Oral antibiotics are the foundation of moderate-to-severe inflammatory acne treatment because they reduce ductal concentrations of P acnes. Improvement can generally be seen within 2-3 weeks.
Tetracycline online is favored because of its better tolerability and lower incidence of P acnes resistance. It is initiated at a dose of 1-2 g/d in 2-4 divided doses. Tetracycline should be taken on an empty stomach. Many individuals whose acne is controlled can be weaned off oral antibiotics after 6 months of therapy, and then topical antimicrobial therapy can be continued for maintenance.
Long-term use is considered safe; the most common side effects are gastrointestinal upset and vulvovaginal candidiasis. Gram-negative folliculitis may occur, typically manifested by the sudden appearance of superficial pustular or cystic acne lesions around the nares and flaring out over the cheeks.
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Minocycline (Minocin) and trimethoprim/sulfamethoxazole (TMP/SMX [Bactrim, Septra]) have a place in treating some refractory cases. Minocycline can be particularly valuable for patients with treatment-resistant inflammatory acne. Minocycline, like all tetracyclines, is contraindicated in pregnant women and in children younger than 9 years of age because of potential adverse effects on developing bones and teeth.
TMP/SMX is prescribed at a dose of 1 regular-strength tablet, qd or bid. Hematologic and dermatologic side effects have restricted its use to patients with severe acne refractory to other antibiotics and to those who develop gram-negative folliculitis secondary to long-term antibiotic therapy.
Hormone therapy improves acne by suppressing sebum production. A triphasic oral contraceptive pill containing ethinyl estradiol, 35 g, and norgestimate (Ortho Tri-Cyclen) has been shown to reduce inflammatory acne lesions by 40%.
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