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A medical records analysis has concluded that physicians who treat severe acne tend to leave too many patients on ineffective antibiotics too long before prescribing more potent therapy with the medication isotretinoin also known by its former name Accutane. The study published in the Journal of the American Academy of Dermatology is the first to focus specifically on the history of antibiotic overuse in severe cases of acne that were treated with isotretinoin.
The Findings
The research team reviewed 137 medical histories between 2005 and 2014 of patients over the age of 12 that were treated at NYU Langone for severe cases of acne. The case reviews were from more than 5,000 files of those that sought treatment for mild to severe acne at the facility. The cases showed that on average those with severe and often cystic acne were kept on initial antibiotic therapy for 11 months before it was recognized that the drugs were not working - and before switching them to isotretinoin therapy.
The researchers also noticed that for the 137 patients with severe acne in the study that eventually received isotretinoin there was an average lag time of nearly six months from when it was first mentioned by their doctor to when they began taking it. Although there were multiple causes for the delays, the researchers report that some were due to the tight controls placed on the drug because of the increased risk it poses for birth defects, and concerns about depression and other potentially serious side effects.
Antibiotic Therapy
"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 Seth Orlow, MD, PhD, the Samuel Weinberg Professor of pediatric dermatology and chairman of the Ronald O. Perelman Department of Dermatology at NYU Langone.
Orlow says that antibiotic therapy can be very effective for inflammatory types of acne and that switching to different antibiotics is routine practice when another antibiotic has failed to reduce symptoms. However, clinical guidelines recommend limiting such antibiotic therapy to two months to three months each, or six months overall, unless significant improvements are seen. "Physicians and patients have become far too complacent about antibiotic overuse and its subsequent danger of increasing microbial drug resistance," he added. The problem is compounded by disruptions in patient care from patients changing physicians or health plans. A lot of time is wasted while continuing antibiotic therapy during these intervals when treatment failure is visibly evident.
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, says lead study investigator and dermatologist Arielle Nagler, MD. He 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. 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," Nagler continued. "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. 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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