 
Benzoyl peroxide  A I,II 
Topical antibiotics  A I,II 
Antibiotics & benzoyl peroxide  A
Topical retinoid  A I,II 
Retinoid & benzoyl peroxide/antibiotic  A I,II 
Azelaic acid  A
Dapson  A I,II 
Salicylic acid  II 

Review prescribing information for recommended acne treatments.

The topical therapy of AV includes the usage of agents that are available over the counter or via prescription. Therapy choice may be influenced by age of the patient, site of involvement, extent and severity of disease, and patient preference. Topical therapies may be used as monotherapy, in combination with other topical agents or in combination with oral agents in both initial control and maintenance. 

Commonly used topical acne therapies include BP, salicylic acid, antibiotics, combination antibiotics with BP, retinoids, retinoid with BP, retinoid with antibiotic, azelaic acid, and sulfone agents. Although most physicians have anecdotal regimens they find beneficial, agents reviewed here are limited to those approved by the US Food and Drug Administration (FDA) for use in the United States, and for which peer-reviewed literature has been published.

BP is an antibacterial agent that kills P acnes through the release of free oxygen radicals and is also mildly comedolytic.171,172 No resistance to this agent has been reported, and the addition of BP to regimens of antibiotic therapy enhances results and may reduce resistance development. BP is available as topical washes, foams, creams, or gels, and can used as leave-on or wash-off agents. Strengths available for acne therapy range from 2.5% to 10%. BP therapy is limited by concentration-dependent irritation, staining and bleaching of fabric, and uncommon contact allergy. Total skin contact time and formulation can also affect efficacy. Lower concentrations (eg, 2.5-5%), water-based, and wash-off agents may be better tolerated in patients with more sensitive skin.57,58 Results can be noted in as soon as 5 days.59

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