Antibiotics should not be first treatment for acne

EDITOR—The recent edition of the BMJ on antimicrobial resistance1 and the booklet The Path of Least Resistance2 raise important issues about the use of antibiotics. It is perhaps surprising, therefore, that the widespread and long term use of antibiotics in acne has not been addressed.

Conventional treatment of acne uses both topical and systemic broad spectrum antibiotics. Treatment is for a minimum of three months and often for several years. It is not unusual to adopt a policy of rotational treatment, changing antibiotics every six months or so. The antibiotics prescribed for acne include tetracyclines, erythromycin, trimethoprim, and topical chloramphenicol. Although individual acne patients may not suffer from antibiotic resistance, long term use of antibiotics may contribute to the pool of resistant organisms.

Acne can be treated without antibiotics by using retinoids such as tretinoin topically and isotretinoin orally. Isotretinoin is more effective than antibiotics3 and more cost effective.4 However, because isotretinoin can be prescribed only by hospital dermatologists, and hospital funds for this drug are limited, antibiotics are considered first line treatment.

In the light of concern about increasing antibacterial resistance it is important to reconsider the …