Navigating Antibiotic Use for Acne and Rosacea: Clinician Insights and Considerations

January 10, 2024

For Emmy Graber, MD, MBA, selecting an appropriate oral antibiotic for dermatological conditions necessitates a careful consideration of efficacy, duration, combination therapy, and resistance issues.

Growing apprehensions surrounding antibiotic resistance in acne and rosacea treatments, coupled with their linked adverse effects, have prompted a closer examination of their use. Emmy Graber, MD, MBA, recently delivered comprehensive insights and considerations regarding these concerns, emphasizing the significance of adhering to guidelines and exploring alternative approaches. Her discourse, a focal point at the virtual Acne and Rosacea (ARM) Meeting, underscored the pivotal role of responsible antibiotic stewardship for achieving effective treatment outcomes.

Dermatologists in particular have been highlighted for prescribing a higher number of oral antibiotic courses than any other specialty. This pattern, she said, raises red flags regarding the potential risks these medications pose to patients, urging a reevaluation of their usage protocols.

Adherence, Acne, and Antibiotics

In adherence to the American Academy of Dermatology's (AAD) 2016 consensus guidelines, oral antibiotics are recommended as a primary treatment for patients with moderate-to severe acne. However, they are suggested to be utilized in conjunction with topical retinoids and benzoyl peroxide products, aiming to shorten the duration of antibiotic use and avoid the development of resistance.

The ideal duration of oral antibiotic therapy remains a point of contention within the dermatological community, as highlighted by Dr. Garber, founder of the Dermatology Institute of Boston and an Affiliate Clinical Instructor at Northeastern University. There are currently no definitive guidelines regarding the abrupt cessation or gradual reduction of these medications, nor is there consensus on retreatment for acne flares post-initial antibiotic courses, she noted.

Antibiotic stewardship, emphasized by the Center for Disease Control and Prevention due to growing concerns about antimicrobial resistance, underlines the importance of appropriate antibiotic use. This initiative advocates for precise dosing, timing, duration, and a preference for narrow-spectrum antibiotics when feasible.

The Tetracycline Family

Dr. Graber underscored the prevalence of tetracycline family antibiotics in dermatological practice. This class, encompassing tetracycline, doxycycline, minocycline, and sarecycline, stands as the most commonly prescribed and extensively studied oral antibiotics for acne treatment. Each member displays efficacy, albeit with varying side-effect profiles.

Doxycycline, for example, possesses both antimicrobial and anti-inflammatory properties at different dosage ranges. However, concerns regarding gastrointestinal side effects prompt recommendations for its consumption with food and water. Additionally, the dose-dependent nature of phototoxicity raises queries about its clinical significance in acne management.

The use of subantimicrobial dosing of doxycycline (40 mg) for rosacea showcases predominantly anti-inflammatory effects, reducing the risk of bacterial resistance and gastrointestinal distress. This modified release formulation is the only FDA-approved oral agent specifically for inflammatory lesions of rosacea.

Minocycline, characterized by increased vestibular side effects and potential skin complications like hyperpigmentation, offers both oral and topical formulations for rosacea and acne treatment, but with varying incidence rates of adverse events. “If one chooses to use minocycline to treat rosacea, there are several strategies to lessen the likelihood of side effects developing. Many of the side effects such as cutaneous hyperpigmentation and drug-induced lupus, are more common with long term use such as use greater than one year. Therefore, shortening the duration of use may help to reduce these types of minocycline specific risks. Reducing the likelihood of vestibular side effects can be accomplished by using weight-based dosing or extended-release formulations,” noted Dr. Graber.

Concerns about antibiotic resistance rates, especially noting the reported 57% antibiotic-resistant Cutibacterium acnes (C. acnes) isolated from acne patients treated with doxycycline, prompt exploration of strategies to mitigate resistance, she said; Dr. Garber suggests multiple strategies for countering these rates. “There are several strategies that one can utilize in order to mitigate resistance rates. Firstly, one could consider using a narrow spectrum rather than a broad-spectrum antibiotic which will give a more targeted approach to reducing Cutibacterium acnes and lessen the likelihood of resistance. Secondly, one could choose to use sub-antimicrobial dosing of an antibiotic which is typically done with doxycycline as it has the highest degree of anti-inflammatory effect of the tetracycline class of antibiotics.” She continued, “At doses less than 50 milligrams a day, there is much more of an anti-inflammatory effect than there is of an antibacterial fact thus lessening the chance for resistance. Thirdly, concomitantly using topical benzoyl peroxide along with a topical or oral antibiotic will lessen the likelihood of the development of antibiotic resistance by cutaneous bacteria,” advised Dr. Garber.

Sarecycline, an FDA-approved narrow-spectrum tetracycline antibiotic, stands out as a novel option for treating inflammatory acne. It boasts efficacy data even in younger patients, with notably lower reported rates of gastrointestinal and phototoxic side effects.

Antibiotics and Oral Contraceptives

Another crucial aspect highlighted by Dr. Graber is the interaction between antibiotics and oral contraceptives. While certain anti-infectives can compromise the effectiveness of combined oral contraceptives, the tetracycline class hasn't demonstrated such effects significantly.

When considering the effectiveness of oral antibiotics versus oral contraceptives in treating acne, Dr. Graber highlights research findings. “Studies indicate that while oral antibiotics are more effective at improving acne in the short term—within three months or less—oral contraceptives demonstrate comparable efficacy to oral antibiotics after six months. Therefore, for patients who are willing to wait six months for their acne to improve, an oral contraceptive may be a better choice than oral antibiotics.  However, for those who desire a faster improvement, oral antibiotics may give more improvement in the shorter term.  In my practice, I will often combine these agents and start female patients on both an oral contraceptive and an oral antibiotic with the goal of stopping the oral antibiotic in the coming months and then continuing the oral contraceptive for long-term maintenance treatment,” elaborated Dr. Graber.

Selecting an appropriate oral antibiotic for dermatological conditions necessitates a careful consideration of efficacy, duration, combination therapy, resistance issues, and the varied side-effect profiles among the tetracycline family members. Such considerations are vital in optimizing treatment outcomes while minimizing risks associated with antibiotic use in dermatology.

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