Review
Approaches to limit systemic antibiotic use in acne: Systemic alternatives, emerging topical therapies, dietary modification, and laser and light-based treatments

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Acne is one of the most common diseases worldwide and affects ∼50 million individuals in the United States. Oral antibiotics are the most common systemic agent prescribed for the treatment of acne. However, their use might be associated with a variety of adverse outcomes including bacterial resistance and disruption of the microbiome. As a result, multiple treatment guidelines call for limiting the use of oral antibiotics in the treatment of acne, although actual prescribing often does not follow these guidelines. In this review, the rationale for concerns regarding the use of oral antibiotics for the management of acne is reviewed. In addition, we will discuss our approach to complying with the intent of the guidelines, with a focus on novel topical agents, dietary modification, laser and light-based modalities, and systemic medications, such as spironolactone, combined oral contraceptives, and oral isotretinoin.

Section snippets

Spironolactone

Given the crucial role of hormones in the pathogenesis of acne, therapies with antiandrogenic or antisebogenic properties are mechanistically enticing options.31, 32, 33, 34, 35 Spironolactone is a synthetic 17-lactone steroid that has antagonistic effects on the androgen and progesterone receptors. Although its original clinical application was as a potassium-sparing diuretic, due to its effect on sebum production through inhibition of the androgen receptor on sebocytes, spironolactone has

Oral contraceptives

COCs containing estrogen and progestin (Table III) address the hormonal pathogenesis of acne, decreasing free testosterone by 40%-50% on average.65, 66 Estrogen also reduces the conversion of testosterone to dihydrotestosterone in the pilosebaceous unit, further decreasing sebum production.

In a Cochrane review, the effectiveness of all COCs for the treatment of acne in women was supported, and a few preparations have been approved specifically for acne.35, 67, 68, 69, 70 In trials in which

Isotretinoin

Isotretinoin is typically started at 0.5 mg/kg/d and uptitrated to 1 mg/kg/d as tolerated (Table IV).19 Several alternative dosing approaches have also been proposed. Compared with higher dose regimens, low-dose isotretinoin (eg, 0.2-0.4 mg/kg/d) has been demonstrated to have similar effectiveness and reduced side effects, although these studies have been in patients with mild-to-moderate acne with limited follow-up.93, 94, 95, 96 There is evidence that higher cumulative doses of isotretinoin

Emerging topical therapies

Topical retinoids, benzoyl peroxide, and topical antibiotics have been a mainstay of the topical management of acne for decades. Novel Food and Drug Administration–approved topical therapies for acne are needed.19, 126 Topical medications aiming to suppress sebum production are an emerging approach.127 The enzyme stearoyl coenzyme A desaturase 1 (SCD1) is a potential target for reducing sebum production. Inhibition of SCD1 has been shown to reduce the synthesis of monounsaturated fatty acids

Photodynamic therapy

Photodynamic therapy (PDT) is an off-label treatment for acne that involves first applying 5-aminolevulinic acid or methyl aminolevulinate to the skin, each of which are preferentially absorbed by the pilosebaceous unit.133 Blue light, red light, pulse dye laser (PDL), or intense pulsed light (IPL) is then used to activate the topical agent to produce photosensitizing porphyrins, which generate free radicals and reactive oxygen species that damage sebaceous glands and result in the destruction

Glycemic index

Because high glycemic load diets (HGLDs) might increase levels of insulin-like growth factor 1 (IGF-1) activity and activation, thereby inducing proliferation of both keratinocytes and sebocytes as well as simulating androgen production, some have proposed that HGLDs might be pathogenic in acne.162, 163, 164, 165, 166, 167, 168, 169 In observational studies, conflicting results were found regarding the influence of HGLD and acne.170, 171, 172, 173, 174, 175, 176, 177 Although individual

Conclusions

Although oral antibiotics are the most frequently prescribed agent for moderate-to-severe acne, their use can be associated with a variety of adverse effects, and multiple guidelines recommend limiting their use. Emerging topical therapies, laser and light-based modalities, dietary modification, spironolactone, COCs, and isotretinoin can all be effective therapeutic alternatives in the appropriate clinical context. Careful consideration of these options is an important opportunity to improve

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    Drs Barbieri and Spaccarelli contributed equally to this work.

    Funding sources: Dr Barbieri is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award number T32-AR-007465 and receives partial salary support through a Pfizer Fellowship grant to the Trustees of the University of Pennsylvania.

    Conflicts of interest: None disclosed.

    Reprints not available from the authors.

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