Antibiotic Resistance and Acne: Where We Stand and What the Future Holds
June 2014 | Volume 13 | Issue 6 | Supplement | s66 | Copyright © 2014
Whitney P. Bowe MD
SUNY Downstate College of Medicine, Brooklyn, NY
Antibiotic resistance is described as “a global public health challenge” and a “major health security challenge of the 21st century”
by global health authorities,1 and there is a growing need for dermatologists to counteract it in their treatments of acne.3,4 Antibiotic
limiting regimens, such as a combination of topical retinoids and benzoyl peroxide, have shown effectiveness in the treatment of
acne; and topical probiotics could also play a needed role.
J Drugs Dermatol. 2014;13(suppl 6):s66-s70.
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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.”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
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