Duration of oral antibiotic therapy for the treatment of adult acne: A retrospective analysis investigating adherence to guideline recommendations and opportunities for cost-savings

Challenges in designing a randomized, double-blind noninferiority trial for treatment of acne: The SD-ACNE trial

BACKGROUND/AIMS

Excessive use of antibiotics has led to development of antibiotic resistance and other antibiotic-associated complications. Dermatologists prescribe more antibiotics per clinician than any other major specialty, with much of this use for acne. Alternative acne treatments are available but are used much less often than antibiotics, at least partially because dermatologists feel that they are less effective. Spironolactone, a hormonal therapy with antiandrogen effects that can address the hormonal pathogenesis of acne, may represent a therapeutic alternative to oral antibiotics for women with acne. However, the comparative effects of spironolactone and oral antibiotics in the treatment of acne have not been definitively studied. The Spironolactone versus Doxycycline for Acne: A Comparative Effectiveness, Noninferiority Evaluation (SD-ACNE) trial aims to answer whether spironolactone, in addition to standard topical therapy, is noninferior to doxycycline (an oral antibiotic) for women with acne. Several interesting challenges arose in the development of this study, including determining acceptability of the comparative regimens to participating dermatologists, identifying data to support a noninferiority margin, and establishing a process for unblinding participants after they completed the study while maintaining the blind for study investigators.

METHODS

We present the scientific and clinical rationale for the decisions made in the design of the trial, including input from key stakeholders through a Delphi consensus process.

RESULTS

The Spironolactone versus Doxycycline for Acne: A Comparative Effectiveness, Noninferiority Evaluation trial (NCT04582383) is being conducted at a range of community and academic sites in the United States. To maximize external validity and inform clinical practice, the study is designed with broad eligibility criteria and no prohibition of use of topical medications. Participants in the trial will be randomized to receive either spironolactone 100 mg/day or doxycycline hyclate 100 mg/day for 16 weeks. The primary outcome is the absolute decrease in inflammatory lesion count, and we have established a noninferiority margin of four inflammatory lesions. Secondary outcomes include the percentage of participants achieving Investigator Global Assessment success, change in quality of life, and microbiome changes and diversity.

CONCLUSIONS

The Spironolactone versus Doxycycline for Acne: A Comparative Effectiveness, Noninferiority Evaluation trial will have substantial implications for the treatment of acne and antibiotic stewardship. In addition, this study will provide important information on the effect of these systemic agents on the development of changes to the microbiome and antibiotic resistance in a healthy population of patients.

Barriers and Facilitators Affecting Long-Term Antibiotic Prescriptions for Acne Treatment

Importance

Dermatologists prescribe more oral antibiotics per clinician than clinicians in any other specialty. Despite clinical guidelines that recommend limitation of long-term oral antibiotic treatments for acne to less than 3 months, there is little evidence to guide the design and implementation of an antibiotic stewardship program in clinical practice.

Objective

To identify salient barriers and facilitators to long-term antibiotic prescriptions for acne treatment.

Design, Setting, and Participants

This qualitative study assessed data collected from stakeholders (including dermatologists, infectious disease physicians, dermatology resident physicians, and nonphysician clinicians) via an online survey and semistructured video interviews between March and August 2021. Data analyses were performed from August 12, 2021, to January 20, 2024.

Main Outcomes and Measures

Online survey and qualitative video interviews developed with the Theoretical Domains Framework. Thematic analyses were used to identify salient themes on barriers and facilitators to long-term antibiotic prescriptions for acne treatment.

Results

Among 30 participants (14 [47%] males and 16 [53%] females) who completed the study requirements and were included in the analysis, knowledge of antibiotic guideline recommendations was high and antibiotic stewardship was believed to be a professional responsibility. Five salient themes were to be affecting long-term antibiotic prescriptions: perceived lack of evidence to justify change in dermatologic practice, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, iPLEDGE-related barriers, and the absence of an effective system to measure progress on antibiotic stewardship.

Conclusions and Relevance

The findings of this qualitative study indicate that multiple salient factors affect long-term antibiotic prescribing practices for acne treatment. These factors should be considered in the design and implementation of any future outpatient antibiotic stewardship program for clinical dermatology.

Prescribing Patterns of Oral Antibiotics and Isotretinoin for Acne in a Colorado Hospital System: Retrospective Cohort Study

BACKGROUND

Guidelines established by the American Academy of Dermatology recommend oral antibiotics as first-line therapy for mild, moderate, and severe acne. However, it is recommended to minimize the duration of oral antibiotic use, and there is increasing support for other systemic agents for acne.

OBJECTIVE

We sought to characterize the use of oral antibiotics and isotretinoin for the treatment of acne in the pediatric and young adult population aged 10 through 20 years and the adult population aged 21 to 45 years from 2011 to 2019.

METHODS

We conducted a retrospective, observational cohort study using electronic data from the enterprise data warehouse of the University of Colorado Anschutz Medical Campus and its affiliates, with data in the format of the Observational Health Data Sciences and Informatics (OHDSI) Observational Medical Outcomes Partnership (OMOP) common data model. Categorical values (sex, race, and ethnicity) were compared using chi-square tests, and continuous variables (age) were compared using 2-tailed t tests.

RESULTS

Our cohort of 15,704 patients was composed of mostly White (12,776/15,704, 81.4%), non-Hispanic or Latino (13,307/15,704, 84.7%), and female (11,093/15,704, 70.6%) patients. Among the 4605 male patients in the eligible cohort, 1810 (39%) received an oral antibiotic treatment, in comparison to 3109 (28%) of the 11,093 eligible women (P<.001). Among the 4605 men who were eligible for treatment with isotretinoin in this population, 988 (21.5%) received a course of isotretinoin, compared to only 10.4% (1159/11,093) eligible women (P<.001). Male patients were 1.67 times more likely to have received an antibiotic prescription (odds ratio [OR] 1.67, 95% CI 1.55-1.79) and over twice as likely to have received an isotretinoin prescription (OR 2.34, 95% CI 2.13-2.57) than female patients.

CONCLUSIONS

Minocycline was the most frequently prescribed antibiotic for the treatment of acne in this study cohort. From 2015 to 2019, there was no significant change in the number of antibiotic prescriptions over time. Men were significantly more likely to receive both oral antibiotics and isotretinoin than female patients. Multiple factors could be contributing to this discrepancy, including the burden of iPLEDGE, additional systemic treatment options for female patients, and the difference in acne severity across sexes. We could not determine the difference in severity of acne between male and female patients in our cohort, and further research is needed to ascertain the variation across sexes.

Efficacy of a retinoid complex plus anti-inflammatory component cream alone or in combination with prebiotic food supplement in adult acne: A randomized, assessor-blinded, parallel-group, multicenter trial on 184 women

BACKGROUND

Adult female acne (AFA) nowadays is a very common skin condition affecting mainly women aged between 25 and 40. The treatment of AFA could be challenging.

STUDY AIM

We evaluate and compare the efficacy and tolerability of a cream formulation containing two retinoid molecules (hydroxypinacolone/retinyl palmitate) combined with Iris Florentina root extract and a complex of three oligopeptides (C) applied twice a day (morning and evening) alone or in combination (C + O) with a food supplement containing a mixture of prebiotic molecules (FOS&GOS) zinc, lactoferrin, and niacinamide.

SUBJECTS AND METHODS

In a multicenter, randomized, assessor-blinded, 12-week trial, we assessed the efficacy of these two regimens in the evolution of AFA lesions (non-inflammatory: NI-L; inflammatory: IL; and total number of lesions: TL). Additional efficacy endpoints were the evolution of the 6-point (from 0 to 5) GEA and Adult Female Acne Scoring Tool (AFAST) scores.

RESULTS

One hundred and eighty-four women (mean age 32 ± 6 years) with AFA agreed to participate after obtaining informed consent. They were randomized (2:1) to the topical product (n = 123) (Group C) or to the combination (n = 61) (Group C + O) treatment. All enrolled patients concluded the trial with no drop-out. At baseline, NI-L, IL, and TL acne lesion count were 15 ± 9, 9 ± 5, and 24 ± 14 in the Group C and 19 ± 8, 9 ± 4, and 29 ± 10 in Group C + O. In comparison with the number of the acne lesions at the baseline, both treatment regimens induced a significant reduction (p = 0.0001, ANOVA test) at Week 12 in NI-L, IL, and TL by -54%, -63%, and - 59% in Group C and by -55%, -73%, and - 61% in the Group C + O, respectively. At Week 12, the absolute IL count reduction vs. baseline was significantly (p = 0.0158) greater in Group C + O (-7.0) in comparison with Group C (-5.5). The GEA absolute score reduction in Group C + O group was significantly greater in comparison with Group C (-1.5 vs. -1.1; p = 0.0097). In the Group C + O, a greater percentage of success treatment (defined as a GEA score of 0/1 at Week 12) was observed in comparison with Group C (39% vs. 27%; p = 0.06). AFAST score at baseline was 2.4 ± 0.5 in group C and 2.8 ± 0.6 in group C + O. AFAST score was reduced by 21% and by 51% after 6 and 12 weeks of treatment in group C and by 22% and 55% in group C + O, respectively. Both treatment regimens were well tolerated. Not relevant adverse events were recorded.

CONCLUSION

A cream containing retinoid molecules and Iris Florentina root extract is effective and well tolerated in the management of AFA. The treatment combination with a prebiotic and anti-inflammatory food supplement offers an additional clinical benefit mainly in reducing inflammatory lesions and improving the severity acne score.

Antibiotic use and bacterial resistance in patients with acne vulgaris

ABSTRACT

Acne vulgaris is a prevalent chronic skin disease caused by obstruction and/or inflammation of pilosebaceous follicles. Each year, about 50 million people in the United States are affected. The use of topical and oral antibiotics to manage acne has been associated with the development of bacterial resistance. This article reviews concerns about antimicrobial use, current treatment recommendations, and emerging research in unconventional treatments.

Host Microbiota Balance in Teenagers with Gum Hypertrophy Concomitant with Acne Vulgaris: Role of Oral Hygiene Associated with Topical Probiotics

Gum hypertrophy is a very frequent condition linked to orthodontic treatment, especially in teenagers, and the same time, about 80% of young adults are affected by acne vulgaris, a chronic inflammatory skin disease, typically treated with antibacterial therapy. The use of probiotics has gained popularity in the medical field, and many studies have demonstrated its effectiveness, such as the positive effects of some bacterial strains belonging to Lactobacillus species. The aim of this study is to document the effect of Lactobacillus reuteri (L. reuteri) on facial skin that was randomly observed in two orthodontic patients. We present two case reports of a 14-year-old female patient and a 15-year-old male patient suffering from acne vulgaris who, during fixed orthodontic treatment, showed clinical signs of gingivitis with high values of Full Mouth Plaque Score (FMPS) and Bleeding on Probing (BOP). The patients were treated first with professional oral hygiene sessions and Scaling and Root Planing (SRP) procedures, and then with the administration of a formulate containing L. reuteri as a probiotic. The follow-up was made at four weeks. During the follow-up analysis, both patients showed a significant clinical remission for gum hypertrophy and skin acne vulgaris.

Temporal Trends and Clinician Variability in Potassium Monitoring of Healthy Young Women Treated for Acne With Spironolactone

Importance

Although recent studies and guideline recommendations indicate that potassium level monitoring is of low usefulness for healthy young women being treated for acne with spironolactone, little is known about whether these recommendations have been implemented in clinical practice.

Objective

To evaluate trends in rates of potassium level monitoring among young women treated for acne with spironolactone and clinician variability in monitoring practices.

Design, Setting, and Participants

This retrospective cohort study was conducted between January 1, 2008, and June 30, 2019, using data from the Optum deidentified Clinformatics Data Mart database. Participants comprised 108 547 healthy female patients aged 12 to 45 years who were treated for acne with spironolactone.

Main Outcome and Measures

The primary outcome was the proportion of women who received a test for baseline potassium level and the proportion of women whose potassium levels were monitored in the first 180 days of being treated for acne with spironolactone. For clinicians who had prescribed at least 5 courses of spironolactone, the percentage of clinicians who ordered baseline potassium testing or monitoring and the percentage of clinicians who always monitored potassium were compared between 2008 and 2015 vs between 2016 and 2018.

Results

For 108 547 women included in this cohort study, the mean (SD) age at the start of treatment was 30.7 (8.6) years, and the mean (SD) course duration was 159 (218) days. Between 2008 and 2018, the percentage of women whose potassium levels were monitored within 180 days of starting spironolactone by all clinicians decreased from 41.4% to 38.5%, with a decrease from 48.9% to 41.0% among dermatologists and from 39.7% to 37.7% among internists but with an increase from 71.4% to 75.4% among advanced practice clinicians (ie, nurse practitioners and physician assistants). The proportion of dermatologists who always monitored potassium decreased from 10.6% between 2008 and 2015 to 4.2% between 2016 and 2018. There was no significant difference in the proportion of internists who always monitored potassium from 2008 to 2015 (15.8%) vs from 2016 to 2018 (17.7%).

Conclusions and Relevance

Despite increasing evidence and guidelines supporting the elimination of potassium monitoring among healthy young women treated for acne with spironolactone, the present study findings suggest that potassium monitoring remains common, with substantial variability in clinician practices. There is a need for future implementation and dissemination research to understand underlying factors for this variation and to develop strategies to address this practice gap.

Long-term use of spironolactone for acne in women: A case series of 403 patients

BACKGROUND

There are limited data regarding the long-term outcomes of spironolactone use for women with acne and its effect on truncal acne.

OBJECTIVE

To comprehensively describe outcomes of patients treated with spironolactone in routine clinical practice, including long-term outcomes.

METHODS

We performed a retrospective case series of 403 adult women treated for acne with spironolactone at an academic medical center between 2008 and 2019. Rates of objective, as assessed by Comprehensive Acne Severity Scale scores, and subjective acne clearance were evaluated, as well as rates of treatment discontinuation, dosage changes, and drug survival. Logistic regression was used to assess for association between incidence of menstrual adverse effects and combined oral contraceptive use.

RESULTS

As evaluated by Comprehensive Acne Severity Scale scores, at the first follow-up, 75.5%, 84.0%, and 80.2% of patients with available data had reduction or complete clearance of acne on the face, chest, and back, respectively. The mean drug survival was 470.7 days. Menstrual adverse effects were less common among those using combined oral contraception (odds ratio, 0.23; 95% confidence interval, 0.11-0.50).

LIMITATIONS

This study was conducted at a single academic medical center.

CONCLUSIONS

Spironolactone improves clinical outcomes and is well tolerated for many adult women with acne using it for an extended duration.

Trends in Oral Antibiotic Prescription in Dermatology, 2008 to 2016

Importance

Dermatologists prescribe more oral antibiotic courses per clinician than any other specialty, and this use puts patients at risk of antibiotic-resistant infections and antibiotic-associated adverse events.

Objective

To characterize the temporal trends in the diagnoses most commonly associated with oral antibiotic prescription by dermatologists, as well as the duration of this use.

Design, Setting, and Participants

Repeated cross-sectional analysis of antibiotic prescribing by dermatologists from January 1, 2008, to December 31, 2016. The setting was Optum Clinformatics Data Mart (Eden Prairie, Minnesota) deidentified commercial claims data. Participants were dermatology clinicians identified by their National Uniform Claim Committee taxonomy codes, and courses of oral antibiotics prescribed by these clinicians were identified by their National Drug Codes.

Exposures

Claims for oral antibiotic prescriptions were consolidated into courses of therapy and associated with the primary diagnosis from the most recent visit. Courses were stratified into those of extended duration (>28 days) and those of short duration (≤28 days).

Main Outcomes and Measures

Frequency of antibiotic prescribing and associated diagnoses. Poisson regression models were used to assess for changes in the frequency of antibiotic prescribing over time.

Results

Between 2008 and 2016 among 985 866 courses of oral antibiotics prescribed by 11 986 unique dermatologists, overall antibiotic prescribing among dermatologists decreased 36.6% (1.23 courses per 100 visits) from 3.36 (95% CI, 3.34-3.38) to 2.13 (95% CI, 2.12-2.14) courses per 100 visits with a dermatologist (prevalence rate ratio for annual change, 0.931; 95% CI, 0.930-0.932), with much of this decrease occurring among extended courses for acne and rosacea. Oral antibiotic use associated with surgical visits increased 69.6% (2.73 courses per 100 visits) from 3.92 (95% CI, 3.83-4.01) to 6.65 (95% CI, 6.57-6.74) courses per 100 visits associated with a surgical visit (prevalence rate ratio, 1.061; 95% CI, 1.059-1.063).

Conclusions and Relevance

Continuing to develop alternatives to oral antibiotics for noninfectious conditions, such as acne, can improve antibiotic stewardship and decrease complications from antibiotic use. In addition, the rising use of postoperative antibiotics after surgical visits is concerning and may put patients at unnecessary risk of adverse events. Future studies are needed to identify the value of this practice and the risk of adverse events.

Association of Systemic Antibiotic Treatment of Acne With Skin Microbiota Characteristics

Importance

Given the widespread use of systemic antibiotics for treatment of moderate to severe acne, it is important to understand the associations of such antibiotic use with changes not only in Cutibacterium acnes (formerly Propionibacterium acnes) but also in the complete bacterial community of the skin.

Objective

To examine the composition, diversity, and resilience of skin microbiota associated with systemic antibiotic perturbation in individuals with acne.

Design, Setting, and Participants

This longitudinal cohort study conducted at an academic referral center in Maryland from February 11 to September 23, 2014, included 4 female participants who had received a recent diagnosis of acne vulgaris, showed comedonal and inflammatory acne on the face, were at least 18 years old, and had no recent use of systemic or topical treatments for acne, including antibiotics and retinoids. Data analysis was performed between July 5, 2017, and November 7, 2018.

Interventions

Participants were prescribed oral minocycline, 100 mg, twice daily for 4 weeks. Skin areas on the forehead, cheek, and chin were sampled for 16S ribosomal RNA gene sequencing at baseline, 4 weeks after starting minocycline treatment, and then 1 week and 8 weeks after discontinuation of treatment.

Main Outcomes and Measures

Skin microbiota examined with respect to relative abundance of bacterial taxa, α diversity (represents within-sample microbial diversity), and β diversity (represents between-sample microbial diversity). Acne status evaluated with photography and lesion count.

Results

Of the 4 patients included in this study, 2 were 25 years old, 1 was 29 years old, and 1 was 35 years old; 2 were white women, 1 was an African American woman, and 1 was an Asian woman. Across all 4 patients, antibiotic treatment was associated with a 1.4-fold reduction in the level of C acnes (difference, -10.3%; 95% CI, -19.9% to -0.7%; P = .04) with recovery following cessation of treatment. Distinct patterns of change were identified in multiple bacterial genera, including a transient 5.6-fold increase in the relative abundance of Pseudomonas species (difference, 2.2%; 95% CI, 0.9%-3.4%; P < .001) immediately following antibiotic treatment, as well as a persistent 1.7-fold increase in the relative abundance of Streptococcus species (difference, 5.4%; 95% CI, 0.3%-10.6%; P = .04) and a 4.7-fold decrease in the relative abundance of Lactobacillus species (difference, -0.8%; 95% CI, -1.4% to -0.2%; P = .02) 8 weeks following antibiotic treatment withdrawal. In general, antibiotic administration was associated with an initial decrease from baseline of bacterial diversity followed by recovery. Principal coordinates analysis results showed moderate clustering of samples by patient (analysis of similarity, R = 0.424; P = .001) and significant clustering of samples by time in one participant (analysis of similarity, R = 0.733; P = .001).

Conclusions and Relevance

In this study, systemic antibiotic treatment of acne was associated with changes in the composition and diversity of skin microbiota, with variable rates of recovery across individual patients and parallel changes in specific bacterial populations. Understanding the association between systemic antibiotic use and skin microbiota may help clinicians decrease the likelihood of skin comorbidities related to microbial dysbiosis.

Acne, the Skin Microbiome, and Antibiotic Treatment

Acne vulgaris is a chronic skin disorder involving hair follicles and sebaceous glands. Multiple factors contribute to the disease, including skin microbes. The skin microbiome in the follicle is composed of a diverse group of microorganisms. Among them, Propionibacterium acnes and Malassezia spp. have been linked to acne development through their influence on sebum secretion, comedone formation, and inflammatory response. Antibiotics targeting P. acnes have been the mainstay in acne treatment for the past four decades. Among them, macrolides, clindamycin, and tetracyclines are the most widely prescribed. As antibiotic resistance becomes an increasing concern in clinical practice, understanding the skin microbiome associated with acne and the effects of antibiotic use on the skin commensals is highly relevant and critical to clinicians. In this review, we summarize recent studies of the composition and dynamics of the skin microbiome in acne and the effects of antibiotic treatment on skin microbes.

Acne antibiotic prescription pattern in Colombia

BACKGROUND

Bacterial resistance to antibiotics has been growing exponentially. Acne is the most common outpatient complains in dermatology, and involve the use of antibiotics for treatment.

METHODS

We conducted a drug utilization study, with a retrospective and descriptive design, in order to evaluated the antibiotic prescription pattern for acne vulgaris patients who were cared for the first time in 2015, and were prescribed with an antibiotic, no matter if it was topical, oral or both, and compared it against the Colombian clinical practice guidelines valid for that year in our country.

RESULTS

Three hundred sixty-nine patients were randomly collected, 221 women and 148 men. There were a correct adherence to guidelines in election of an antibiotic, its dosage, and time of use in 51.7%, 94.85%, and 76.1%, respectively. 37.1% of patients has being correctly prescribe globally, taking into consideration the three previously describe variables.

CONCLUSIONS

A no adherent antibiotic prescription was documented for less than half of the patients. In almost a quarter of the patients it was not prescribed for the right time and in most patients the correct dose was chosen. It is important to know the prescription pattern as it allows decisions to be made that lead to an adequate use of antibiotics, and thus prevent the development of antimicrobial resistance.

Approaches to limit systemic antibiotic use in acne: Systemic alternatives, emerging topical therapies, dietary modification, and laser and light-based treatments

Acne is one of the most common diseases worldwide and affects ∼50 million individuals in the United States. Oral antibiotics are the most common systemic agent prescribed for the treatment of acne. However, their use might be associated with a variety of adverse outcomes including bacterial resistance and disruption of the microbiome. As a result, multiple treatment guidelines call for limiting the use of oral antibiotics in the treatment of acne, although actual prescribing often does not follow these guidelines. In this review, the rationale for concerns regarding the use of oral antibiotics for the management of acne is reviewed. In addition, we will discuss our approach to complying with the intent of the guidelines, with a focus on novel topical agents, dietary modification, laser and light-based modalities, and systemic medications, such as spironolactone, combined oral contraceptives, and oral isotretinoin.

Verantwortlicher Umgang mit Antibiotika: Notwendigkeit der Antibiotikareduktion in der Aknetherapie

Der übermäßige oder unkritische weltweite Einsatz von Antibiotika in der Medizin hat die Ausbreitung von Antibiotikaresistenzen beschleunigt. In einigen Bereichen sind viele Antibiotika bei bakteriellen Infektionen, die zuvor noch gut auf antibakterielle Wirkstoffe reagierten, mittlerweile wirkungslos geworden. Dermatologen/Venerologen setzten orale und topische Antibiotika bei der Behandlung von Acne vulgaris routinemäßig ein, obwohl Akne weder eine infektiöse Erkrankung ist noch alleine durch das Propionibacterium getriggert wird. Vielmehr ist sie eine komplexe, chronische entzündliche Hauterkrankung, die durch verschiedene pathogenetische Faktoren wie follikuläre Hyperkeratose, erhöhter Sebumproduktion, bakterielle Proliferation und Entzündung zustande kommt. Folglich sollte eine erfolgreiche Therapie auf die Bekämpfung verschiedener pathogenetischer Faktoren und nicht nur auf die von Propionibacterium acnes abzielen. Daher wurden topische Retinoide und Benzoylperoxid als Mittel der ersten Wahl definiert. Monotherapien mit lokalen Antibiotika sollten insgesamt vermieden werden. Systemische Antibiotika der Tetrazyklin-Gruppe haben bei bestimmen Krankheitsstadien ihren Sinn, ihre Wirkung könnte aber eher auf der antientzündlichen als auf der antibiotischen Reaktion beruhen. Gesundheitsbehörden ermahnen alle Gesundheitsdienstleister, den Einsatz von Antibiotika einzuschränken. Das Nutzen-Risiko-Verhältnis muss bei der Entscheidung für oder gegen eine antibiotische Therapie bei einem einzelnen Patienten immer auch in Bezug auf das öffentliche Interesse am Erhalt der Wirksamkeit von Antibiotika abgewogen werden. Im Folgenden werden das aktuelle Krankheitskonzept zu Acne vulgaris und die sich daraus ableitenden Konsequenzen für den Einsatz von Antibiotika vorgestellt.

Oral Antibacterial Therapy for Acne Vulgaris: An Evidence-Based Review

BACKGROUND

To some degree, acne vulgaris affects nearly every individual worldwide. Oral antibiotic therapy is routinely prescribed for the treatment of moderate to severe inflammatory acne; however, long-term use of oral antibiotics for acne may have unintended consequences.

OBJECTIVE

The aim of this study was to provide a systematic evaluation of the scientific evidence on the efficacy and appropriate use of oral antibiotics in the treatment of acne.

METHODS

A systematic search of MEDLINE was conducted to identify randomized controlled clinical trials, systematic reviews, and meta-analyses evaluating the efficacy of oral antibiotics for acne. Overall, 41 articles that examined oral antibiotics compared with placebo, another oral therapy, topical therapy, alternate dose, or duration were included in this study.

RESULTS

Tetracyclines, macrolides, and trimethoprim/sulfamethoxazole are effective and safe in the treatment of moderate to severe inflammatory acne. Superior efficacy of one type or class of antibiotic could not be determined, therefore the choice of antibiotic is generally based on the side-effect profile. Although different dosing regimens have been studied, there is a lack of standardized comparator trials to determine optimal dosing and duration of each oral antibiotic used in acne. The combination of oral antibiotics with a topical therapy is superior to oral antibiotics alone.

CONCLUSION

This article provides a systematic evaluation of the scientific evidence of the efficacy of oral antibiotics for acne. Due to heterogeneity in the design of the trials, there is insufficient evidence to support one type, dose, or duration of oral antibiotic over another in terms of efficacy; however, due to increasing resistance to antibiotics, dermatologists should heed consensus guidelines for their appropriate use.

Trends in prescribing behavior of systemic agents used in the treatment of acne among dermatologists and nondermatologists: A retrospective analysis, 2004-2013

BACKGROUND

Despite recommendations to limit the use of oral antibiotics and increasing support for hormonal agents in the treatment of acne, it is unclear whether there have been any significant changes in practice patterns.

OBJECTIVE

To characterize changes in prescribing behavior for systemic agents in the treatment of acne in the United States between 2004 and 2013.

METHODS

We conducted a retrospective analysis using the OptumInsight Clinformatics DataMart (Optum, Eden Prairie, MN).

RESULTS

The number of courses of spironolactone prescribed per 100 female patients being managed for acne by dermatologists and nondermatologists increased from 2.08 to 8.13 and from 1.43 to 4.09, respectively. The median duration of therapy with oral antibiotics was 126 and 129 days among patients managed by dermatologists and nondermatologists, respectively, and did not change significantly over the study period.

LIMITATIONS

The OptumInsight Clinformatics DataMart lacks information on acne severity and clinical outcomes.

CONCLUSIONS

Additional work to identify patients who would benefit most from alternative therapies such as spironolactone, oral contraceptives, or isotretinoin represents a potential opportunity to improve the care of patients with acne.

Variation in the Cost of Managing Actinic Keratosis

Importance

Actinic keratosis (AK), a skin growth induced by ultraviolet light exposure, requires chronic management because a small proportion can progress into squamous cell skin cancer. Spending for AK management was more than $1 billion in 2004. Investigating geographic variation in AK spending presents an opportunity to decrease waste or recoup excess spending.

Objective

To evaluate geographic variation in health care cost for management of AKs and the association with patient-related and health-related factors.

Design, Setting, and Participants

This retrospective cohort study was performed using data from the MarketScan medical claims database of 488 324 continuously enrolled members with 2 or more claims for AK. Data from January 1, 2008, to December 31, 2012, was used.

Main Outcomes and Measures

Annual costs of care were calculated for outpatient visits, AK destruction, and medications for AKs, and the total of these components. Costs were adjusted for inflation to 2014 US dollars. To display cost variation, we calculated the ratio of mean cost in the highest quintile (Q5) relative to the mean in the lowest quintile (Q1), or the Q5:Q1 ratio; Q5:Q1 ratios were adjusted based on age, sex, history of nonmelanoma skin cancer, US geographic region, and population density (metropolitan statistical area).

Results

Overall, data from 488 324 continuously enrolled members (mean [SD] age, 53.1 [7.5] years; 243 662 women) with 2 or more claims for AK were included. Overall, patients had 1 085 985 claims related to AK, and dermatologists accounted for 71.0% of claims. The 2-year total cost was $111.5 million, with $52.4 million in 2011 and $59.1 million in 2012. The unadjusted Q5:Q1 ratios for total annual cost per patient ranged from 9.49 to 15.10. Adjusted ratios ranged from 1.72 to 1.80.

Conclusions and Relevance

There is variation in AK management cost within and between regions. This is not fully explained by differences in patient characteristics such as age, sex, or comorbidities. The annual cost for 10 common conditions from Medicare had lower Q5:Q1 ratios that ranged from 1.33 (joint degeneration of back/neck) to 1.69 (chronic sinusitis) when compared with 1.72 to 1.80 for AKs. This suggests an opportunity to investigate and improve the value of health care delivery in the management of AKs.

Infectious Disease Practice Gaps in Dermatology

The article highlights different educational and practice gaps in infectious diseases as they pertain to dermatology. These gaps include the use of antibiotics in relation to atopic dermatitis and acne vulgaris, treatment of skin and soft tissue infection, and diagnosis and treatment of onychomycosis. In addition, practice gaps related to use of imiquimod for molluscum contagiosum, risk of infections related to immunosuppressive medications and rates of vaccination, and the use of bedside diagnostics for diagnosing common infections were discussed.