Doctors frequently prescribe antibiotics to treat acne, especially severe acne. This is highly controversial because they do not tend to work better than other medications, and sometimes do not work at all. They also only offer short-term relief, when they do work at all, and have significant drawbacks that limit their usefulness. These drawbacks include many side effects, which range from mild skin irritation to permanent tooth and skin discoloration or life-threatening diarrhea, and a phenomenon called antibiotic resistance, which affects not only the individual taking the antibiotic but the world as a whole. In this article, we will discuss the problem of antibiotic resistance.
What Is Antibiotic Resistance, and Why Is It a Problem?
Treatment with antibiotics, especially over long periods of time, leads to antibiotic resistance. Antibiotic resistance means that bacteria becomes immune to the effects of antibiotics, and eventually the antibiotics can no longer kill the bacteria. Antibiotic resistance is a serious global problem because:
When bacteria become resistant to an antibiotic, that antibiotic becomes less effective and less able to treat the condition for which it was prescribed, and also any other bacterial condition. This applies to both the person taking the antibiotic and, eventually, the population at large.
Bacteria can share their genes with each other and transfer antibiotic resistance from one strain of bacteria to another.
Ultimately, antibiotic resistance could result in many types of bacteria becoming resistant to all antibiotic medications. This means that doctors may eventually be unable to treat bacterial infections and that people may die from even common bacterial diseases such as strep throat, as people did before antibiotics were developed.
Antibiotic Resistance and Scientific Recommendations for Acne Treatment
Antibiotic resistance is a worrisome global threat, and over-prescription of antibiotics contributes to it.
A study in the Journal of the American Academy of Dermatology noted, “Despite the efficacy of antibiotics, there have been calls to limit their use in acne because of concerns for bacterial resistance.”1
In fact, several researchers have pointed out that antibiotic prescriptions for acne is a major source of concern, as acne is the most common condition for which dermatologists prescribe antibiotics.
For example, according to a 2015 article in Expert Review of Anti-infective Therapy, “The worldwide data suggest that the resistance is on the rise and breakpoint levels have been breached in many regions. The transmission of resistant strains to other patients is a major problem. Acne patients are considered to be reservoirs of antibiotic-resistant strains and it was shown … that 41–85.7% of untreated close contacts of acne patients who had received antibiotic treatment may carry EM-resistant strains. The resistance seems to move from the acne patients to the community.”2
Because of increasing concern about antibiotic resistance, scientists recommend that antibiotics be used only to treat acne in severe cases, and only for short periods of time.
According to the 2007 guidelines in the Journal of the American Academy of Dermatology, “A major problem affecting antibiotic therapy of acne has been bacterial resistance, which has been increasing. For this reason, it is the opinion of the work group that patients with less severe forms of acne should not be treated with oral antibiotics, and where possible the duration of such therapy should be limited.”3
A 2015 article in the Journal of the American Academy of Dermatology noted that current guidelines recommend limiting antibiotic use to a maximum of three months. The authors stated, “Expert guidelines recommend responsible use of antibiotics in acne in light of emerging resistance. In 2003 and 2009, the Global Alliance to Improve Acne Outcomes published recommendations for acne treatment and suggested limiting the use of systemic antibiotics to 3 months if a patient demonstrates limited clinical improvement. Similarly, European consensus statements published in 2004 and 2012 also explicitly recommended limiting antibiotic use to 3 months.”1
Why Using Antibiotics for Longer Periods of Time Causes Problems
The reason that scientists recommend never using an antibiotic for more than three months is that longer treatment periods expose bacteria to the antibiotic for extended periods of time, giving the bacteria time to develop resistance. However, doctors often prescribe antibiotics for considerably longer than three months.
A 2014 study in the Journal of the American Academy of Dermatology found that the average duration of antibiotic therapy is 127 days (approximately four months), but that in 18% of cases, the duration exceeds six months.4
A 2015 study in the Journal of the American Academy of Dermatology found that in patients in whom oral antibiotics failed to yield improvement, the average duration of antibiotic therapy before discontinuing treatment and switching to another medication was almost 11 months. The authors noted, “Systemic antibiotics are used widely to treat moderate to severe acne, but increasing antibiotic resistance makes appropriate use a priority…We found that patients [in whom antibiotic treatment had failed] had extended exposure to antibiotics, exceeding recommendations. Early recognition of antibiotic failure…can curtail antibiotic use.”1
Antibiotics Used to Treat Acne Cause Antibiotic Resistance
Recent research indicates that some of the antibiotics that are most frequently prescribed for acne, such as erythromycin and clindamycin, are already creating a high incidence of antibiotic resistance.
For example, as far back as 2002, a study in The British Journal of Dermatology studied 4274 acne patients and found that an average of 51% of patients have harbored colonies of resistant bacteria.5
A 2010 study in the Journal of the German Society of Dermatology found that more than half of acne patients in Europe treated with antibiotics harbored bacteria that were resistant to at least one antibiotic. In addition, this study also found that resistant bacteria could be transmitted between the patient and close contacts, and even between patients and dermatologists. The authors noted, “In Europe, more than half of acne patients harbor erythromycin- or clindamycin-resistant and 20% tetracycline-resistant strains. These strains may be transmitted to close contacts (41–86 %) and even physicians (25/39 acne specialists compared to 0/27 physicians without contact to acne patients).”6
A more recent 2013 study in the Journal of the European Academy of Dermatology and Venereology collected P. acnes (bacteria associated with acne) samples from acne patients in Hong Kong. This study also found that more than half of the P. acnes samples were resistant to at least one antibiotic. Because of this finding, the authors cautioned, “Dermatologists should be more vigilant in prescribing antibiotics for acne patients.”7
Interestingly, researchers have noted similar levels of resistance both in patients treated with and without antibiotics, although those who were not treated with antibiotics have only somewhat lower levels of resistance:8this is because resistant strains of bacteria are easily transmitted between people.9
Of all topical antibiotics, erythromycin contributes the most to antibiotic resistance.
According to a 2007 article in the Journal of the American Academy of Dermatology, “Resistance has been seen with all antibiotics, but is most common with erythromycin.”3
Similarly, a 2015 article in the American Journal of Clinical Dermatology noted, “While resistance has emerged to all topical antimicrobial agents, erythromycin resistance is the most common and the drug has demonstrated waning efficacy relative to clindamycin.”9
Resistance to erythromycin and clindamycin is now a worldwide problem, which is made worse by the fact that resistant bacteria can be transferred among people. Oral antibiotics is also a large part of the problem because they are systemic and do not discriminate. They eliminate many groups of bacteria: this can cause many different strains of bacteria to become resistant.9
In order to reduce the risk of antibiotic resistance, scientists recommend combining antibiotics with benzoyl peroxide or topical retinoids such as tretinoin, in addition to keeping treatment duration short.
A 2015 article in the American Journal of Clinical Dermatology states, “In an effort to reduce resistance, avoid using topical antibiotics as maintenance therapy or monotherapy. Instead, treatment should be combined with a topical retinoid and/or benzoyl peroxide and limited to the shortest possible duration. Furthermore, simultaneous use of oral and topical antibiotics should be avoided, especially if they are chemically different.”9
As we have seen in this article, treatment with antibiotics, especially for prolonged periods of time, leads to antibiotic resistance, and this resistance is becoming a significant worldwide problem that threatens to undermine our ability to treat bacterial infections at all in the future. This could lead to people dying from even simple bacterial infections that we now routinely treat with antibiotics. We have also seen that some of the antibiotics that doctors commonly prescribe to treat acne are particularly prone to causing antibiotic resistance, and that practices such as limiting the duration of antibiotic treatment, only prescribing antibiotics for severe acne cases, and combining topical antibiotics with benzoyl peroxide or tretinoin can help reduce the development of antibiotic resistance.
Given the dangers of antibiotics, they should only be used as drugs of last resort for your acne treatment. If deemed necessary, they should be administered sparingly and for short duration.