The management of acne vulgaris in primary care: a cohort study of consulting and prescribing patterns using CPRD

Background Effective management of acne vulgaris in primary care involves support (usually provided over a number of consultations) and prescribing effective treatments. However, consulting and prescribing patterns for acne in primary care are not well described. Objective To describe the rate of primary care consultations and follow-up consultations; prescribing patterns, including overall use of acne related medications (ARM) and initial and follow-up prescribing, for acne vulgaris in the UK. Methods UK primary care acne consultations and prescriptions for ARMs were identified in the Clinical Practice Research Datalink (CPRD). Annual consultation rates (between 2004 and 2013) by age and gender, new consultations and consultations in the subsequent year; prescribing trends, prescribing during a new consultation and over the subsequent 90 days and year were calculated, using number of registered patients as the denominator. Results 65.9% of patients who had a new acne consultation had no further acne consultations in the subsequent year. 26.6%, 25.2%, 23.5% and 2.8% of patients were prescribed no ARM, an oral antibiotic, a topical antibiotic, or an oral plus topical antibiotic respectively during a new acne consultation. 59.9% and 38.5% of patients prescribed an ARM received no further ARM prescriptions in the following 90 days and one year respectively, despite most prescriptions being for 2 months or less. Prescribing rates for lymecycline and topical combined clindamycin/benzoyl peroxide increased substantially between 2004 and 2013. There were no important changes in consultation rates between 2004 and 2013. Conclusion These data suggest that patients with acne are receiving sub-optimal initial choice of ARMs, longitudinal care and prescribing

Oral Spironolactone for Acne Vulgaris in Adult Females: A Hybrid Systematic Review

Dermatology-oncolog

AGREE II assessments of recent acne treatment guidelines: how well do they reveal trustworthiness as defined by the US Institute of Medicine criteria?

Dermatology-oncolog

Phenotypic and genotypic characterization of antibiotic-resistant Propionibacterium acnes isolated from acne patients attending dermatology clinics in Europe, the U.S.A., Japan and Australia

NoPropionibacterium acnes is the target of antimicrobial treatments for acne vulgaris. Acquired resistance to erythromycin, clindamycin and tetracyclines has been reported in strains from diverse geographical loci, but the molecular basis of resistance, via mutations in genes encoding 23S and 16S rRNA, respectively, has so far only been elucidated for isolates from the U.K. The study set out to determine whether similar or different resistance mechanisms occur in resistant P. acnes isolates from outside the U.K. The phenotypes and genotypes of 73 antibiotic-resistant strains of P. acnes obtained from the skin of acne patients in the U.K., U.S.A., France, Germany, Australia and Japan were compared. Antibiotic susceptibilities were determined by minimum inhibitory concentration (MIC) measurements, and polymerase chain reaction and DNA sequencing were used to identify mutations in genes encoding rRNA. Most erythromycin-resistant isolates (MIC90¿ 512 ¿g mL¿1) were cross-resistant to clindamycin but at a much lower level (MIC90¿ 64 ¿g mL¿1). As in the U.K., resistance to erythromycin was associated with point mutations in 23S rRNA in 49 of 58 strains. An A¿G transition at Escherichia coli equivalent base 2058 was present in 24 strains. This gave a unique cross-resistance phenotype against a panel of macrolide, lincosamide and type B streptogramin antibiotics. Two further point mutations (at E. coli equivalent bases 2057 and 2059) were identified (in three and 22 isolates, respectively) and these were also associated with specific cross-resistance patterns originally identified in isolates from the U.K. However, nine of 10 erythromycin resistant-strains from Germany did not exhibit any of the three base mutations identified and, in six cases, cross-resistance patterns were atypical. Consistent with previous U.K. data, 34 of 38 tetracycline-resistant strains carried a base mutation at E. coli 16S rRNA equivalent base 1058. Tetracycline-resistant isolates displayed varying degrees of cross-resistance to doxycycline and minocycline, but isolates from the U.S.A. had higher MICs for minocycline (4¿16 ¿g mL¿1) than isolates from other countries and, in particular, Australia. All the P. acnes isolates resistant to one or more of the commonly used antiacne antibiotics were sensitive to penicillin, fusidic acid, chloramphenicol and the fluoroquinolone, nadifloxacin. All but one isolate (from the U.K.) were sensitive to trimethoprim. This study shows that 23S and 16S mutations identified in the U.K. conferring antibiotic resistance in P. acnes are distributed widely. However, resistant strains were isolated in which mutations could not be identified, suggesting that as yet uncharacterized resistance mechanisms have evolved. This is the first report of high-level resistance to minocycline and is of concern as these strains are predicted to be clinically resistant and are unlikely to remain confined to the U.S.A. Epidemiological studies are urgently required to monitor how resistant strains are selected, how they spread and to ascertain whether the prevalence of resistance correlates with antibiotic usage patterns in the different countries