The article highlights different educational and practice gaps in infectious diseases as they pertain to dermatology. These gaps include the use of antibiotics in relation to atopic dermatitis and acne vulgaris, treatment of skin and soft tissue infection, and diagnosis and treatment of onychomycosis. In addition, practice gaps related to use of imiquimod for molluscum contagiosum, risk of infections related to immunosuppressive medications and rates of vaccination, and the use of bedside diagnostics for diagnosing common infections were discussed.
Key points
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Infectious disease practice gaps in dermatology involve the inappropriate use of antibiotics in atopic dermatitis and acne vulgaris, in the treatment of skin and soft tissue infections, and onychomycosis.
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The use of imiquimod with molluscum contagiosum has been demonstrated as ineffective in unpublished clinical trials and has potential risk for adverse effects.
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Risk of infections related to biological immunosuppressive medications and rates of vaccination are important considerations when choosing therapy and for dermatology education and practice today.
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Bedside diagnostics for diagnosing common infections is an essential component of dermatology training that can be helpful in future practice.
Introduction
Infectious disease is an essential part of dermatology education with infections being a common presenting sign to dermatologists among all age groups. Furthermore, a recent investigation into outpatient prescribing of antibiotics revealed that dermatologists prescribe more antibiotics per provider in the outpatient setting than any other specialty with an average of 724 antibiotic prescriptions per provider per year. Increased attention and focus on antimicrobial stewardship is necessary in order to help minimize unnecessary antimicrobial resistance. Prolonged duration and increased use of antibiotics in patients increase the likelihood of colonization with resistant organisms.
This article highlights different educational and practice gaps in infectious diseases as they pertain to dermatology. These gaps include the use of antibiotics in relation to atopic dermatitis and acne vulgaris, treatment of skin and soft tissue infection (SSTI), and diagnosing and treating onychomycosis. In addition, the use of imiquimod for molluscum contagiosum, risk of infections related to immunosuppressive medications and rates of vaccination, and the use of bedside diagnostics for diagnosing common infections were explored.
Introduction
Infectious disease is an essential part of dermatology education with infections being a common presenting sign to dermatologists among all age groups. Furthermore, a recent investigation into outpatient prescribing of antibiotics revealed that dermatologists prescribe more antibiotics per provider in the outpatient setting than any other specialty with an average of 724 antibiotic prescriptions per provider per year. Increased attention and focus on antimicrobial stewardship is necessary in order to help minimize unnecessary antimicrobial resistance. Prolonged duration and increased use of antibiotics in patients increase the likelihood of colonization with resistant organisms.
This article highlights different educational and practice gaps in infectious diseases as they pertain to dermatology. These gaps include the use of antibiotics in relation to atopic dermatitis and acne vulgaris, treatment of skin and soft tissue infection (SSTI), and diagnosing and treating onychomycosis. In addition, the use of imiquimod for molluscum contagiosum, risk of infections related to immunosuppressive medications and rates of vaccination, and the use of bedside diagnostics for diagnosing common infections were explored.
Oral antibiotics for treatment of atopic dermatitis
Background
Atopic individuals are predisposed to skin infections secondary to a compromised physical barrier, diminished immune regulation, and impaired antimicrobial peptide production. Staphylococcus aureus colonization occurs in greater than 90% of patients and triggers multiple inflammatory cascades. Recent studies have shown that S. aureus may be not only a complication of atopic dermatitis but also an important factor in the initiation of inflammation. Besides bleach baths and intranasal mupirocin, no other topical antistaphylococcal treatment has been shown to be clinically beneficial. Furthermore, the evidence to support the use of oral antibiotics is lacking, and quantitative bacterial changes do not translate into clinical improvement. Systemic antibiotics reduce the colony count of Staphylococcus spp., but antigens may persist for prolonged periods and counts may return to previous levels within days to weeks. Based on a recent investigation, improvement is seen in children with methicillin-resistant S. aureus (MRSA) when treated with cephalexin and other standard therapies, even when the organism was resistant to the antibiotic, suggesting that systemic antibiotics may not be necessary in secondarily impetiginized atopic dermatitis. MRSA is also reported to be more problematic in children with multiple antibiotic exposures. A rising incidence of MRSA has also been noted in a pediatric population and is associated with antibiotic use. Gong and colleagues also noted that an antibiotic-corticosteroid combination and corticosteroid alone both gave adequate therapeutic effect in eczema and in atopic dermatitis, and both reduced colonization by S. aureus .
Best Practice
Antimicrobial therapy should only be considered in patients with atopic dermatitis when there is clinical evidence of infection and should be used in conjunction with other standard treatments.
Current Practice
The current practice may include the use oral and topical antibiotics as a standard treatment in patients with moderate to severe atopic dermatitis.
Practice Gap
The practice gap includes the overuse of topical and systemic antimicrobial therapy in atopic dermatitis with an underemphasis of other standard therapies, including topical corticosteroids, when there is no evidence of secondary impetiginization.
Educational Gap
The educational gap includes the use of antibiotics in atopic dermatitis without clinical evidence of infection (medical knowledge, system-based practice, patient care, professionalism).
Barriers
Barriers include provider beliefs that topical and systemic antibiotics are necessary in moderate to severe atopic dermatitis and a hesitancy to use topical steroids when there is evidence of secondary impetiginization.
Treatment of common skin and soft tissue infections in the outpatient dermatology practice
Background
Common SSTIs resulting from Staphylococcal spp. and Streptococcal spp. infection include furuncles, carbuncles, abscesses, and cellulitis. Antimicrobial selection and duration of treatment often vary by provider. The Infectious Disease Society of America has provided clear guidelines to assist in diagnosis and treatment. Guidelines indicate that incision and drainage alone are considered therapeutic for uncomplicated furuncles or abscesses, although antibiotics often are prescribed. For practicing dermatologists, knowledge of this practice is important because bacterial infections may comprise 20% of any dermatology practice.
Best Practice
Warm compresses with consideration of incision and drainage is recommended for uncomplicated furuncles or abscesses. Culture should be obtained with incision and drainage of a suspected furuncle and drainage of other purulent lesions. Systemic antimicrobial therapy is recommended with associated cellulitis, comorbidities, systemic signs of infection, or inadequate response to therapy. Systemic antimicrobials and culture are not necessary with inflamed epidermal inclusion cysts. For cellulitis, if treatment is indicated in the outpatient setting, therapy for purulent cellulites should be directed toward MRSA. In nonpurulent cellulitis, therapy should be directed to β-hemolytic Streptococci spp. and methicillin-sensitive S. aureus (MSSA). Recommended duration of antimicrobial therapy is 5 to 6 days with longer courses if infection has not improved ( Table 1 ).
| Disease | Organism | Primary Antibiotics | Duration of Therapy | Practice/Educational Gaps |
|---|---|---|---|---|
| Acne | P acnes | Tetracyclines, macrolides, topical clindamycin | 3–6 mo | Extended durations, use of nonrecommended antibiotics |
| Atopic dermatitis | S. aureus | Bleach baths, intranasal mupirocin | — | Routine use of oral antimicrobial therapy |
| Impetigo | S. aureus/S pyogenes | Mupirocin, retapamulin, cephalexin, dicloxacillin, clindamycin, amoxicillin-clavulanate | Topical therapy: 5 d Oral therapy: 7 d | Extended durations |
| MSSA SSTI | S. aureus | Nafcillin, oxacillin, cefazolin, clindamycin, cephalexin, doxycycline, minocycline, trimethoprim-sulfamethoxazole | 5 d in uncomplicated and if improving | Extended durations, broad spectrum antibiotics |
| MRSA SSTI | S. aureus | Vancomycin, linezolid, clindamycin, daptomycin, ceftaroline, doxycycline, minocycline, trimethoprim-sulfamethoxazole | 5 d in uncomplicated and if improving | — |
| Nonpurulent SSTI | Streptococcal | Penicillin, clindamycin, nafcillin, cefazolin, penicillin VK, cephalexin | 5 d in uncomplicated and if improving | Extended durations, difficulty in distinguishing purulent from nonpurulent, therapy directed at Staphylococcus spp. |
| Necrotizing infections | S pyogenes, S. aureus, Clostridium perfringens, V vulnificus, A hydrophilia |
| — | Essential to recognize signs and symptoms of necrotizing infections |
Current Practice
Current practice may include using antibiotics in the treatment of uncomplicated furuncles and extended and broad-spectrum therapy in uncomplicated cellulitis.
Practice Gap
The practice gap includes the overuse of systemic antimicrobials in settings where antimicrobial therapy is not indicated or the duration could be limited to 5 to 6 days.
Educational Gap
The educational gap includes the use of systemic antimicrobials in uncomplicated furuncles, inflamed epidermal inclusion cysts, and extended duration therapy for uncomplicated infections (medical knowledge, system-based practice, patient care, professionalism).
Barriers
Barriers include a reluctance to decrease the duration of antimicrobial therapy; current practices of routine use of antimicrobial therapy with inflamed epidermoid cysts; and clinical uncertainty regarding purulent versus nonpurulent cellulitis.
Antibiotic use in acne and proposed course
Background
Acne is a disease of the pilosebaceous unit that affects almost all people aged 15 to 17 years and is moderate to severe in approximately 15% to 20%. There is notable variation in therapeutic regimens with numerous treatment options available including topical and oral antibiotics. In a recent survey of pediatricians, almost one-third of providers self-rated knowledge of and confidence in prescribing according to the guidelines as ‘‘poor.” After attending an educational session, significantly more providers selected a regimen for moderate acne that used retinoids and benzoyl peroxide. Furthermore, although 6% of providers inappropriately used antibiotics preintervention, no providers made these errors at 3 months. Topical antibiotics and benzoyl peroxide are indicated in patients with mild to moderate inflammatory acne with systemic antibiotics reserved for moderate to severe acne. Systemic antibiotics exhibit their effects via inhibition of bacterial lipase, downregulating inflammatory cytokines, preventing neutrophil chemotaxis, and inhibiting matrix metalloproteinases. There is no conclusive evidence that oral antibiotics are more effective than topical preparations for mild to moderate facial acne. Furthermore, antibiotics are frequently prescribed without topical retinoid therapy, possibility as a result of tolerability or issues related to cost and insurance coverage ; this leads to prolonged duration of antimicrobial therapy and decreased efficacy of treatment.
Best Practice
Choice of antibiotic therapy should be based on side-effect profile, cost, and antibiotic-resistance profiles with preferred agents being tetracycline and derivatives. Published guidelines suggest oral antibiotic courses should be limited to 3 to 6 months and discontinued if an individual does not respond. There is no evidence that increasing dose or frequency increases efficacy. Antibiotics should not be used as monotherapy and should be combined with topical retinoids and benzoyl peroxide. Finally, concomitant use of oral and topical therapy with chemically dissimilar antibiotics should be avoided.
Current Practice
In a recent study comparing the duration of oral antibiotic use in acne with recent guidelines, it was shown that the average course duration was 129 days, and most courses were less than 9 months. Although duration of antibiotic appears to be decreasing, many courses still exceeded 6 months, leaving an opportunity for reduced antibiotic use and potential cost savings. Furthermore, topical and oral antibiotics are often prescribed as monotherapy, without concomitant topical retinoid, which contributes to prolonged durations.
Practice and Educational Gap
The practice and educational gap includes the extended courses of antibiotics (>6 months) and use of antibiotics without the use of a concomitant retinoid in acne vulgaris (medical knowledge, system-based practice, patient care, professionalism).
Barriers
Barriers include a patient and provider reluctance to discontinue antibiotic therapy, worsening of acne off of antimicrobial therapy, and intolerance to topical retinoid therapy.
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