Antibacterial therapy for acne: a guide to selection and use of systemic agents

Acne vulgaris is a very common disorder, affecting virtually every adolescent at some point in time. Systemic antibacterials have been used in the treatment of acne for many years, and there are several commonly used antibacterials which have established efficacy and safety records. In recent years, the issue of antibacterials resistance has become more prominent, especially with concerns that Propionibacterium acnes can transfer antibacterials resistance to other bacteria within the resident skin flora. Commonly used antibacterials include tetracycline, doxycycline, minocycline, erythromycin (and other macrolides) and trimethoprim/sulfamethoxazole (cotrimoxazole). The choice of antibacterial should take into account efficacy, cost-effectiveness, benefit-risk ratios, patient acceptability and the potential for the development of resistance. Poor clinical response can be the result of poor compliance, inadequate duration of therapy, development of gram-negative folliculitis, resistance of P. acnes to the antibacterial(s) administered, or a high sebum excretion rate. In order to help prevent the development of resistance a number of measures should be undertaken: antibacterials are prescribed for an average of 6 months; if retreatment is required, utilize the same antibacterial; generally, antibacterials should be given for at least 2 months before considering switching due to poor therapeutic response; concomitant use of oral and topical chemically-dissimilar antibacterials should be avoided (try benzoyl peroxide and/or retinoids instead) and systemic isotretinoin should be considered if several antibacterials have been tried without success.