Department of Medicine, University of Western Ontario, London, ON, Canada
Windsor Clinical Research Inc, Windsor, ON, Canada
Background
Topical medications are the cornerstone of therapy for the vast majority of acne patients. However, use of these products is generally regarded by patients to be time-consuming, inconvenient, irritating, and less effective than oral medications. Adherence to topical agent use is also compromised by the lag time to effect, the potential complexity of treatment regimens, and the desire to incorporate cosmetics such as foundations, moisturizers, and sunscreen. While adherence rates to the use of topical acne medications have previously been reported to be as high as 48%-49% [Flanders PA, et al. Behav Res Ther 23:225-7 (1985); Flanders P, et al. J Psychol 118:31-6 (1984)], a recent Canadian observational survey of acne patients provided a rate of only 24% (Tan J. unpublished data). In this group of patients, the most common reasons for poor adherence were forgetfulness, side-effects, did not feel the need, and inconvenience. Poor adherence to topical acne therapy contributes to treatment failure, wasted health care resources, and dissatisfaction with physician care. This paper presents tips to maximize adherence and effectiveness of topical acne therapy.
Factors Influencing Patient Compliance
In dermatology patients, the two primary areas identified in poor adherence to treatment include [Renzi C, et al. Arch Derm 138:337-42 (2002)]:
Considerations for Treatment Selection
In choosing topical acne products, the following considerations may further enhance adherence:
- accessibility of anatomical site for topical therapy (i.e., face, chest and shoulders are accessible; the back is harder to treat)
- efficacy
- tolerability, e.g., facial erythema, irritation, dryness, redness, and scaling
- cosmetic acceptability
- regimen simplicity
- convenience
- ease of application.
Patients should then be evaluated at 2-4 weeks to encourage adherence and to evaluate for potential side effects; thereafter every 2-3 months to evaluate treatment effectiveness.
Types of Treatment Vehicles
In determining the most appropriate topical treatment
regime for each patient, physicians must conduct an
individualized assessment that includes disease severity,
patient preference, skin type, formulation availability,
and delivery vehicle considerations. Active agents are
formulated in a variety of vehicles to address the possible
combinations. In general, patients with drier skin may favor
creams for their moisturizing effect while those with oilier
skin may prefer gels or solutions. The use of foams may be
particularly well suited for application to larger regions and
hair bearing sites.
- Creams
- are available in oil and water base formulations.
- tend to be less irritating.
- help to retain moisture in the skin.
- are most suitable for patients with dry or sensitive skin.
- may result in an oily feel due to thicker consistency.
- Lotions
- can have either water or alcohol base.
- are the most versatile.
- can be used for all skin types.
- can cause skin irritation, e.g., burning and dryness.
- have a lighter feel, which patients may prefer.
- preferred for treatment of large or hairy areas.
- Solutions
- usually contain an alcohol base, which can exacerbate dryness and irritation.
- Gels
- contain high water content.
- are most suitable for oily skin types.
- have a cooling effect on the face.
- may leave a surface residue.
- tend to cause skin irritation, e.g., burning and dryness.
- Foams
- spread easily, especially helpful if treating larger areas of the body.
- leave minimal residue on skin surface.
Topical Acne Agents
The spectrum of effective topical acne medications may be grouped into:
Antibiotics
- Clindamycin
- Erythromycin
- Sodium sulfacetamide
Overview of Antibiotics:
- They are directed against P. acnes.
- They are formulated in creams, lotions, gels and foam.
- There is one product also available with SPF 15 + antibiotic.
- It may induce irritation.
Combination Products
- Benzoyl peroxide (BPO) + antibiotic
- Topical retinoid + antibiotic
Overview of Combination Products:
- BPO inhibits selection of antibiotic resistant bacteria.
- They may induce irritation and dryness; BPO can fade colored fabrics.
- They treat multiple pathogenic factors.
- They are gel formulations.
- The combined efficacy is typically greater than either agent alone.
- They reduce treatment regimen complexity.
- They have the potential to improve adherence because there are two active ingredients.
Retinoids
- Adapalene
- It is photostable, can be applied in the morning.
- Tazarotene
- It photostable, can be applied in the morning.
- Tretinoin
- It is photolabile, best to apply in evening.
- Micronized version may be less irritating, but more costly.
Overview of Retinoids:
- They are formulated in creams, gels and solutions.
- Advancements in vehicle delivery for retinoids to reduce irritation:
- emollient cream
- microsponge gel
- They are known to be effective against acne vulgaris through comedolysis, which acts to reduce dyskeratosis at the pilosebaceous outlet.
- They are formulated as gels and creams, which may induce irritation and dryness.
Tips for Topical Treatment
- Minimize irritation by using aqueous vehicles rather than those containing alcohol when possible.
- Adjust frequency and duration of application to reduce potential for dryness and irritation; increase duration as tolerated.
- Provide estimates of amounts to apply (e.g., pea-size amount to each of the 4 facial regions: forehead, each cheek, central face).
- Use simple regimens:
- for patients not using foundation or sunblock, apply topical medications in the morning and evening.
- for those using foundation and sunblock, apply medication in the evening only or apply combination clindamycin/ SPF 15 product in morning.
- Gentle cleansers should be used to avoid compounding irritation and dryness.
Conclusion
Successful treatment of acne with topical therapy can be achieved with:
- Patient education on acne and the aims of initial and maintenance treatment.
- Patient engagement in treatment selection.
- Counseling on aggravating factors, such as stress, dairy intake, occlusive hair products, hats, sports equipment, damp clothing, make-up, medication use, adverse events, and the importance of adherence.
