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