The Problem With Adult Acne
-- As Antibiotics Become Less Effective, Doctors Try a Range of New Treatments
BY DANA WECHSLER LINDEN
Three months after Danielle Schwarz began taking antibiotics for a severe case of acne, her doctor began to notice a disturbing pattern among her patients—this mainstay treatment for the skin condition increasingly wasn’t working.
“I was canceling plans, didn’t want anyone to see me,” says Ms. Schwarz, a 25-year-old bank analyst in New York.
Her doctor, Whitney Bowe, a clinical assistant professor of dermatology at the Icahn School of Medicine at New York’s Mount Sinai Medical Center, kept Ms. Schwarz on the antibiotics a short while longer. Then, about 18 months ago she switched her to a completely different approach to treatment: a variety of yet-to-be proven therapies that included diet modification and alternating monthly chemical peels and light treatments.
“We used to get more success with oral antibiotics,” says Dr. Bowe. But the bacteria responsible for causing acne have become so resistant to the drugs “that our ability to treat moderate to severe acne has become compromised,” she says.
Growing concern over antibiotic resistance is changing how dermatologists treat acne. They are relying more on topical treatments, which can require a lot of patient education and hand-holding to assure reliable use, and on hormonal medications for some women. Some dermatologists say they are putting more patients on isotretinoin, an effective acne drug with a controversial history that used to be sold under the brand name Accutane.
Also gaining in use is a variety of newer approaches whose efficacy for acne hasn’t been extensively researched. Among these are laser and light-based therapies, chemical peels, diet changes, probiotics and so-called sub-antimicrobial doses of antibiotics, which are designed to be too small to kill bacteria but still able to fight inflammation.
Acne is the most common skin disorder in the U.S., affecting about 85% of teenagers and a sizable number of adults. Some 51% of women and 43% of men in their 20s have acne, along with 15% of women and 7% of men over age 50, a 2008 University of Alabama study found. Acne can persist beyond adolescence, or develop in adulthood.
Antibiotics are one of the main ways to treat moderate to severe acne, and patients often are put on them for months or years. Although dermatologists represent only 1% of the nation’s physicians, they prescribe 5% of antibiotics, pharmaceutical-industry data show. Over time the microorganisms the antibiotics are designed to kill adapt to them, making the drugs less effective.
In a study in Britain, antibiotic-resistant strains of Propionibacterium acnes, the bacterium involved in acne, were found in 56% of all acne patients in 2000, up from 35% a decade earlier. Many countries now report that more than half of P. acnes strains have developed a resistance to antibiotics.
Concerned dermatologists—in conferences, medical journals and professional newsletters—are urging more judicious use of antibiotics for acne. The American Academy of Dermatology is expected to issue updated acne guidelines later this year in part to address antibiotic resistance.
Antibiotic resistance has hampered treatments for other types of infections, including methicillin-resistant Staphylococcus aureus, or MRSA, which causes skin infections, pneumonia and meningitis. The World Health Organization says antibiotic resistance is an increasingly serious threat to global public health.
Many doctors are concerned that taking antibiotics for acne can create resistance among different types of bacteria in the body. Two antibiotics commonly prescribed for acne, clindamycin and doxycycline, are also important treatments for some types of MRSA infections.
“The pit in my stomach grows a little bigger every time I prescribe oral antibiotics to healthy, athletic teenagers for their acne knowing I am increasing their risk of contracting MRSA from the locker room, classroom or anywhere in the community,” dermatologist Sandra Johnson of Fort Smith, Ark., wrote in a February letter to the professional newsletter Dermatology Times. Dr. Johnson says many patients ask for antibiotics because their friends are on them and it is difficult to steer them to other treatments.
Acne occurs when dead skin cells clog the pores of tiny hair follicles instead of flaking off. The immune system also attacks, creating inflammation. P. acnes, which normally live harmlessly on the skin, flourish in the dark, oily, closed environment.
Mild acne usually clears up with over-the-counter topical treatments. When the condition is slightly more stubborn, doctors prescribe more potent topical medications, such as creams or gels containing antibiotics or retinoids, which help unplug the follicles. For moderate to severe conditions, a combination of topical and systemic therapies, including antibiotics, is usually called for.
One treatment gaining favor among some dermatologists is isotretinoin. Its brand-name version, Accutane, was taken off the U.S. market in 2009 amid claims it heightened risk for suicide and inflammatory bowel disease, but subsequent, controlled studies failed to prove causality. Some research has shown that acne itself is a major risk factor for psychological distress.
Isotretinoin, a vitamin A derivative taken orally as a pill, can cause birth defects or loss of pregnancy in women. A complex system of prescribing rules is now in place that seeks to prevent the drug’s use by women who might become pregnant.
A six-month course of isotretinoin clears up some 95% of acne patients, studies show. For 85% of patients, the improvement lasts for many years, according to the American Academy of Dermatology, which says evidence supports the use of isotretinoin when acne has a severe physical or psychological impact or doesn’t respond to other treatment.
“I think the over-caution about prescribing isotretinoin is a huge error,” says Amy Wechsler, a board certified psychiatrist and an assistant clinical professor of dermatology at SUNY Downstate Medical Center, in Brooklyn, N.Y. “Unless you get pregnant on it, with monitoring it’s extremely safe.”
Newer treatments are increasingly being used, although research on them is still limited. Chemical peels work by exfoliating, or peeling off, the top layers of skin so new skin can grow in their place. Some also aim to calm inflammation and decrease oil production.
Laser- and light-based treatments show promise for treatment of scars but uneven results in treating acne flare-ups, according to the American Academy of Dermatology. Most types involve application of a medicated cream, then exposing it to light wavelengths that activate its ingredients.
Some dermatologists, impressed by positive results in early studies, are prescribing so-called subantimicrobial doses of antibiotics: tiny amounts that retain the anti-inflammatory powers of antibiotics without stoking resistance. The treatment has regulatory approval for another skin condition, but not for acne.
“None of those [newer treatments] by itself has a dramatic impact on acne,” says Dr. Bowe, the New York dermatologist. “But together they can contribute to keeping the disease under control.”
For Ms. Schwarz, Dr. Bowe’s patient, a combination of therapies has gradually been working. “At this point, I have minimal breakouts, I’m mainly dealing with the scarring,” she says. “Do I want it to be perfect and finished? Yes, but it’s no longer holding me back.”