Topical combination products for facial acne

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