Since when did antibiotics become the one and only treatment for acne? It seems to be a common thing for patients with little or no acne to present to the jail medical clinic requesting (or demanding) doxycycline. “My outside doctor gives it to me,” they say. And they are right. I have had two recent cases of this. In the first, a 19 year old with no acne (none!) demanded that I continue his minocycline prescription for the six months that he was to serve in jail. When I refused (but offered alternative therapy), he had his family bring in a brand new bottle of antibiotics prescribed by his outside doctor. (See The Right Way to Deal With Outside Doctors).
In the second case, I was called by the defense attorney of a patient, wanting to know why I was “denying” his client appropriate care for his (very mild) acne. By “appropriate treatment,” he meant, of course, oral antibiotics.
I assume that one reason for this demand for antibiotics is that it is easier for a doctor to write an antibiotic prescription than take the time to teach patients how to do proper skin care. And it is easier for the patient to just pop a pill than to wash their face 2 or 3 times a day and use astringents. I am also told that some topical medications have a mask-like feel to them that is somewhat unpleasant.
Save Doxycycline for MRSA
However, one very important downside to the indiscriminant use of antibiotics for mild acne is, of course, MRSA. Doxycycline is an important front line drug for the treatment of MRSA, but doxycycline resistance is already cropping up at various places around the country. If we continue to use doxycycline for cases of acne where it is not needed or indicated, we will not have it in the future for MRSA cases where it can be very important.
Stepwise Approach to Acne
So I thought I would go over the stepwise approach to acne. As is true for most medical problems, the therapy for acne is based on severity and on response to previous therapy. It is as inappropriate to use advanced therapy for mild acne as it is to use mild-acne therapy for severe acne. Also, you can step up and step down therapy depending on how the acne progresses with time. So: the steps:
Step one: Skin cleansing with soap and water twice or three times a day. Religiously.
Step 2A, 2B and 2C: The astringents. Usually, begin with Salicylic acid (Stridex pads) applied one a day. If that is not enough, progress to benzoyl peroxide 5% and then 10%
Step 3: Tretinoin 0.02% gel applied every third day and progressing up.
Step 4: Topical antibiotics, such as erythromycin or clindamycin topical gel.
Step 5: Oral antibiotics, such as as doxycycline or erythromycin.
Step 6: Referral to a dermatologist for consideration of isotretinoin therapy. I have actually done this for some juveniles in our state juvenile prison who had truly severe disfiguring acne.
Notice that oral antibiotics are a late therapy properly reserved for at least moderate cystic acne unresponsive to topical treatments.
In adult facilities, acne is mostly a cosmetic issue rather than a medical issue. The best way to handle it is to put OTC acne treatments on the commissary which gives inmates the means to treat themselves without going through the clinic. I recommend that Salicylic acid and Benzoyl Peroxide be placed on the inmate commissary. I am a strong believer in an OTC commissary.
In juvenile facilities, acne is more often a true medical problem. However, if you are skipping tretinoin and going straight to oral antibiotics, well, I think you are providing inferior medical care. Juveniles, like our kids at home, often need direct observation of their face washing and astringent application to make sure that they are really doing a good job.
If you would like a sample protocol for dealing with acne in juvenile detention facilities, email me and I will send you mine.