37. Pros and cons of oral antibiotics for acne

Doctor Jacob here, and we're talking about the pros and cons of oral antibiotic therapy for the treatment of acne.

First let's talk about when is it appropriate to use an oral antibiotic for treating acne. Antibiotics kill bacteria and they also have anti-inflammatory properties, but one thing that you have to know is they do not unclog pores, they are not comedolytic. There are a bunch of different antibiotics out there, but only a few can really help acne, or at least do a good job of it. But one thing that I want to stress is that they're kind of temporary treatments. You can take them and they'll help you out for a while, but when you stop taking them the acne tends to return, and it's not a good idea in most cases to be on oral antibiotics for years and years, because of potential side effects.

In most cases, I like to use oral antibiotics in patients with inflammatory acne when I'm trying to buy time for other therapies to work. For example, starting a patient on some oral antibiotic and then giving a good topical regimen, and hopefully after six weeks the topical regimen will start to work, unclogging the pores, working at the root cause of acne, whereas the antibiotics work quickly to control the inflammation, and then allow time for the topical therapies to do their thing.

Not all antibiotics help acne. Penicillins for example don't really do a good job - penicillin, cephalexin or Keflex, amoxicillin are not so helpful for acne.

Next I want to talk a little bit about the concept of antibiotic resistance. We don't want your neighbor having to get in trouble with a bacterial infection and suddenly all the bacteria in the community are now resistant to this antibiotic because everyone has used it for acne for years and years. So that's something that everyone's talking about these days with antibiotics and acne - minimizing their use to minimize the development of antibiotic resistance in the community. So I definitely do try to minimize the use for that reason, of oral antibiotics.

Another reason not to favor the use of antibiotics for the treatment of acne is that antibiotics disturb the human microbiome. The microbiome means the set of all the bacteria and microorganisms that are living alongside of us in our bodies - on mucus membranes, on the skin and so forth. By taking antibiotics to treat acne to get the bacteria in the pores we also have a lot of collateral damage, where we lose a lot of bacteria that live with us. This could lead to some side effects, for example in many cases antibiotics can cause yeast infection in women, antibiotics can cause loose stools or tummy upset or diarrhea, and in certain cases can cause nastier problems of the intestines in particular. There has been a link showing that repeated courses of antianaerobic antibiotic - those that disturb bacteria typically that live in the gut - can raise the risk of developing a certain type of chronic inflammatory disorder of the intestines called inflammatory bowel disease, and we'll talk more about that in a later episode.

There are two main antibiotics currently in use for the treatment of acne, and that's doxycycline and its cousin, minocycline. There are others which you may hear of, for example azithromycin, which has its use in pregnancy, as well as a combination antibiotic called sulfamethoxazole trimethoprim, which because it's such a long name it's often referred to as Bactrim, Septra or Sulfatrim. This drug is actually very effective, but has some serious potential side-effects. We'll talk about each of these individual antibiotics in detail later. I do want to mention one in particular now called clindamycin, which I do not recommend using for acne because of a serious gastrointestinal issue called pseudomembranous colitis, also known as clostridium difficile colitis. This is a condition which is basically a side effect of clindamycin therapy. Topical clindamycin is very safe, but oral clindamycin when taken as a pill kills off a lot of the bacteria and lets one bacteria grow in particular, to the point where it can take over and cause a serious infection that could lead to removal of parts of the intestines - very bad thing, and we don't need that when we treat acne. So I won't mention any more of this drug clindamycin when used orally in these episodes.

We'll talk more about each of the antibiotics that are in use for acne in the coming episodes, but just to summarize so far, oral antibiotics tend to work when the right antibiotic is chosen. I try to avoid long-term antianaerobic antibiotics, and we'll talk about which ones those are in the coming episodes. I pretty much always avoid the use of oral clindamycin in the treatment of acne, because I don't think the use is justified when the risks are taken into account. And I do worry about antibiotic resistance from the overuse of full-strength antibiotics for the treatment of acne.

In the next episode we will touch on sub-antimicrobial dosing, which means using antibiotics in tiny doses to get the anti-inflammatory effect, but without actually killing bacteria.

That's all for today, I'm Doctor Jacob. We'll see you next time.