Clinical question
How effective are topical combination products for moderate facial acne?
Bottom line
For patients using combination products (benzoyl peroxide with either adapalene or clindamycin), 40% to 50% perceive complete or nearly complete improvement in their acne, compared with 30% to 40% using individual products and 20% to 30% using placebo.
Evidence
This meta-analysis focused on RCTs with patient-reported outcomes. Patients had mostly moderate facial acne. Results were statistically significant unless noted.
Two RCTs (2187 patients) compared daily 2.5% benzoyl peroxide–0.1% adapalene with individual components or vehicle (placebo).1,2 At 12 weeks:
-Rates of marked or complete improvement: combination 48%, adapalene 42%, benzoyl peroxide 37%, and vehicle 27%. Numbers needed to treat (NNTs): 17, 10, and 5, respectively.
-Rates of local adverse events (AEs) (eg, stinging, erythema, dryness, scaling): combination 27%, adapalene 19%, benzoyl peroxide 11%, and vehicle 8%. Numbers needed to harm: 13, 7, and 6, respectively. The AEs were mostly transient and typically worse in the first 2 weeks.
Two RCTs (3311 patients) compared daily benzoyl peroxide (varying concentrations)–1.2% clindamycin with individual components or vehicle.3,4 At 12 weeks:
-Rates of clear or almost clear skin: combination 38%, clindamycin 30%, benzoyl peroxide 30%, and vehicle 17% (NNTs: 12, 12, and 5, respectively).
-There were no differences in AEs.
Limitation: No trials were clearly publicly funded.
Context
Topical retinoids and benzoyl peroxide (alone or combined with each other or with topical antibiotics) are first-line treatments for mild papulopustular facial acne.5 Oral contraceptives, antibiotics, and isotretinoin are second-line treatments or are used for severe acne.5
No RCTs with patient-reported outcomes were found for the combination of clindamycin-tretinoin.
Different concentrations of benzoyl peroxide have similar effectiveness and tolerability.6
Estimated costs for 90 days (once-daily application)7,8: 5% benzoyl peroxide, $35; 0.025% tretinoin cream, $50; 5% benzoyl peroxide–1% clindamycin, $100 to $120; 2.5% benzoyl peroxide–0.1% adapalene, $220; and adapalene 0.1% cream or 0.3% gel, $300 to $340.
Implementation
Despite the lack of conclusive evidence,9 many patients believe their acne is related to diet, lack of face washing, or sun exposure.10 Topical combination products should be trialed for 2 to 3 months before trying other treatments.5 Women of reproductive age with severe acne (or failure of topical products) should be counseled about the teratogenic and other potential risks of isotretinoin and tetracycline antibiotics before use. Lower-dose oral isotretinoin options (eg, 20 mg/d) may help minimize AEs.11
Notes
Tools for Practice articles in CFP are adapted from peer-reviewed articles at http://www.toolsforpractice.ca and summarize practice-changing medical evidence for primary care. Coordinated by Dr G. Michael Allan and Dr Adrienne J. Lindblad, articles are developed by the Patients, Experience, Evidence, Research (PEER) team and supported by the College of Family Physicians of Canada and its Alberta, Ontario, and Saskatchewan Chapters. Feedback is welcome at toolsforpractice@cfpc.ca.
Footnotes
Competing interests
None declared
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La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro de juin 2022 à la page e180.
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