Antibiotic Resistance: Shifting the Paradigm in Topical Acne Treatment

November 2014 | Volume 13 | Issue 11 | Journal Article | 1358 | Copyright © November 2014


Charles W. Lynde MD FRCPC and Anneke Andriessen PhD

University of Toronto, Toronto, Ontario, Canada
Andriessen Consultants, Radboud Nijmegen, The Netherlands

Abstract
INTRODUCTION: Multiple topical therapies are available for mild to moderate acne vulgaris. The role of antibiotics and their resistance in the treatment of acne was reviewed by an expert panel of dermatologists who practice in Canada.
METHODS: Prior to the consensus meeting, the panel members filled out a survey on their current practice using topical treatment for acne. A literature review was carried out using information obtained from PubMed, Cochrane Library, Medline, and EMBASE. During a consensus meeting organized at the Spring Dermatology Update on April 27, 2014 in Toronto, ON, the panel had a blind vote on the issues at hand.
RESULTS: The panel reached consensus on: 1) Antibiotics are an integral part of acne treatment not only due to their antibiotic effect but also by their anti-inflammatory action. 2) Oral antibiotics should be used for a short period of time if possible. 3) Topical antibiotics should not be used in monotherapy. 4) Retinoids are effective in reducing antibiotic resistance. 5) A benzoyl peroxide wash is as effective as topical benzoyl peroxide in reducing antibiotic resistance. 6) Therapy needs to be re-evaluated in 6-8 weeks versus 12 weeks. The recommendations given by the panel are to be disseminated to both general practitioners and dermatologists.
CONCLUSION: For mild to moderate acne treatment, topical antibiotics in monotherapy are not to be used but may be combined with a retinoid or BPO to safely achieve more successful outcomes.

J Drugs Dermatol. 2014;13(11):1358-1364.

INTRODUCTION

Acne vulgaris traditionally is thought to be related to hyperkeratosis, increased sebum production, colonization, and inflammation.1 Research has shown that acne pathophysiology is more complex and interrelated with Propionibacterium acnes (P. acnes) contributing to inflammation by direct and indirect mechanisms.1 These include generation of chemotactic and pro-inflammatory factors, specifically activation of TLR on inflammatory cell membranes, and oxidized lipids from sebum, which stimulate inflammatory mediators.1 Multiple acne therapies are available such as systemic and topical retinoids, antibacterials, systemic and topical antibiotics, and benzoyl peroxide (BPO) and combination products.2 Topical antibiotics and benzoyl peroxide are the two main topical antibacterial treatments indicated for mild-to-moderate acne vulgaris.2 Topical antibiotics act as antibacterial agents, suppressing P. acnes in the sebaceous follicle and as anti-inflammatory agents.2 However, there is growing concern about antibiotic resistance in general and specifically as a result of its long term use, such as in the treatment of acne.3

Purpose of the Project

The project aimed to review the present role of antibiotics in the treatment of acne and to examine the evidence behind antibiotic resistance using topical acne treatment. For this purpose, new insights of pathogenic factors in acne were reviewed and current understanding of the role of topical molecules in managing these pathogenic factors was explored.

Role of the Panel

An expert panel, which consisted of 18 dermatologists who practice in Canada in medical dermatology, was established. The panel reviewed the role of topical antibiotics in the treatment of acne and examined the evidence behind antibiotic resistance. The procedure is outlined in Table 1. During the consensus meeting, 22 dermatologists (the 18 panel members including the key note speakers) voted blindly on the proposed statements. The panel reached consensus on recommendations given for an acne treatment strategy, taking into account new insights of pathogenic factors in acne and antibiotic resistance.

Literature Review

A literature review was carried out by an advisor with an international clinical and scientific background in this field using information obtained from PubMed, Cochrane Library, Medline, and EMBASE. The search took place on March 29, 2014. Key words used were: antibiotic resistance, topical antibiotic treatment of acne, and antibiotic resistance. The selected articles were limited to systematic reviews, meta-analyses, RCTs, controlled studies, and new research- based primary papers in the English language.

Results of the Literature Review

When exploring the evidence behind antibiotic resistance in the treatment of acne, the following was noted: Antibiotic resistance is widely recognized as a global priority.3 It has been called
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