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Use of antibiotics for acne exceeds guideline recommendations
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The duration of use of systemic antibiotics for treatment of inflammatory and nodulocystic acne in patients aged older than 12 unnecessarily exceeded published recommendations, according to data in the Journal of the American Academy of Dermatology.
“Our study reports the extended durations of antibiotics used in the treatment of severe acne and highlights opportunities for improvement,” Arielle R. Nagler, MD, instructor at the Ronald O. Perelman Department of Dermatology of New York University School of Medicine, and colleagues wrote. “Systemic antibiotics were used for 6 months or more in the majority of patients, exceeding most consensus recommendations.”
Arielle R. Nagler
The researchers analyzed medical charts of 5,053 patients aged 12 years and older presenting with inflammatory or nodulocystic acne at a single center between 2005 and 2014. Inclusion criteria included patients who were prescribed isotretinoin during the study period, and patients who received more than 30 days of antibiotic treatment.
Study results showed that the average duration of antibiotic treatment was 331.3 days, exceeding the current recommendation which limits treatment to 3 months. Only 15.3% of patients used antibiotics for 3 months or less, while 64.2% of patients used antibiotics 6 months or longer and 33.6% used them for at least 1 year.
The researchers wrote that patients treated only at the study site had a lower average duration of antibiotic use compared with patients treated at multiple sites (283.1 days vs. 380.2 days; P = .054).
Nagler and colleagues also said a delay in the deployment of isotretinoin causes unnecessary long-term exposure to other noneffective antibiotics, while increasing the burden of antimicrobial resistance. According to researchers, isotretinoin can provide durable remission, but its use is limited due to adverse events related to inflammatory bowel disease and psychiatric disturbances.
“In an effort to promote responsible antibiotic prescribing practices, institution of isotretinoin should be considered at an earlier time point, especially in those with severe acne,” Nagler and colleagues wrote. “In addition, dermatologists should be aware that patients presenting to them who have been cared for by other providers are at particular risk for extended courses of antibiotics.” – by David Costill
Disclosure: Nagler reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Steven R. Feldman, MD, PhD
While antibiotics play an important role in acne treatment, antibiotic resistance is a growing problem. Dermatologists need to balance the risks and benefits with little firm evidence to guide them. This study found patterns of antibiotic prescription for acne exceeding expert recommendations, highlighting the need to avoid use of topical antibiotic monotherapy, to use topical adjuncts to minimize oral antibiotic use, and to consider earlier use of isotretinoin, which comes with its own baggage.
Perspective
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Lawrence F. Eichenfield
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.
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.
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
Research associate
Rady Children’s Hospital San Diego.
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