Antibiotic prescribing in acne - can we all do our little bit to reduce antibiotic resistance?

There have been so many challenges to ‘best practice’ during the COVID pandemic, it sometimes feels a bit overwhelming knowing where we can start to re-engage with important areas of individual and public health. One area I’m sure we all feel somewhat uncomfortable about is antibiotic prescribing. The push to remote consultations has necessitated a lower threshold to prescribing for infections, and I’m sure we would all stick our hands up and accept that our prescribing rates must have increased over the past 12 months as a result.

 But we all know antibiotic resistance remains a major challenge for us, and one we must not side-line. Indeed, antibiotic resistance is no.5 on the WHO list of the biggest threats to global health. My colleague Neal has given us all a wake-up call in the last few weeks, by highlighting the ‘biggie’ and no.1 on the WHO list of threats to global health - air pollution and climate change. His excellent podcast last month and discussion with Terry Kemple highlighted how we can aim to become a bit greener in General Practice. As this discussion highlighted, we cannot arrest climate change in General Practice but we all know we can do things to help. On the back of this, Neal has given us a really helpful guide to reducing our carbon footprint by changing our inhaler prescribing, which is thought to account for 3-4% of the total NHS carbon footprint - a potential ‘easy win’.

 But back to antibiotic resistance, and are there any 'easy wins' for us to look at? Well, antibiotic prescribing in acne management could well be one. This crossed my radar again with an interesting qualitative study in the BJGP in January (BJGP 2021; 71 (702)). We don’t see that many qualitative studies, but they represent a very important facet to primary care evidence base. They give insights into the ‘why’ not the ‘what’. This study reviewed GPs' perspectives on acne management and highlighted a number of themes that I think we would all recognise, including a reliance on oral antibiotics (often for prolonged courses) and a reluctance to use to non antibiotic topical treatments due to perceived side effects and acceptability for patients.

 The issue of antibiotic resistance and implications in acne management was reviewed in a BJGP editorial back in 2018 (BJGP 2018; 68 (667). This editorial highlighted that there has been a substantial improvement in antibiotic prescribing generally in primary care, yet little emphasis has been given to antibiotic prescribing in acne, despite the fact that antibiotics for acne represent a substantial proportion of antibiotic use, particularly in young people. Resistance rates to erythromycin and clindamycin in acne bacterial strains are now as high as 45-91%. These papers point out that in about 1/3 of first acne consultations in the UK oral antibiotics alone are initiated, and in another 1/3 topical antibiotics are initiated, despite the recommendations that non-antibiotic topical treatments should be considered initially in the majority of people. 

 So, what can we do to try to improve antibiotic prescribing in acne, and reduce resistance? I think there are a number of practical learning points for us:

•   First, a recognition that non-antibiotic topical treatments are probably as effective as antibiotics for people with mild/moderate papular/pustular acne and are recommended first-line by NICE and the Primary Care Dermatology Society (PCDS) - topical benzoyl peroxide (BPO) or topical retinoid, either alone or in combination (‘Epiduo’ is the combination treatment recommended by the PCDS).*

•   Work with your patient to encourage initial non-antibiotic treatment and the reasons. Warn them it will take 2 months of regular treatment to see benefits, give good patient information (excellent PIL from British Association of Dermatology here), and give practical tips to manage side effects (e.g. start topical treatment on a small area of skin, only 2-3 times per week, and gradually build up to larger areas daily).

•   If using antibiotics ALWAYS combine with non-antibiotic topical treatment, ideally BPO (or topical retinoid if BPO not tolerated) - this helps reduce resistance.

•   If using antibiotics, do not use both oral and topicals at the same time, and use for 3 months only - the acne may not have totally cleared by this time, but in the majority of patients it will be improved enough that they can then step down to non-antibiotic treatment.

These suggestions are not going to solve antibiotic resistance by any stretch, but they will all help, and along a similar theme to Terry’s points on climate change, small changes by the majority will give bigger overall gains than massive changes by the few. We can all do our little bit.

* Many thanks to one of our colleagues who has clarified that the first line topical treatment recommended by the PCDS (and before combination treatment) is a topical retinoid (adapalene) rather than benzoyl peroxide, because retinoids are better at preventing comedone formation than benzoyl peroxide, are also better tolerated and don’t bleach the face towels!