How Narrow-Spectrum Antibiotics Shifted Acne Treatment Strategy

For many who follow the headlines of dermatology, it may be easy to neglect the importance of acne vulgaris.

Each of atopic dermatitis, plaque psoriasis, vitiligo, and alopecia areata—among other skin diseases—have been subject to headline developments in research, US Food and Drug Administration (FDA) approvals and more promising news in the last year.

And still, they pale in comparison to the reach of acne globally.

“A lot of times we forget with all these new approvals from the FDA—of cutting-edge precision medicine in dermatology—we forget that acne vulgaris is the eighth most common disease on planet Earth,” Christopher Bunick, MD, PhD, told HCPLive. “There’s almost a billion people here on Earth with acne vulgaris.”

In an interview with HCPLive during the 2022 Clinical Fall Dermatology Meeting this week, Bunick, associate professor of dermatology at Yale School of Medicine, discussed how while many of his colleagues would spend the meeting highlighting the advancement of precision medicines for other chronic skin diseases, there remains a core need to understand and adequately treat acne—a condition that’s “more central to the skin” than any other.

Bunick’s discussions at Fall Clinical this year review the progression from broad-spectrum antibiotics such as doxycycline and minacycline—agents that comprise about 75% of all prescriptions for acne—to alternatives that offer less concerning risk.

“It turns out, in the last few years, there’s been at least in the treatment of moderate-to-severe inflammatory acne, a pretty major advance in the antibiotic space,” Bunick said. “Now there’s still a lot of controversy about the use of antibiotics to treat acne, but the bottom line is for a lot of patients, oral antibiotics—both for their antibacterial efficacy…as well as their anti-inflammatory properties—are very effective for our patients.”

Bunick discussed the advancement of narrow-spectrum antibiotics such as sarecycline, a first-in-class agent approved for acne vulgaris that has been shown to mitigate broad-spectrum antibiotic risks including gut microbiome harm, digestive distress, photosensitivity and blood-brain barrier penetration. He called the resolution of the latter issue “an amazing advantage for reducing vestibular side effects” such as dizziness or vertigo in older patients.

The advancement of narrow-spectrum antibiotics in acne also warrant the discussion of antibiotic stewardship in dermatology—a subject that Bunick believes has been carried quietly in the last 2 decades. Risk of antibiotic resistance has swayed some of the general public completely against the drugs’ use. But narrow-spectrum agents have been shown to have the least association with antibiotic resistance.

Later, Bunick discussed other innovations in acne care including a topical triple-combination therapy currently under investigation, as well as some advancements in case-specific strategy: managing patients on birth control, prescribing for patients on spironolactone, among others.