Alternatives to Antibiotics When Treating Acne

Many people are familiar with antibiotics. They’re used to treat infections, acne, and other inflammatory skin diseases. Nonmedical uses of antibiotics are seen in agriculture and water systems, as well as in domestic products such as soaps.^[1] With the widespread use of antibiotics, one has to wonder—what are the ramifications?

Potential Consequences of Antibiotic Use

There is a growing understanding that antibiotics must be used with caution. With the rapid emergence of antibiotic-resistant strains of bacteria, the ultimate concern is that the drugs that we currently have will no longer be able to fight off infections.

Another major concern of antibiotic use is the depletion of the healthy bacteria that commonly live in and on the human body, known as the human microbiota. These good bacteria function to prevent the growth of more dangerous bacteria that can cause disease—thus, depletion and alteration of these with antibiotics could lead to impairment in immunity and certain infections. Many studies have been conducted to evaluate the effects of antibiotics on the gut microbiome, and further research is necessary to continue to understand all the complex interactions and possible implications.

Effects of Antibiotics on the Skin Microbiota

Antibiotics are a mainstay treatment of many dermatologic skin diseases, especially in the treatment of acne. However, the downside is that treatment with antibiotics kills bacteria, including healthy bacteria, leading to an imbalance in the normal skin microbiota. Many dermatological diseases are now suspected to be associated with a disruption in the skin microbiota, including:

• Acne
• Psoriasis
• Atopic dermatitis (eczema)
• Rosacea^[2]

The story with acne and bacteria

It has been known that skin bacteria, most notably Cutibacterium acnes (previously known as Propionibacterium acnes), is involved in the acne disease process. A causal relationship has always been suspected but is difficult to totally blame C. acnes since it is also found on the skin of people without acne.

In fact, a recent study found that there was a greater abundance of C. acnes on healthy skin, suggesting that it might even play a protective role in acne. They postulated that C. acnes produces an antimicrobial substance that provides benefits to the skin and suggested that the development of acne is due to an imbalance of the normal skin bacteria, rather than the presence of “bad” bacteria.^[3] Another study even went a step further to suggest that it might be that people with acne have the wrong type of C. acnes bacteria.^[4] 

So it seems that while bacteria may have a role in acne, it is not a simple story. While antibiotics may be an option, there is clearly more to the story of how bacteria may affect acne. Also, dermatologists use antibiotics in acne because it has anti-inflammatory actions apart from the antibiotic effects.

Alternative Treatments for Acne

There are several approaches that are taken by dermatologists to reduce antibiotic exposure (Table 1).

Lower dose of antibiotic

One way to minimize the effects on the microbiome is by using lower doses of antibiotics. At lower doses, antibiotics work to treat skin conditions based on their anti-inflammatory activity, not their antibiotic activity. These lower doses are considered, “sub-antimicrobial” doses. To reduce antibiotic resistance, it is important that doctors reserve oral antibiotics only for the correct patients who can benefit from them the most, and limit the duration of time that they are used. 

Combine with benzoyl peroxide

For topical antibiotics, combining them with topical benzoyl peroxide (which kills bacteria by a different mechanism) can help reduce the risk of antibiotic resistance.

Hormonal therapies

Hormonal therapies such as oral contraceptives and spironolactone can also be used to treat acne in women, which can minimize the need for antibiotics in people who have hormonally-mediated acne.^[5] Weight loss and stress reduction may also help reduce acne.

Isotretinoin (previously known as Accutane)

Isotretinoin is a vitamin A derivative that is commonly used to treat moderate to severe acne. It is thought to work mainly by reducing sebum (oil) production and keratinocyte (skin cell) production and maturation. A 2017 study found that isotretinoin reduced the number of the acne-associated bacteria C. acnes in moderate to severe acne—even the ones resistant to antibiotic treatment. They demonstrated that this reduction was only present on the patients’ cheek, and not in the nose or toe web, indicating that isotretinoin could have different effects on the skin microbiome, depending on the location.^[6]

As we learn more about the human microbiome, we can begin to understand how it can be altered with treatment or disease. To this day, we are still learning about the effects of antibiotic treatment, and the role that it plays in skin health.