Dermatologists use a lot of antibiotics! Estimates are that dermatologists represent 1% of health care providers but prescribe 4.9% of all antibiotics in the United States. Pediatricians use antibiotics even more liberally, overly relying on them for acne care in teens and pre-teens, and often using them without topical regimens, inconsistent with standard guidelines for care.2-4
The study by Nagler et al. is an interesting one, finding that acne patients eventually treated with isotretinoin received a prolonged course of antibiotics, with a mean duration of almost one year (331 days), before starting isotretinoin. This far exceeds standard recommendations that oral antibiotic usage be limited to several months and raises concerns, as antibiotics are suboptimal therapy for severe acne and prolonged antibiotic use may contribute to antibiotic resistance. The study also shows a significant time lag between the initial consideration of isotretinoin and the actual initiation of treatment. The study evaluated antibiotic use in patients with inflammatory or cystic acne in the NYU system prior to being prescribed isotretinoin. This population may represent a group with more severe and/or persistent acne, while there are probably a great many more patients treated with prolonged oral antibiotic therapy who never receive isotretinoin.
Lawrence F. Eichenfield
Antibiotic resistance is a growing concern, with studies showing P.acnes resistance increasing throughout the world. Acne patients can become reservoirs of antibiotic-resistant strains; in one study 41-86% of untreated close contacts of antibiotic-treated acne patients carried antibiotic-resistant strains. Staphylococcal resistance also may develop and be transmitted to close contacts. The ecologic impact of broad antibiotic use clearly is contributing to the emergence of resistant “superbugs” that have been shown to increase morbidity and mortality across the population.
Isotretinoin is not without drawbacks, and some delays in its use may be due to concerns about associated adverse effects. Isotretinoin is an established teratogen, and its use requires extra work from prescribers and female patients, including registration with the iPledge system, monthly pregnancy tests, and monthly iPledge verifications. While there are concerns about other associations, including mood disorders, inflammatory bowel disease, and premature epiphyseal closure, these associations are less clear. Published reviews of the existing evidence for and against these associations should be used to inform discussions with families. The risk of rare adverse effects must be weighed against risks of scarring and psychological effects of severe acne, as well as direct and indirect concerns about long-term antibiotic use.
What are the takeaways from the study and “best practices” for the judicious use of antibiotics in acne care?
1. Oral antibiotics are appropriate for moderate to severe acne, but should be utilized for only a limited time, with recommendations ranging from 6 weeks to within 1-2 months of clinical response. Oral antibiotics always should be accompanied by topical regimens, usually including retinoids to improve responsiveness and topical benzoyl peroxide to prevent emergence of bacterial resistance.
2. Recognize severe or persistent disease, and when contemplating prolonged antibiotic use, instead consider initiation of isotretinoin or referral to dermatologists, who manage most isotretinoin use. Isotretinoin may be appropriate for pre-teens as well as teens.
3. In those who respond well to the combination of oral antibiotics and appropriate topical regimens, attempt conversion to “maintenance” regimens of topical retinoids and antimicrobials. Data show that a significant percentage of moderate to severe acne patients will respond well and “keep their improvement” with appropriate topical care.
4. Get uncomfortable with prolonged oral antibiotic use for acne! Our present therapeutic armamentarium (and new medications under development) allows us to treat the vast majority of acne patients effectively without months or years of oral antibiotics.
Lawrence F. Eichenfield, MD
Chief of pediatric and adolescent dermatology
Rady Children’s Hospital San Diego
Ellen S. Haddock, AB, MBA
Rady Children’s Hospital San Diego.
Disclosures: Dr. Eichenfield and Ms. Haddock reported no relevant financial disclosures.