Antibiotics can help treat severe, painful acne that is related to bacteria on the skin. They can also help reduce inflammation more generally, which may ease swelling and reduce the risk of scarring.

A dermatologist may recommend topical antibiotics, which a person applies to the skin, or oral antibiotics, which a person takes as a pill.

However, it is important to note that prolonged or repeated use of oral antibiotics has risks. They can harm healthy bacteria in the gut, disrupting the balance of someone’s gut flora.

The frequent prescription of antibiotics can also contribute to antibiotic resistance, which occurs when bacteria evolve so that they can survive antibiotic treatment.

Whether antibiotics are the right choice for someone depends on their unique circumstances.

This article will look at how effective antibiotics are for acne, the types available, side effects, risks, and other acne treatments.

Lower half of a person's face. They have mild acne and are stood outside.Share on Pinterest
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Acne develops when hair follicles, or pores, become clogged with dead skin or oil. A number of things can contribute to this, including:

  • having oily skin
  • hormonal changes or imbalances
  • genetics
  • inflammation
  • excessive sunlight exposure
  • certain medications

However, bacteria also play a role.

Many species of bacteria naturally live on the skin. Some are beneficial, while others can cause problems if they become too prevalent. Scientists know that several species of bacteria can aggravate acne, including:

  • Cutibacterium acnes, previously called Propionibacterium acnes, in teenagers
  • Staphylococcus epidermis, which increases inflammation

Antibiotics help to slow or stop the growth of harmful bacteria on the skin. However, numerous studies have found that antibiotics may help treat moderate to severe acne, regardless of the underlying cause.

For example, a 2019 study tested the efficacy of azithromycin in various doses. The antibiotic was both effective and generally well tolerated.

A 2018 study compared pulsed doses — brief periods of antibiotics — to longer doses of doxycycline and found that both were effective.

Furthermore, a 2017 review compared several classes of antibiotics, including tetracyclines, macrolides, and trimethoprim-sulfamethoxazole, for the treatment of inflammatory acne. All were effective.

Across 41 articles that compared antibiotics to one another, to placebos, or to other treatments, researchers were unable to find evidence that one type of antibiotic was superior to another.

Topical antibiotics are applied directly to the skin. Clindamycin and erythromycin are the most common topical antibiotics.

A 2018 Cochrane review emphasizes that these antibiotics work best for inflammatory acne, which develops when bacteria enter blocked pores. Other types of acne may not respond as well.

Topical antibiotics come in many forms, including gels, lotions, and pads. Because they are localized, topical antibiotics do not affect gut flora. Typically, they do not cause systemic side effects either.

However, they may still play a role in the development of antibiotic resistance. For this reason, the American Academy of Dermatology (AAD) recommends using topical antibiotics alongside another treatment, such as retinoids or benzoyl peroxide.

The AAD recommends oral antibiotics for moderate to severe acne that does not respond to other treatments or for inflammatory acne that does not respond to topical antibiotics.

The most well-studied antibiotics for acne are tetracyclines and macrolides. Other types of antibiotics, such as doxycycline and minocycline, have less evidence behind them. Still, doctors may prescribe other types if a person does not see an improvement.

Similar to topical antibiotics, the AAD recommends that people do not use oral antibiotics on their own. Combining medication with benzoyl peroxide or retinoids may make the treatment more effective and maintain the results after the course is over.

To reduce the risk of antibiotic resistance, it is also important to take oral antibiotics for as brief a time as possible. However, this can be difficult, as longer or repeated treatments may improve the results.

A 2020 review of previous research analyzed studies that used antibiotics for time frames ranging from 3–24 weeks. Longer periods of use generally resulted in a greater reduction in inflammatory acne.

Some studies also suggest pulsed doses may be effective. This is when a person takes antibiotics less frequently or in short bursts.

A 2018 study compared pulsed azithromycin therapy, in which people took the drug one to three times weekly or four times monthly, to 12 weeks of consistent doxycycline.

The results for each group were similar, suggesting that pulsed antibiotics can be just as effective as a standard course.

Many people tolerate antibiotics well. However, side effects are always possible. The potential side effects vary depending on the type of antibiotic someone is using.

Topical antibiotics may cause:

  • mild dryness or irritation
  • skin flakiness
  • contact dermatitis due to an allery

Oral antibiotics may cause:

  • yeast infections
  • gastrointestinal symptoms, such as nausea, vomiting, or diarrhea
  • permanent tooth discoloration
  • skin that is more sensitive to UV light
  • interactions with other drugs and medications

Severe allergic reactions

Some people have allergies to specific antibiotics. Rarely, taking them can result in anaphylaxis.

Anaphylaxis is a severe allergic reaction that can be life threatening. The symptoms develop suddenly and include:

  • hives
  • swelling of the face or mouth
  • wheezing
  • fast, shallow breathing
  • a fast heart rate
  • clammy skin
  • anxiety or confusion
  • dizziness
  • vomiting
  • blue or white lips
  • fainting or loss of consciousness

If someone has these symptoms:

  1. Check whether they are carrying an epinephrine pen. If they are, follow the instructions on the side of the pen to use it.
  2. Dial 911 or the number of the nearest emergency department.
  3. Lay the person down from a standing position. If they have vomited, turn them onto their side.
  4. Stay with them until the emergency services arrive.

Some people may need more than one epinephrine injection. If the symptoms do not improve in 5–15 minutes, or they come back, use a second pen if the person has one.

One of the most serious risks of antibiotic use is antibiotic resistance. This occurs when bacteria evolve so that they are no longer affected by a specific drug.

Antibiotic resistance can mean an antibiotic no longer works for an individual. It can also contribute to the growth of “super bacteria,” which are difficult to treat.

Antibiotics also affect the microbiome, which is the ecosystem of bacteria, yeasts, and other microorganisms that live in the gut. A balanced and diverse microbiome is key for overall health.

A 2020 study describes antibiotics as “major disruptors” of the microbiome and states that it is possible this disruption could lead to chronic health problems.

Low levels of beneficial gut bacteria are associated with a number of chronic conditions, such as inflammatory bowel disease (IBD), obesity, and type 2 diabetes. However, whether changes in gut flora play a direct role in causing these conditions is still unknown.

Other potential risks of oral antibiotic use depend on the drug. They can include:

  • permanent tooth discoloration
  • hyperpigmentation of the skin
  • reduction in bone growth
  • harm to a developing fetus during pregnancy
  • drug hypersensitivity syndrome

Because of the impact of some antibiotics on bone growth, doctors should not prescribe them to people who are still growing or who are pregnant.

Antibiotics are not the only option for treating moderate to severe acne. Some other treatment options include:

  • Topical treatments: Benzoyl peroxide and retinoids are among the most effective topical treatments for acne. Inflammatory acne can also respond well to topical dapsone gel, particularly in females. Salicylic acid can be helpful for reducing oiliness and unblocking pores.
  • Oral isotretinoin: This oral form of vitamin A can help with treatment-resistant acne and with severe nodular acne.
  • Hormonal treatment: Hormonal birth control that contains estrogen may help some females with acne. Spironolactone, a drug that reduces the effects of androgens, may also help.
  • Scar treatment: Azelaic acid can help minimize pigmentation that lingers after acne lesions heal. Microneedling, laser therapy, and other procedures can also reduce the appearance of acne scars.

The AAD emphasizes that there is not sufficient evidence to support specific dietary changes for acne. However, a 2021 article notes that foods with a high glycemic index may aggravate acne. This includes sugary foods, such as cakes, candy, and soda.

Following a balanced and healthy diet with fewer high glycemic index foods may help some people. For others, reducing or stopping milk consumption helps.

Before beginning acne treatment, it helps to have all the facts. A person may wish to ask a doctor the following questions:

  • What type of acne do I have?
  • Will topical antibiotics help?
  • What about oral antibiotics?
  • What benefits and risks does the recommended treatment have?
  • Can I use antibiotics at the same time as other treatments, such as benzoyl peroxide?
  • Is this treatment safe if I am pregnant or breastfeeding?
  • Does this treatment interact with any drugs, supplements, or medical conditions?
  • How long will the treatment be?
  • Could pulsed doses help me?
  • Are there alternatives?
  • What happens if it does not work?
  • Can we treat acne scarring at the same time?

Antibiotics for acne can reduce the presence of bacteria on the skin that are associated with acne and inflammation. Doctors typically prescribe them for people with inflammatory acne or for those with moderate to severe acne that is not responding to first-line treatments.

While evidence shows a number of antibiotics can help reduce the symptoms, both topical and oral antibiotics have some potential risks.

Topical antibiotics are less likely to cause systemic side effects, such as digestive disturbances, but they may still contribute to antibiotic resistance.

It is important to discuss all the pros and cons of this treatment with a dermatologist.