Choosing topicals when mainstream treatments fail

When the tried-and-true mainstream acne treatments fail, it helps to use newer or lesser-known options. A few often-overlooked ingredients include topical nicotinamide, topical dapsone gel and glycolic acid, according to Rachel Nazarian, M.D., an assistant clinical professor of dermatology at Mount Sinai Hospital, who practices in New York.

Nicotinamide

“Topical nicotinamide, or niacinamide, is used for its anti-inflammatory and sebo-suppressive properties,” she said. “Several studies have shown statistically significant improvement, both in the number of acne lesions (including comedones and pustules) and sebum levels. The additional benefit of bacterial-resistance-avoidance makes this topical application a favorable option.”

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Topical dapsone

This topical antibiotic has anti-inflammatory and antimicrobial properties. In randomized, controlled studies, topical dapsone has shown effectiveness in adult women with mild-to-moderate facial inflammatory acne, according to Dr. Nazarian.

“Both inflammatory and non-inflammatory acne lesions showed improvement with usage,” Dr. Nazarian said. “The most appealing aspect of topical dapsone is its non-irritating form and its tolerability in patients with sensitive skin. Obstacles to usage include twice daily dosing, and considerations should be made for its rare but potential induction of methemoglobinemia.”

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Glycolic acid

Glycolic acid and other alpha-hydroxy acids are antimicrobial, comedolytic and safe, according to Dr. Nazarian.

While researchers have found treatment success with 10% glycolic acid as a monotherapy, Dr. Nazarian said she often recommends it in addition to a facial cleansing routine, or as a leave-on formula can boost improvement of acne vulgaris.

NEXT: adult acne and skin of color patients

Special considerations for adult acne and skin of color patients

Chevy Chase, Md., dermatologist and Johns Hopkins faculty member Rebecca Kazin, M.D., said ingredients that work to rid teens of their pimples often don’t work as well for adult patients.

“Most of the prescription medications are very irritating and drying and, therefore, can’t be tolerated in adults with acne because their skin is not as oily,” Dr. Kazin said.

Among the adult-unfriendly ingredients: benzoyl peroxide and tretinoin.

“… if you significantly irritate the skin with something like Retin-A, it can actually cause a breakout,” Dr. Kazin said.

These irritating ingredients can also cause unwanted hyperpigmentation in skin of color patients.

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Her go-to alternatives include clindamycin lotion, because it’s not drying. And, typically, Dr. Kazin will include a sodium sulfacetamide wash to address skin redness, which is common among adult acne patients.

Dr. Kazin said she uses retinoids for some adult and skin of color patients, but usually starts with a physician-dispensed retinol and will go to higher strengths if patients tolerate the ingredient.

And for those with inflammatory lesions, Dr. Kazin might use an oral anti-inflammatory to calm the inflammation, then maintain on topicals.

READ: Pre-adolescent acne 

“My favorite for adult acne patients is spironolactone. You have to give it to very specific patients because you absolutely cannot get pregnant on it. So, I make sure that patients are on some sort of birth control or are postmenopausal. And I do some screening bloodwork because it can elevate your potassium level. But with all of that, it literally changes people’s skin,” she said.  

NEXT: Acne ingredients: the evidence

Acne ingredients: the evidence

Draelos ZD, Matsubara A, Smiles K. The effect of 2% niacinamide on facial sebum production. J Cosmet Laser Ther. 2006;8(2):96-101.
http://www.ncbi.nlm.nih.gov/pubmed/?term=The+effect+of+2%25+niacinamide+on+facial+sebum+production

Abels C, Reich H, Knie U, Werdier D, Lemmnitz G. Significant improvement in mild acne following a twice daily application for 6 weeks of an acidic cleansing product (pH 4). J Cosmet Dermatol. 2014;13(2):103-8.
http://www.ncbi.nlm.nih.gov/pubmed/?term=Significant+improvement+in+mild+acne+following+a+twice+daily+application+for+6+weeks+of+an+acidic+cleansing+product+(pH+4)

Lynde CW, Andriessen A. Cohort study on the treatment with dapsone 5% gel of mild to moderate inflammatory acne of the face in women. Skinmed. 2014;12(1):15-21.
http://www.ncbi.nlm.nih.gov/pubmed/24720080

Abels C, Kaszuba A, Michalak I, Werdier D, Knie U, Kaszuba A. A 10% glycolic acid containing oil-in-water emulsion improves mild acne: a randomized double-blind placebo-controlled trial. J Cosmet Dermatol. 2011;10(3):202-9. http://www.ncbi.nlm.nih.gov/pubmed/?term=A+10%25+glycolic+acid+containing+oil-in-water+emulsion+improves+mild+acne%3A+a+randomized+double-blind+placebo-controlled+trial.

Disclosures: Drs. Kazen and Nazarian report no relevant disclosures.