The American Academy of Dermatology (AAD) recently released treatment recommendations for the use of systemic antibiotics. They are indicated for use in moderate-to-severe inflammatory acne and should be used in combination with a topical retinoid and benzoyl peroxide (BP). Evidence supports the efficacy of tetracycline, doxycycline, minocycline, trimethoprim/sulfamethoxazole (TMP/SMX), trimethoprim, erythromycin, azithromycin, amoxicillin, and cephalexin. Key guidelines are as follows:
- Systemic antibiotics are recommended in the management of moderate and severe acne, and forms of inflammatory acne that are resistant to topical treatments.
- Doxycycline and minocycline are more effective than tetracycline, but neither is superior to each other.
- Although oral erythromycin and azithromycin can be effective in treating acne, its use should be limited to those who cannot use the tetracyclines (ie, pregnant women or children aged <8 years).
- Erythromycin use should be restricted due to its increased risk of bacterial resistance.
- Use of systemic antibiotics, other than the tetracyclines and macrolides, is discouraged as there is limited data for their use in acne.
- Systemic antibiotic use should be limited to the shortest possible duration, typically 3 months, to minimize the development of bacterial resistance.
- Monotherapy with systemic antibiotics is not recommended.
- Concomitant topical therapy with BP and/or a retinoid should be used with systemic antibiotics, as well as for maintenance after completion of systemic antibiotic therapy.
American Academy of Dermatology. Acne clinical guideline. Systemic antibiotics: Recommendations. AAD Web site. 2017. https://www.aad.org/practicecenter/quality/clinical-guidelines/acne/systemic-antibiotics.
Systemic antibiotics have been used for years in patients with moderate-to-severe inflammatory acne, in combination with topical agents, including retinoids and benzoyl peroxide. The tetracycline family of antibiotics, including minocycline and doxycycline, are most commonly prescribed. Over the years, there has been an increase in the development of resistance to erythromycin. We see this with other antibiotics, and there is an effort to encourage antibiotic stewardship among dermatologists. The recent guidelines address this and recommend limiting duration of oral use to 3 months and using concomitant topicals, such as benzoyl peroxide, which decreases the development of resistance. Monotherapy with antibiotics (both topical and systemic) should also be avoided; the overuse of topical antibiotics alone for many years may have also contributed to the development of resistant organisms. These recommendations are valuable and important for the practicing dermatologist and we are fortunate to have many effective options from which to choose to offer our patients the most successful outcome. —Diane S. Berson, MD, FAAD
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