Topical Antibiotics: Addressing the Growing Concern of Antimicrobial Resistance

During the third day of Fall Dermatology Week, James Del Rosso, DO, FAOCD, reviewed antibiotics, both topical and systemic, that are frequently prescribed in dermatology, not only for infections but also for long-term conditions. He noted that, while antibiotics are essential for managing acne and rosacea, dermatologists need to approach their use thoughtfully, especially considering the potential for antibiotic resistance.

At the start of his presentation, he shared key areas of focus, such as:

1. The impact of antibiotic resistance on prescribing practices.

2. Differentiating between topical and systemic antibiotics in treating dermatologic conditions.

3. Reviewing commonly used antibiotics for acne and rosacea.

4. Trends in antibiotic usage over time and methods for optimizing usage to minimize resistance.

Dr Del Rosso noted that treatment options for acne include topical dapsone, which is often used as an anti-inflammatory but also has mild antibiotic properties, and clindamycin, another topical antibiotic that has debatable anti-inflammatory effects but shows efficacy for acne. It is typically combined with benzoyl peroxide to curb resistance. Combining antibiotics with benzoyl peroxide can prevent resistance buildup in localized tissues. While antibiotics like erythromycin were once heavily used for acne, resistance has limited their efficacy in treating staph infections.

Although oral antibiotics are part of treatment guidelines, particularly for moderate to severe cases of acne that do not respond well to topical regimens, they are not recommended as standalone therapies and should be combined with topicals like benzoyl peroxide or retinoids. The aim of using oral antibiotics is to reduce inflammation and prevent long-term sequelae such as scarring. Although guidelines suggest limiting antibiotics to about 3to 4 months, data show many patients benefit from prolonged use.

“We try to minimize extended use but recognize that individual patient needs can dictate different durations,” Dr Del Rosso stated.

While dermatologists are encouraged to limit antibiotic use to essential cases, it is also critical to provide alternative treatment options. Alternatives include hormone-based treatments (e.g., spironolactone in adult women), devices like laser therapy, and oral isotretinoin for severe cases. These options can help manage acne without relying heavily on antibiotics.

Dr Del Rosso continued by addressing research that indicated antibiotic use, even topically, can lead to resistant strains in the skin’s flora. When antibiotics like erythromycin are used topically, they can lead to increased resistance in staph bacteria as well as C. acnes (formerly P. acnes) and affect even the normal bacterial flora. Some studies show that long-term antibiotic use in acne treatment results in resistant strep strains in the throat, which can be transmitted to others. He shared that when antibiotic use is minimized, resistance rates tend to decrease.

He concluded by sharing how antibiotics remain crucial for managing acne and rosacea, yet dermatologists must employ them judiciously. By optimizing antibiotic use, dermatologists can address resistance concerns, allowing for effective treatment options without compromising future effectiveness.

Reference
Del Rosso J. Antibiotic stewardship. Presented at: Dermatology Week; November 13–16, 2024; Virtual.