The use of antibiotics to treat inflammatory skin conditions like acne and rosacea is decreasing over time, but there has been an increase in prescriptions associated with dermatologic surgical procedures. Those are the findings of a new study from researchers at the Perelman School of Medicine at the University of Pennsylvania, who say the results show some encouraging signs in the effort for greater antibiotic stewardship in dermatology, while also pointing to a clear need for further research. The study was published Monday in JAMA Dermatology.

Dermatologists prescribe more antibiotics per provider than any other specialty—more than 7.1 million prescriptions per year. That number is further complicated by the fact that many patients, such as those taking antibiotics for acne, can stay on the drugs for extended periods of time, as opposed to other antibiotic uses that may only involve a 7- or 10-day course. The more antibiotics are used, the more the issue they are treating will build resistance, meaning the drugs become less and less effective over time until they eventually stop working altogether. That reality has led to a renewed focus on stewardship across all fields of medicine, but dermatology has a particular onus given the field’s sheer volume of prescriptions.

“To track our field’s efforts, we wanted to know two things: In what settings do dermatologists prescribe antibiotics most frequently, and how is this use changing over time?” said the study’s lead author John Barbieri, MD, Dermatology Research Fellow at Penn. David J. Margolis, MD, PhD, a professor of dermatology, was the study’s senior author.

To answer both questions, researchers examined a commercial claims database of privately insured patients in the US and looked at data from 2008 through 2016. During that time, overall dermatologic antibiotic prescriptions went from 3.36 per 100 visits to 2.13 per 100—which translates to about 500,000 fewer antibiotic prescriptions each year. The drop was especially noticeable in patients taking extended courses of antibiotics, which saw a 53.2% decrease from 2008 to 2016. This includes a 28.1% reduction in antibiotic prescriptions for acne.

However, during the same window, prescriptions for short courses of antibiotics actually increased. This was particularly driven by prescriptions associated with a surgical procedure, in which prescriptions increased 69.6%, from 3.92 prescriptions per 100 visits to 6.65 per 100. Prescribing associated with the diagnosis of cysts also went up 35.3%.

“Overall, our findings are hopefully a sign that we’re making progress, but we need to evaluate how we can optimize the use of antibiotics in dermatologic surgery,” Barbieri said. He noted that further studies will seek to better characterize the value of antibiotics in a surgical setting to figure out which patients can benefit from them the most.

The study also found that while prescription rates are down overall, the duration and the type of antibiotic are both largely unchanged. In other words, for patients who are still treated with antibiotics, the usage is the same, even if it’s less common.

"This may be a sign that treatment guidelines have raised awareness about overuse, though it’s also noteworthy that there are biologic and other alternate treatments that give patients more options than they’ve ever had before,” Barbieri said.