Are Antibiotics a Good Idea for the Treatment of Acne?

Antibiotics Come with Many Side Effects, so Is There a Reason to Use Them?

Are Antibiotics a Good Idea for the Treatment of Acne?

Article Summary

Antibiotics can sometimes be somewhat effective in treating acne. However, there are several problems with using antibiotics to treat acne:

  • Oftentimes, antibiotics fail to work at all. When they do work, there are limits to the efficacy of antibiotics, and other, safer medications can be more effective.
  • Even when they work to some degree, the benefits are temporary since antibiotics should not be prescribed for longer than 3 months. This leaves the user with only temporary and partial relief.
  • Antibiotics can cause a wide variety of side effects that range from uncomfortable to life-threatening.
  • Treatment with antibiotics, especially over long periods of time, leads to antibiotic resistance, and this resistance is becoming a worldwide problem that threatens to undermine our ability to treat bacterial infections at all in the future. This could lead to people dying from even simple bacterial infections that we now routinely treat with antibiotics.
  • Even though scientists recommend limiting antibiotic use to severe acne and to short courses of treatment, many doctors prescribe antibiotics for less severe acne and for long periods of time. These treatment practices contribute to the problem of antibiotic resistance.

Antibiotics are powerful medicines that can save lives when used appropriately for bacterial infections. They may have a legitimate role in acne treatment in the short term in some cases, but they should be drugs of last resort, not the first options used. And when they are necessary, they should be used sparingly and only for short periods of time.

Special Note: If your doctor prescribes an antibiotic to treat your acne, do not simply accept it without question. Ask your doctor about side effects and about other options instead of antibiotics. If you do decide to use antibiotics, never use them for more than three months and always administer them on time and complete the entire prescribed course, because skipping doses or stopping too soon increases the chances of developing resistant bacteria. Before considering antibiotics, always try other topical medications such as benzoyl peroxide first, and only use antibiotics if these other medications do not work.

Benefits vs. Risks: Are Antibiotics a Good Treatment for Acne?

Doctors often prescribe both topical and oral antibiotics to treat acne, especially severe acne. Antibiotic medications are sometimes helpful in treating acne, but they also have many side effects that range from mild skin irritation and stomach upset to severe neurological problems and life-threatening diarrhea. Topical and oral antibiotics should be prescribed for a maximum of three (3) months. And even though they can sometimes be somewhat effective, results are only temporary. 
 

Side Effects of Oral and Topical Antibiotics for Acne



Furthermore, while antibiotics can be useful in acne treatment, there is no evidence that they are any more effective than other acne treatments, such as benzoyl peroxide or oral contraceptives. There is also evidence that antibiotics sometimes fail to work at all. Therefore, it is important that acne patients try other options first.
 

Antibiotic Resistance in Bacteria



Treatment with antibiotics, especially over longer periods of time, can also lead to a phenomenon called antibiotic resistance. Antibiotic resistance means that bacteria become immune to the effects of antibiotics over time, and eventually the antibiotics can no longer kill the bacteria. Antibiotic resistance is a serious global problem, because:

  • When bacteria become resistant to an antibiotic, that antibiotic becomes less effective and less able to treat the condition for which it was prescribed as well as for other bacterial conditions. This applies to both the person taking the antibiotic as well as the population at large.
  • Bacteria can share their genes with each other and transfer antibiotic resistance from one strain of bacteria to another.
  • Ultimately, antibiotic resistance could result in many types of bacteria becoming resistant to all antibiotic medications. This means that doctors may eventually be unable to treat bacterial infections, and people may die from even common bacterial diseases such as strep throat, as people did before antibiotics were developed.

Given the potentially severe side effects of antibiotics, the lack of evidence for their superiority over other medications, the fact that they should only be used for three months and thus results are temporary, and the dangers of antibiotic resistance, is there a reason to use them?


How Effective Are Antibiotics and How Do They Compare with Other Medications?

The antibiotics used to treat acne fall into two broad categories:

  1. Oral antibiotics, which are taken by mouth. Oral antibiotics are systemic medications, meaning that they have effects throughout the body.
  2. Topical antibiotics, which are applied to the skin. Topical antibiotics work locally, meaning that they affect the area of skin to which they are applied.

Oral Antibiotics

Doctors frequently prescribe oral antibiotics to treat moderate to severe acne. The most commonly prescribed oral antibiotics for acne are:

  • Minocycline
  • Doxycycline
  • Tetracycline
  • Erythromycin
     
Prescription Antibiotic Pill Bottle
 



Let's have a look at some articles and studies that show us that, while antibiotics are at least somewhat effective at times, sometimes they fail to work, and other options may be better: 

Journal of the American Academy of Dermatology (JAAD)

Doctors and scientists agree that oral antibiotics can be at least somewhat effective in treating acne. According to a 2007 article in the Journal of the American Academy of Dermatology, “Antibiotics have been widely used for many years in the management of acne. There is evidence to support the use of tetracycline, doxycycline, minocycline, erythromycin, trimethoprim-sulfamethoxazole, trimethoprim, and azithromycin…[and] Systemic antibiotics are a standard of care in the management of moderate and severe acne and treatment-resistant forms of inflammatory acne.”1

Journal of the American Academy of Dermatology (JAAD)

Scientists consider minocycline to be the most effective oral antibiotic for acne, and doxycycline to be the next most effective. A 2007 article in the Journal of the American Academy of Dermatology noted, “Doxycycline and minocycline are more effective than tetracycline, and there is evidence that minocycline is superior to doxycycline in reducing P. acnes [bacteria associated with acne].”1

Family Practice Journal

A 2011 review in The Journal of Family Practice found that doxycycline reduced acne lesions by about 50%. The authors noted, “A 2003 randomized, double-blind, controlled trial of 51 patients demonstrated that a subantimicrobial dose of doxycycline (20 mg orally twice a day) reduced comedonal lesions by 53.2%...and inflammatory lesions by 50.1%”2

Iranian Journal of Dermatology

A 12-week 2012 study in the Iranian Journal of Dermatology compared the efficacy of doxycycline and azithromycin (a less frequently prescribed antibiotic for acne) administered along with the topical retinoid medication tretinoin. This study found doxycycline and azithromycin to be equally effective, with between 40% and 67% of patients showing a greater than 80% reduction in acne lesions. However, since the patients in the study were also treated with tretinoin at the same time as the antibiotics, it is impossible to determine which medication improved their acne.3

Journal of the American Academy of Dermatology (JAAD)

A 2014 study in the Journal of the American Academy of Dermatology compared the efficacy of oral contraceptives and oral antibiotics for treating acne in females. This study found that antibiotics were more effective at reducing acne lesions in the first three months of treatment, but by six months of treatment, oral contraceptives were equally effective. The authors noted, “Although antibiotics may be superior at 3 months, [oral contraceptives] are equivalent to antibiotics at 6 months in reducing acne lesions and, thus, may be a better first-line alternative to systemic antibiotics for long-term acne management in women.”4 

Journal of the American Academy of Dermatology (JAAD)

According to a 2015 study in the Journal of the American Academy of Dermatology, in a significant number of patients with severe acne who are initially prescribed oral antibiotics, the antibiotics fail to work. Many patients with severe acne are prescribed oral antibiotics and eventually have to change to isotretinoin due to lack of efficacy.5

 

Quote Regarding Antibiotic Efficacy for Acne



Topical Antibiotics

Doctors also frequently prescribe topical antibiotics to treat acne. The most commonly prescribed topical antibiotics for treating acne are:

  • Clindamycin
  • Erythromycin
     
Prescription Topical Antibiotic Tube
 

Let's look at a few articles and studies that show that topical antibiotics also work to some degree in some people, but that other medications can work better: 

Journal of the American Academy of Dermatology (JAAD)

A 2007 article in the Journal of the American Academy of Dermatology noted, “The value of topical antibiotics in the treatment of acne has been investigated in many clinical trials. Both erythromycin and clindamycin have been demonstrated to be effective and are well tolerated.1

Journal of the European Academy of Dermatology and Venereology (JEADV)

Both clindamycin and erythromycin are at least moderately effective in treating acne. Both medications can reduce the number of inflammatory lesions by about 40–60%. According to a 2015 article in the Journal of the European Academy of Dermatology, “Clinical data show that erythromycin reduced the inflammatory lesion count by between 40–60%. Clindamycin applied for 12 weeks provided similar results.”6

Journal of the European Academy of Dermatology and Venereology (JEADV)

The same 2015 article in the Journal of the European Academy of Dermatology noted that topical benzoyl peroxide was just as effective as antibiotics for inflammatory lesions and even more effective for non-inflammatory lesions. The authors stated, “After 3 months of treatment, [benzoyl peroxide] was similar to clindamycin in reducing the number of inflammatory lesions and reduced the non-inflammatory lesion count by 30% compared to 9% with clindamycin. Similar results were obtained when compared to erythromycin.”6


Doctors almost always prescribe topical antibiotics with benzoyl peroxide or one of the available topical retinoids such as tretinoin in order to reduce the antibiotic resistance that occurs with antibiotic use. This is especially true of erythromycin and clindamycin since they cannot be used as a single therapy due to their high potential of causing antibiotic resistance.1
 

Resistance Potential of Antibiotics Used for Acne
 


Here is an article explaining that combining other medications with topical antibiotics is superior than either used alone:

journal-1.jpg.6a0db7c21175f427c9f9197cd1

According to a 2007 article in the Journal of the American Academy of Dermatology, “A combination of topical retinoids and topical erythromycin or clindamycin is more effective than either agent used alone. Combining erythromycin or clindamycin with benzoyl peroxide eliminates or reduces bacterial resistance and enhances efficacy.”1 Similarly, a 2014 study in Drug Therapy Topics also found that combined treatment with clindamycin and benzoyl peroxide was more effective than either medication alone.7

 

And here is a study that shows us that safe over-the-counter medications are superior to topical antibiotics, even when topical antibiotics are combined with other medications:

Journal of the American Academy of Dermatology (JAAD)

A 2010 study in the Journal of the American Academy of Dermatology found that combination treatment with two popular over-the-counter medications, benzoyl peroxide and salicylic acid, was more effective than a topical antibiotic alone and a topical antibiotic in combination with benzoyl peroxide.8

 

Side Effects of Antibiotics

Even when they do show some results, both oral and topical antibiotics frequently cause side effects that range from mild to severe.
 

Side Effects of Oral and Topical Antibiotics for Acne



Oral Antibiotic Side Effects

Oral antibiotics cause a wide variety of side effects, the most common of which is gastrointestinal upset, such as nausea and diarrhea, which occurs in up to half of patients taking oral antibiotics.9

Here are some of the other side effects that oral antibiotics can cause:

  • Doxycycline causes sensitivity to sunlight. Other antibiotics in the tetracycline family, such as tetracycline and minocycline, also cause sensitivity to sunlight, but to a lesser degree than doxycycline.1
  • Tetracycline antibiotics can cause skin irritation such as rashes.9
  • Minocycline can cause permanent discoloration of the skin, acne scars, and teeth.1
  • Minocycline can also cause rare but very severe side effects such as dizziness, vertigo, and autoimmune diseases.1,9
  • Clindamycin can cause candidiasis (a fungal infection) and colitis (severe irritation of the colon).1,9
  • Erythromycin can cause stomach cramps, nausea, and vomiting.9
  • Systemic antibiotics may be associated with higher frequency of upper respiratory tract infections.6

The majority of the side effects from oral antibiotics stem from the fact that antibiotics do not just kill the bacteria that they are targeting for a particular condition; they also kill beneficial bacteria along with the harmful ones. This leads to an imbalance in the bacterial composition of the intestines.
 

Antibiotics Kill Both Bad and Good Bacteria



Topical Antibiotic Side Effects

Topical antibiotics cause less severe side effects than oral antibiotics. The most common side effects of topical antibiotics are:

  • Skin irritation
  • Rashes
  • Dryness1

However, when applied to large areas of skin, clindamycin can also be absorbed into the body and cause serious systemic side effects, including:

  • Diarhhea
  • Severe Colitis
  • Dryness11


Conclusion

Antibiotics are powerful medicines that can save lives when used appropriately for bacterial infections. They may have a legitimate role in acne treatment in some special cases in the short term, but they should be drugs of last resort, not the first options used. And when they are prescribed, they should be used sparingly and only for short periods of time.

 

The Experts at Acne.org

Our team of medical doctors, biology & chemistry PhDs, and acne experts work hand-in-hand with Dan (Acne.org founder) to provide the most complete information on all things acne. If you find any errors in this article, kindly use this Feedback Form and let us know.

References:

  1. Strauss, J. S. et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 56, 651–663 (2007).
  2. Gannon, M., Underhill, M. & Wellik, K. E. Clinical inquiries. Which oral antibiotics are best for acne? J Fam Pract 60, 290–292 (2011).
  3. Yousefi, M. et al. Efficacy of doxycycline versus azithromycin in the treatment of acne. J Dermatol 15, 7–10 (2012).
  4. Koo, E. B., Petersen, T. D. & Kimball, A. B. Meta-analysis comparing efficacy of antibiotics versus oral contraceptives in acne vulgaris. J Am Acad Dermatol 71, 450–459 (2014).
  5. Nagler, A. R., Milam, E. C. & Orlow, S. J. The use of oral antibiotics before isotretinoin therapy in patients with acne. J Am Acad Dermatol 74, 273–279 (2016).
  6. Leccia, M. T. et al. Topical acne treatments in Europe and the issue of antimicrobial resistance. J Eur Acad Dermatol Venereol 29, 1485–1492 (2015).
  7. Del Rosso, J. Q. Topical therapy for acne in women: is there a role for clindamycin phosphate-benzoyl peroxide gel? Cutis 94, 177–182 (2014).
  8. Seidler, E. M. & Kimball, A. B. Meta-analysis comparing efficacy of benzoyl peroxide, clindamycin, benzoyl peroxide with salicylic acid, and combination benzoyl peroxide/clindamycin in acne. J Am Acad Dermatol 63, 52–62 (2010).
  9. Tripathi, S. V., Gustafson, C. J., Huang, K. E. & Feldman, S. R. Side effects of common acne treatments. Expert Opin Drug Saf 12, 39–51 (2013).
  10. Ochsendorf, F. [Systemic antibiotic therapy of acne vulgaris]. J Dtsch Dermatol Ges 8 Suppl 1, S31–46 (2010).
  11. Oudenhoven, M. D., Kinney, M. A., McShane, D. B., Burkhart, C. N. & Morrell, D. S. Adverse effects of acne medications: recognition and management. Am J Clin Dermatol 16, 231–242 (2015).
  12. Luk, N. M. et al. Antibiotic-resistant Propionibacterium acnes among acne patients in a regional skin centre in Hong Kong. J Eur Acad Dermatol Venereol 27, 31–36 (2013).
  13. Sardana, K., Gupta, T., Garg, V. K. & Ghunawat, S. Antibiotic resistance to Propionobacterium acnes: worldwide scenario, diagnosis and management. Expert Rev Anti Infect Ther 13, 883–896 (2015).
  14. Lee, Y. H., Liu, G., Thiboutot, D. M., Leslie, D. L. & Kirby, J. S. A retrospective analysis of the duration of oral antibiotic therapy for the treatment of acne among adolescents: investigating practice gaps and potential cost-savings. J Am Acad Dermatol 71, 70–76 (2014).
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