Selection of therapy for acne vulgaris: balancing concerns about antibiotic resistance

The widespread use of long-term antibiotics to treat acne and rosacea has resulted in increased Propionibacterium acnes resistance to antibiotics. Although resistance may decrease treatment effectiveness in some cases, it also is clear that antimicrobial activity is not the only role antibiotics play in acne management. The anti-inflammatory activity of antibiotics contributes to antipropionibacterial efficacy. In addition, the use of benzoyl peroxide (BPO) in combination with antibiotics to reduce resistant populations of propionibacteria is widely advocated, as P acnes has not developed resistance to it. P acnes now is known to form biofilms, which are bacterial communities that live encased in a glycocalyx polymer that aids in adherence to surfaces, thereby delaying antibiotic penetration. In addition to drug resistance, patient compliance with acne treatment is an important issue. Because compliance is a function of tolerability and convenience, new moisturizing noncomedogenic vehicles and fixed BPO-antibiotic combinations can be expected to improve compliance. Better efficacy has been noted with BPO-antibiotic combination therapy.