News & Perspective > American Journal of Clinical Dermatology

Oral Antibacterial Therapy for Acne Vulgaris

An Evidence-Based Review

Amanda Bienenfeld; Arielle R. Nagler; Seth J. Orlow

DISCLOSURES 

Am J Clin Dermatol. 2017;18(4):469-490

 

Abstract

Background To some degree, acne vulgaris affects nearly every individual worldwide. Oral antibiotic therapy is routinely prescribed for the treatment of moderate to severe inflammatory acne; however, long-term use of oral antibiotics for acne may have unintended consequences.

Objective The aim of this study was to provide a systematic evaluation of the scientific evidence on the efficacy and appropriate use of oral antibiotics in the treatment of acne.

Methods A systematic search of MEDLINE was conducted to identify randomized controlled clinical trials, systematic reviews, and meta-analyses evaluating the efficacy of oral antibiotics for acne. Overall, 41 articles that examined oral antibiotics compared with placebo, another oral therapy, topical therapy, alternate dose, or duration were included in this study.

Results Tetracyclines, macrolides, and trimethoprim/sulfamethoxazole are effective and safe in the treatment of moderate to severe inflammatory acne. Superior efficacy of one type or class of antibiotic could not be determined, therefore the choice of antibiotic is generally based on the side-effect profile. Although different dosing regimens have been studied, there is a lack of standardized comparator trials to determine optimal dosing and duration of each oral antibiotic used in acne. The combination of oral antibiotics with a topical therapy is superior to oral antibiotics alone.

Conclusion This article provides a systematic evaluation of the scientific evidence of the efficacy of oral antibiotics for acne. Due to heterogeneity in the design of the trials, there is insufficient evidence to support one type, dose, or duration of oral antibiotic over another in terms of efficacy; however, due to increasing resistance to antibiotics, dermatologists should heed consensus guidelines for their appropriate use.

Can Adolescent Obesity Increase Risk for Midlife Stroke?

Authors: Sue Hughes; CME Author:Laurie Barclay, MD;

CME Released: 7/28/2017

 MEDSCAPE CLINICAL BRIEFING

For unknown reasons, stroke incidence has been increasing among young adults, in tandem with the obesity epidemic. High body mass index (BMI) in young adulthood, but not in prepubertal childhood, is a risk factor for stroke in men. However, previous studies have been limited by the availability of only 1 BMI measurement, precluding separation of the effects on stroke risk of BMI at childhood and of BMI increase through puberty and adolescence.

The goal of the population-based BMI Epidemiology Study (BEST) in Gothenburg, Sweden, was to evaluate the contribution of prepubertal childhood BMI and BMI change through puberty and adolescence to risk for adult stroke in men.

• BMI increase through puberty and adolescence is a risk marker of adult stroke, based on findings from the BEST population-based study in Gothenberg, Sweden.
• Higher BMI increases during puberty may contribute to greater risk for adult stroke at least partly via increased blood pressure.
• Implications for the Healthcare Team: Avoiding excessive BMI increase during puberty may lower the risk for adult stroke; clinicians should consider monitoring adult blood pressure in men who had excessive BMI increase during puberty.
• An accompanying editorial highlights the exponential increase in obesity in adolescents, which may predict serious health consequences later in life.
• Because overweight children who normalized their BMI by age 20 years had no long-term increased risk for stroke, it is crucial that interventions target children and adolescents to prevent overweight and obesity in early adulthood.

Are all Penicillin Allergies in Children Real ?

Authors:Nicola M. Parry, DVM; CME Author: Charles P. Vega, MD
Medscape Clinical briefs 8/4/2017

Allergy to penicillin is 1 of the most common drug allergies encountered by clinicians, and the presence of penicillin allergy can significantly change prescribing patterns. This may result in the application of broad-spectrum antibiotics for common infections amenable to treatment with beta-lactam antibiotics.

The vast majority of patients with penicillin allergy never receive formal testing, in part because the gold standard for testing for penicillin allergy is laborious. 

• Standard testing for penicillin allergy begins with a percutaneous skin test, followed by a second test at the more sensitive intracutaneous layer, and concludes with an oral drug challenge. Previous research has found that more than 90% of adults with penicillin allergy presenting to the ED had a negative result on skin testing.
• The current study suggests a 17-item questionnaire completed by parents of children with a history of penicillin allergy can successfully identify children with a low risk for true allergy.
• Implications for the Healthcare Team: Every new entry added to a patient's list of medication allergies is usually present for a very long time. The current study suggests we should look at the list of medication allergies more critically to avoid limiting therapeutic options for patients.

Surviving a Stampede

BEIJING, Jan. 2 (Xinhuanet) -- What do you do, if faced with a stampede like situation as in Shanghai?

Scientists have found that the combined force of 7 to 8 adults can reach well over 1000 pounds. To avoid getting hurt, the best choice for you is to leave the crowd at the first available opportunity.

But if you find you are already trapped, here are some basic rules to follow if you are packed in big crowd of people.

First, stay balanced and steady. Try to stay steady on your feet and do not try to pick up anything on the ground, including your wallet, cellphone or shoes.

Second, follow the crowd in the direction that it moves in, in small steps. Do not try to go past others or push them.

Third, quickly find buildings nearby and use them as s solid support. Don't forget to raise your arms and make room for you to breathe. Be aware, glasses and windows are what you need to stay away from.

Last but not the least, if you do fall down, you need to stay calm, lay sideways, curl up your body, and raise your arms to cover your head.

These tips should help you avoid direct damage to your head and major organs.

Green Tea, Coffee May Guard Against Stroke

Medscape Medical News > Neurology

Megan Brooks

April 03, 2013

Green tea and coffee consumption may help protect against stroke, according to a large Japanese population-based study.

The study showed that people who drank green tea or coffee regularly had about a 20% lower risk for stroke than their peers who seldom drank these beverages.

"This is the first large-scale study to examine the combined effects of both green tea and coffee on stroke risks," Yoshihiro Kokubo, MD, PhD, head of the Department of Preventive Cardiology, National Cerebral and Cardiovascular Center in Osaka, said in a statement.

Their findings were published online March 14 in Stroke.

Inverse Link

The study involved 82,369 Japanese adults aged 45 to 65 years without cardiovascular disease or cancer at baseline who were followed for a mean of 13 years. "Green tea and coffee consumption was assessed by self-administered food-frequency questionnaire at baseline," Dr. Kokubo toldMedscape Medical News.

During more than 1 million person-years of follow-up, the researchers documented 3425 strokes (1964 cerebral infarctions, 1001 intracerebral hemorrhages, and 460 subarachnoid hemorrhages) and 910 coronary heart disease (CHD) events (489 definite myocardial infarctions and 28 sudden cardiac deaths).

In multivariate analysis, higher coffee and green tea consumption were inversely associated with risk for cardiovascular disease (CVD) and stroke.

For example, people who drank at least 1 cup of coffee daily had a 20% lower risk for any stroke (adjusted hazard ratio [aHR], 0.80; 95% confidence interval [CI], 0.72 - 0.90) compared with those who seldom drank coffee.

People who drank 2 to 3 cups of green tea daily had a 14% lower risk for any stroke (aHR, 0.86; 95% CI, 0.78 - 0.95), and those who consumed at least 4 cups had a 20% lower risk (aHR, 0.80; 95% CI, 0.73 - 0.89), compared with those who seldom drank green tea.

The risk reduction for intracerebral hemorrhage was 17% (aHR, 0.83; 95% CI, 0.68 - 1.02) with consumption of at least 1 cup of coffee daily and 23% (aHR, 0.77; 95% CI, 0.63 - 0.92) for 2 cups of green tea daily compared with rare consumption of either beverage.

There was no significant association between coffee and tea consumption and CHD, largely mirroring findings from other studies.

Experts Weigh In

Victoria J. Burley, PhD, senior lecturer in nutritional epidemiology, School of Food Science and Nutrition, University of Leeds, United Kingdom, who wasn't involved in the study, called it "very interesting."

She noted that "both high-fiber foods and these particular beverages may have anti-inflammatory properties. Whole grains, fruit and vegetables, and these beverages are all rich in polyphenols, which appear to have multiple potential actions on markers of CVD risk: blood pressure, glucose homeostasis, lipid metabolism, and so on."

"This appears to be a well-conducted study," Dr. Burley said, "with good power (plenty of cases), with long follow-up and a respectable method of assessing green tea and coffee intake (for these dietary aspects I think an FFQ [food-frequency questionnaire] is likely the best approach)."

She cautioned, however, that the intakes of green tea in this Japanese cohort "far exceed" usual consumption in western populations and that, conversely, intakes of coffee may generally be somewhat lower in Japan.

"The highest coffee intake category was 2-3 cups per day, which is not particularly high. Other studies (eg, conducted in Sweden) have reported elevated CVD risk in people with much higher intakes ( > 7 cups per day), so in setting their highest category this low these study authors may not have been able to pick up evidence of increased CVD risk with greater intakes," Dr. Burley said.

"Overall, it's encouraging data that suggest people who incorporate coffee and green tea in their diet may experience lower CVD risk in later life," she added.

Commenting on the coffee findings, Susanna C. Larsson, PhD, from the Unit of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden, found it "interesting that such a small amount as 1 cup of coffee per day reduces the risk of stroke by 20% (quite a large reduction in risk)."

"Otherwise, this Japanese study confirms results from studies conducted in the US and Europe showing an inverse association between coffee consumption and stroke risk. This study adds further support that moderate coffee consumption may lower the risk of stroke," said Dr. Larsson, who was not involved in the study.

The study was supported by Grants-in-Aid for Cancer Research and the Third-Term Comprehensive Ten-Year Strategy for Cancer Control from the Ministry of Health, Labor and Welfare of Japan. The authors, Dr. Burley, and Dr. Larsson have disclosed no relevant financial relationships.

Stroke. Published online March 14, 2013. Abstract

Fruit, Tea, and Wine Could Guard Against Type 2 Diabetes

Medscape Medical News

Lisa Nainggolan

January 20, 2014

A new study in healthy women suggests that consuming high levels of flavonoids, including compounds found in berries, tea, grapes, and wine, could potentially lower the risk of type 2 diabetes.

The study, published in the February issue of the Journal of Nutrition, indicates that greater intake of these dietary compounds is associated with lower insulin resistance and better blood glucose regulation. The researchers, led by Amy Jennings, PhD, from the department of nutrition, University of East Anglia, Norwich, United Kingdom, say their study is one of the first to examine consumption of different flavonoid subclasses and insulin resistance.

"We found that those who consumed plenty of anthocyanins and flavones had lower insulin resistance. So what we are seeing is that people who eat foods rich in these 2 compounds — such as berries, herbs, red grapes, wine — are less likely to develop the disease," said senior author Aedin Cassidy, PhD, also from the department of nutrition, University of East Anglia, in a statement.

Researchers also found that those who ate the most anthocyanins were least likely to suffer chronic inflammation, which is associated with diabetes, obesity, cardiovascular disease, and cancer. And those who consumed the most flavone compounds had improved levels of adiponectin, which helps regulate a number of metabolic processes, including glucose levels, Dr. Cassidy noted.

Importantly, the difference between the highest and lowest intakes of foods containing these compounds was small, consisting of just one portion of grapes or berries or a couple of oranges, say the authors. Also, the effects on insulin that were associated with high consumption of such foods was equivalent to those observed for other lifestyle factors, such as an hour's walk a day or low-fat diet for a year, they noted.

Nevertheless, Dr. Cassidy said it is not yet know exactly how much of one of these compounds is necessary to potentially reduce the risk of type 2 diabetes. "Dose–response trials are needed to ascertain optimal intakes for the potential reduction of type 2 diabetes risk," she and her colleagues stress.

One of the First Large Human Studies of Flavonoid Subclasses

Researchers note that a previous prospective study, published last year in the American Journal of Clinical Nutrition suggested a 15% reduction type 2 diabetes risk by comparing the highest and lowest quintiles of anthocyanin intake. However, the researchers emphasize that their current study is one of the first large-scale human trials to examine all subclasses of these powerful bioactive compounds to see how they might affect insulin resistance, blood glucose regulation, and inflammation.

The cross-sectional study was conducted in almost 2000 women aged 18 to 76 years from the Twins UK registry. Women who had high glucose levels were excluded. Participants completed a 131-item food-frequency questionnaire, from which flavonoid intakes were estimated using a United States Department of Agriculture database.

The researchers looked at the self-reported intake of 6 subclasses of flavonoids: flavanones, anthocyanins, flavan-3-ols, polymeric flavonoids, flavanols, and flavones.

In multivariable analyses, higher anthocyanin and flavone intakes were associated with significantly lower peripheral insulin resistance (homeostasis model assessment of insulin resistance; quintile 5 [Q5] to Q1 = 20.1, P-trend = .04 for anthocyanins and flavones), as a result of a decrease in insulin concentrations (Q5–Q1 = 20.7 mU/mL, P-trend = .02 anthocyanins; Q5–Q1 = 20.5 mU/mL, P-trend = .02 flavones).

Tea was the main source of overall flavonoid intake, with 4 foods contributing more than 10% of anthocyanin intake (grapes, pears, berries, and wine) and 3 foods making up more than 10% of flavone consumption (oranges, wine, and peppers).

Higher anthocyanin intake was also associated with lower C-reactive protein (hs-CRP) levels (Q5–Q1 = 20.3 mg/L, P-trend = .04), whereas those in the highest quintile of flavone intake had improved adiponectin levels (Q5–Q1 = 0.7 mg/L, P-trend = .01).

Higher intakes of both anthocyanins and flavones were associated with improvements in insulin resistance and hs-CRP, the researchers note.

No significant associations were observed for total or other flavonoid subclasses.

Findings Are Clinically Relevant, Easy to Achieve

Although these findings are from cross-sectional data and require confirmation, they are clinically relevant because of the 0.7-mU/mL difference in insulin observed between the top and bottom quintiles of anthocyanin intake, the researchers note.

The difference in anthocyanin intake between the top and bottom quintiles was 35 mg, which can be readily incorporated into the diet by consuming approximately one portion of grapes (78 g) or berries, such as strawberries (105 g), raspberries (90 g), blueberries (21 g), or blackberries (39 g).

Similarly, the difference in flavones between the top and bottom quintiles was 3.6 mg, equivalent to that found in approximately 2.5 oranges.

These results "are of public-health importance because the intakes associated with these findings are easily achievable through the habitual diet" and make a significant contribution to the knowledge base needed to refine the current fruit and vegetable dietary recommendations, the authors conclude.

The authors have reported no relevant financial relationships.

J Nutr. 2014;144. Abstract

Gout Guidelines From ACR Include New Drugs, Diet

Medscape Medical News

Janis C. Kelly

October 02, 2012
The ACR guidelines recommend treating patients with a xanthine oxidase inhibitor, such as allopurinol, as the first-line pharmacologic urate-lowering therapy approach. The recommended goal is to reduce serum urate to less than 6 mg/dL, and the initial allopurinol dosage should be no greater than 100 mg/d, the guidelines say. This should be followed by gradual increase of the maintenance dose, which can safely exceed 300 mg even in patients with chronic kidney disease.

"Clinicians often start allopurinol at doses that are too high but maintain allopurinol at doses that are too low," Dr. Terkeltaub said. "We give specific guidance on start low, go slow dose escalation."

To avoid allopurinol toxicity, the guidelines recommend considering HLA-B*5801 prescreening of patients at particularly high risk for severe adverse reaction to allopurinol (eg, Koreans with stage 3 or worse kidney disease and all patients of Han Chinese and Thai descent).

For CTGA, the guidelines recommend combination therapy, with 1 xanthine oxidase inhibitor (allopurinol or febuxostat) and 1 uricosuric agent, when target urate levels are not achieved. They advise using probenecid as an alternative first-line urate-lowering drug in the setting of contraindication or intolerance to at least 1 xanthine oxidase inhibitor (except in patients with creatinine clearance below 50 mL/min). They also recommend pegloticase in patients with severe gout disease who do not respond to standard, appropriately dosed urate-lowering therapy.

"We provide guidance for dose-escalation of urate-lowering therapy for specific case scenarios of mild, moderate, and severe disease including for patients with destructive joint disease that is chronic to their gout. These provide ways to assess the patient in an office setting on clinical findings alone, with serum uric acid. Pictorial representation of most severe patients should help identify who needs more intensive uric acid-lowering therapy," Dr. Terkeltaub said.

Acute Gout Requires Prompt Treatment

Part 2 of the guidelines covers therapy and prophylactic antiinflammatory treatment for acute gouty arthritis. These guidelines recommend initiating pharmacologic therapy within 24 hours of onset of acute gouty arthritis attack while continuing urate-lower therapy without interruption.

Nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids, or oral colchicine are the recommended first-line treatment for acute gout, and combinations of these medications can be used for severe or unresponsive cases.

To prevent the acute gout flares that may accompany the early stages of urate-lowering therapy, the guidelines recommend oral colchicine or low-dose NSAIDs as long as there is no medical contraindication or lack of tolerance.

Dr. Terkeltaub advised caution with colchicine dosing. "One of the major problems in quality of care is that people were getting drowned in colchicine for acute gout. We assessed the evidence and decided to go with the FDA [Food and Drug Administration]-approved regimen of low-dose colchicine for early acute gout flare. That is a major recommendation. When people get drowned in high doses of colchicine for a long time for acute gout, the rate of adverse events is quite high."

The recommendations were prepared during a 2-year project by an ACR task force panel that included 7 rheumatologists, 2 primary care physicians, a nephrologist, and a patient representative. The draft guidelines then went through 3 rounds of peer review, Dr. Terkeltaub said.

"I'd like to see better education of physicians and other primary caregivers, including nurse practitioners and physician assistants, and then better education of gout patients. If we only accomplish that, we'll have accomplished a lot. There has been a systematic failure of both quality of care and patient education in gout," Dr. Terkeltaub said.

Doug Campos-Outcalt, MD, scientific analyst for the American Academy of Family Physicians, reviewed the new guidelines for Medscape Medical News. Dr. Capos-Outcalt is chair of the Department of Family Medicine at the University of Arizona College of Medicine in Phoenix.

Dr. Campos-Outcalt said, "This is a reasonable, limited number of guidelines that are implementable. You don't like to see guidelines that have 50 recommendations. The ACR guidelines also present, from a family physician perspective, no major changes in standard-of-care." However, Dr. Campos-Outcalt suggested that a broader effort to disseminate the guidelines to primary care physicians will be needed because few of them regularly read the journal in which the guidelines appear.



Dr. Campos-Outcalt told Medscape Medical News that the guidelines seem reasonable but that before being influenced by them, he would like to take a closer look at the level of evidence each recommendation is based on. "We don't like to see recommendations based on low-level evidence," he said. Only about 20% of the ACR recommendations were based on top-quality "level A" evidence (supported by more than 1 randomized clinical trial or meta-analysis). About half of the recommendations were based on level C evidence (consensus opinion of experts, case studies, or standard of care).