I spend a lot of time looking at, talking about, thinking about and treating skin conditions. So, when a patient comes in with a common problem, such as acne, I can often anticipate many of the issues that will come up, and make sure to take the time discuss them even if a patient is too shy, embarrassed or confused to ask. I also make sure to answer the questions they do remember to pose. For example, one of the most controversial issues in treating acne is the use of antibiotics. These can be applied topically or taken by mouth. Even though some of the issues surrounding their use are identical whether you rub them on or swallow them down, most people are much more cautious when it comes to taking a pill for a condition that isn't dangerous to their physical well being. Unfortunately, even problems that are not life-threatening can be life-altering for those who are suffering from them, so as a dermatologist I often find it appropriate to use strong medication when treating my acne patients.

There are alternatives to antibiotics for treating acne. Most of my patients use a retinoid (such as RetinA, Differin or Tazorac) along with benzoyl peroxide or salicylic acid cleansers and chemical peels. Some do well with laser treatments from the Smoothbeam or VBeam, or light treatments such as BluLight. But there are other patients who get too irritated by many topical medications, and some who don't want to come in for monthly treatments with peels or lasers, or who simply can't afford them. These people need another choice, and antibiotics often work. Most are also covered by insurance, and for those patients who don't have insurance, affordable generics are readily available. So, for now, antibiotics play an important role in managing acne, and I continue to prescribe them, although with some reluctance.

This reluctance stems from several important issues relating to antibiotic use in treating acne. Some antibiotics can produce unpleasant side effects, including stomach upset, light sensitivity, dizziness or nausea; some interact with other medications. And any antibiotic can produce an allergic reaction that may require stopping its use. Another concern about antibiotics is the question of antibiotic resistance. This is one of the most frequent causes of concern for my patients and is also widely misunderstood. What will happen when I'm really sick, I am often asked, if I'm already taking an antibiotic, won't I be resistant next time I need one? Many people think that by using antibiotics they are causing these medications to be less effective because their own bodies will no longer respond to them. In fact, antibiotics produce resistance because the bacteria, which contribute to acne or make us sick, become resistant to them over time. So, overuse of antibiotics allows bacteria to learn how to grow even in the presence of antibiotics. Recent studies have even shown that the main bacteria involved in acne may be able to pass its own resistance on to other bacteria, amplifying the damage done by treating acne. Then these bacteria can cause infections that are difficult to treat in any susceptible person who gets an infection.

If all of this sounds scary, it should. So, what can we do? When antibiotics are used, there are ways to minimize the development of resistance, and in some cases, to decrease the level of resistant bacteria. First of all, when a course of antibiotics is prescribed, it should be used as directed, and a course should be completed. Partially treating a condition can cause resistant bacteria to emerge. When acne improves, antibiotics should be discontinued for as long as other treatments can control the problem. Antibiotics should be used in combination with other medications. Using topical clindamycin (an antibiotic) along with topical benzoyl peroxide (available in many prescriptions and over-the-counter acne medications) can actually decrease levels of bacteria resistant to clindamycin. As newer treatment options develop, they should be considered. One agent now being investigated is a type of tetracycline (an antibiotic commonly used to treat acne) that no longer has antibiotic activity, but helps acne by reducing inflammation. Finally, antibiotics should only be used when there is no reasonable alternative. When other treatments work and are tolerated, use them first. If you're on antibiotics now and are uncomfortable using them, see your dermatologist to learn about other options.