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Currently, benzoylperoxide is still the gold standard for mild-to-moderate acne. Bacterial resistances have not been detected yet. Fixed combination preparations are available with erythromycin, and those with clindamycin are in preparation. They are more efficacious and better tolerated then benzoylperoxide alone. BPO is available as a solution, washing gel or cream 1-5% concentration. 10% concentrations are not significantly more efficacious but more irritative [2, 46, 51, 52].

Micromolar concentrations of benzoyl peroxide were found to inhibit the release of reactive oxygen species from human neutrophils but associated with a marked drug-induced cytotoxicity. When in cell-free assays the effects of benzoyl peroxide on protein kinase C and cal-modulin as regulators of the release of reactive oxygen species were investigated, there was only a marginal inhibition of protein kinase C and no inhibition of calmodulin was detectable. Thus, the anti-inflammatory activity of benzoyl peroxide is unlikely to be mediated by protein kinase C or calmodulin [53].

In one study the sebum excretion rate was shown to increase by 22.5% after 1 or 2 months of treatment with 5% benzoyl peroxide. This was felt to be due to the come-dolytic activity and thus influence the pooling of sebum in the upper parts of the pilobaceous duct [54]. Nevertheless, today any activity on sebaceous gland activity and direct comedolytic activity can be excluded.

Benzoylperoxide does not target the comedo at the primary route and does not have significant in vivo anti-inflammatory potency.

The side effect profile of BPO depends on the galenic formulation of i.p. dryness of the skin and exsiccation eczema. It can bleach the hair and clothes. The following recommendations can be given: ideal for mild-to-moderate inflammatory acne papulo-pustulosa; optimal combi nation with topical retinoids; treatment for about 6-8 weeks as monotherapy; short contact benzoylperoxide washes followed by topical retinoids or azelaic acid are useful.

The common induction of an irritant dermatitis can be avoided by less frequent application making the incidence of true contact sensitivity low [55]. A water-based benzoyl peroxide preparation was found to cause significantly less skin irritation than an alcohol-based preparation [56]. In a comparison of 2.5, 5 and 10% gel formulations of benzoyl peroxide, the 2.5% formulation was equivalent to the other two concentrations in reducing inflammatory lesions and significantly reduced P. acnes after 2 weeks of topical application. The local adverse effects were less frequent with the 2.5% gel than with the 10% preparation, but similar to the 5% gel [57].

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