Medication Summary

In general, the most effective medication has been the use of topical retinoids including tretinoin, adapalene, or tazarotene.

Class Summary

Retinoid-like agents are the treatment of choice in the elimination of comedones. These medications assist in the removal of the comedones and may reduce the appearance of actinic damage in the area. More severe cases have been treated with oral isotretinoin, but oral therapy should be reserved for severe cases refractory to topical therapy.

Tretinoin topical (Avita, Retin-A, Retissa, Renova)

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Tretinoin inhibits microcomedo formation and eliminates lesions. It makes keratinocytes in sebaceous follicles less adherent and easier to remove. Tretinoin is available as 0.025, 0.05, and 0.1% creams and as 0.01 and 0.025% gels. Cream formulations usually are well tolerated. Individuals may begin with the 0.025% cream. Those who do not respond to this concentration may require the 0.05% or 0.1% concentration.

Adapalene (Differin)

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Adapalene modulates cellular differentiation, inflammation, and keratinization. It may be tolerated by individuals who cannot tolerate tretinoin creams. A therapeutic response can be expected following 8-12 weeks of therapy. Adapalene is available as 0.1% gel or solution.

Tazarotene (Tazorac, Avage)

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Tazarotene is a retinoid prodrug whose active metabolite modulates differentiation and proliferation of epithelial tissue; it may also have anti-inflammatory and immunomodulatory properties.

Isotretinoin (Amnesteem, Claravis, Sotret)

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Isotretinoin is an oral agent that treats serious dermatologic conditions. Isotretinoin is the synthetic 13-cis isomer of the naturally occurring tretinoin (trans-retinoic acid). Both agents are structurally related to vitamin A.

Isotretinoin decreases sebaceous gland size and sebum production. It may inhibit sebaceous gland differentiation and abnormal keratinization.

Isotretinoin should only be prescribed by individuals who are completely familiar with the drug and appropriate prescribing practices and precautions. A US Food and Drug Administration–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy.

Questions

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Media Gallery

Multiple comedones, dilated and plugged follicular infundibula, and epidermal cyst formation. Courtesy of DermNet New Zealand and Pathlab Bay of Plenty (https://www.dermnetnz.org/assets/Uploads/pathology/t/figure2favrerac.jpg).

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