Acne vulgaris: a review of the topical treatments
Julie Brackenbury outlines cause, myths, and various topical treatment options currently available for acne
As an aesthetic nurse practitioner who suffered from severe acne at age 18, helping others who suffer from this disease has become one of my passions. There are various topical treatments available as per guidance and recommendations from NICE. Whilst examining these, I would like to share my insight into how a patient may have already been managed in primary care before deciding to seek a second opinion from a private dermatological service.
Acne is a chronic inflammatory disease of the pilosebaceous unit resulting from androgen-induced increased sebum production, altered keratinisation, inflammation, and bacterial colonisation of hair follicles on the face, neck, chest, and back by Propionibacterium acnes.
Cause and effect
According to Goulden et al, although the pathogenesis of acne is multifactorial, the key factor is genetics and they suggest that familial factors are important to bear in mind both when determining an individual’s susceptibility to acne and in medical consultations. An evolutionary perspective as outlined by Eckel suggests that sebum (oil naturally produced within our skin) has no purpose apart from causing skin disease. He suggests that dryness, eczema, rosacea, large pores, fine lines, pigmentation and age spots are all down to the presence of oil and advocates that as humans evolved, we lost the hair from all over our bodies—however, the oil glands designed to lubricate our hair follicles remained.
Myths about acne
There are plenty of ‘old wives’ tales about topical treatments that are reported to help acne, but actually have no therapeutic effect. Some example include using aloe vera, egg white, honey, sudocrem, TCP, distilled white vinegar, cucumber, teatree oil and toothpaste—this is certainly not an exhaustive list. With reference to the teatree oil as a myth, recent research from the International Journal of Antimicrobial Agents has challenged this and found that in fact, tea tree oil does reduce lesion numbers in patients with mild-to-moderate acne. It’s tolerability is similar to other topical treatments whilst the efficacy may be attributed to antimicrobial and anti-inflammatory activities. More importantly, experts believe that dispelling ‘myths’ is an integral component of the management of acne thus, practitioners need to be mindful about educating patients about such myths. However, one of the challenges we face in practice is the internet and mass media, which can often result in our clinical judgement and expertise being questioned.
A systematic review of the literature found no clear evidence of dietary components increasing the risk of acne development. However, one small randomised controlled trial showed that low glycaemic index (GI) diets can lower acne severity. Evidence suggests that Western diets, particularly dairy products, require closer scrutiny.
Fat or fibre intake may also mediate the effect of diet on acne risk. A study by Burris et al found that a high glycemic load diet, processed cheese, a high-fat diet and iodine play a role in the exacerbation of acne in Korean adults. In addition, irregular dietary habits may also aggravate acne.
First line topical treatments for mild acne
- Benzoyl Peroxide (BPO)
– Acnecide (Galderma UK Ltd)
– Brevoxyl (GlaxoSmithKline Consumer Healthcare)
– PanOxyl (GlaxoSmithKline Consumer Healthcare)
If papules and pustules are present, BPO is recommended as a first-line treatment. It is a potent bactericide that reduces the P. acnes and is effective in treating mild to moderate acne. P. acnes cannot live in the presence of oxygen and BPO strength of 2.5% or more, applied once or twice daily is needed for it to have any effect. BPO is available over the counter, but generally patients will be unaware of this. There is good evidence from placebo-controlled trials that benzoyl peroxide reduces both inflammatory and non-inflammatory lesions, although, it is important to note that combination treatment is rarely necessary at this stage for mild acne.
Duac Once Daily from Stiefel, contains BPO and clindamycin and has demonstrated a better tolerability profile than combined antibiotic/BPO during the first two weeks of treatment. Both agents are effective in reducing overall acne severity and achieving high levels of patient satisfaction, and continued use for a further six weeks may be associated with better adherence to therapy, clinical improvement in acne, and quality of life.
Quinoderm from Alliance Pharmaceuticals, is available over the counter is an effective combined preparation of benzoyl peroxide and potassium hydroxyquinoline sulphate which also has antibacterial and antifungal actions. It is included in this medicine to reinforce the antimicrobial actions of the benzoyl peroxide. It is the only topical acne treatment available without a prescription.
Azelaic acid (Skinoren, Finacea from Bayer HealthCare) is a second-line option that should be considered if other treatments are unsuitable. There is evidence from two small placebo-controlled trials that azelaic acid is effective in the treatment of acne. However, these were taken from small samples and had methodological shortcomings. Azelaic acid has been shown to be effective in the treatment of comedonal acne and papulopustular, nodular and nodulocystic acne.
Skinoren is a 20% cream licensed for acne vulgaris. It is applied twice a day, but this may be reduced to once a day during the first week if the patient has sensitive skin. It is licensed for six months, although it is frequently used for longer periods by specialists.
Finacea is a 15% gel licensed for facial acne vulgaris. It is applied twice a day and can be continued over several months according to clinical outcome, although it should be stopped after one month if there is no improvement or deterioration occurs. It is important to note that azelaic acid can lighten the colour of the skin, but this is rarely problematic in practice (it also has a role in reducing post-inflammatory hyperpigmentation in people with dark skin). Similarly, photosensitivity can occur but this is rare and usually mild.
Moderate acne treatment
In moderate acne, inflammatory lesions (papules and pustules) predominate. The acne may be widespread and there may be a risk of scarring resulting in considerable psychosocial morbidity—all of which are indications for aggressive treatment. A topical retinoid combined with BPO is an alternative, but this may be poorly tolerated.
- Adapalene (Differin, Galderma UK Ltd)
– Adapalene combined with benzoyl peroxide (Epiduo, Galderma UK Ltd)
– Isotretinoin (Isotrex, Stiefel)
– Isotretinoin combined with an antibacterial (Isotrexin, Stiefel)
– Tretinoin combined with antibacterial (AknemycinPlus, Almirall Limited)
Topical retinoids normalise follicular keratinisation, promote drainage of comedones, and inhibit new comedone formation. Unfortunately, they have no direct impact on P. acnes. Therefore, treatment with both a topical retinoid and topical antimicrobial is recommended. It is important to note that there is a lack of evidence from comparative randomised controlled trials to show that any particular topical retinoid is superior to another. Moreover, retinol doesn’t come without it’s side effects, such as redness, dryness and peeling so it is paramount that patients are educated about what to expect. This treatment is absolutely contraindicated in pregnancy due to its teratogenic effects.
- Dalacin T (clindamycin1%) (Pharmacia Limited)
– Stiemycin (erythromycin2%) (Stiefel)
– Zindaclin (clindamycin 1%) (Crawford Healthcare Ltd)
– Zineryt (erythromycin 40 mg, zinc acetate 12 mg) (Astellas Pharma Ltd)
Topical antibacterial agents are indicated for mild-to-moderate acne and are most effective against papules and pustules. A topical antibiotic combined with BPO or a topical retinoid is the preferred regimen, as it is proven to be effective and may limit the development of bacterial resistance.
Where possible, a topical antibiotic course should be limited to a maximum of 12 weeks. All of the above are licensed for twice daily application, except for clindamycin gel which is licensed for once daily application.
There is no data available to guide practitioners on clinical selection, although topical erythromycin has been associated with increased rates of bacterial resistance.
Topical antibiotics usually cause less irritation than BPO, and have no specific contraindications. Where possible, treatment with topical antibiotic should be limited to 12 weeks duration. There is good evidence that topical antibiotics are an effective treatment for inflammatory acne, but there is a lack of reliable comparative data to guide choice of antibiotics.
Fig. 2 shows the trends in prescribing of topical preparation in general practice in England and highlights that topical erythromycin and combined BPO preparations are the most prescribed, whereas tretinonin and azelaic acid are the least prescribed—suggesting that research is being implemented in practice. With any treatment process, treatment concordance is a predominant factor for successful treatment. Relapses are frequent, which ultimately can result in treatment fatigue that may contribute to overall adherence difficulties.
Acne’s manifestation is not just physical—it’s also emotional. Qualitative research from a study conducted by Murray and Rhodes study revealed that adults suffering from acne experience;
– Feelings of powerlessness
– Poor self-image and identify
– Negative experiences with social situations, relationship with family and friends, gender, sexuality, romantic relationships.
Topical preparations constitute, for many, the soul of acne vulgaris therapy. It is vital that practitioners have an historical understanding of the topical treatment regime a patient has been prescribed in the past, to enable a more effective management plan. Moreover, the patient will have more confidence knowing that a practitioner has an overall understanding of his or her history—this will also enhance rapport and the patient-practitioner relationship. It is also important to be aware that patients seeking an initial consultation, or even second opinion within private dermatological practice to discuss their acne, will have a higher expectation. In addition, practitioners must be aware that new research is still required into the therapeutic comparative effectiveness and safety of the many products available, as well as better understanding of the natural history, subtypes, and triggers of acne.
Topical therapies when used in combination usually improve and can control mild to moderate acne. Ultimately, managing acne vulgaris requires patience, reassurance and time, whilst transparency and authenticity with your patient will enhance rapport and possibly medication concordance. There is no one ideal treatment for acne, although a suitable regimen for reducing lesions can be found for most patients. Overall, knowledge and understanding is key, for both the practitioner and the patient to enable a successful treatment plan. By combining both disciplines of dermatology and aesthetic medicine, patients with this skin condition can certainly benefit and are more likely to have a successful journey.
Julie Brackenbury is an Aesthetic Nurse Practitioner and Independent Prescriber based South West of England.
1. Eckel (2014) Rosacea the Strawberry Fields of Dermatology PRIME Europe Jun 2014 Volume 4 Issue 4
2. National Institute for Health and Care Excellence (2013) Clinical Knowledge Summaries. Acne vulgaris. http://tinyurl.com/qfsoc65 (Accessed 15.04.15)
3. Haider, A. and Shaw, J.C. (2004) Treatment of acne vulgaris. Journal of the American Medical Association 292(6), 726-735 Williams and Garner (2012) Acne vulgaris The Lancet. Vol.379(9813):361–37
4. Goulden V, Glass D, Cunliffe WJ. Safety of long term high dose minocycline in the treatment of acne. Br J Dermatol. 1996;134:693–5
5. Bhate, K., and H. C. Williams (2013) Epidemiology of acne vulgaris. British Journal of Dermatology 168.3: 474-485
6. Hammer, K. A (2015) Treatment of acne with tea tree oil (melaleuca) products: A review of efficacy, tolerability and potential modes of action. International Journal of Antimicrobial Agents Vol.45(2):106–110
7. Dawson, Annelise L., and Robert P. Dellavalle (2013) Acne vulgaris. BMJ 346: f2634
8. Smith, Robyn N., et al (2007) A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial. The American Journal of Clinical Nutrition 86.1: 107-115
9. Spencer, Elsa H., Hope R. Ferdowsian, and Neal D. Barnard (2009) Diet and acne: a review of the evidence. International Journal of Dermatology 48.4: 339-347
10. Burris, Jennifer, William Rietkerk, and Kathleen Woolf (2013) Acne: the role of medical nutrition therapy. Journal of the Academy of Nutrition and Dietetics 113.3: 416-430
11. Jung, Jae Yoon, et al (2010) The influence of dietary patterns on acne vulgaris in Koreans.” European Journal of Dermatology 20.6: 768-772.
12. Purdy, S., Langston, J. and Tait, L. (2003) Presentation and management of acne in primary care: a retrospective cohort study. British Journal of General Practice 53(492), 525-529
13. Eichenfield, Lawrence F., and Andrew C. Krakowski (2012) Moderate to severe acne in adolescents with skin of color: benefits of a fixed combination clindamycin phosphate 1.2% and benzoyl peroxide 2.5% aqueous gel. Journal of Drugs in Dermatology: JDD 11.7: 818-824
14. Acne Working Group (2008) Management of mild and moderate acne vulgaris. GP Review 1: 1–11
15. James WD (2005) Clinical practice. Acne. N Eng J Med 352(14) 1463–72
16. Shalita A (2001) The integral role of topical and oral retinoids in the early treatment of acne. J Eur Acad Dermatol Venereol 15(Suppl 3): 43–9
17. Strauss JS, Krowchuk DP, Leyden JJ et al(2007) Guidelines of care for acne vulgaris management. J Am Acad Dermatol 56(4): 651–63
18. Murray, Craig D., and Katharine Rhodes (2005) Nobody likes damaged goods: the experience of adult visible acne. British Journal of Health Psychology 10.2: 183-202.
Fig 1. http://acner.org/acne-info/clogged-pores/acne-stages/(Accessed 15.04.15)
Fig 2. NHS Business Services Authority (2013) Skin preparations. National charts http://tinyurl.com/nhj3xrj (Accessed 15.04.15)