Antibiotic Resistance and Acne: Where We Stand and What the Future Holds

The Global Alliance to Improve Outcomes in Acne has recommended several strategies for the prevention of P. acnes antibiotic resistance that limit antibiotics and use a topical retinoid and BPO. Antibiotics should be limited to the shortest duration possible and never be used as a monotherapy.¹³ The number of patients still filling prescriptions for antibiotics in the absence of a BPO topical treatment is astounding. Whether or not these patients are being advised to use the two concurrently, or they stop using the BPO independently despite counseling to the contrary, remains unclear. But it is our responsibility to our patients to emphasize the importance of using BPO every time an oral or topical antibiotic is prescribed or refilled. Moreover, dermatologists should discontinue antibiotics when there is no further improvement or the improvement is only slight.¹³ Oral antibiotics should ideally be used for 3 months, but 6 to 8 weeks into treatment might be an appropriate time point at which to assess the response to antibiotics. Lastly, the concurrent use of oral and topical antibiotics, particularly if chemically different, should be discontinued.¹³

Antibiotics should also be avoided for maintenance therapy. In lieu of antibiotics, maintenance therapy should include the use of a topical retinoid and BPO to limit antibiotic resistance. Benzoyl peroxide reduces the likelihood of antibiotic- resistant P. acnes emerging, and rapidly reduces the number of sensitive and resistant strains of P. acnes at the site of application. Benzoyl peroxide should be used either concomitantly or pulsed as an anti-resistance agent, and it may be helpful to use BPO for a minimum of 5 to 7 days between antibiotic courses. As studies continue to further validate the efficacy of BPO, and validate its essential role in the fight against antibiotic resistance, it will continue to assume a larger role in the practice of dermatology.

While thought leaders in the fields of public health, infectious disease, and dermatology continue to explore ways to maintain the efficacy of our antibiotic armamentarium and prevent further resistance from developing, other researchers are searching for novel therapeutic options. Topical probiotics have the potential to be a treatment of interest for acne. While studies are still very preliminary, they do show some promising results.¹⁴

Probiotics are healthy strains of bacteria that potentially improve the health of their host, and there are 3 means by which probiotics can benefit a patient via topical administration. First, if a live culture is actually capable of surviving on the skin’s surface, that strain could potentially provide a protective shield on the patient’s skin, blocking colonization by possibly harmful organisms.¹⁴ Second, some probiotics are capable of producing and secreting antimicrobial substances into their environment; so one can envision an antimicrobial alternative to antibiotics that works via a unique mechanism.¹⁴