Antibiotic resistance and acne

Q What is your take on antibiotic resistance? How do you respond to statements that dermatologists have used antibiotics too indiscriminately, compounding resistance problems? Are we, as a specialty, doing something bad for medicine?

A: Us as a specialty, or industry? I don't think we're doing anything bad for medicine. Granted, they used a lot of erythromycin; I remember when I was in the Navy, erythromycin was what I used for bronchitis, and it worked. So, in that sense, for some common infections, they are used more for an anti-inflammatory than an antibiotic activity. The problem is that makes them use other drugs, not the cephalosporins but the Cipros (Bayer), levoquin and things like that which maybe they can save for more severe, rare diseases. And let's not call it resistance, let's call it decreased sensitivity.

Q What is the difference?

But the incidences of infections, severe infections, that were the result of that (resistance), had not changed at all. So what is the implication? If you recall, when we first started to use tetracycline for acne in dermatology, there was an outcry from the early infectious disease people, saying we were creating all of these resistances. Fortunately tetracycline really is probably useful for only psittacosis, but the erythromycin was a little bit more useful. Clindamycin still is a very valuable antibiotic for anaerobic infections, and the decrease in sensitivity to erythromycin translates to the decreased sensitivity to clindamycin. We have clearly shown that the combination with benzoyl peroxide (BP) virtually eliminates those decreased sensitivities.

Q Is there ever a time to use erythromycin or clindamycin without benzoyl peroxide?

A: I don't. Well, I do in rosacea, sometimes, strictly for the anti-inflammatory activity and if the patient doesn't tolerate BP. If they don't tolerate a leave-on product, I use a cleanser. There are a few BP cleansers out there that have what we call substantivity; they leave a residual effect and that's really beneficial. What we haven't done, and what we really should do, is show via studies that you can use a BP cleanser and get the same effect as you can with a leave-on product.

Q Let's talk about some specifics that we, as dermatologists, may or may not be doing with regard to antibiotics. A lot of the surgeons now use antibiotics prophylactically after a procedure. Is that contributing to the problem?

A: I don't think that's contributing to the problem, specifically, depending on what they're using. Some of them just use topical things like a triple antibiotic or bacitracin. There is definitely a resistance to Bactroban (GlaxoSmithKline). There are guidelines published by the American College of Surgeons about when prophylactic antibiotics should be used and when they should not be used. Obviously the patients who have rheumatic heart disease always; or it's routine for people with mitral valve prolapse. After that, it depends. I never have used it in dermatologic surgery; I'm doing a lot of routine surgery and I've never run into a problem with any infection.