On the first day of Fall Clinical 2022, in their session, “Practicing Good Antibiotic Stewardship When Treating Acne,” Christopher G. Bunick, MD, PhD, and Emmy Graber, MD, MBA, discussed the practice of antibiotic stewardship in treating acne vulgaris.

They started the session by defining antibiotic stewardship. “[Antibiotic stewardship] is an initiative to promote the appropriate use of antibiotics where patients receive the right dose of the right antibiotics at the right time for the right duration,” explained Dr Graber.

They answered the question of why we use antibiotics. Inflammation and Cutibacterium acnes (C. acnes) are targeted by antibiotics. “Recent guidelines advocate the use of oral antibiotics for both moderate and severe acne. This could be a first-line treatment or an alternative treatment. The use of oral antibiotics is pervasive throughout these guidelines,” Dr Graber elaborated.

Next, Drs Bunick and Graber dived into case studies, with the first case concerning antibiotic resistance for moderate to severe acne on the face. They suggested narrow-spectrum antibiotics to reduce the risk of resistance. Some take-home pearls from the first case were:

• C. acnes resistance is prevalent and increasing.
• Narrow-spectrum antibiotics can minimize resistance.
• Sarecycline is a narrow-spectrum antibiotic with very low incidence of photosensitivity and vestibular side effects.
• Consider combination therapy using oral antibiotics to minimize antibiotic duration and create a durable regimen.

In the second case study of mild to moderate acne on the face, Drs Bunick and Graber touched upon a new treatment option on the horizon: triple combination topicals such as IDP-126. “It can enhance efficacy in the treatment of acne vulgaris and is likely to increase patient compliance,” Dr Bunick said. Some take-home pearls from the second case were:

• Acne has a huge psychological impact, and we have the tools to not only improve the skin but also the psyche.
• Combination therapy improves adherence and minimizes resistance.

In the third and last case study of acne on the face and back, Drs Bunick and Graber stated that “broad-spectrum antibiotics harm the microbiome maybe more than we previously realized.” Dr Bunick emphasized the benefits of narrow-spectrum sarecycline: “It can be taken with our without food and it tends to be weight-based dosing.” Dr Graber also remarked on the antibiotic interactions with oral contraceptive pills (OCP) and mentioned that rifampin and griseofulvin are the only antibiotics less effective when combined with OCPs. “After 6 months, oral antibiotics were similar to the efficacy of the oral contraceptives.” Some take-home pearls from the third case were:

• Doxycycline and minocycline should be taken with food; sarecycline can be taken either with food or on an empty stomach.
• Tetracycline does not impact the efficacy of oral contraceptives.
• Consider hormonal modalities in women, which can be used alone or in combination with oral antibiotics.

To conclude, Drs Bunick and Graber discussed various antibiotic therapies for the management of acne, shared strategies to individualize care with newer antibiotic treatment options, and described techniques to incorporate antibiotic acne treatment into clinical practice.

Reference
Bunick CG, Graber E. Practicing good antibiotic stewardship when treating acne. Presented at: Fall Clinical Dermatology Conference 2022; October 20–23, 2022; Las Vegas, NV.