Maintenance therapy vital to acne treatment after antibiotics

Jonette Elizabeth Keri

NEW YORK — Acne experts gave key takeaways on antibiotics, hormonal therapies, isotretinoin and how diet may impact acne management in a session here at the American Academy of Dermatology Summer Meeting.

The speakers in the session were authors who compiled the 2016 Guidelines of Care for the Management of Acne Vulgaris, published in Journal of the American Academy of Dermatology.

On antibiotic resistance, Jonette Elizabeth Keri, MD, PhD, FAAD, said, “Primary care physicians treating acne aren’t getting it, which is why we’re still talking about it.” Keri is associate professor of dermatology at the University of Miami and chief of service at Miami VA.

Based on data from British Journal of Dermatology, by the year 2050, there will be 10 million deaths per year and £66 trillion in loss of productivity from antibiotic resistance, she added.

Antibiotic stewardship means giving the right antibiotic for the proper duration. Monotherapy is not recommended, and systemic therapy should be limited to 3 months, Keri said.

Resistant P. acnes can be found on the skin of untreated contacts of acne patients prescribed antibiotics. Topical antibiotics are associated with S. aureus resistance.

Keri said that topical antibiotics are effective as acne treatment, but not as monotherapy. “Whenever I can, I give benzoyl peroxide. It has no reported resistance and treats noninflammatory and inflammatory acne,” she said.

As for new treatments, topical minocycline gel and foam are coming down the pipeline, she said. “both of these formulations will reduce lesion counts and can work faster than oral minocycline, which I found interesting.”

VCD-004 exhibits a superior mutant prevention index, has good skin penetration and has an anti-inflammatory effect.

In moderate to severe acne or forms of inflammatory acne that are not improving, systemic therapy is recommended. Doxycycline and minocycline tend to be more effective than tetracycline. Erythromycin should be limited or avoided as resistance develops fast.

Three months of therapy is recommended and not monotherapy. “The literature show that we are doing a very good job here. We are getting patients off oral antibiotics in about 120 days. We are doing a good job, but we need to educate others.”

Evidence supports the use of the following oral antibiotics: tetracycline, doxycycline, minocycline, sarecycline, trimethoprim/sulfamethoxazole, trimethoprim, erythromycin, azithromycin, amoxicillin and cephalexin. “I’ve used all of these and probably a few more, because I often get the worst of the worst cases,” Keri said. Sarecycline is a new addition and not part of the 2016 guidelines.

Sarecycline was specifically designed for acne, has a low incidence of side effects and can be used on patients aged 9 years and older.

She does not recommend routine microbiologic testing.

Maintenance is necessary to limit antibiotic usage in practice. Keri guides her residents to have an exit plan, “To consider what can help you keep patients off of antibiotics, when they are done whether it’s retinoids, benzoyl peroxide, azelaic acid, and alpha and beta hydroxy acid. “When they are done with the antibiotics, they don’t just leave and don’t do anything.” – by Abigail Sutton

Reference:

Harper JC, et al. Translating evidence into practice: Acne guidelines. Presented at: American Academy of Dermatology Summer Academy Meeting 2019; July 25-28, New York.

Disclosures: Keri reported being an advisor or consultant to Dermira, Hoffman-La Roche, Ortho Dermatologics, Pierre Fabre Dermatologie, Sonoma Pharmaceuticals and Sun Pharmaceutical Industries. Please see the meeting website for all speakers’ financial disclosures.