Trends in the Treatment of Acne Vulgaris: Are Measures Being Taken to Avoid Antimicrobial Resistance?

May 2010 | Volume 9 | Issue 5 | Original Article | 519 | Copyright © May 2010

Megan A. Kinney MHAM BS,a Brad A. Yentzer MD,a Alan B. Fleischer Jr. MD,a Steven R. Feldman MD PhDa,b,c

Center for Dermatology Research, Departments of Dermatology,a Pathologyb and Public Health Sciences;c Wake Forest University School of Medicine; Winston-Salem, NC

Abstract
Background: Acne vulgaris has been treated with long-term courses of antibiotics since the 1960s. Antibiotic-resistance of Propionibacterium acnes (P. acnes) was first documented in the late 1970s, and, over 20 years later, the problem of antibiotic resistance still exists.

Purpose: The aim of this study was to assess trends in prescribing antibiotics for acne from 1997−2006.

Methods: The authors examined the National Ambulatory Medical Care Survey (NAMCS) database and recorded medications at all visits to the physician in which acne vulgaris (ICD-9-CM code 706.1) was the only diagnosis from 1997−2006.

Results: Declines in the use of erythromycin and isotretinoin (both P<0.001) for acne were noted for all physicians. Tetracyclines saw significant increases in use by both dermatologists and non-dermatologists (P<0.01 and P=0.05, respectively). Prescribing of benzoyl peroxide monotherapy was unchanged for non-dermatologists (P=0.22) and is on the decline for dermatologists (P<0.001). The use of BPO + clindamycin combination topical treatments rose sharply for all physicians (P<0.001), resulting in greater use of both total BPO and total clindamycin for acne over time (P<0.001). Topical retinoid use increased among dermatologists (P<0.05) but appeared to be on the decline among non-dermatologists (P=0.067).

Conclusion: The development of antibiotic resistance is of concern. Greater awareness of retinoid use for maintenance therapy, using topical benzoyl peroxide to prevent resistance, and limiting use of oral antibiotics to as short a time period as possible are measures to contribute to better eco-responsible acne treatment.

INTRODUCTION

Affecting 85-100% of the world’s population at some time in their lives, acne vulgaris has been treated with long-term courses of antibiotics since the 1960s.1,2 The pathogenesis of this extremely common condition consists of four main processes, including: an androgen-stimulated increase in sebum production; creation of a microcomedo through follicular hyperkeratinization; proliferation of propionibacteria (mainly Propionibacterium acnes [P. acnes]) within the sebaceous follicle; and inflammation.2 Antibiotics reduce inflammation as well as target propionibacteria residing in the hair follicle. When the efficacy of antibiotic treatment for acne was first established, it was believed that cutaneous propionibacteria were incapable of becoming resistant, as a resistant organism could not be detected at that time.1 This belief was shattered by the first documentation of antibiotic-resistant propionibacteria in acne patients in 1979. This report indicated that one in five patients being treated topically with erythromycin or clindamycin in the United States (U.S.) had antibiotic resistant strains on their skin.3 Similar reports surfaced globally.4
Over 20 years later, the problem of antibiotic resistance has grown. Eco-responsible practice encompasses considering the worldwide problem of antibiotic resistance, the impact prescribing antibiotics can have with every treatment decision and prescribing the antibiotics only if the benefits outweigh the risks— including the risk of resistance—and only for the treatment duration necessary for these benefits. The aim of this study was to assess the trends in prescribing antibiotics for acne from 1997−2006. Additionally, using current treatment guidelines and recommendations from the literature for prevention of antimicrobial resistance, the authors offer suggestions for a more eco-responsible approach to treating acne vulgaris.

METHODS

The National Ambulatory Medical Care Survey (NAMCS) database was analyzed for trends in prescriptions for acne vulgaris from 1997−2006. The NAMCS collects nationwide outpatient data from U.S. non-federally employed physicians and uses a multi-stage probability design with the primary sampling unit consisting of the physician office visit. The NAMCS uses the term drug “mention” to include medications that are either discussed by the physician and patient, currently taken by the patient, administered in office, or prescribed by the physician. For the purposes of this analyses, the authors assume that a mention refers to a new prescrip-