Submicrobial Dosing of Antibiotics in Dermatology: A Survey of Real World Practice Patterns

Dermatologists frequently employ the anti-inflammatory properties of tetracyclines and macrolides [1]. Submicrobial dosing (sD), doses that do not impact bacteria, demonstrates equal efficacy with reduced adverse effects in acne and rosacea [2-4]. We present a survey assessing how dermatologists view and utilise sD in acne, rosacea, bullous pemphigoid (BP), pemphigus vulgaris (PV) and hidradenitis suppurativa (HS). An anonymous survey (Appendix S1) was emailed to the Association of Professors of Dermatology listserv. Respondent data were grouped according to practice setting (academic, private) and number of years in practice (1–5, 5–10 and 10+ years) for analysis. Using R, ANOVA and t-tests compared years in practice and practice settings to responses. Fifty dermatologists responded (34 academic, 9 private and 7 unreported). Respondents with > 40% unanswered questions (n = 14) were excluded. t-tests comparing academic and private practice settings revealed no significant differences. ANOVAs comparing years in practice contained three groups: 1–5 years (n = 10), 5–10 years (n = 12) and 10+ years (n = 14). Respondents with 10+ years were less likely (p = 0.0019) to agree that ‘sD is comparable in efficacy to antimicrobial dosing’ compared to respondents with 1–5 years (Table S1). Inter-group prescribing patterns did not differ significantly. In another ANOVA analysis (Table S2), respondents were separated into two groups based on survey question 4 (‘if insurance coverage and cost were no issue when utilizing antibiotics in the treatment of acne, I would:’): Submicrobial supportive (n = 17) and submicrobial sceptical (n = 19). Supportive respondents were more likely to prescribe sD for acne (p < 0.0001), rosacea (p = 0.0473), BP (p = 0.0113) and HS (p = 0.0332) in actual practice. If insurance coverage/cost were no issue, they were also more likely to prescribe sD for rosacea (p = 0.0098), BP (p = 0.0029) and HS (p = 0.0426). They were more likely to attempt full dose antibiotics for acne (p = 0.0098) and HS (p = 0.0433) if a patient was unresponsive to sD and to agree that ‘sD is comparable in efficacy to antimicrobial dosing’ (p = 0.0016). In a level of agreement question (Q16_5), 27 dermatologists agreed or strongly agreed with the statement that ‘lack of research is a barrier to prescribing sD’, and two dermatologists commented on the lack of clinical and translational data regarding sD outside of rosacea. A randomised clinical trial (N = 91) found that sD was equally effective as antimicrobial dose but had fewer incidences of adverse effects for rosacea [5]. In the comments, one dermatologist reported starting with antimicrobial and then transitioning to sD, while another reported starting with full dose for acne and HS but then bridging to topical and laser therapies for long-term results. In our survey, dermatologists with more recent training were more likely to view sD as comparable to full dose. Dermatologists' view of sD influenced their prescribing patterns. Further research of sD beyond acne and rosacea may provide support for sD and advance antimicrobial stewardship in treating noninfectious diseases. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. The data that supports the findings of this study are available in the Supporting Information of this article. Appendix S1. Table S1. Table S2. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.