Weekly Pulse Dosing of Tetracyclines for Treatment of Acne

Dear Editor:

Tetracyclines are a key component of acne treatment, with standard daily or twice daily dosing.1 The most recent AAD guidelines of care in the management of acne vulgaris recommends continued maintenance therapy of oral antibiotics until clinical improvement allows discontinuation of the drug and encourages limiting use to the shortest duration possible.1 However, follow up appointments are often scheduled 1 to 3 months later, meaning that patients may be continuing the tetracycline antibiotic for a longer period than needed. This is potentially problematic given increasing antibiotic resistance, as well as drug side effects such as gastrointestinal upset and photosensitivity.1 Additionally, longer courses of antibiotics may lead to higher potential for medication non-adherence.

Pulse dosing is commonly used in the treatment of onychomycosis to reduce the risk of side effects, with high efficacy.2 Likewise, pulse dosing of azithromycin, a second-line antibiotic agent, has been explored for treating acne vulgaris, with success in some studies.3 Dosing regimens in previous studies have varied. Interestingly, one small study noted no difference between daily dosing for four/five days per month and three times weekly dosing over a three-month period.4

To the best of our knowledge, there have been no published studies exploring pulse dosing with tetracyclines in the treatment of acne. Over the last 20 years, one of the authors, has observed great efficacy, safety, and patient satisfaction by instructing patients with inflammatory acne to take doxycycline or minocycline twice daily for 7 to 10 days when having moderate-to-severe flares (in combination with a topical retinoid and benzoyl peroxide-clindamycin gel). This utilizes a pulse dosing strategy on an as needed basis rather than having the patient continually take the oral antibiotic daily until the next follow-up appointment.

The literature highlights that more than half of Cutibacterium acnes strains are resistant to antibiotics.5 Erythromycin shows the highest resistance rates followed by clindamycin and doxycycline.5 This is concerning given that antibiotic resistant pathogens are emerging faster than new antibiotics can be developed.5 Prolonged and inappropriate use of antibiotics plays a large role in the development of antibiotic resistance;5 consequently, weekly pulse dosing of oral tetracyclines for flares could be an effective strategy for addressing this public health issue for both men and, especially, women who experience acne surges during their menstruation. Moreover, this strategy may lead to greater patient satisfaction and compliance given that it actively involves patients by requiring them to evaluate the severity of their acne and the need for the oral antibiotic. Additionally, taking the oral antibiotic for a week is more convenient than taking it daily for a few months. In order to assist patients with assessing the need to take the oral antibiotic, the author who employs this strategy advises patients to take the oral antibiotic when 10 or more inflammatory acne lesions are present and to forgo usage when less than 10 lesions are present.

We encourage future studies exploring pulse dosing of oral antibiotics in the treatment of moderate-to-severe acne vulgaris to assess treatment outcomes, safety (including rates of antibiotic resistance), and cost-effectiveness.