Acne Treatment Tetracycline

Tomorrow when we arrive into clinic (or this afternoon if you are reading this during your lunch break), we will invariably be greeted with patients who struggle with one of the most common diseases we treat – acne.  More than likely, we will reach for topical retinoids, topical antibiotics, and the occasional systemic antibiotic.  Evidence supports the short-term use of systemic antibiotics to gain control of acne and help our topical regimens overcome the disease process. Yet, in an era when concerns of antibiotic resistance are ever-present and our knowledge of the microbiome is ever-increasing – are we doing the right thing? How can we be stewards of proper antibiotic use in light of resistance concerns while simultaneously bringing out the best skin for our patients?

During the 2020 GW Virtual Appraisal of Advances in Acne Conference, Dr. Neal Bhatia, Director of Clinical Dermatology at Therapeutics Clinical Research in San Diego, CA, helped us fine-tune our use of these effective, but sometimes misused, elements of our armamentarium against acne. In his lecture, Use of Antibiotics in Acne, Dr. Bhatia displayed his eminent ability to breakdown important research and guidelines to help us answer clinically relevant questions.

Before we get into the full review, here are my “practice barometers” – what I took away from the lecture that may change my practice or confirm my standards:

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Consider anti-inflammatory dose antibiotics, photodynamic therapy, hormonal therapies, and other adjuncts in a patient who needs longer-term control, but is not a candidate for isotretinoin

Per capita, what specialty writes the greatest number of oral antibiotic prescriptions? Answer: dermatologists.  It should be no surprise that the majority are in the tetracycline class.  These tetracyclines have multiple effector points on the pathogenesis of acne – but how? Prior to comedogenesis, there are elevated inflammatory markers in uninvolved skin of patients with acne (increased CD4+ T-cells, increased macrophages, follicular IL-1 expression, aberrant integrin expression).  So, what comes first, the comedone or the inflammation? Note, a similar discussion is occurring in hidradenitis suppurativa. Either way, tetracyclines are able to inhibit the activation or impact of matrix metalloproteinases (MMPs), kallikrein 5 (KLK5), and human cationic antimicrobial protein 18 (hcap18) which lead to inflammation in acne lesions. In that light, maybe our script pads are being used correctly!

I am sure we have all considered, or even prescribed, other antibiotics for treatment of acne.  Each comes with advantages and disadvantages.

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Guidelines and consensus statements in the JAAD support the use of systemic antibiotics in patients with moderate to severe acne – but only when used with the right patient

So, it seems we are prescribing the right medicine.  But do we use a low dose? Regular dose? Dr. Bhatia presents a study that shows slightly better results with inflammatory lesion counts when treated with doxycycline 40mg modified-release as opposed to the traditional doxycycline dosed at 100mg daily in patients with moderate to severe acne

This information was presented by Dr. Neal Bhatia at the GW Virtual Appraisal of Advances in Acne Conference held July 30th, 2020. The above highlights from his lecture were written and compiled by Dr. James Contestable, staff dermatologist at Naval Medical Center Camp Lejeune. Images of slides courtesy by Dr. Neal Bhatia

Oral Antibiotics For Acne

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the US Government. The author is a military service member.

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In this series, we take a deep dive into the literature and guidelines to give you a quick reference on the use of new or complex therapies.  This series will become your go-to for information about dosing, potential interactions and laboratory monitoring, just to name a few.

Get your free copy of the Next Steps in Derm Guide, the expert’s guide to post-residency career choices and practice management advice from experienced physicians.It's also used to treat certain bacterial infections, for example chest infections such as bronchitis, pneumonia and mycoplasma infections, mouth infections and some sexually-transmitted infections. Additionally, it is used to treat infections transmitted by ticks, lice, fleas and mites, such as Rocky Mountain spotted fever, typhus group, Q fever and Coxiella endocarditis and tick fevers.

Tetracycline is a tetracycline-type antibiotic. It works by interfering with the ability of bacteria to produce proteins that are essential to them. Without these proteins the bacteria cannot grow, multiply and increase in numbers. Tetracycline therefore stops the spread of the infection and the remaining bacteria are killed by the immune system or eventually die.

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. This is a common type of bacteria that feeds on sebum produced by the sebaceous glands in the skin. It produces waste products and fatty acids that irritate the sebaceous glands, making them inflamed and causing spots. By controlling bacterial numbers, tetracycline brings the inflammation of the sebaceous glands under control and allows the skin to heal.

To make sure the bacteria causing an infection are susceptible to tetracycline your doctor may take a tissue sample, for example a swab from the infected area, or a urine, sputum or blood sample.

Tetracycline tablets should be taken on an empty stomach. This means an hour before food or two hours after food. Do not take the tablets at the same time as food, milk or dairy products, as these can stop the medicine being absorbed into the body properly and make it less effective.

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Swallow the tablets whole with plenty of water while you are sitting or standing to avoid the medicine irritating the throat. Avoid taking a dose just before going to bed.

Don't take indigestion remedies or medicines containing aluminium, calcium, iron, magnesium or zinc in the two hours before or after taking tetracycline tablets. These can reduce the absorption of tetracycline from the gut and make it less effective.

If you forget to take a tetracycline dose, take it as soon as you remember, unless it's nearly time for your next dose. In this case just leave out the missed dose and take your next dose as usual. Do not take a double dose to make up for a missed dose.

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A typical dose is 500mg (two tablets) taken twice a day, morning and evening. For rosacea you'll need to take it for 6 to 12 weeks. For acne you'll need to continue treatment for at least three months. Follow the instructions given by your doctor.

One or two tablets are taken four times a day. Take your doses spaced evenly throughout the day, ideally every six hours. Dosage and length of treatment depends on the type and severity of your infection. Always follow your doctor's instructions, which will be printed on the dispensing label that your pharmacist has put on the packet of medicine.

Finish the prescribed course of tetracycline even if you feel better or it seems the infection has cleared up. Stopping the course early increases the chance that the infection will return and that the bacteria will grow resistant to the antibiotic.

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However, just be aware that if you feel unwell with an infection or find tetracycline gives you a headache or upset stomach then this might be made worse by drinking alcohol. It's also possible that drinking excessive amounts of alcohol with tetracycline could increase the risk of getting side effects on your liver.

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with tetracycline. Just because a side effect is stated here doesn't mean that all people taking this antibiotic will experience that or any side effect.

If you take tetracycline for long periods of time your doctor may want to see you regularly to monitor for any possible side effects of the medicine.

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Read the leaflet that comes with the medicine or talk to your doctor or pharmacist if you want any more information about the possible side effects of tetracycline. If you think you have experienced a side effect, did you know you can report this using the yellow card website?

Before you take tetracycline, tell your doctor or pharmacist if you're already taking any medicines, including those bought without a prescription and herbal medicines. Similarly, always check with your doctor or pharmacist before taking any new medicines while you're taking tetracycline.

Tetracycline doesn't affect hormonal contraceptives such as the pill. However, if you experience vomiting or diarrhoea while taking this antibiotic, this can potentially make your pill less effective at preventing pregnancy. If this happens to you, follow the instructions for vomiting and diarrhoea described in the leaflet provided with your pills.

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Tetracycline may increase the anti-blood-clotting effects of coumarin anticoagulant medicines such as warfarin. If you're taking warfarin your doctor may want to check your blood clotting time