Which oral antibiotics are best for acne?

A 2006 RCT randomized 290 patients to the macrolide azithromycin (500 mg daily for 3 consecutive days a week in the first month, then 250 mg every other day for 2 months) or tetracycline (1 g daily for 1 month, then 500 mg daily for 2 months). The drugs produced comparable results: an 84.7% improvement with azithromycin and a 79.7% improvement with tetracycline (P<.05).⁶ Compared with other macrolides and tetracycline, azithromycin has a more tolerable side-effect profile with fewer GI disturbances.

Lack of sufficient data on trimethoprim±sulfamethoxazole, fluoroquinolones, and cephalosporins precludes their inclusion in routine acne treatment.

Recommendations

The American Academy of Pediatrics (AAP) recommends topical retinoids as the foundation of treatment for most acne patients, and a topical microbial agent for additional therapy. Oral antibiotics should be reserved for moderate to severe inflammatory acne; tetracyclines are the standard first-line choice in most cases. The AAP warns against giving tetracyclines to children younger than 10 years because of the risk of permanent discoloration of teeth and abnormal skeletal development.^7,8

The American Academy of Dermatology also recommends topical retinoids as first-line therapy for acne followed by oral doxycycline or minocycline if needed. Erythromycin is recommended for patients who can’t use tetracyclines, but with a warning about possible bacterial resistance.⁹

TABLE 1 shows the cost of various acne medications. TABLE 2 outlines their safety and risk profiles.

TABLE 1
Estimated cost of oral acne medications