Loading ...

The selection of patients, duration of therapy, and combination with other drug categories are key factors in optimizing antibiotic use for acne vulgaris, helping to minimize their contribution to the global issue of antimicrobial resistance. This topic was discussed at The World Congress of Pediatric Dermatology (WCPD) 2025 Annual Meeting, held recently in Buenos Aires, Argentina.

Topical and systemic antibiotics are crucial components of acne treatment due to their antimicrobial and anti-inflammatory properties. Since acne is the eighth most common disease worldwide, affecting 85% of adolescents, it’s no surprise that dermatologists are the primary prescribers of these drugs. In an electronic poll during the session, three quarters of the attending professionals reported prescribing antibiotics for acne.

However, recent studies have shown a concerning rise in resistant strains of Cutibacterium acnes (formerly Propionibacterium acnes), a bacterium responsible for acne development. It has also been identified as a pathogenic factor in other nondermatologic diseases, such as sarcoidosis, endophthalmitis, joint prosthesis infections, prostate cancer, and postoperative infections. The use of antibiotics for acne may also disrupt gut microbiota and is linked to Streptococcus pyogenes colonization and resistance in the oropharynx.

“Now is the time to reconsider our approach! Whenever possible, we should select nonantibiotic therapies for acne,” said Patricia Troielli, MD, dermatology expert, advisor to the Acne Committee of the Argentine Society of Dermatology, and former vice president of the Ibero-Latin American College of Dermatology. She acknowledged that many of her colleagues feel nonantibiotic alternatives are less effective.

Troielli advocated for a multimodal approach, combining topical and oral treatments with procedures. She suggested starting with topical retinoids or fixed combinations (benzoyl peroxide plus adapalene, trifarotene, or tazarotene), as well as using moisturizing dermocosmetics, which can improve results when used alongside medical therapy. Other real-world alternatives to antibiotics include isotretinoin, spironolactone (for female patients only), photodynamic therapy, and lasers.

Marimar Sáez-de-Ocariz, MD, pediatric dermatologist at Hospital Ángeles del Pedregal in Mexico City, Mexico, emphasized that “antibiotics remain a valuable treatment option, with strong evidence supporting their effectiveness in inflammatory acne.” She stressed that the key is adhering to proper prescribing practices.

What are the three key factors for optimal use of topical or systemic antibiotic therapy for acne? Sáez-de-Ocariz answered Medscape’s Spanish edition:

1. Proper Patient Selection

“Antibiotics should only be prescribed for inflammatory lesions (papules, pustules, and nodules), not for comedones,” Sáez-de-Ocariz emphasized. According to a 2023 network meta-analysis of 204 clinical studies, the most effective treatment for inflammatory lesions is oral isotretinoin, followed by topical antibiotics combined with azelaic acid, oral antibiotics plus retinoids, and benzoyl peroxide combined with topical antibiotics or retinoids.

Topical antibiotics are recommended as first-line treatment for mild to moderate inflammatory acne. She highlighted four scenarios where oral antibiotics should be considered: Moderate to severe inflammatory acne, failure of topical treatments (after 8-12 weeks), acne on extensive areas (such as the face, chest, and back), and the risk of scarring (eg, tendency to form scars or postinflammatory hyperpigmentation).

However, antibiotics should not be prescribed if there is a history of previous treatment failure with the same medication. “A thorough patient history is essential. If a patient has had inflammatory acne treated with antibiotics two or three times, even if it’s my first time seeing them, we should consider escalating treatment to isotretinoin or, for female patients, spironolactone or contraceptives,” Sáez de Ocariz explained.

2. Combining With Other Drugs (But Not Other Antibiotics)

Although studies show that monotherapy with topical and oral antibiotics is as effective as retinoids for inflammatory lesions, “all guidelines recommend using antibiotics in combination with other drugs to mitigate the risk of bacterial resistance,” Sáez-de-Ocariz stressed. For example, topical antibiotics can be combined with benzoyl peroxide or retinoids. The 2024 updated guidelines from the American Academy of Dermatology recommend concomitant use of benzoyl peroxide with oral antibiotics as part of best practices to reduce antibiotic resistance and limit the duration of systemic exposure to antibiotics.

However, one practice to avoid is combining topical antibiotics (eg, clindamycin) with systemic antibiotics (eg, doxycycline). “This is inappropriate, and unfortunately, it happens, even within our profession. While it’s not common, it does occur,” she noted.

3. Respecting Therapy Duration (and Communicating It to Patients)

Sáez-de-Ocariz added that systemic antibiotics should generally be prescribed for 3-6 months on the basis of clinical response, though guidelines from the American Academy of Dermatology suggest even shorter durations, ie, between 3 and 4 months. The guidelines of the National Institute for Health and Care Excellence, London, England, recommend an initial evaluation after 12 weeks. For oral antibiotics, treatment may continue alongside topical therapy for another 12 weeks when lesions have improved but have not completely resolved. Other guidelines set a strict maximum of 3 months to prevent microbial resistance.

She emphasized the importance of planning and respecting the duration of oral antibiotic treatment, clearly communicating this to patients, and ensuring they comply with the accompanying topical regimen. “It’s necessary to tell the patient that the antibiotic treatment is only for the prescribed duration. Sometimes they don’t want to stop, or they feel better after using the systemic treatment but neglect the topical retinoid. When they stop the systemic antibiotic, they relapse and blame the discontinuation of the antibiotics,” Sáez-de-Ocariz explained to Medscape’s Spanish edition.

Troielli disclosed being a speaker and member of the Acne Advisory Board for Eucerin and Beiersdorf, as well as a speaker and researcher for L’Oréal and La Roche-Posay. Sáez-de-Ocariz declared having no relevant financial conflicts of interest.

This story was translated from Medscape’s Spanish edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.