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Use of antibiotics in acne vulgaris

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In the area of skin, the laser can often play a regular home care can not achieve effect. Similarly, the laser can make acne more with less. Currently, the laser for acne more than one item, which may be anti-inflammatory acne, oil control conditioning, repair smallpox in India, to improve skin texture and so focused. "Doudou Zu," according to their own needs, the doctor suggested, select a package or a combination of the way into the acne treatment.

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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
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                                                             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: zahidaraffad@yahoo.com


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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

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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

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