All antibiotics are associated with individual side-effects that are well documented and must be considered. The potential systemic side-effects are theoretically reduced by topical application as usually less than 10% absorption occurs.175 However, prolonged and extensive application to the skin, which is a good medium for gene exchange amongst bacteria,176 may facilitate the spread of resistance.177 This has implications for clinical practice as P. acnes resistance is associated with poor therapeutic response to antibiotics. Of greater importance, however, is the spread of resistance to other microorganisms and there have been calls for policies to restrict the prescribing of antibiotics in acne.65,178 One systematic review examined P. acnes resistance to systematic antibiotics.179 The 12 articles examined demonstrated an overall increase in P. acnes resistance from 20% in 1978 to 62% in 1996. Resistance was most commonly reported to erythromycin, clindamycin, tetracycline, doxycycline and trimethoprim; resistance to minocycline was rare. The authors concluded that long-term rotational antibiotics are inappropriate and that treatment should be adjusted when therapeutic failure becomes evident.

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