If your acne isn’t responding to topical treatments, then oral therapy is probably the next step. This article looks at the primary oral agents used to treat acne: antibiotics. We sometimes treat acne in women with hormones. These oral agents are usually prescribed to be used in combination with the topical drugs you may have already been applying.

I give you the scoop on the advantages and disadvantages to the major acne-fighting oral antibiotics. I help you understand the dosing strategies and give you the tips to discuss with your doctor for using the medication to get the best results for you. (You can only get these drugs with a prescription from your doctor.) And finally, I show you where to get help if you’re having trouble with your oral medications.

Understanding Oral Antibiotic

Oral antibiotics are used in the management of moderate to severe acne. Oral antibiotics work on acne by virtue of their antibacterial and anti-inflammatory effects. Compared with topical therapy, oral therapy has a more rapid onset of action and works faster to improve your acne.

Commonly, though, multiple medications are combined for the most effective treatment of acne. So in most cases, patients use more than one medication at any given time.

By using drugs that have different means and modes of activity — for example, by taking oral antibiotics and applying a topical treatment — you attack your acne on several fronts.

In designing your treatment regimen, your doctor can choose combinations of different classes of drugs that work on different targets, based on the severity of your acne and the possible side effects of the medication.

Being prescribed oral medications is not a message that you should stop applying topical medications! Make sure you go over your full medication regimen with your doctor before you leave her office. If you have questions later after you leave, call back to clarify.

Deciding it’s time for oral antibiotics

Your doctor may decide to add oral antibiotic therapy to your topical therapy because the topical medications are:

• Working too slowly
• Not doing the job well enough to suit you
• Not working at all

Or:

• Your acne is scarring
• You have moderate to severe inflammatory lesions
• Your lesions are widespread, even on your chest and your back
• Your prom is coming up next month
• You experience big swings in your acne that are related to your period (if you’re female, of course)
• You’re becoming depressed

Addressing some common concerns

Whenever oral drugs are taken, the potential dangers — including side effects, drug allergy, drug resistance, drug intolerance, drug interactions, and fetal exposure in women who are or may become pregnant — must be carefully considered.

A risk-benefit assessment is particularly important whenever a benign (non-life-threatening) condition such as acne is being treated. That means that you should ask your doctor about the advantages of taking an oral medication versus the disadvantages (such as possible scarring) of not taking it.

Ask about the possible side effects — the risks — and what positive things you might expect — the benefits — if you take the drug. Antibiotics, both topical and oral, have been central to the treatment of acne for many years. However, public health concerns about their widespread use has increased in recent years due to a number of issues:

• Bacterial resistance: Resistance means that a medicine no longer works, or becomes less effective, because the bacteria change (mutate) and no longer respond to the drug that is trying to kill or suppress them.

No matter how many new antibiotics we come up with to fight P. acnes, the bacterium seems to find a way to outwit us and become resistant to our latest weapons. It’s like trying to fight computer viruses that find ways to adapt to ever-changing methods we use to destroy them.

Despite the well-founded concerns about creating bacterial resistance, these drugs have a long track record of safety. They’re effective, efficient treatments for many people who have acne as well as acnelike disorders, such as rosacea.

• Purported links between oral antibiotics and breast cancer: A well-publicized study suggested that the long-term use of antibiotics is associated with an increased risk of developing breast cancer.

The study indicated that the risk was dependent on the cumulative dose and the amount of time a woman was taking antibiotics. The study had many flaws and never came to the conclusion that there was a direct causal link between antibiotics and breast cancer.

• Antibiotics’ influence on the efficacy of birth control pills: Studies have shown that none of the antibiotics used commonly to treat acne interfered with the efficacy of oral contraceptives. But a woman can get pregnant while on any brand of birth control pill, whether taking antibiotics or not.

A recent study has suggested that the ingestion of oral antibiotics as well as the use of topical antibiotics in the treatment of acne may be associated with an increased risk of infectious respiratory diseases such as strep throat infections.

The best take-home message for you is that you should try your best to limit long-term use of antibiotics as much as possible until further studies and more data become available.

Worry about the safety of long-term oral medications has lead to a recent interest in the use of physical treatments such as lasers and other special light therapies to treat acne.

Tetracyclines

The tetracyclines are the workhorses in oral acne therapy. They’re the first-line oral antibiotic drugs of choice in the management of moderate to severe acne. The tetracycline preparations inhibit the growth of P. acnes by going right to your sebaceous glands to attack the bacteria.

They’re bacteriostatic antibiotics, which means that they inhibit the growth of bacteria rather than kill them. In addition, they have an anti-inflammatory action that is equally important in the treatment of patients with papules and pustules. There are three types of tetracyclines:

• “Plain” (generic) tetracycline
• Minocycline
• Doxycycline

Improvement of acne is usually noticeable in a matter of a few weeks or less with all of these tetracyclines. This response varies and depends on the severity of your acne; however, you may see the papules and pustules begin to flatten and disappear, and new ones should stop popping up.

Tetracyclines may be tapered when this improvement persists. The decision about when and if to taper your dosage will be up to you and your doctor to decide. Often they have to be continued for long stretches of time — sometimes even for years.

Tetracyclines - warnings, risks, and side effects

Despite the low risk of side effects from tetracyclines, before taking the drugs, you should know a few things. Because patients frequently use anti-acne oral antibiotics on a long-term basis (in some instances, for years), many people are understandably concerned about possible consequences.

Studies have indicated that routine laboratory supervision of healthy young people given long-term tetracycline therapy isn’t necessary. In a nutshell, in most cases, you don’t need regular blood tests done while taking these antibiotics.

When treatment extends for more than one to two years, however, some dermatologists recommend periodically monitoring certain blood tests. This is particularly important if you have a history of liver, kidney, or an autoimmune disease. In such cases, you should get them checked more often.

Damage to teeth and bones

One of the main side effects of tetracycline is staining the teeth of children. There are also risks to the teeth and bones of unborn babies and nursing children. You shouldn’t take them if you are:

• A child under 10 years of age: The use of any of the tetracyclines during a child’s tooth development (before the age of 10) may cause a permanent discoloration of the teeth.

• A woman who is breastfeeding or pregnant: If a tetracycline is taken during pregnancy or while breastfeeding, an infant’s teeth can become discolored and there also may be a slowing down of the infant’s bone growth. The discoloration of the baby teeth is due to calcification (hardening) of the teeth, which starts in the second trimester (after 12 weeks of pregnancy).

Tetracyclines may also temporarily stain the teeth of older patients, particularly those with orthodontic braces. When taking any one of the tetracyclines, you should practice good dental hygiene, including flossing.

Other side effects

Here are some other side effects that may occur when taking the tetracyclines:

• As with many other antibiotics, you may experience mild indigestion and abdominal upset. They can also cause more severe gastrointestinal irritation (inflammation of your esophagus or stomach).

• Rashes are uncommon, but when they appear, they can be severe.

• They can sometimes produce phototoxic reactions (an increased tendency to sunburn). This reaction is more likely to occur with doxycycline.

• If you have a history of vaginal yeast infections known as candidal vulvovaginitis, a broad-spectrum antibiotic such as a tetracycline or an erythromycin can permit such an infection to reappear. Candidal vulvovaginitis can also occur for the first time when using these antibiotics.

And use them cautiously if you have a personal or family history of lupus erythematosus (an autoimmune disease). And don’t take them if you’re allergic to any of the tetracyclines. Tetracyclines also have the following very rare risks:

• Severe headaches due to increased pressure in the brain (intracranial hypertension) are seen very rarely. However, you can get “regular” headaches from the tetracyclines without developing this complication.

• A hivelike, hypersensitivity rash, which includes joint swelling.

• Drug-induced hepatitis with jaundice (yellowish discoloration of the whites of the eyes, skin, and mucous membranes), nausea, and dark urine.

If you develop any of the preceding symptoms, call your doctor immediately.

Taking generic (“plain”) tetracycline

By “plain” tetracycline we doctors mean the original, generic, or “branded generic,” tetracyclines. I list the available forms in Table 1.

Brand Name	Generic Name	Delivery	Common Starting Dosages
[Generic]	Tetracycline	Capsule, tablet, syrup	250 or 500 mg, twice a day
Achromycin (Branded generic)	Tetracycline	Capsule, tablet, syrup	250 or 500 mg, twice a day
Sumycin (Branded generic)	Tetracycline	Capsule, tablet, syrup	250 or 500 mg, twice a day

“Plain” tetracyclines are the most cost-effective of the tetracyclines and are much less expensive than minocycline and doxycycline. However, “plain” tetracycline isn’t always as effective as these two drugs when it comes to treating your acne. Tetracycline is given in dosages ranging from 250 milligrams twice a day to 500 milligrams twice a day.

It is usually begun at a dose of 500 milligrams twice daily, although 250 milligrams twice daily may also be effective. Plain tetracycline is taken with a full glass of water so it doesn’t irritate your esophagus, which can be a really painful experience. Take it on an empty stomach. (Your stomach is empty one hour before or two hours after meals.)

And finally, don’t take it with dairy products such as milk or with products that contain iron, magnesium, zinc, or calcium, because these compounds may interfere with tetracycline’s absorption from your stomach and make it less effective.

The dosage of the drug may be tapered as inflammation lessens (usually after six to eight weeks), but this will vary depending upon your individual response.

Taking minocycline

Minocycline is a very effective oral antibiotic for treating acne. It’s also the most expensive. Minocycline is available in generic formulations and is sold under several brand names, including those I list in Table 2.

Brand Name	Generic Name	Delivery Dosages	Common Starting
[Generic]	Minocycline	Capsule, tablet, liquid	50, 75, or 100 mg, twice a day
Minocin	Minocycline	Capsules, oral suspension	50 or 100 mg, twice a day
Dynacin	Minocycline	Capsules, tablets	50 or 100 mg, twice a day
Vectrin	Minocycline	Capsules	50, or 100 mg, twice a day

Minocycline is given in doses ranging from 50 milligrams twice a day to 100 milligrams once or twice a day. Minocycline’s excellent absorption means it may be taken with food, even dairy products, without interfering with its efficacy, so you’re less likely to get an upset stomach than if you were taking a “plain” tetracycline.

As with “plain” tetracycline and doxycycline, the dosage of the drug can be tapered when the inflammation has lessened. Additional advantages of minocycline include:

• Few, if any, sun-related problems.
• It appears to be less likely to induce vaginal yeast infections than plain tetracycline.

But, in addition to the expense, minocycline use includes other disadvantages:

• Dizziness: This side effect usually settles after a few days or when the dosage is lowered.

• Skin pigmentation: A reversible bluish darkening of the gums and/or skin may occur with long-term use.

• Nausea: Minocycline is more likely than plain tetracycline to cause such side effects as nausea, vomiting, and, in high doses (those that approach 200 milligrams per day), dizziness or vertigo.

• Permanent tooth discoloration: A very rare, irreversible blue discoloration of permanent teeth has been reported. Professional capping may be necessary to hide it.

One very rare, more serious side effect may exist with minocycline: A syndrome known as drug-induced lupus erythematosus occurs (most often in young women), and usually develops late in the course of therapy with minocycline.

It has rarely proved fatal. The symptoms consist of swollen glands, rash, fever, and joint pains. This condition generally resolves within weeks or months of stopping minocycline.

Taking doxycycline

Doxycycline is also a tetracycline. It is available in generic formulations as well as brand names that I include in Table 3. In addition, doxycycline is available as a branded generic that goes by a number of names. It is somewhat less expensive and probably somewhat less effective than minocycline.

Brand Name	Generic Name	Delivery	Common Starting Dosages
[Generic]	Doxycycline	Capsule, tablet, liquid	50, 75, or 100 mg, twice a day
Periostat	Doxycycline hyclate	Tablets	20 mg, twice a day
Adoxa	Doxycycline	Tablets	75 or 100 mg, twice a day

Doxycycline is given in doses ranging from 50 milligrams twice a day to 100 milligrams once or twice a day. It may also be prescribed to be taken as 75 milligrams once or twice a day. Doxycycline is well absorbed and may be taken with food. Taking it with food will make you less likely to get an upset stomach.

In addition to the slightly lower cost of doxycycline versus minocycline, another advantage of doxycycline is that the potential serious side effects sometimes seen with minocycline (dizziness, vertigo, skin darkening, and the lupus-like syndrome) have not been reported with doxycycline.

However, doxycycline’s main disadvantage is its phototoxic potential — severe reactions to sun exposure— the highest of the tetracyclines. You should be advised about sun protection if you’re prescribed this medication. Realistically, however, this is an uncommon side effect.

Second-Line Oral Antibiotics

In some cases, tetracyclines may not work and your doctor will have to resort to some other oral antibiotic. Less commonly used oral antibiotics for moderate to severe inflammatory acne include:

• Erythromycin: It’s useful as a second-line alternative when tetracycline fails or isn’t tolerated. Younger children (under age 10) can take it because it doesn’t stain their teeth like tetracycline does.

Although you should strive to avoid the use of oral drugs if you’re pregnant, trying to become pregnant, or breastfeeding, in exceptional circumstances, erythromycin can be taken safely during these times. There are a couple of drawbacks associated with erythromycin:

Bacterial resistance is a concern, and stomach upsets and diarrhea are not uncommon side effects of erythromycin.

An enterically coated (designed to pass through the stomach undigested and into the intestines where they’re absorbed) erythromycin product such as E-Mycin is less likely to cause gastrointestinal upsets and diarrhea.

As with the tetracyclines, erythromycin can permit vaginal yeast infections, known as candidal vulvovaginitis, to reappear. Candidal vulvovaginitis can also occur for the first time when taking erythromycin.

• Amoxicillin: This penicillin derivative is another safer alternative to a tetracycline that can be used during pregnancy.

• Azithromycin (Zithromax): The use of azithromycin, an antibiotic, as a four- or five-day pulse therapy in women who have monthly premenstrual acne flares has recently gained some interest.

Pulse therapy (also called intermittent therapy) means not taking a medicine every day; rather it’s taken, for example, for several days per week or for one week per month, discontinued, and then started again.

The pattern repeats itself as necessary. Other pulsing routines have been suggested to reduce the cost of this very expensive drug that is effective in the reduction of inflammatory acne lesions.

Some dermatologists suggest that azithromycin is an alternative to tetracycline in patients with moderate to severe acne. It has no serious side effects; however, as with all of the antibiotics, buildup of bacterial resistance is a concern.

• Clindamycin: This antibiotic is a very effective acne fighter; however, the resistance pattern is similar to that of erythromycin and it has potentially serious side effects. Furthermore, this drug has been associated with a severe type of gastrointestinal infection.

• Cephalosporins: The new-generation cephalosporin antibiotics appear to have good activity against acne. Again, bacterial resistance is a concern with these agents.

• Trimethoprim sulfasoxazole (TMZ): This is an oral sulfonamide that is very effective as an anti-acne agent. It is reserved for unusually stubborn cases of severe acne that don’t respond to any of the other antibiotics listed here.

It is sometimes used in situations in which Accutane isn’t appropriate. TMZ has been associated with severe side effects and may precipitate severe allergic reactions. These reactions are quite rare. The development of resistance is also an issue.

Surveying Strategies to Reduce Antibiotic Use

I recommend that you make every effort to taper off oral antibiotics as soon as your acne is under control. An oral antibiotic may be intended for daily use over an extended period of time, often for four to six months and possibly much longer.

Eventually, your doctor will taper off the medication and finally discontinue using it as your acne improves. The ideal long-term goal is to stop oral antibiotics altogether and rely only on topical therapy. In this section, I explain ways your doctor may decrease the total amount of antibiotic that you have to take while treating your acne.

If necessary, antibiotics may be continued at the lowest effective dose for long periods of time, especially if your acne is persistent. However, this practice can lead to antibiotic resistance. But remember, always discuss these options with your doctor. Don’t just change your doses on your own. Your doctor knows more about your skin and appropriate treatment for your acne than I do.

Rollercoastering is a term I use to describe a method of fine-tuning the dosage of oral antibiotics that may help to minimize some potential side effects, lessen the total dosage you take, and bring the cost of the medication down. For example, a dosage schedule can begin with two 50 milligram minocycline capsules to be taken in the morning and one in the evening, which equals 150 milligrams per day.

Because the highest recommended dosage is 200 milligrams in one day, this dosage allows for a possible increase of an additional 50 milligrams per day on your next follow-up visit to your dermatologist. However, if your acne shows marked improvement on the follow-up visit, your doctor may lower your dosage to say, 50 milligrams twice a day.

If you experience premenstrual flares of acne, talk to your doctor about increasing the dosage five to seven days before your next menstrual period and then lowering your dosage afterward. Other ways to reduce the amount of antibiotics used to treat acne include pulsing, using Accutane and other oral isotretinoins, and cortisone injections.

Your Guides to Your Medications

How did the doctor say that I should apply that cream? What were the side effects of that pill? Should I take it on an empty stomach or with food? If you’re like most people, you probably don’t remember half of what was said to you in your dermatologist’s or healthcare provider’s office.

Be sure to ask for written material about acne in general and also be sure you get written directions on how to use the medications that are prescribed for you. When you get home, make sure you read the material so that you understand the possible side effects, correct dosage, and everything else you need to know.

If you have any questions, be sure to call your dermatologist or healthcare provider rather than waiting for your next office visit. Your pharmacist should be a great resource for you. You can always ask for information about any of the drugs you were prescribed, as well as any of the over-the-counter drugs that you may be buying without a prescription.

Better yet, ask your pharmacist for a printout that describes all of the actions and possible reactions you may experience with a prescription drug. You can also turn to the package insert (the piece of paper that’s supplied by the drug manufacturer), which has all that small print that describes every possible thing that has happened, or might happen, to anybody who takes the drug.

It has more information than you’ll ever need to know about the drug you were prescribed and it may convince you never to take it. If you desire, remember to ask your dermatologist or pharmacist whether there is a generic substitute for the prescribed medication.