What is the best treatment approach for a patient presenting with closed comedones?

Management of Closed Comedones

Start with adapalene 0.1-0.3% gel applied once nightly as first-line monotherapy for closed comedones, and add benzoyl peroxide 2.5-5% once daily if comedones are moderate or to prevent future inflammatory lesions. 1

Why Topical Retinoids Are the Foundation

Topical retinoids are the cornerstone of comedonal acne treatment because they directly target the underlying pathophysiology by normalizing follicular keratinization, resolving the precursor microcomedone lesion, and providing comedolytic action. 1 The FDA mechanism describes how tretinoin decreases cohesiveness of follicular epithelial cells with decreased microcomedo formation and stimulates mitotic activity causing extrusion of comedones. 2

Adapalene is preferred over tretinoin for closed comedones because it demonstrates significantly superior tolerability with less erythema, dryness, desquamation, and burning/stinging while maintaining equivalent or superior efficacy. 3, 4 Additionally, adapalene can be applied with benzoyl peroxide without oxidation concerns and lacks photolability restrictions, making it more practical for patients. 1

Specific Retinoid Options

Available FDA-approved retinoid options include: 1

• Adapalene 0.1-0.3% gel or cream (available over-the-counter at 0.1%)
• Tretinoin 0.025-0.1% in cream, gel, or microsphere gel formulations
• Tazarotene 0.05-0.1% cream, gel, or foam
• Trifarotene (newer FDA-approved option)

Adding Benzoyl Peroxide for Moderate Disease

Combine the topical retinoid with benzoyl peroxide 2.5-5% applied once daily for moderate comedonal acne to optimize efficacy through a multimodal approach targeting multiple pathogenic factors. 1 Benzoyl peroxide is mildly comedolytic and antimicrobial, with lower concentrations (2.5%) causing less irritation than higher concentrations (5-10%) while maintaining similar efficacy. 1 Importantly, no bacterial resistance develops with benzoyl peroxide. 1

Alternative Agents When Retinoids Cannot Be Tolerated

• Azelaic acid 15-20% gel or cream applied twice daily is mildly comedolytic, antibacterial, and particularly useful for patients with post-inflammatory hyperpigmentation or sensitive skin, especially for Fitzpatrick skin types IV or greater. 1
• Salicylic acid 0.5-2% can be used as an over-the-counter comedolytic agent for patients who cannot tolerate retinoids, though clinical trial evidence is limited. 1
• Salicylic acid chemical peels at 20-30% concentration applied for 2-4 minutes provide more intensive treatment for resistant comedonal acne. 1

Managing Retinoid Side Effects

Common retinoid side effects include dry skin, peeling, scaling, erythema, burning sensation, and photosensitivity. 1 Mitigate these by starting with reduced frequency of application (every other night initially), using concurrent emollients, and applying daily sunscreen. 1, 2 Wait 20-30 minutes after washing before applying tretinoin to ensure skin is completely dry and minimize irritation. 2

Maintenance Therapy to Prevent Recurrence

Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence of comedonal acne, as maintenance therapy with retinoids prevents new microcomedone formation and maintains clearance. 1, 3

Critical Pitfalls to Avoid

• Never use topical antibiotics for comedonal acne as they are ineffective against comedones and increase bacterial resistance risk. 1
• Do not apply traditional tretinoin formulations with benzoyl peroxide simultaneously as oxidation inactivates tretinoin; adapalene does not have this limitation. 3
• Avoid applying retinoids to broken skin or areas with active wounds. 1
• Do not expect immediate results—many patients see improvement by 12 weeks, and some may experience an initial appearance of new blemishes at 3-6 weeks before improvement occurs. 2

Special Considerations for Resistant Lesions

For macrocomedones (closed comedones larger than 3 mm) that are resistant to topical therapy, gentle cautery under topical local anesthesia or extraction techniques using cautery and dissecting forceps can be useful adjunctive therapies. 5, 6 These physical removal methods enhance the efficacy of topical comedolytic agents and speed up therapeutic results. 7