A Mainstay in Treating Acne: The Role of Benzoyl Peroxide

Findings from a roundtable discussion with leading dermatologists and pediatric dermatologists about acne treatment challenges, the importance of early treatment, and the potential benefits of over-the-counter treatment options are presented ahead. Roundtable participants included Zoe Draelos, MD; Julie Harper, MD; Peter Lio, MD; Anthony Rossi, MD; Kalyani Marathe, MD; and Adelaide A. Hebert, MD.

Most people will suffer from acne at some point in their lives—we know 85 percent of teens are affected by acne, and it can persist throughout or reappear in adulthood. As understanding of the pathogenesis of acne evolves and improves, and additional effective therapies are brought to market, topical benzoyl peroxide (BP) and topical retinoids continue to remain first-line treatment options for a majority of our acne patients.¹ And importantly, with recent shifts in drug regulation and market availability, these agents are now more readily accessible and potentially more affordable with availability over the counter (OTC).

Patient Education is Key

Physicians—including pediatricians who are often on the front lines of treating adolescents and pre-adolescents with acne—should stress the importance of early diagnosis and management of acne. Patients need to be educated that as an inflammatory disease that can be persistent and has potential to worsen without treatment, acne can result in scarring or pigmentary alterations.¹ The goals of acne treatment are to reduce or eliminate inflammatory and noninflammatory lesions by eradicating Cutibacterium acne (C acnes, formerly Propionibacterium acnes), normalizing follicular keratinization, and preventing the formation of new lesions.² Implementation of effective treatment can prevent worsening of acne and reduce the risks of long-term sequelae.²

According to the American Academy of Dermatology’s evidence-based acne treatment guidelines for the topical treatment of acne in adolescents and young adults, benzoyl peroxide (BP) alone or in combination with topical antibiotics is the first-line treatment recommendation for mild acne.³ BP plus topical retinoids or a systemic antibiotic is the first-line recommendation for moderate to severe acne.³

Educate patients—and their parents—about the acne treatment guidelines. It’s also important to note that many parents of patients seeking acne treatment may not believe that OTC options are effective based on their own experiences 20-plus years ago. Ensure that they understand that the changing OTC landscape and improved formulations mean that the right first-line evidence-based therapies include OTC topicals, such as BP. Patients and parents should understand the risks of delaying treatment, including potential scarring, worsening disease, and negative psychosocial effects.⁴

The Benefits of BP

Benzoyl peroxide is effective as a first-line acne management therapy. It reduces C acnes on the skin, inhibiting its inflammatory by-products. And for patients treated with systemic or topical antibiotics, concomitant topical therapy with a benzoyl peroxide-containing product is a strategy that has been shown to reduce the development of bacterial resistance.³

Benzoyl peroxide is available in a range of OTC formulations from washes and foams to creams and gels in strengths ranging from 2.5-10%. Clinicians should consider a number of factors when recommending a benzoyl peroxide product, including formulation, vehicle tolerability, and concentration. The effectiveness of BP is well known, but patient adherence to treatment with BP may be limited by concentrations that cause irritation, dryness, erythema, and peeling. BP can also cause bleaching of hair and clothing when applied. Certain formulations may be more tolerable, and it’s essential to recommend a product which patients will be willing to use.

One attempt to improve the tolerability and availability of BP is micronization. BP is milled to a consistent small size that allows for better penetration into the pores and reduces clumping, which can lead to irritation. One such product is La Roche-Posay’s Effaclar Duo, a dual action acne treatment with 5.5% micronized benzoyl peroxide and micro-exfoliating lipo-hydroxy acid (LHA). LHA is a derivative of salicylic acid bearing an acyl fatty chain which imparts unique physiochemical properties.⁵ The lipophilic character of the molecule slows its penetration and allows it to remain on the surface of the skin to facilitate the desquamation of corneosomes in a gentle, but efficient manner.

In one study, patients applied topical BP 5.5% with LHA in combination with topical tretinoin 0.025% cream.⁶ The combination was found to be as effective as BP 5%-clindamycin 1% gel and tretinoin 0.025% cream for the treatment of mild to moderate acne. In addition, the BPO 5.5% with LHA formulation was found to be more tolerable, demonstrating significantly less erythema at Week 2 compared to the BPO 5%/clindamycin gel arm.

Increasing Adherence

As research continues to bring new understanding of the pathogenesis of acne and new treatments to market, an important factor in efficacy is to ensure that patients have access to treatment and are adhering to their treatment regimen. Having effective treatments available OTC, such as La Roche-Posay’s OTC BP product and its adapalene product, offers physicians the option to recommend specific products with proven efficacy and tolerability that they know their patients can easily obtain. Physicians can also let patients know how much the treatments will cost. This eliminates potential issues with barriers to access to prescription medications.

Another roadblock to effective treatment is non-compliance. Simple regimens improve compliance. Offer patients instructions about exactly how to use a product, when to use it, and how much they should be using. It’s also important to set appropriate expectations for treatment. Let patients know of possible side effects—discuss tolerability, safety, and potential risks. Instruct patients that they may experience some dryness or peeling during the initial weeks of treatments—explain what is considered normal so that they’re encouraged not to give up on treatment. Patients should also be told that treatment will not work overnight—most patients start to see improvement after about two months. If a patient doesn’t understand this, you risk causing frustration when results are not seen after two weeks. With clear expectations, patients are more likely to continue with treatment.

Let patients know that they should contact your office with questions or if tolerability is an issue, rather than stopping the treatment and waiting until their next appointment. Communication is key to ensuring adherence, which will result in improved efficacy and patient and physician satisfaction.

1. Layton AM. Optimal management of acne to prevent scarring and psychological sequelae. Am J Clin Dermatol. 2001;2:135-141.

2. Leyden JJ. Current issues in antimicrobial therapy for the treatment of acne. J Eur Acad Dermatol Venereol. 2001;15(suppl 3):51-55.

3. Zaenglein, Andrea L. et al. Guidelines of care for the management of acne vulgaris. JAAD. 2016;74:945 - 973.e33

4. Layton AM. Optimal management of acne to prevent scarring and psychological sequelae. Am J Clin Dermatol. 2001;2:135-141.

5. Zeichner, JA. The use of lipohydroxy acid in skin care and acne treatment. J Clin Aesthet Dermatol. 2016;9(11):40-43.

6. Draelos ZD, Shalita AR, Thiboutot D, et al. A multicenter, double-blind study to evaluate the efficacy and safety of 2 treatments in participants with mild to moderate acne vulgaris. Cutis. 2012;89:287–293.