Barriers and Facilitators Affecting Long-Term Antibiotic Prescriptions for Acne Treatment

Key Points

Questions

Which factors affect long-term oral antibiotic prescribing for acne?

Findings

This qualitative study of 30 stakeholders found that knowledge of guideline recommendations on limiting antibiotic prescribing was high and most believed that antibiotic stewardship is a professional responsibility. Perceived lack of evidence to justify practice changes, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, iPLEDGE-related barriers, and the absence of an effective system to measure progress of antibiotic stewardship were reported to affect prescribing practices.

Meaning

These findings suggest that the design and implementation of an antibiotic stewardship program in acne is needed and should address multiple salient factors in clinical dermatology practices.

Abstract

Importance

Dermatologists prescribe more oral antibiotics per clinician than clinicians in any other specialty. Despite clinical guidelines that recommend limitation of long-term oral antibiotic treatments for acne to less than 3 months, there is little evidence to guide the design and implementation of an antibiotic stewardship program in clinical practice.

Objective

To identify salient barriers and facilitators to long-term antibiotic prescriptions for acne treatment.

Design, Setting, and Participants

This qualitative study assessed data collected from stakeholders (including dermatologists, infectious disease physicians, dermatology resident physicians, and nonphysician clinicians) via an online survey and semistructured video interviews between March and August 2021. Data analyses were performed from August 12, 2021, to January 20, 2024.

Main Outcomes and Measures

Online survey and qualitative video interviews developed with the Theoretical Domains Framework. Thematic analyses were used to identify salient themes on barriers and facilitators to long-term antibiotic prescriptions for acne treatment.

Results

Among 30 participants (14 [47%] males and 16 [53%] females) who completed the study requirements and were included in the analysis, knowledge of antibiotic guideline recommendations was high and antibiotic stewardship was believed to be a professional responsibility. Five salient themes were to be affecting long-term antibiotic prescriptions: perceived lack of evidence to justify change in dermatologic practice, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, iPLEDGE-related barriers, and the absence of an effective system to measure progress on antibiotic stewardship.

Conclusions and Relevance

The findings of this qualitative study indicate that multiple salient factors affect long-term antibiotic prescribing practices for acne treatment. These factors should be considered in the design and implementation of any future outpatient antibiotic stewardship program for clinical dermatology.

This qualitative study assesses antibiotic prescribing practices for acne to identify challenges to antibiotic stewardship among dermatologists.

Introduction

Oral antibiotics remain the most commonly prescribed systemic acne treatment despite potential associations with rising antibiotic resistance,^1,2 collateral damage to the normal microbiome,³ and potential adverse outcomes such as upper respiratory infections,⁴ pharyngitis,⁵ inflammatory bowel disease,⁶ breast cancer,⁷ and colon cancer.⁸ The American Academy of Dermatology acne treatment guidelines⁹ specify that oral antibiotics should be prescribed for patients with moderate to severe acne for no longer than 3 to 4 months. However, adherence to limiting long-term antibiotic prescription use in acne clinical practice remains inconsistent.^10,11,12 Dermatologists continue to prescribe more outpatient systemic antibiotics than do clinicians in any other specialty.¹³

There have been no systematic interventions designed or implemented for outpatient antibiotic stewardship in acne treatment in the US, to our knowledge. Existing antibiotic stewardship interventions focus on acute infections and have limited relevance to managing acne and other chronic skin conditions.¹⁴ Successful design and implementation of antibiotic stewardship programs in dermatology require careful consideration of the clinical factors associated with long-term antibiotic treatment for acne, including clinician and patient values, institutional context, and resources.¹⁵ This study aimed to identify the salient barriers and facilitators to long-term antibiotic prescriptions for moderate to severe acne treatment by dermatologists in the clinical setting.

Methods

This qualitative study was approved by the Emory University Institutional Review Board. All participants provided verbal informed consent per protocol. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline.

Study Design and Participant Recruitment

The study design, conduct, and interpretation were underpinned by the Theoretical Domains Framework (TDF), a comprehensive theoretical approach to identifying determinants of clinician behavior through 14 domains.¹⁶

Participants were purposely sampled to recruit experts and key stakeholders from various backgrounds to maximize diversity of participants and responses, including academic and community dermatologists, dermatology residents, infectious disease physicians with expertise in antimicrobial stewardship, and advanced practice practitioners in dermatology. Infectious disease physicians were recruited to glean insights on outpatient antibiotic stewardship interventions.¹⁷ Participants were recruited via email to listservs of the Atlanta Association of Dermatology and Dermatologic Surgery, Georgia Society for Dermatology and Dermatologic Surgery, Emory Antibiotics Resistance Center and Division of Infectious Diseases, and American Acne & Rosacea Society (including those from the scientific panel on Antibiotic Use in Dermatology). Study recruitment and data collection occurred from March 26 to August 24, 2021.

Research Team and Reflexivity

Study procedures were conducted by 2 female medical students (K.C., E.T.) and a male research projects manager with graduate-level public health training (J.B.). Data coding and thematic analyses were performed by a male medical student (R.A.F.), a female medical student (A.S.A.), and a male undergraduate student (J.Y.C.). The principal investigator (H.Y.) trained each research staff member on interview guide administration or qualitative analysis. Participants and interviewers did not have any prior relevant relationships. All participants understood that the interviewers were interested in understanding barriers and facilitators to long-term antibiotics for acne.

Interview Data Collection

After submitting the online informed consent, participants completed an online survey, self-reporting demographic information and data on clinical practice variables, and they participated in a semistructured interview with a duration 45 to 60 minutes via an internet-based video conferencing platform. An interview guide was developed to elicit open-ended responses exploring TDF domains affecting the prescribing of long-term systemic antibiotic medications for acne treatment (eSurvey in Supplement 1). The interview guide was piloted with 3 participants and revised. The revised version was used with the remaining participants. The interview guide and transcripts were not provided to study participants, and repeat interviews were not conducted. Participants did not provide feedback on any findings. Interviews were audio-recorded, deidentified, and professionally transcribed verbatim. The study team did not document field notes.

Data Analysis

Qualitative data analysis was performed using a thematic analysis framework in the following phases: (1) familiarization with the data, (2) generation of initial codes, (3) identification of themes, (4) review of themes, (5) defining and naming of themes, and (6) report production.¹⁸ Transcribed interviews were deductively analyzed using a codebook derived from 14 a priori TDF domains. Detailed descriptions of each code were previously described.¹⁶ Coding discrepancies were resolved via consensus meetings, generating a single unanimously coded transcript for each interview. Intra-interview codes were summarized by domain for each transcript. These summaries were used to generate a comprehensive summary for each domain across all transcripts, producing 14 unique summaries (each corresponding to a single domain).

Salient themes were named, reviewed, and refined through discussion to outline a theme map that reflected the data on salient domains that affecting prescribing practices for long-term antibiotic treatment for acne.¹⁸ Themes were conceptualized as either a patterned response or a response that captured something crucial in relation to acne antibiotic prescribing practices.¹⁸ Illustrative quotes were identified with relevant demographic information (participant number, gender, professional role). Contradictory scenarios were also noted. Salient themes within TDF domains were organized based on the Capability, Opportunity, and Motivation−Behavior model, which posited that interactions among these may affect behavior, and it has been linked mapped to TDF to provide a basis for designing behavioral change interventions.^16,19

The data achieved meaning saturation with the responses from 30 interviews (eTable in Supplement 1). Meaning saturation was defined as “the point when we fully understand issues, and when no further dimensions, nuances, or insights of issues can be found.”²⁰ Prior research has suggested that 16 to 24 interviews are required to achieve meaning saturation.^20,21

Data analyses were performed from August 12, 2021, to January 20, 2024. Survey data were summarized descriptively using SAS, version 9.4 (SAS Institute). Qualitative analysis was performed using MAXQDA, version 2022.7 (VERBI Software GmbH).

Results

Among 46 eligible clinicians who were approached, 30 participants (14 [47%] males and 16 [53%] females; 6 [20%] Asian, 1 [3%] Black, 1 [3%] Hispanic, and 22 [73%] White individuals) completed the study requirements, ie, both the online survey and the video interview. Regarding practice setting, 20 (67%) reported practicing in an academic setting (Table 1). Salient themes and TDF domains regarding Capability, Opportunity, and Motivation are shown in Tables 2, 3, and 4.

Table 1. Demographic and Practice Characteristics of Study Participants.

Characteristic	Participants, No. (%)
Total participants, No.	30
Age group, y
25-34	6 (20)
35-44	11 (37)
45-64	9 (30)
≥65	4 (13)
Female	16 (53)
Male	14 (47)
Race and ethnicity
Asian	6 (20)
Black	1 (3)
Hispanic	1 (3)
White	22 (73)
Professional role
Dermatologist	22 (73)
Dermatology advanced practice practitioner	2 (7)
Dermatology resident	2 (7)
Infectious disease specialist	4 (13)
Primary practice setting
Academic institution	20 (67)
Group practice	6 (20)
Private practice	1 (3)
Hospital	3 (10)
Patients with acne, estimated No./mo (per wk or d)a
None	5 (17)b
1-5 (<1 wk)	4 (13)
6-20 (1/wk to <1/d)	6 (20)
20-60 (1-3/d)	8 (27)
>60 (>3/d)	7 (23)
Professional membershipc
American Academy of Dermatology	23 (77)
American Acne & Rosacea Society	8 (27)
AARS scientific panel on antibiotic use in dermatology	2 (7)
Atlanta Association for Dermatology and Dermatologic Surgery	11 (37)
Georgia Association of Dermatology and Dermatologic Surgery	8 (27)
Emory Antibiotics Resistance Center	4 (13)

Abbreviation: AARS, American Acne & Rosacea Society.

^a A week was defined as 5 working days.

^b Included 4 infectious disease physicians and 1 retired dermatologist with expertise in acne and antibiotic stewardship.

^c Percentage does not total 100 because respondents were able to select multiple memberships.

Table 2. Capability-Related to Salient Barriers or Facilitators to Antibiotic Stewardship in Acne Treatment.

Domain and theme	Representative quote (participant No., male/female [M/F], degree, role)
Knowledge
Lack of evidence in the dermatologic literature	“I think the mounting evidence of resistance is huge [but] it’s not in the dermatologic literature necessarily.” (9, F, MD, dermatology resident)
Skills
Navigating patient discussions about tapering antibiotics	“Antibiotic resistance doesn’t really have a face or a way of really identifying it. So, as with a lot of things in public health, when you have a patient in front of you who’s like, ‘This is really debilitating. I have a real problem with this. Why can’t you give me more of this?’ It puts the provider under a lot of pressure and a bad place to be able to say no. It’s a lot easier to say yes than it is to say no.” (17, M, MD, infectious diseases attending physician) “I guess the main conflict would be if the antibiotic was working while the patient was on it, and then it’s withdrawn because of the treatment duration limitation. Then that would be a conflict, because the patient’s going to say, ‘Well, it’s working. Why can’t I just stay on it?” (16, F, MD, dermatology attending physician)
Discomfort with contraceptive discussion	“The first-line therapy for [women] would be OCPs [oral contraceptive pills]. However, the term ‘contraceptive’ has some connotations. And so, there’s some reluctance among some of my women patients.” (1, M, MD, dermatology attending physician)
Clinical inertia	“…probably two-thirds or more know how to do it, but they’re just, they’re lazy. They take the path of least resistance.” (19, M, MD, dermatology attending physician)
Using antibiotics as bridge therapy	“I’ll tell them that the goal is to come off the antibiotics in three months and just be maintained on the cream and the wash.” (30, F, MD, dermatology attending physician)

Table 3. Opportunity-Related Salient Barriers or Facilitators to Antibiotic Stewardship in Acne Treatment.

Domain and theme	Representative quote (participant No., male/female [M/F], degree, role)
Environmental context and resources
iPLEDGE22 barriers	“Doxycycline takes seconds to renew. Isotretinoin takes, depending on circumstances, hours sitting on iPLEDGE.” (12, M, MD, dermatology attending physician) “When you present somebody with a consent form to take a drug, [they think], ‘okay this is really serious.’ And it is, but we don’t have them sign a consent form for some of the other drugs that we use which are equally serious, like methotrexate, for instance.” (16, F, MD, dermatology attending physician)
Absence of effective system for measuring progress	“…there’s no flagging feature. There’s no buddy. We don’t have clinical pharmacists looking over us to kind of give us warnings or notifications.” (4, M, MD, dermatology attending physician) “I think that [we need] more systems in place to be able to see the prescriptions that patients received in the past, something that’s user-friendly and can easily pull from multiple different pharmacies...” (14, F, MD, dermatology attending physician)
Need for effective nonantibiotic alternative therapies	“Patients that flare as soon as they come off, basically, or I try something different, they don’t tolerate it and just want to go back to the antibiotic. Those are things that would make it difficult to follow the [guidelines].” (3, F, MD, dermatology attending physician) “It’s challenging because you have to find something else that works, and something that is deployable that people will adhere to and accept that works as well or better. That’s the limitation here. Antibiotics are cheap; they’re easy to take. They’re well tolerated by individual patients, and they work. The alternatives are either potentially more expensive, more difficult to deploy, or have just as many or more concerns associated with them.” (12, M, MD, dermatology attending physician)
Refill protocols	“If [patients] don’t have their follow-up or she’s not scheduled or something happens, you have nurse protocols that allow someone else to refill it without knowing the overall plan or following the guidelines.” (3, F, MD, dermatology attending physician)
Limited capacity for follow-up	“… let’s say you have acne…I think you could probably be done [with antibiotics] in a month. But I don’t have access to see you in a month. So, sometimes I think there is an incentive to give you a longer dose because of that access to care issue.” (8, M, MD, dermatology attending physician)
Financial considerations	“I think [payers] probably would prefer to pay for an antibiotic than they would isotretinoin and the topicals. The cost of some of the [prescription] topicals are quite extreme now.” (16, F, MD, dermatology attending physician)
Social influences
Patient satisfaction	“…[limiting antibiotic use] conflicts with my goal of, I like being well-liked by my patients. I like it when they give me positive reviews...” (14, F, MD, dermatology attending physician) “I think there’s a balance between doing what’s recommended by societies and also based on what patients want and making the patients happier, not necessarily if it’s the most kosher thing to do.” (10, M, MD, dermatology resident)
Other clinicians’ prescribing practices	“If that practitioner sticks to the 3-month rule, then the patient simply goes to a different practitioner, gets antibiotics, and then they’re actually getting more antibiotics. They’re starting over and over and what’s worse than being on an antibiotic continuously is starting and stopping an antibiotic and developing resistance.” (5, M, MD, dermatology attending physician)

Table 4. Motivation-Related Salient Barriers or Facilitators to Antibiotic Stewardship in Acne Treatment.

Domain and theme	Representative quote (participant No., male/female [M/F], degree, role)
Social professional role and identity
Professional responsibility to reduce antibiotic resistance	“I think it’s my responsibility because, overall, we as a field have a duty to make sure we’re contributing to antibiotic stewardship as well.” (2, F, MD, dermatology attending physician)
Commitment to the patient	“I do not believe that the societal harm of putting a single individual on longer-term antibiotics outweighs a potential benefit to that individual.” (25, M, MD, dermatology attending physician) “…my responsibility to that patient sometimes trumps my responsibility to stewardship.” (9, F, MD, dermatology resident)
Beliefs about capabilities
High level of perceived confidence in ability to limit antibiotic use	“It’s really easy to limit antibiotics. You just don’t prescribe them again.” (30, MD, F, dermatology attending physician)
Lack of data to justify confidence	“In the absence of feedback, you can talk all you want about how important this is and how you’re adhering to it. But, without actually knowing whether you’re doing it, it’s a third-grade math problem. It’s the numerator and denominator. [For] it to make any sense, you’ve got to have both numbers. Otherwise, it’s just a feeling.” (12, M, MD, dermatology attending physician)
Goals
Prevalence vs duration	“The goal in my mind is not to limit the usage in a patient who needs it, but to limit the patients who receive it, to treat them with something else.” (29, M, MD, dermatology attending physician)
Beliefs about consequences
No immediate consequences to prolonged antibiotic use	“…[increasing antibiotic resistance] is a much more abstract concept. The number goes up on some graph somewhere, but I think folks don’t necessarily appreciate how it’s going to affect their patient.” (17, F, MD, infectious diseases attending physician)
Intentions
Do no harm	“…I don’t want my patients to develop antibiotic resistance. As providers we’re supposed to do no harm…” (18, F, PA-C, dermatology advanced practice practitioners)
Reinforcement
Notion of a greater good	“My main incentive would be that I feel like I’m doing the right thing…not only for the patient, but for society in general.” (3, F, MD, dermatology attending physician)

Capability

Knowledge of Acne Guidelines

Most clinicians were familiar with the guidelines and understood the concept of limiting antibiotic use for acne treatment. Many were not very familiar with the evidence behind the guidelines or felt the evidence behind the guidelines ranged from being strong to moderate to nonexistent. Some participants mentioned that the dermatologic literature on antibiotic resistance in acne treatment is not convincing. Some participants believed that the guidelines were arbitrary and that limiting duration to 3 months was not a realistic goal. Some participants had not personally reviewed the literature behind the recommendations but trusted that the recommendations were strong. Participants reported that most dermatologists are knowledgeable in nonantibiotic acne therapies.

Skills in Antibiotic Stewardship

Most participants agreed that dermatologists should know how to limit long-term antibiotic prescriptions; however, they cited several barriers. Clinicians who have practiced for decades were perceived as less likely to adapt to new standards of care. Although many reported feeling uncomfortable with contraceptive counseling and felt less inclined to prescribe isotretinoin, most agreed that dermatologists must be competent in contraceptive counseling. Participants consistently emphasized difficulties with navigating patient demands and tapering-off antibiotic therapy with insistent patients. Other challenges cited included limited patient communication skills, inability to find another therapy with equivalent efficacy, and lack of foresight regarding individual patient barriers to medication adherence. Robust clinical skills in prescribing different acne treatments and discussing alternative therapies and adverse effects were stated as essential for limiting antibiotic use.

Opportunity

Environmental Context and Resources

Participants cited a need for nonantibiotic alternative therapies that are comparably effective, easy to prescribe, simple to use, and well tolerated. Numerous environmental limitations were identified, the most common being regulatory barriers to prescribing isotretinoin. Participants noted that iPLEDGE²² is unnecessarily complex for prescribing isotretinoin in the US. Patients were inconvenienced by having to make office visits for pregnancy tests, and clinicians struggled to fit these visits into busy schedules. While participants noted that their clinic organization was either supportive or a non-factor, many noted the lack of time as a barrier to discuss nonantibiotic acne treatments. Existing refill protocols that automatically renewed prescriptions also prolonged antibiotic use. Other environmental barriers included pressure to maximize number of patients that can be seen, lack of external accountability, lack of electronic medical record features to indicate patients who previously received prolonged antibiotics, and limitations in insurance coverage for nonantibiotic treatments.

Social Influences

Several participants recognized that patients were less likely to be concerned over antibiotic resistance and would prioritize their individual needs. Patient satisfaction was a large influence on acne prescribing practices. Many clinicians felt forced to choose between keeping their patients satisfied with their effective antibiotic therapy when considering tapering oral antibiotics in practicing antibiotic stewardship. One cited online reviews from dissatisfied patients as a possible influence on long-term antibiotic prescribing. Many participants believed that if they did not continue long-term antibiotics in patients who were highly satisfied with their oral antibiotic treatment, they would switch care to other clinicians who would. Variation in prescribing practice and in clinicians’ and patients’ values on the importance of antibiotic stewardship and patient satisfaction discouraged some clinicians to adhere to acne guidelines.

Motivation

Social or Professional Role and Identity

All participants noted competing responsibilities between “professional responsibility” and “commitment to the patient.” Participants agreed that it was generally their role to follow the guidelines. Some were steadfast in their responsibility to strictly adhere to guidelines; however, many championed their commitment to individual patient needs over guideline adherence. Some dermatologists described the guidelines as “strictly recommendations,” as one tool to be considered when caring for patients on a case-by-case basis. Infectious disease physicians strongly disapproved of long-term antibiotic use, but several dermatologists argued that other specialties “underestimate the impact acne has on people’s lives.”

Beliefs About Capabilities

Responses varied widely on the ease by which one could limit antibiotic use for acne to less than 3 months. Participants did not perceive themselves incapable of limiting antibiotics, but many reported feeling constrained by external demands that the guidelines did not comprehensively address.

Goals

Most participants did not aim for 3 months as a strict goal for all patients. A metric generally cited was to limit antibiotic prescriptions to 3 months 80% to 90% of the time. For some, a 3-month stop would not adequately address some unique patient scenarios. One participant advocated for limiting the prevalence of antibiotic prescriptions for acne as opposed to focusing on treatment duration. Participants described sharing antibiotic stewardship goals with patients by setting clear expectations and educating patients on guideline-adherent antibiotic use.

Beliefs About Consequences

Almost all participants believed that the fundamental consequence of prolonged antibiotic prescriptions for acne is the threat of increased antibiotic resistance. There was skepticism among several participants regarding the effect of individual patient prescriptions on antibiotic resistance in the broader population. For many participants, the lack of immediate consequences from prescribing prolonged antibiotics reduced antibiotic stewardship to a theoretical principle rather than a measured outcome. Other consequences less frequently reported include the adverse effects of prolonged doxycycline use, potentially pathologic alterations in gut flora, and a false sense of security among patients.

Intentions

For many, their intention to reduce antibiotic prescriptions for acne considered the implications of resistance. Some participants emphasized the effectiveness and beneficial adverse effects profile of alternative treatments such as isotretinoin as a more compelling argument than the threat of antibiotic resistance. Some did not believe in abiding by the 3-month guidelines and would treat the acne regardless of antibiotic duration or frequency.

Reinforcement

Incentives cited for limiting antibiotic prescriptions include personal satisfaction in adhering to the guidelines and contribution to the “greater good.” Most reported no financial benefit in antibiotic stewardship. One reported that antibiotic stewardship could be financially advantageous as patients would be inclined to follow-up sooner after starting systemic antibiotics.

Discussion

This study systematically assessed barriers and facilitators—as described by key stakeholders—for future antibiotic stewardship interventions to identify pragmatic factors that affect long-term antibiotic prescribing practices in acne treament. The salient themes included (1) lack of evidence to justify change in dermatologic practice, (2) navigating patient discussions about tapering-off of antibiotics, (3) discomfort in discussing contraception, (4) iPLEDGE-related barriers, and (5) the absence of an effective system for measuring antibiotic stewardship progress. Current calls to action on antibiotic stewardship based on expert opinions suggest that clinician education should be the key intervention.²³ However, most stakeholders were well aware of the guidelines, yet few reported strict guideline adherence. Therefore, passive education alone would likely be insufficient to curtail unnecessary antibiotic use, and any antibiotic stewardship program should be actively tailored to actual clinical practice in acne treatment.

The lack of robust dermatologic evidence hindered some participants from justifying a change in prescribing behavior. Emerging trends are indicating that Cutibacterium acnes and coagulase-negative staphylococci are increasingly resistant to the antibiotics used to treat acne.^24,25,26 Erythromycin, historically the standard of care for acne treatment, is seldom used due to increasing resistance patterns.²⁷ C acnes strains isolated from patients who have previously received long-term oral tetracyclines, macrolides, or clindamycin demonstrate higher rates of resistance than patients on shorter-term therapies.²⁸ In a small pilot trial,²⁹ oral doxycycline and trimethoprim/sulfamethoxazole were associated with the emergence, expansion, and persistence of antibiotic-resistant strains of staphylococci in skin flora of healthy volunteers.

Developing high-quality evidence on the relationship between long-term antibiotic use for acne and antibiotic resistance is urgently needed.² Development of comparative effectiveness studies and dissemination of current evidence on topical regimens³⁰ and oral spironolactone³¹ as feasible alternatives to long-term antibiotic use in an active, relevant, accessible, and actionable manner are needed to support clinical decision-making and antibiotic stewardship efforts.

Clinician concerns regarding patient demand for oral antibiotics and limited patient knowledge of antibiotic resistance hindered discussion of nonantibiotic treatment options. Findings from a survey of patients with acne showed that many patients may not necessarily expect, demand, or want antibiotics.³² Most patients were familiar with the concept of antibiotic resistance, and more than 90% of patients prescribed antibiotics for acne agreed that physicians should educate patients on this issue.³² Clinician assumptions regarding patients’ desire for antibiotics, and concern about negative repercussions from stewardship efforts on patient satisfaction may give way to more antibiotic prescriptions.

Some clinicians were concerned that switching away from antibiotics may negatively affect patient satisfaction and draw patients to seek another clinician, one who prioritizes patient satisfaction over antibiotic stewardship. In primary care settings, physicians poorly predicted which patients desired antibiotics,³³ and were more likely to prescribe antibiotics inappropriately in pediatric encounters when parents were perceived to expect antibiotics.³⁴ Patient perceptions of primary care clinicians did not change after behavioral and educational interventions aimed to reduce antibiotic prescriptions for respiratory tract infections.^35,36 Future antibiotic stewardship interventions in acne should facilitate communication and shared decision-making between patients and clinicians on acne therapeutic options and evaluate how it affects patient satisfaction.

Discomfort around discussing and prescribing combined oral contraceptive pills (OCP) was frequently reported despite several combined oral contraceptive pills being FDA-approved to treat acne. Women prescribed teratogenic medications were frequently not prescribed OCP or reported nonadherence.³⁷ Dermatologists were less likely to prescribe OCP to women with acne than primary care clinicians or gynecologists.³⁸ Adherence to OCP prescribed by dermatologists was lower than those prescribed by primary care clinicians or gynecologists.³⁷ Patients receiving isotretinoin described their contraceptive counseling encounters as inadequate, anxiety-provoking, brief, and not patient-centered.³⁹ Many patients receiving isotretinoin reported lacking information on pregnancy avoidance strategies and contraceptive options.^39,40 With patients facing increasing restrictions to reproductive health care access,^41,42 facilitate acne treatment with OCP for patients who desire contraception and meet medically eligibility criteria may reduce downstream antibiotic need.

An association has been found between the introduction of iPLEDGE²² in 2006 and reduced prescribing of isotretinoin.^43,44 Clinicians found iPLEDGE difficult to use and may delay isotretinoin use.⁴⁵ Patients described iPLEDGE as stressful and overwhelming, citing high time and financial burdens from monthly follow-up visits.^39,45 Simplifying contraceptive requirements,⁴⁶ allowing home pregnancy testing and telemedicine visits,⁴⁷ and individualizing follow-up and pregnancy testing frequency based on the patient’s reproductive and contraception status⁴⁸ have been proposed to facilitate isotretinoin access.

Multiple acne treatment guidelines have emphasized antibiotic stewardship efforts as a professional priority for dermatologists.^9,24 Outpatient antibiotic stewardship programs are effective in decreasing antibiotic prescribing without adversely affecting patient outcomes in a systematic review of low to moderate strength evidence outside of dermatology settings.⁴⁹ Nationally, the Core Elements of Outpatient Antibiotic Stewardship Programs¹⁴ include commitment, action for policy and practice, tracking and reporting, and education and expertise. Important examples of effective outpatient antibiotic stewardship strategies that may address the themes that our study identified include training clinicians on shared decision-making and communication skills,^50,51 implementing clinical pathways and order sets in electronic health records,⁵² displaying commitment posters on reducing inappropriate antibiotic use,⁵³ auditing antibiotic prescription rates prospectively with individual feedback and peer comparison,^54,55 and requiring documentation of guideline discordant antibiotic prescribing.^56,57,58 Adapting and implementing antibiotic stewardship interventions in dermatology should address specific behavioral determinants of long-term antibiotic prescriptions for acne treatment.

Limitations

Although this qualitative study did not intend to generate generalizable data, the study participants were mostly White, US-based academic physicians with relatively low volumes of patients with acne; the study sample did not include those practicing in other clinical, cultural, and international contexts. Our findings may inform future quantitative studies, such as surveying clinicians using adaptations of the Influences on Patient Safety Behaviors Questionnaire⁵⁹ or other tools to obtain generalizable estimates of the relative importance of facilitators and barriers across practice settings. Inclusion of diverse patient perspectives will further inform acne antibiotic stewardship interventions. Guidelines used in other countries may recommend a different treatment duration from the 3 to 4 months recommended in the US.^60,61,62,63 Strict interpretation of guidelines that limit antibiotic use to less than 3 months may constrain applicability in some guideline-concordant scenarios; eg, when a patient requires a longer course of oral antibiotics because alternative therapies are clinically inappropriate.

Our study participants did not discuss spironolactone extensively. Emerging evidence suggesting similar effectiveness between spironolactone and oral antibiotics may be leveraged to address evidence gaps in future antibiotic stewardship efforts.^64,65,66 In addition, diverse and international settings may evaluate how cultural differences, geographic variations in prescribing patterns, and medication access may be associated with antibiotic prescribing for acne.

Conclusions

The findings of this qualitative study indicate that while clinicians consider antibiotic stewardship a professional responsibility and they are aware of antibiotic stewardship guidelines in acne treatment, future interventions must address the need for robust evidence-based knowledge on the clinical implications of long-term antibiotic prescriptions for acne and clearly disseminate this information to clinicians and patients; clear and effective nonantibiotic alternatives that consider cultural and financial contexts; communication skills training to empower clinicians to navigate discussions on treatment selection, switching to alternatives, and contraceptive considerations; and systems that provide individualized feedback to support antibiotic stewardship. An antibiotic stewardship program for acne treatment should be adapted, piloted, and evaluated in dermatology practices to assess its acceptability, feasibility, and effectiveness.

Supplement 1.

eSurvey Interview Guide

eTable. Data Matrix of Domains and Themes across Interviews

Supplement 2.

Data Sharing Statement