MIAMI BEACH – It borders on heresy, but dermatologists should consider no longer prescribing any full-dose antibiotic to combat acne because of side effects, antibiotic resistance, and a number of effective alternative therapies, Dr. Theodore Rosen said.
"Should we stop using antibiotics for acne? I’m going to take the absolute affirmative," Dr. Rosen said at the South Beach Symposium. "Everybody in this room should go back to their practice and not write another prescription for an oral antibiotic to treat acne."
Dr. Theodore Rosen
As his rationale, Dr. Rosen cited the risks of gastrointestinal side effects, overgrowth of gram-negative microbes, fixed drug eruptions and other rare allergic reactions, and dyschromia. Other rare side effects of antibiotic use include autoimmune disease; pseudotumor cerebri and other neurologic conditions; and hepatic, renal, and hematologic adverse events, said Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.
Two of Dr. Rosen’s patients had adverse reactions to doxycycline, one experiencing a fixed drug eruption and one urticaria. In addition, minocycline can cause cutaneous, oral, and/or ophthalmologic dyschromia. Pseudomembranous ulcerative colitis can result from the overgrowth of Clostridium difficile after clindamycin use, but "it’s not just clindamycin – it can be any antibiotic administered over a long enough period of time in a susceptible patient," Dr. Rosen added.
In countering Dr. Rosen’s arguments, session moderator Dr. James Q. Del Rosso said, "If we didn’t prescribe because of side effects, we couldn’t give topical bacitracin over the counter because people occasionally die from anaphylaxis. So nothing is perfect."
Dr. Del Rosso also noted that without oral antibiotics, there would be essentially no therapies between topical treatments for mild acne and isotretinoin to combat more severe cases. "You are going to have a group of unhappy patients who have smoldering, continuing inflammatory disease that is just going to lead to more scarring," said Dr. Del Ross, residency director at Valley Hospital Medical Center in Las Vegas.
To bolster his case, Dr. Rosen cited two studies that demonstrated similar efficacy between an oral antibiotic and benzoyl peroxide for acne. One compared patients taking 100 mg doxycycline with those using 5% topical benzoyl peroxide (Int. J. Dermatol. 2006;45:1438-9).
In the other study, researchers contrasted five antimicrobial regimens to benzoyl peroxide (Lancet 2004;364:2188-95). Dr. Rosen noted that both trials enrolled patients with mild to moderate acne and not severe disease, but said there was "no difference whatsoever in either of these studies" between antibiotics and benzoyl peroxide.
Further evidence that antibiotics might not be necessary includes a study in which researchers showed that a 6% benzoyl peroxide wash reduced strains of antibiotic-resistant Propionibacterium acnes, Dr. Rosen said (Cutis 2008;82:417-21). "We don’t need another oral antibiotic to do that."
"The fact is that those topical therapies are for a different subset of patients," Dr. Del Rosso said. "They don’t necessarily address the moderate to severe patients. When you look in those patients, the maximum you get is about a 40% lesion reduction. That means 60% of the acne is still there after 12 weeks."
Antibiotic-resistant P. acnes reflects both individual patient and global issues, Dr. Rosen said (J. Drugs Dermatol. 2010;9:655-64). "There are P. acnes that are inherently antibiotic resistant before you prescribe the antibiotic."
In the study of 6% benzoyl peroxide wash, patients untreated for acne at baseline already demonstrated some resistance to various antibiotics, he said, "because we misuse, overuse, and abuse" these agents. Antibiotic use for acne can worsen the already serious public health problem of drug resistance, Dr. Rosen emphasized.
"If you take all the evidence, I don’t think we should be using full-dosage antibiotics anymore for acne," he said. "There are alternatives that can do the same things without the same risk."
If you do still prescribe antibiotics, limit the duration of therapy, avoid combining oral and topical antibacterial agents, and use an adjunct like benzoyl peroxide, he recommended.
Dr. Rosen said that he had no relevant disclosures.