Be Ready to Discuss Alternatives to Benzoyl Peroxide

Patients will ask you if they should stop benzoyl peroxide for acne...due to the carcinogen benzene found in some products.

You may have heard of other products, such as hand sanitizers and aerosols (sunscreen, etc), being recalled due to benzene contamination.

But this is different. An independent analysis shows benzoyl peroxide breaks down into benzene...especially under high temperatures.

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Now FDA and USP are raising questions about these testing methods...and asking for more data, such as benzene levels with recommended storage.

Explain that so far there’s no proof benzoyl peroxide causes cancer...and it’s been an acne treatment for decades.

Stay tuned for more evidence.

In the meantime, help patients navigate options...since benzoyl peroxide is found in many OTCs (PanOxyl, Proactiv, etc) and Rx combos (Cabtreo, Epiduo, etc).

Counsel patients to discard expired benzoyl peroxide products and those stored at high temps, such as in a hot shower or car.

Advise storing benzoyl peroxide products in the possibly slow benzene formation...and replacing them every few months.

Discuss other acne treatments with patients wanting to avoid benzoyl peroxide.

Recommend a topical retinoid, such as OTC adapalene 0.1% or Rx tretinoin 0.025%, for most patients.

Give tips to limit irritation, such as drying skin thoroughly before use and applying 2 to 3 times/week to start. Counsel patients to use sunscreen...since retinoids can cause photosensitivity.

Suggest trying salicylic acid or azelaic acid if patients want to avoid or can’t tolerate retinoids. Or consider adding these to retinoids for added efficacy if patients can tolerate the combo.

Save the topical androgen receptor inhibitor clascoterone (Winlevi) as a last resort. But expect payer rejects. It costs about $600/60 g.

Don’t recommend topical antibiotics (clindamycin, etc) OR oral antibiotics (doxycycline, etc) alone...since these should be used WITH benzoyl peroxide to limit resistance.

Consider a combo OC or spironolactone...or both...for females with moderate to severe acne.

Think of isotretinoin for patients with severe cystic or nodular acne...or less severe, scarring acne when first-line meds aren’t enough.

Use our resource, Pharmacotherapy of Acne, to compare options. Review our resource, Topical Medications in Pregnancy and Lactation, for considerations with acne meds.

Key References

  • Kucera K, Zenzola N, Hudspeth A, et al. Benzoyl Peroxide Drug Products Form Benzene. Environ Health Perspect. 2024 Mar;132(3):37702.
  • FDA.  Frequently Asked Questions on Benzene Contamination in Drugs. December 27, 2023. (Accessed April 16, 2024).
  • Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024 May;90(5):1006.e1-1006.e30.
Pharmacist's Letter. May 2024, No. 400503

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