Acne Topical Retinoid Therapy

Until the retinoids became available, there wasn't anything that really affected comedonal acne. Theoretically, if you prevent the formation of the precursor, you prevent all the subsequent lesions from forming. That probably can occur if you can get enough of the right retinoid, either systemically or topically.

Retinoic acid binds to all three kinds of retinoid receptors: alpha, beta, and gamma. It is thought that the gamma receptor is the most important in the pathogenesis of acne, and retinoic acid has a very high affinity for gamma receptors. First of all, there is sebum. Sebum itself might be comedogenic, but whether it is or not, it certainly provides the nutrient material for P acnes. The proliferation of this microorganism is the next pathogenic factor.

In addition to reversing abnormal keratinization, there is evidence that the topical retinoids may have some anti-inflammatory properties. Both adapalene (Differin®) and tretinoin have been shown to do this in different experiments. Because Retin-A has been on the market for more than 25 years, patients will frequently come in and say, "I've already used tretinoin; it didn't work." For many physicians, their first inclination is to try something else. My favorite therapy is a topical retinoid used in conjunction with a combination of benzoyl peroxide and erythromycin.

Or I might use one of the newer benzoyl peroxides, such as benzoyl peroxide mixed with zinc and glycolic acid. With moderate to moderate/severe inflammatory acne, I would probably think about systemic antibiotics. If the patient is a woman, one might consider using birth control pills as acne therapy. Everyone should use sunscreens all the time.

I recommend a minimum sun protection factor (SPF) of 15 or greater. Patients should apply their topical acne therapy first thing in the morning, and then put on the sunscreen before they go outside. I recommend moisturizers for patients who are experiencing irritation from topical therapy.

I tend to encourage them to use the lighter moisturizers, rather than heavier ones, and to use only those that have been tested and are labeled as noncomedogenic or nonacnegenic. Unemployment is much greater in patients with acne than in people who don't have acne. That increases with the severity of disease.

I recommend moisturizers for patients who are experiencing irritation from topical therapy. I tend to encourage them to use the lighter moisturizers, rather than heavier ones, and to use only those that have been tested and are labeled as noncomedogenic or nonacnegenic.

Significant inflammation is the primary one. With moderate to moderate/severe inflammatory acne, I would probably think about systemic antibiotics. If the patient is a woman, you might consider using birth control pills as acne therapy.

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