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Treatment of severe acne hampered by antibiotic overuse, delays in prescribing more potent medicatio

Data from a retrospective, single-site chart review of medical records suggests that physicians who treat severe acne leave too many patients on ineffective antibiotics for far too long before prescribing isotretinoin, according to researchers who reported their findings online in the Journal of the American Academy of Dermatology (Oct. 30, 2015).

The research team's analysis involved a detailed review of 137 medical histories of patients, all over the age of 12—who were treated at New York University (NYU) School of Medicine at Langone Medical Center for severe cases of acne between January 1, 2005 and December 31, 2014.

The aim of the investigation was to determine the duration of systemic antibiotic use in patients with inflammatory/nodulocystic acne who eventually required isotretinoin, the authors reported.

Findings revealed that the average duration of antibiotic use was 331 days. In all, 21 patients (15.3%) were prescribed antibiotics for three months or less, 88 patients (64.2%) for six months or more, and 46 patients (33.6%) for one year or longer, the authors wrote.

Researchers also reported that the patients treated only at the study site had a mean duration of antibiotic treatment of 283 days whereas patients who also received antibiotics from another institution had a mean duration of 380 days. This difference approached statistical significance (p=0.054).

"Our study suggests that physicians need to recognize within weeks, not months, when patients are failing to respond to antibiotic therapy in cases of severe acne," says study senior investigator Dr. Seth Orlow, the Samuel Weinberg Professor of pediatric dermatology and chairman of the Ronald O. Perelman Department of Dermatology at NYU Langone, who was quoted in a press release.

According to Dr. Orlow, antibiotic therapy can be effective for inflammatory types of acne. And switching to different antibiotics is routine practice when another antibiotic has failed to reduce symptoms. However, Dr. Orlow says clinical guidelines recommend limiting such antibiotic therapy to two months to three months each, or six months overall, unless significant improvements are seen.

Physicians, patients often complacent about antibiotic overuse and microbial drug resistance

"Physicians and patients have become far too complacent about antibiotic overuse and its subsequent danger of increasing microbial drug resistance," says Orlow. The problem, he notes, is compounded by disruptions in patient care from patients changing physicians or health plans. Dr. Orlow says a lot of time is wasted while continuing antibiotic therapy during these intervals when treatment failure is visibly evident.

Lead study investigator and dermatologist Dr. Arielle Nagler, says fears about isotretinoin side effects, as well as federal restrictions meant to prevent use of the medication during pregnancy, have also all helped contribute to prolonged antibiotic overuse and delayed access to the drug.

Dr. Nagler acknowledges that the risk of side effects is real, but says protocols are in place to prevent or carefully manage them. Among these is the iPledge registry set up by the Food and Drug Administration in 2006, which requires all patients, physicians and pharmacists to track isotretinoin prescriptions and side effects and to monitor compliance by women of child-bearing age with monthly pregnancy tests. She notes, however, that registration delays or technical holdups often keep patients from getting their medications as prescribed by as much as a month.

"Acne remains the number one reason for young people to visit a dermatologist, and there are no other medications as effective as isotretinoin for treating severe cases of the skin condition," says Dr. Nagler, an instructor at NYU Langone, which also funded the study. "We need to find a better balance between trying antibiotics that may work and getting isotretinoin quickly to patients for whom antibiotics are not working.”

Dr. Nagler concluded that “physicians also need to start talking to their acne patients earlier about possible isotretinoin therapy, so when and if they do need to switch to it, patients are more receptive to the drug and any concerns about side effects have already begun to be addressed."

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