What is the best topical medication for treating cystic acne?

From the Guidelines

Benzoyl peroxide is generally considered the best topical medication for treating cystic acne, as supported by the most recent guidelines from 2024 1.

Key Points to Consider:

• It's available over-the-counter in concentrations ranging from 2.5% to 10%, with 2.5% often being as effective as higher strengths but with less irritation.
• Apply a thin layer to affected areas once or twice daily after cleansing, starting with a lower concentration and using every other day, gradually increasing frequency as your skin adjusts.
• Benzoyl peroxide works by killing acne-causing bacteria (P. acnes) and reducing inflammation while helping to unclog pores.
• For severe cystic acne, prescription-strength topical retinoids like tretinoin or adapalene may be combined with benzoyl peroxide for enhanced effectiveness, as retinoids are the core of topical therapy for acne due to their comedolytic, anti-inflammatory properties, and ability to resolve precursor microcomedone lesions 1.
• Topical antibiotics such as clindamycin may also be prescribed as part of a combination therapy.
• Be aware that benzoyl peroxide can cause dryness, redness, and peeling, especially initially, and it can bleach fabrics.
• If cystic acne doesn't respond to topical treatments within 4-6 weeks, consult a dermatologist as oral medications like antibiotics or isotretinoin may be necessary for more severe cases.

Additional Considerations:

• The 2024 guidelines 1 strongly recommend benzoyl peroxide, topical retinoids, and oral doxycycline for acne treatment, emphasizing the importance of combining topical therapies with multiple mechanisms of action.
• Limiting systemic antibiotic use and combining systemic antibiotics with topical therapies are also recommended as good practice statements.
• Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy.

From the FDA Drug Label

INDICATIONS AND USAGE: Erythromycin Topical Solution is indicated for the topical treatment of acne vulgaris. The best topical medication for treating cystic acne is not explicitly stated in the provided drug labels, as cystic acne is not directly mentioned. However, erythromycin topical solution is indicated for the treatment of acne vulgaris, which may include cystic acne.

• The provided information does not specify the best medication for cystic acne.
• Erythromycin topical solution may be used to treat acne lesions on the face, neck, shoulder, chest, and back 2. It is essential to consult a healthcare professional for a proper diagnosis and treatment plan, as they can recommend the most suitable topical medication for cystic acne.

From the Research

Topical Medications for Cystic Acne

• Topical retinoids are considered a mainstay of acne treatment, including cystic acne, due to their ability to expel mature comedones, reduce microcomedone formation, and exert anti-inflammatory effects 3, 4, 5, 6.
• The most commonly used topical retinoids for acne treatment include tretinoin, adapalene, and tazarotene, which have been approved by the US FDA and are accredited in Canada and Europe 3, 4.
• These topical retinoids have a favorable safety profile, with local adverse effects such as erythema, dryness, itching, and stinging being the most common side effects 3, 4.
• Adapalene 0.1% gel is considered to be equally effective to tretinoin 0.025% or tretinoin microsphere 0.1% gel, and is significantly better tolerated than tazarotene 0.1% gel 4.
• Combination therapy, including the use of topical retinoids with antimicrobial agents such as clindamycin and benzoyl peroxide, may be effective in treating acne, including cystic acne 7, 6.

Efficacy of Topical Retinoids

• Topical retinoids have been shown to be effective in treating mild to moderate acne, and may be used as a single agent or in combination with other treatments 4, 5.
• Tazarotene 0.1% has been shown to be more effective than tretinoin 0.025% or 0.1% microsphere gel, or adapalene 0.1% gel or cream 4.
• Adapalene 0.1% gel is considered to be a good option for patients with sensitive skin, due to its lower irritation potential compared to other topical retinoids 4, 5.

Recommendations for Use

• Topical retinoids are recommended as a first-line treatment for most types of non-inflammatory and inflammatory acne, including cystic acne 3, 6.
• The American Academy of Dermatology and the European Dermatology Forum recommend the use of topical retinoids in combination with antimicrobial therapy for the treatment of acne 6.