Acne Treatment Oral Antibiotics Doxycycline

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DermnetDermatology
September 28, 2009

Dr. Thomas P. Habif MD discusses Acne Treatment with Oral Antibiotics Doxycycline, Minocycline, Tetracycline and Erythromycin. See more at http://www.dermnet.com PLEASE RATE AND COMMENT!!! Mechan...

Dr. Thomas P. Habif MD discusses Acne Treatment with Oral Antibiotics Doxycycline, Minocycline, Tetracycline and Erythromycin. See more at http://www.dermnet.com PLEASE RATE AND COMMENT!!!

Mechanism of action

P. acne initiates inflammatory acne. The bacteria is usually present in
small numbers. P. acne proliferates in the lipid rich environment of
the microcomedo and produces proinflammatory mediators that cause
papules, pustules and cysts. P. acnes is highly sensitive to many
antibiotics. The problem is to deliver the drug into the lipid rich
environment of the microcomedo..

Topical vs. Systemic antibiotics
Moderate inflammatory acne with papules and pustules covering a wide area is treated with oral antibiotics and topical therapy. Patients
treated with an oral antibiotic may be given topical antibiotics when
the dose of the oral antibiotic is tapered.

The response to oral antibiotics is unpredictable. Some patients
respond while other do not. It is difficult to predict who will
benifit. Patients with nodular cystic acne may improve with oral
antibiotic therapy, but that response is often limited. These patients
frequently fail a course of oral antibiotics and topical therapy and
require isotretinoin.

Treatment strategy
Patients are treated with either a prolonged course or intermittent
courses of antibiotics before a complete response is achieved. Oral
antibiotics are usually given for a minimum of 1 to 3 months before the
dose is reduced. Once the appearance of new inflammatory lesions has decreased or stopped, the dose is gradually tapered then withdrawn. Topical retinoid therapy should be continued to maintain remission. Most P. acnes are sensitive to many antibiotics but less sensitive strains have appeared. Resistance to erythromycin has increased and limited the use of this drug.

Commonly used antibiotics
The most frequently prescribed antibiotics are tetracycline,
erythromycin, doxycycline, and minocycline. Clindamycin, and
trimethoprim杝ulfamethoxazole are very effective but are not used as
first line drugs because of their potential to cause serious side
effects. Tetracycline derived antibiotics are usually not given to
children under the age of 7 for fear of causing tooth staining.

Doxycycline, minocycline, and trimethoprim杝ulfamethoxazole are more lipid-soluble and therefore more effective than tetracycline and
erythromycin. P. acnes are sensitive to several antibiotics but the
prevalence of P. acnes resistant to antibiotics is increasing. Typical
starting dosages are tetracycline 500 mg bid, doxycycline 100 mg qd or bid, and minocycline 100 mg bid. All medications are available in
generic form. P. acnes is sensitive to other antibiotics such a
cephalosporins and ampicillin.

Tetracycline

Starting dose 500 mg bid
Taper dose 250 mg bid
Not taken with dairy products
GI intolerance
Photosensitivity-low incidence
Candida albicans vaginitis
Pseudotumor cerebri

Tetracycline is inexpensive. Food, particularly dairy products,
antacids, and iron interfere with the intestinal absorption. The
incidence of photosensitivity is low but increase with higher doses.
Gastrointestinal intolerance is common. Candida albicans vaginitis is a
common side effect. Pseudotumor cerebri in which the regulation of
intracranial pressure is impaired, is a rare complication. Increased
intracranial pressure causes papilledema and severe headaches.

Doxycycline

Starting dose 20, 50, 75, 100 bid
May take with food
GI intolerance
Photosensitivity
Candida vaginitis low incidence

Doxycycline is safe and commonly prescribed. It is less expensive than
minocycline. Recent evidence indicates that very low doses such as 20
mg bid may be effective . GI intolerance is common. The incidence of
photosensitivity is low but increases with increasing dose levels.
Photosensitivity reactions look like exaggerated sunburns.

Minocycline

Starting dose 50, 75, 100 bid
Most effective
May take with food
Photosensitivity-none
Vertigo ?dose related
Rare serious reactions
Blue-gray pigmentation

Minocycline is possibly the most effective oral antibiotic. Minocycline
is expensive but available as a generic. Photosensitivity does not
occur. It is highly lipid-soluble and penetrates the cerebrospinal
fluid, causing dose-related ataxia, vertigo, nausea, and vomiting in
some patients. Pseudotumor cerebri is rarely reported.

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Acne Treatment Oral Antibiotics Doxycycline

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