Overuse of Antibiotics for Acne Vulgaris: Too Much of a Good Thing

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In recent years, resistance to antimicrobial drugs has become increasingly widespread, resulting in a health threat of epidemic proportions. The long list of drug-resistant bacteria continues to expand at an accelerated pace. What does this mean in the dermatology world? We are not the only problem but are certainly part of the problem, representing 5% of all antibiotic prescriptions annually even though we represent only 1% of all physicians in the United States. These prescriptions certainly do not just include skin and soft tissue functions, as a survey-based study by Chouake et al (J Drugs Dermatol. 2014;13:119-124.) showed that dermatologists are overusing antibiotics in the treatment of simple skin abscesses such as acne vulgaris, one of the most common inflammatory skin diseases.

Although the inappropriate utilization of antibiotics for acne has been a subject of great discourse for years, it recently reentered the limelight in a study by Nagler et al published online in October 2015 in the Journal of the American Academy of Dermatology. They showed that patients who ultimately were treated with isotretinoin had been receiving antibiotics for months without any sign of therapeutic life or course end in sight. This retrospective chart review evaluated the duration of systemic antibiotic use prior to starting isotretinoin in 137 patients with inflammatory/nodulocystic acne. Antibiotic use continued for a mean of 331.3 days (median, 238 days). Duration of antibiotic use was divided into categories: 3 months or less (15.3%), 6 months or more (64.2%), or 1 year or more (33.6%).

Let’s take a broad look at antimicrobial resistance. Bacterial drug resistance has numerous negative effects on medicine and society. Drug-resistant bacterial infections result in higher doses of drugs, the addition of treatments with higher toxicity, longer hospital stays, and increased mortality. In the United States, infections due to antibiotic-resistant bacteria add $20 billion to total health care costs plus $35 billion in costs to society.

Unfortunately, it is relatively easy for bacterium to develop drug resistance through 3 simple steps: acquisition by microbes of resistance genes, expression of those resistance genes, and selection for pathogens expressing those resistance genes. The selective pressure in favor of resistance occurs whenever microbes are exposed to a drug but not eradicated, either by the killing effects of the drug itself or by inhibitory effects of the drug followed by killing by the host’s immune system. In any setting that creates this selective pressure in favor of drug resistance, such as poor patient compliance (ie, infrequent dosing, taking an antibiotic for too long as we see with the use of antibiotics for the treatment of inflammatory skin diseases such as acne), the likelihood of that resistance actually developing is increased. In addition, drugs that inhibit but do not kill microbes are more likely to allow some microbial cells to live and therefore develop resistance when exposed to a drug, which accounts for the majority of antibiotics in our armament. Lastly, abuse of broad-spectrum antibiotics has further spurred the emergence of many antibiotic-resistant strains. For instance, Pseudomonas aeruginosa is one of many evolving multidrug-resistant microorganisms that have been collectively coined the “ESKAPE” pathogens (Enterococcus faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, P aeruginosa, Enterobacter species) to emphasize the fact that they “escape” the effects of many antibacterial agents.

All of the above does not take into account the environmental factors that play a role in this resistance. The close quarters, mass/public transportation, and stressful pace of life of urban living not only bring these organisms together to share resistance genes but also increase our susceptibility.

What’s the issue?

We can all do our part in the fight against microbial resistance and join the antimicrobial stewardship. Here are a couple tips for dermatologists:

  1. Stop using over-the-counter antibiotic ointment for every biopsy or minor procedure, which is one of the recommendations of the American Academy of Dermatology based on the ABIM Foundation’s Choosing Wisely campaign.
  2. Oral and topical antibiotics for inflammatory skin diseases such as acne, rosacea, and hidradenitis suppurativa should only be used temporarily or at subantimicrobial dosing. Always combine a benzoyl peroxide–containing wash with a topical or oral antibiotic to hit the bacteria with multiple mechanisms of antibacterial activity to limit resistance. Don’t use benzoyl peroxide stronger than 2.5% for the face; make sure to wash it off completely to avoid staining your towels, sheets, and clothing.

We can all play our part in the fight against antimicrobial resistance. How do you fight the resistance?

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