What are the recommended topical medications for treating acne?

Recommended Topical Medications for Acne

The cornerstone of topical acne treatment is a combination of topical retinoids with benzoyl peroxide as first-line therapy, with additional agents selected based on acne severity and patient characteristics. 1

First-Line Topical Treatments

Topical Retinoids

• Serve as the foundation of acne treatment due to their comedolytic, anti-inflammatory properties, and ability to resolve microcomedones 2
• Available options include:
  • Tretinoin (0.025-0.1% in cream, gel, or microsphere gel) 2
  • Adapalene (0.1%, 0.3% cream, or 0.1% lotion) - 0.1% gel available over-the-counter 2
  • Tazarotene (0.05%, 0.1% cream, gel or foam) 2
  • Trifarotene (newer option) 2
• Adapalene 0.1% is better tolerated than tretinoin and tazarotene, making it an excellent first choice for many patients 3
• Some tretinoin formulations should be applied in the evening due to photolability and should not be used with benzoyl peroxide 2

Benzoyl Peroxide (BP)

• Effective antimicrobial agent that releases free oxygen radicals and is mildly comedolytic 2
• Available in 2.5-5% concentrations, with lower concentrations causing less irritation 2
• No bacterial resistance has been reported with BP 2
• Can bleach clothing and bedding - advise patients accordingly 4

Combination Approaches Based on Acne Severity

For Mild Acne

• Topical retinoid monotherapy or topical retinoid + benzoyl peroxide 2, 1
• Alternative: Azelaic acid 20% for patients with sensitive skin or post-inflammatory hyperpigmentation 2

For Moderate Acne

• Fixed-dose combination of topical retinoid + benzoyl peroxide 1
• Add topical antibiotics (clindamycin or erythromycin) for inflammatory lesions, but always in combination with BP to prevent bacterial resistance 2, 1
• Available fixed combinations include:
  • Erythromycin 3%/BP 5% 2, 5
  • Clindamycin 1%/BP 5% 2, 6
  • Clindamycin 1%/BP 3.75% 2

For Inflammatory Acne

• Topical dapsone 5% gel is particularly effective for inflammatory acne, especially in adult females 2
• No glucose-6-phosphate dehydrogenase testing required before starting topical dapsone 2

Additional Topical Options

Azelaic Acid

• Mildly effective as comedolytic, antibacterial, and anti-inflammatory agent 2
• Particularly useful for patients with post-inflammatory hyperpigmentation 2, 1
• Pregnancy category B 2

Salicylic Acid

• Over-the-counter comedolytic agent (0.5-2% strengths) 2
• Available in wash-off and leave-on preparations 2
• Limited clinical trial evidence for efficacy 2

Clascoterone

• Newer topical antiandrogen that inhibits androgen-mediated lipid and inflammatory cytokine synthesis 2
• Conditionally recommended based on high certainty evidence 2

Common Pitfalls to Avoid

• Using topical antibiotics as monotherapy increases the risk of bacterial resistance 2, 1
• Stopping treatment once acne clears - maintenance therapy with topical retinoids is essential to prevent relapse 1, 4
• Underestimating the importance of combination therapy - multimodal approaches targeting different aspects of acne pathogenesis are more effective 2, 7
• Not accounting for side effects - topical retinoids may cause photosensitivity; daily sunscreen use is recommended 2, 8
• Failing to warn patients about potential bleaching of fabrics with benzoyl peroxide 4

Treatment Algorithm

1. Start with topical retinoid (adapalene 0.1% for better tolerability) + benzoyl peroxide for most acne types 1, 3
2. For inflammatory lesions, add topical antibiotic (always combined with BP) 2, 1
3. Consider topical dapsone for inflammatory acne, especially in adult females 2
4. For post-inflammatory hyperpigmentation, incorporate azelaic acid 2
5. Maintain with topical retinoid after clearance to prevent recurrence 1, 9

For moderate to severe acne that doesn't respond to topical therapy alone, consider adding systemic treatments such as oral antibiotics or hormonal therapy 1, 10.