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.
I love these blogs! I currently work for Jeff one day a week in a small county jail. I also work in dermatology ( I know, what a combo). Some other important info to remember when treating ance is:
1. The tretinoin gel (a retinoid) is the key in treating acne. It helps control “blackheads” and “whiteheads,” which lead to acne. Furthermore, YOU HAVE TO APPLY A PEA SIZED AMOUNT to the face or a little larger amount to the back and chest BEFORE BEDTIME, as it is light inactivated. Some people complain of feeling too dry or peeling, which is normal. Most of the time you can get around this using some facial moisturizer mixed with the tretinoin gel. IF THEY DON’T USE THE GEL THE ACNE WILL NOT IMPROVE.
2. A benzoyl peroxide wash, 5-10%, should be used at least one time daily ( I prefer to have them use it in the morning). Again, use a facial moisturizer if they feel a little dry. This is what is going to control the bacterial, and you really shouldn’t have them on an antibiotic without this important wash.
3. They need to wash at night, so a mild over the counter wash like Cetaphil is suggested.
4. Remember, the antibiotics are used for the anti-inflammatory effects, rather than “to kill the bacteria.” Get them on a low dose antibiotic as soon as possible if they need it for long-term control of their acne.
5. One last thing, it takes time!!! Do not expect to see any good results for at least 6-12 weeks after starting the above suggestions.
Thanks Neelie! I learned a lot from this little comment. I am going to go over your recommendations with the staff at my juvenile facilities.
BTW, tretinoin comes as a cream and as a gel–I assume from your comment that we should not order the cream. The tretinoin gel also comes in two strengths, 0.025% and 0.1%. I assume you start with the 0.025%?
Finally, we need to know the cost of the medications we prescribe. Tretinoin gel is moderately expensive (one reason why oral antibiotics are prescribed instead). But it is not break-the-bank expensive.
You can find the current acquisition cost for tretinoin gel 0.025% here. As of today, it costs $0.76 a gram, so a 45 gram bottle would cost $30.40 (plus a fill fee). But I assume that much would last a long time.
I’ve experienced the same demands from inmates for doxycycline and the like. It often stems from a lack of understanding about what acne is and how the different agents used to treat it work. As in most cases, a little education goes a long way.
Except in advanced cases, I rarely use antibiotics for acne. Where I do use them, I favor “pulse” therapy where I’ll treat for a week or two and get off the antibiotics to avoid resistance.
Dear Dr. Keller ~
As a LPN at a juvenile detention center, I see antibiotics used regularly as a first line treatment for acne.
I would really appreciate seeing your sample protocol for dealing with acne in juvenile detention facilities.
Michelle Pruchnicki, LPN