Optimizing use of oral antibiotics in acne vulgaris

Increased Incidence of Pseudotumor Cerebri Syndrome Among Users of Tetracycline Antibiotics

BACKGROUND

To determine whether the use of a tetracycline-class antibiotic is associated with an increased risk of developing pseudotumor cerebri syndrome (PTCS).

METHODS

We identified patients in the University of Utah Health system who were prescribed a tetracycline-class antibiotic and determined what percentage of those individuals were subsequently diagnosed with PTCS secondary to tetracycline use. We compared this calculation to the number of patients with PTCS unrelated to tetracycline use.

RESULTS

Between 2007 and 2014, a total of 960 patients in the University system between the ages of 12 and 50 were prescribed a tetracycline antibiotic. Among those, 45 were diagnosed with tetracycline-induced PTCS. We estimate the incidence of tetracycline-induced PTCS to be 63.9 per 100,000 person-years. By comparison, the incidence of idiopathic intracranial hypertension (IIH) is estimated to be less than one per 100,000 person-years (Calculated Risk Ratio = 178).

CONCLUSIONS

Although a causative link between tetracycline use and pseudotumor cerebri has yet to be firmly established, our study suggests that the incidence of pseudotumor cerebri among tetracycline users is significantly higher than the incidence of IIH in the general population.

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.

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.

A Comparison Between the Clinical Features of Pseudotumor Cerebri Secondary to Tetracyclines and Idiopathic Intracranial Hypertension

PURPOSE

Comparisons between clinical features of tetracycline-induced pseudotumor cerebri (PTC-T) and those of idiopathic intracranial hypertension (IIH) are absent in the literature. We hypothesized that significant clinical differences between these etiologies exist and could be better understood by retrospective analysis.

DESIGN

Retrospective cohort study.

METHODS

We reviewed patients diagnosed with pseudotumor cerebri syndrome (PTCS) at our center and identified those who developed PTC-T after treatment with a tetracycline-class antibiotic and those with IIH. Groups were compared by demographics, body mass index, ophthalmic examination, treatment, clinical course, and visual outcomes.

RESULTS

We identified 52 cases of PTC-T and 302 cases of IIH. Obesity rates were significantly different (43.8% for PTC-T vs 79.2% for IIH, P < .001). The mean age at diagnosis was younger for PTC-T (19.8 years vs 28.1 years for IIH, P < .001). Diplopia was more common with PTC-T (40.4% vs 20.1% for IIH, P = .001). The mean illness duration was shorter for PTC-T (18.3 weeks vs 62.9 weeks for IIH, P <.0001). Recurrence rates were significantly different (4.0% for PTC-T vs 16.5% for IIH, P <.001). The frequency of surgical intervention was similar. Vision loss was uncommon but occurred with similar frequency.

CONCLUSION

We identified significant clinical differences but also identified important similarities between the 2 groups. There appear to be nonobese patients who develop PTC-T, discontinue the antibiotic, and never develop PTCS again. There are other patients who develop PTC-T, discontinue the antibiotic, and later develop IIH. We conclude that PTC-T represents a spectrum of disease in susceptible individuals.

The susceptibility of pathogens associated with acne vulgaris to antibiotics

BACKGROUND Acne vulgaris is a pilosebaceous disorder. Bacterial activity and inflammation both influence acne formation. Antibiotics suppress the bacterial activities and elicit anti-inflammatory effects. The overuse of antibiotics may lead to resistance in bacteria. This study was aimed to provide an overview of bacteria that may cause acne and determine their susceptibility to antibiotics.METHODS This was a cross-sectional study sampling from 93 patients with acne in Ciptomangunkusumo Hospital. Comedones were extracted and cultured on Brucella blood agar, under aerobic and anaerobic conditions at 35oC for 24–48 hours. Bacterial identification was performed using Vitek®, and susceptibility test using E-test. Data interpretation was based on the Clinical and Laboratory Standards Institute 2015.RESULTS Staphylococcus epidermidis (50.5%), Propionibacterium acnes (11.0%), and Staphylococcus aureus (7.7%) were identified. Bacteria were not found in 69.2% and 1.1% of samples in anaerobic and aerobic cultures, respectively. P. acnes was susceptible to doxycycline (100%) and minocycline (100%), while 10% was resistant to erythromycin, clindamycin, and tetracycline. S. epidermidis was susceptible to minocycline (100%); but resistant to erythromycin (65.2%), clindamycin (52.2%) and tetracycline (32.6%). The susceptibility of S. epidermidis to doxycycline was 89.1%, which was lower than that of P. acnes (100%). S. aureus was found to be sensitive to minocycline (100%), doxycycline (71.4%), clindamycin (71.4%), and tetracycline (71.4%); but it was resistant to erythromycin (42.9%).CONCLUSIONS Doxycycline and minocycline showed 100% effectiveness for P. acnes. The isolated bacteria were more susceptible to doxycycline compared to tetracycline. The use of clindamycin and erythromycin needs to be limited as most S. epidermidis isolates were resistant to both.

Preoperative Doxycycline Does Not Reduce Propionibacterium acnes in Shoulder Arthroplasty

BACKGROUND

Propionibacterium acnes (P. acnes) is the most common bacteria associated with infection after shoulder arthroplasty. These bacteria can be grown on culture of skin after standard preoperative skin preparation and antibiotics. The purpose of this study was to determine whether adding preoperative intravenous doxycycline reduces the prevalence of positive P. acnes cultures of skin and deep tissues at the time of prosthetic joint implantation during shoulder arthroplasty.

METHODS

This was a randomized controlled trial. An a priori power analysis determined that a sample size of 56 patients was necessary. Patients scheduled to undergo shoulder arthroplasty were randomized to receive either standard perioperative cefazolin or a combination of doxycycline and cefazolin. Tissue specimens for culture were then taken from the skin edge, and swabs of the superficial dermal tissue and glenohumeral joint were obtained. All cultures were maintained for 14 days to allow for P. acnes detection. Groups were compared to determine if the addition of doxycycline reduced the rate of culture positivity.

RESULTS

Fifty-six patients were enrolled and randomized. Twenty-one (38%) had ≥1 positive cultures for P. acnes, with no significant difference between the group treated with cefazolin alone (10 [37%] of 27 patients) and the combined doxycycline and cefazolin group (11 [38%] of 29 patients) (p = 0.99). The greatest numbers of culture-positive samples were obtained from the skin (30%), followed by dermal tissue (20%) and the glenohumeral joint (5%). Patients who had ≥1 positive cultures were younger than those who did not (mean age [and standard deviation], 64.9 ± 7.7 versus 69.4 ± 7.7 years; p = 0.041), had a greater tendency to be male (16 [76%] of 21 versus 17 [49%] of 35; p = 0.053), and had a lower Charlson Comorbidity Index (3.35 ± 1.3 versus 4.09 ± 1.4; p = 0.051). There were no significant differences between the culture-positive and culture-negative groups in terms of body mass index (BMI) (p = 0.446) or arthroplasty type, with positive cultures found for 8 of the 29 anatomic shoulder arthroplasty procedures compared with 13 of the 27 reverse shoulder arthroplasty procedures (p = 0.280). There were no doxycycline-related adverse events.

CONCLUSIONS

In this randomized controlled trial, doxycycline did not significantly decrease P. acnes culture positivity of the skin, dermis, or glenohumeral joint of patients undergoing shoulder arthroplasty. The addition of prophylactic intravenous antibiotics to cover P. acnes may not be an effective method to reduce postoperative and periprosthetic shoulder joint infections.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Synchronizing Pharmacotherapy in Acne with Review of Clinical Care

Acne is a chronic inflammatory skin disease that involves the pathogenesis of four major factors, such as androgen-induced increased sebum secretion, altered keratinization, colonization of Propionibacterium acnes, and inflammation. Several acne mono-treatment and combination treatment regimens are available and prescribed in the Indian market, ranging from retinoids, benzoyl peroxide (BPO), anti-infectives, and other miscellaneous agents. Although standard guidelines and recommendations overview the management of mild, moderate, and severe acne, relevance and positioning of each category of pharmacotherapy available in Indian market are still unexplained. The present article discusses the available topical and oral acne therapies and the challenges associated with the overall management of acne in India and suggestions and recommendations by the Indian dermatologists. The experts opined that among topical therapies, the combination therapies are preferred over monotherapy due to associated lower efficacy, poor tolerability, safety issues, adverse effects, and emerging bacterial resistance. Retinoids are preferred in comedonal acne and as maintenance therapy. In case of poor response, combination therapies BPO-retinoid or retinoid-antibacterials in papulopustular acne and retinoid-BPO or BPO-antibacterials in pustular-nodular acne are recommended. Oral agents are generally recommended for severe acne. Low-dose retinoids are economical and have better patient acceptance. Antibiotics should be prescribed till the inflammation is clinically visible. Antiandrogen therapy should be given to women with high androgen levels and are added to regimen to regularize the menstrual cycle. In late-onset hyperandrogenism, oral corticosteroids should be used. The experts recommended that an early initiation of therapy is directly proportional to effective therapeutic outcomes and prevent complications.

The Clinical Relevance of Antibiotic Resistance: Thirteen Principles That Every Dermatologist Needs to Consider When Prescribing Antibiotic Therapy

Antibiotics are commonly used by dermatologists in clinical practice, primarily because of the overall track record of favorable efficacy and safety with the most commonly used agents. During the past decade, increased attention has been given to the problems associated with antibiotic resistance. This article summarizes important principles gleaned from the continued efforts of the Scientific Panel on Antibiotic Use in Dermatology; other groups working diligently in this area, such as the Centers for Disease Control and Prevention and the Canadian Antimicrobial Resistance Alliance; and from the published literature.

A consensus-based practical and daily guide for the treatment of acne patients

BACKGROUND

Many current guidelines provide detailed evidence-based recommendations for acne treatment.

OBJECTIVE

To create consensus-based, simple, easy-to-use algorithms for clinical acne treatment in daily office-based practice and to provide checklists to assist in determining why a patient may not have responded to treatment and what action to take.

METHODS

Existing treatment guidelines and consensus papers were reviewed. The information in them was extracted and simplified according to daily clinical practice needs using a consensus-based approach and based on the authors' clinical expertise.

RESULTS

As outcomes, separate simple algorithms are presented for the treatment of predominant comedonal, predominant papulopustular and nodular/conglobate acne. Patients with predominant comedonal acne should initially be treated with a topical retinoid, azelaic acid or salicylic acid. Fixed combination topicals are recommended for patients with predominant papulopustular acne with treatment tailored according to the severity of disease. Treatment recommendations for nodular/conglobate acne include oral isotretinoin or fixed combinations plus oral antibiotics in men, and these options may be supplemented with oral anti-androgenic hormonal therapy in women. Further decisions regarding treatment responses should be evaluated 8 weeks after treatment initiation in patients with predominant comedonal or papulopustular acne and 12 weeks after in those with nodular/conglobate acne. Maintenance therapy with a topical retinoid or azelaic acid should be commenced once a patient is clear or almost clear of their acne to prevent the disease from recurring. The principal explanations for lack of treatment response fall into 5 main categories: disease progression, non-drug-related reasons, drug-related reasons, poor adherence, and adverse events.

CONCLUSION

This practical guide provides dermatologists with treatment algorithms adapted to different clinical features of acne which are simple and easy to use in daily clinical practice. The checklists to establish the causes for a lack of treatment response and subsequent action to take will facilitate successful acne management.

Evidence-based recommendations for the diagnosis and treatment of pediatric acne

INTRODUCTION

Acne vulgaris is one of the most common skin conditions in children and adolescents. The presentation, differential diagnosis, and association of acne with systemic pathology differs by age of presentation. Current acknowledged guidelines for the diagnosis and management of pediatric acne are lacking, and there are variations in management across the spectrum of primary and specialty care. The American Acne and Rosacea Society convened a panel of pediatric dermatologists, pediatricians, and dermatologists with expertise in acne to develop recommendations for the management of pediatric acne and evidence-based treatment algorithms.

METHODS

Ten major topic areas in the diagnosis and treatment of pediatric acne were identified. A thorough literature search was performed and articles identified, reviewed, and assessed for evidence grading. Each topic area was assigned to 2 expert reviewers who developed and presented summaries and recommendations for critique and editing. Furthermore, the Strength of Recommendation Taxonomy, including ratings for the strength of recommendation for a body of evidence, was used throughout for the consensus recommendations for the evaluation and management of pediatric acne. Practical evidence-based treatment algorithms also were developed.

RESULTS

Recommendations were put forth regarding the classification, diagnosis, evaluation, and management of pediatric acne, based on age and pubertal status. Treatment considerations include the use of over-the-counter products, topical benzoyl peroxide, topical retinoids, topical antibiotics, oral antibiotics, hormonal therapy, and isotretinoin. Simplified treatment algorithms and recommendations are presented in detail for adolescent, preadolescent, infantile, and neonatal acne. Other considerations, including psychosocial effects of acne, adherence to treatment regimens, and the role of diet and acne, also are discussed.

CONCLUSIONS

These expert recommendations by the American Acne and Rosacea Society as reviewed and endorsed by the American Academy of Pediatrics constitute the first detailed, evidence-based clinical guidelines for the management of pediatric acne including issues of special concern when treating pediatric patients.

Neolitsea aciculata Essential Oil Inhibits Drug-Resistant Skin Pathogen Growth and Propionibacterium acnes-Induced Inflammatory Effects of Human Monocyte Leukemia

This study examined the chemical composition of Neolitsea aciculata essential oil (NAE) and its biological activities. NAE was obtained by hydrodistillation of N. aciculata leaves collected in Jeju Island and analyzed by gas chromatography equipped with a mass spectrometer detector. 1-Dodecen-3-yne (12.5%), calarene (11.5%) and elemol (9.5%) were identified as the major components of NAE. The antibacterial and anti-inflammatory activities of NAE against skin pathogens were examined to determine the protective properties against acne vulgaris. NAE exhibited moderate to strong antibacterial activity against drug-susceptible and -resistant Propionibacterium acnes and Staphylococcus epidermidis, which are known as acne-causing bacteria. In addition, NAE reduced the P. acnes-induced secretion of tumor necrosis factor-α (TNF-α) and interleukin-8 (IL-8) in THP-1 cells, highlighting its anti-inflammatory effects. The DPPH radical scavenging activities of NAE also revealed moderate antioxidant properties (IC50, 21.3 μL/mL). Overall, NAE is an attractive candidate as an ingredient in skin care products.

Interaction and efficacy of Keigai-rengyo-to extract and acupuncture in male patients with acne vulgaris: a study protocol for a randomized controlled pilot trial

BACKGROUND

In consideration of patients seeking to use traditional Chinese medicine, an evidence-based potentiality for safe and effective use of herbal medicine and acupuncture in treatment of acne vulgaris has been suggested. However, despite common use of a combination of herbal medicine and acupuncture in clinical practice, the current level of evidence is insufficient to draw a conclusion for an interaction and efficacy of herbal medicine and acupuncture. Therefore, considering these methodological flaws, this study was designed to assess the interaction and efficacy of an available herbal medicine, Keigai-rengyo-to extract (KRTE), and acupuncture for treatment of acne using the 2 × 2 factorial design and the feasibility of a large clinical trial.

METHODS/DESIGN

A randomized, assessor single blinded, 2 × 2 factorial pilot trial will be conducted. Forty four participants with acne vulgaris will be randomized into one of four groups: waiting list group (WL), KRTE only group (KO), acupuncture only group (AO), and KRTE and acupuncture combined treatment group (KA). After randomization, a total of 8 sessions of acupuncture treatment will be performed twice a week in the AO- and KA groups, respectively. Patients in the KO- and KA groups will be prescribed KRTE 3 times a day at a dose of 7.4 g after meals for 4 weeks. The following outcome measurements will be used in examination of subjects: the mean percentage change and the count change of inflammatory and non-inflammatory acne lesions, the Skindex 29, visual analogue scale (VAS) and investigator global assessment (IGA) from baseline to the end of the trial.

TRIAL REGISTRATION

The trial is registered with the Clinical Research Information Service (CRiS), Republic of Korea: KCT0000071.

Treating acne with antibiotic-resistant bacterial colonization

INTRODUCTION

Acne is a chronic skin disorder of the pilosebaceous unit; it has a multifactorial pathogenesis. Propionibacterium acnes within the follicle is considered to be a triggering factor of inflammation in acne. Antibiotics have been the primary treatment against P. acnes for more than 40 years. However, a gradual increase in the prevalence of antibiotic-resistant strains of P. acnes has been observed.

AREAS COVERED

This review discusses the pathophysiology of antibiotic-resistant acne development. It focuses on strategies to minimize the development of resistance and, most importantly, confront the development of antibiotic-resistant acne. The literature search was conducted up to August 2010, using the search terms 'acne', 'antibiotic-resistant acne' and 'bacterial resistance'.

EXPERT OPINION

Antibiotic-resistant acne is a real phenomenon. Strategies to prevent and confront it should include not only the use of certain treatment regimens but also rational prescribing policies, combination therapies, use of antibacterial non-antibiotic agents and treatment options targeting all the pathogenetic components of acne. Benzoyl-peroxide-based treatment is the most evidence-based approach. Oral isotretinoin remains the most efficacious option for severe acne.

Perspectives on therapeutic options for acne: an update

It is clear that acne vulgaris often has medical and psychosocial implications that can range from mild to severe. To minimize these risks, evaluation and appropriate treatment are necessary, even in the younger pediatric patient. This article provides an overview of the current information on the topical and systemic treatment of acne, including innovative delivery options and new formulations and combinations of existing medications.

Assessing potential human health hazards and benefits from subtherapeutic antibiotics in the United States: tetracyclines as a case study

Many scientists, activists, regulators, and politicians have expressed urgent concern that using antibiotics in food animals selects for resistant strains of bacteria that harm human health and bring nearer a "postantibiotic era" of multidrug resistant "super-bugs." Proposed political solutions, such as the Preservation of Antibiotics for Medical Treatment Act (PAMTA), would ban entire classes of subtherapeutic antibiotics (STAs) now used for disease prevention and growth promotion in food animals. The proposed bans are not driven by formal quantitative risk assessment (QRA), but by a perceived need for immediate action to prevent potential catastrophe. Similar fears led to STA phase-outs in Europe a decade ago. However, QRA and empirical data indicate that continued use of STAs in the United States has not harmed human health, and bans in Europe have not helped human health. The fears motivating PAMTA contrast with QRA estimates of vanishingly small risks. As a case study, examining specific tetracycline uses and resistance patterns suggests that there is no significant human health hazard from continued use of tetracycline in food animals. Simple hypothetical calculations suggest an unobservably small risk (between 0 and 1.75E-11 excess lifetime risk of a tetracycline-resistant infection), based on the long history of tetracycline use in the United States without resistance-related treatment failures. QRAs for other STA uses in food animals also find that human health risks are vanishingly small. Whether such QRA calculations will guide risk management policy for animal antibiotics in the United States remains to be seen.