INTRODUCTION
Antibiotic resistance has become a global priority, and
the science ministers of the G8 countries have deemed
it to be a “major health security challenge of the 21st
century.â€1 The World Health Organization has also identified antibiotic
resistance as a “rapidly evolving health issue extending
far beyond the human health sector,†emphasizing the urgent
need for a cross-sectoral approach.2
Although dermatologists account for approximately 1% of the
physicians in the United States, they prescribe 4.9% of the
antibiotics (Figure 1).3 Dermatologists regularly prescribe antibiotics
for acne vulgaris (AV) and other long-term inflammatory
dermatoses; but antibiotic resistance has led to a decreased
sensitivity of certain bacterial organisms, such as Propionibacterium
acnes, to antibiotics.4
For example, Ross et al collected phenotypes and genotypes
of 73 antibiotic-resistant strains of P. acnes that were acquired
from the skin of acne patients in the United Kingdom, United
States, France, Germany, Australia, and Japan, and found that
most erythromycin-resistant isolates were cross-resistant to
clindamycin.5 Tetracycline-resistant isolates had differing degrees
of cross-resistance to doxycycline and minocycline, and
isolates from the United States had higher cross-resistance to
minocycline than isolates from other countries.5 The investigators
also found resistant strains in which mutations could not
be identified, which suggests that uncharacterized resistance
mechanisms have evolved.5
DISCUSSION
As the sensitivity of P. acnes to several oral and topical antibiotics
has decreased, the efficacy of oral tetracyclines and
erythromycin has also noticeably decreased, which has led to
an escalation in the prescribing of doxycycline, minocycline,
and other antibiotics for P. acnes.6 Additionally, changing patterns
of antibiotic sensitivity and the escalation of more virulent
pathogens, such as community-acquired methicillin-resistant
Staphylococcus aureus, macrolide-resistant staphylococci and
streptococci, and mupirocin-resistant S. aureus, have led to
major changes in clinicians prescribing patterns of antibiotics.7
Although most of the time clinicians are responding to these
new resistance patterns in an appropriate fashion, it is important
to note that both correct and incorrect use of antibiotics can
promote antimicrobial resistance. Oral and topical antibiotics account
for 54% of all prescriptions written for acne in the field
of dermatology, and approximately 66% of antibiotic use in dermatology
is for acne.7 Even when dermatologists use antibiotics
responsibly, we are contributing to resistance. However, when
used inappropriately, resistance rates grow at an even more
rapid rate. Antibiotic monotherapy, long-term administration of
antibiotics, and dosing below the recommended levels especially
promote the development of bacterial resistance.8 Not only do
these practices result in P. acnes resistance and acne treatment
failures, but they have also resulted in the spread of resistance
to other organisms colonizing the skin.8 Long-term use of antibiotics
has even yielded systemic consequences, including an
increased risk of upper respiratory tract infections.8
Studies have demonstrated that antibiotic limiting regimens,
such as a combination of topical retinoids and benzoyl peroxide
(BPO), can be highly effective for the treatment of acne.8,9,10
The ACCESS I and ACCESS II trials have shown that topical
retinoids with BPO are effective for both the primary and maintenance
treatment of P. acnes (Figure 2).
ACCESS I was a randomized, vehicle-controlled, multicenter,
double-blind study that assessed the efficacy and safety of
combination therapy using doxycycline and an adapalene 0.1%
and BPO 2.5% combination gel (Epiduo®) for the treatment of
