The November article on acne treatment (“What is the best treatment for mild to moderate acne?” J Fam Pract 2006; 55:994–996) offers useful recommendations for the best pharmacotherapy for mild to moderate acne. However, we would like to make some clarifications and suggest some further treatments.
In those with mild acne whose disease is not adversely affecting their quality of life, antibacterial washes should also be considered first-line management strategies.1 More specifically, evidence suggests that antibacterial skin cleansers can be effective in the management of mild acne,2 and can achieve outcomes similar to benzoyl peroxide in moderate acne.3
Furthermore, azelaic acid has been shown to normalize the increased keratinocyte production and keratinization associated with acne, to have a direct anti-inflammatory effect, and to inhibit growth of Propionibacterium acnes.4 In addition, it is better tolerated than benzoyl peroxide5 and tretinoin,6 and has not been shown to have depigmenting effects.7 Thus, it could serve as valuable therapy in mild-to-moderate papulopustular acne and also substitute topical isotretinoin therapy in comedonal acne (in problematic patients who cannot tolerate topical retinoids), especially during the summer months, because it does not produce any photosensitization.8
Women who are nonresponsive to other therapies and have proven ovarian or adrenal hyperandrogenism, hirsutism, androgenetic alopecia, severe sebum secretion, and acne beginning or worsening in adulthood, flaring premenstrually, and located on the beard area as well as those who desire contraception and control of their menstrual period are good candidates for hormonal acne treatment.9 Hormonal therapy for acne consists of anti-androgens and agents that inhibit androgen production from the ovary or the adrenal glands.
Another important matter is cost-effectiveness. Despite the paucity of studies investigating the issue, there is some evidence indicating that topical antimicrobial therapies perform at least as well as oral antibiotics in terms of clinical efficacy, while benzoyl peroxide seems to be the most cost-effective and minocycline the least cost-effective therapy for facial acne.10 In addition, data on cost-effectiveness and outcomes in patients with resistant P acnes floras, did not support the first line use of minocycline for mild to moderate inflammatory acne of the face.10
Moreover, we also believe that patient preferences should be taken under serious consideration, since they can affect compliance. Results from a questionnaire-based randomized controlled trial regarding patient preferences on topical antibiotic treatment regimens demonstrated that clindamycin phosphate gel was a popular choice. Patients clearly preferred a gel formulation that could be applied with the fingers once daily and stored at room temperature for as long as 18 months.11
The development of a variety of pharmacologic regimens with proven efficacy for acne is an expected and positive progress. Hopefully, family physicians will gain confidence in the use of these therapies to expand the treatment of acne patients.
Alevizos Alevizos, MD
and Anargiros Mariolis MD, PhD
Department of General Practice/Family Medicine, Health
Center of Vyronas, Athens, Greece
Georgios Larios, MD
Department of Dermatology, “A. Sygros” Hospital,
Athens, Greece