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Is it safe to use long course of oral antibiotics for acne?

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Posted on Thu, 14 May 2015
Question: Hello I would really like Dr Kakka to answer this question but if He can not, I'd appreciate the help of any dermatologist this week.

My concern is controlling my acne

For the past few years I might have got 2-3 big spots per year, but from autumn last year they have become more regular.. We were treating them with topicals of differin & antibiotics plus short bursts of oral antibiotics, usually clarithromycin & I had added in differin & BP daily as preventative treatment. My GP likes short 5 days clarithromycin for treating deep lesio but I have not felt that sufficient to clear deep spots and recently clarithromycin doesn't seem to have done much.

# # #recent bout from February to April
My most recent bout (I will post pictures in my reply when I switch from browser to app) saw a particularly sore nodule under my chin, which even weeks on is still visible and quite tender ( for that We tried short bursts of antibiotics which did not heal it & so on dermatologist advice we went for longer course of clarithromycin, 2-3 weeks to resolve it) . Unfortunately over that time I had another largish spot come up on one jaw and then last l week another bit lesser size spot under the other, despite being on clarithromycin and using either differin and BP daily. These spots have been very tender so I have to try to sit and wash over a bowl to avoid rubbing.

# #my need for assistance is regarding furthur & best management/treatment options & how to use them properly # #
Anyway so my course of clarithromycin is over & the 3 spots are slowly lessening. My GP doesn't want to give me any more oral antibiotics (as in move onto longer course management) as she says clinically what I have doesn't warrant it which leaves topicals, so as I'm getting spots quite easily now I want to better manage my acne - maybe step up a gear prevention & improve my topical treatment so its effective but non sensitizing. Due to having sensitive skin, which easily irritates when I try to apply good twice day gel topicals, it's harder to both treat and prevent new acne topically and I often have to rest it off a while.

So

# # #Questions I have are:
1). Is it correct that i should not take continue on long course antibiotics oral in view of the the acne I have had?
One dermatologist here mentioned a possible 3 month course but I do understand my GP caution with long term oral antibiotics use, especially as I'm not a healthy individual. I could however try to pursue getting a private prescription regardless if GP, depending on what you advise


2).maintenance
which topicals would be most effective for sensitive skin if I did just a once day preventative plan? (As I'm extremely debilitated I prefer face washing & treating just once/day as its very very tiring)
ive been using differin or BP once/day alternating the days - Would you expect IT to be enough? I could maybe stick as I am & just up application treatment to using each one daily pre menstrual?
OR
If I increased that to a combination therapy (2 in 1) daily eg adapalene /BP combination gel. (Unfortunately my skin doesn't love gels!) or azaliac acid /BHA combination cream - would they be better or is combined treatment likely too much for my sensitive skin?



3) acne treatment
I first use zindaclin gel, as it erases my occasional chest acne - better than other spot treatment. However I often, after a day or two, start getting irritation from it using it on my face, especially if I try to also (at different time of day) use differin. I do apply a very light moisturizer first if my skin feels too dry or irritated for gels - is that ok? however I still often get irritation or itching, is that something to just put up with or a warning sign that I should stop using?sometimes I have to Cease any treatment for a while.. Are there any other equally good but less irritating topical treatments available? I do have clinadamycin lotion but I have never found that particularly good

. Would moisturizing on top of the zindaclin reduce irritation or reduce its effectiveness as a treatment? Gels are good for my skin but as soon as I get sensitized I struggle with them.
I sometimes switch from differin gel to differin cream for the same reason ( irritation or intolerance of gels) but am not sure if that is very suited to oily skin? can I moisturize on top of that too?

I read that applying differin a few minutes before zindaclin was a good way to get maximum benefit - is that right and I am best to use those treatments together? I was using them separately, morning and night.... It would suit me better as a dual treatment, just once a day combination - but does this again risk increasing irritation?. When is it best to moisturize in all this - beneath or on top of the gels or not at all?


4) light therapy
I have been reading about a portable red-blue light therapy device for acne called Lumie clear. I know its not for treating deep nodular or cystic spots but I thought that it might help with prevention and also healing up nasty lesions. Do you think it would be useful for those purposes?

will such bright lights be compatible with adapalene usage if at different times of the day?

Thanks very much for your time XXXXXXX XXXXXX
doctor
Answered by Dr. Kakkar S. (12 hours later)
Brief Answer:
Advice regarding acne

Detailed Answer:
Hello XXXXXXX

I have gone through the details of your query and I could gather that your main concerns are..

-Occasional new acne eruptions which are inflammatory i.e red, nodular and painful and that may take a long time to resolve.

-Need for topical treatment which is less irritating yet effective

-Not in favor of prolonged Oral antibiotics either due to pre-existing medical illness or your GP not in favor of long term antibiotics.

-Need for an effective maintenance treatment.

Regarding the duration of Oral antibiotics..
Antibiotics can be continued for weeks or months depending on the severity of acne and response to treatment. It can be as short as 2 weeks Or extend for 3 months.
As I also mentioned in my previous communication with you, the role of antibiotics in acne is not exactly to kill acne bacteria but they are mainly used because they have an anti-inflammatory effect in acne.
The various antiacne antibiotics that are commonly used in acne are either Doxycycline, Minocycline, Azithromycin, Lymecycline, Clarithromycin.

Besides Oral antibiotics, for nodular acne one can also consider Isotretinoin. It is a vitamin A derivative. It is not an Oral antibiotic.
Isotretinoin is one of the most effective antiacne oral remedy for severe nodular and cystic type of acne.
However, Isotretinoin can also be started even for lesser grades of acne severity i.e resistant to traditional antiacne treatment (i.e oral antibiotics and topical antiacne treatment) OR acne that is recurring frequently OR adversely affecting the psychology of the patient.
Isotretinoin is sebostatic i.e inhibits sebum over production, it is comedolytic as well as antiinflammatory. Therefore it has multi-pronged mechanism of action in acne.

Regarding topical treatment I would suggest you to stick to Adapalene gel (Differin gel), to be applied over the whole affected area, either once daily Or every alternate days.
Adapalene gel is ideal for treatment as well as maintenance of improvement in acne i.e Adapalene is indispensable.

Use a gentle cleanser for face wash e.g cetaphil cleansing lotion rather than soaps or face washes, because you have sensitive skin.

Topical antiacne treatment can cause irritation particularly in those who have sensitive skin.. it is important to use just a thin film of topicals and the frequency of application can be reduced to alternate night rather than daily.

Adapalene makes skin sensitive therefore it predisposes to irritation to other topicals like benzoyl peroxide.
Therefore, it is important that you don't use adapalene and benzoyl peroxide together Or use it at different times of the day i.e adapalene at night Or every alternate night and benzoyl peroxide during day time.

You may apply benzoyl peroxide during day time only as a spot treatment for acne.

Yes, you may use clindamycin 1% gel over and above adapalene gel unlike benzoyl peroxide because clindamycin is not irritating when compared to topical benzoyl peroxide gel.
You can apply clindamycin gel as soon as after 15-30 minutes after adapalene gel.
Adapalene enhances the penetration of topical clindamycin and therefore makes it more effective.

Alternatively, you can use a nadifloxacin 1% gel in place of benzoyl peroxide, if it is irritating too much.

Yes, you can moisturize your skin before topical antiacne treatment. This would reduce irritation without compromising on efficacy.
Make sure you use a light moisturizer that is non-greasy Or oily. Preferably use the moisturizer only once daily i.e either day or night.
You may use the moisturizer during day before using topical antiacne treatment.
A moisturizer can also be used at night before you apply adapalene gel.

Light therapy can be used as a complementary treatment in addition to other topical and oral treatments for acne.
It can be used along with adapalene.
It would help in resolution of inflammation in acne lesions and can be considered for maintenance improvement too.

Hope this answers most of your concerns. However if I missed out on something you can get back for more information.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kakkar S. (2 days later)
Hello again Dr Kakka,

Thanks for your welcomed help on my acne management. I really appreciated it.

You covered much of what i asked. Just a few points i would appreciate clarifying if you would be ok about that..

1) is adapalene on its own as good as "combination" of adapalene and benzo for prevention? I think you said ot was but i just check!

2) Is it ok to use light therapy every day and differin also? Just at different times? (I wasn't sure if the bright light affected differin).
Would the skin need to be washed before using light therapy?
I've ordered one mainly because my spots take such a long time to heal - is there anything else are can do to speed up the healing? The spots have sort of subsided but they then hang around as lumps - still tender - for ages.

3) If I do get feelings of irritation from any treatment ,especially from zindaclin gel, is it best to stop using it a while or carry on regardless?

4)Is it NOT advisable to put moisturiser ON TOP of a treatment gel like differin or clindamycin? I ask this because, as I said, my poor health means I need to ideally just wash and treat my face once per day - & I feel differin can make the face feel quite fragile. I also read someone on a forum say it was Important to moistirise a lot when using differin so if I don't and face goes dry, could it harm skin?

I find If I don't moisturise in the evening (after applying differin) by the next morning my face is bone dry (And it's a long wait until that evening to wash and cream again). So, Would it be ok to moistirise on top of differin with a heavier, oil free, moisturiser , even if I have already very lightly moisturized prior to treatment? I could leave it maybe 2-3 hours before I moisturised? I use la roche posey Effaclar H soothing moisturiser as a heavier, oil free moisturiser.

5) is it ok to use differin cream sometimes if my skin feels delicate - but I do have very oily skin & i was worrying it might clog my pores further?

6) finally, further to what you said regarding accutane. I was actually quite surprised it could be considered for non very severe cases. I enclose some pictures of my recent outbreak and wondered if you would consider that defintely deserving that possible approach? so i can raise it with my GP.

Thanks so much for your further time.
XXXXXXX XXXXX .
doctor
Answered by Dr. Kakkar S. (15 hours later)
Brief Answer:
Advice regarding acne

Detailed Answer:
Hi XXXXXXX

Thank you. I have reviewed the Images. I can see inflammatory acne mainly along the jaw/ lower face.

One more oral option that is available for you is Spironolactone.
It is essentially a diuretic but it has antiandrogen action on skin by blocking cutaneous androgen receptors and is thus beneficial for hormonal acne in females, specially for acne on lower face.
The dose is 50- 200 mg daily. It is started at a lower dose and titrated upwards.
Effects are noticeable by 2-4 weeks.
It can be give long term.

1) Adapalene on its own is ideal for prevention, on account of its comedolytic actions. Comedones are precursor lesions of acne.
Whereas Benzoyl peroxide+Adapalene combination Or Clindamycin+Adapalene combination is preferred when one already has inflammatory acne.
Once the inflammatory lesions resolve, patient can be maintained on adapalene alone.
Therefore adapalene is useful in all grades of active inflammatory acne as well as for prevention.

2) Regarding light therapy.. Initially use it for a few minutes on alternate days for 2 weeks, since you would also be using adapalene and then make it daily, if there is irritation.
The exact method of use and daily time of use would be mentioned in the instructions provided with it.
Wash your face before light therapy and use it at a separate time from adapalene (though adapalene is photostable). Adapalene is usually for night use.

3)Use Clindamycin/ Zindaclin only as a spot treatment for active acne during day time Or 15-30 minutes over and above adapalene at night.
Clindamycin does not usually irritates but if you feel irritation you may use it every alternate days.

4) Differin/ Adapalene can cause facial skin to become sensitive and may also cause the skin to peel/ feel dry.
Therefore using a moisturizer with adapalene would reduce side effects like redness and dryness.
It is better to use a moisturizer first and then use differin/adapalene over it rather than the other way round.
Using moisturizer over differin gel can have an occlusive effect on the gel applied and therefore may cause more irritation i.e redness.
Moisturize with a light oil free moisturizer that is non-comedogenic and suitable for oily skin. Avoid a moisturizer that is too oily Or greasy.

5) Yes, you may use differin either every alternate days if your skin gets too sensitive.
Differin is comedolytic/ unclogs pores. It should work well even if used alternate days in those who have sensitive skin.

6) Though accutane is drug of choice for severe acne & dermatologists usually avoid it in mild to moderately severe acne, however, accutane can be considered for long standing, stubborn moderately severe acne and for acne that is not responding as expected to traditional antiacne treatment.

Spironolactone is another option that is suitable for you that I mentioned at the start of my discussion.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kakkar S. (30 hours later)
Thanks so much for your considered replies Dry, and that answered everything except regarding using differin cream rather than gel if extra sensitive - Would it be ok to use that sometimes rather than gel or would its ingredients/heavier base block pores and so be unsuitable for my oily areas of skin?

Regarding spironlactone, I had raised that with doctors in the past but neither were keen but I will try again as I also have some hursutism which I believe it can also help with.

Thanks again XXXXXXX XXXX
doctor
Answered by Dr. Kakkar S. (19 minutes later)
Brief Answer:
You may use cream form.

Detailed Answer:
Hi.

Differin cream would be Ok. Gels are drying and therefore may irritate even though gels are preferred in oily skin
Therefore if irritation is a problem you may use a cream form. No, it won't block pores.

Spironolactone is worth trying, specially since you have lower face acne along with oily skin and hirsutism. It would benefit with all these issues.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Is it safe to use long course of oral antibiotics for acne?

Brief Answer: Advice regarding acne Detailed Answer: Hello XXXXXXX I have gone through the details of your query and I could gather that your main concerns are.. -Occasional new acne eruptions which are inflammatory i.e red, nodular and painful and that may take a long time to resolve. -Need for topical treatment which is less irritating yet effective -Not in favor of prolonged Oral antibiotics either due to pre-existing medical illness or your GP not in favor of long term antibiotics. -Need for an effective maintenance treatment. Regarding the duration of Oral antibiotics.. Antibiotics can be continued for weeks or months depending on the severity of acne and response to treatment. It can be as short as 2 weeks Or extend for 3 months. As I also mentioned in my previous communication with you, the role of antibiotics in acne is not exactly to kill acne bacteria but they are mainly used because they have an anti-inflammatory effect in acne. The various antiacne antibiotics that are commonly used in acne are either Doxycycline, Minocycline, Azithromycin, Lymecycline, Clarithromycin. Besides Oral antibiotics, for nodular acne one can also consider Isotretinoin. It is a vitamin A derivative. It is not an Oral antibiotic. Isotretinoin is one of the most effective antiacne oral remedy for severe nodular and cystic type of acne. However, Isotretinoin can also be started even for lesser grades of acne severity i.e resistant to traditional antiacne treatment (i.e oral antibiotics and topical antiacne treatment) OR acne that is recurring frequently OR adversely affecting the psychology of the patient. Isotretinoin is sebostatic i.e inhibits sebum over production, it is comedolytic as well as antiinflammatory. Therefore it has multi-pronged mechanism of action in acne. Regarding topical treatment I would suggest you to stick to Adapalene gel (Differin gel), to be applied over the whole affected area, either once daily Or every alternate days. Adapalene gel is ideal for treatment as well as maintenance of improvement in acne i.e Adapalene is indispensable. Use a gentle cleanser for face wash e.g cetaphil cleansing lotion rather than soaps or face washes, because you have sensitive skin. Topical antiacne treatment can cause irritation particularly in those who have sensitive skin.. it is important to use just a thin film of topicals and the frequency of application can be reduced to alternate night rather than daily. Adapalene makes skin sensitive therefore it predisposes to irritation to other topicals like benzoyl peroxide. Therefore, it is important that you don't use adapalene and benzoyl peroxide together Or use it at different times of the day i.e adapalene at night Or every alternate night and benzoyl peroxide during day time. You may apply benzoyl peroxide during day time only as a spot treatment for acne. Yes, you may use clindamycin 1% gel over and above adapalene gel unlike benzoyl peroxide because clindamycin is not irritating when compared to topical benzoyl peroxide gel. You can apply clindamycin gel as soon as after 15-30 minutes after adapalene gel. Adapalene enhances the penetration of topical clindamycin and therefore makes it more effective. Alternatively, you can use a nadifloxacin 1% gel in place of benzoyl peroxide, if it is irritating too much. Yes, you can moisturize your skin before topical antiacne treatment. This would reduce irritation without compromising on efficacy. Make sure you use a light moisturizer that is non-greasy Or oily. Preferably use the moisturizer only once daily i.e either day or night. You may use the moisturizer during day before using topical antiacne treatment. A moisturizer can also be used at night before you apply adapalene gel. Light therapy can be used as a complementary treatment in addition to other topical and oral treatments for acne. It can be used along with adapalene. It would help in resolution of inflammation in acne lesions and can be considered for maintenance improvement too. Hope this answers most of your concerns. However if I missed out on something you can get back for more information. Regards