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Journal of Pakistan Association of Dermatologists 2010; 20: 1-3. Editorial Use of antibiotics in acne vulgaris Zahida Rani Dermatology Department, Unit II, King Edward Medical University/Mayo Hospital, Lahore Acne vulgaris is one of the most frequent A serious problem with the extended use of oral disorders encountered in dermatology practice. antibiotic therapy is emergence of strains of P. Although the disease affects teenagers, acnes less sensitive/resistant to oral antibiotics prepubertal onset is not uncommon and many e.g. tetracyclines and erythromycin.4 To patients present with acne in their thirties. The overcome this rising problem, various devastating psychosocial impact of disease researchers recommend optimal use of oral especially in teenagers outweighs its physical antibiotics for treating acne vulgaris.5 Such disability.1 This necessitates an early and recommendations include limiting the duration effective treatment. of therapy, using combination therapy regimens with a topical agent from the outset, avoiding Although the pathogenesis of acne vulgaris is unnecessary switching of oral antibiotics, and multifactorial, Propionibacterium acnes is adding a benzoyl peroxide-containing believed to play a major role in the formation of formulation to reduce emergence of antibiotic- inflammatory lesions of acne and possibly resistant P. acnes strains. Adverse drug reactions comedogenesis.2 P. acnes triggers innate and interactions associated with specific oral immune response and the inflammatory reaction antibiotics are also another important aspect. involving inflammatory cells such as monocytes, macrophages, neutrophils, dendritic cells, and Among the conventionally prescribed oral keratinocytes. As evidenced by clinical data, antibiotics for acne vulgaris, the greatest suppressing P. acnes with antimicrobial therapy reduction in P. acnes has been documented with is an important aspect of the management plan minocycline, followed in order by doxycycline, in moderate to severe acne vulgaris. Some tetracycline, and erythromycin. Alternative oral antibiotics e.g. tetracyclines exhibit anti- antibiotics useful in the treatment of acne inflammatory effects besides their antibiotic vulgaris are trimethoprim/sulfamethoxazole, properties, which adds to their therapeutic trimethoprim alone, azithromycin, benefit in acne vulgaris.3 clarithromycin, cephalosporins and 6 fluoroquinolones. Many trials reported the The primary indication for oral antibiotic efficacy of azithromycin in acne vulgaris; therapy in acne vulgaris is moderate to severe however, considering the utility of azithromycin inflammatory involvement on the face or trunk. and other antibiotics in many other systemic infections, these antibiotics should be reserved Address for correspondence Dr. Zahida Rani, for short-term use in selected refractory cases of Assistant Professor, acne to avoid the risk of development of Department of Dermatology, Unit II, resistant organisms.5 King Edward Medical University/Mayo Hospital, Lahore Email: firstname.lastname@example.org 1 Journal of Pakistan Association of Dermatologists 2010; 20: 1-3. Antibiotic monotherapy should be avoided therapy in acne vulgaris is not generally because of promotion of antibiotic resistance.5 recommended.3 Individual patients may Oral antibiotic therapy is best used in experience marked flares after discontinuing oral combination with a topical regimen that includes antibiotic therapy, despite the use of a rational a benzoyl peroxide (BPO)-containing topical maintenance program. In such cases, the formulation and a topical retinoid.7,8 BPO itself previously effective oral antibiotic be continued is effective in reducing inflammatory acne in combination with the topical regimen to lesions and moderately reduces sustain acceptable remission. Alternatively, noninflammatory acne lesions. It also suppresses subantimicrobial therapy with doxycycline i.e. preexisting P. acnes organisms resistant to 50mg/day, shown to exhibit anti-inflammatory multiple antibiotics, including erythromycin, activity without antibiotic effects, may be a tetracycline, doxycycline, and minocycline and ‘‘step down’’ option after discontinuing oral reduces the emergence of antibiotic-resistant antibiotic therapy.3 strains of P. acnes and It may be beneficial to initiate BPO use for 2 to 3 weeks before starting Another recommendation suggests that oral antibiotic therapy. A ‘‘leave on’’ concomitant use of oral and topical antibiotics formulation of BPO (i.e. gel, cream), with or that are chemically different be avoided because without topical clindamycin, is optimal for facial of risk of development of multidrug-resistant use. Alternatively, a quality BPO cleanser or bacterial strains.9 Instead, concomitant use of wash may be used, especially for truncal skin, in BPO would also reduce emergence of P. acnes patients less tolerant to ‘‘leave on’’ BPO or resistance. those who show poor compliance with application of multiple ‘‘leave on’’ products.5,8 Oral antibiotics used for treating acne vulgaris may be associated with a plethora of side effects It is suggested that oral antibiotic therapy for which may range from mild gastrointestinal acne vulgaris be administered over a minimum upset to life threatening Stevens-Johnson of 6 to 8 weeks and over a maximum of 12 syndrome, toxic epidermal necrolysis and drug weeks to 6 months.8 At 6 to 8 weeks after hypersensitivity syndrome.5 Consideration of therapy, if there is no improvement in spite of an potential adverse reactions may also influence adequate compliance, oral antibiotic therapy oral antibiotic selection. Hence, before may be changed. However, if partial prescribing an oral antibiotic, a complete improvement is observed, the current regimen be medical history is mandatory with special continued for another 6 to 8 weeks and then reference to history of hepatitis or renal reevaluated. Once reasonable control of acne i.e. insufficiency, which may necessitate avoidance no new lesion or a marked decrease in of specific antibiotics because of relative inflammatory lesions, is observed, oral antibiotic contraindications or potential side effects. therapy should be discontinued while the topical Similarly, trimethoprim/sulfamethoxazole regimen be continued for another 3 to 6 months. should be avoided in patients having folate No consensus exists on whether oral antibiotic deficiency or megaloblastic anemia. A complete therapy should be discontinued abruptly or drug history, including prescription and over- tapered.8 the-counter medications, is also important to assess any food-drug or drug-drug interactions, Overall, the long-term use of oral antibiotic which may lead to a poor therapeutic response 2 Journal of Pakistan Association of Dermatologists 2010; 20: 1-3. or side effects, respectively. current regimen or make changes. Unless a definite poor response, adverse reactions, or To reduce the risk of gastrointestinal upset, major compliance issues are noted, the treatment erythromycin, doxycycline and minocycline are regimen should not be changed. Prolonged administered with food; however, concomitant intervals in follow-up and interaction frequently use of iron supplements may decrease lead to decreased patient compliance. Patients gastrointestinal absorption of doxycycline and should be informed to discontinue oral antibiotic minocycline. Reduced gastrointestinal therapy and report if they develop a skin absorption of the antibiotic may cause a eruption or flu-like symptoms, such as fever, diminished therapeutic response. In contrast, malaise, and sore throat. Baseline or periodic absorption of tetracycline and azithromycin may laboratory testing is generally not recommended be reduced and delayed with food. Concomitant with oral antibiotics for acne vulgaris; however, ingestion of metal ions, such as calcium, complete blood counts be performed at baseline magnesium, and aluminum found in many and periodically if vitamin-mineral supplements and antacids, may trimethoprim/sulfamethoxazole is used. also significantly reduce gastrointestinal absorption of tetracycline. To avoid References gastrointestinal upset and esophagitis, erythromycin and doxycycline, should be 1. Tan JK. Psychosocial impact of acne vulgaris: evaluating the evidence. Skin ingested when the patient is upright for at least a Therapy Lett 2004; 9: 1-3. few hours, and not before anticipated reclining, 2. Harper JC. An update on the pathogenesis such as before bedtime. An enteric-coated and management of acne vulgaris. J Am Acad Dermatol 2004; 51: S36-8. formulation of doxycycline reduces the potential 3. Tan AW, Tan HH. Acne vulgaris: a review for gastrointestinal upset and allows for once of antibiotic. therapy. Expert Opin daily administration. Pharmacother 2005; 6: 409-18. 4. Ross JI, Snelling AM, Carnegie E, et al. Antibiotic-resistant acne: lessons from Erythromycin may inhibit hepatic enzymes Europe. Br J Dermatol 2003; 148: 467-78. involved in the metabolism of other drugs, such 5. Del Rosso JQ, Kim G. Optimizing use of as carbamazepine, cyclosporine, and some oral antibiotics in acne vulgaris. Dermatol Clin 2009; 27: 33-42. cholesterol lowering agents, such as lovastatin, 6. Amin K, Riddle CC, Aires DJ, Schweiger simvastatin, and atorvastatin.3 As a result, ES. Common and alternate oral antibiotic toxicity may result from significant elevations in therapies for acne vulgaris: a review. J Drugs Dermatol 2007; 6: 873-80. serum level of the inhibited drug. Similarly, 7. Leyden JJ. A review of the use of trimethoprim/sulfamethoxazole should not be combination therapies for the treatment of prescribed for patients on methotrexate because acne vulgaris. J Am Acad Dermatol 2003; 49: S206-10. of an increased risk for serious hematologic 8. Alexis AF. Clinical considerations on the reactions. use of concomitant therapy in the treatment of acne. J Dermatolog Treat 2008; 19: 199- Patients should be followed-up at 6 to 8 weeks 209. 9. Leyden JJ. Antibiotic resistance in the for response to treatment, compliance, patient topical treatment of acne vulgaris. Cutis feedback on ease of use and degree of 2004; 73: 6-9. satisfaction, tolerability and potential adverse effects, and determine whether to continue the 3
"Use of antibiotics in acne vulgaris"