Antibiotics and acne: updated prescriptions' guidelines – Pr. P. Humbert

The role of local and oral antibiotic therapy for the treatment of acne has decreased significantly in recent years, and the recommendations of learned societies are increasingly restrictive regarding its use.

The first reason is linked to the emergence of P. acnes resistant to erythromycin and clindamycin, and more rarely to tetracyclines^1,2,3. The resistant strains may not only be transmitted to other individuals, the resistance may also affect other bacteria; moreover, oral antibiotic therapy affects the microbial ecosystem.
To potentiate its effectiveness and limit the emergence of resistance, local antibiotic therapy must not be used alone but only in combination with another topic (benzoyl peroxide or local retinoid). Its effect will be assessed after 2-3 months. Local antibiotic therapy is not recommended for maintenance therapy. In practice, moderate to severe inflammatory acnes as well as extensive acnes of the face and torso require antibiotic therapy or at least the prescription of cyclines whose mechanism of action is not unequivocal, although they are expected to have an anti-inflammatory effect, although they are not recommended for mild acnes on the face, chest and back or comedogenic acnes.
Although it is minor compared to the risk of bacterial resistance, the phototoxic risk of cyclines is a second reason for limiting their use⁴.
Several clinical signs of phototoxic reactions have in fact been predescribed, from acute erythema of exposed regions (sunburn), to photo-onychlysis observed after 2-4 weeks of treatment with doxycycline. These reactions are dose-dependent and generally arise with doses higher than those recommended for acne⁵.

Guidelines of the AAD

The American Academy of Dermatology recently published its guidelines of care for the management of acne⁶. The treatment algorithm is based on the clinical form and grade of the lesions (Table).

The AAD guidelines give priority to topical treatments for firstline treatment, preferably combining at least two or even three molecules: benzoyl peroxide and/or antibiotics and/or retinoids.

This article has been written by Pr. P. Humbert, dermatologist at Hôpital Jean Minjoz, Besançon