Recent research has shown that the mildest of the newer topical retinoids, when combined with antibiotics, can work synergistically to control inflammation in patients with inflammatory or mixed acne, while simultaneously minimizing the risk for skin irritation as well as resistance to antibiotics.
Inflammation Is the Result of a Multi-faceted Process
o Hormonal changes are at the root of acne pathogenesis.
o The primary target of acne is the pilosebaceous unit of the follicle.
o Hormones stimulate increased production of lipids in the follicle.
o Inflammation probably arises from the presence of prostaglandins and cytokines that are attracted to the lipids within the follicle.
o Some individuals may be genetically prone to overactive inflammatory pathways,
which increases their chances of having severe inflammatory acne.
Treating the Various Etiologic Factors
o Female acne patients respond well to hormonal therapy, such as oral contraceptives.
o Male acne patients are not good candidates for hormonal therapy because of the risk for feminizing disorders.
o To unclog the pores and normalize keratinization, benzoyl peroxide and salicylic acid can be used, but the most potent and effective agents for this indication are the retinoids.
o Other than the hormonal aspects, retinoids address every area of acne pathogenesis - including inflammation.
o The proliferation of P acnes can be controlled with antibiotics, benzoyl peroxide, and the retinoids.
Combination Therapy Produces Synergistic Effects
o The use of several different products allows slightly lower doses, which diminishes the risk for side effects.
o When benzoyl peroxide is combined with an antibiotic, the antibiotic minimizes benzoyl peroxide irritation by controlling inflammation and the benzoyl peroxide reduces the risk of antibiotic resistance by killing resistant strains of bacteria.
o Antibiotics can also reduce erythema in patients whose skin is irritated by the harsher topical retinoids.
o Adapalene, the least irritating of the topical retinoids, has anti-inflammatory effects that can be enhanced by the addition of an antibiotic.
Selecting Regimens for Inflammatory Acne
o Dr Millikan's first line of therapy for mild inflammatory acne is a combination of benzoyl peroxide and adapalene.
o For grade 2 acne, he might use adapalene with a benzoyl peroxide topical antibiotic combination.
o Patients with grade 3 or 4 acne will probably do well on adapalene combined with an oral antibiotic.
o Those whose acne is severe enough may need to be upgraded to a course of oral isotretinoin, followed by a maintenance regimen of adapalene.
Prevention and Maintenance of Remission in Inflammatory Acne
o Some dermatologists put very young patients with comedonal acne on a regimen of a mild topical retinoid to squelch microcomedones and prevent their development into inflammatory lesions.
o After successful acne treatment, Dr Millikan likes to maintain remission with topical retinoid therapy.
o In addition to maintaining clear skin, the topical retinoids can also slow photoaging and therefore may be used throughout adulthood.
Dark-Skinned Patients Need Mild Medication
Once the Skin Is Clear
o After acne has resolved, the skin might be prone to sunburn, owing to the dryness that occurs once sebum has been diminished.
o Dr Millikan advises all his patients to use sunscreens to reduce their risk for skin cancer and photoaging.
o Long-term use of a mild topical retinoid, such as adapalene, can both maintain remission of acne and prevent the fine lines, wrinkling, and photoaging caused by prior sun exposure
