Doctors at the British Association of Dermatologists’ Annual Conference have warned that oral antibiotics, which are routinely prescribed for acne, are being used for durations that exceed recommendations, despite concerns about antibiotic resistance.
Dr Alison Layton and the dermatology team at Harrogate and District NHS Foundation Trust say that reliance on oral antibiotics beyond the recommended duration is harmful for two key reasons. The practice could cause the emergence of antibiotic-resistant Propionibacterium acnes, the bacterium implicated in acne, making acne harder to treat in some cases. Worryingly, the use of oral antibiotics is also likely to drive resistance in other bacteria, unrelated to acne*
Their recent study shows that patients are facing delays in starting treatment options which could be used effectively in place, or alongside, antibiotics resulting in more rapid and better outcomes. This is important, as delay in implementing effective treatments is known to increase the risk of acne scarring**.
A retrospective review of oral antibiotic duration for 928 patients with acne found the mean duration of oral antibiotic use prior to referral to dermatology services was six and a half months (195 days). The longest exposure to a single antibiotic was 84 months (2520 days) – a little short of seven years.
Guidance from the National Institute for Health and Care Excellence (NICE) recommends that, unless an improvement in the patient’s acne is seen, GPs should only continue to prescribe antibiotics for up to three months (90 days) before considering referral to a dermatologist. In cases where patients are responding to the antibiotics, then treatment should continue for four to six months, 120 to 180 days, alongside appropriate topical (applied to the skin) treatment.
A second study being presented at the conference by the same authors, in which 4518 patients and 1227 healthcare professionals were surveyed, offers an insight into why efforts by advisory bodies are falling short. The survey found that only small numbers of healthcare providers say that they ‘often’ consult evidence-based guidance (dermatologists 15%, GPs with a Special Interest 13%, and GPs 3%), questioning the impact of guidelines on prescribing habits.
Despite this, over 50 per cent of HCPs agreed that ‘antibiotic resistance is a big problem in managing acne’, but only 25 per cent said it was a concern for their patients. This contrasts with 74 per cent of patients worrying about antibiotic-resistant infections later in life.
Dr Heather Whitehouse, one of the authors, said: “Antibiotics remain an important part of acne management, but given concerns about antibiotic resistance we should be using antibiotics judiciously as part of a treatment regime, limited to the shortest possible time period.
“Oral antibiotics are frequently being prescribed on their own for patients with acne, this is not something that guidelines advocate as individually they are not effective at treating all aspects of the condition. Not to mention the fact that this sort of monotherapy is implicated in driving antimicrobial resistance.
“From the patient perspective the study has shown that the duration of oral antibiotic use is longer than we would wish to ensure patients are receiving optimum therapy.”
Matthew Gass of the British Association of Dermatologists said: “As the NHS and advisory bodies get increasingly serious about the responsible use of antibiotics, it is important for doctors to reflect on how they prescribe for such a common condition which relies so heavily on antibiotic usage. This study provides an important warning, and will hopefully help healthcare professionals and patients alike.”
Facts about acne and acne treatments
What is acne?
Acne is a very common skin condition characterised by blackheads and whiteheads and pus-filled spots. It usually starts at puberty and varies in severity from a few spots on the face, neck, back and chest, which most adolescents will have at some time, to a more significant problem that may cause scarring and impact on self-confidence. For the majority it tends to resolve by the late teens or early twenties, but it can persist for longer in some people.
According to a 2013 study** a degree of acne affects nearly all people between the ages of 15 and 17, and in 15 to 20 per cent of young people, acne is moderate to severe.
What causes acne?
The sebaceous (oil-producing) glands of people who get acne are particularly sensitive to normal blood levels of certain hormones, which are present in both men and women. These cause the glands to produce an excess of oil. At the same time, the dead skin cells lining the pores are not shed properly and clog up the follicles. These two effects result in a build-up of oil, producing blackheads and whiteheads.
Propionibacterium acnes lives on everyone’s skin, usually causing no problems, but in those prone to acne, the build-up of oil creates an ideal environment in which these bacteria can multiply. This triggers inflammation and the formation of spots.
NICE Clinical Knowledge Summary recommendations:
To minimize the risk of P. acnes developing resistance, antibiotics should be limited to the shortest possible period, and discontinued when further improvement of acne is unlikely
Oral antibiotics should always be combined with a topical treatment (retinoid and/or benzoyl peroxide). Topical antibiotics and oral antibiotics should not be combined together, as this combination is unlikely to confer additional benefit and may encourage the development of bacterial resistance
Response to oral antibiotics should be reviewed at six to eight weeks. If the person has responded to treatment:
o Continue for an additional 4–6 months
o Continue topical treatment after stopping
o If the person has not responded adequately, continue for 3 months before assuming treatment is ineffective. At this stage, consider seeking specialist advice or referring to a dermatologist.
Notes to editors:
Oral antibiotics are used globally for the treatment of moderate-to-severe acne vulgaris due to their antimicrobial affects against Propionibacterium acnes. While they are still a mainstay of management, the use of antibiotics has come under increasing scrutiny from advisory bodies including the Global Alliance to Improve Acne Outcomes and the European Evidence-Based (S3) Guidelines for the Treatment of Acne. The prolonged use of antibiotics in acne is a concern due to the potential to drive antibiotic resistance in commensal bacteria, as well as antibiotic-resistant P. acnes, which may translate to reduced or lack of efficacy. The incorporation of antibiotic stewardship into commissioning programmes has therefore become a key focus for the National Health Service in England, manifest as the National Antibiotic Premium 2015–2016. Given the emphasis on antibiotic stewardship, surprisingly few studies have focused on antibiotic duration in this chronic disease. A recent study in the U.S.A. found that the average duration of antibiotic use in acne prior to commencing isotretinoin far exceeded current recommendations. To our knowledge, there are no comparable studies for antibiotic duration in the U.K. An initial pilot study has been retrospectively conducted on 100 patients with moderate-to-severe acne treated with oral antibiotics prior to referral into the secondary-care acne clinic. We now aim to determine the duration of oral antibiotic use in patients with inflammatory acne prior to referral to a secondary-care clinic for consideration of isotretinoin, by conducting a further retrospective review of data held on an ethically approved secure acne database of 1178 patients. The pilot data demonstrate that the mean age of onset of acne was 13.7 years. Lymecycline (75%) was most frequently prescribed, followed by oxytetracycline (52%), erythromycin (44%), trimethoprim (19%), doxycycline (12%), minocycline (10%) and other (4%). A mean number of 2.2 different antibiotics were prescribed per patient (range 1–5). The mean duration of antibiotic use was 305.3 days (range 7–3240). The longest duration for a single antibiotic was 1230 days. This demonstrates that patients with acne in the U.K. have exposure to antibiotics beyond current recommendations, and delays in securing adequate treatment. Delay in initiating effective therapy is known to increase the risk of acne scarring (Layton AM, Henderson CA, Cunliffe WJ. A clinical evaluation of acne scarring and its incidence. Clin Exp Dermatol 1994; 19: 303–8). Results from this study could help to drive a change in prescribing habits in line with the national antibiotic quality premium.
Prescribing for acne in the U.K.: patterns and influencers
H.J. Whitehouse, E.A. Eady, C.J. Ward and A.M. Layton
Department of Dermatology, Harrogate and District NHS Foundation Trust, Harrogate, North Yorkshire, U.K.
We sought to examine beliefs among U.K. healthcare practitioners (HCPs) and patients about acne management to identify influences on practice, including consideration of antibiotic resistance. In the U.K., acquired resistance in Propionibacterium acnes, the target of antibiotic therapy in acne, is among the highest globally. Although U.K. prescribing data are not publicly available, data on file show heavy reliance on antibiotics. Structured questionnaires developed by multidisciplinary teams were launched on 1 March 2015. To date, 4518 patient and 1227 professional responses have been secured. The professionals included 372 general practitioners (GPs), 101 GPs with a special interest (GPwSIs), 277 dermatologists, 47 nurse prescribers and 430 others/not disclosed. The results suggest that professionals consult a wide range of information concerning acne treatments. The British National Formulary (BNF) is used most widely (86%), followed by National Institute for Health and Care Excellence Clinical Knowledge Summaries (70%). Overall 89% of GPs may seek advice from consultant colleagues, GPwSIs are more likely to obtain information from training courses (33%), and dermatologists are most likely to consult specialist journals (55.6%). Multiple clinical features are considered when prescribing; acne severity and presence of scarring are the most frequent (‘always’ or ‘often’ by 98% and 91%, respectively), followed by psychological impact (88%), type of lesion (87%) and treatment history (85%). In total 33% most commonly prescribe regimens that include an oral tetracycline, whereas 24% include a topical antibiotic. Lymecycline was the most frequently prescribed oral antibiotic (90%) for moderate-to-severe acne. However, 28% of respondents used tetracyclines ‘always’ or ‘most of the time’ for comedonal acne, and 19% for mild acne. Around half (45%) of all professionals have not changed prescribing habits in the last 3 years. Over 50% agreed that ‘antibiotic resistance is a big problem in managing acne’, but only 25% said it was a concern for their patients, contrasting with 74% of patients worrying about antibiotic-resistant infections later in life. Changes in local and (inter)national guidance plus regulatory warnings were stated as factors that would alter practice. However, only small numbers suggest that they ‘often’ consult evidence-based guidance (dermatologists 15%, GPwSIs 13% and GPs 3%), questioning the impact of guidelines on prescribing habits. These initial results suggest that a significant number of HCPs are aware that antibiotic resistance should influence prescribing behaviour. However, there are some potential differences between prescribers, and possible educational requirements, including the need to appreciate patients’ concerns about antimicrobial resistance. Advice contained within the BNF and a Medicines and Healthcare Products Regulatory Agency warning might be the best ways of drawing attention to the need to reduce reliance on antibiotics for managing acne.
* This occurs because the use of anti-biotics results in selective pressure in bacteria beyond the skin, meaning that only those that are resistant to anti-biotics survive, in a form of natural selection.
** Layton AM, Henderson CA, Cunliffe WJ (1994). A clinical evaluation of acne scarring and its incidence. Clin Exp Dermatol, 19: 303–8 DOI: 10.1111/j.1365-2230.1994.tb01200.x
***Bhate, K. and Williams, H.C. (2013), Epidemiology of acne vulgaris. British Journal of Dermatology, 168: 474–485. DOI: 10.1111/bjd.12149
For more information on acne please visit: http://www.bad.org.uk/for-the-public/patient-information-leaflets/acne
The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease. For further information about the charity, visit www.bad.org.uk