Know the Risks of Acne Antibiotics: A Q&A With Dr. John Barbieri
Acne antibiotics are a common prescription for people to take when they want to manage skin health. However, a potential danger often lurks in these seemingly innocent medicines: severe adverse drug reactions.
Severe drug reactions can occur when medicines cause unintended and often life-threatening symptoms, like long-term disability and organ failure. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) — or DRESS Syndrome — is just one of several severe drug reactions that acne antibiotics can cause. In fact, antibiotics are one of the top drugs that people develop DRESS from.
Fortunately, treatments exist that don’t rely on taking acne antibiotics. Today, we’re talking with Dr. John Barbieri, a leading dermatologist and researcher. He’s exploring alternatives to oral antibiotics for acne and helping to shine the light on the risks of prescribing and taking these medications.
DRESS Syndrome Foundation (DSF): Briefly share your research focus/expertise, including any experience you may have with DRESS Syndrome:
Dr. Barbieri: I’m a board-certified dermatologist at the Brigham and Women’s Hospital in Boston, Massachusetts. My research focuses on acne management, particularly alternatives to oral antibiotics. In addition, my group focuses on patient-reported outcomes to ensure that we’re capturing the patient voice in clinical practice and clinical trials.
In terms of my experience with DRESS, as part of our role as dermatologists, we take care of patients with serious drug reactions such as DRESS and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). I have personally cared for many patients with these drug reactions.
DSF: You co-chair the AAD Acne Guidelines Work Group and have dedicated much of your career to responsible antibiotic prescribing. What inspired you to take on this work?
Dr. Barbieri: When I was a resident, I was shocked to learn that dermatologists prescribe more antibiotics per physician than any other major medical specialty. As we studied this topic further, we found that much of this use is for acne and rosacea. These conditions are non-infectious and don’t inherently need antibiotics as part of their treatment. In addition, many of these acne antibiotic courses last months to years in duration. So, this isn’t giving someone a few days of antibiotics because we aren’t sure if they have a bacterial or viral pneumonia. This is giving people years of antibiotics for something that we know is not infectious.
As a result, I became interested in how can we reduce relying on oral antibiotics in dermatology, with a focus on acne and rosacea. This interest translated into conducting a range of studies on acne and rosacea. Eventually, I was given the opportunity by the American Academy of Dermatology to lead the current update of the clinical guidelines for acne. I hope these new guidelines will help clinicians throughout medicine provide better care for patients with acne.
DSF: What are the risks of treating acne with antibiotics?
Dr. Barbieri: Although we often think of antibiotic resistance as the main risk with antibiotic use, other potential harms exist, including:
Disturbing your body’s microbiome (good bacteria)
Increasing infection risks like strep throat
Increasing risk of inflammatory bowel disease
Potentially increasing the risk of colon and breast cancers
These risks highlight the need to be careful with prescribing and using oral antibiotics.
DSF: While DRESS is uncommon, the effects can be devastating. Should high-risk DRESS drugs like minocycline and trimethoprim-sulfamethoxazole (Bactrim) antibiotics be so commonly prescribed for acne?
Dr. Barbieri: Currently, about 80% of prescribed acne antibiotics are tetracyclines — such as doxycycline, minocycline, and sarecycline — with about half of this being for minocycline. In addition, about 10% of prescribed acne antibiotics are trimethoprim-sulfamethoxazole.
In my personal opinion, for the typical patient with acne, clinicians should avoid prescribing both minocycline and trimethoprim-sulfamethoxazole. A Cochrane systematic review found that minocycline:
Is no more effective than doxycycline in managing acne
Has more potential serious safety risks, including severe drug eruptions like DRESS, neurologic side effects like vertigo, and permanent skin discoloration
Is notorious for causing severe drug eruptions like SJS/TEN and DRESS Syndrome
Can cause acute respiratory failure, particularly among younger individuals, such as those treating acne
Has no evidence that it is any better for acne than doxycycline
In my practice, I almost never use minocycline or trimethoprim-sulfamethoxazole for patients with acne.
DSF: What responsibility does the prescriber have in educating their patients on an antibiotic’s risks?
Dr. Barbieri: When it comes to this evidence-to-practice gap, I think we need a few things:
1. We need more education so that clinicians are aware of these risks and can appropriately counsel their patients. I hope that our work on the clinical guidelines — and awareness efforts by specialty societies, the CDC/FDA, and by groups like the DRESS Syndrome Foundation — can educate our community about how best to manage acne and rosacea.
2. We need insurance formularies (the list of medicines that an insurance plan will cover) to reflect evidence-based medicine. Sadly, sometimes the insurance company requires the doctor to use a medication like minocycline even if they don’t think it’s appropriate for the patient. While I can understand the need to consider evidence-based medication use and the potential role of insurance companies, we don’t want insurance companies to be practicing medicine. Ultimately, treatment decisions should be between a patient and their doctor, guided by clinical evidence.
3. We need healthcare reforms to help ensure that insurance companies make decisions based on appropriate care practices, not just on cost.
DSF: What acne treatment alternatives to antibiotics do you suggest doctors and patients consider?
Dr. Barbieri: We have many exciting new treatment options that can help patients with acne. For instance:
Clascoterone is the first FDA-approved topical medication that can target the root cause of all acne-related to hormones
A new FDA-cleared 1726nm laser can selectively target the sebaceous gland to improve acne
Novel formulations and combinations of medications exist that can improve tolerability and convenience
For female patients with acne, we often underutilize hormonal therapies — such as spironolactone and combined oral contraceptives — which can be effective for almost any female patient with acne. And while not the right medicine for everyone, we also probably underutilize isotretinoin, which is the only acne medication that can result in a durable remission of acne.
DSF: What does a world of improved antibiotic prescribing look like?
Dr. Barbieri: I think increased shared-decision making is an important opportunity to improve antibiotic use. Most patients don’t want to be on an oral antibiotic for their acne or rosacea. It’s important for clinicians to be aware of non-antibiotic alternatives and to present these options to patients. In my practice, we’re often able to help patients reach their treatment goals without using oral antibiotics.
I also think we need to be more thoughtful about limiting who we prescribe antibiotics to rather than focusing on the antibiotic’s duration or type. Microbiome changes can happen as soon as a few weeks after starting an oral antibiotic. In addition, as oral antibiotics are not disease-modifying treatments, most patients need to continue using them to see improvements. I think the focus on limiting treatment duration (for example, for 3 – 6 months) distracts us from the broader goal of reducing overall use. This duration focus often results in forcing patients to arbitrarily stop treatment and then have their acne return.
In addition, although low dose, “subantimicrobial” antibiotic regimens are often presented as a solution to the antibiotic-resistance issue. But, the evidence really doesn’t support that these regimens are not associated with antibiotic resistance or other antibiotic-associated complications. Narrow-spectrum antibiotics, such as sarecycline, can potentially help, but these are still ultimately an antibiotic. I think we can get a lot more out of our non-antibiotic options if we give them a chance.
Finally, we need continued research to develop non-antibiotic treatment strategies for patients with acne and rosacea.