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Antibiotics for acne

Everything You Need to Know
About Acne and Antibiotics

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A top expert explains when—and how—antibiotics can help clear your skin.

Sure, antibiotics are a good option for treating sinus infections and strep throat, but they can also be an invaluable tool when it comes to combating acne. With both topical and oral antibiotic options available, there’s also a wide range of ways to reap their benefits. That being said, using antibiotics as an acne treatment isn’t nearly as simple or straightforward as it may seem. So, we enlisted the help of dermatologist Julie Harper, M.D., founding director of the American Acne and Rosacea Society and an Acne Store advisory board, who’s giving us the lowdown on antibiotics and acne.

Q: Why are antibiotics a good option for treating acne?

A: Antibiotics address two of the four components that contribute to acne: They can help combat Cutibacterium acnes, or C acnes, the strain of bacteria associated with acne, and they also have an anti-inflammatory effect.

"You do have to be patient with antibiotics, so don’t get discouraged if you don’t see results immediately."

Q: Who is a good candidate for antibiotics as an acne treatment?

A: Well, all acne has an inflammatory component to it, but typically we think of antibiotics for acne that’s characterized by more inflamed red pimples and pustules than, say, blackheads. In other words, if a teenage patient comes in with blackheads and some little bumps on his or her T-zone, that’s not when I’m thinking about prescribing antibiotic. These medications are also used for deeper, more cystic or nodular acne, which we often see in adult women, typically on the lower face.

Q: What types of oral antibiotics are good for treating acne?

A: There are three oral, or systemic, antibiotics used to treat acne, all part of the tetracycline family: doxycycline, minocycline, and sarecycline. The first two have been out since the late 1960s or early 1970s. We’ve used them for a long time, have good data on their effects, and know they’re safe. However, these are both broad-spectrum antibiotics. That means that along with hitting the bacteria that’s contributing to acne, they’re also affecting the bacteria in your gut, which is part of the reason why we need to be careful when prescribing antibiotics for acne. Sarecycline is a recent favorite. It’s a newer option that has a narrower spectrum in terms of the bacteria it targets, so it doesn’t do quite as much collateral damage on the normal bacteria in the gut.

Q: What about topical antibiotics for acne?

A: As far as topical options go, clindamycin is the one that is most often prescribed. However, when you’re using a topical antibiotic, bacterial resistance can develop pretty quickly. This is why we usually prescribe a topical product that combines clindamycin with benzoyl peroxide. This kills bacteria in a different way and helps lessen the development of bacterial resistance. Topical minocycline is another, newer option that’s only been around for a few years. It’s formulated in an oily base, which is different from other topical acne products, but it has been well-received and delivers high levels of the antibiotic into the skin, potentially with less bacterial resistance (this point is still up for discussion in the medical community).

Q: How do you determine whether to prescribe an oral or topical antibiotic?

A: This is really a question to discuss with your doctor, as is which specific antibiotic to go with once you decide whether oral or topical is best. I don’t love to use oral and topical antibiotics at the same time, so usually it’s one or the other. Typically, if the acne is more severe, that might push me towards an oral option, but the topical minocycline also works well for that.

Ultimately the patient really does have a voice in this decision, because you have to consider compliance as well. There are some people who don’t want to take a pill, and there are some people who don’t want to rub products onto their face. Either way, this is something to discuss with your dermatologist, who will also talk about other topical products to work into your routine. For example, if you’re taking an oral antibiotic, you may also use a benzoyl peroxide topically. And if you’re using a topical antibiotic in the morning, you may also need a topical retinoid at night.

Q: Are there side effects associated with taking antibiotics for acne?

A: The short answer is yes, though more so with the oral or systemic options. The side effects of doxycycline are increased sun sensitivity—you must be extra diligent with sunscreen application while you’re taking it—and gastrointestinal issues. Minocycline can cause dizziness, while sarecycline can cause nausea in a very small percentage of people. Regardless, we worry most about the development of bacterial resistance, which is why we need to be good stewards when we prescribe them and make sure people aren’t taking them for long periods of time. 

Q: On that note, how do you dose oral antibiotics for acne and how long do people take them for?

A: It depends on the antibiotic—minocycline is weight based, as is sarecycline. We aim for about one to 1.5 milligrams per kilogram per day. Doxycycline isn’t weight-based; the standard dose is about 100 milligrams per day or twice daily. Regardless, I don’t like people to stay on these for more than three or four months at a time. You can stay on topical antibiotics for a bit longer than that, but if an antibiotic doesn’t clear up acne after a few months, it’s time to change things up.

Q: What happens if the antibiotics don’t clear up my acne? 

A: You do have to be patient with antibiotics, so don’t get discouraged if you don’t see results immediately. The increments in acne improvement are pretty small, usually about 40 to 50 percent improvement after eight weeks, and then 80 to 90 percent improvement after 16 weeks. However, with the oral antibiotics, if one three-to-four-month course hasn’t gotten you to where you want to be, I’m not simply going to try a different antibiotic. I don’t think there’s a lot of wisdom in terms of that, because there’s really not that much to differentiate their effect. If an oral antibiotic hasn’t worked after a few months, I’m going to suggest trying hormonal therapy or Accutane—something other than antibiotics. 

Julie Harper, M.D.

Dr. Julie Harper is a member of the Acne Store Board of Dermatologists and the owner of The Dermatology and Skin Care Center of Birmingham in Birmingham AL. She also served on the faculty at the University of Alabama-Birmingham as an Assistant Professor of Dermatology and was promoted to Associate Professor during her time there. She is a founding director of the American Acne and Rosacea Society and is the society’s immediate past president. She has served on the American Academy of Dermatology’s task force assigned to develop guidelines for the management of acne, which were published in 2016. Dr. Harper is also a former president of the Alabama Dermatologic Society. She has written and spoken on the subjects of acne and rosacea extensively.

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