Oral Antibacterial Therapy for Acne Vulgaris

An Evidence-Based Review

Amanda Bienenfeld; Arielle R. Nagler; Seth J. Orlow


Am J Clin Dermatol. 2017;18(4):469-490. 

In This Article

Abstract and Introduction


Background To some degree, acne vulgaris affects nearly every individual worldwide. Oral antibiotic therapy is routinely prescribed for the treatment of moderate to severe inflammatory acne; however, long-term use of oral antibiotics for acne may have unintended consequences.

Objective The aim of this study was to provide a systematic evaluation of the scientific evidence on the efficacy and appropriate use of oral antibiotics in the treatment of acne.

Methods A systematic search of MEDLINE was conducted to identify randomized controlled clinical trials, systematic reviews, and meta-analyses evaluating the efficacy of oral antibiotics for acne. Overall, 41 articles that examined oral antibiotics compared with placebo, another oral therapy, topical therapy, alternate dose, or duration were included in this study.

Results Tetracyclines, macrolides, and trimethoprim/sulfamethoxazole are effective and safe in the treatment of moderate to severe inflammatory acne. Superior efficacy of one type or class of antibiotic could not be determined, therefore the choice of antibiotic is generally based on the side-effect profile. Although different dosing regimens have been studied, there is a lack of standardized comparator trials to determine optimal dosing and duration of each oral antibiotic used in acne. The combination of oral antibiotics with a topical therapy is superior to oral antibiotics alone.

Conclusion This article provides a systematic evaluation of the scientific evidence of the efficacy of oral antibiotics for acne. Due to heterogeneity in the design of the trials, there is insufficient evidence to support one type, dose, or duration of oral antibiotic over another in terms of efficacy; however, due to increasing resistance to antibiotics, dermatologists should heed consensus guidelines for their appropriate use.


Acne vulgaris is the eighth most prevalent disease worldwide. Almost every individual between 15 and 17 years of age is affected.[1,2] Acne may be associated with lasting side effects, including facial scars, feelings of low self-esteem, and depression.[3]

Several independent, interacting factors contribute to acne pathogenesis, including increased sebum production, increased keratinization of the follicular epithelium, inflammation, and overgrowth of normal skin microflora, particularly Gram-positive Propionibacterium acnes.[4–6] These factors are inter-related and synergistic; therefore, it is difficult to tease out the primary or initiating process. Sebum, the nutrient source of P. acnes, is necessary for acne development.[5] In turn, P. acnes, relying on sebum, forms biofilms in sebaceous sites, which promotes follicular hyperkeratinization and stimulates the host inflammatory response.[6,7] The resulting inflammation leads to follicular wall rupture, and the downstream inflammatory response stimulates further tissue destruction and scar formation.[6] In addition, increased follicular keratinization promotes even more proliferation of P. acnes, creating a complex cycle.[4]

Acne therapies include topical and systemic treatments, targeting different aspects of acne pathogenesis. Oral antibiotics are routinely prescribed for the treatment of moderate–severe inflammatory acne and are believed to be successful because they target both the bacteria and associated inflammation. The antibiotics used in the treatment of acne include tetracyclines, macrolides, clindamycin, and trimethoprim/sulfamethoxazole. However, despite their efficacy, prolonged use of oral antibiotics may potentially alter the skin and gut microbiome and contribute to antibiotic resistance, a growing global concern. The aim of this review was to critically evaluate the published literature on the role of oral antibiotics in the treatment of acne, as well as the specific classes, doses, and duration of treatment.