P.acnes bacteria

Antibiotics have been a mainstay of acne treatment for decades, despite the fact that it is well known that they never completely clear acne and must always be administered alongside topical treatments.1-6 They should only be used for a maximum of 3 months and thus, even when they do help reduce acne, offer only temporary relief. Oral antibiotics help kill acne bacteria (P. acnes) in people who are not resistant to their effects and also help reduce inflammation.7-10 Topical antibiotics do not kill acne bacteria, but do help reduce inflammation.11 Oral and topical antibiotics should never be used at the same time.

It has long been noted that antibiotics only work for about half of the population, and produce only moderate effectiveness.12 When they do help, they often only work for a short period of time. Acne tends to "get used to" both oral and topical antibiotic treatments and become resistant to it.7,13 It has become accepted practice that antibiotics must always be used in conjunction with other topical treatments because this helps reduce the chance for resistance, and because antibiotics do not work well enough on their own. As more research comes to light, it appears antibiotics are not helping clear acne as well as they once did. Researchers theorize this may be directly related to increased bacterial resistance across the population.13

A large study conducted by The British Journal of Dermatology studied 4274 acne patients and found that since 1991 an average of 51% of patients harbored colonies of resistant bacteria.14 Other studies have shown similar levels of antibiotic resistant acne bacteria.15-24 Interestingly, researchers are finding similar levels of resistance in both patients treated with antibiotics and those untreated as well, although those untreated have somewhat lower levels of resistance.25 This is because it is quite easy to pass antibiotic resistant strains of bacteria to people close to you.26

On a microscopic level, geneticists and biologists are finding multiple possible reasons why this occurs. The first reason is gene mutation within a bacteria cell.8,27-29 Bacteria have also been observed banding together and producing biofilms, a coating which slows penetration of antibacterial medication.10

All antibiotics are well known to create resistant strains of bacteria, and these resistant strains of bacteria now colonize upwards of half of the population.30-31 However, antibiotics have side effects beyond creating resistant bacteria. Oral antibiotics have more side effects than topical antibiotics and commonly cause gastrointestinal disorders (diarrhea, nausea, stomach cramps) and skin reactions. Depending on which antibiotic is prescribed, neurological problems (dizziness, vertigo) and photosensitivity (increased sensitivity to the sun) are also common. Less frequent side effects include permanent bluish-gray discoloration of the skin, permanent yellow/gray/brown discoloration of teeth, and sudden outbreaks of acne. In rare cases, oral antibiotics can cause auto-immune diseases (i.e. lupus), irreversible hearing loss, and heart problems which can lead to death.26,32-35

Topical antibiotics have fewer side effects but can also be absorbed through the skin and into the body and cause gastrointestinal problems. Upon application, topical antibiotics commonly cause peeling, skin irritation, including redness, dryness, and burning.26,32

Neither oral nor topical antibiotics should be used while attempting to become pregnant, while pregnant, or while breast feeding unless specifically directed by a physician.32

First, if your doctor attempts to prescribe antibiotics for your acne, ask her why she wants you to do this and if there are other options you can try instead. If you are prescribed antibiotics from a doctor, do not stop your course before speaking with her about it since this can make it more likely that you will create resistant strains of bacteria that will be with you for the rest of your life.

Also keep in mind that benzoyl peroxide kills 99.9% of bacteria almost instantly and when used correctly will reliably and completely clear acne. It will never cause antibiotic resistance or the potential for systemic or long-term side effects and can be used for as long as you need to use it until you naturally grow out of acne.

If you have severe, widespread and deeply scarring acne, Accutane (isotretinoin) is also an option, but comes with severe and potentially long-term side effects and must be entered into carefully alongside a trusted physician.

  I took oral and/or topical antibiotics for a year or so altogether during high school and college which is far longer than is prudent. Oral antibiotics did nothing for me and my skin did not improve nor get worse while on them. My skin worsened when I was put on clindamycin (clindamycin phosphate 1%), a topical antibiotic, but in retrospect this was likely because I stopped using benzoyl peroxide and instead started using clindamycin and sulfur, the two prescriptions my doctor wanted me to try. Antibiotics for me were like a bad joke—promising help but delivering nothing. It is more than likely that I now harbor colonies of resistant bacteria. Accutane cleared me up temporarily, but my acne returned post-Accutane. The Acne.org Regimen here at Acne.org finally got me cleared up for good."

  1. Costa CS, and Bagatin E. “Evidence on acne therapy.” Sao Paulo Medical Journal. 2013; 18(1): 193-197.
  2. Leyden JJ. "Antibiotic resistance in the topical treatment of acne vulgaris." Cutis. 2004 Jun;73(6 Suppl):6-10.
  3. Leyden JJ, Wortzman M, Baldwin EK. "Antibiotic-resistant Propionibacterium acnes suppressed by a benzoyl peroxide cleanser 6%." Cutis. 2008 Dec;82(6):417-21.
  4. Leyden JJ. "Effect of topical benzoyl peroxide/clindamycin versus topical clindamycin and vehicle in the reduction of Propionibacterium acnes." Cutis. 2002 Jun;69(6):475-80.
  5. Worret WI, Fluhr JW. "Acne therapy with topical benzoyl peroxide, antibiotics and azelaic acid." [Article in German] Journal of the German Society of Dermatology. 2006 Apr;4(4):293-300.
  6. Kircik LH. "Ther role of benzoyl peroxide in the new treatment paradigm for acne." Journal of Drugs in Dermatology. 2013; 12(6): s73-4.
  7. Leyden J, Levy S. "The development of antibiotic resistance in Propionibacterium acnes." Cutis. 2001 Feb;67(2 Suppl):21-4.
  8. Leyden, JJ. "Current issues in antimicrobial therapy for the treatment of acne." Journal of the European Academy of Dermatology and Venereology. 2001;15 Suppl 3:51-5.
  9. Ochsendorf F. "Systematic therapy of acne vulgaris." Journal of the German Society of Dermatology. 2006 Oct;4(10):828-41.
  10. Thevarajah S, Balkrishnan R, Camacho FT, Feldman SR, Fleischer AB Jr. "Trends in prescription of acne medication in the US: shift from antibiotic to non-antibiotic treatment." The Journal of Dermatologic Treatment. 2005;16(4)224-8.
  11. Dreno B. “Topical antibacterial therapy for acne vulgaris.” Drugs. 2004; 64(21): 2389-2397.
  12. Ozolins M, Eady EA, Avery A, Cunliffe WJ, O'Neill C, Simpson NB, Williams HC. "Randomised controlled multiple treatment comparison to provide a cost-effectiveness rationale for the selection of antimicrobial therapy in acne." Health Technology Assessment. 2005 Jan;9(1):iii-212.
  13. Eady AE, Cove JH, Layton AM. "Is antibiotic resistance in cutaneous propionibacteria clinically relevant? : implications of resistance for acne patients and prescribers." American Journal of Clinical Dermatology. 2003;4(12):813-31.
  14. Coates P, Vyakrnam S, Eady EA, Jones CE, Cove JH, Cunliffe WJ. "Prevalence of antibiotic-resistant propionibacteria on the skin of acne patients: 10-year surveillance data and snapshot distribution study." The British Journal of Dermatology. 2002 May;146(5):840-8.
  15. Luk NM, et al. "Antibiotic-resistant Propionibacterium acnes among acne patients in a regional skin centre in Hong Kong." Journal of the European Academy of Dermatology and Venereology. 2013; 27(1): 31-6.
  16. Nakase K, et al. “First report of high levels of clindamycin-resistant Propionibacterium acnes carrying erm(X) in Japanese patients with acne vulgaris.” The Journal of Dermatology. 2012; 39(9): 794-6.
  17. Narahari S, Gustafson CJ and Feldman SR. “What’s new in antibiotics in the management of acne?” Journal of the Italian Society of Dermatology. 2012; 147(3): 227-38.
  18. Chon SY, et al. “Antibiotic overuse and resistance in dermatology." Dermatology and Therapy. 2012; 25(1): 55-69.
  19. Toyne H, et al. “Propionibacterium acnes (P. acnes) resistance and antibiotic use in patients attending Australian general practice. Australasian Journal of Dermatology. 2012; 53(2): 106-11.
  20. Dreno B, Reynaud A, Moyse D, Habert H, Richet H. "Erythromycin-resistance of cutaneous bacterial flora in acne." European Journal of Dermatology. 2001 Nov-Dec;11(6):549-53.
  21. Nakase K, et al. "First report of high levels of clindamycin-resistant Propionibacterium acnes carrying erm(X) in Japanese patients with acne vulgarism." The Journal of Dermatology. 2012 39(9): 794-6.
  22. Luk NM, et al. "Antibiotic-resistant Propionibacterium acnes among acne patients in a regional skin centre in Hong Kong." Journal of the European Academy of Dermatology and Venereology. 2013 27(1): 31-6.
  23. Narahari S, Gustafson CJ and Feldman SR. "What's new in antibiotics in the management of acne?" Giornale Italiano di Dermatologia e Venereologia. 2012 147(3): 227-38.
  24. Chon SY, et al. "Antibiotic overuse and resistance in dermatology." Dermatology and Therapy. 2012; 25(1): 55-69.
  25. Del Rosso JQ, Leyden JJ, Thiboutot D, Webster GF. "Antibiotic use in acne vulgaris and rosacea: clinical considerations and resistance issues of significance to dermatologists." Cutis. 2008 Aug;82(2 Suppl 2):5-12.
  26. Oudenhoven MD, et al. “Adverse Effects of Acne Medications: Recognition and Management.” American Journal of Clinical Dermatology. 2015; 16(4): 231-242.
  27. Ishida N, Nakaminami H, Noguchi N, Kurokawa I, Nishijima S, Sasatsu M. "Antimicrobial susceptibilities of Propionibacterium acnes isolated from patients with acne vulgaris." Microbiology and Immunology. 2008 Dec;52(12):621-4.
  28. Ross JI, Snelling AM, Eady EA, Cove JH, Cunliffe WJ, Leyden JJ, Collignon P, Dr Kno B, Reynaud A, Fluhr J, Oshima S. "Phenotypic and genotypic characterization of antibiotic-resistant Propionibacterium acnes isolated from acne patients attending dermatology clinics in Europe, the U.S.A., Japan and Australia." The British Journal of Dermatology. 2001 Feb;144(2):339-46.
  29. Coates P, Vyakrnam S, Ravenscroft JC, Stables GI, Cunliffe WJ, Leyden JJ, Johnson J, Eady EA, Cove JH. "Efficacy of oral isotretinoin in the control of skin and nasal colonization by antibiotic-resistant propionibacteria in patients with acne." The British Journal of Dermatology. 2005 Dec;153(6):1126-36.
  30. Eady, EA, Gloor M, Leyden JJ. "Propionibacterium acnes resistance: A world wide problem." Dermatology. 2003;206:11-16.
  31. Ross JI, Snelling AM, Carnegie E, Coates P, Cunliffe WJ, Bettoli V, Tosti G, Katsambas A, Galvan Perez Del Pulgar JI, Rollman O, Torok L, Eady EA, Cove JH. "Antibiotic-resistant acne: lessons from Europe." The British Journal of Dermatology. 2003 Mar;148(3)467-78.
  32. Tripathi S V, et al. “Side effects of common acne treatments.” Expert Opinion on Drug Safety. 2013; 12: 39-51.
  33. McMullan BJ, and Mostaghim M. “Prescribing azithromycin.” Australian Prescriber Web. 2015; 38(3): 87-90.
  34. Turowski CB, and James WD. “The Efficacy and Safety of Amoxicillin, Trimethoprim-Sulfamethoxazole, and Spironolactone for Treatment-Resistant Acne Vulgaris.” Advances in Dermatology. 2007; 23: 155-163.
  35. Gillies M, et al. “Common harms from amoxicillin: a systematic review and meta-analysis of randomized placebo-controlled trials for any indication.” Canadian Medical Association Journal. 2015; 187(1): E22-E31.

Further Reading

  1. Bojar RA, Holland KT. "Acne and Propionibacterium acnes." Clinics in Dermatology. 2004 Sep-Oct;22(5):375-9.
  2. Del Rosso JQ. "Selection of therapy for acne vulgaris: balancing concerns about antibiotic resistance." Cutis. 2008 Nov;82(5 Suppl):12-6.
  3. Dr Kno B. "General antibiotic therapy in acne." [Article in French] La Revue du praticien. 2002 Apr 15;52(8):841-3.
  4. Garner SE, Eady EA, Popescu C, Newton J, Li WA. "Minocycline for acne vulgaris: efficacy and safety." Cochrane Database of Systematic Reviews. 2003;(1):CD002086.
  5. Leyden JJ, Del Rosso JQ, Webster GF. "Clinical considerations in the treatment of acne vulgaris and other inflammatory skin disorders: a status report." Dermatologic Clinics. 2009 Jan;27(1):1-15.
  6. Leyden JJ. "Effect of topical benzoyl peroxide/clindamycin versus topical clindamycin and vehicle in the reduction of Propionibacterium acnes." Cutis. 2002 Jun;69(6):475-80.
  7. McInturff JE, Wang SJ, Machleidt T, Lin TR, Oren A, Hertz CJ, Krutzik SR, Hart S, Zeh K, Anderson DH, Gallo RL, Modlin RL, Kim J. "Granulysin-derived peptides demonstrate antimicrobial and anti-inflammatory effects against Propionibacterium acnes." Journal of Investigative Dermatology. 2005 Aug;125(2):256-63.
  8. Mills O Jr, Thornsberry C, Cardin CW, Smiles KA, Leyden JJ. "Bacterial resistance and therapeutic outcome following three months of topical acne therapy with 2% erythromycin gel versus its vehicle." Acta Dermato-venereologica. 2002;82(4):260-5.
  9. Ochsendorf F. "Systematic therapy of acne vulgaris." Journal of the German Society of Dermatology. 2006 Oct;4(10):828-41.
  10. Oprica C, Emtestam L, Lapins J, Borglund E, Nyberg F, Stenlund K, Lundeberg L, Sillerstem E, Nord CE. "Antibiotic-resistant Propionibacterium acnes on the skin of patients with moderate to severe acne in Stockholm." Anaerobe. 2004 Jun;10(3):155-64.
  11. Qureshi A. "Survival of antibiotic-resistant Propionibacterium acnes in the environment." 14th European Congress of Clinical Microbiology and Infectious Diseases 2004, Prague, poster presentation. Abstract number: 902_p818. Accessed online on the 8th of April, 2009. link.
  12. Zouboulis CC, Piquero-Martin J. "Update and future of systemic acne treatment." Dermatology. 2003;206(1):37-53.