There are 2 issues.

One is antibiotic resistance in P acnes, making P acnes less susceptible to antibiotics, both oral
and topical, that used to work. The other issue can be posed in the form of a question: Does acne therapy with
antibiotics raise up resistant populations of pathogens on the bodies of people being treated for acne? et!s talk
about the first issue first.
"t is clear that P acnes that is resistant to erythromycin and clindamycin is much less responsi#e to treatment in
acne, and patients with these resistant organisms do not do as well as patients who ha#e sensiti#e organisms. The
incidence of resistance to erythromycin and clindamycin has risen steadily since these drugs were introduced about
$% years ago. "t is now at the point that oral and topical erythromycin and clindamycin are useless as monotherapy
in acne and contribute #ery little to any acne therapy, e#en when used in combination therapy. There are patients
who seem to ha#e acne that is resistant because their bugs are resistant to those 2 drugs. &ith do'ycycline and
minocycline, you can show that the minimal inhibitory concentration in P acnes has crept upward o#er the years but
does not reach the le#el of true resistance.
The bigger issue of whether long(term acne therapy is raising up resistant populations on patients is tougher to
answer. &e know that $% or )% years of using oral tetracyclines has not resulted in an increase in *taphylococcus or
*treptococcus infections in those patients. +owe#er, at the same time, we note that these patients carry bugs that
could learn to be resistant to do'ycycline with enough e'posure. Staphylococcus aureus would be a particular
tragedy because e#en the resistant *taphylococcus infections, such as methicillin(resistant S aureus,-.*/0, at
least in most geographic areas, tend to be susceptible to do'ycycline. "f we o#eruse do'ycycline and educate the
-.*/ to resist do'ycycline, we will ha#e lost a #ery safe and effecti#e drug to treat -.*/ infections.
&hene#er you treat a human with an antibiotic, the presumption is that there is a good reason for it. 1or e'ample,
take a teenager with scarring acne, which is a guaranteed risk #s a theoretical risk of generating resistance
somewhere on the patient!s body. " will choose to treat the patient!s acne first and worry second about resistance.
This is not being ca#alier about the issue of resistance, it is being more concerned about the patient who is in front
of me.
Oral antibiotic use should be minimi2ed to reduce the possibility of resistant strains of P acnes. "f you can get a
patient better without antibiotics, great. "f you ha#e to use antibiotics, do it boldly and get it o#er with as quickly as
you can.Oral antibiotics are generally used in patients with moderate to se#ere inflammatory acne. One consensus
panel has recommended limiting the duration of oral antibiotic therapy to 32 to 34 weeks.
567

There are se#eral ways to limit the duration of oral antibiotic treatment. One would be to not fiddle around with a low
dose but to gi#e a higher dose in combination with a second drug that will work to make the acne more treatable in
time. That second drug would be a topical retinoid: ta2arotene, tretinoin, or adapalene. Topical retinoids ha#e a
direct effect on the formation of comedones and also ha#e anti(inflammatory effects. These drugs are used in the
treatment of both comedonal and inflammatory acne and are generally recommended in the initial management of
most patients with acne. /ll these retinoid drugs will help get patients off oral antibiotics more quickly if you use one
of them from day 3. 8atients who ha#e done well after 2 or $ months of oral antibiotic therapy, which will be the
ma9ority of patients, can be taken off the antibiotic and maintained 9ust on the topical regimen. That is a great way to
get people off oral antibiotics relati#ely quickly.
"ncluding ben2oyl pero'ide in acne regimens is another tactic to a#oid bacterial resistance. :en2oyl pero'ide is a
bactericidal agent that is directly to'ic to microorganisms. -aking sure that ben2oyl pero'ide is part of any topical
antibiotic regimen will discourage the de#elopment of resistance in P acnes and, presumably, any bacteria it comes
in contact with. "f you are going to use topical clindamycin, make sure ben2oyl pero'ide is on board too, whether it is
in a combination ben2oyl pero'ide(clindamycin product or a ben2oyl pero'ide wash. ;rythromycin(ben2oyl pero'ide
combination products are also a#ailable.
/ fi'ed combination of adapalene and ben2oyl pero'ide is a#ailable in a gel formulation. "n a )(week, open(label
study, this fi'ed(combination product inhibited both antibiotic(resistant and antibiotic(susceptible P acnes.
5<7

/nother way to a#oid bacterial resistance is to prescribe isotretinoin for se#ere, resistant acne. "n the =nited
>ingdom, for e'ample, the standard of care is $ months of therapy with an oral antibiotic and a topical retinoid. "f the
patient is not clear after $ months, you go right to isotretinoin. "n the =nited >ingdom, they worry more about
bacterial resistance than they do about birth defects. "n the =nited *tates, we take a different approach and worry
more about the teratogenicity of isotretinoin than we worry about antibiotic resistance. "t is something to ponder
when making treatment decisions.?
/nother option is hormonal treatment. "t only works in women because men get femini2ed when you inhibit their
androgens, but in women, there are great approaches. *pironolactone entered the world @% years ago as a diuretic,
but it is also an oral antiandrogen that has been used off(label in the =nited *tates for the treatment of acne in
women for appro'imately $% years. Oral spironolactone is an efficacious way to treat fairly se#ere acne without
going anywhere near an antibiotic. **
"n the ;uropean =nion, cyproterone acetateAethinylestradiol is appro#ed for the treatment of moderate to se#ere
acne related to androgen sensiti#ity ,with or without seborrhea0 in women of reproducti#e age for whom topical or
systemic antibiotic acne treatment has failed. This drug is not a#ailable in the =nited *tates, and recent concerns
about the risks for #enous thromboembolism ha#e spurred labeling changes in the ;uropean =nion.
53%7

The problem of antibiotic resistance has informed current guidelines for the treatment of acne #ulgaris ,Tables 3 to
)0.
Table 1. Pediatric Treatment Recommendations for Mild Acne
Initial Treatment :8
OR
Topical retinoid
OR Topical Bombination Therapy?
:8 C /ntibiotic
OR
.etinoid C :8
OR
.etinoid C /ntibiotic C :8
If Inadequate Response*

/dd :8 or retinoid, if not already prescribed

OR
Bhange topical retinoid concentration, type, andAor formulation
OR
Bhange topical combination therapy
:8 D ben2oyl pero'ide.
?Topical fi'ed(combination prescriptions are a#ailable.
E/ssess adherence.
1rom ;ichenfield 1, et al.
5@7

Table 2. Pediatric Treatment Recommendations for Moderate Acne
Initial Treatment Topical Bombination Therapy?
.etinoid C :8
OR
.etinoid C ,:8 C /ntibiotic0
OR
,.etinoid C /ntibiotic0 C :8
OR Oral antibiotic
C
Topical retinoid C :8
OR
Topical retinoid C /ntibiotic C :8
If Inadequate
Response*

Bhange topical retinoid concentration, type,
andAor formulation
AND/OR
Bhange topical combination therapy
AND/
OR
/dd or change oral antibiotic
Bonsider hormonal therapy for
female patients
F

OR Bonsider oral
isotretinoin
F

:8 D ben2oyl pero'ide.
?Topical fi'ed(combination prescriptions are a#ailable.
E/ssess adherence.
FBonsider dermatology referral.
1rom ;ichenfield 1, et al.
5@7

Table 3. Pediatric Treatment Recommendations for Seere Acne
Initial Treatment
!
Bombination Therapy?
Oral antibiotic
C
Topical retinoid
C
:8
CA(
Topical antibiotic
If Inadequate Response
!
Bonsider changing oral antibiotic
AND
Bonsider oral isotretinoin
Bonsider hormonal therapy for female patients
F

:8 D ben2oyl pero'ide.
?Topical fi'ed(combination prescriptions are a#ailable.
E/ssess adherenceG consider change of topical retinoid.
FBonsider dermatology referral.
1rom ;ichenfield 1, et al.
5@7

Table ". #uropean Acne Treatment $uidelines
%i&'(stren&t' Recommendations Medium(stren&t' Recommendations Alternaties for )emale Patients
*omedonal acne+ Ho high(strength
recommendation
Mild(to(moderate papulopustular
acne+ /dapalene C :8 ,fc0 OR :8 C
clindamycin ,fc0
Seere papulopustular,moderate
nodular acne+ "sotretinoin
Seere nodular,con&lobate acne+
"sotretinoin
*omedonal acne+ Topical retinoid
Mild(to(moderate papulopustular acne+ /2elaic
acid OR :8 OR topical retinoid OR systemic
antibiotic C adapalene
Seere papulopustular,moderate nodular acne+
*ystemic antibiotics C adapalene OR systemic
antibiotics C a2elaic acid OR systemic antibiotics C
adapalene C :8 ,fc0
Seere nodular,con&lobate acne+ *ystemic
antibiotics C a2elaic acid
Seere papulopustular,moderate nodular
acne+ +ormonal antiandrogens C topical
treatment O. hormonal antiandrogens C
systemic antibiotics
Seere nodular,con&lobate acne+ +ormonal
antiandrogens C systemic antibiotics
:8 D ben2oyl pero'ide.
1rom Hast /, et al.
5)7

Medscape+ -'at is t'e current role of topical antibiotics in t'e treatment of acne. &ien t'e problem of
antibiotic resistance and t'e efficac/ of ot'er topicals suc' as ben0o/l pero1ide and topical retinoids2
3r -ebster+ Topical erythromycin and clindamycin as monotherapy ha#e little role in treating acne because of the
predominance of resistant strains of P acnes. 8roducts that pair erythromycin or clindamycin with ben2oyl pero'ide
remain effecti#e.
Medscape+ 4ou 5ere part of t'e &roup t'at deeloped t'e #idence(6ased Recommendations for t'e
3ia&nosis and Treatment of Pediatric Acne. 5'ic' 5ere publis'ed in 2713.
89:
T'ese recommendations 5ere
deeloped t'rou&' t'e American Acne and Rosacea Societ/ and endorsed b/ t'e American Academ/ of
Pediatrics. -'/ are t'ese &uidelines important2
3r -ebster+ /cne is one of the most common skin conditions in children and adolescents, but until now there ha#e
not been standard guidelines for the management of pediatric acne. One of the messages of the guidelines is that
treatment should be appropriately aggressi#e. &hen a kid has acne, e#en at an age when you do not e'pect acne,
the child!s age is not a reason to not treat or to undertreat. Iounger kids deser#e sufficiently #igorous treatment to
get them better, 9ust like older kids. That message needs to be emphasi2ed, especially to pediatricians. /cne is not
nothing, and it is reasonable to treat it properly e#en in a younger child.
* "n the =nited >ingdom, isotretinoin must be prescribed under the super#ision of a dermatologist with an
understanding of the risks of retinoid treatment and the monitoring requirements for the use of isotretinoin. /
8regnancy 8re#ention 8rogramme is also in place.
547

??=* 1ood and Drug /dministration labeling for spironolactone carries the following bo'ed warning: J*pironolactone
has been shown to be a tumorigen in chronic to'icity studies in rats. *pironolactone should be used only in those
conditions described under "ndications and =sage. =nnecessary use of this drug should be a#oided.J