Approaches to limit systemic antibiotic use in acne: Systemic alternatives, emerging topical therapies, dietary modification, and laser and light-based treatments

J Am Acad Dermatol. 2019 Feb;80(2):538-549. doi: 10.1016/j.jaad.2018.09.055. Epub 2018 Oct 5.


Acne is one of the most common diseases worldwide and affects ∼50 million individuals in the United States. Oral antibiotics are the most common systemic agent prescribed for the treatment of acne. However, their use might be associated with a variety of adverse outcomes including bacterial resistance and disruption of the microbiome. As a result, multiple treatment guidelines call for limiting the use of oral antibiotics in the treatment of acne, although actual prescribing often does not follow these guidelines. In this review, the rationale for concerns regarding the use of oral antibiotics for the management of acne is reviewed. In addition, we will discuss our approach to complying with the intent of the guidelines, with a focus on novel topical agents, dietary modification, laser and light-based modalities, and systemic medications, such as spironolactone, combined oral contraceptives, and oral isotretinoin.

Keywords: acne; antibiotic stewardship; antibiotics; diet; evidence-based medicine; guidelines; isotretinoin; laser; spironolactone.

Publication types

  • Comparative Study
  • Review

MeSH terms

  • Acne Vulgaris / diagnosis
  • Acne Vulgaris / therapy*
  • Administration, Oral
  • Administration, Topical
  • Adult
  • Anti-Bacterial Agents / therapeutic use*
  • Diet, Protein-Restricted*
  • Esthetics
  • Evidence-Based Medicine
  • Female
  • Humans
  • Isotretinoin / therapeutic use
  • Laser Therapy / methods*
  • Male
  • Phototherapy / methods
  • Practice Guidelines as Topic*
  • Risk Assessment
  • Severity of Illness Index
  • Spironolactone / therapeutic use
  • Treatment Outcome
  • Young Adult


  • Anti-Bacterial Agents
  • Spironolactone
  • Isotretinoin