INTRODUCTION
Sarecycline is a third-generation tetracycline that is only currently FDA-approved for the treatment of moderate to severe inflammatory acne vulgaris in patients greater than or equal to 9 years old. It functions as a bacteriostatic translation inhibitor that targets grampositive bacteria on the skin, most notably Cutibacterium acnes. Sarecycline shares anti-inflammatory properties with first- and second-generation tetracyclines, however, it is differentiated by its narrow spectrum of activity and less potent effect on gastrointestinal microbes. These features of sarecycline reduce the risk of antibiotic resistance and minimize side effects.1-3 The most common side effects, nausea, nasopharyngitis, and headache, have been demonstrated by both short- and long-term safety investigations.4-5 Importantly, sarecycline has comparable efficacy to older tetracyclines in reducing both inflammatory and non-inflammatory acne lesions on the face and trunk. Finally, the drug's once-daily administration helps to promote treatment adherence.
In addition to its use for acne, sarecycline has also been leveraged for the management of a myriad of other dermatologic conditions, including rosacea, perioral dermatitis, mucous membrane pemphigoid, and the papulopustular eruption of tyrosine kinase inhibitors.6-10 Given that dermatologists have the highest antibiotic prescription rate per clinician among all medical specialties and that two-thirds of these prescriptions are for minocycline or doxycycline, dermatologists should be familiar with sarecycline's on- and off-label uses as part of their treatment armamentarium.9
In addition to its use for acne, sarecycline has also been leveraged for the management of a myriad of other dermatologic conditions, including rosacea, perioral dermatitis, mucous membrane pemphigoid, and the papulopustular eruption of tyrosine kinase inhibitors.6-10 Given that dermatologists have the highest antibiotic prescription rate per clinician among all medical specialties and that two-thirds of these prescriptions are for minocycline or doxycycline, dermatologists should be familiar with sarecycline's on- and off-label uses as part of their treatment armamentarium.9
Rosacea
Oral (and now even topical) tetracyclines are a mainstay in the treatment of the papulopustular subtype of rosacea due to their anti-inflammatory properties. However, given that the broadspectrum action of older-generation tetracyclines poses risks of antibiotic resistance and off-target side effects, sarecycline is a viable alternative antibiotic choice.12-13
To further investigate the safety and efficacy of sarecycline in treating rosacea, a pilot study comparing sarecycline versus a multivitamin as a placebo in 102 subjects with rosacea was performed. The study found an improvement in Investigator's Global Assessment score of rosacea to clear or almost clear (P<0.0001) at week 12 of treatment, a reduction in total inflammatory lesion count (P<0.0001), a Subjective Global Assessment improvement reported by subjects (P<0.001), and greater reductions in erythema (P<0.0001), dryness (P=0.01), peeling (P=0.02), and burning (P=0.01) when compared to placebo. Adverse events did include gastroenteritis, however only in 2.6% of subjects.6 While studies comparing sarecycline with older-generation tetracyclines have not been performed, this pilot study indicates that sarecycline could be a safe and effective option for the treatment of rosacea.
To further investigate the safety and efficacy of sarecycline in treating rosacea, a pilot study comparing sarecycline versus a multivitamin as a placebo in 102 subjects with rosacea was performed. The study found an improvement in Investigator's Global Assessment score of rosacea to clear or almost clear (P<0.0001) at week 12 of treatment, a reduction in total inflammatory lesion count (P<0.0001), a Subjective Global Assessment improvement reported by subjects (P<0.001), and greater reductions in erythema (P<0.0001), dryness (P=0.01), peeling (P=0.02), and burning (P=0.01) when compared to placebo. Adverse events did include gastroenteritis, however only in 2.6% of subjects.6 While studies comparing sarecycline with older-generation tetracyclines have not been performed, this pilot study indicates that sarecycline could be a safe and effective option for the treatment of rosacea.
Perioral Dermatitis
As perioral dermatitis has previously been associated with a dysregulated skin microbiome, conventional treatment paradigms for treating severe perioral dermatitis include doxycycline.14 Given the established role of tetracycline antibiotics in the treatment of perioral dermatitis and the challenging nature of managing this condition, sarecycline may function as a novel therapy for perioral dermatitis.
The first reported case of sarecycline use for the treatment of perioral dermatitis was documented in a patient with Crohn's disease, who exhibited clinical and symptomatic improvement within 5 days of treatment initiation and almost complete resolution within 13 days. Notably, sarecycline was chosen for this patient in part due to their history of inflammatory bowel disease to minimize the risk and sequelae of gut dysbiosis. Another published report demonstrated improvement in treatment-resistant steroid-induced perioral dermatitis after two months of treatment with sarecycline. Sarecycline was well tolerated in both cases.7,8
The first reported case of sarecycline use for the treatment of perioral dermatitis was documented in a patient with Crohn's disease, who exhibited clinical and symptomatic improvement within 5 days of treatment initiation and almost complete resolution within 13 days. Notably, sarecycline was chosen for this patient in part due to their history of inflammatory bowel disease to minimize the risk and sequelae of gut dysbiosis. Another published report demonstrated improvement in treatment-resistant steroid-induced perioral dermatitis after two months of treatment with sarecycline. Sarecycline was well tolerated in both cases.7,8
Mucous Membrane Pemphigoid
Treatment modalities for Mucous membrane pemphigoid (MMP) vary but include systemic, topical, and intralesional corticosteroids and immune modifying agents.16 The use of systemic minocycline has been reported as a therapeutic option for oral MMP, however, treatment success was limited by drug side effects.17 In one report, a patient with MMP who was treated with sarecycline after previous unsuccessful treatment with doxycycline showed improvement in inflammation and disease activity. The patient was maintained on treatment for 3 months,
