Do Antibiotics for Acne Really Work?
One of the most influential bloggers about acne in the world, an individual known as Dan, recently blogged about the declining confidence of dermatologists in antibiotic treatments for acne. Many antibiotics that used to work for acne don’t work any more because of antibiotic resistance, Dan correctly points out, and antibiotics never have worked all that well at getting rid of blemishes anyway. But just how effective—or ineffective—are antibiotics for acne, anyway?
The Problem of Antibiotic Resistance
One of the reasons antibiotics don’t work for acne like they used to is the phenomenon of antibiotic resistance. Individual bacteria sometimes develop resistance to an antibiotic by sheer random mutation. Most mutations kill bacteria so that they don’t reproduce and pass the mutation to their progeny. Some mutations, however, give a single bacterium the ability to resist a medication.
One bacterium isn’t a problem. But bacteria can reproduce as often as every 20 minutes. And bacteria also have the ability to swap genetic material through a process called horizontal gene transfer. A bacterium can share its mutation with its neighbors by direct transfer of DNA. One resistant bacterium can become millions or billions and spread from person to person, unhindered by treatment with the antibiotic to which it has acquired resistance.
Antibiotic resistance is not necessarily an all-or-nothing proposition. A mutation may enable to a bacterium to survive longer in the presence of an antibiotic but the antibiotic may still kill the bacterium if it is used long enough.
That’s the problem with antibiotics for acne. Doctors prescribe the medication and acne sufferers use it until their skin looks better, not until all the bacteria are killed. The antibiotic just wipes out the most susceptible bacteria and leaves the resistant bacteria. When the patient stops taking the antibiotic, then resistant bacteria are free to multiply unchecked by competition from other microbes, and acne can be worse than it was before treatment.
The antibiotics to which acne bacteria have become resistant include:
- Rifampin, to which 17% of acne bacteria are resistant.
- Tetracycline, to which 35% of acne bacteria are resistant.
- Amoxycillin, to which 40% of acne bacteria are resistant.
- Clindamycin, to which 50% of acne bacteria are resistant.
- Erythromycin, to which 52% of acne bacteria are resistant.
- Neomycin, to which 80% of acne bacteria are resistant.
- Cloxacillin, to which 100% of acne bacteria are resistant.
But antibiotic resistance is just part of the story. There is emerging evidence that the old idea that just one strain of bacteria, Propionibacterium acnes, causes acne is wrong. Acne experts in Asia are finding Staphylococcus aureus in pimples, although they do not know whether the reason staph bacteria seem to contribute to acne in Asia has to do with Asian skin or Asian weather.
This means that, in Asia, you don’t just need to control one kind of acne bacteria, you need to control two, and that getting rid of one without getting rid of the other may just allow one strain to grow unchecked. It also means that impetigo, a staph infection that grows in cuts in the skin, can aggravate acne, which occurs in pores, and vice versa. If doctors have to prescribe two different kinds of antibiotics, then patients have to deal with two different sets of potential side effects.
More and more dermatologists are recommending that antibiotics should be just one part of acne treatment. Most skin doctors recommend benzoyl peroxide as a way to get rid of bacteria that antibiotics miss. But benzoyl peroxide isn’t perfect, either.
The figure that gets quoted on the Internet for benzoyl peroxide is that it kills 99.99% of acne bacteria on contact. There was a time, about 30 years ago, when this was true. Nowadays, however, benzoyl peroxide only kills 65% to 85% of acne bacteria, even when it is combined with erythromycin or clindamycin. This is part of the reason neither antibiotics nor benzoyl peroxide, nor a combination of the two, usually gets rid of more than about 2/3 of blemishes.
Adding to the problem, a concentration of benzoyl peroxide that is strong enough to kill most acne bacteria on contact (about 5% or more) is usually also strong enough to cause stinging, burning, itching, and peeling skin. Tiny flakes of dead skin can clog pores and cause whiteheads that can become blackheads.
It’s possible to have fewer pimples but more non-inflammatory acne when you use benzoyl peroxide. Antibiotics are not enough to defeat acne. Killing bacteria isn’t enough to get rid of acne, either.
Getting Rid of Acne Requires Systematic Treatment
Infection is just part of the process of acne—and there are forms of acne that don’t necessarily involve infection at all. At the very beginning of the formation of blemishes, however, there is excessive growth and shedding of skin inside pores. If clumps of dead skin cells don’t accumulate in pores, then acne bacteria never accumulate and skin oil does not build up, either, assuming the skin is regularly cleansed.
On the other hand, not just infection but also stress can cause inflammation of the skin. Often efforts to prevent acne actually cause it through harsh detergent cleansing of the skin or use of excessively concentrated benzoyl peroxide to kill bacteria in the skin. Acne treatments used in the wrong way can actually cause acne. So what’s the best approach to getting rid of blemishes?
Here are four simple steps.
- Keep your skin clean but not “too clean.” Your primary objective in skin cleansing is keeping your pores free of dead skin. This means you don’t want to use a cleanser that is so harsh that it kills the topmost layer of your skin. You don’t ever want to scrub your skin. Cleanse your face once a day or maybe twice, but don’t try to wash your acne away.
- Keep your skin moist but not oily. Moisture in your skin keeps it flexible so pores stay open. Oil in your pores can be a problem if it is locked in the pore under dead skin. Keep your skin moist by avoiding any kind of skin care products that contain alcohol, and by using moisturizer if necessary. Even people who have oily skin sometimes need moisturizer on the sides of the face and along the jawline.
- Keep your skin exfoliating but not “raw.” Gently removing the topmost layer of skin cells with alpha- or beta-hydroxy acids makes room for fresher, younger skin to emerge to the surface, and stimulates the production of collagen that fills out your skin. Exfoliating two or three times a week is enough. Exfoliating two or three times a day usually injures the skin.
- Keep your skin disinfected but not sterile. It’s important to avoid excessive growth of acne bacteria. When your immune system detects excessive acne bacteria it tries to destroy them with inflammation, but it usually only manages to inflame the skin. Acne bacteria actually serve a useful function on the skin, by consuming excess oil produced by pores. They are only a problem when they grow in large numbers and can’t escape to the surface of the skin.
We can’t recommend any antibiotics you could buy over the Internet (and we recommend you only take antibiotics under a doctor’s supervision). We can, however, recommend an affordable and effective system of acne skin care that does everything for your skin that antibiotics do not, Exposed Skin Care.