Trends in prescription of acne medication in the US: Shift from antibiotic to non‐antibiotic treatment

Pharmacist Prescriptive Authority for Acne: An Evidence-Based Approach to Policy

The diagnosis of acne is typically straightforward and based on physical signs and symptoms. Some jurisdictions in Canada, the United Kingdom, and United States have enabled a pharmacist treatment model to diagnose and manage patients with mild acne using prescription medications. Studies have found the model to be safe and effective, while simultaneously increasing more timely access to care for patients which may reduce the potential adverse impacts of acne. Further, use of a standardized protocol may alleviate some of the concerns expressed over the model. This paper summarize answers to frequent questions to help policymakers consider the objective evidence for their jurisdiction.

Treatment effects of lysozyme-shelled microbubbles and ultrasound in inflammatory skin disease

Acne vulgaris is the most common skin disorder, and is caused by Propionibacterium acnes (P. acnes) and can induce inflammation. Antibiotic therapy often needs to be administered for long durations in acne therapy, which results in extensive antibiotic exposure. The present study investigated a new treatment model for evaluating the antibacterial effects of lysozyme (LY)-shelled microbubbles (MBs) and ultrasound (US)-mediated LY-shelled MBs cavitation against P. acnes both in vitro and in vivo, with the aims of reducing the dose and treatment duration and improving the prognosis of acne vulgaris. In terms of the in vitro treatment efficacy, the growth of P. acnes was inhibited by 86.08 ± 2.99% in the LY-shelled MBs group and by 57.74 ± 3.09% in the LY solution group. For US power densities of 1, 2, and 3 W/cm² in the LY-shelled MBs group, the growth of P. acnes was inhibited by 95.79 ± 3.30%, 97.99 ± 1.16%, and 98.69 ± 1.13%, respectively. The in vivo results showed that the recovery rate on day 13 was higher in the US group with LY-shelled MBs (97.8 ± 19.8%) than in the LY-shelled MBs group (90.3 ± 23.3%). Our results show that combined treatments of US and LY-shelled MBs can significantly reduce the treatment duration and inhibit P.-acnes-induced inflammatory skin diseases.

Acne vulgaris

Acne vulgaris is a chronic inflammatory disease - rather than a natural part of the life cycle as colloquially viewed - of the pilosebaceous unit (comprising the hair follicle, hair shaft and sebaceous gland) and is among the most common dermatological conditions worldwide. Some of the key mechanisms involved in the development of acne include disturbed sebaceous gland activity associated with hyperseborrhoea (that is, increased sebum production) and alterations in sebum fatty acid composition, dysregulation of the hormone microenvironment, interaction with neuropeptides, follicular hyperkeratinization, induction of inflammation and dysfunction of the innate and adaptive immunity. Grading of acne involves lesion counting and photographic methods. However, there is a lack of consensus on the exact grading criteria, which hampers the conduction and comparison of randomized controlled clinical trials evaluating treatments. Prevention of acne relies on the successful management of modifiable risk factors, such as underlying systemic diseases and lifestyle factors. Several treatments are available, but guidelines suffer from a lack of data to make evidence-based recommendations. In addition, the complex combination treatment regimens required to target different aspects of acne pathophysiology lead to poor adherence, which undermines treatment success. Acne commonly causes scarring and reduces the quality of life of patients. New treatment options with a shift towards targeting the early processes involved in acne development instead of suppressing the effects of end products will enhance our ability to improve the outcomes for patients with acne.

The National Ambulatory Medical Care Survey: a resource for understanding the outpatient dermatology treatment

BACKGROUND

The National Ambulatory Care Survey (NAMCS) collects information on outpatient medical care in the United States. Key characteristics of the NAMCS methodology are not well recognized. We describe the NAMCS survey design and patient visits to dermatologists and to present information on the validity of the NAMCS data by comparing key features of the dermatologist sample to other surveys of dermatologists.

METHODS

NAMCS data on dermatologists and skin-related visits from 1993 to 2010 were analyzed and compared to the Dermatology Physician Profile Survey (DPPS), a survey by the American Academy of Dermatology.

RESULTS

A total of 29 554 patient visits to dermatologists were sampled from 1993 to 2010. On average, 118 dermatologists were sampled annually to participate in the NAMCS, and response rates ranged from 47 to 77%. The NAMCS and the DPPS found similar dermatologist demographics, practice settings and reimbursement sources.

CONCLUSION

Overall, the NAMCS achieves high-response rates and provides a generalizable sample that has been used in scores of studies of dermatology outpatient treatment. In a time of changing health care delivery systems, NAMCS is valuable for understanding how physicians care for patients with skin disease.

Treatment of preadolescent acne in the United States: an analysis of nationally representative data

The prevalence of acne in younger children is increasing. Of the acne treatments that the U.S. Food and Drug Administration (FDA) has approved for ages 12 years and older, it is unclear which medications are being prescribed off-label for this younger patient population. The purpose of this study is to compare the therapies being prescribed to preadolescent patients with acne (defined in this study as ages 7 to 11 years) with those being prescribed to adolescent patients (ages 12 to 18 years) and to determine whether prescribing patterns differ between dermatologists and pediatricians. Leading therapies for the treatment of children with a diagnosis of acne were collected from the National Ambulatory Medical Care Survey (NAMCS) from 1993 to 2009. Data were stratified according to age group and physician specialty. Physicians prescribed a wide variety of FDA-approved and off-label medications to preadolescent patients with acne. The leading medications were topical treatments, including adapalene (14.4%), benzoyl peroxide (12.8%), and tretinoin (12.5%). Treatment of this age group differed substantially between specialties, with dermatologists frequently prescribing topical retinoids and primary care physicians preferring antibiotics, particularly oral antibiotics. Limitations included a lack of data on acne severity and morphology through NAMCS, as well as the absence of longitudinal data. With the limited number of FDA-approved treatment options, off-label prescribing for acne in preadolescent patients is common. Furthermore, this study identified a potential knowledge gap between pediatricians based on their prescribing patterns in this patient population.

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.

Isotretinoin is not associated with inflammatory bowel disease: a population-based case-control study

OBJECTIVES

There is anecdotal evidence that isotretinoin use is associated with development of colitis. We aimed at determining whether there is an association between isotretinoin use and development of inflammatory bowel disease (IBD).

METHODS

The population-based University of Manitoba IBD Epidemiology Database and a control group matched by age, sex, and geographical residence were linked to the provincial prescription drug registry, a registry that was initiated in 1995. The number of users and duration of isotretinoin use were identified in both IBD cases and controls.

RESULTS

We found that 1.2% of IBD cases used isotretinoin before IBD diagnosis, which was statistically similar to controls (1.1% users). This was also similar to the number of IBD patients who used isotretinoin after a diagnosis of IBD (1.1%). There was no difference between isotretinoin use before Crohn's disease compared with its use before ulcerative colitis.

CONCLUSIONS

Patients with IBD were no more likely to have used isotretinoin before diagnosis than were sex-, age-, and geography-matched controls. Although there may be anecdotes of isotretinoin causing acute colitis, our data suggest that isotretinoin is not likely to cause chronic IBD.

Is it necessary to have routine blood tests in patients treated with isotretinoin?

OBJECTIVES

Several side effects can be observed from isotretinoin use, which has been used in acne therapy for years. In this study, the side effects of isotretinoin on skin and mucosa, blood test changes and their relation with total dose were investigated in patients who used equal doses of isotretinoin.

MATERIALS AND METHODS

A total of 91 outpatients with acne vulgaris (57 females and 34 males; age range 17-28 years, mean 21+/-2.19 years) were enrolled in this study. Skin and mucosal findings and pre- and post-treatment blood tests and their correlation with the total dose were investigated. Student's t-test and the Mann-Whitney U-test were used in the statistical analyses.

RESULTS

In all, 89 out of 91 patients completed the study. Cholesterol (p = 0.00), triglyceride (p = 0.00) and low density lipoprotein (LDL) (p = 0.001) levels were found to be significantly elevated. But these values were not over the double of the upper limits. No correlations were found among the total dose and the skin and mucosal changes as well as the blood test results.

CONCLUSION

It is concluded that examination of cholesterol, triglyceride and LDL-cholesterol should be performed monthly if the initial blood tests are close to the upper limits; otherwise, examinations at 2- or 3-month intervals are sufficient, which would save unnecessary costs.

Optimizing use of oral antibiotics in acne vulgaris

Oral antibiotics are commonly used to treat acne vulgaris, primarily in patients presenting with moderate to severe facial or truncal disease severity. These agents are most appropriately used in combination with a topical regimen containing benzoyl peroxide and a topical retinoid. The most common oral antibiotics for treating acne vulgaris are the tetracycline derivatives, although macrolide agents such as erythromycin have also been used extensively. Over the past 4 decades, as the sensitivity of Propionibacterium acnes to several oral and topical antibiotics has decreased, the efficacy of oral tetracycline and erythromycin has markedly diminished, leading to increased use of doxycycline, minocycline, and other agents, such as trimethoprim/sulfamethoxazole.

Bacteria isolated from sewage influent resistant to ciprofloxacin, chloramphenicol and tetracycline

This study assessed the presence of antibiotic-resistant bacteria in sewage influent. Resistance was measured by determining the lowest concentration of antibiotic, in micrograms per milliliter (microg mL(- 1)). To determine the minimum inhibitory concentration (MIC), which is used in diagnostic laboratories, we used the Etest, a plastic strip containing an antibiotic concentration gradient. In total, we sampled five sewage treatment plants of various sizes in Kansas and isolated bacteria resistant to three broad-spectrum antibiotics; ciprofloxacin (1-cyclopropyl-6-fluoro-4-oxo-7-piperazin-1-yl-quinoline-3-carboxylic acid), chloramphenicol 2,2-dichlor-N-[(aR, bR)-b-hydroxy-a-hydroxymethyl-4-nitrophenethyl] acetamide), and tetracycline (2-(amino-hydroxy-ethylidene)-4-dimethylamino-6,10,11,12a-tetrahydroxy-6-methyl-4,4a,5,5a-tetrahydrotetracene-1,3,12-trione). In total, 25 Gram-negative isolates were found to be resistant to at least one of the antibiotics tested. Some isolates were multi-drug resistant, regardless of the amount of influent the sewage treatment plant received. A Pseudomonas isolate from the smallest sewage treatment plant (approximately 2 million gallons treated per day) showed resistance to all three antibiotics, albeit at low levels (10 microg mL(- 1)). The largest number of bacteria (6 species) were isolated from the largest sewage treatment plant (45 million gallons per day). Regardless, the results of this study are in agreement with similar studies, antibiotic resistance can persist long after the antibiotics have been forgotten.

Differences in acne treatment prescribing patterns of pediatricians and dermatologists: an analysis of nationally representative data

BACKGROUND

Acne vulgaris is a very common disease process that is seen frequently by both pediatricians and dermatologists. However, treatment may be different depending on specialty.

OBJECTIVES

To compare pediatricians' and dermatologists' patterns of treatment for acne vulgaris.

METHODS

National Ambulatory Medical Care Survey data on office visits to pediatricians and dermatologists for acne vulgaris were analyzed from 1996 to 2005.

RESULTS

During this 10-year time period, dermatologists managed an estimated 18.1 million acne visits and pediatricians managed an estimated 4.6 million acne visits. Dermatologists prescribed topical retinoids considerably more frequently than did pediatricians (46.1% of acne visits for dermatologists vs 12.1% for pediatricians).

CONCLUSIONS

There is an opportunity for pediatricians to play a greater role in the management of patients with acne. A shift toward greater use of topical retinoids by pediatricians would be more in line with the practice of dermatologists and with current acne treatment consensus guidelines.

What is the best approach to reducing birth defects associated with isotretinoin?

Isotretinoin is an effective treatment for severe acne, a condition which can be physically, emotionally, and socially disabling. Because the drug is teratogenic, causing severe birth defects, women taking the drug are directed to avoid pregnancy. In the United States, a series of risk reduction programs have been implemented that aim to prevent pregnant women from taking the drug and to prevent women taking it from getting pregnant. The most recent, and most stringent, is an Internet-based, performance-linked system called iPLEDGE, which tries to ensure that the drug is dispensed only when there is documentary proof that the patient is not pregnant and is using two forms of birth control. Is iPLEDGE the best way to reduce isotretinoin birth defects, or is it an unproven and overly burdensome system?