A Call to Limit Antibiotic Use in Acne
December 2013 | Volume 12 | Issue 12 | Editorials | 1331 | Copyright © December 2013
Diane Thiboutot MD,a Brigitte Dreno MD PhD,b Harald Gollnick MD,c Vincenzo Bettoli MD,d Sewon Kang MD,e James J. Leyden MD,f Alan Shalita MD,g and Vicente Torres MDh for the Global Alliance to Improve Outcomes in Acne
aDepartment of Dermatology, Penn State University College of Medicine, Hershey, PA
bDepartment of Dermato-Cancerology, University of Nantes, France
cDepartment of Dermatology and Venereology Medical Faculty, Otto-Von- Guericke-Universitat, Magdeburg, Germany
dDepartment of Clinical and Experimental Medicine, Section of Dermatology, Azienda Ospedaliera University of Ferrara, Italy
eDepartment of Dermatology, Johns Hopkins Medicine, Baltimore, MD
fDepartment of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, PA
gDepartment of Dermatology, State University of New York Downstate Medical Center, Brooklyn, NY
hDepartment of Dermatology, Juarez Hospital, Mexico City, Mexico
the efficacy of topical clindamycin alone is similar to what is
observed in the vehicle arm of acne studies.27, 28
Oral antibiotics have a role in managing acne, but should be
used judicially. Oral antibiotics, particularly lipophilic cycline
antibiotics (such as doxycycline, lymecycline, and minocycline),
continue to have a valuable role in management of patients with
more severe acne. As with topical antibiotics, however, current
guidelines recommend that oral antibiotics should not be used
as monotherapy.5, 6, 29 Currently, there is interest in the use of
subantimicrobial-dose doxycycline to provide anti-inflammatory
benefits without selective pressure on bacteria.22, 23, 30
First-line therapy for acne involves retinoid-based combinations.
Updated acne management recommendations call for avoiding
antibiotic monotherapy and prescribing antibiotics only in combination
with benzoyl peroxide and retinoids. 6 Retinoid-based
combination therapy should be considered as first-line therapy
for almost all patients with acne since it reduces the risk of bacterial
resistance and there is a large evidence base showing that
combinations have greater efficacy.6 Current recommendations
also include limiting the duration of systemic antibiotic use,
avoiding use of topical and systemic antibiotics together, adding
BPO to retard emergence of resistant bacteria, including a topical
retinoid to improve outcomes and using topical retinoids for
maintenance therapy adding BPO if needed.*6
*A fully-referenced discussion of acne pathophysiology and clinical trial evidence
supporting current recommendations is beyond the scope of this letter; thus, we
encourage clinicians to review the detailed information summarized in Gollnick et
al5 and Thiboutot et al.6
D.T. has served as a consultant or investigator for Allergan, Inc,
Anacor, Galderma, Intrepid, and Stiefel/GSK. B.D. has served
as a consultant or investigator for Meda, Galderma, Fabre,
and Labcatal. S.K. has served as a consultant or investigator
for Anacor and Galderma. J.L. has served as a consultant or
investigator for Anacor, Allergan, Galderma, Sol-Gel, Sienna,
and Sebacia. V.T. has been a consultant and speaker for Galderma.
H.G. has served as Consultant or Speaker for Intendis,
GSK, Galderma, Merz, Pierre Fabre, Novartis, Roche, Basilea
and Meda. V.B. and A.S. Have no relevant conflicts to disclose.
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Diane Thiboutot MDdthiboutot@psu.edu