Association of pharyngitis with oral antibiotic use for the treatment of acne: a cross-sectional and prospective cohort study

Guidelines of care for the management of acne vulgaris

BACKGROUND

Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9 years or older.

OBJECTIVE

The objective of this study was to provide evidence-based recommendations for the management of acne.

METHODS

A work group conducted a systematic review and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of evidence and formulating and grading recommendations.

RESULTS

This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements.

LIMITATIONS

Analysis is based on the best available evidence at the time of the systematic review.

CONCLUSIONS

These guidelines provide evidence-based recommendations for the management of acne vulgaris.

Barriers and Facilitators Affecting Long-Term Antibiotic Prescriptions for Acne Treatment

Importance

Dermatologists prescribe more oral antibiotics per clinician than clinicians in any other specialty. Despite clinical guidelines that recommend limitation of long-term oral antibiotic treatments for acne to less than 3 months, there is little evidence to guide the design and implementation of an antibiotic stewardship program in clinical practice.

Objective

To identify salient barriers and facilitators to long-term antibiotic prescriptions for acne treatment.

Design, Setting, and Participants

This qualitative study assessed data collected from stakeholders (including dermatologists, infectious disease physicians, dermatology resident physicians, and nonphysician clinicians) via an online survey and semistructured video interviews between March and August 2021. Data analyses were performed from August 12, 2021, to January 20, 2024.

Main Outcomes and Measures

Online survey and qualitative video interviews developed with the Theoretical Domains Framework. Thematic analyses were used to identify salient themes on barriers and facilitators to long-term antibiotic prescriptions for acne treatment.

Results

Among 30 participants (14 [47%] males and 16 [53%] females) who completed the study requirements and were included in the analysis, knowledge of antibiotic guideline recommendations was high and antibiotic stewardship was believed to be a professional responsibility. Five salient themes were to be affecting long-term antibiotic prescriptions: perceived lack of evidence to justify change in dermatologic practice, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, iPLEDGE-related barriers, and the absence of an effective system to measure progress on antibiotic stewardship.

Conclusions and Relevance

The findings of this qualitative study indicate that multiple salient factors affect long-term antibiotic prescribing practices for acne treatment. These factors should be considered in the design and implementation of any future outpatient antibiotic stewardship program for clinical dermatology.

Antibiotics and Antimicrobial Resistance in Acne: Epidemiological Trends and Clinical Practice Considerations

Antimicrobial resistance is an increasing public health problem worldwide. The interest of a focus on antimicrobial resistance in acne lies on the facts that acne vulgaris (acne) is the most common skin disease worldwide, that the bacterium Cutibacterium acnes (C. acnes, formerly Propionibacterium acnes) plays a key role in the pathogenesis of acne, while at the same time being part of the skin flora, and that antibiotics are commonly recommended for acne treatment. The overuse of topical and/or systemic antibiotics, the long treatment courses used for acne, and the availability of over-the-counter antibiotic preparations, have led to the worldwide emergence of resistant strains in acne patients. In this review, we discuss the epidemiological trends of antimicrobial resistance in acne, the need to avoid the perturbation of the skin microbiome caused by anti-acne antibiotics, and the clinical practice considerations related to the emergence of resistant strains in acne patients. In light of the increasing risk of antimicrobial resistance, raising concerns over the misuse of antibiotics, prescribing patterns can be a critical target for antibiotic stewardship efforts. Also, the selection of non-antibiotic therapies for acne, whenever possible, may offer significant advantages.

Antibiotic Resistance Risk with Oral Tetracycline Treatment of Acne Vulgaris

Almost 1 billion people worldwide have acne, and oral tetracyclines, including doxycycline and minocycline, are effective and frequently prescribed treatments for acne. However, there is growing concern for the development of antibiotic resistance with such widespread utilization by dermatologists. Additionally, tetracyclines are known to have various potential side effects, including gut dysbiosis, gastrointestinal upset, photosensitivity, dizziness, and vertigo. However, in 2018 a novel narrow-spectrum tetracycline, sarecycline, was Food and Drug Administration-approved to treat moderate-to-severe acne vulgaris in patients 9-years-old and above. Sarecycline was designed to target Cutibacterium acnes, the pathogenic bacterium in acne vulgaris, which may reduce the risk of resistance. This paper examines the growing concerns of antibiotic resistance due to oral tetracycline usage in the treatment of acne vulgaris, with a focus on the promising third-generation, narrow-spectrum tetracycline, sarecycline.

Challenges of repurposing tetracyclines for the treatment of Alzheimer's and Parkinson's disease

The novel antibiotic-exploiting strategy in the treatment of Alzheimer's (AD) and Parkinson's (PD) disease has emerged as a potential breakthrough in the field. The research in animal AD/PD models provided evidence on the antiamyloidogenic, anti-inflammatory, antioxidant and antiapoptotic activity of tetracyclines, associated with cognitive improvement. The neuroprotective effects of minocycline and doxycycline in animals initiated investigation of their clinical efficacy in AD and PD patients which led to inconclusive results and additionally to insufficient safety data on a long-standing doxycycline and minocycline therapy in these patient populations. The safety issues should be considered in two levels; in AD/PD patients (particularly antibiotic-induced alteration of gut microbiota and its consequences), and as a world-wide threat of development of bacterial resistance to these antibiotics posed by a fact that AD and PD are widespread incurable diseases which require daily administered long-lasting antibiotic therapy. Recently proposed subantimicrobial doxycycline doses should be thoroughly explored for their effectiveness and long-term safety especially in AD/PD populations. Keeping in mind the antibacterial activity-related far-reaching undesirable effects both for the patients and globally, further work on repurposing these drugs for a long-standing therapy of AD/PD should consider the chemically modified tetracycline compounds tailored to lack antimicrobial but retain (or introduce) other activities effective against the AD/PD pathology. This strategy might reduce the risk of long-term therapy-related adverse effects (particularly gut-related ones) and development of bacterial resistance toward the tetracycline antibiotic agents but the therapeutic potential and desirable safety profile of such compounds in AD/PD patients need to be confirmed.

Guidance for the pharmacological management of acne vulgaris

INTRODUCTION

Many international guidelines and expert consensuses are available to help the clinician diagnose and treat acne vulgaris; however, a simplified practical guidance that integrates current existing published recommendations is still lacking. This article aims to give practical and simplified insight into the treatment of acne.

AREAS COVERED

Herein, the author discusses the treatment of comedonal, papulopustular, and nodular/cystic/conglobate acne. The author also proposes a simplified treatment escalation strategy that is based on disease severity and extension, starting with topical treatments for mild cases and progressing over to systemic therapies in more severe cases.

EXPERT OPINION

The ideal acne treatment would simultaneously and safely target all the pathogenic factors implicated in the appearance of acne lesions with minimal side effects. Since no such treatment currently exists, combination therapies are usually recommended for most types of acne. A major limitation in choosing an appropriate treatment plan is the discrepant use of classification systems across the published literature making it difficult to draw clear and succinct conclusions about the recommendations given. Acne is not a traditional infectious disease and so while antibiotics may improve symptoms, they do not reliably resolve the condition. Thus, there is currently a tendency to opt for antibiotic-sparing treatment strategies whenever possible.

Prescribing of long-term antibiotics to adolescents in primary care: a retrospective cohort study

Background

Antibiotic overuse is linked to increased risk of antimicrobial resistance. Long-term antibiotics are commonly used for treating acne and prophylaxis of urinary tract infection. Their contribution to the overall burden of antibiotic use is relatively unknown.

Aim

To describe the volume of commonly prescribed long-term (≥28 days) antibiotic prescriptions in adolescents and young adults, trends over time, and comparisons with acute prescriptions.

Design and setting

A retrospective cohort study using UK electronic primary care records.

Method

Patients born between 1979 and 1996 and with data in the Care and Health Information Analytics database were included. The main outcome measures were antibiotic prescription rates per 1000 person-years and antibiotic prescription days per person-year between the ages of 11 and 21.

Results

In total, 320 722 participants received 710 803 antibiotic prescriptions between the ages of 11 and 21 years from 1998 to 2017. Of these 710 803 prescriptions, 191 443 (26.93%) were for long-term antibiotics (≥28 days and ≤6 months in duration). Long-term antibiotics accounted for more than two-thirds (72.48%) of total antibiotic exposure (days per person-year). Total long-term antibiotic prescribing peaked in 2013 at just under 6 days per person-year and declined to around 4 days in 2017.

Conclusion

Among adolescents and young adults, exposure to long-term antibiotics (primarily lymecycline used for acne) was much greater than for acute antibiotics and is likely to make an important contribution to antimicrobial resistance. Urgent action is needed to reduce unnecessary exposure to long-term antibiotics in this group. Increasing the use of, and adherence to, effective non-antibiotic treatments for acne is key to achieving this.

Is there an association between long-term antibiotics for acne and subsequent infection sequelae and antimicrobial resistance? A systematic review

BACKGROUND

Antimicrobial resistance (AMR) is a global health priority. Acne vulgaris is a common skin condition for which antibiotic use ranges from a few months to years of daily exposure.

AIM

To systemically search for and synthesise evidence on the risk of treatment-resistant infections, and other evidence of AMR, following long-term oral antibiotic use for acne.

DESIGN & SETTING

In this systematic review, a literature search was carried out using the databases Embase, MEDLINE, Cochrane, and Web of Science. They were searched using MeSH, Emtree, or other relevant terms, and followed a pre-registered protocol.

METHOD

Search strategies were developed with a librarian and undertaken in July 2019. All searches date from database inception. The primary outcome was antibiotic treatment failure or infection caused by a resistant organism. Secondary outcomes included detection of resistant organisms without an infection, rate of infection, or changes to flora.

RESULTS

A total of 6996 records were identified. Seventy-three full-text articles were shortlisted for full review, of which five were included. Two investigated rates of infection, and three resistance or changes to microbial flora. Three studies had 35 or fewer participants (range 20-118 496). Three studies had a serious or high risk of bias, one moderate, and one a low risk of bias. Weak evidence was found for an association between antibiotic use for acne and subsequent increased rates of upper respiratory tract infections and pharyngitis.

CONCLUSION

There is a lack of high quality evidence on the relationship between oral antibiotics for acne treatment and subsequent AMR sequelae. This needs to be urgently addressed with rigorously conducted studies.

Oral Antibiotics for Acne

Oral antibiotics are integral for treating inflammatory acne based on what is understood about the pathogenesis as well as the role of Cutibacterium acnes. However, rising concerns of antibiotic resistance and the perception of "antibiotic phobia" create potential limitations on their integration in an acne treatment regimen. When prescribing oral antibiotics, dermatologists need to consider dosage, duration, and frequency, and to avoid their use as monotherapy. These considerations are important, along with the use of newer strategies and compounds, to reduce adverse-event profiles, antibiotic resistance, and to optimize outcomes. Aside from concomitant medications, allergies, and disease severity, costs and patient demographics can influence variability in prescribing plans. There are multiple published guidelines and consensus statements for the USA and Europe to promote safe antibiotic use by dermatologists. However, there is a lack of head-to-head studies and evidence for comparative superiority of any individual antibiotic, as well as any evidence to support the use of agents other than tetracyclines. Although oral antibiotics are one of the main options for moderate to severe acne, non-antibiotic therapy such as isotretinoin and hormonal therapies should be considered. As newer therapies and more outcomes data emerge, so will improved management of antibiotic therapy to foster patient safety.

The Canadian Dermatology Association's Top Five Choosing Wisely Canada Recommendations

INTRODUCTION

In this article, we present the Canadian Dermatology Association's (CDA) Choosing Wisely Canada (CWC) list of top "Five Things Physicians and Patients Should Question in Dermatology" and the evidence in support of each recommendation.

METHODS

Using a nominal technique, the CDA Working Group and Task Force generated an initial list based on literature review and expert consultation. After several rounds of list refinement via a modified Delphi process, a final list of recommendations was generated. These were approved by the CDA Board of Directors, presented at the CDA 93rd Annual Conference in 2018, and published by CWC in 2019.

RESULTS

The top five recommendations are as follows: (1) Don't routinely prescribe antibiotics for bilateral lower leg redness and swelling; (2) Don't routinely prescribe topical combination corticosteroid/antifungal products; (3) Don't routinely use topical antibiotics on a surgical wound; (4) Don't prescribe systemic antifungals without mycological confirmation of dermatophyte infection; and (5) Don't use oral antibiotics for acne vulgaris for more than 3 months without assessing efficacy.

DISCUSSION

This list of recommendations aims to encourage both physicians and patients to reevaluate ineffective, yet common, practices in treating dermatologic conditions. These recommendations represent actionable changes in practice, and therefore have considerable potential to enhance value-based care in dermatology.

CONCLUSIONS

This list was developed to identify tangible changes in practice within dermatology that may reduce inefficiencies, prevent potential patient harm, and improve care. Future advocacy work may include updates, feedback obtainment, and patient care handouts, to continue to promote value-based healthcare and best practices.

Trends in Oral Antibiotic Prescription in Dermatology, 2008 to 2016

Importance

Dermatologists prescribe more oral antibiotic courses per clinician than any other specialty, and this use puts patients at risk of antibiotic-resistant infections and antibiotic-associated adverse events.

Objective

To characterize the temporal trends in the diagnoses most commonly associated with oral antibiotic prescription by dermatologists, as well as the duration of this use.

Design, Setting, and Participants

Repeated cross-sectional analysis of antibiotic prescribing by dermatologists from January 1, 2008, to December 31, 2016. The setting was Optum Clinformatics Data Mart (Eden Prairie, Minnesota) deidentified commercial claims data. Participants were dermatology clinicians identified by their National Uniform Claim Committee taxonomy codes, and courses of oral antibiotics prescribed by these clinicians were identified by their National Drug Codes.

Exposures

Claims for oral antibiotic prescriptions were consolidated into courses of therapy and associated with the primary diagnosis from the most recent visit. Courses were stratified into those of extended duration (>28 days) and those of short duration (≤28 days).

Main Outcomes and Measures

Frequency of antibiotic prescribing and associated diagnoses. Poisson regression models were used to assess for changes in the frequency of antibiotic prescribing over time.

Results

Between 2008 and 2016 among 985 866 courses of oral antibiotics prescribed by 11 986 unique dermatologists, overall antibiotic prescribing among dermatologists decreased 36.6% (1.23 courses per 100 visits) from 3.36 (95% CI, 3.34-3.38) to 2.13 (95% CI, 2.12-2.14) courses per 100 visits with a dermatologist (prevalence rate ratio for annual change, 0.931; 95% CI, 0.930-0.932), with much of this decrease occurring among extended courses for acne and rosacea. Oral antibiotic use associated with surgical visits increased 69.6% (2.73 courses per 100 visits) from 3.92 (95% CI, 3.83-4.01) to 6.65 (95% CI, 6.57-6.74) courses per 100 visits associated with a surgical visit (prevalence rate ratio, 1.061; 95% CI, 1.059-1.063).

Conclusions and Relevance

Continuing to develop alternatives to oral antibiotics for noninfectious conditions, such as acne, can improve antibiotic stewardship and decrease complications from antibiotic use. In addition, the rising use of postoperative antibiotics after surgical visits is concerning and may put patients at unnecessary risk of adverse events. Future studies are needed to identify the value of this practice and the risk of adverse events.

Association of Systemic Antibiotic Treatment of Acne With Skin Microbiota Characteristics

Importance

Given the widespread use of systemic antibiotics for treatment of moderate to severe acne, it is important to understand the associations of such antibiotic use with changes not only in Cutibacterium acnes (formerly Propionibacterium acnes) but also in the complete bacterial community of the skin.

Objective

To examine the composition, diversity, and resilience of skin microbiota associated with systemic antibiotic perturbation in individuals with acne.

Design, Setting, and Participants

This longitudinal cohort study conducted at an academic referral center in Maryland from February 11 to September 23, 2014, included 4 female participants who had received a recent diagnosis of acne vulgaris, showed comedonal and inflammatory acne on the face, were at least 18 years old, and had no recent use of systemic or topical treatments for acne, including antibiotics and retinoids. Data analysis was performed between July 5, 2017, and November 7, 2018.

Interventions

Participants were prescribed oral minocycline, 100 mg, twice daily for 4 weeks. Skin areas on the forehead, cheek, and chin were sampled for 16S ribosomal RNA gene sequencing at baseline, 4 weeks after starting minocycline treatment, and then 1 week and 8 weeks after discontinuation of treatment.

Main Outcomes and Measures

Skin microbiota examined with respect to relative abundance of bacterial taxa, α diversity (represents within-sample microbial diversity), and β diversity (represents between-sample microbial diversity). Acne status evaluated with photography and lesion count.

Results

Of the 4 patients included in this study, 2 were 25 years old, 1 was 29 years old, and 1 was 35 years old; 2 were white women, 1 was an African American woman, and 1 was an Asian woman. Across all 4 patients, antibiotic treatment was associated with a 1.4-fold reduction in the level of C acnes (difference, -10.3%; 95% CI, -19.9% to -0.7%; P = .04) with recovery following cessation of treatment. Distinct patterns of change were identified in multiple bacterial genera, including a transient 5.6-fold increase in the relative abundance of Pseudomonas species (difference, 2.2%; 95% CI, 0.9%-3.4%; P < .001) immediately following antibiotic treatment, as well as a persistent 1.7-fold increase in the relative abundance of Streptococcus species (difference, 5.4%; 95% CI, 0.3%-10.6%; P = .04) and a 4.7-fold decrease in the relative abundance of Lactobacillus species (difference, -0.8%; 95% CI, -1.4% to -0.2%; P = .02) 8 weeks following antibiotic treatment withdrawal. In general, antibiotic administration was associated with an initial decrease from baseline of bacterial diversity followed by recovery. Principal coordinates analysis results showed moderate clustering of samples by patient (analysis of similarity, R = 0.424; P = .001) and significant clustering of samples by time in one participant (analysis of similarity, R = 0.733; P = .001).

Conclusions and Relevance

In this study, systemic antibiotic treatment of acne was associated with changes in the composition and diversity of skin microbiota, with variable rates of recovery across individual patients and parallel changes in specific bacterial populations. Understanding the association between systemic antibiotic use and skin microbiota may help clinicians decrease the likelihood of skin comorbidities related to microbial dysbiosis.

Use of Antibiotics for Dermatologic Procedures From 2008 to 2016

Importance

Although overall antibiotic use among dermatologists is decreasing, there has been an increase in use associated with dermatologic procedures during the past decade. This higher antibiotic use may increase antibiotic-associated adverse events and promote the development of antibiotic resistance.

Objective

To characterize antibiotic use associated with dermatologic procedures, including geographic variation.

Design, Setting, and Participants

Using Optum Clinformatics DataMart deidentified commercial claims data, we performed a repeated cross-sectional analysis of antibiotic prescribing by dermatologists from 2008 to 2016. Dermatology clinicians were identified by their National Uniform Claim Committee taxonomy codes, encounters for surgical procedures were identified by Common Procedure Terminology codes, and courses of oral antibiotics prescribed by these clinicians were identified by their National Drug Codes.

Exposures

Claims for oral antibiotic prescriptions associated with encounters with dermatologists associated with dermatologic procedures.

Main Outcomes and Measures

Frequency of antibiotic prescribing and associated procedures. Poisson regression models were used to assess for changes in the frequency of antibiotic prescribing over time.

Results

Between 2008 and 2016, among 1 934 633 encounters (1 128 244 unique patients, 854 072 [44.1%] were women and the median [interquartile range] age was 66 [52-76] years) for dermatologic procedures, oral antibiotic prescribing associated with benign excisions increased from 2.9% to 4.4% of visits (52.5% relative change; incidence rate ratio [IRR], 1.04; 95% CI, 1.03-1.04), antibiotic prescribing associated with malignant excisions increased from 4.2% to 6.3% of visits (49.5% relative change; IRR, 1.06; 95% CI, 1.05-1.06), and antibiotic prescribing associated with Mohs surgery increased from 9.9% to 13.8% of visits (39.7% relative change; IRR, 1.04; 95% CI, 1.03-1.04). There was greater than 2-fold variation in antibiotic prescribing rates across geographic census divisions. If higher prescribing divisions were to develop antibiotic prescribing rates similar to lower prescribing divisions, antibiotic use could be decreased by over 50%.

Conclusions and Relevance

Oral antibiotic prescribing by dermatologists associated with benign excisions, malignant excisions, and Mohs surgery is increasing over the past decade and there is substantial geographic variation. These findings highlight that there may be opportunities to optimize antibiotic use associated with dermatologic procedures.

Growth Inhibitory Activity of Callicarpa americana Leaf Extracts Against Cutibacterium acnes

Acne vulgaris is a common skin disease affecting adolescents and young adults of all ethnic groups, negatively impacting self-esteem, self-confidence, and social life. The Gram-positive bacteria Cutibacterium acnes colonizes the sebum-rich follicle and contributes to inflammation of the pilosebaceous gland. Long-term antibiotic therapies targeting C. acnes lead to the development of antimicrobial resistance, and novel acne vulgaris therapies are needed. This study investigated the C. acnes inhibitory activity of Callicarpa americana leaves, a native Southeastern United States shrub historically used by Native Americans to treat fever, stomachache, and pruritis. Flash chromatography fractions of the ethyl acetate-soluble C. americana ethanol leaf extract (649C-F9 and 649C-F13) exhibited MICs ranging from 16 to 32 µg ml-1 and IC50 range of 4-32 μg ml-1 against a panel of 10 distinct C. acnes isolates. Cytotoxicity against an immortalized human keratinocyte cell line (HaCaTs) skin was detected at more than eight times the dose required for growth inhibitory activity (IC50 of 256 μg ml-1 for 649C-F9 and IC50 of >512 μg ml-1 for 649C-F13). This work highlights the potential of C. americana leaf extracts as a cosmeceutical ingredient for the management of acne vulgaris. Further research is necessary to assess its mechanism of action and in vivo efficacy.

Approaches to limit systemic antibiotic use in acne: Systemic alternatives, emerging topical therapies, dietary modification, and laser and light-based treatments

Acne is one of the most common diseases worldwide and affects ∼50 million individuals in the United States. Oral antibiotics are the most common systemic agent prescribed for the treatment of acne. However, their use might be associated with a variety of adverse outcomes including bacterial resistance and disruption of the microbiome. As a result, multiple treatment guidelines call for limiting the use of oral antibiotics in the treatment of acne, although actual prescribing often does not follow these guidelines. In this review, the rationale for concerns regarding the use of oral antibiotics for the management of acne is reviewed. In addition, we will discuss our approach to complying with the intent of the guidelines, with a focus on novel topical agents, dietary modification, laser and light-based modalities, and systemic medications, such as spironolactone, combined oral contraceptives, and oral isotretinoin.

A review of diagnosis and treatment of acne in adult female patients

This review focuses on the treatment options for adult female patients with acne. Acne in adult female patients may start during adolescence and persist or have an onset in adulthood. Acne has various psychosocial effects that impact patients’ quality of life. Treatment of acne in adult women specifically has its challenges due to the considerations of patient preferences, pregnancy, and lactation. Treatments vary widely and treatment should be tailored specifically for each individual woman. We review conventional therapies with high levels of evidence, additional treatments with support from cohort studies and case reports, complementary and/or alternative therapies, and new agents under development for the treatment of patients with acne.

Oral Antibacterial Therapy for Acne Vulgaris: An Evidence-Based Review

BACKGROUND

To some degree, acne vulgaris affects nearly every individual worldwide. Oral antibiotic therapy is routinely prescribed for the treatment of moderate to severe inflammatory acne; however, long-term use of oral antibiotics for acne may have unintended consequences.

OBJECTIVE

The aim of this study was to provide a systematic evaluation of the scientific evidence on the efficacy and appropriate use of oral antibiotics in the treatment of acne.

METHODS

A systematic search of MEDLINE was conducted to identify randomized controlled clinical trials, systematic reviews, and meta-analyses evaluating the efficacy of oral antibiotics for acne. Overall, 41 articles that examined oral antibiotics compared with placebo, another oral therapy, topical therapy, alternate dose, or duration were included in this study.

RESULTS

Tetracyclines, macrolides, and trimethoprim/sulfamethoxazole are effective and safe in the treatment of moderate to severe inflammatory acne. Superior efficacy of one type or class of antibiotic could not be determined, therefore the choice of antibiotic is generally based on the side-effect profile. Although different dosing regimens have been studied, there is a lack of standardized comparator trials to determine optimal dosing and duration of each oral antibiotic used in acne. The combination of oral antibiotics with a topical therapy is superior to oral antibiotics alone.

CONCLUSION

This article provides a systematic evaluation of the scientific evidence of the efficacy of oral antibiotics for acne. Due to heterogeneity in the design of the trials, there is insufficient evidence to support one type, dose, or duration of oral antibiotic over another in terms of efficacy; however, due to increasing resistance to antibiotics, dermatologists should heed consensus guidelines for their appropriate use.

Trends in prescribing behavior of systemic agents used in the treatment of acne among dermatologists and nondermatologists: A retrospective analysis, 2004-2013

BACKGROUND

Despite recommendations to limit the use of oral antibiotics and increasing support for hormonal agents in the treatment of acne, it is unclear whether there have been any significant changes in practice patterns.

OBJECTIVE

To characterize changes in prescribing behavior for systemic agents in the treatment of acne in the United States between 2004 and 2013.

METHODS

We conducted a retrospective analysis using the OptumInsight Clinformatics DataMart (Optum, Eden Prairie, MN).

RESULTS

The number of courses of spironolactone prescribed per 100 female patients being managed for acne by dermatologists and nondermatologists increased from 2.08 to 8.13 and from 1.43 to 4.09, respectively. The median duration of therapy with oral antibiotics was 126 and 129 days among patients managed by dermatologists and nondermatologists, respectively, and did not change significantly over the study period.

LIMITATIONS

The OptumInsight Clinformatics DataMart lacks information on acne severity and clinical outcomes.

CONCLUSIONS

Additional work to identify patients who would benefit most from alternative therapies such as spironolactone, oral contraceptives, or isotretinoin represents a potential opportunity to improve the care of patients with acne.

Optimizing Non-Antibiotic Treatments for Patients with Acne: A Review

Acne is a very common non-infectious skin condition that is frequently treated in dermatological practices. Because acne is often chronic and may persist for years, safe and effective long-term maintenance therapy is often required. Given the increasing frequency of antibiotic-resistant bacteria and the gravity of the consequences of this trend, it behooves dermatologists to maximize use of non-antimicrobial therapy when treating acne. In this review of the literature we present data regarding the efficacy and appropriate use of non-antimicrobial treatments for acne. A variety of topical and oral treatment options exist that can be used in a step-wise manner according to the patients’ severity and therapeutic response. Non-antimicrobial treatments can be highly efficacious at controlling acne, especially when used as maintenance therapy. While antibiotics have a role in acne treatment, they should not be used as monotherapy, and lengthy courses of antibiotic use are discouraged.

Guidelines of care for the management of acne vulgaris

Acne is one of the most common disorders treated by dermatologists and other health care providers. While it most often affects adolescents, it is not uncommon in adults and can also be seen in children. This evidence-based guideline addresses important clinical questions that arise in its management. Issues from grading of acne to the topical and systemic management of the disease are reviewed. Suggestions on use are provided based on available evidence.

Systematic review of antibiotic resistance in acne: an increasing topical and oral threat

Topical and oral antibiotics are routinely used to treat acne. However, antibiotic resistance is increasing, with many countries reporting that more than 50% of Propionibacterium acnes strains are resistant to topical macrolides, making them less effective. We reviewed the current scientific literature to enable proposal of recommendations for antibiotic use in acne treatment. References were identified through PubMed searches for articles published from January, 1954, to March 7, 2015, using four multiword searches. Ideally, benzoyl peroxide in combination with a topical retinoid should be used instead of a topical antibiotic to minimise the impact of resistance. Oral antibiotics still have a role in the treatment of moderate-to-severe acne, but only with a topical retinoid, benzoyl peroxide, or their combination, and ideally for no longer than 3 months. To limit resistance, it is recommended that benzoyl peroxide should always be added when long-term oral antibiotic use is deemed necessary. The benefit-to-risk ratio of long-term antibiotic use should be carefully considered and, in particular, use alone avoided where possible. There is a need to treat acne with effective alternatives to antibiotics to reduce the likelihood of resistance.

The use of oral antibiotics before isotretinoin therapy in patients with acne

BACKGROUND

Systemic antibiotics are used widely to treat moderate to severe acne, but increasing antibiotic resistance makes appropriate use a priority.

OBJECTIVE

We sought to determine the duration of systemic antibiotic use in patients with inflammatory/nodulocystic acne who eventually required isotretinoin.

METHODS

We performed a retrospective, single-site chart review of patients with acne diagnostic codes evaluated January 1, 2005 to December 31, 2014, at a dermatology practice in an academic medical center. Included patients were prescribed isotretinoin during the study period and received 30 days or more of antibiotics.

RESULTS

The average duration of antibiotic use was 331.3 days. In all, 21 patients (15.3%) were prescribed antibiotics for 3 months or less, 88 patients (64.2%) for 6 months or more, and 46 patients (33.6%) for 1 year or longer. Patients treated only at the study site had a mean duration of antibiotic treatment of 283.1 days whereas patients who also received antibiotics from another institution had a mean duration of 380.2 days. This difference approached statistical significance (P = .054).

LIMITATIONS

This study was limited to a single center.

CONCLUSION

Expert guidelines recommend responsible use of antibiotics in acne in light of emerging resistance. We found that patients who eventually received isotretinoin had extended exposure to antibiotics, exceeding recommendations. Early recognition of antibiotic failure and the need for isotretinoin can curtail antibiotic use.

Epidemiology and extracutaneous comorbidities of severe acne in adolescence: a U.S. population-based study

BACKGROUND

Little is known about the epidemiology of severe acne in the U.S.

OBJECTIVES

We sought to study the U.S. prevalence, determinants and comorbidities of severe acne in adolescence.

METHODS

We analysed data from the 2007 National Health Interview Survey, a cross-sectional questionnaire-based study of 9417 children ages 0-17 years. Prevalence of severe acne, demographics and comorbid disorders were determined.

RESULTS

The U.S. prevalence of severe acne was virtually nil in the first decade of life, but increased in a linear fashion from 11 years [1·7% (95% confidence interval (CI) 0·4-3·0%)] to 17 years of age [12·1% (95% CI 7·8-16·5%)] (Rao-Scott Chi-square, P < 0·0001). Severe acne was more common in Whites compared with other racial groups at age 14-15 years (P = 0·0004) and girls at age 11-13 (P = 0·02). Severe acne was associated with a number of comorbid disorders. Sinopulmonary disease included sinus infection (P = 0·0003), sore throat other than strep infection (P = 0·0003), asthma (P = 0·03) and nonasthmatic lung disease (P = 0·03). Upper gastrointestinal comorbidities included reflux/heartburn (P = 0·0003), abdominal pain (P = 0·03), nausea/vomiting (P = 0·0001) and food/digestive allergy (P = 0·01). Psychological comorbidities included depression (P = 0·02), anxiety (P < 0·0001), attention deficit disorder/attention deficit hyperactivity disorder (P = 0·01) and insomnia (P = 0·02).

CONCLUSIONS

In conclusion, severe acne was more prevalent in older age, Whites, female sex and higher socioeconomic status. Future studies are needed to confirm the associations with sinopulmonary, upper gastrointestinal and psychological disorders in adolescents.

The skin microbiome: potential for novel diagnostic and therapeutic approaches to cutaneous disease

A vast diversity of microorganisms, including bacteria, fungi, viruses, and arthropods, colonize the human skin. Culture-independent genomic approaches for identifying and characterizing microbial communities have provided glimpses into the topographical, temporal, and interpersonal complexity that defines the skin microbiome. Identification of changes associated with cutaneous disease, including acne, atopic dermatitis, rosacea, and psoriasis, are being established. In this review, our current knowledge of the skin microbiome in health and disease is discussed, with particular attention to potential opportunities to leverage the skin microbiome as a diagnostic, prognostic, and/or therapeutic tool.