Antibiotics in Acne: When to Start, How to Stop, Why Stewardship is Important
NEW YORK—“Why do we care” about antibiotic stewardship? Jonette Elizabeth Keri, MD, PhD, FAAD, asked at the beginning of her presentation on antibiotics use in acne during the 2019 American Academy of Dermatology Summer Meeting.
She discussed a recent study from the United Kingdom that looked at antibacterial resistance from oral antibiotics used to treat acne. The study found that by 2050 there will be 10 million deaths per year and about 66 trillion pounds of productivity lost attributable to antibiotic resistance. What is interesting, Dr Keri said, is they found that from 2004 to 2017, the average duration of antibiotics for acne was almost a year.
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A new article published in the British Journal of Dermatology showed that while dermatologists understand and implement antibiotic stewardship, there is a knowledge gap among primary care specialists treating acne, Dr Keri added. This is why discussions on antibiotics and antibiotic stewardship remains an important topic area in acne treatment.
Antibiotic stewardship is ensuring the patient is prescribed the right antibiotic with the right dose and for the right duration. In dermatology, clinicians limit the use of antibiotics for acne, said Dr Keri. Monotherapy is not recommended, systemic treatment should be limited to 3 months, and benzoyl peroxide should be used in combination to prevent resistance.
According to Dr Keri, resistant P acnes strains can be found in the skin of untreated contacts, such as family, of patients with acne prescribed antibiotics. Other adverse effects associated with antibiotic use and/or resistance include severe infections and resistance of other microbes, such as S Aureus. This resistance can persist after discontinuation of therapy, said Dr Keri. Slow response and relapses are good ways to judge whether patients may be developing resistance, she added.
The current acne guidelines try to address resistance, Dr Keri noted. Topical antibiotics should not be used as monotherapy, she said, they should be used in combination with benzoyl peroxide, erythromycin, or clindamycin. Benzoyl peroxide is recommended for topical antibiotics because there is no reported resistance to this agent.
A new topical option is minocycline, available as gel or foam, which has about 8 times less systemic absorption. Adapalene and benzoyl peroxide, clindamycin, and clindamycin with benzoyl peroxide can be prescribed for patients who do not want oral medications, added Dr Keri. Another new topical therapy on the horizon that Dr Keri mentioned is VCD-004, which has high potency against resistant P acnes.
Systemic antibiotics are recommended for patients with moderate to severe acne or inflammatory acne that is not responding to treatment. These should be limited to only 3 months and not prescribed as monotherapy but combined with a topical therapy. Dr Keri reiterated that dermatology, as a field, is doing a very good job of limiting duration and getting patients off antibiotics in 120 days or less.
Evidence in the guidelines for systemic medication supports all antibiotics for the treatment of acne, said Dr Keri. Sarecycline is a new antibiotic that was designed specifically for acne that is narrow spectrum, has less activity against gram negative bacteria, and less incidence of adverse effects. It is indicated for patients aged 9 years and older and dosing is based on weight.
“No routine microbiologic testing is necessary” for treating acne, said Dr Keri. Gram negative strains are rarer than we think, she said, adding physicians should use what works in their practice and keep in mind stewardship.
The best way to limit the use of antibiotics is through maintenance, Dr Keri emphasized. Options Dr Keri reviewed for maintenance included retinoids, benzo peroxide, among other agents. She also discussed light therapies and niacinamide, and mentioned other nonantibiotic therapies, such as isotretinoin. Niacinamide was found to work the same as clindamycin gel without resistance.
Envision and discuss an exit plan with patients to discontinue antibiotic use and set expectations right at the beginning of treatment, Dr Keri said.
Improving antibiotic stewardship is important because other specialties are seeing resistance. For example, Dr Keri said, patients in orthopedic clinics are developing infections from P acne in their native joints, which presents as a vague arthritis.
Dr Keri discussed the benefits of probiotic use as well, with evidence showing people do tend to do better with probiotics compared with placebo.
“When all else fails consider Instagram,” said Dr Keri. She discussed a study that monitored Instagram posts related to antibiotic use for acne over 8 years. Many posts showed individuals did not like oral antibiotics 25% of the time and topical antibiotics 9% of the time. These negative posts were mostly related to treatments not working. According to the authors of the study, dermatologists may need to consider reaching patients in different ways. Instagram may help dermatologists increase their reach and ability to educate patients about antibiotic use and ensure they get the correct information. “So, maybe Instagram can help,” Dr Keri concluded.
—Melissa Weiss
Reference
Keri JE. Antibiotics in acne. Presented at: the 2019 American Academy of Dermatology Summer Meeting; July 25-28, 2019; New York, NY.