INTRODUCTION
Acne vulgaris is a common skin disease affecting ~9% of the global population and ~85% of the population aged 12 to 24 years.1 Clinical management of acne primarily targets inflammation and hyperproliferation of Cutibacterium (formerly Propionibacterium) acnes bacteria.1,2 Oral antibiotics are mainstays of moderate-to-severe acne therapy owing to their established efficacy and tolerability and, because of the chronic nature of the disease, they are often used for extended durations.3,4 Because of both their antibacterial and anti-inflammatory effects, oral tetracycline-class antibiotics have been a key component of the acne treatment regimen, comprising ~75% of antibiotic prescriptions by dermatologists.2 Oral antibiotics currently approved by the US Food and Drug Administration for the treatment of severe acne include tetracycline, doxycycline, and minocycline (as adjunctive therapy); sarecycline is indicated for treatment of moderate-tosevere acne vulgaris.2 Noticeable acne improvement with oral tetracycline-class antibiotics such as sarecycline is observed early as 3 weeks, if used as indicated.5,6 Use of oral antibiotics can be associated with adverse events, as summarized in Table 2.
However, antibiotic resistance related to nonselective, prolonged, and intermittent antibiotic use is an emerging concern. With regard to C acnes, rates of resistance to antibiotic monotherapy have been increasing from ~20% in the 1960s to ~60% in 2003.2 Resistance of C acnes may be associated with poor outcomes as patients with resistant strains are less likely to demonstrate clinical improvement of inflammatory lesions than those with sensitive strains.7 Moreover, widespread use of oral broad-spectrum antibiotics is associated with increased rates of pharyngitis and other upper respiratory infection, as well as disruption of the cutaneous and gut microbiota.8,9
However, antibiotic resistance related to nonselective, prolonged, and intermittent antibiotic use is an emerging concern. With regard to C acnes, rates of resistance to antibiotic monotherapy have been increasing from ~20% in the 1960s to ~60% in 2003.2 Resistance of C acnes may be associated with poor outcomes as patients with resistant strains are less likely to demonstrate clinical improvement of inflammatory lesions than those with sensitive strains.7 Moreover, widespread use of oral broad-spectrum antibiotics is associated with increased rates of pharyngitis and other upper respiratory infection, as well as disruption of the cutaneous and gut microbiota.8,9
