BAD 2014 Report: No more antibiotics for acne?

Report from the British Association of Dermatologists Conference, held in Glasgow,  30th June -3^rd July 2014 by Christine Clark.  The use of antibiotics for acne could be phased out within 10 years  as it is poorly supported by the available evidence and could be contributing to the widespread development of resistant organisms, according to consultant dermatologist Keith Freeman. Speaking at a satellite meeting at the British Association of Dermatologists conference in Glasgow he said that about eight per cent of all antibiotics prescribed in the UK are for dermatological indications. Part of the problem is that antibiotics are prescribed for long periods for acne. Current European guidelines advise against the use of topical or systemic antibiotic monotherapy for acne. Moreover, systemic antibiotic therapy in combination with a topical (non-antibiotic) agent for 12 weeks receives only a medium-strength recommendation.

Large surveys from 1976-1996 showed that up to 62% of Propionibacterium acnes isolates were resistant to erythromycin, clindamycin and tetracycline so that treatment was unlikely to be effective. However, the use of antibiotics could contribute to the development of resistant bacteria elsewhere in the human biome, for example in the gut. At present clindamycin and doxycycline, two antibiotics that are commonly recommended in acne treatment, are first-line treatments for MRSA but indiscriminate use for acne could limit their usefulness for MRSA management in future.

Dr Freeman called for rigorous antibiotic stewardship and recommended a treatment scheme for acne that would use little or no antibiotics.  Two measures that could be introduced immediately would be to discontinue the use of topical antibiotics and to shorten the courses of systemic antibiotics for acne treatment. Dr Freeman suggested that greater use should be made of intense pulsed light (IPL) laser therapy, photodynamic therapy and oral spironolactone treat (to inhibit androgen metabolism in the skin. He recommended that mild acne should be treated with a combination product containing adapalene and benzoyl peroxide (Epiduo®). Moderate acne could be treated with Epiduo and either lymecycline for six-12 weeks or low-dose (40mg), modified-release doxycycline. (At this dose doxycycline has no antibiotic activity but exerts an anti-inflammatory action.) Epiduo could then be used for maintenance treatment. Severe acne should be treated with isotretinoin.