Journal of Dermatological Treatment, 2014; 25: 97–99 © 2014 Informa Healthcare USA on behalf of Informa UK Ltd. ISSN: 0954-6634 print / 1471-1753 online DOI: 10.3109/09546634.2013.852297

EDITORIAL

Topical antibiotic monotherapy prescribing practices in acne vulgaris William D Hoover1, Scott A Davis1, Alan B Fleischer1, & Steven R Feldman1,2,3 1

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Center for Dermatology Research, Departments of Dermatology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1071, USA, 2Center for Dermatology Research, Departments of Pathology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1071, USA and 3Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA

Abstract Objective: The aim of this study is to evaluate the frequency of dosing topical antibiotics as monotherapy in the treatment of acne vulgaris, and physician specialty prescribing these medications. Methods: This study is a retrospective review of all visits with a sole diagnosis of acne vulgaris (ICD-9-CM code 706.1) found on the National Ambulatory MedicalCareSurvey(NAMCS)in1993–2010.Werecordedthenumber of visits surveyed where acne vulgaris was the sole diagnosis, number of visits where topical antibiotics were the only treatment prescribed, and the specialty of physician in each encounter. Results: Topical erythromycin or clindamycin were the sole medication prescribed in 0.81% of the visits recorded, with 60% of these prescriptions arising from dermatologists and 40% from non-dermatologists. The trend of prescribing topical antibiotic monotherapy is declining (p < 0.001) over the 18-year study period. Conclusions: The development of resistance of Propionibacterium acnes to topical antibiotic regimens has led to the need to re-evaluate the use of topical antibiotics in the treatment of acne vulgaris. While the rate of topical antibiotic monotherapy is declining, their use should be reserved for situations where the direct need for antibiotics arises. If a clinician feels that antibiotics are a necessary component to acne therapy, they should be used as part of a combination regimen.

Methods

Key words: erythromycin, clindamycin, antibiotic resistance, practice gap, NAMCS

Acne vulgaris was the sole diagnosis made in an estimated 69 million visits. Of these visits, topical erythromycin or clindamycin was the sole prescribed medication in 560 000 visits (0.81%), with 336 000 (60%) of the prescriptions from dermatologists and 224 000 (40%) from non-dermatologists. Over time the frequency of topical antibiotic monotherapy for acne vulgaris has declined (p < 0.001), while the frequency of topical antibiotic therapy combined with benzoyl peroxide had increased (Figures 1 and 2).

Introduction Topical regimens for acne have traditionally targeted multiple points in the pathogenesis, including the use of topical antibiotics such as erythromycin and clindamycin to address the role of Propionibacterium acnes (P. acnes) (1). Unfortunately, over time bacterial resistance develops when topical antibiotics are used as a sole treatment (2). Given the problems of resistant bacteria and given the availability of many other treatment options, should topical antibiotics ever be prescribed as a monotherapy for acne? Topical antibiotics can be administered concurrently with benzoyl peroxide to decrease the rate of developing resistance, or other options (topical retinoids, other combination regimens) could be used to avoid the use of topical antibiotics alone (3). The purpose of this study is to determine how frequently topical erythromycin and topical clindamycin are used as monotherapy for acne.

The National Ambulatory Medical Care Survey (NAMCS) is a nationally representative database documenting physician visits, diagnoses, and prescribing habits from physicians who are not federally employed. The database was sampled in regards to visits in which the sole diagnosis of acne vulgaris (ICD-9-CM code 706.1) was made in the span from 1993 to 2010. Information collected included physician specialty (dermatology vs. non-dermatology) as well as medication prescribed (topical clindamycin or erythromycin monotherapy vs. other). The data were analyzed to determine the frequency of topical antibiotics as monotherapy for acne vulgaris, the trends in prescribing of topical antibiotics with or without benzoyl peroxide over the 18-year period, and differences in prescribing habits between dermatologists and nondermatologists. We examined the use of topical antibiotics (clindamycin, erythromycin, sulfacetamide, or dapsone) together with or without benzoyl peroxide, either in a combination product or as separate products. All data analysis was performed using SAS 9.2 (SAS Institute, Cary, NC), and the study was declared exempt by the Wake Forest Baptist Hospital Institutional Review Board.

Results

Discussion Over time, antibiotics become less effective as bacteria develop the means to evade destruction. As bacteria become resistant, they are able to induce resistance in other bacteria by transferring plasmids containing the resistance trait, rendering an antibiotic therapy ineffective for more than just the initial condition (4,5). While topical antibiotics were effective for acne in the past, the growing development of resistance is decreasing their effectiveness and raising concern that use for a common problem like acne could result in more widespread resistance issues.

Correspondence: Scott A. Davis, MA, Department of Dermatology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1071, USA. Tel: +1 336 716 2702, Fax: +1 336 716 7732, E-mail: [email protected] (Accepted 3 October 2013)

 W. D. Hoover et al. 25 Topical antibiotic with BPO Topical antibiotic w/o BPO

Percent of visits

20 15 10 5

1995

2000

2005

2010

Figure 1. Rates of physician visits with a diagnosis of acne where topical antibiotic and benzoyl peroxide combination is prescribed and visits where topical antibiotics without benzoyl peroxide is prescribed. Points are plotted for 3-year intervals (1993–1995, 1996–1998, 1999–2001, 2002–2004, 2005–2007, and 2008–2010).

Ratio of antibiotic-benzoyl peroxide combination to antibiotic alone

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0 1990

4 3.5 3 2.5 2 1.5 1 0.5 0 1992

1994

1996 1998

2000

2002

2004

2006 2008

2010

Figure 2. Ratio of prescriptions for topical antibiotics and benzoyl peroxide combined compared to topical antibiotics alone over time. Points are plotted for 3-year intervals (1993–1995, 1996–1998, 1999–2001, 2002–2004, 2005–2007, and 2008–2010).

While P. acnes has been implicated in the pathogenesis of acne vulgaris implying the need for antibiotics, recent data finds that inflammation plays a much larger role in acne than previously understood (1,4). For this reason, a treatment that focuses more on combating inflammation rather than, or in addition to, a limited antibiotic strategy should be considered (6). If it is strongly felt, or preferred, by the physician for topical antibiotics to be a part of the treatment regimen for acne vulgaris, the concurrent use of benzoyl peroxide decreases the risk of resistance development (7–9). Do we need topical antibiotic monotherapy products? Topical benzoyl peroxide in a combination treatment with a topical antibiotic is more effective at eliminating P. acnes and treating acne vulgaris than treatment with either topical benzoyl peroxide or topical antibiotics alone (10,11). However, the potential reduction in adherence with the more complex two-drug regimen could offset the potential therapeutic gain. Given the potential for poor adherence in patients with acne, use of combination topical benzoyl peroxide–clindamycin as a single product (available as a generic) or use of a benzoyl peroxide-retinoid product may be appropriate. Given the development of resistance as well as the efficacies of other treatment options for acne, perhaps avoiding use topical antibiotic monotherapy in acne could be considered as a quality metric for dermatology.

Acknowledgment Financial disclosure: The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma

Laboratories, L.P. S R Feldman is a consultant and speaker for Galderma, Connetics, Abbott Labs, Warner Chilcott, Centocor, Amgen, Photomedex, Genentech, BiogenIdec, and Bristol Myers Squibb. S R Feldman has received grants from Galderma, Connetics, Astellas, Abbott Labs, Warner Chilcott, Centocor, Amgen, Photomedex, Genentech, BiogenIdec, Coria, Pharmaderm, Ortho Pharmaceuticals, Aventis Pharmaceuticals, Roche Dermatology, 3M, Bristol Myers Squibb, Stiefel, GlaxoSmithKline, and Novartis and has received stock options from Photomedex. A B Fleischer has received support for research, speaking, or consulting from Astellas, Centocor, Amgen, Abbott, Galderma, Stiefel, Medicis, and Intendis and is employed by Merz Pharmaceuticals. W D Hoover and S A Davis have no conflicts to disclose. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References 1. Beylot C, Auffret N, Poli F, et al. Propionibacterium acnes: an update on its role in the pathogenesis of acne. J Eur Acad Dermatol Venereol. 2013;10, http://www.ncbi.nlm.nih.gov/pubmed/?term=23905540. 2. Leyden JJ, McGinley KJ, Cavalieri S, Webster GF, Mills OH, Kligman AM. Propionibacterium acnes resistance to antibiotics in acne patients. J Am Acad Dermatol. 1983;8:41–45. 3. Eady EA, Farmery MR, Ross JI, Cove JH, Cunliffe WJ. Effects of benzoyl peroxide and erythromycin alone and in combination against antibiotic-sensitive and -resistant skin bacteria from acne patients. Br J Dermatol. 1994;131:331–336.

Topical antibiotic monotherapy prescribing practices in acne vulgaris

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4. Schafer F, Fich F, Lam M, Garate C, Wozniak A, Garcia P. Antimicrobial susceptibility and genetic characteristics of Propionibacterium acnes isolated from patients with acne. Int J Dermatol. 2013;52:418–425. 5. Kircik LH. The role of benzoyl peroxide in the new treatment paradigm for acne. J Drugs Dermatol. 2013;12:s73–s74. 6. McKeage K, Keating GM. Clindamycin/benzoyl peroxide gel (BenzaClin): a review of its use in the management of acne. Am J Clin Dermatol. 2008;9:193–204. 7. Zeichner JA. Optimizing topical combination therapy for the treatment of acne vulgaris. J Drugs Dermatol. 2012;11:313–317.

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8. Kinney MA, Yentzer BA, Fleischer AB Jr, Feldman SR. Trends in the treatment of acne vulgaris: are measures being taken to avoid antimicrobial resistance? J Drugs Dermatol. 2010;9:519–524. 9. Gamble R, Dunn J, Dawson A, et al. Topical antimicrobial treatment of acne vulgaris: an evidence-based review. Am J Clin Dermatol. 2012;13: 141–152. 10. Simonart T. Newer approaches to the treatment of acne vulgaris. Am J Clin Dermatol. 2012;13:357–364. 11. Whitney KM, Ditre CM. Management strategies for acne vulgaris. Clin Cosmet Investig Dermatol. 2011;4:41–53.

Topical antibiotic monotherapy prescribing practices in acne vulgaris.

The aim of this study is to evaluate the frequency of dosing topical antibiotics as monotherapy in the treatment of acne vulgaris, and physician speci...
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