Aside from the pill, antibiotics like doxycycline are a first line treatment for acne and pimples. This perpetuates the misconception that acne and pimples are solely caused by a bacterial infection and can be solved by taking oral antibiotics. But bacteria isn’t the only factor in acne.

Is acne a bacterial infection?

Acne cysts and pimples form when the psilosebaceous gland within a hair follicle becomes blocked, inflamed and infected. The redness, pain, swelling and pus associated with acne lesions is a normal inflammatory response executed by the skin in response to the infected, clogged hair follicle. Propionobacterium acnes (P.acnes) is just one strain of bacteria that lives on human skin, regardless of whether that person has acne. When P.acnes out of balance, it is more likely to grow and infect the hair follicle, contributing to inflammation.

So does it really make sense to take an oral antibiotic to address just this one variable in the whole acne picture?

Oral antibiotics are not selective – they cause widespread damage to the microbiome.

It would be like pouring weed killer in the soil and waterways of a natural habitat in the hope that it kills off just one species of weed. Antibiotics don’t get to the cause of the problem (which is multi-factorial and unique to the individual).

Health care providers need to be thinking about why there is an overproduction of sebum, keratin and slow skin cell turnover that results in acne.

Hint: the answer is not just about bacteria.

Underlying causes of acne:

·      Excess androgens like testosterone leading to more sebum and keratin production

·      Gut inflammation (antibiotics have been linked to leaky gut syndrome). An inflamed gut = inflamed skin

·      Poor liver clearance of hormones and toxins

·      Nutrient deficiencies like zinc and vitamin A, both of which help regulate sebum, keratin production and skin cell turnover

·      Compromised lymphatic flow leading to accumulation of physiological wastes which are excreted through the skin

·      Systemic inflammation driven by a processed diet, leaky gut, alcohol and sugar intake

·      Oestrogen excess relative to progesterone leading to pre-menstrual break-outs

·      Stress and poor quality of sleep - the skin has stress receptors that cause inflammation when triggered

·      Interplay between the bacteria and fungal species of the gut and skin

Do antibiotics address all of these factors? No.

Antibiotics do have the potential to address bacterial overgrowth that affects the microbial balance of the skin as well as inflammation in the skin, however they also disturb the balance between species. Here is the sciencey stuff: 

The initial trials of doxycline in acne in the 1970’s found that doxycycline only improved the severity in 33% of participants, compared to 22% in the placebo group. That’s 10% more effective than no treatment at all(1). The number of particpants was also small and uneven, with 21 participants administered docycline compare to 14 in the placebo group(1). There are other studies that report doxycline is most effective in combination with other antibiotics and topical therapies(2). So it is difficult to ascertain how effective just one antibiotic on its own can be. Most trials are no longer than 3 months, which limits the data on safety and efficacy of long term use. There is a need for more trials.

I’ve included the Australian product information leaflet for doxycycline monohydrate for you to read here - the leaflet includes a nice long list of potential side effects.

The professional recommendation is that antibiotics in acne should be prescribed concurrently with other treatments and should not be taken for longer than three months(2) due to the risk of antibiotic resistance and the lack of safety data. Antibiotic resistance is a real problem that medicine is facing and not just in the realm of skin conditions. Antibiotics also disturb the balance of the gut microbiome which can have flow on effects to nutrient breakdown and absorption, vaginal health and thrush, hormonal detoxification and excretion and damage to the lining of the gut, contributing to leaky gut syndrome and systemic inflammation.

Remember that the body is not a machine - it’s a living eco-system! Nothing is seperate and interventions affect the body as a whole.

Lastly, your skin may improve while you’re on antibiotics, but in many cases, skin doesn’t clear up completely and after you finish antibiotics, the acne returns.

As always, this is not intended to diagnose or treat any medical condition. Nor is it intended to replace the advice given by your medical or health care professional. If you have been prescribed this medication by your doctor, it is best to discuss any questions or concerns you have with them, or seek a second opinion from another qualified health professional in a consultation setting so that you recieve the best care.

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Reference List: 

1.        Plewig G, Petrozzi JW, Berendes U. Double-Blind Study of Doxycycline in Acne Vulgaris. Arch Dermatol. 1970;101(4):435-438. doi:10.1001/archderm.1970.04000040057011

2.        Walsh TR, Efthimiou J, Dréno B. Systematic review of antibiotic resistance in acne: An increasing topical and oral threat. Lancet Infect Dis. 2016;16(3):e23-e33. doi:10.1016/S1473-3099(15)00527-7