For people with 10 or more cystic lesions, oral antibiotics may be prescribed. Oral antibiotics are recommended as a treatment option in cases of moderate and severe cystic acne with inflammation. The antibiotics work to reduce the number of bacteria and the associated inflammation.
The most commonly prescribed oral antibiotics are tetracycline, doxycycline, and minocycline. Some of the other groups of antibiotics prescribed include macrolides, co-trimoxazole, and trimethoprim. Oral antibiotics are typically used for 2 to 5 months or until the person is no longer developing new cysts.
Antibiotics that may work well for cystic acne include cephalexin and cefadroxil. Co-trimoxazole, trimethoprim, and in recent times, azithromycin have also been shown effective in the treatment of severe acne.
In some research studies, the use of doxycycline in sub-antimicrobial dose (this means around 20 mg twice daily) together with a delayed release minocycline tablet have been successfully used for the effective control of moderate and severe cystic acne, but more studies and clinical trials are required to validate these results.
Side Effects Associated With The Use of Oral Antibiotics
The most common side effects experienced with the use of oral antibiotics include gastrointestinal issues as well as vaginal candidiasis. Doxycycline has been linked with the development of photosensitivity (sensitivity to the sun) in the user, especially in long-term use. Minocycline has been implicated in possible incidents of production of pigment deposits within the skin, in the mucous membrane and even on the teeth.
Long-term treatment of severe forms of acne using oral antibiotics has the potential risk of not only promoting antibiotic resistance in P. acnes, but also within coagulase negative Staphylococci residing on the skin, in species of Staphylococcus aureus living in the nostrils and naturally found Streptococci within the mouth cavity. A very high level of association has been found between long term or inappropriate oral antibiotic use in acne treatment or management and episodes of frequent upper respiratory tract infections like sore throats, cough and tonsillitis. Accordingly, oral antibiotic use should be optimized and limited to shorter time frames.
Optimization of Oral Antibiotic Treatments for Cystic Acne
Several research studies have shown that issues related to the development of antibiotic-resistant P. acnes strains involved in cystic acne outbreaks is on the rise and it is more prevalent with users of oral erythromycin. As such, oral antibiotic use should be limited and non-antibiotic formulations should be explored whenever feasible and useful.
If antibiotics are selected as a treatment option, it should be in combination with a topical retinoid or benzoyl peroxide, dependent on each patient’s acne history. Whenever possible the length of the treatment must be curtailed.
The use of oral antibiotics is generally restricted to cases of very severe acne, outbreaks of cystic acne mostly on the trunk, in outbreaks of cystic acne that has proven to be unresponsive to topical options, and in patients that have types of skin with greater risk for scar development.
Usually, people who search for treatment are looking to achieve total clearance of the acne and not just a decrease in the number of lesion counts. Even though antibiotics have been found be effective in the context of decreasing the outbreaks as well as the numbers of inflammation related acne lesions, they are unable to completely resolve acne.
Presently, there is a lack of clear evidence of data which can prove that one oral antibiotic is more efficient than the others in resolving cystic acne, or even show that use of oral antibiotics is a more effective treatment option as compared to topical formulations. In addition, there is not much data indicating that the use of high doses of oral antibiotics is more effective as compared to use of low doses, or that taking controlled or delayed release formulations is a better option.
The option of oral antibiotics thus has to be chosen as per the suitability for the patient, the patient’s preference, the side-effect profile, how severe the acne is, as well as the cost in terms of one patient can afford.
The normal minimum time frame for oral antibiotic treatment of acne is six to nine weeks. In some cases of stubborn acne, it could be extended up to 10 to 16 weeks. Research studies and clinical trials done on a large scale have shown that 6 to 8 weeks in a sufficient time frame for assessing the response of the patient. If a patient does not show a suitable response to the oral antibiotics or at any stage stops responding, it has already been documented that giving a higher dose for more frequent doses can work. If no significant improvement is seen, then the antibiotics must be discontinued. Furthermore, use of oral antibiotics should not be utilized for routine maintenance of acne prevention since there are many treatment options at the same level of effectiveness.
Benzoyl peroxide provides protection against antibiotic resistance simply through the elimination of resistant bacteria. The Global Alliance to Improve Outcomes in Acne has recommended in its guidelines that when oral antibiotics are used for treatment over a period that extends beyond 2 months, benzoyl peroxide must be utilized for at least a week in between the courses of the antibiotic, so as to decrease the growth of resistant bacteria on the affected area of the skin.
Due to the global rise in the levels of antibiotic resistance, use of oral antibiotics should be carefully considered. Antibiotics are not able to effectively address all the other causative factors in acne and usually require many weeks or months of treatment to have some impact on acne. Antibiotics are best when they are used together with other combination drugs which are able to “unclog” the skin follicles.
Estimated costs for commonly available products containing oral antibiotics:
Approximate cost of 30 capsules of tetracycline: $70 to $420 [GoodRx_Tetracycline].
Approximate cost of 30 capsules of doxycycline: $10 to $40 [GoodRx_Doxycycline].
Approximate cost of 30 tablets of minocycline: $40 to $180 [GoodRx_Minocycline].