Thread by @tcelltracker

Today's @dermtalks is about #acne by @DrJohnBarbieri from @bwhdermatology ! 🌎🌍🌏

Dermatologists prescribe lots of #antibiotics , 60% of which are used for #acne

Antibiotic use contributes to resistance as well as other harms such as breast cancer. It disrupts the microbiome.

Even though 50% of patients received antibiotics for acne, 75% of them would prefer a non-antibiotic therapy
ncbi.nlm.nih.gov/pmc/articles/P…

Are low dose antibiotics really below MIC? Are they ok to use?
They may actually contribute to drug residence:
pubmed.ncbi.nlm.nih.gov/20159551/

This is observed particularly in skin:

pubmed.ncbi.nlm.nih.gov/34936382/

Rather than limiting duration of use or using low-rise antibiotics, @DrJohnBarbieri proposes that the number of patients treated with antibiotics should be reduced, especially given other options such as hormonal therapy.

Patients often end up on these treatments anyway!

Combined oral contraceptives may be as effective as oral antibiotics for women w #acne .

These may be started on the day of prescription as long as pregnancy is excluded.

@DrJohnBarbieri @DermTalks

To contextualize the risks of malignancy and embolism for patients on oral contraceptives, this is rather low (3/100,000). Pregnancy confers a higher risk of embolism than oral contraceptives. @DrJohnBarbieri @DermTalks

Another option is spironolactone, which is supported by large case series e.g.
pubmed.ncbi.nlm.nih.gov/33434594/

Spironolactone seems to have equivalent efficacy as tetracyclines as evidence by number of patients who do or do not switch therapies:
pubmed.ncbi.nlm.nih.gov/29879250/

Spironolactone is generally well tolerated, and has no known evidence of increased malignancy risk: jamanetwork.com/journals/jamad…

@DrJohnBarbieri does inquire about postural hypotension which can happen in about 1-5% of patients

Potassium monitoring for patients on spironolactone varies and may not be necessary in certain populations:
jamanetwork.com/journals/jamad…

Can we improve outcomes w isotretinoin?

Virtually everyone gets cheilitis (dry skin) on isotretinoin.
Some experience ocular changes, which may be attributed to meibomian glands.

Omega-3s can help w mucocutaneous dryness ncbi.nlm.nih.gov/pmc/articles/P…

Antihistamines can reduce risk of initial flaring pubmed.ncbi.nlm.nih.gov/25081735/

Low vs medium dose isotretinoin has very similar response rates, so could consider dosing based on clinical endpoints: pubmed.ncbi.nlm.nih.gov/21114478/

What about labs/monitoring patients on isotretinoin? If we aren't affecting the endpoint, why are we monitoring?
jaad.org/article/S0190-…

Even though rhabdomyolysis can occur, it's very rare. Consider checking CPK only in setting of severe myalgia, as baseline varies so much between people and w activity level.

Lab monitoring consensus study here:
pubmed.ncbi.nlm.nih.gov/35704293/

@DrJohnBarbieri encourages having discussions w patients about how fast they want to get better vs how many side effects (dry skin, etc) they might experience.

He encourages patient-centered care & consideration of which monitoring is needed, if any, depending on age, etc.

Check out one of @DrJohnBarbieri & colleagues' latest articles about topical treatments for acne:
pubmed.ncbi.nlm.nih.gov/35041198/

And a hot-off-the-press article about acne management in pregnant people:
pubmed.ncbi.nlm.nih.gov/36447117/

Thank you so much @DrJohnBarbieri from @bwhdermatology for your excellent @DermTalks seminar and for all that you do for patients! 🌎🌍🌏❤️