TABLE 5

Oral Antibiotics Used for Treatment of Moderate-to-Severe Acne Vulgaris

AntibioticRecommended DosagePotential Adverse EffectsComments
Doxycyclinea50–100 mg QD or BID; 150 mg QDGastrointestinal upset especially pill esophagitis (reduced with enteric coated formulation); photosensitivity (especially in doses of ≥100 mg daily); staining of forming tooth enamel (if given ≤8 y of age); vaginal candidiasis; BIH (rare).Can be taken with meals, take with large glass of water and maintain upright position ≥1 h to decrease risk of esophagitis; optimize photoprotection especially in sunny season or with known increased outdoor exposure; avoid in children who have not developed set of permanent teeth; monitor for blurred vision, severe headaches sometimes with nausea and/or vomiting.
Erythromycinb250–500 mg QD-BIDGastrointestinal upset; drug-drug interactions such as increase in carbamazepine serum levels → toxicity.High prevalence of antibiotic-resistant P acnes.
Tetracycline500 mg BIDFixed drug eruption; gastrointestinal symptoms; staining of forming tooth enamel (if given ≤8 y of age); vaginal candidiasis; BIH (rare).Ingest on empty stomach preferable; absorption is decreased if taken with iron, calcium, or many other metal ions found in vitamins/supplements, dairy products (including milk, yogurt); avoid in children who have not developed set of permanent teeth; avoid in renal or hepatic disease; monitor for blurred vision, severe headaches sometimes with nausea and/or vomiting.
Minocycline (immediate release)50–100 mg QD-BIDCutaneous and/or mucosal hyperpigmentation of skin and mucosal sites (oral, sclera, conjunctiva); bone may be affected in some cases; DHS (systemic) often with hepatitis and/or pneumonitis (most often will occur within the first 1–2 mo); hepatitis (hypersensitivity [tends to occur more acutely early in treatment course] or autoimmune [more often to occur with more chronic use of several months to years]); LLS; Stephens-Johnson syndrome; vestibular toxicity (tends to occur within the first few days after starting therapy); staining of forming tooth enamel (if given ≤8 y of age); vaginal candidiasis; BIH (rare).Can be taken with meals; warn patient about dizziness/vertigo (suggest initial doses be given when at home and not driving to assess if patient susceptible to these effects); avoid in children who have not developed set of permanent teeth; monitor for malaise, flulike symptoms, diffuse erythema with facial swelling, respiratory complaints suggestive of drug hypersensitivity especially within the first few months after starting therapy; discontinue therapy if this side effect suspected; monitor for malaise, distal arthralgias with or without arthritis especially with more prolonged use of several months to years suggestive of LLS; monitor for pigmentary changes on skin especially face, trunk, legs, and scars; monitor for blue or gray discoloration of sclera, oral mucosa, nail beds; monitor for blue discoloration of acne scars; some cases may be persistent even with discontinuation; monitor for blurred vision, severe headaches sometimes with nausea and/or vomiting.
Minocycline extended-release tablets (available since 2006)1 mg/kg QDSame potential reactions as above although above side effects reported predominantly with immediate-release formulations (available since 1971); lower incidence of acute vestibular side effects with weight-based dosing (1 mg/kg per day).Same as above except lower incidence of acute vestibular side effects with weight-based dosing (1 mg/kg per day); not yet known if other potential side effects reduced with weight-based dosing of the extended-release formulation; less accumulation of minocycline over time due to pharmacokinetic properties of extended-release formulation; may possibly correlate with decreased risk of cutaneous or mucosal hyperpigmentation if dosed properly by patient weight.
Trimethoprim/ sulfamethoxazole160–800 mg BIDSevere cutaneous eruptions (toxic epidermal necrolysis, Stevens-Johnson syndrome); bone marrow suppression (anemias, neutropenia, and thrombocytopenia); hypersensitivity reactions; drug eruptions (rash); fixed drug eruption.Not generally recommended for use as first or second-line agent for acne; to be used judiciously in selected refractory cases; obtain complete blood cell count at baseline and periodically thereafter; additional caution in patients with history of anemia (megaloblastic types); may warrant hematologic consultation if use of this agent highly considered.
  • BID, twice daily; QD, once daily. Adapted from Tan,69 Gollnick et al,15 and Del Rosso and Kim.70

  • a Enteric-coated and double-scored 150 mg tablet available; double-scored tablet provides 50 mg/unit (tablet can be administered whole or broken into total of 3 segments).

  • b Use of lower dose for maintenance therapy based on anecdotal experience or clinical impression and not by large-scale clinical trials.