Tools for Practice


#288 Clearing up the Evidence for Topical Acne Combination Products


CLINICAL QUESTION
How effective are topical combination products for moderate facial acne?

BOTTOM LINE
For patients using combination products, including benzoyl peroxide/adapalene and benzoyl peroxide/clindamycin, about 40-50% will perceive complete or near complete improvement in their acne, compared to 30-40% using individual products, and 20-30% using vehicle. No direct head-to-head trials with patient reported outcomes exist between combination products. Cost may influence product choice.


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EVIDENCE
Focused on randomized, controlled trials (RCTs) with similar patient reported outcomes. Patients had mostly moderate facial acne. Outcomes meta-analyzed by TFP authors. Benzoyl peroxide/adapalene (Tactupump®):
  • 2 RCTs,1,2 2187 patients; benzoyl peroxide 2.5%/adapalene 0.1% daily versus individual components or vehicle. At 12 weeks:
    • Marked or complete improvement:
      • Combination 48% versus adapalene 42%, benzoyl peroxide 37%, vehicle 27%. Numbers needed to treat (NNT): 17, 10, 5, respectively.
  • Local adverse events (most commonly stinging, erythema, dryness, scaling):
    • Combination 27% versus adapalene 19%, benzoyl peroxide 11%, vehicle 8%. Numbers needed to harm (NNH)=13, 7, 6, respectively.
    • Mostly transient and worse in first two weeks.
Benzoyl peroxide/clindamycin (Clindoxyl®, Benzaclin®):
  • 2 RCTs,3,4 3311 patients; benzoyl peroxide (varying concentrations)/clindamycin 1.2% daily versus individual components or vehicle. At 12 weeks:
    • Clear or almost clear skin:
      • Combination ~38%, clindamycin 30%, benzoyl peroxide 30%, vehicle 17%. NNTs 12, 12, 5, respectively.
    • Adverse events: No difference.
Limitations:
  • No trials clearly publicly funded.
Context
  • Topical retinoids and benzoyl peroxide (alone or combined with adapalene or clindamycin) are first line for mild papulopustular facial acne.5
    • Oral contraceptives, antibiotics, and isotretinoin are recommended for failure of above or severe acne.5
  • Clindamycin/tretinoin (Biacna®): no RCTs with patient reported outcomes found.
  • Different concentrations of benzoyl peroxide have similar effectiveness/tolerability.6
  • Estimated costs for 90 days (once daily application):7,8
    • Benzoyl peroxide 5% (Benzagel®): $35
    • Tretinoin 0.025% cream (Stieva-A Cream®): $50
    • Benzoyl peroxide 5%/clindamycin 1% (Benzaclin®, Clindoxyl®): $100-120
    • Benzoyl peroxide 2.5%/adapalene 0.1% (Tactupump®): $220
      • Adapalene 0.1% cream, 0.3% gel (Differin®): $300-340
April 19, 2021

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Author(s):

  • Michael R Kolber MD CCFP MSc
  • Paul Fritsch MD CCFP
  • Stacy Jardine BScPharm

1. Gollnick HP, Draelos Z, Glenn MJ, et al. Brit J Derm. 2009; 161(5):1180-9.

2. Thiboutot DM, Weiss J, Bucko A, et al. J Am Acad Derm. 2007; 57(5):791-9.

3. Pariser DM, Rich P, Cook-Bolden FE, et al. J Drugs Derm. 2014; 13(9):611-7.

4. Thiboutot D, Zaenglein A, Weiss J, et al. J Am Acad Derm. 2008; 59(5):792-800.

5. Asai Y, Baibergenova A, Dutil M, et al. CMAJ. 2016; 188(2):118-26.

6. Yang Z, Zhang Y, Mosler EL, et al. Cochrane Database Syst Rev. 2020; 3(3):CD011154.

7. Interactive Drug Benefit List [website]. Edmonton, AB: Government of Alberta; 2020. Available from: https://idbl.ab.bluecross.ca/idbl/load.do. Accessed 2020 Nov 12.

8. Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) [website]. Edmonton, AB: Government of Alberta; Effective November 13, 2020. Available from: https://www.ab.bluecross.ca/dbl/pdfs/ABCDPL_2020_11_03.xlsx. Accessed on 2020 Nov 12.

Authors do not have any conflicts of interest to declare.