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 study published online October 30 in the Journal of the American Academy of Dermatology.
"Expert groups and global committees have repeatedly made recommendations to limit the use of systemic antibiotics," write Arielle R. Nagler, MD, from New York University School of Medicine Department of Dermatology in New York City, and colleagues. "Prolonged courses of systemic antibiotics are discouraged for several reasons including increasing resistance of [Propionibacterium] acnes to antibiotics."
The authors note that the Centers for Disease Control and Prevention has ranked antibiotic 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.
"Dermatologists must 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 seen at 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 study received antibiotics for at least 30 days and received isotretinoin. Of these, 25.5% patients had inflammatory acne and 74.5% had nodulocystic acne. Scarring was 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.
Patients used 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 more likely 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 who were also prescribed antibiotics elsewhere (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 a complete 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 percentage of patients were on oral antibiotics for such a long stretch of time," Doris Day, MD, a dermatologist at Lenox Hill Hospital in New York City, told Medscape Medical News. "I don't think of oral antibiotics as a long-term approach," said Dr Day, who was 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 happy and cleared by continuing that course," Dr Day said. "Another part of it 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.
J Am Acad Dermatol. Published online October 30, 2015. Abstract
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Cite this: Acne: Antibiotic Use Regularly Exceeds Recommended Duration - Medscape - Nov 06, 2015.