Antibiotic overuse for acne common, misunderstood

Recent research suggests dermatologists are prescribing antibiotics for acne patients even when the drugs are proven ineffective, and acne patients and their parents often underestimate the risks and potential consequences associated with antibiotic acne treatment.

The evidence

In a study published online September 30 in the Journal of the American Academy of Dermatology, New York University (NYU) researchers found the average duration of antibiotic use among dermatology patients with acne was 331.2 days. More than a third of those patients who were on antibiotics for a year or longer.

The study’s lead author, Arielle Nagler, M.D., instructor, Ronald O. Perelman Department of Dermatology at NYU Langone Medical Center, told Dermatology Times that if a patient’s acne is not well controlled after six to eight weeks of antibiotic therapy, dermatologists should begin to discuss this with their patients and create alternative treatment plans.

READ: Faster response to antibiotic therapy failure needed

“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,” the researchers concluded in the study’s abstract.

While dermatologists might be overprescribing antibiotics for acne treatment, patients and their parents seem unaware of the consequences, as well as alternatives to antibiotic treatment for acne, according to a new survey by Galderma Laboratories. The survey of 809 acne patients and 210 parents of acne patients found:

• Sixty-four percent of survey respondents were not aware that overuse of topical antibiotics to treat acne could make them a carrier of drug-resistant bacteria.
• More than 50 percent of respondents had not spoken with their doctor about the risk of antibiotic use for acne treatment.
• While 65 percent of respondents said that they try to avoid antibiotics unless they are the only option, only a third of those not prescribed antibiotic-free acne treatment were aware such treatments existed. 
• Only 28 percent of those who were not prescribed antibiotic-free acne treatment had ever discussed antibiotic-free treatment for acne with their healthcare providers.

NEXT: Talking points for dermatologists

Talking points for dermatologists

Joshua Zeichner, M.DJoshua Zeichner, M.D, director of cosmetic and clinical research in dermatology at Mt. Sinai Hospital in New York City and a Galderma consultant, told Dermatology Times that physicians are comfortable writing prescriptions for antibiotics. The drugs are easy to use - even when they are being used incorrectly.

ALSO READ: Partnering with pharmacists in responsible prescribing

“Isotretinoin is a very safe medication when used appropriately, but there is a lot of patient education necessary when prescribing it and hurdles to cross with the iPledge program,” Dr. Zeichner says. “Antibiotics should be used for limited periods, to get severe patients under control, after which they should be discontinued.”

It’s time to consider treatments such as isotretinoin after several months of combination therapy using oral antibiotics with topicals without improvement or if the skin significantly flares after discontinuation of oral antibiotics, according to the dermatologist.

NEXT: Tips for how dermatologists can engage with their acne patients

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Dr. Zeichner offers these tips for how dermatologists can engage in more productive dialogue with their acne patients:

• Dermatologists must understand the issues and be proactive about treating their patients. “Explain the risks to patients, who may not be asking the questions, themselves. Let them know that topical antibiotics must be used with benzoyl peroxide to reduce the risk of developing bacterial resistance. Also, there are effective antibiotic-free options, including retinoids, BPO, and dapsone that do not promote resistance. Examples include Epiduo Forte Gel (adapalene and benzoyl peroxide) 0.3%/2.5% [Galderma]; Retin-A Micro Gel (tretinoin) microsphere, 0.1%, 0.08% and 0.04% [Valeant Pharmaceuticals]; Atralin Gel (tretinoin) 0.05% [Medicis]; Differin Gel (adapalene), 0.3% [Galderma]; Tazorac Cream and Gel (tazarotene) 0.1%; and Aczone (dapsone) Gel 5% [Allergan],” he says.
• Set your limits. If patients cannot get off antibiotics, it may be time to consider alternative treatments, like oral isotretinoin. “If patients do not agree, then you may not be able to continue treating the patient. Choosing to discontinue antibiotics or making sure that you are truly using them correctly can be a challenge and may be the more difficult road to take initially,” Dr. Zeichner says. “In the long run, however, for the overall health of your patient and the greater good in general, proper use of antibiotics is important.”
• Go the extra mile. It might take an extra five minutes of conversation in the room, but it is an important conversation to have. Dermatologists who don’t have time for these discussions with their acne patients should make sure that their staff members or physician extenders are properly trained to talk patients about antibiotic use.

If not curbed, antibiotic overuse can have serious implications for patients.

Continuing ineffective antibiotics for the treatment of acne can result in scarring. And resistant p. acnes and commensal organisms can contribute to multidrug resistant infections, including MRSA and vancomycin resistant enterococcus, according to Dr. Zeichner.

READ: Antimicrobial stewardship programs aim to curb resistance problem

“The commensals are like innocent bystanders who experience the effects of the antibiotics,” he says. “They develop resistance genes that may be passed on to close contacts. When the commensals spread resistant genes to pathogenic bugs that invade the body--that is where the problem lies. Because this is a long-term, distant problem and not immediately recognizable, many providers feel that it is not a real issue or it is not their problem. We all need to work together to protect our patients in the present, and in both the immediate and distant future.”