ORAL ANTIBIOTICS: TETRACYCLINE, DOXYCYLINE & MINOCYCLINE
Oral antibiotics have been used for more than 30 years to treat rosacea symptoms. Today, these drugs are the mainstay of therapy due to their relative safety and effectiveness. Medical specialists now know that antibiotics work primarily through their anti-inflammatory actions; they are not used for ‘antibacterial’ actions because rosacea is not caused by facial bacteria. (1-3)
Due to their effectiveness and low cost, oral tetracycline antibiotics are usually the first choice for rosacea treatment. Oral tetracycline antibiotics (tetracycline-HCl or oxytetracyline) are usually quite effective at decreasing rosacea papules and pustules, and moderately effective at reducing facial inflammation. (4, 5) In some patients, reduction in facial inflammation may help to alleviate chronic facial redness and burning sensations.
Tetracycline dosage: The usual starting dose is 250 milligrams four times daily, or 500 milligrams, twice daily. These antibiotics should not be taken with meals due to decreased absorption of the medication. Patients are instructed to take this medication one hour before, or two hours after meals. (4, 6) If the patient responds adequately within one to three months, the dose may slowly be tapered by 250 milligrams to the lowest level that maintains control. (7)
Tetracycline side effects: The most common side effects include gastrointestinal tract disturbances (i.e., upset stomach, diarrhea and constipation), and photosensitization (i.e., facial skin becomes more sensitive to sunlight).
Doxycycline is a tetracycline-derivative that has several potential advantages over the standard tetracyclines. First, it is absorbed in the gastrointestinal tract much more efficiently than standard tetracycline antibiotics, and therefore may be taken in smaller dosages. Second, it has a longer half-life than standard tetracyclines, making it effective for longer periods of time. Third, it is much gentler on the stomach and may be taken with meals if needed. (8) Doxycycline is very effective at reducing rosacea papules and pustules, and moderately effective on facial inflammation. (5, 9, 10) In some patients, reduction in facial inflammation may help to decrease chronic facial redness and burning sensations.
Doxycycline dosage: The normal dose for rosacea treatment is 50 to 100 milligrams, one to two times daily. (4)
Doxycycline side effects: Doxycycline is a very strong photosensitizer (i.e., it is much easier to get a sunburn while on this medication). Due to this side effect, Dr. Wilkin does not recommend this drug to patients who spend a great deal of time outdoors, or whom cannot wear sunscreen on a daily basis. (8)
Minocycline is very similar to doxycycline; it is a tetracycline-derivative that is well absorbed by the gastrointestinal tract and is long acting. Minocycline has an additional advantage -- it usually does not cause photosensitization. (11) Minocycline is very effective in the treatment of rosacea papules and pustules, and moderately effective at reducing facial inflammation. (4, 7, 12) In some patients, reduction in facial inflammation may help to alleviate chronic facial redness and burning sensations. Personal reports from hundreds of rosacea subjects, and dozens of medical physicians indicate that minocycline is one of the most popular oral antibiotics used for rosacea treatment.
Minocycline dosage: The usual starting dose for rosacea treatment is 50 to 100 milligrams, one to two times daily. (4, 6).
Minocycline side effects: Some patients may experience bouts of dizziness during the first couple weeks of treatment. In order to minimize dizzy spells, Dr. Wilkin recommends starting patients on low doses for the first two weeks (50 milligrams twice a day); he then gradually increases the dose to 100 milligrams, twice a day. (8)
ORAL ANTIBIOTICS: CLARITHROMYCIN & AZITHROMYCIN
Medical experts are now realizing that the most effective oral antibiotics are those with the greatest anti-inflammatory actions. In this respect, the newer macrolide antibiotics may offer significant advantages over standard tetracycline antibiotics. Experimental and clinical studies demonstrate that macrolide antibiotics possess strong anti-inflammatory actions that are generally greater than tetracycline antibiotics. (1, 9, 13, 14) Two of the most popular macrolide antibiotics are clarithromycin and azithromycin.
Clarithromycin is a recently synthesized macrolide antibiotic that possesses strong anti-inflammatory actions. (9) Clarithromycin is also highly bioavailable, extremely long acting, can be taken with or without food, and has very few side effects. Medical experts indicate that all of these attributes make clarithromycin a great choice for rosacea treatment. (1, 9, 15)
In a recent medical article, “Clarithromycin Versus Doxycycline in the Treatment of Rosacea”, Drs. Torresani, Pavesi and Manara compared the effects of oral doxycycline to clarithromycin in 40 rosacea patients. (9) After 4 weeks of treatment, these physicians found that facial papules and redness were significantly better in the clarithromycin-treated group. These physicians also documented that clarithromycin treatment was associated with fewer side effects. These medical researchers conclude that clarithromycin is an extremely safe medication that is virtually free of side effects. (1, 9)
In a more recent article, “Clarithromycin: A New Perspective in Rosacea Treatment”, Dr. Torressani document that oral clarithromycin is very effective in the treatment of other inflammatory skin disorders such as acne vulgaris, perioral dermatitis, and steroid-induced rosacea. (1) He states, “The effectiveness of clarithromycin in treating steroid-induced rosacea is truly impressive.” (1) Dr. Torressani attributes clarithromycin’s positive effect on skin inflammation to its powerful anti-inflammatory action.
In his medical practice, Dr. Torressani has found clarithromycin to be superior to standard antibiotics in the treatment of rosacea. (1) In fact, he has documented a case in which a rosacea patient, who was previously unresponsive to tetracycline antibiotics, cleared dramatically with clarithromycin.
Clarithromycin dosage: The standard rosacea treatment protocol is 250 milligrams, twice daily for the first month, followed by 250 milligrams once daily. (1, 9) Experts point out that due to its strong anti-inflammatory actions, long-lasting effectiveness, and quick onset of action, clarithromycin may also be used intermittently each month (pulse-dosing) to maintain rosacea clearance. (1)
My personal experience with Clarithromycin: Throughout the years, I have tried many oral antibiotics including tetracycline-HCl, doxcycline, minocycline, and clarithromycin. In my particular case, clarithromycin was the fastest- and best-acting antibiotic. While the standard tetracycline antibiotics had no sustainable effect on my rosacea, clarithromycin was moderately effective on my facial papules, pustules, and generalized inflammation.
Azithromycin is similar to clarithromycin, in that it is a macrolide antibiotic that possesses strong anti-inflammatory actions. Two recent studies have shown azithromycin to be a powerful tool in the fight against rosacea.
At a recent American Academy of Dermatology Meeting (1998) in Orlando, Florida, Dr. Thomas Fitzpatrick of Harvard Medical School detailed an effective rosacea treatment regimen that consisted of pulse dosing with azithromycin. (14) Pulse-dosing therapy is possible with azithromycin due to its fast onset of action, powerful anti-inflammatory actions, and long half-life (it remains in the body for extended periods of time, maintaining therapeutic serum levels for 6 days following discontinuation of the drug). In this study, Dr. Fitzpatrick treated his patients for only 10 days out of the month -- azithromycin was given on the first of the month for 5 straight days, and on the fifteenth of the month for 5 straight days. All rosacea patients reported significant reductions in symptoms while on this treatment regimen.
In a recent clinical study, Dr. Adolfo Fernandez-Obregon, of the Hudson Dermatology and Skincare Center, demonstrated that azithromycin is one of the more effective antibiotics for rosacea treatment. (13) In this study, he treated 10 rosacea patients with azithromycin (each of whom did not respond to previous treatment with standard tetracycline antibiotics). His treatment protocol consisted of only a single dose of azithromycin (250 milligrams), three times a week. Within three to four weeks, all patients reported moderate to marked improvement in their rosacea symptoms. So, not only did these patients respond markedly to low doses of azithromycin; but, they did so very quickly.
Azithromycin dosage: Although there are no general guidelines yet for rosacea treatment, the mild to moderate sufferers may only need pulse-dose therapy (i.e., 250 milligrams three times a week). (13, 14) In the more severe cases, daily treatment may be needed for one to three months to control the symptoms. If the patient responds adequately after this time, pulse dosing may be employed to maintain clearance.
Important: Limitations of Oral Antibiotics
While oral antibiotics are the mainstay of rosacea treatment and are relatively safe, it must be stressed that these medications only decrease some of the superficial symptoms. They do not treat the underlying disease. (16) While patients are often grateful for reduced symptoms, they are usually not satisfied with the overall clearance of rosacea, or lack of effectiveness on the underlying vascular disorder. These medications do not result in a “story book ending” for most sufferers in the moderate to severe stages. In fact, there are numerous medical reports suggesting that rosacea sufferers in the moderate to severe stages may only experience minor improvements while on oral antibiotics, or may not respond at all:
•In a study on 20 rosacea sufferers with moderate to severe rosacea, oral antibiotic treatment was documented to have no significant effect on their rosacea symptoms. (17)
•In a review of 27 rosacea patients, oral antibiotics were found to be only moderately effective at reducing some of the papules and pustules, and were not effective at treating the underlying vascular disorder, flushing, facial redness, and telangiectasia. (18)
•In four different medical reviews, rosacea experts stress that oral antibiotics are not effective in treating the underlying vascular disorder such as facial flushing, chronic redness, and telangiectasia. (16, 19-21)
•In agreement with the above, Dr. Grousshans states, “Tetracycline and metronidazole are very useful for therapy, but they only influence the cutaneous and ocular complications and do not act upon the basic vascular trouble.” (22)
•In two in-depth case reports, rosacea sufferers did not respond at all to oral antibiotic therapy. (23)
•Medical experts indicate that the main problem with traditional oral and topical antibiotic therapy is that they, “Treat the symptoms rather than the root cause or causes of this chronic disorder, and must be used on a long-term basis.” (24)