Dermatologists have been at the forefront of the use of other antimicrobial approaches, such as the use of bleach baths for chronic skin infections. These approaches may appropriately control cutaneous skin infection without the use of oral antibiotics. The Get Smart: Know When Antibiotics Work campaign has joined forces with Galderma Laboratories and the American Acne and Rosacea Society (AARS).
The Centers for Disease Control and Prevention (CDC) is focusing efforts to promote responsible antibiotic use in dermatology. That’s with good reason. Dermatologists, according to new government data, prescribe more antibiotics per provider than doctors in any other specialty, including primary care and pediatrics.
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CDC’s efforts to improve antibiotic use goes back to the mid-1990s, according to Lauri Hicks, D.O., an infectious disease doctor and medical director of the CDC’s Get Smart: Know When Antibiotics Work campaign. Historically, the government has partnered primarily with pediatricians, internists and family practitioners because they’re known to prescribe antibiotics for upper respiratory infections. But a recent data analysis turned the CDC’s attention to dermatology and dentistry, because of those
specialties’ high antibiotic prescribing rates.
“…dermatologists came out on top in terms of the frequency of providing per provider across the U.S. Dermatologists prescribed 724 prescriptions per provider … in 2011,” Dr. Hicks says.
The next highest prescriber by specialty was family practice, at 667 prescriptions per provider in 2011, followed by pediatrics at 598, according to Dr. Hicks.
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Derms at forefront of alternative approaches
To get a handle on antibiotic use in dermatology and promote responsible prescribing, the Get Smart: Know When Antibiotics Work campaign has joined forces with Galderma Laboratories and the American Acne and Rosacea Society (AARS).
“I think the first step is we need to better understand what is behind that high prescribing rate. …we’re going to be doing some analyses to look at the conditions that lead to the prescribing,” Dr. Hicks says. “We’re also actively reaching out the American Acne and Rosacea Society. What we would like to do is to work with the folks in the dermatology field who are already interested in this topic… and better understand what would help dermatologists improve their prescribing practices.”
Lawrence F. Eichenfield, M.D., president of AARS and professor of pediatrics and medicine (dermatology), University of California, San Diego School of Medicine, says dermatologists’ high antibiotic prescribing rates make sense given that dermatologists may see more patients and new patients each year than family practice physicians or pediatricians.
“But I think there are other important reasons for dermatologists’ prescribing so many antibiotics. The most important of which is that, compared to other physicians, antibiotic prescriptions in dermatology are written for treatment of chronic inflammatory disorders, such as acne and rosacea, and not necessarily for acute infections,” Dr. Eichenfield says. “In dermatology, many of the conditions treated with antibiotics are chronic and the antibiotics are being used both for their influence on bacterial colonization and quantity, as well as for direct antiinflammatory effects.”
The dermatology community is interested in becoming more conscious about the relevance of antibiotic resistance to dermatology practice, as well as the broader ecologic influences of antibiotic use and its impact to antibiotic resistance, according to Dr. Eichenfield. AARS’s partnership with the CDC
will help to educate dermatologists about resistance and encourage appropriate, judicious use of antibiotics. That includes minimizing overuse of antibiotics, extended courses of oral antibiotics when not necessary, as well as overuse of topical antibiotics, if not necessary for disease control, according to Dr. Eichenfield, who is AARS president.
“The Scientific Panel on Antibiotic Use in Dermatology (SPAUD) is a group that is dedicated to addressing antibiotic use in dermatology. The third meeting of this group was held in September of 2014 and put together a superb panel of experts in dermatology, microbiology, pharmacology and a representative of the CDC,” Dr. Eichenfield says.
The CDC needs to gather information before trying to intervene, according to Dr. Hicks.
“There are many different types of possible interventions. I think the first one would just be education efforts and outreach and collaboration with the professional societies that reach dermatologists,” Dr. Hicks says.
Other interventions include providing feedback on provider performance relative to certain syndromes. One example, according to Dr. Hicks, is a quality measure that evaluates provider performance when treating adults with bronchitis. Basically, doctors are not supposed to prescribe antibiotics for adult bronchitis. Providers who do would receive feedback on their performance. The goal, she says, is to work with dermatologic societies to better understand how to introduce quality metrics related to prescribing for common dermatologic conditions that lead to antibiotic overuse.
An acne focus
Opportunities to improve antibiotic stewardship are clear when one looks at the treatment of acne. Acne, which affects from 40 to 50 million Americans1 is the most common skin disorder in U.S. and the most common condition dermatologists treat, according to Diane S. Berson, M.D., associate clinical professor of dermatology, Weill Medical College of Cornell University New York-Presbyterian Hospital and a founding member of the American Acne and Rosacea Society.
“Traditionally, dermatologists have treated acne with antibiotics, both topically and orally. It is now known that P. acnes, which is involved in the development of acne, has developed a resistance to topical and now some oral antibiotics,” Dr. Berson says.
Dr. Berson says she thinks dermatologists are beginning to appreciate the problem of antibiotic overuse.
“Dermatologists are often the first physicians to treat patients with MRSA,” she says.
The message seems to be getting through to dermatologists about using oral antibiotics less and for shorter durations, Dr. Berson says.
“I think the message we need to get through to dermatologists is that we should not be using topical antibiotics as a monotherapy,” she says. “We have lots of great topical options now including medications that contain both retinoids and benzoyl peroxide. And if you’re using retinoids and benzoyl peroxide, you really don’t need to add a topical antibiotic.”
Dermatologists may, in fact, have a leg up on other specialties, when it comes to prescribing non-antibiotic options for acne, according to a study published in late 2013 in Pediatric Dermatology. Researchers who combed information about the leading therapies for children diagnosed with acne, collected from the National Ambulatory Medical Care Survey (NAMCS) from 1993 to 2009, found pediatricians and dermatologists had different prescribing patterns.2
“The leading medications were topical treatments, including adapalene (14.4%), benzoyl peroxide (12.8%), and tretinoin (12.5%). Treatment of this age group differed substantially between specialties, with dermatologists frequently prescribing topical retinoids and primary care physicians preferring antibiotics, particularly oral antibiotics,” according to the study’s abstract.
Another consideration about the high antibiotic prescribing rates in dermatology is that cutaneous infections are quite common, according to Dr. Eichenfield.
“One of the manifestations of antibiotic resistance has been the emergence of [MRSA], which can commonly present as cutaneous infection,” he says. “The management of MRSA and other staph infections in dermatologic disease, for instance atopic dermatitis, where there are high colonization rates of staph as part of the disease process, put dermatologists in the situation where they are managing skin infections and complications of the infections-many times with appropriate use of antibiotics.”
Dermatologists have been at the forefront of the use of other antimicrobial approaches, such as the use of bleach baths for chronic skin infections. These approaches may appropriately control cutaneous skin infection without the use of oral antibiotics, according to Dr. Eichenfield.
1 Acne Facts. Retrieved from: https://www.aad.org/media-resources/stats-and-facts/conditions/acne
2 Davis SA, Sandoval LF, Gustafson CJ, Feldman SR, Cordoro KM. Treatment of preadolescent acne in the United States: an analysis of nationally representative data. Pediatr Dermatol. 2013 Nov-Dec;30(6):689-94. Epub 2013 Jul 22