Antibiotics for Acne

What is acne?
Oral antibiotics for acne

Tetracycline
Doxycycline
Minocycline
Lymecycline
Trimethoprim-Sulfamethoxazole
Erythromycin
Azithromycin
Clindamycin
Cephalexin

Topical antibiotics for acne
Antibiotics that do NOT work

Based on "Acne vulgaris"
written by Michael Romano, MD; Robert P. Dellavalle, MD

What is Acne?

Acne vulgaris is a disorder of the pilosebaceous follicles of the skin. Acne is characterized by comedones, papules, pustules, cysts and scars. The condition affects the face, back and chest.

Antibiotics for Acne Treatment

Antibiotics work by killing the acne causing skin bacteria Propionibacterium acnes and reducing inflammation. Additionally, they may produce direct anti-inflammatory effect and reduce oily sebum secretion, resulting in a decreased accumulation of follicular free fatty acids.

Antibiotics are more effective for inflammatory than for non-inflammatory acne. They don’t unclog blocked pores, which are blackheads and whiteheads.

Antibiotics can be taken orally or applied to the skin in the form of creams, gels and lotions.

What is the best acne treatment? Both topical and oral antibiotics work best if they are used in combination with topical retinoid, benzoyl peroxide, or azelaic acid 13.

choice of antibiotic for acne infographic

When to expect an improvement?

Any acne treatment should be continued for at least 4 weeks before there is a noticeable improvement6. There is often a good response by 6 weeks. However, it can take up to 4 months (and sometimes even longer) for maximum benefits, and for the skin to be virtually free of spots.

The main reason for acne treatment failure is giving up after couple of weeks, thinking that medication is not working.

How long to take antibiotics for acne?

The minimum recommended course of antibiotic therapy is 3 months, and 6 months for the best results6. The treatment may be continued longer until satisfactory improvement is achieved. In some cases, antibiotics can be safely used for up to 4 years7.

Many dermatologists5 recommend a maintenance therapy with a topical benzoyl peroxide or a topical retinoid to prevent acne from flaring up again.

Oral Antibiotics

Oral antibiotics are recommended for the treatment of moderate or severe inflammatory acne (papules, pustules, nodules, and cystic acne). They work by killing the acne causing skin bacteria Propionibacterium acnes and reducing inflammation.

Over time, the P. acnes bacteria can become resistant to the antibiotic being used. In such cases doctors prescribe another antibiotic or an alternative treatment.

Tetracycline

The main problem with tetracycline is that it must be taken on an empty stomach to be fully effective. For persons who eat frequently, this can be very troublesome.

Benefits

Effective for various types of acne, including severe cystic inflammatory lesions14.
Low cost.

Drawbacks

Frequent side effects such as gastrointestinal upset, nausea, diarrhea, vomiting.
Tetracycline must be taken on an empty stomach to be fully effective. It is particularly a problem for persons who eat frequently.
Higher dosages are necessary to achieve full effectiveness.
Co-ingestion with dairy food, antacids that contain calcium, magnesium, or aluminum decreases the drug absorption.
Contraindicated in pregnant and breast-feeding women as tetracycline may cause discoloration and enamel hypoplasia of developing milk-teeth.
Contraindicated in children younger than 8 years of age because this medication can affect growth and stain developing permanent teeth.

Tetracycline dosage for acne: The usual starting dose is 500 mg twice a day continued until a significant decrease in acne lesions is achieved. Then the dose can be reduced to 250 mg twice a day or even discontinued.

Doxycycline (Doryx®, Oracea®)

Benefits

Favorable balance of efficacy and safety.
Doxycycline is especially effective in treating inflammatory acne.
Doxycycline is more lipophilic than tetracycline and has excellent penetration into the pilosebaceous unit. It has direct effect on sebum production.
More convenient dosage regimen – less frequent and the medication can be taken with food.
Doxycycline is better tolerated than tetracycline.
Several low-dose formulations are available.
Patients with gastrointestinal problems can take Doryx® -- delayed-release tablets of doxycycline in the form of enteric-coated pellets. Doryx® causes fewer gastrointestinal side effects in comparison to capsules containing the powdered form.
Combination of adapalene with doxycycline provides superior and faster response than an antibiotic alone for the treatment of severe acne 17.
Sub-antimicrobial dose of doxycycline is well tolerated, has no detectable antimicrobial effect on the skin flora, and does not result in an increase in antibiotic resistance 18.
Sub-antimicrobial doxycycline dosage is an effective maintenance therapy in patients with inflammatory acne 19. Long-term treatment with sub-antimicrobial dose of doxycycline does not destroy intestinal or vaginal flora 20.

Drawbacks

Gastro-intestinal side effects, particularly "pill esophagitis".
Dose-related photosensitivity. It is more likely to increase sensitivity to the sun or cause sunburns than other tetracyclines. Therefore doxycycline should be used with caution during the summer and in hot climates.
Contraindicated in pregnant and breast-feeding women, and children younger than 8 years.

Doxycycline dosage for acne: 50 to 100 mg twice a day.

Doxycycline sub-antimicrobial dose: 20 mg twice daily. Doxycycline subantimicrobial dosing provides 84-90% reduction in the number of papules and pustules2.

Oracea®, a controlled-release formulation, is dosed 40 mg once daily and may be a more convenient choice.

Minocycline (Solodyn®)

Benefits

Very effective. Minocycline has a long history of use in acne vulgaris. It is the most lipophilic tetracycline, allowing greater penetration into sebaceous follicles. Minocycline is effective in treating acne that has not responded to other oral antibiotics. It is especially useful for pustular type acne.
Negligible photosensitivity.
There is some evidence that antibiotic resistance is less likely to develop with minocycline than other tetracyclines.

Drawbacks

Safety concerns. Minocycline is known to cause vestibular toxicity, and various autoimmune reactions (lupus, autoimmune hepatitis, serum sickness, vasculitis, and hypersensitivity pneumonitis).
May cause bluish-gray pigmentation of nail, skin and sclera.
Contraindicated in pregnancy, nursing, and young children.

Minocycline dosage for acne: The usual starting dose is 50 to 100 mg twice a day.

Solodyn® is an extended-release formulation of minocycline for once-daily dosing.

Lymecycline (Tetralysal®)

Lymecycline is used outside of the US for acne. It is very popular among dermatologists in France, Italy, and Nordic countries. Lymecycline is generally safe and well tolerated.

Lymecycline dosage for acne: 300-600 mg of lymecycline daily.

Trimethoprim-Sulfamethoxazole (TMP-SMX, Co-trimoxazole, Bactrim®)

Benefits

Effective against inflammatory acne. Trimethoprim-sulfamethoxazole may be a reasonable treatment for refractory acne9.
Trimethoprim-Sulfamethoxazole is a reasonable treatment for refractory acne 9.

Drawbacks

TMP-SMX is not approved by the U.S. FDA for acne vulgaris.
Use in dermatologic conditions is limited because of possible serious adverse reactions: Stevens-Johnson syndrome, toxic epidermal necrolysis, hyperkalemia, hematological reactions (blood dyscrasias).
Note: Despite being serious, above side effects are rare in practice, and the most common side effect is maculopapular rash.

Bactrim dosage for acne: 160 mg/800 mg of trimethoprim/ sulfamethoxazole twice daily.

Erythromycin

Benefits

Safe for patients in whom tetracyclines are contraindicated, that is pregnant women and children.

Drawbacks

Widespread resistance of P. acne. So oral erythromycin is suitable only for acne during pregnancy, breastfeeding, or in young children.

Erythromycin dosage for acne: 500 mg twice daily.

Azithromycin

Benefits

Favorable safety. Azithromycin is a valid alternative for patients intolerant or unable to take tetracyclines for various reasons.
Efficacy. Azithromycin has been widely prescribed to treat acne in recent years 10.
Very convenient regimen. Because azithromycin is effective at doses given only 1 to 3 times weekly, it is a very good option for adolescents with poor compliance.

Drawbacks

The main concern with azithromycin is emerging resistance.

Azithromycin dosage for acne: 500 mg once-thrice weekly.

Clindamycin

Benefits

Effective treatment.

Drawbacks

Oral clindamycin is rarely used to treat acne because of possible serious side effects 8.
Clindamycin may cause overgrowth of Clostridium difficile resulting in pseudomembranous colitis. About 20-30% of patients taking oral clindamycin experience diarrhea.

Clindamycin dosage: 300 mg 3 times per day.

Cephalexin (Keflex®)

Benefits

Cephalexin is safe and very inexpensive antibiotic.
Cephalexin may be tried for treatment-refractory acne, as well as in persons who can not use traditional acne therapies15.
Cephalexin can be Moderate to severe inflammatory acne in pregnant women16.

Drawbacks

The main problem with Cephalexin its poor efficacy.

Cephalexin dosage: 500 mg twice daily16.

Topical Antibiotics

Topical antibiotics are effective for treating mild to moderate inflammatory acne. Topical antibiotics work by killing the Propionibacterium acnes bacteria. This also indirectly keeps the pores open.

Clindamycin (Cleocin-T®, Clinda-Derm®)

Topical clindamycin is indicated for the treatment of acne. It works by suppressing the growth of P. acnes and decreasing inflammation. In topical form, clindamycin has proven to be safe and is well tolerated11.

Topical clindamycin decreases inflammatory acne lesions better than oral tetracycline12.

Topical clindamycin comes in various forms, including gel, lotion, solution and foam.

Clindamycin and Benzoyl Peroxide (Acanya®, BenzaClin®, Duac®)

Clindamycin phosphate 1.2% plus benzoyl peroxide 3% gel has a favourable safety and tolerability, and may be superior than clindamycin alone in the treatment of acne vulgaris3. Clindamycin works synergistically with benzoyl peroxide by increasing free-radical formation.

Clindamycin and Tretinoin (Ziana®, Veltin®, Biacna®)

Clindamycin phosphate 1.2% plus tretinoin 0.025% gel was approved by the FDA in 2006 for the treatment of acne vulgaris. The gel combines anti-inflammatory and antibacterial properties of clindamycin with beneficial comedolytic action of tretinoin4. This combination is very well-tolerated and has a low incidence of irritation. Noticeable improvement in acne is usually seen after 12 weeks of application.

Erythromycin (Akne-mycin®, Erygel®, Ery®)

Topical erythromycin is an antimicrobial and anti-inflammatory. Like topical clindamycin, erythromycin may cause skin dryness and irritation. Erythromycin is safe for use by pregnant women.

Erythromycin and Benzoyl Peroxide (Benzamycin®)

Erythromycin and benzoyl peroxide combination is indicated for the treatment of acne. This combination proves to be quite effective. Benzoyl peroxide is an antibacterial agent with keratolytic and desquamative properties. This combination produces keratolytic and comedolytic effects.

Antibiotics NOT recommended for acne

Penicillins, cephalosporins, and aminoglycosides have a very limited ability to penetrate microcomedones due to their hydrophilicity, and are therefore NOT recommended for the treatment of acne.

Important things to know

Although acne vulgaris is widely treated with antibiotics, this skin condition is not an infectious disease.
You can get better results if along with antibiotic therapy you apply topical retinoid, benzoyl peroxide, or azelaic acid.
Antibiotics do not cure acne. Antibacterial drugs work by reducing P. acne bacteria, which trigger inflammation in acne lesions. They do not address other causes of acne.
Antibiotics have delayed onset of action.

Types of acne:

Noninflammatory or comedonal acne: blackheads (open comedones) occur in partially blocked pores; whiteheads (closed comedones) are slightly raised, skin-colored bumps, develop from a blockage deeper in a pore. Whiteheads are more likely to lead to the inflammation known as pimples or zits.
Inflammatory acne: papules are inflamed lesions that usually appear as small, pink bumps on the skin and can be tender to the touch; pustules are closed comedones, which become inflamed and begin to rupture into the skin forming pustular heads of various sizes; nodules are large, tender, swollen acne lesions, which have become intensely inflamed and rupture under the skin, and if untreated, nodules can produce deep scarring; cysts are deep, painful, pus-filled lesions that can cause scarring.

Conclusion: Now you know that each acne medication has its own potential advantages in specific situations. However, potential benefits also depend on the individual taking the medication.

References & Resources

1. The Merck Manual of Medical Information. Mark H. Beers et al., eds. 2nd Home Edition. Whitehouse Station, NJ: Merck; 2003.
2. Toossi P, Farshchian M, Malekzad F, Mohtasham N, Kimyai-Asadi A. Subantimicrobial-dose doxycycline in the treatment of moderate facial acne. J Drugs Dermatol. 2008 Dec. PubMed
3. Eichenfield LF, Alió Sáenz AB. Safety and efficacy of clindamycin phosphate 1.2%-benzoyl peroxide 3% fixed-dose combination gel for the treatment of acne vulgaris: a phase 3, multicenter, randomized, double-blind, active- and vehicle-controlled study. J Drugs Dermatol. 2011 Dec. PubMed
4. Abdel-Naser MB, Zouboulis CC. Clindamycin phosphate/tretinoin gel formulation in the treatment of acne vulgaris. Expert Opin Pharmacother. 2008 Nov;9(16):2931-7. PubMed
5. Wolf JE Jr. Maintenance therapy for acne vulgaris: the fine balance between efficacy, cutaneous tolerability, and adherence. Skinmed. 2004 Jan-Feb;3(1):23-6. PubMed
6. Hywel Williams, Michael Bigby, Andrew Herxheimer. Evidence based dermatology. 3rd ed. Wiley Blackwell, Oxford, p.98
7. FORBES MA Jr, KING WC. Treatment of acne vulgaris with tetracycline: a 4 year study. Tex State J Med. 1959 Apr;55(4):281-3.
8. Basler RS. Potential hazards of clindamycin in acne therapy. Arch Dermatol. 1976 Mar;112(3):383-5.
9. Turowski CB, James WD. The efficacy and safety of trimethoprim-sulfamethoxazole for treatment-resistant acne vulgaris. Adv Dermatol. 2007;23:155-63. PubMed
10. Bardazzi F, Savoia F, Parente G, Tabanelli M, Balestri R, Spadola G, Dika E. Azithromycin: a new therapeutical strategy for acne in adolescents. Dermatol Online J. 2007 Oct 13;13(4):4. PubMed
11. Guay DR. Topical clindamycin in the management of acne vulgaris. Expert Opin Pharmacother. 2007 Oct;8(15):2625-64. PubMed
12. Braathen LR. Topical clindamycin versus oral tetracycline and placebo in acne vulgaris. Scand J Infect Dis Suppl. 1984;43:71-5.
13. Bienenfeld A, Nagler AR, Orlow SJ.Oral Antibacterial Therapy for Acne Vulgaris: An Evidence-Based Review.Am J ClinDermatol. 2017 Aug;18(4):469-490.
14. Baer RL, Leshaw SM, Shalita AR.High-dose tetracycline therapy in severe acne.Arch Dermatol. 1976 Apr;112(4):479-81
15. Fenner JA, Wiss K, Levin NA. Oral cephalexin for acne vulgaris: clinical experience with 93 patients. PediatrDermatol. 2008 Mar-Apr;25(2):179-83. PubMed
16. Chien AL, Qi J, Rainer B, Sachs DL, Helfrich YR. Treatment of Acne in Pregnancy. J Am Board Fam Med. 2016 Mar-Apr;29(2):254-62.
17. Thiboutot DM, Shalita AR, Yamauchi PS, Dawson C, Arsonnaud S, Kang S. Combination therapy with adapalene and doxycycline for severe acne vulgaris. Skinmed. 2005 May-Jun;4(3):138-46. PubMed
18. Skidmore R, Kovach R, Walker C, Thomas J, Bradshaw M, Leyden J, Powala C, Ashley R. Effects of subantimicrobial-dose doxycycline in the treatment of moderate acne. Arch Dermatol. 2003 Apr;139(4):459-64.
19. Parish LC, Parish JL, Routh HB, Witkowski JA. The treatment of acne vulgaris with low dosage doxycycline. Acta Dermatovenerol Croat. 2005;13(3):156-9.
20. Walker C, Preshaw PM, Novak J, Hefti AF, Bradshaw M, Powala C. Long-term treatment with sub-antimicrobial dose doxycycline has no antibacterial effect on intestinal flora. J Clin Periodontol. 2005 Nov;32(11):1163-9. PubMed

Originally published: July, 2009
Last updated: July 05, 2018