Roni Munk MD. 1538 Rue Sherbrooke O #410, Montréal, QC H3G 1L5, Canada

TREATING ACNE WITH TOPICAL COMBINATION THERAPY

Roni Munk, M.D., FRCPC, FAAD
Munk MD Dermatology

1538, rue Sherbrooke Ouest, bureau no 705

Montréal (Québec) H3G 1L5

Consultation médicale : 514 937-3773

Consultation esthétique : 514 937-2757

TREATING ACNE WITH TOPICAL COMBINATION THERAPY

When selecting treatment options for our patients with acne, we should remember the main objective—
to
treat as many age-appropriate pathogenic factors as possible
to prevent scarring.

Recall that acne pathogenesis occurs from
4 main factors
: infl ammation,
Propionibacterium acnes
(P. acnes
) overgrowth, excess sebum production and altered follicular growth. The components of acne
therapies include benzoyl peroxide (BPO), retinoids and antibiotics, and each component targets certain
pathogenic factors (fi gure 1).

This is why the use of combination therapy is eff ective.

When combined, these components have complementary modes of action, targeting multiple pathogenic factors.

Antibiotic-free Topical Retinoid + BPO TactuPump (adapalene 0.1%/ BPO 2.5%)Considering the appropriate use of antibiotics for acne management

Antibiotics (oral or topical) are an important part of acne therapy as they can effectively suppress P. acnes growth and reduce inflammation. However, due to the growing worldwide problem of antibiotic resistance, it is essential to consider the appropriate use of antibiotics. In acne therapy, antibiotic resistance can occur due to inappropriate and/or prolonged use of antibiotics. As physicians, antibiotic resistance is a major concern because it can result in reduced clinical responses to antibiotics, even within acne therapy.

DID YOU KNOW?

Antibiotic-free options are an important consideration due to the emergence of antibiotic resistance

When deciding on a treatment plan for your patient with acne, consider the following points:

• Combine a topical retinoid plus an antimicrobial (BPO or antibiotics) as a first-line therapy for most patients with acne

• To reduce the risk of antibiotic resistance, avoid the use of antibiotics (oral/topical) alone. If antibiotics are used, use BPO as a washout

• Limit the use of antibiotics to 3–4 months and avoid in maintenance therapy

Combination acne treatment options and their effects in acne pathogenesis

Combination therapy Normalize follicular desquamation Reduce inflammatory response Reduce P. acnes Reduce sebum production de sébum Trade name
Antibiotic-free
Topical Retinoid + BPO
TactuPump

(adapalene 0.1%/ BPO 2.5%)

PBO + antibiotique topique BenzaClin(clindamycin 1%/ BPO 5%) Clindoxyl (clindamycin 1%/BPO 5%)Clindoxyl ADV (clindamycin 1%/BPO 3%)
Topical Retinoid + Topical Antibiotic Biacna(clindamycin 1.2%/tretinoin 0.025%)

Acne involves multiple pathogenic features. Choosing theappropriateacne therapy that targets as many features as possible is a key consideration for an effective treatment

Treatment recommendations for acne management

Treatment recommendations for acne management Our better understanding of acne pathogenesis has led to changes in acne management. The Global Alliance to Improve Outcomes in Acne recommends the following algorithm for the treatment of acne (figure 2).

ACNE SEVERITY
MILD MODERATE SEVERE
Comedona Mixte et papuleuse/ pustuleuse Mixed and Papular/pustular Nodulaire Nodular/conglobate
1st Choice Topical Retinoid Topical Retinoid + Topical Antimicrobial Oral Antibiotic + Topical Retinoid ± BPO Oral Antibiotic + Topical Retinoid + BPO Oral Isotretinoin
Alternatives AIt. Topical Retinoidor Azelaic acid or Salicylic acid Alt. Topical Retinoid Antimicrobial Agent + Alt. Topical Retinoidor Azelaic Acid Alt. Oral Antibiotic + Alt. Topical Retinoid ± BPO Oral Isotretinoinor Alt. Oral Antibiotic + Alt. Topical Retinoid ± BPO/Azelaic Acid High Dose Oral Antibiotic + Topical Retinoid + BPO
Alternatives for Females See 1st Choicetd> See 1st Choice Oral Antiandrogen + Topical Retinoid/Azelaic Acid ± Topical Antimicrobiael Oral Antiandrogen + Topical Retinoid ± Oral Antibiotic ± Alt. Antimicrobial High Dose Oral Antiandrogen + Topical Retinoid ± Alt. Topical Antimicrobia
Maintenance Therapy Topical Retinoid ± BPO 500, Jaynagar Industrial Area, Bangalore

DID YOU KNOW?

Based on guideline recommendations, retinoids are the foundationof acne therapy and should be used for all patients.

When deciding on a treatment plan for your patient with acne, consider the following points:

• Combine a topical retinoid plus an antimicrobial (BPO or antibiotics)as a first-line therapyfor most patients with acne

• To reduce the risk of antibiotic resistance,avoid the use of antibiotics (oral/topical) alone. If antibiotics are used, use BPO as a washout

• Limit the use of antibiotics to
3 — 4 months and avoid in maintenancetherap

Managing potential irritation with topical treatments

Some patients may experience irritation with the use of topical acne therapy. Below are some tips and suggestions to counsel patients experiencing irritation to help them adhere to their prescribed treatment plan.

General skin care tips:

The basis of minimizing skin irritation associated with topical acne therapy is to maintain the natural skin barrier.

• Use a gentlecleanser and non-comedogenicmoisturizer

• Avoid “scrubbing” while cleansing the face

• Avoid the use of facial toners

• Use a broad spectrum, oil-free sunscreen

Treatment application tips:

Further counselling can help patients get the most of their treatment regimen. These tips may help patients tolerate their topical acne therapy, especially at the beginning of their treatment.

• Short contact (e.g., washing the treatment off an hour after daily application)

• Leave time between cleansing the face and applying medication (e.g., wash face after dinner, and then apply the medication before bedtime)

• Apply moisturizer prior to the acne treatment

• Adjust patient’s treatment regimen based on their symptoms

• Consider starting topical therapy slowly and titrate up according to the patient’s tolerance (e.g., apply treatment every 2 days for the first month, then every day)

Combined with the right acne treatment, it is important that we counsel our patients on treatment expectations, basic skin care and managing tolerability to ensure they get the full benefits of their treatment plan.

References:

1 . Gollnick H, et al. J Am Acad Dermatol. 2003;49(Suppl 1):S1–S37.

2. Eichenfield LF, et al.
Pediatrics. 2013;131(Suppl 3):S163–S186.

3. Tanghetti E. Cutis. 2007;80(Suppl 1):5–9.

4. Thiboutot D, et al.J Am Acad Dermatol. 2009;60(5):S1–S5