SG: Acne in youths managed suboptimally in primary care

The prescribing patterns for acne among local primary care physicians appear to deviate from clinical practice guidelines used to achieve optimal outcomes for young people, as shown in a Singapore study.

Local clinical practice guidelines recommend a combination of oral antibiotics and topical nonantibiotics for moderate acne treatment. It is also recommended that doxycycline be used as a first-line oral antibiotic. [J Clin Aesthet Dermatol 2019;12:34-50; Singap Med J 2021;62:568-573]

However, data from a cluster of eight public primary care clinics in Singapore show that nearly a third of adolescents and young adults did not receive acne-related medications and that one in three received oral antibiotics as monotherapy, according to investigators from SingHealth Polyclinics and SingHealth-Duke NUS Family Medicine Academic Clinical Program, Singapore, Singapore, led by Dr Aminath Shiwaza Moosa.

Additionally, nearly half of the youths received shorter antibiotics courses than recommended, the investigators noted.

The analysis included 2,700 youths (mean age at presentation 19.2 years, 56.1 percent male, 73.8 percent Chinese) with acne, of whom 69.7 percent received an acne-related medication. The top three prescribed medications were doxycycline (53.0 percent), acne cream (combination of sulfur, salicylic acid, and resorcinol; 35.0 percent), and benzoyl peroxide 5% gel (28.4 percent). [Front Med 2023;doi:10.3389/fmed.2023.1152391]

Overall, oral antibiotics were prescribed in 54.1 percent, with 33.5 percent receiving antibiotic monotherapy. Only 32.4 percent were prescribed oral antibiotics in combination with topical nonantibiotics.

For the 59.8 percent of youths who received antibiotics overall, the treatment duration was inappropriate, being either less than 6 weeks (54.3 percent) or more than 16 weeks (5.5 percent).

“While primary care physicians generally are familiar with the choice of oral antibiotics, the results suggest that [the physicians] seem less aware of [the medication’s] appropriate treatment duration. Inadequate antibiotic duration results in subinhibitory and subtherapeutic antibiotic concentrations, which promote the development of antibiotic resistance and frequent relapse,” Moosa and colleagues pointed out. [Front Microbiol 2011;2:1-17; Pharm Ther 2015;40:277]

It is also possible that the insufficient antibiotic duration reflected a lack of follow-up by patients, the investigators added.

“Guidelines suggest that patients should be reviewed after 6–8 weeks to assess treatment response and provide support. Thus, primary care physicians may prescribe a trial of medication for a shorter period to determine the patient’s tolerability and treatment response, particularly when incidences of side effects are high,” they said.

Follow-up and referral to specialist care

Meanwhile, longitudinal care appeared to be suboptimal in primary care, with only a minority (15.8 percent) of youths returning for at least one follow-up visit for their acne.

“Some patients in the current study may have had follow-up with other physicians or self-medicated with over-the-counter medications. Other patients may have their symptoms resolved with the initial treatment and did not consider a need for follow-up,” Mossa and colleagues noted.

In addition, young people often look at acne as a short-term, self-limiting condition of adolescence, the investigators added. This perception, in turn, influences the youth’s health and help-seeking behaviour for acne. Effective communication and shared decision-making are needed to increase patient engagement and subsequently improve adherence to medication regimens and promote continuity of care among young people. [Br J Dermatol 2020;183:349-356; BMJ Open 2021;11:e041794; Malaysian Fam Phys Off J Acad Fam Phys Malaysia 2021;16:2-7]

In terms of referral to specialist care, more than half of the youths in the current study were referred to specialists for further treatment. Moosa and colleagues also highlighted that only two individuals were referred to a psychiatrist, despite the well-recognized psychosocial impact of acne and associated mood disorders.

“These findings may reflect the stigma associated with mental disorder among local Asian adults,” they said. “Primary care physicians should pay attention to acne-associated psychosocial and mood disorders and manage the affected youths sensitively.”

Taken together, the present data suggest that “medical training and refresher course for acne clinical practice guidelines will empower primary care physicians to optimize acne treatment for young people,” according to the investigators.

The study was limited by the possible under-reporting of over-the-counter topical medications or adjuvant therapy topicals that the study participants might have been using, as well as the lack of data on certain medications that were unavailable in the drug formulary, such as oral isotretinoin. In addition, the study did not assess the severity of the acne, making it difficult to determine the appropriateness of the referral to specialist, the therapeutic choice, and the clinical outcome.

Finally, “the study was based on data collected from a public primary care service institute in Singapore and may not reflect the practice of the primary care physicians in the private sector,” the investigators acknowledged.