Key points

• Antibacterial washes should be considered in the first-line management of mild acne and in the maintenance of individuals who have improved following other therapy. They should not be used routinely in conjunction with other therapies. There is no evidence to support the use of abrasives, which may further irritate already sensitised skin. Alkaline syndet bars are less irritant than soap for cleansing.

• Topical retinoids can be used in both noninflammatory and inflammatory acne and in conjunction with oral and topical antibiotics. The evidence suggests that adapalene is less irritant than other retinoids.

• Azelaic acid is effective in mild to moderate acne and may be less irritant than topical retinoids, but has a slower onset of response.

• Benzoyl peroxide is an effective treatment in mild to moderate acne but causes an initial sensitisation that may persist in some individuals. Higher strength benzoyl peroxide is in general no more effective than lower strength but is associated with more irritation.

• Antibiotics are more effective against inflamed lesions than non-inflamed lesions. There is no evidence to support a difference in efficacy between any of the agents, either oral or topical.

• There is no good quality evidence to support recommendations about either the dose of antibiotics to be used or the duration of therapy; further research is urgently required.

• Benzoyl peroxide appears to have similar activity to antibiotics against inflamed lesions and greater activity against non-inflamed lesions, but causes local irritation. The evidence suggests that combined use of antibiotics with retinoids is more active than either agent alone, and whilst benzoyl peroxide combinations are more effective than antibiotics alone, the data against benzoyl peroxide alone are equivocal.

• Given concerns about the development of resistance, further research is urgently required to assess the efficacy of antibiotics relative to other agents and to provide data for an appropriate assessment of the risks and benefits associated with their continued use.

• Benzoyl peroxide should be used intermittently during extended antibiotic therapy to eliminate any resistant strains.

on inflammatory lesions are visible after a few days, a minimum of 3 weeks is required before any improvement can be categorically stated89,194 and therapy should therefore be continued for a minimum of 3 months, and 6 months for maximum benefit.1 As antibiotics do not expel existing comedones, the effect on these lesions only becomes evident after a few months of continual use; it takes approximately 8 weeks for a micro-comedone to develop into a visible lesion. Relapse occurs in nearly half of all patients up to 8 weeks after stopping therapy,200 necessitating additional courses.181 In patients who relapse immediately, the antibiotic used should be rotated every 6 months.201 Two RCTs that included intermediate assessments showed that improvement continued beyond 4-6 weeks to 3 months.85,100

An observational cohort study of 543 patients with moderate acne treated with erythromycin, 1 g/day, combined with 5% benzoyl peroxide suggested that the median percentage improvement at 6 months was 78% (interquartile range 67-90%); 408/492 individuals showed over 50% reduction in acne grade; 247/279 who continued with benzoyl peroxide alone maintained improvement; 174 individuals who continued with combination for a further 6 months showed no additional benefit but this group also included a subgroup of responders, non-responders and those switched to alternative antibiotics. Therapy was continued in 31 patients who had not shown 50% improvement within the 6 month period: the percentage improvement was greater in the 29 individuals treated with minocycline.

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