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Medscape Medical News

Acne: Antibiotic UseRegularly Exceeds Recommended Duration

Tara Haelle
November 06, 2015

Patients with severe acne tend to receive treatment with antibiotics for a much

longer duration than guidelines recommend before eventually receiving

isotretinoin, according to a retrospective studypublished online October 30 in the Journal of the American Academy of Dermatology.

"Expertgroups and global committees have repeatedly made recommendations

to limit theuse of systemic antibiotics," write Arielle R. Nagler, MD, from New

York University School of Medicine Department of Dermatology in New York City, andcolleagues. "Prolonged courses of systemic antibiotics are discouraged for

several reasons including increasing resistance of [Propionibacterium] acnes

toantibiotics."

Theauthors note that the Centers for Disease Control and Prevention has rankedantibiotic resistance as one of the top five health threats. Early recognition of patients who fail to respond to systemic antibiotics and early prescription of

isotretinoin would help curtail antibiotic use, they point out.

"Dermatologistsmust play an essential role in antibiotic stewardship because

although dermatologists only account for approximately 1% of the physicians in

the United States, their prescriptions account for 4.9% of the yearly antibiotic

prescriptions," Dr Nagler and colleagues write.

The researchers retrospectively reviewed all 5053 charts of patients with acne

seenat a single academic medical center dermatology practice between January 2005 and December 2014. After excluding 4916 patients who did not meet

criteria or who did not have enough data, the remaining 137 patients analyzed for the studyreceived antibiotics for at least 30 days and received isotretinoin. Of

these, 25.5% patients had inflammatory acne and 74.5% had nodulocystic acne. Scarringwas present in 73.0% of the patients.

The most commonly prescribed systemic antibiotic was minocycline, making up 72.5%of the prescriptions, followed by doxycycline and then azithromycin. Others included tetracycline, sulfamethoxazole-trimethoprim, cefadroxil, and

erythromycin. Each patient was prescribed an average of 1.96 antibiotic classes.

Patientsused antibiotics for a mean 331.3 days overall, ranging from 37 to 1501 days(median, 238 days). Only 15.3% of patients were prescribed antibiotics for 3 months or less, whereas 64.2% took them for at least 6 months and 33.6%

took them for at least a year.

Many expert groups around the world have recommended that antibiotic use in

acne be time limited. "Three months is the most commonly used cut-off point

for limiting the duration of antibiotics in acne," the authors write."The duration of

treatment required before resistance emerges varies greatly between patients,

but the longer the duration of treatment, the morelikely antibiotic resistance will

emerge. Courses 6 months or longer are highly likely to induce resistance."

Those treated only at the study site took systemic antibiotics for an average

duration of 283.1 days, whereas average duration was 380.2 days for those whowere also prescribed antibiotics else where (P = .054). "When encountering

patients who have been treated for acne previously, dermatologists should be

aware of the risk for extended antibiotic durations, attempt to get acomplete

antibiotic history, and consider timely initiation of isotretinoin if appropriate," the

authors write.

An average 155.8 days passed between the first chart notation of considering isotretinoin and actually initiating isotretinoin treatment, but the authors note that

"iPLEDGE requirements make isotretinoin prescription more complicated," and

"controversies surrounding the possible association between isotretinoin and

inflammatory bowel and psychiatric diseases may make patients and their

families more wary of the medication." Chart reviews confirmed that parents had concerns about inflammatory bowel disease and depression, anxiety, or suicidal

thoughts.

"I was surprised that such a large percent age of patients were on oral antibioticsfor such a long stretch of time," Doris Day, MD, a dermatologist at Lenox Hill

Hospital in New York City, told Medscape Medical News. "Idon't think of oral

antibiotics as a long-term approach," said Dr Day, whowas not involved in the

research.

She said oral antibiotics should take only 3, or maximum 4, months to clear

acne enough so that topical treatments work as maintenance therapy or to

determine that the patient needs different topicals or isotretinoin. But patient

preferences may play a role lengthening durations of antibiotic use.

"For physicians, it's easy to prescribe an antibiotic and to keep the patient happyand cleared by continuing that course," Dr Day said. "Another part ofit is patients often want a quick and easy fix, and taking a pill is easier than using a cream or

set of creams that may be drying and irritating to the skin and which take time to work. As much as possible, oral antibiotic use should be limited to relatively short courses of about 3 months and alternatives should be considered to maintain

acne clearance."

The research did not use external funding. One coauthor served as a consultant

for Dermira, Galderma, GSK/Stiefel, and Provectus and as an investigator for

Amgen.

JAm Acad Dermatol. Published online October 30, 2015.

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