My 19-year-old patient wishes treatment for his chronic acne while waiting for his dermatology appointment. What treatment should I recommend?

Irrespective of your patient’s acne severity, a good starting point is over-the-counter topical benzoyl peroxide.1 Benzoyl peroxide not only kills the bacteria that causes acne (Cutibacterium acnes) through the release of free oxygen radicals, but also functions as a comedolytic.2

If your patient’s acne is mild to moderate (defined as non-inflammatory lesions [comedones] or less than 5 inflammatory lesions [papulopustules]), you may consider prescribing a topical retinoid such as tretinoin 0.025%, adapalene 0.1%, or tazarotene 0.05% in combination with the benzoyl peroxide.1,3 These agents have been shown to have both comedolytic and anti-inflammatory effects, and are the cornerstone of topical therapy for all acne cases, save for the most mild.1,4

In moderate to severe acne (defined as multiple inflammatory lesions), you can consider prescribing an oral antibiotic in combination with the retinoid and benzoyl peroxide.1,3 The first-line therapy in this situation is often a tetracycline, such as daily doxycycline in the 1.7 to 2.4 mg/kg dose range.5,6 

As with all medications, please familiarize yourself with contraindications and adverse side effects of these drugs before prescribing (eg, doxycycline-related photosensitivity or adverse impact on GI flora, or avoiding tretinoin in pregnancy).

For extremely severe acne (defined as widespread inflammatory lesions, nodules, and/or scarring), you should consider referral to a dermatologist for Accutane (isotretinoin) treatment.3 However, the aforementioned treatment options should be sufficient to control your patient’s symptoms until seen by a dermatologist!           

Bonus Pearl: Did you know that besides anabolic-androgenic steroids, dietary supplements containing vitamins B6/B12, iodine and whey have also been linked to acne?7

Contributed by Aditya Nellore, Fourth-Year Medical Student, St. Louis University Medical School, St. Louis, Missouri   

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References:

  1. Zaenglein AL, Pathy AL, Schlosser BJ, Alikhan A, Baldwin HE, Berson DS, Bowe WP, Graber EM, Harper JC, Kang S, Keri JE, Leyden JJ, Reynolds RV, Silverberg NB, Stein Gold LF, Tollefson MM, Weiss JS, Dolan NC, Sagan AA, Stern M, Boyer KM, Bhushan R. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 May;74(5):945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17. Erratum in: J Am Acad Dermatol. 2020 Jun;82(6):1576. PMID: 26897386. https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext#tbl6
  2. Cunliffe WJ, Holland KT. The effect of benzoyl peroxide on acne. Acta Derm Venereol. 1981;61(3):267-9. PMID: 6167116. https://pubmed.ncbi.nlm.nih.gov/6167116/
  3. Purdy S, Deberker D. Acne vulgaris. BMJ Clin Evid. 2008 May 15;2008:1714. PMID: 19450306; PMCID: PMC2907987. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907987/
  4. Cunliffe WJ, Caputo R, Dreno B, Förström L, Heenen M, Orfanos CE, Privat Y, Robledo Aguilar A, Meynadier J, Alirezai M, Jablonska S, Shalita A, Weiss JS, Chalker DK, Ellis CN, Greenspan A, Katz HI, Kantor I, Millikan LE, Swinehart JM, Swinyer L, Whitmore C, Czernielewski J, Verschoore M. Clinical efficacy and safety comparison of adapalene gel and tretinoin gel in the treatment of acne vulgaris: Europe and U.S. multicenter trials. J Am Acad Dermatol. 1997 Jun;36(6 Pt 2):S126-34. doi: 10.1016/s0190-9622(97)70056-2. PMID: 9204091. https://pubmed.ncbi.nlm.nih.gov/9204091/
  5. Tan J, Humphrey S, Vender R, Barankin B, Gooderham M, Kerrouche N, Audibert F, Lynde C; POWER study group. A treatment for severe nodular acne: a randomized investigator-blinded, controlled, noninferiority trial comparing fixed-dose adapalene/benzoyl peroxide plus doxycycline vs. oral isotretinoin. Br J Dermatol. 2014 Dec;171(6):1508-16. doi: 10.1111/bjd.13191. Epub 2014 Oct 28. PMID: 24934963. https://pubmed.ncbi.nlm.nih.gov/24934963/
  6. Leyden, James J., et al. “A randomized, phase 2, dose-ranging study in the treatment of moderate to severe inflammatory facial acne vulgaris with doxycycline calcium.” Journal of Drugs in Dermatology: JDD6 (2013): 658-663. https://pubmed.ncbi.nlm.nih.gov/23839182/
  7. Zamil DH, Perez-Sanchez A, Katta R. Acne related to dietary supplements. Dermatol Online J. 2020 Aug 15;26(8):13030/qt9rp7t2p2. PMID: 32941710. https://pubmed.ncbi.nlm.nih.gov/32941710/

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

My 19-year-old patient wishes treatment for his chronic acne while waiting for his dermatology appointment. What treatment should I recommend?

Should I choose a bactericidal over bacteriostatic antibiotic in the treatment of my patient with pneumonia complicated by bacteremia?

You don’t have too!  Although “bacteriostatic” antibiotics have traditionally been regarded as inferior to “bactericidal” antibiotics in the treatment of serious infections, a 2018 “myth busting” systemic literature review1 concluded that bacteriostatic antibiotics are just as effective against a variety of infections, including pneumonia, non-endocarditis bacteremia, skin and soft tissue infections and genital infections; no conclusion can be made in regards to endocarditis or bacterial meningitis, however, due insufficient clinical evidence.1-3

Interestingly, most of the studies included in the same systemic review showed that bacteriostatic antibiotics were more effective compared to bactericidal antibiotics.1 So, for most infections in hospitalized patients, including those with non-endocarditis bacteremia, the choice of antibiotic among those that demonstrate in vitro susceptibility should not be based on their “cidal” vs “static” label.

Such conclusion should not be too surprising since the definition of bacteriostatic vs bactericidal is based on arbitrary in vitro constructs and not validated by any available in vivo data. In addition, static antibiotics may kill bacteria as rapidly as cidal antibiotics in vitro at higher antibiotic concentrations.3

Another supportive evidence is a 2019 study finding similar efficacy of sequential intravenous-to-oral outpatient antibiotic therapy for MRSA bacteremia compared to continued IV antibiotic therapy despite frequent use of bacteriostatic oral antibiotics (eg, linezolid, clindamycin and doxycycline). 4

 

References

  1. Wald-Dickler N, Holtom P, Spellberg B. Busting the myth of “static vs cidal”: as systemic literature review. Clin Infect Dis 2018;66:1470-4. https://academic.oup.com/cid/article/66/9/1470/4774989
  2. Steigbigel RT, Steigbigel NH. Static vs cidal antibiotics. Clin Infect Dis 2019;68:351-2. https://academic.oup.com/cid/article-abstract/68/2/351/5067395
  3. Wald-Dickler N, Holtom P, Spellberg B. Static vs cidal antibiotics; reply to Steigbigel and Steigbigel. Clin Infect Dis 2019;68:352-3. https://academic.oup.com/cid/article-abstract/68/2/352/5067396?redirectedFrom=fulltext
  4. Jorgensen SCJ, Lagnf AH, Bhatia S, et al. Sequential intravenous-to-oral outpatient antbiotic therapy for MRSA bacteraemia: one step closer.  J Antimicrob Chemother 2019;74:489-98.  https://www.ncbi.nlm.nih.gov/pubmed/30418557

 

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Should I choose a bactericidal over bacteriostatic antibiotic in the treatment of my patient with pneumonia complicated by bacteremia?