It takes a motivated, dedicated patient to adhere to their prescribed acne regimen. According to Moradi Tuchayi et al, primary nonadherence occurs when the medication is not even started. This may be due to lack of knowledge, confusion about usage, a weak physician-patient relationship, fear of adverse reactions, and cost. Secondary nonadherence exists when the medication is started but is not taken as directed because of a lack of results, complex regimens, side effects, a busy lifestyle, forgetfulness, inconvenience, and psychiatric comorbidity. Proposed solutions to these hurdles include treatment simplification, technology (such as text reminders to use medication), and education so that the patient truly understands how to use the medications properly and what to expect from them (1).
Earlier this year, the AAD published its guidelines for the treatment of acne vulgaris, based on the recommendations of the workgroup co-chaired by Drs. Andrea Zaenglein and Arun Pathy. Regarding the use of systemic antibiotics, two key points were:
1) Systemic antibiotic use should be limited to the shortest possible duration. Re-evaluate at 3-4 months to minimize the development of bacterial resistance. Monotherapy with systemic antibiotics is not recommended
2) Concomitant topical therapy with benzoyl peroxide or a retinoid should be used with systemic antibiotics and for maintenance after completion of systemic antibiotic therapy (2).
|Aside from specific adverse reactions that may occur with antibiotics (e.g. DRESS syndrome with minocycline, photosensitivity from doxycycline, Stevens-Johnson syndrome with trimethoprim-sulfamethoxazole, etc.), or the potential for other adverse reactions noted with long-term use of antibiotics (e.g. pharyngitis, inflammatory bowel disease, Candidal vaginitis, or pseudomembranous colitis due to Clostridium difficile), the prime motivation for limiting the use of antibiotics is to limit developing antibiotic resistance.
Barbieri et al evaluated the duration of therapy with oral tetracyclines and the use of topical retinoids among patients with acne treated primarily by general practitioners in the United Kingdom. They conducted a retrospective cohort study using the Health Improvement Network database. The mean duration of therapy was 175.1 days. Of antibiotic courses, 62% were not associated with a topical retinoid; 29% exceeded 6 months in duration. The authors concluded that prescribing behavior for oral antibiotics in the treatment of acne among general practitioners is not aligned with current guideline recommendations. They suggest that by increasing the use of topical retinoids and considering alternative agents to oral antibiotics (i.e. oral contraceptives, spironolactone, or isotretinoin), when appropriate, represent opportunities to reduce antibiotic exposure and associated complications such as antibiotic resistance (3). In a recent study of antibiotic use for acne performed at an academic medical center, the average duration of antibiotic therapy for acne was 331.3 days (4).
I fully appreciate the necessity of limiting antibiotic exposure. I am also grateful for the disclaimer in the guidelines that they should not be interpreted as setting a standard of care. Additionally, Barbieri et al state: “For some patients who cannot achieve adequate improvement with topical agents alone and for whom an alternative oral agent such as isotretinoin or spironolactone is not feasible or contraindicated, longer courses of oral antibiotics may be the most appropriate treatment approach” (3).
A realistic scenario is that an attentive primary physician starts his teenage patient on doxycline for a 3 months course of therapy, while prescribing a benzoyl peroxide wash and a retinoid. A follow-up examination 3 months later demonstrates that there was minimal improvement, so a referral is made to a dermatologist. It takes another 3 months to get that appointment. Even if it is clear that the patient requires other treatment, if the choice is isotretinoin (and the patient is female), another delay ensues.
The evidence behind the guidelines both for acne treatment and limitation of antibiotic use is based on a consensus of expert opinions. While these should be respected, they should not be considered sacrosanct. Education of how to use antibiotics properly for acne patients should be expected of all health care providers who prescribe them. Importantly, it must always be remembered that guidelines are just that – there must always be flexibility for all prescriptions based on the patient’s unique circumstances.
- Moradi Tuchayi S, et al. Interventions to increase adherence to acne treatment. Patient Prefer Adherence 2016; 10: 20191-6.
- Zaenglein AL, Pathy AL, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016; 74: 945-73.
- Barbieri JS, et al. Duration of oral tetracycline-class antibiotic therapy and use of topical retinoids for the treatment of acne among general practitioners (GP): A retrospective cohort study. J Am Acad Dermatol 2016; 75: 1142-50.
- Nagler AR, et al. The use of oral antibiotics before isotretinoin in patients with acne. J Am Acad Dermatol 2016; 74: 273-9.