Oral antibiotics

Journal of Drugs in Dermatology,  July-August, 2004  

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Dr. Robins: We have to discuss oral antibiotics.

Dr. Shalita: The problem I started alluding to before, the decreased sensitivity of bacteria to antibiotics, is getting to be a major issue. The bacteria are virtually all resistant to erythromycin, as well as to azithromycin and clarithromycin, even though somebody has said you could use Zithromax[R] for 10 days a month.

Dr. Robins: Four days.

Dr. Shalita: Absolute nonsense. It doesn't work any better than the others. It's better-absorbed than erythromycin, but the organism is resistant and you can't get the anti-inflammatory effect. Tetracycline is increasingly resisted, too. There's the least amount of resistance to minocycline, although that resistance is increasing as well. Next best is doxycycline, followed by the other tetracyclines. Trimethoprim sulfate is still okay, but as with the others, if you use it for any length of time you're going to develop resistance. The advantage to minocycline is that it penetrates better and lasts longer than the other antibiotics. It has side effects, but the only one that really is problematic is the pigmentation. Pseudotumors, lupus, and all the other side effects are rare.

Dr. White: Headaches and vertigo are also side effects.

Dr. Robins: Does the pigmentation occur whether or not there's sun exposure?

Dr. Shalita: It occurs in areas of trauma--when there's both acne and trauma.

Dr. White: Without sun exposure.

Dr. Shalita: Doxycycline is alleged to be phototoxic, but again that's a very rare phenomenon. Of course, if you're the one developing phototoxicity, it's no longer rare. And now they have all this low-dose doxycycline hydrate and doxycycline monohydrate treatments taken once a day or twice a day; they can make you crazy with all these different plans. I think they are both very valuable drugs, and I use trimethoprim sulfate when I need to go to the well. If those don't work, I go to Accutane.

Dr. Shupack: Don't forget, there's also oral clindamycin.

Dr. Shalita: Yes, but according to the work they did at Pennsylvania State University, the resistance pattern to clindamycin is virtually identical to the pattern with erythromycin. They crossed.

Dr. Shupack: Do you think there's any role for systemic cephalosporin in acne treatment?

Dr. Shalita: Yes, perhaps a bit of a role for the new generation cephalosporins. You know what is very simple? If you want to find out if a drug is going to work in acne, see if they use it in the prostate. That's true of some of the new quinolones, but I wouldn't want to use them with acne because they are very valuable drugs and you see what's happening to the resistance pattern of systemic drugs. Levaquin[R] for now is the drug of choice for prostatitis, and so is Bactrim[TM].

Dr. White: And Levaquin is once a day.

Dr. Shalita: So is trimethoprim sulfate. But I wouldn't want to see it widely used with acne.

Dr. Robins: Because then you won't have it when you really need it. What percentage of your patients do you put on oral antibiotics?

Dr. Berson: It depends on the variables, such as how they responded first to the topicals.

Dr. White: If they have a very deep nodular component, I'll immediately give them an oral antibiotic.

Dr. Robins: But you don't prescribe it routinely?

Dr. Berson: Not on a first visit, unless they have very inflamed acne.

Dr. Brand: What about prescribing isotretinoin?

Dr. Shalita: Let's do the antibiotics first.

Dr. Robins: I mean, Roche terminated their isotretinoin sales force, the reason being that the drug is off patent and will be available generically.

Dr. Shalita: They don't have a dermatology sales force, but they still have a sales force; they call on us periodically.

Dr. Berson: They call on us as well. They also give us the forms for filling out the yellow stickers and the qualifiers.

Dr. Brand: The generics are doing that as well.

Dr. Berson: Are you finding any differences with the generics?

Dr. Brand: I sometimes don't know what patients are getting.

Dr. Shalita: I don't either.

Dr. Shupack: Are the generic companies giving stickers, too?

Dr. Shalita: Yes.

Dr. Berson: I've been told that some of them don't get absorbed as well.

Dr. Shalita: I don't know. One was made in India, and someone claimed that the other one was made by Roche Pharmaceuticals, but I don't believe it.

Dr. Berson: But as we were discussing, they know exactly which prescription you've given anyway, because they put it in the computer. So it doesn't matter that it's not physician-specific.

Dr. White: Well, that depends on whether or not you write D.A.W. (dispense as written) on it.

COPYRIGHT 2004 Journal of Drugs in Dermatology, Inc.
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