Acne Vulgaris Medications

Pharmacy and Therapeutics

The following categories medications are used to treat acne.

  1. Topical retinoids
  2. Topical non-antibiotic therapy
  3. Topical antibiotics
  4. Oral antibiotics
  5. OCPs
  6. Spironolactone
  7. Oral retinoids (isotretinoin)

Topical Retinoids for the Treatment of Acne Vulgaris

  • Adapalene topical – comes as a cream 0.1%; Gel (0.1%  0.3%) —[Pregancy category C] . Differin gel OTC is Adapalene topical 0.1%.
  • Tretinoin topical (Retin-A) comes as Cream (0.025%, 0.05%, 0.1%), Gel (0.01%, 0.025%, 0.05%), Microsphere gel (0.04%, 0.1%) —[Preg Cat C]
  • Adapalene/benzoyl peroxide topical (Epiduo) gel (0.1% / 2.5%)
  • Tazarotene topical (Tazorac) comes as Cream, gel (0.05%, 0.1%)—[Preg cat X]

Side effects: The side effects of topical retinoids are all the same and are: Local erythema, peeling, dryness, pruritus, stinging.
**Apply all topical retinoids at night (QHS) because of photosensitivity.

**Some insurance companies like Molina won’t pay for tretinoin topical (Retin-A) until you try Differin gel (Adapalene topical 0.1%) OTC

Topical Nonantibiotic Therapies for the Treatment of Acne Vulgaris

  • Benzoyl peroxide Bar, cream, gel, lotion, pad, wash (2.5% to 10%). Preg cat = C; Side effects: Dry skin, local erythema
  • Azelaic acid comes as a Cream (Azelex, 20%; approved for acne vulgaris). Preg Cat = B; Side effects: Hypopigmentation, burning, stinging, tingling, pruritus
  • Dapsone Gel (Aczone, 5%). Preg Cat = C; Side effects: Local oiliness, peeling, dryness, erythema
  • Salicylic acid Cream, dressing, foam, gel, liquid, lotion, ointment, pad, paste, shampoo, soap, solution, stick (0.5% to 3%). Preg cat = C. Side effects: Dryness, mild skin irritation

Benzoyl peroxide and Salicylic acid are very cheap – about $5 over the counter. Azelaic acid is very expensive ($210)

“Benzoyl peroxide is unique as an antimicrobial because it is not known to increase bacterial resistance. It is most effective for the treatment of mild to moderate mixed acne when used in combination with topical retinoids. Benzoyl peroxide may also be added to regimens that include topical and oral antibiotics to decrease the risk of bacterial resistance.” AAFP

“Benzoyl peroxide is the only topical antibiotic without evidence to suggest that its use contributes to bacterial antimicrobial resistance. For this reason it is recommended as first-line therapy in mild to moderate inflammatory acne and as an adjunctive agent with other topical antibiotics that can induce bacterial resistance, such as clindamycin and erythromycin. Metronidazole is used chiefly in acne rosacea rather than acne vulgaris and it may contribute to antimicrobial resistance.“ABFM

Topical Antibiotics for the Treatment of Acne Vulgaris

Topical antibiotics are recommended only in combination with benzoyl peroxide.

  • Clindamycin topical Foam 1%, gel 1%, lotion 1%, solution 1%.
  • Erythromycin Gel, solution, ointment (2%)
  • Erythromycin/Benzoyl peroxide (Benzamycin) gel (3%/5%)

Side effects: S/e are the same for both antibiotics which are: Local erythema, peeling, dryness, pruritus, burning, oiliness
Pregnancy category: Both clindamycin topical and erythromycin topical are pregnancy category B.

note: Topical antibiotics are more effective when combined with a topical retinoid. 

 

Oral Antibiotics for the Treatment of Acne Vulgaris

  • Doxycycline 50 to 100 mg once or twice per day. Preg cat = D; Side effects: Photosensitivity, pseudotumor cerebri, esophageal irritation
  • Minocycline 50 to 100 mg once or twice per day. Preg cat = D; Side effects: Vestibular dysfunction, photophobia, hepatotoxicity, lupus-like reaction, pseudotumor cerebri
  • Tetracycline 250 to 500 mg once or twice per day. Preg cat = C; Side effects: GI upset, photosensitivity, pseudotumor cerebri
  • Bactrim 160/800 mg twice per day. Preg cat = C; Side effects: Allergic reactions
  • Erythromycin 250 to 500 mg two to four times per day. Preg Cat = B. Side effects: GI upset.

Duration: Oral antibiotics should be used for a limited course, ideally up to 3 to 4 months. Concomitant topical benzoyl peroxide should be prescribed to decrease the risk of antibiotic resistance

*”For patients with moderate to severe inflammatory acne with or without prominent comedonal lesions, we suggest the use of a topical retinoid, topical benzoyl peroxide, and an oral antibiotic, rather than topical agents alone. Oral antibiotics should be used for a limited course, ideally up to 3 to 4 months. Concomitant topical benzoyl peroxide should be prescribed to decrease the risk of antibiotic resistance”UTD

There is an AAFP article that talks of limiting oral antibiotics to less than 6 months. However, I will be more conservative and go with the 3 to 4 month recommendation from UTD.

Oral Retinoids

Isotretinoin (Acutane)

Providers and patients must register in the iPLEDGE program (http://www.ipledgeprogram.com) before using isotretinoin.

OCPs

Several estrogen-containing OCPs are FDA-approved for the treatment of acne. OCPs are generally are considered 2nd line treatments. but they may be considered first-line treatments in women with adult-onset acne or perimenstrual flare-ups.

Spironolactone

Spironolactone (Aldactone) is an androgen receptor antagonist sometimes used to treat acne. It is usually reserved as a 2nd or 3rd line agent for treating acne or as an alternative to isotretinoin in women who can’t use the medication.

References 

http://www.aafp.org/afp/2012/1015/p734.html (Diagnosis and Treatment of Acne)

http://www.aafp.org/afp/2004/0501/p2123.html

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