ANTIBIOTICS

15 May

Ciprofloxacin and  trimethoprim-sulfamethoxazole are  both  sometimes useful  in acne. No large,  detailed studies exist to document efficacy, but  there  are sufficient anecdotes to believe that they are effective in acne (35,36). Whether these important drugs should receive wide  usage  in acne is a matter of some debate, but few would dispute that  they  should be reserved for patients who  cannot  be treated with  con- ventional regimens.

TREATMENT REGIMENS

Because acne is a multifactorial disease, and  because most  acne treatments (isotre- tinoin  excepted) are  not  completely effective,  typical  treatment regimens involve one or more  medications. Multidrug treatment schemes are an undesirable fact of acne  therapy. They  make   compliance  difficult   in  a  patient  population  that   is

fundamentally noncompliant, and  add  expense. Therefore, regimens should be as streamlined as  possible. Table  3  presents useful   antibiotic treatment  plans   for acne of varying severites.

THE PROBLEM  OF ANTIBIOTIC OVERUSE  AND A PHILOSOPHY FOR ACNE TREATMENT

Overuse of antibiotics has received increased attention from public  health experts and  the lay press  for some  time.  The increase in resistant organisms is a real and a significant phenomenon that  results in greater illness  and  expense in treatment of  acne  and  other   diseases as  well.  Moreover, chronic   antibiotic use  has  been implicated in increasing the  risk  of breast  cancer  (37,38) and  increasing the  inci- dence  of upper respiratory infections (39), all in single  studies that  have  yet to be confirmed.

Whether or not this link to nonbacterial diseases proves to be real, there is suf- ficient reason to avoid long-term antibiotic therapy whenever possible. Acne, unfor- tunately, is neither a short-term disease nor one that is quickly  controllable in many patients, and prolonged courses of antibiotics are often needed. Steps must  be taken by the practitioner to minimize the need  for chronic  treatment by optimizing regi- mens  so as to minimize antibiotic exposure. There are several  methods that may be employed to achieve  this end.

First, the use of combination therapy with  topical  retinoids should be begun early in treatment. It has been clearly  shown by several  studies that  many  patients treated with  oral antibiotic and  topical  retinoid for 12 weeks  may  have  long-term control  of their  acne  with  topical  retinoids alone  after  12 weeks  (40,41). In  my experience, almost  70% of patients with  papular acne  will  have  no need  for oral antibiotic use  after  12 weeks,  if they  have  used  topical  retinoids aggressively for the first 12 weeks.

Second,   patients who   are  severe   enough to  warrant isotretinoin therapy should get  the  drug sooner  rather than  later.  A prolonged trial  of antibiotics is not justifiable  if the patient is a legitimate candidate for isotretinoin.

Third, when long-term antibiotic therapy is required, BP should be part of the regimen because of its ability  to discourage the acquisition of resistance.

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