Tetracyclines are equally effective for the treatment of acne vulgaris

Clinical question What is the most effective way to use tetracyclines for the treatment of acne vulgaris?

Bottom line There is no difference between tetracyclines regarding their efficacy in reducing lesion counts in acne. Although minocycline and doxycycline cost more, they require only once-daily dosing and may be better tolerated. There is no clear advantage to higher doses. (Level of evidence = 1a–)

Synopsis Tetracyclines have anti-inflammatory and antibacterial properties and are recommended for the treatment of moderate to severe acne vulgaris. In this systematic review, the authors identified clinical trials of tetracycline (48), minocycline (29), doxycycline (10), and lymecycline (7) and included a total of 57 studies after excluding for fewer than six patients, duplicate publication, combination therapies, recent antibiotic therapy, specific forms of acne, non-English language, and crossover studies. The authors focused on lesion count (inflammatory and noninflammatory) as the most objective and widely used outcome measure. Only seven studies had more than 100 patients, only 22 were double-blinded and used only intention-to-treat analysis, and none lasted more than 24 weeks. Studies comparing different drugs found no consistent difference in the effect on inflammatory or noninflammatory lesion counts. There was no difference in efficacy over time, which might have happened if resistance had occurred. There was also no benefit to higher doses.

Simonart T, Dramaix M, De Maertelaer V. Efficacy of tetracyclines in the treatment of acne vulgaris: a review. Br J Dermatol. 2008;158(2):208-216.