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Oral Antibiotics for Acne

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Abstract

Oral antibiotics are integral for treating inflammatory acne based on what is understood about the pathogenesis as well as the role of Cutibacterium acnes. However, rising concerns of antibiotic resistance and the perception of “antibiotic phobia” create potential limitations on their integration in an acne treatment regimen. When prescribing oral antibiotics, dermatologists need to consider dosage, duration, and frequency, and to avoid their use as monotherapy. These considerations are important, along with the use of newer strategies and compounds, to reduce adverse-event profiles, antibiotic resistance, and to optimize outcomes. Aside from concomitant medications, allergies, and disease severity, costs and patient demographics can influence variability in prescribing plans. There are multiple published guidelines and consensus statements for the USA and Europe to promote safe antibiotic use by dermatologists. However, there is a lack of head-to-head studies and evidence for comparative superiority of any individual antibiotic, as well as any evidence to support the use of agents other than tetracyclines. Although oral antibiotics are one of the main options for moderate to severe acne, non-antibiotic therapy such as isotretinoin and hormonal therapies should be considered. As newer therapies and more outcomes data emerge, so will improved management of antibiotic therapy to foster patient safety.

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References

  1. Lynn D, et al. The epidemiology of acne vulgaris in late adolescence. Adolesc Health Med Ther. 2016;7:13–25.

    PubMed  PubMed Central  Google Scholar 

  2. Collier CN, et al. The prevalence of acne in adults 20 years and older. J Am Acad Dermatol. 2008;58(1):56–9.

    PubMed  Google Scholar 

  3. Jeremy AH, et al. Inflammatory events are involved in acne lesion initiation. J Investig Dermatol. 2003;121(1):20–7.

    CAS  PubMed  Google Scholar 

  4. Golub LM, Lee H-M, Ryan ME, et al. Tetracyclines inhibit connective tissue breakdown by multiple non-antimicrobial mechanisms. Adv Dent Res. 1998;12(2):12–26.

    CAS  PubMed  Google Scholar 

  5. Lee DY, Yamasaki K, Gallo R, et al. Sebocytes express functional cathelicidin antimicrobial peptides and can act to kill Propionibacterium acnes. J Investig Dermatol. 2008;128:1863–6.

    CAS  PubMed  Google Scholar 

  6. Di Caprio R, et al. Anti-inflammatory properties of low and high doxycycline doses: an in vitro study. Mediat Inflamm. 2015;2015:329418.

    Google Scholar 

  7. Del Rosso JQ. A status report on the use of subantimicrobial-dose doxycycline: a review of the biologic and antimicrobial effects of the tetracyclines. Cutis. 2004;74(2):118–22.

    PubMed  Google Scholar 

  8. Sapadin AN, Fleischmajer R. Tetracyclines: nonantibiotic properties and their clinical implications. J Am Acad Dermatol. 2006;54(2):258–65.

    PubMed  Google Scholar 

  9. Leyden JJ. The evolving role of Propionibacterium acnes in acne. Semin Cutan Med Surg. 2001;20(3):139–43.

    CAS  PubMed  Google Scholar 

  10. Zaenglein AI, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945–73.

    PubMed  Google Scholar 

  11. Nast A, et al. European evidence-based (S3) guidelines for the treatment of acne. J Eur Acad Dermatol Venereol. 2012;26(Suppl. 1):1–29.

    PubMed  Google Scholar 

  12. Thiboutot DM, et al. Practical management of acne for clinicians: an international consensus from the Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2018;78(2):S1–23.

    PubMed  Google Scholar 

  13. Margolis D, et al. Potential association between the oral tetracycline class of antimicrobials used to treat acne and inflammatory bowel disease. Am J Gastroenterol. 2010;105(12):2610–6.

    CAS  PubMed  Google Scholar 

  14. Margolis D, et al. Association of pharyngitis with oral antibiotic use for the treatment of acne: a cross-sectional and prospective cohort study. Arch Dermatol. 2012;148(3):326–32.

    PubMed  Google Scholar 

  15. Velicer CM, et al. Antibiotic use in relation to the risk of breast cancer. JAMA. 2004;291(7):827–35.

    CAS  PubMed  Google Scholar 

  16. Dik VK, et al. Frequent use of antibiotics is associated with colorectal cancer risk: results of a nested case–control study. Dig Dis Sci. 2015;61(1):255–64.

    PubMed  PubMed Central  Google Scholar 

  17. Cao Y, et al. Long-term use of antibiotics and risk of colorectal adenoma. Gut. 2018;67(4):672–8.

    CAS  PubMed  Google Scholar 

  18. Moore J. Efficacy and safety of subantimicrobial dose, modified-release doxycycline 40 mg vs doxycycline 100 mg vs placebo in the treatment of severe acne. J Drugs Dermatol. 2015;14(6):581–6.

    CAS  PubMed  Google Scholar 

  19. Kohanski M, et al. Sub-lethal antibiotic treatment leads to multidrug resistance via radical-induced mutagenesis. Mol Cell. 2010;37(3):311–20.

    CAS  PubMed  PubMed Central  Google Scholar 

  20. Gollnick H, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2003;49(Suppl. 1):S1–37.

    PubMed  Google Scholar 

  21. Tan AW, et al. Acne vulgaris: a review of antibiotic therapy. Exp Opin Pharmacother. 2005;6(3):409–18.

    CAS  Google Scholar 

  22. Del Rosso JQ, et al. Optimizing use of oral antibiotics in acne vulgaris. Dermatol Clin. 2009;27:33–42.

    PubMed  Google Scholar 

  23. Raflel R, Yaghoobi R. Azithromycin versus tetracycline in the treatment of acne vulgaris. J Dermatol Treat. 2006;7(4):217–21.

    Google Scholar 

  24. Leyden JJ. Absorption of minocycline hydrochloride and tetracycline hydrochloride: effect of food, milk, and iron. J Am Acad Dermatol. 1985;2(Pt 1):308–12.

    Google Scholar 

  25. Stockley IH. Antibiotic and anti-infective agent drug interactions. In: Stockley IH, editor. Drug interactions. 5th ed. London: Pharmaceutical Press; 1999. p. 194–7.

    Google Scholar 

  26. Garrido-Mesa N, et al. Minocycline: far beyond an antibiotic. Br J Pharmacol. 2013;169(2):337–52.

    CAS  PubMed  PubMed Central  Google Scholar 

  27. Eady EA, Cove JH, Holland KT, Cunliffe WJ. Superior antibacterial action and reduced incidence of bacterial resistance in minocycline compared to tetracycline-treated acne patients. Br J Dermatol. 1990;122(2):233–44.

    CAS  PubMed  Google Scholar 

  28. Leyden JJ, Del Rosso JQ. Oral antibiotic therapy for acne vulgaris: pharmacokinetic and pharmacodynamic perspectives. J Clin Aesthet Dermatol. 2011;4(2):40–7.

    PubMed  PubMed Central  Google Scholar 

  29. Leyden JJ, et al. The antimicrobial effects in vivo of minocycline, doxycycline, and tetracycline in humans. J Dermatol Treat. 1996;7:223–5.

    Google Scholar 

  30. Garner SE, et al. Minocycline for acne vulgaris: efficacy and safety. Cochrane Database Syst Rev. 2012;2012(8):CD002086. https://doi.org/10.1002/14651858.CD002086.pub2.

    Article  PubMed Central  Google Scholar 

  31. Goulden V, et al. Safety of long-term high-dose minocycline in the treatment of acne. Br J Dermatol. 1996;134(4):693–5.

    CAS  PubMed  Google Scholar 

  32. Ray WA, et al. Azithromycin and the risk of cardiovascular death. New Engl J Med. 2012;366(20):1881–90.

    CAS  PubMed  Google Scholar 

  33. Sardesai VR, Deka YT. Comparison of efficacy of oral azithromycin with oral minocycline in the treatment of acne vulgaris. Clin Dermatol Rev. 2017;1:37–40.

    Google Scholar 

  34. Bardazzi F, et al. Azithromycin: a new therapeutical strategy for acne in adolescents. Dermatol Online J. 2007;13(4):4.

    PubMed  Google Scholar 

  35. Fernandez-Obregon A. Azithromycin for the treatment of acne. Int J Dermatol. 2000;39(1):45–50.

    CAS  PubMed  Google Scholar 

  36. Grech J. Susceptibility profiles of Propionibacterium acnes isolated from patients with acne vulgaris. J Glob Antimicrob Resist. 2014;2:35–8.

    PubMed  Google Scholar 

  37. Guzman AK, et al. Safety and effectiveness of amoxicillin in the treatment of inflammatory acne. Int J Womens Dermatol. 2018;4(3):174–5.

    CAS  PubMed  PubMed Central  Google Scholar 

  38. Barbieri JS, et al. Trends in oral antibiotic prescription in dermatology, 2008 to 2016. JAMA Dermatol. 2019;155(3):290–7.

    PubMed  PubMed Central  Google Scholar 

  39. Turowski CB, James WD. The efficacy and safety of amoxicillin, trimethoprim-sulfamethoxazole, and spironolactone for treatment-resistant acne vulgaris. Adv Dermatol. 2007;23:155–63.

    PubMed  Google Scholar 

  40. Lin KJ, et al. Maternal exposure to amoxicillin and the risk of oral clefts. Epidemiology. 2012;23(5):699–705.

    PubMed  PubMed Central  Google Scholar 

  41. Fenner JA. Oral cephalexin for acne vulgaris: clinical experience with 93 patients. Pediatr Dermatol. 2008;5(2):179–83.

    Google Scholar 

  42. McCarty M, Del Rosso J. Chronic administration of oral trimethoprim-sulfamethoxazole for acne vulgaris. J Clin Aesth Dermatol. 2011;4(8):58–66.

    Google Scholar 

  43. Amin K, et al. Common and alternate oral antibiotic therapies for acne vulgaris: a review. J Drugs Dermatol. 2007;6(9):873–80.

    PubMed  Google Scholar 

  44. Leyden J, et al. Efficacy and safety of sarecycline, a novel, once-daily, narrow spectrum antibiotic for the treatment of moderate to severe facial acne vulgaris: results of a phase 2, dose-ranging study. J Drugs Dermatol. 2018;17(3):333–8.

    PubMed  Google Scholar 

  45. Moore A, et al. Once-daily oral sarecycline 1.5 mg/kg/day is effective for moderate to severe acne vulgaris: results from two identically designed, phase 3, randomized, double-blind clinical trials. J Drugs Dermatol. 2018;17(9):987–96.

    CAS  PubMed  Google Scholar 

  46. Del Rosso JQ, Rosen T, Palceski D, Rueda MJ. Patient awareness of antimicrobial resistance and antibiotic use in acne vulgaris. J Clin Aesthet Dermatol. 2019;12(6):30–41.

    PubMed  PubMed Central  Google Scholar 

  47. Barbieri JS, Spaccarelli N, Margolis DJ, James WD. Approaches to limit systemic antibiotic use in acne: systemic alternatives, emerging topical therapies, dietary modification, and laser and light-based treatments. J Am Acad Dermatol. 2019;80(2):538–49.

    PubMed  Google Scholar 

  48. Layton A. The use of isotretinoin in acne. Dermatoendocrinology. 2009;1(3):162–9.

    CAS  Google Scholar 

  49. Rademaker M. Isotretinoin: dose, duration, relapse. Australas J Dermatol. 2013;54:157–62.

    PubMed  Google Scholar 

  50. Azoulay L, Blais L, Koren G, et al. Isotretinoin and the risk of depression in patients with acne vulgaris: a case-crossover study. J Clin Psychiatry. 2008;69:526–32.

    CAS  PubMed  Google Scholar 

  51. Margolis DJ, Attie M, Leyden JJ. Effects of isotretinoin on bone mineralization during routine therapy with isotretinoin therapy for acne vulgaris. Arch Dermatol. 1996;132:769–74.

    CAS  PubMed  Google Scholar 

  52. Reddy D, Siegel CA, Sands BE, et al. Possible association between isotretinoin and inflammatory bowel disease. Am J Gastroenterol. 2006;101:1569–73.

    CAS  PubMed  Google Scholar 

  53. Pochi PE. Hormones and acne. Semin Dermatol. 1982;1:265.

    Google Scholar 

  54. Thiboutot D, et al. New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol. 2009;60(5 Suppl.):S1–50.

    PubMed  Google Scholar 

  55. Del Rosso JQ, Leyden JJ. Status report on antibiotic resistance: implications for the dermatologist. Dermatol Clin. 2007;25:127–32.

    PubMed  Google Scholar 

  56. Del Rosso JQ, Zeichner JA. The clinical relevance of antibiotic resistance thirteen principles that every dermatologist needs to consider when prescribing antibiotic therapy. Dermatol Clin. 2016;34:167–73.

    PubMed  Google Scholar 

  57. Kourtis AP, Hatfield K, Baggs J, et al. Vital signs: epidemiology and recent trends in methicillin-resistant and in methicillin-susceptible Staphylococcus aureus bloodstream infections: United States. MMWR Morb Mortal Wkly Rep. 2019;68:214–9.

    PubMed  PubMed Central  Google Scholar 

  58. Mendoza N, et al. Antimicrobial susceptibility of Propionibacterium acnes isolates from acne patients in Colombia. Int J Dermatol. 2013;52(6):688–92.

    CAS  PubMed  Google Scholar 

  59. Sardana K, et al. Cross-sectional pilot study of antibiotic resistance in Propionibacterium acnes strains in Indian acne patients using 16S-RNA polymerase chain reaction: a comparison among treatment modalities including antibiotics, benzoyl peroxide, and isotretinoin. Indian J Dermatol. 2016;61(1):45–52.

    PubMed  PubMed Central  Google Scholar 

  60. Dessinioti C, et al. Propionibacterium acnes and antimicrobial resistance in acne. Clin Dermatol. 2017;35(2):163–7.

    PubMed  Google Scholar 

  61. Walsh T, et al. Systematic review of antibiotic resistance in acne: an increasing topical and oral threat. Lancet. 2016;16(3):23–33.

    Google Scholar 

  62. Chien A, et al. Association of systemic antibiotic treatment of acne with skin microbiota characteristics. JAMA Dermatol. 2019;155(4):425–34.

    PubMed  PubMed Central  Google Scholar 

  63. Hirotsu K, et al. Association of antibiotic resistance with antibiotic use for epidermal growth factor receptor inhibitor-related papulopustular eruption. JAMA Dermatol. 2019;155(7):848–50.

    PubMed  PubMed Central  Google Scholar 

  64. Barbieri J, et al. Trends in prescribing behavior of systemic agents used in the treatment of acne among dermatologists and nondermatologists: a retrospective analysis, 2004–2013. J Am Acad Dermatol. 2017;77(3):456–463.e4.

    PubMed  Google Scholar 

  65. Tan H. Antibacterial therapy for acne: a guide to selection and use of systemic agents. Am J Clin Dermatol. 2003;4(5):307–14.

    PubMed  Google Scholar 

  66. Kim S, et al. Systemic antibacterial agents. In: Comprehensive dermatologic drug therapy. 3rd ed.; 2012. p. 61–97.

  67. Kim JE, Park AY, Lee SY, Park YL, Whang KU, Kim HJ. Comparison of the efficacy of azithromycin versus doxycycline in acne vulgaris: a meta-analysis of randomized controlled trials. Ann Dermatol. 2018;30(4):417–26.

    CAS  PubMed  PubMed Central  Google Scholar 

  68. Cotterill JA, Cunliffe WJ, Forster RA, et al. A comparison of trimethoprim-sulphamethoxazole with oxytetracycline in acne vulgaris. Br J Dermatol. 1971;84:366–9.

    CAS  PubMed  Google Scholar 

  69. Hersle K. Trimethoprim-sulphamethoxazole in acne vulgaris: a double blind study. Dermatologica. 1972;145:187–91.

    CAS  PubMed  Google Scholar 

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    Authors and Affiliations

    1. Biochemistry and Cell Biology, University of California San Diego, La Jolla, USA

      Dillon J. Patel

    2. Therapeutics Clinical Research, 9025 Balboa Avenue, San Diego, CA, 92123, USA

      Neal Bhatia

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    Dillon J. Patel has no conflicts of interest that are directly relevant to the content of this article. Neal Bhatia has been an advisor, consultant, and investigator for Almirall, Biofrontera, BiopharmX, Dermira, EPI Health, Ferndale, Foamix, Galderma, Intraderm, ISDIN, LaRoche-Posay, Leo, Mayne, Ortho, SunPharma, and Vyome.

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    Patel, D.J., Bhatia, N. Oral Antibiotics for Acne. Am J Clin Dermatol 22, 193–204 (2021). https://doi.org/10.1007/s40257-020-00560-w

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