Topical Antibiotics and Benzoyl Peroxide for Treatment of Acne

TO THE EDITOR: I found this review to be well written and informative. The authors have nicely summarized the differential diagnosis and included the latest treatments for acne. However, the implication that topical retinoids are the best treatment for simple comedones and mild acne is a little overstated.

An estimated 45 million persons in the United States have acne vulgaris, with a prevalence of approximately 85% in persons 15 to 24 years of age.¹ The average cost of single or combination topical acne therapy ranges from $21 to $208 per patient per year, and the direct cost of acne may exceed $1 billion per year in the United States.¹ As a physician serving predominantly Medicaid-insured and uninsured patients, I have observed that successful and cost-effective treatment is achievable with the use of combined topical antibiotics and benzoyl peroxide, especially in patients with comedones and mild inflammatory acne.

Guidelines from the American Academy of Dermatology (AAD) and the Agency for Healthcare Research and Quality (AHRQ) found that most topical acne treatments are equally effective.^1,2 Several meta-analyses and randomized controlled trials have confirmed this fact.³ There are also questions about the safety of topical retinoids during pregnancy.³ Therefore, I would be reluctant to use a topical retinoid as a first-line treatment in my patients with comedones or mild acne.

IN REPLY: I appreciate Dr. Thomas' comments regarding cost-effectiveness, and the references to the AAD guidelines for the treatment of acne¹ and the AHRQ review of the management of acne.²

In 2009, the AAD published further guidance on the treatment of acne.³ Across the spectrum of acne disorders, it consistently recommends topical retinoids, except in cases of severe nodular acne that necessitates the use of oral isotretinoin. This includes using topical retinoids alone for mild comedonal acne.³ The AAD found strong evidence from a systematic review of multiple randomized controlled trials to support the use of combination retinoid-based treatments as first-line therapy.³

Of the existing studies on the treatment of acne, AHRQ stated: “the literature is extremely heterogeneous, severely limiting the number of meaningful conclusions that can be drawn.”² It also found no evidence regarding quality-of-life outcomes or cost-effectiveness.² Therefore, we should keep in mind the specific concerns of the populations we treat. It is always appropriate to tailor treatment regimens to the individual patient's circumstances.

Lastly, I share Dr. Thomas' sentiment regarding the cautious use of retinoids in pregnant women, which is why pregnancy categories were included in the treatment tables in the article.