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Moderate Acne Vulgaris Management

See Also
1. Adjunctive Acne Vulgaris Management
Indication
1. Mild to moderate Inflammatory Acne Vulgaris
2. Comedonal Acne Vulgaris
Step 1: OTC topical medications for 6 weeks
1. Acne washes (Phisohex) regularly
2. Topical Benzoyl Peroxide 2.5% gel qAM
  1. Benzoyl Peroxide 2.5% is as effective as 5-10%
  2. Lower strength is much less irritating than 5-10%
Step 2: Comedolytics and Topical Antibiotics for 6 weeks
1. Start Comedolytic (discontinue Benzoyl Peroxide)
  1. First-line options
    1. Topical Tretinoin (Retin A) 0.025% cream qhs
    2. Adapalene (Differin) 0.1% gel
      1. May be better tolerated than Retin A
    3. Topical Tretinoin microsphere 0.1%
  2. Warn regarding redness and irritation
    1. Use only pea size amount per triangle of face
    2. Use only at night-time
2. Consider adding a topical antibiotic
  1. Topical Erythromycin
  2. Topical Clindamycin
Step 3: Add Topical Antibiotics
1. General
  1. Apply topical antibiotic in the morning
  2. Apply topical Comedolytic at bedtime (see above)
    1. Continue Tretinoin or Adapalene or
    2. 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
2. Antibiotics Half lives
  1. Clindamycin (longest half life)
  2. Erythromycin (mid range half life)
  3. Tetracycline (shortest half life)
3. Topical Antibiotic Preparations
  1. Clindamycin HCl (Cleocin-T)
  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)
4. 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)
      1. More effective than Clindamycin alone
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
4. Gollnick (2003) J Am Acad Dermatol 49:S1

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 5/16/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.