To the Editor: Acne vulgaris is a chronic inflammatory skin disease with varying treatments.1 Limited literature exists on the prescription behavior of physicians for acne. Evidence-based clinical guidelines from the American Academy of Dermatology (AAD) for acne vulgaris were published in 2016.2 Our objective was to analyze adherence to a subset of the AAD guidelines regarding antibiotic and combination therapy (Table I).
Table I.
Select recommendations from the American Academy of Dermatology’s acne clinical guidelines (2016)
| AAD recommendation | Topical therapy |
|---|---|
| Recommendation 1 | Benzoyl peroxide is recommended for all patients using a topical or systemic antibiotic to prevent antibiotic resistance. |
| Recommendation 2 | Topical antibiotics are not recommended as monotherapy∗ because of the risk of bacterial resistance. |
| Recommendation 3 | Combination therapy with multiple topical agents that target different aspects of acne pathogenesis (ie, topical retinoid + topical antibiotic) is recommended for the majority of patients with acne. |
| AAD recommendation | Systemic therapy |
|---|---|
| Recommendation 4 | Systemic antibiotic monotherapy∗ is not recommended because of the risk of antibiotic resistance. |
| Recommendation 5 | Topical benzoyl peroxide or topical retinoids should be used concurrently with systemic antibiotic therapy. |
Monotherapy implies the patient is not prescribed any other pharmacologic therapy for acne treatment, regardless of drug class or formulation.
A retrospective study using patient data from the Northwestern Medicine Enterprise Data Warehouse was approved by the Northwestern University Institutional Review Board (STU00037913). The inclusion criteria included adult patients aged ≥18 years with acne vulgaris diagnosed between January 2017 and December 2019. Data were included from >40 clinic locations and >100 providers across the Chicago metropolitan area, resulting in 4050 analyzed patient encounters. Information collected included prescription list, physician specialty, and the clinical encounter note.
There were varying rates of adherence to individual AAD guidelines for the treatment of acne among all physicians of all specialties (Table II). Compliance with specific recommendations ranged from 41.0% to 84.0% among physicians of any specialty and from 44.6% to 90.9% among dermatologists, highlighting a mix of both satisfactory evidence-based care and the need for improvement in acne treatment.
Table II.
Adherence to the American Academy of Dermatology acne guidelines by all physicians, dermatologists, and nondermatologists
| AAD recommendation | Percent of eligible encounters that followed recommendation | Percent of eligible dermatology encounters that followed recommendation | Percent of eligible nondermatology encounters that followed recommendation | P value |
|---|---|---|---|---|
| Recommendation 1 | 55.6 (1501/2701) | 57.4 (1342/2337) | 43.7 (159/364) | <.001 |
| Recommendation 2 | 82.9 (2105/2538) | 85.4 (1935/2267) | 62.7 (170/271) | <.001 |
| Recommendation 3 | 41.0 (1659/4050) | 44.6 (1548/3470) | 19.1 (111/580) | <.001 |
| Recommendation 4 | 84.0 (789/939) | 90.9 (750/825) | 34.2 (39/114) | <.001 |
| Recommendation 5 | 73.7 (692/939) | 80.1 (661/825) | 27.2 (31/114) | <.001 |
Guidelines regarding topical and systemic antibiotic monotherapy (recommendations 2 and 4) were more likely to be followed, with <20% of all patients prescribed an antibiotic receiving antimicrobial monotherapy. This is lower than the previously reported measures of antibiotic monotherapy prevalence,3,4 possibly because of revised guidelines in 2016. Dermatologists were significantly more likely than nondermatologists to follow these recommendations, especially with regard to systemic antibiotic monotherapy (recommendation 4).
Guidelines concerning combination therapy were the least followed (recommendations 1, 3, and 5) with adherence as low as 41.0% among all physicians. Severity and acne type may explain the lower compliance rates because not all patients have acne severe enough to warrant combination therapy. Nondermatologists were less likely to use multiple agents targeting different aspects of acne pathogenesis, potentially limiting treatment efficacy.
One limitation of this study is the absence of data on the outcomes of prescribed treatments. These data were not possible to obtain within the study design and therefore no conclusions can be drawn on the efficacy of the prescription plans. This study was unable to evaluate guidelines regarding oral antibiotic prescription duration because of inconsistencies in the documentation of treatment length. It is important to recognize that AAD guidelines may not apply to patients who are pregnant or hold contraindications to acne medications, where alternative guidelines specific to pregnancy5 or other comorbid conditions should be taken into account.
Our findings not only emphasize the importance of access of specialist care for improved outcomes for patients, but also reveal the need for increased internalization of guidelines among all physicians. Dermatologists can increase the awareness of guidelines by creating online and print reference guides, targeted and accessible to other specialties that commonly encounter patients with acne such as internal medicine and family medicine.
Conflict of interest
None disclosed.
Footnotes
Funding sources: None.
IRB approval status: Reviewed and approved by Northwestern IRB (approval STU00037913).
References
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