Topical antibacterials

Topical antibacterials are as effective as oral agents but encourage resistance and are more expensive. Topical antibacterials are probably best reserved for patients who wish to avoid oral agents or who cannot tolerate them. 

Antibacterial resistance of propionibacterium acnes is increasing; there is cross-resistance between erythromycin and clindamycin. To avoid development of resistance:

• when possible use non-antibiotic antimicrobials (such as benzoyl peroxide or azelaic acid);
• avoid concomitant treatment with different oral and topical antibacterials;
• if a particular antibacterial is effective, use it for repeat courses if needed (short intervening courses of benzoyl peroxide or azelaic acid may eliminate any resistant propionibacteria);
• do not continue treatment for longer than necessary (however, treatment with a topical preparation should be continued for at least 6 months).