Topical treatments
Clindamycin (topical)
In this section:
Key points | Benefits and harms | Comment
Key points
- For GRADE evaluation of interventions for Acne vulgaris, see table.
- Topical antibiotics such as clindamycin reduce inflammatory lesions compared with placebo, but have not been shown to reduce non-inflammatory lesions.
- Antimicrobial resistance can develop with use of topical or oral antibiotics, and their efficacy may decrease over time.
Benefits and harms
Topical clindamycin versus placebo:
We found two systematic reviews.[16][17] The first review (search date 1999, 7 RCTs,[18][23][24][25][26][27][28] 1502 people with mild to severe acne) compared topical clindamycin 1% (phosphate or hydrochloride) 1 to 4 times daily versus placebo or vehicle for 8 to 12 weeks.[16] The review did not perform a meta-analysis owing to heterogeneity among the trials in comparisons and outcomes assessed. The second systematic review (search date 2004), which had more stringent inclusion criteria, identified two RCTs,[18][27] both of which were identified by the earlier review.
Acne severity
Topical clindamycin compared with placebo/vehicle Topical clindamycin may be more effective at reducing the number of inflammatory lesions at 8 to 12 weeks in people with mild to severe acne, but we don't know whether it is more effective at reducing total lesion count or non-inflammatory lesions (very low-quality evidence).
| Ref (type) | Population | Outcome, Interventions | Results and statistical analysis | Effect size | Favours |
|---|---|---|---|---|---|
Total lesion count |
|||||
|
RCT |
46 people with moderate to severe acne |
Mean lesion count, 12 weeks 0.2 with clindamycin phosphate 1% twice daily 0.6 with placebo |
P = 0.34 |
not-significant |
not significant |
Non-inflammatory lesions |
|||||
|
RCT 4-armed trial Other comment Pooled data from one single-centre and one multicentre trial |
393 people with moderate acne Other comment The remaining arms evaluated benzoyl peroxide 5% and benzoyl peroxide plus clindamycin |
Mean percentage change in non-inflammatory lesions from baseline, 11 weeks –9% with clindamycin 1% 4 times daily +11% with vehicle 4 times daily |
P = 0.04 for clindamycin v vehicle |
not-calculated |
Clindamycin |
|
RCT |
40 people with mild to moderate acne In review [16] |
Percentage reduction in open comedones, 12 weeks 38% with clindamycin phosphate 1% twice daily 32% with placebo Other comment Only 76% of people completed the trial, but intention-to-treat analysis was performed |
Reported as not significant P value not reported |
not-significant |
not significant |
|
RCT |
46 people with moderate to severe acne |
Mean number of open comedones per person, 12 weeks 3.3 with clindamycin phosphate 1% twice daily 5.2 with placebo |
P = 0.49 |
not-significant |
not significant |
|
RCT |
46 people with moderate to severe acne |
Mean number of closed comedones per person, 12 weeks 3.4 with clindamycin phosphate 1% twice daily 5.1 with placebo |
P = 0.47 |
not-significant |
not significant |
Inflammatory lesions |
|||||
|
RCT 4-armed trial Other comment Pooled data from one single-centre and one multicentre trial |
393 people with moderate acne Other comment The remaining arms evaluated benzoyl peroxide 5% and benzoyl peroxide plus clindamycin |
Mean percentage reduction in inflammatory lesions from baseline, 11 weeks 35% with clindamycin 1% 4 times daily 5% with vehicle 4 times daily |
P <0.001 for clindamycin v vehicle |
not-calculated |
Clindamycin |
|
RCT 3-armed trial |
108 people with mild to moderate acne In review [16] Other comment The remaining arm evaluated oral tetracycline 500 mg twice daily |
Mean reduction in inflammatory lesion count (change from baseline), 8 weeks From 8.52 to 2.38 with clindamycin From 7.10 to 6.24 with placebo Other comment 87 people in this analysis (completer analysis); intention-to-treat analysis not performed P = 0.0001 for reduction in lesion count from baseline with clindamycin Reduction in lesion count from baseline with placebo reported as not significant (P value not reported) |
No direct comparison of topical clindamycin v placebo RCT designed to compare topical clindamycin v oral tetracycline | ||
|
RCT |
40 people with mild to moderate acne In review [16] |
Percentage reduction in papules, 12 weeks 22% with clindamycin phosphate 1% twice daily 19% with placebo Other comment Only 76% of people completed the trial, but intention-to-treat analysis was performed |
Reported as not significant P value not reported |
not-significant |
not significant |
|
RCT |
40 people with mild to moderate acne In review [16] |
Percentage reduction in pustules, 12 weeks 12% with clindamycin phosphate 1% twice daily 22% with placebo Other comment Only 76% of people completed the trial, but intention-to-treat analysis was performed |
Reported as not significant P value not reported |
not-significant |
not significant |
|
RCT 3-armed trial |
367 people with moderate to severe acne In review [16] Other comment The remaining arm evaluated oral tetracycline |
Mean number of papules per person, 8 weeks 8.3 with clindamycin 11.7 with placebo Other comment Completer analysis of 305/367 (83%) people who completed the trial |
P <0.05 for clindamycin v placebo |
not-calculated |
Clindamycin |
|
RCT 3-armed trial |
367 people with moderate to severe acne In review [16] Other comment The remaining arm evaluated oral tetracycline |
Mean number of pustules per person, 8 weeks 1.1 with clindamycin 2.7 with placebo Other comment Completer analysis of 305/367 (83%) people who completed the trial |
P <0.05 for clindamycin v placebo |
not-calculated |
Clindamycin |
|
RCT 3-armed trial |
413 people with moderate acne Other comment The third arm evaluated clindamycin hydrochloride 1% twice daily |
Percentage reduction in papules, 8 weeks 56% with clindamycin phosphate 1% twice daily 42% with vehicle Other comment Analysis of 358/413 (87%) people who completed the trial |
P = 0.05 or less for clindamycin phosphate v vehicle |
not-calculated |
Clindamycin |
|
RCT 3-armed trial |
413 people with moderate acne Other comment The third arm evaluated clindamycin phosphate 1% twice daily |
Percentage reduction in papules, 8 weeks 64% with clindamycin hydrochloride 1% twice daily 42% with vehicle Other comment Analysis of 358/413 (87%) people who completed the trial |
P = 0.05 or less for clindamycin hydrochloride v vehicle |
not-calculated |
Clindamycin |
|
RCT 3-armed trial |
413 people with moderate acne Other comment The third arm evaluated clindamycin hydrochloride 1% twice daily |
Percentage reduction in pustules, 8 weeks 72% with clindamycin phosphate 1% twice daily 43% with vehicle Other comment Analysis of 358/413 (87%) people who completed the trial |
P = 0.05 or less for clindamycin phosphate v vehicle |
not-calculated |
Clindamycin |
|
RCT 3-armed trial |
413 people with moderate acne Other comment The third arm evaluated clindamycin phosphate 1% twice daily |
Percentage reduction in pustules, 8 weeks 62% with clindamycin hydrochloride 1% twice daily 43% with vehicle Other comment Analysis of 358/413 (87%) people who completed the trial |
Significance not assessed | ||
|
RCT |
46 people with moderate to severe acne |
Mean number of pustules per person, 12 weeks 1.5 with clindamycin phosphate 1% twice daily 3.1 with placebo |
P = 0.02 |
not-calculated |
Clindamycin |
|
RCT |
46 people with moderate to severe acne |
Mean number of papules per person, 12 weeks 6.8 with clindamycin phosphate 1% twice daily 10.6 with placebo |
P = 0.16 |
not-significant |
not significant |
Patient perception of improvement
Topical clindamycin compared with placebo/vehicle Topical clindamycin may be more effective at increasing the proportion of people with mild to severe acne who rate their acne as markedly improved or improved (very low-quality evidence).
| Ref (type) | Population | Outcome, Interventions | Results and statistical analysis | Effect size | Favours |
|---|---|---|---|---|---|
Patient perception of improvement |
|||||
|
RCT 3-armed trial |
108 people with mild to moderate acne In review [16] Other comment The remaining arm evaluated oral tetracycline 500 mg twice daily |
Proportion of people whose acne had "markedly improved" or "improved" from baseline, 8 weeks 72% with clindamycin 3% with placebo Other comment 87 people in this completer analysis; intention-to-treat analysis not performed |
No direct comparison of topical clindamycin v placebo RCT designed to compare topical clindamycin v oral clindamycin | ||
|
RCT 3-armed trial |
367 people with moderate to severe acne In review [16] Other comment The remaining arm evaluated oral tetracycline |
Proportion of people who thought their acne was "markedly improved" or "improved", 8 weeks 88% with clindamycin 57% with placebo Other comment Completer analysis of 305/367 (83%) people who completed the trial |
P <0.05 for clindamycin v placebo |
not-calculated |
Clindamycin |
|
RCT 3-armed trial |
413 people with moderate acne, 8 weeks Other comment The third arm evaluated clindamycin hydrochloride 1% twice daily |
Proportion of people who rated acne "markedly improved" or "improved" compared with vehicle, 8 weeks 77% with clindamycin phosphate 1% twice daily 56% with vehicle Other comment Analysis of 358/413 (87%) people who completed the trial |
Difference for clindamycin phosphate versus placebo reported as significant P value not reported |
not-calculated |
Clindamycin |
|
RCT 3-armed trial |
413 people with moderate acne, 8 weeks Other comment The third arm evaluated clindamycin phosphate 1% twice daily |
Proportion of people who rated acne "markedly improved" or "improved" compared with vehicle, 8 weeks 77% with clindamycin hydrochloride 1% twice daily 56% with vehicle Other comment Analysis of 358/413 (87%) people who completed the trial |
Difference for clindamycin hydrochloride versus placebo reported as significant P value not reported |
not-calculated |
Clindamycin |
No data from the following reference on this outcome.[18][25][28]
Psychological distress
No data from the following reference on this outcome.[18][23][25][26][27][28]
Quality of life
No data from the following reference on this outcome.[18][23][25][26][27][28]
Adverse effects
| Ref (type) | Population | Outcome, Interventions | Results and statistical analysis | Effect size | Favours |
|---|---|---|---|---|---|
Adverse effects |
|||||
|
RCT 4-armed trial Other comment Pooled data from one single-centre and one multicentre trial |
393 people with moderate acne Other comment The remaining arms evaluated benzoyl peroxide 5% and benzoyl peroxide plus clindamycin |
Adverse effects (erythema, dryness, peeling, burning, or pruritus), 11 weeks clindamycin 1% 4 times daily vehicle 4 times daily |
Reported as not significant P value not reported |
not-significant |
not significant |
|
RCT 3-armed trial |
108 people with mild to moderate acne In review [16] Other comment The remaining arm evaluated oral tetracycline 500 mg twice daily |
Adverse effects, 8 weeks clindamycin placebo Other comment One person using clindamycin, and one using placebo had diarrhoea 87 people in this completer analysis Intention-to-treat analysis not performed | |||
|
RCT 3-armed trial |
367 people with moderate to severe acne In review [16] Other comment The remaining arm evaluated oral tetracycline |
Adverse effects, 8 weeks clindamycin placebo Other comment 9 people taking clindamycin and 6 people taking placebo had diarrhoea Completer analysis of 305/367 (83%) people who completed the trial | |||
|
RCT 3-armed trial |
413 people with moderate acne |
Adverse effects, 8 weeks clindamycin phosphate 1% twice daily clindamycin hydrochloride 1% twice daily vehicle Other comment 12 people taking clindamycin and 2 people taking placebo had diarrhoea Completer analysis in 358/413 (87%) people who completed the trial | |||
|
RCT |
46 people with moderate to severe acne |
Adverse effects, 12 weeks clindamycin phosphate 1% twice daily placebo Other comment 3 people taking clindamycin and 5 taking placebo had diarrhoea. One person taking clindamycin had burning and one had eczema | |||
No data from the following reference on this outcome.[25]
Further information on studies
Comment
The review[16] identified one open-label RCT, which did not meet Clinical Evidence inclusion criteria (135 people with moderate acne),[24]which found that clindamycin significantly reduced papules and pustules at 12 weeks compared with placebo. It found that clindamycin was associated with burning.
Studies of development of bacterial resistance to antibiotics suggest that topical application of antibiotics in acne may result in antibiotic resistance to Propionibacterium acnes.[7][29] One systematic review (search date 2003) analysed the efficacy of topical antibiotics in clinical trials (randomised and non-randomised) conducted between 1966 and 2003 using linear regression.[30] It found no significant change in the efficacy of 12 weeks' treatment with topical clindamycin 1.0% to 1.2% for inflammatory or non-inflammatory lesion count over this period (inflammatory lesions: 8 studies, change in efficacy [regression coefficient]: +0.2%/year, P = 0.7; non-inflammatory lesions: 7 studies, change in efficacy: –0.3%/year, P = 0.7).[30]
Clinical guide:
Topical antibiotics or topical retinoids are indicated as treatments for mild acne that does not respond to benzoyl peroxide. Within the antibiotic class, there is more evidence of benefit with topical clindamycin or erythromycin than with erythromycin plus zinc or tetracycline. A conjoint analysis study of patient preference for different topical antibiotic characteristics found that acne patients preferred a gel formulation that could be applied with the fingers once daily and stored at room temperature for up to 18 months.[31]
Web publication date: 5 Jan 2011 (based on February 2010 search)
