28. Combo therapy

Doctor Jacob here today, and we're talking about combo therapy. That's combination therapy, and what it means is two products being combined into one. For example one cream that contains both benzoyl peroxide and a retinoid, or for example one cream that contains both benzoyl peroxide and clindamycin. Of course, clindamycin and a retinoid can be done in a combination, as well.

So what are the advantages of using combination therapy? Well, the ease of use. Not having to sit there and put two creams on in succession on the face, and better compliance or adherence, meaning that patients will actually use the drug, instead of just toss it aside or forget to use it after a week. They'll go hand-in-hand with them. The easier something is to use, the more chance that patients will use it.

So let's talk about the combination of benzoyl peroxide and a retinoid. That is a great combo, and the only downside is that it could be a little bit irritating, especially for patients with dry skin, sensitive skin or eczema-prone skin. So benzoyl peroxide and retinoids, in combinations.

Well, if you remember from the episode on retinoids, tretinoin and tazarotene are not stable in combination with benzoyl peroxide. The chemical structure of retinoids is not stable, whereas adapalene - that is the retinoid that goes by the brand name of Differin - is stable in combination with benzoyl peroxide.

Keep in mind, benzoyl peroxide and retinoids are kind of the two main workhorses of topical acne treatment, so to have one product that combines both of them into one easy-to-use product is a wonderful thing. That product has a brand name called Epiduo, which is 0.1% adapalene in combination with 2.5% benzoyl peroxide gel. Epiduo can be monotherapy for comedonal acne, so just one product, that's all you need, used once a day and you're done.

There is another spin-off product called Epiduo Forte, which has the same concentration of benzoyl peroxide - 2.5% - but the adapalene concentration has been raised up to a strong level of 0.3%.

With regards to Epiduo, it's a wonderful product for patients with normal to oily skin. Often times it does cause some dryness, which requires moisturization and if patients are dry-skinned or with eczema-prone or sensitive skin, this product is generally too strong for their use. That's the only downside in my books of this product, otherwise it's wonderful. Keep in mind, any product that contains benzoyl peroxide can bleach clothing, pillow cases or towels. It has peroxide in it, just like hydrogen peroxide and you can bleach these things - that's the other potential downside. So irritation and causing dryness, best used with moisturizer, especially in patients who are not super oily.

So that being said, I do see probably a patient every other week who has been prescribed the combination product of adapalene and benzoyl peroxide known as Epiduo, who has come from their pediatrician or another dermatologist, or their primary care doctor, family practice, whatever - I see a patient that has irritant reaction and says, "Oh doctor, that product doesn't work for me. I don't want adapalene, I don't want benzoyl peroxide", and that's kind of hard because these are the work horses of the acne treatments, and it's not that the patient just can't use these drugs, they're not bad drugs for the patient. The patient just used them in too high concentration, or without moisturizer, or used too much of them. So at that point I just have to stop the drug and kind of separate them out, give the retinoid without the benzoyl peroxide first, let the patient slowly adjust their skin to tolerate the retinoid, plus some moisturizing cream and then over the course of time, at a follow-up visit we could add on benzoyl peroxide if needed, or clindamycin if it's going to be too much of an irritant reaction to go with the benzoyl peroxide. So there is a role for non-combination therapy, where we have the separate ingredients as well, especially in patients with drier skin types.

Let's move on to talking about combinations of benzoyl peroxide with clindamycin. So no retinoids, just BP and clinda.

Let's talk about Benzaclin, which is 1% clindamycin and 5% benzoyl peroxide. That's a good one. There's Duac or Nuac, which is 1.2% clindamycin and 5% benzoyl peroxide - clinically there's probably no significant difference between these products - and Acanya, which is 1.2% clindamycin and 2.5% benzoyl peroxide, and Onexton, which is 1.2% clindamycin and 3.75% benzoyl peroxide.

I would suggest products that have relatively lower strengths of benzoyl peroxide, because the higher you go on that, the more irritant reaction without necessarily more help to the patient, whereas with the clindamycin, whether it's 1% or 1.2%, I can tell you there's not much of a difference there. It's all just kind of how it's formulated, what's available, what's on your insurance plan, what you can get your hands on, as to what you should use.

So these products are really good for patients who can't tolerate retinoids if they have eczema-prone skin, or in certain places where they accept benzoyl peroxide used during pregnancy, then BP-clindamycin combinations are very convenient for use.

Finally, let's talk about clindamycin/retinoid combinations. Now, for some reason these are only available with tretinoin, and there are two on the market. One is called Ziana, which is 1.2% clindamycin combined with tretinoin 0.025% gel. The next is called Veltin, which is 1.2% clindamycin with 0.025% tretinoin as well. So same exact concentrations, very similar products.

In terms of use, these are good for people for example who have true benzoyl peroxide allergy or for people who have a little more drier or sensitive skin, but have inflammatory acne with pimples or zits. So that's a good use for these medicines.

Let's talk about treatment regimens - when to use what, how to avoid getting the pillow case bleached, etc. One of my favorite ways to utilize combination therapy is to recommend the benzoyl peroxide/clindamycin product in the morning, for example Acanya or Onexton brand, and then to use the retinoid at bed time. In this fashion you can kind of pick a low strength of benzoyl peroxide, use it in the morning, and use the retinoid at night and you can custom-select the retinoid strength as needed. That retinoid may be retinol, or tretinoin, or adapalene, whatever. Then that's good, because the morning use of benzoyl peroxide in that regimen would not get your pillow case bleached.

For patients with purely comedonal acne, that's just the clogged pores without the zits, there is another option which is just monotherapy - only one product, once a day. That's of course the combination of benzoyl peroxide with adapalene, which is my favorite therapy, going by the brand name Epiduo. It has the two most important topicals, the staples of acne treatment - retinoids and benzoyl peroxides combined into one product. You can get that in two strengths, with the adapalene as either at the lower strength, 0.1%, or the higher strength, three times as much at 0.3%. Epiduo vs. Epiduo Forte, at the higher strength.

And now, another use of combination therapy in another situation for a patient who just wants monotherapy, just one simple application, but the patient is a drier skin type, Ziana or Veltin are great choices. The clindamycin is non-irritating, and just a little bit of retinoid at 0.025% tretinoin. Usually we're able to squeak that in with a little bit of moisturizer, without too much added irritation.

So that does it for combo therapy. I'm Doctor Jacob, we'll see you next time.