The Antibiotic Families

There are many different families of antibiotics. Each antibiotic family targets bacteria in a unique way. Each antibiotic family tends to be more effective against certain types of bacteria, and less effective against others.

Antibiotics from several different families are used for the treatment of acne. The antibiotic families most commonly used in acne treatment are Macrolides, Tetracyclines, Pleuromutilins, Sulfonamides and Quinolones. Antibiotics can be used applied topically or ingested orally. The route of delivery, the ability of an antibiotic to accumulate in the skin and the susceptibility of P. acnes bacteria to an antibiotic all impact the efficacy of a given antibiotic treatment.

For more information about the sensitivity of Propionibacterium acnes (P. acnes) to specific antibiotics, visit our Antibiotic Susceptibility of Propionibacterium acnes page. For more information about the P. acnes bacterium, visit our What Is Propionibacterium acnes? page. Below is a summary of the different antibiotic families that are used in the treatment of acne.

Aminoglycosides

Aminoglycoside Family Members: Gentamicin (Garamycin), Neomycin (Neosporin), Paromomycin (Gabbroral), Tobramycin (Tobrex).
Frequency of Use For Acne Treatment: Uncommon.
General Efficacy as Acne Treatments: Poor.
Frequency of High-Level Antibiotic Resistance: Very Common.

Aminoglycoside antibiotics tend to be ineffective treatments for acne vulgaris. The acne-causing P. acnes bacterium is naturally resistant to most antibiotics in the Aminoglycoside family.

Aminoglycoside antibiotics are modified sugar molecules that are pimarily effective against gram-negative bacteria (P. acnes bacteria are gram-positive). Aminoglycoside antibiotics work by binding to bacterial ribosomes and inhibiting the bacteria’s ability to synthesize new proteins. Aminoglycosides are popular antibiotics for topical first-aid treatments (the primary ingredient in Neosporin is neomycin, an aminoglycoside). Topical aminoglycoside ointments (eg. Neosporin) may help prevent secondary infections of damaged skin and/or popped pimples. Therefore, they may help prevent mild acne scarring and accelerate the healing process.

Aminoglycoside Antibiotics

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Amphenicols

Amphenicol Family Members: Chloramphenicol (Clorin), Thiamphenicol (Biothicol).
Frequency of Use For Acne Treatment: Rare.
General Efficacy as Acne Treatments: Unknown.
Frequency of High-Level Antibiotic Resistance: Rare.

Amphenicols are a family of broad spectrum antibiotics that are used in many topical antibacterial medications, such as opthalmic solutions (eye drops). Amphenicols work by disrupting the ability of bacteria to synthesize new proteins. Antibiotic susceptibility testing indicates that P. acnes bacteria tend to be moderately susceptible to Amphenicols, and P. acnes bacteria with high-level resistance to Amphenicols are rare.

Amphenicols are rarely used for the treatment of acne. But topical formulations of Amphenicols (eg. Chloramphenicol) may be a useful acne treatment for some individuals. Topical Amphenicols may complement other types of acne treatments.

Amphenicol Antibiotics

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Cephalosporins

Cephalosporin Family Members: Cefaclor (Ceclor), Cefadroxil (Duricef), Cefdinir (Omnicef), Cefixime (Suprax), Cefpodoxime (Cefpo), Cefprozil (Cefzil), Cefradine (Cefradune), Ceftibuten (Cedax), Cephalexin (Keflex).
Frequency of Use For Acne Treatment: Occasional.
General Efficacy as Acne Treatments: OK.
Frequency of High-Level Antibiotic Resistance: Uncommon.

Cephalosporins are occasionally used as oral antibiotic treatments for moderate to severe acne symptoms (Acne Types: 2-4). Many individuals with acne have reported positive results from treatment with various Cephalosporin antibiotics. But not all acne patients achieve significant improvement with Cephalosporins.

Cephalosporins are type of beta-lactam antibiotic and they are structurally-related to the Penicillins. Cephalosporins kill bacteria by disrupting their cell walls via inhibition of peptidoglycan layer assembly. In contrast to Penicillins, Cephalosporins are effective against a broader range of bacteria and are more resistant to a bacterial antibiotic-resistance enzyme called Penicillinase. In antibiotic susceptibility testing, Cephalosporins were effective against P. acnes bacteria, but they tend to be less toxic to P. acnes than Penicillins.

Cephalosporin Antibiotics

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Fusidic Acid

Fusidic Acid Family Members: Fusidic Acid (Fucidin).
Frequency of Use For Acne Treatment: Occasional.
General Efficacy as Acne Treatments: OK.
Frequency of High-Level Antibiotic Resistance: Uncommon.

Fusidic Acid is an antibiotic that prevents bacteria from synthesizing proteins by disrupting the function of a bacterial protein, Elongation Factor G (EF-G). Fusidic acid is available in oral and topical formulations. Topical Fusidic Acid is the form of this antibiotic that is generally used for the treatment of acne.

Antibiotic susceptibility testing indicates that the acne-causing P. acnes bacterium tends to be moderately susceptible to Fusidic Acid. Many patients have reported positive results with the use of topical Fusidic Acid. Fusidic Acid is generally used in combination with a complementary antibiotic.

Fusidic Acid Antibiotics

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Lincosamides

Lincosamide Family Members: Clindamycin (Cleocin).
Frequency of Use For Acne Treatment: Very Common.
General Efficacy as Acne Treatments: Good.
Frequency of High-Level Antibiotic Resistance: Occasional (Increasing).

One member of the Lincosamide family, Clindamycin, is frequently used for the treatment of acne. Clindamycin is generally used as a topical medication, but oral versions of this antibiotic are also available. Topical Clindamycin can be an effective treatment for mild to moderate acne symptoms (Acne Types: 1-3).

Lincosamides are structurally related to the Macrolide family of antibiotics. Lincosamides work by binding to the bacterial 23S ribosome, which inhibits the ability of the bacteria to synthesize new proteins. Lincosamides are generally very toxic to P. acnes bacteria, but Lincosamide-resistant P. acnes bacteria are becoming increasingly common. Research reports indicate that Clindamycin-resistant P. acnes bacteria are especially common in the United States and Europe.

Lincosamide Antibiotics

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Macrolides

Macrolide Family Members: Azithromycin (Zithromax), Clarithromycin (Biaxin), Dirithromycin (Dynabac), Erythromycin (E-Mycin), Josamycin (Josalid), Pristinamycin (Pyostacine), Roxithromycin (Roximycin), Spiramycin (Spirex), Telithromycin (Ketek).
Frequency of Use For Acne Treatment: Common.
General Efficacy as Acne Treatments: Good.
Frequency of High-Level Antibiotic Resistance: Occasional (Increasing).

Macrolides are a diverse class of antibiotics that includes several medications that are commonly used for the treatment of acne. Macrolides work by preventing bacteria from synthesizing new proteins. They do this by binding to a bacterial enzyme called Peptidyltransferase and/or binding to the bacterial 50S ribosome subunit. Macrolides are structurally related to Lincosamide antibiotics.

Macrolides are commonly used to treat infections caused by gram-positive bacteria. Topical macrolide antibiotics (eg. Erythromycin) are a very common treatment for acne, but oral Macrolides are also widely used. Antibiotic susceptibility testing indicates that Macrolides are usually very toxic to acne-causing P. acnes bacteria. However, Macrolide-resistant P. acnes bacteria are becoming increasingly common in many areas. Current research now indicates that a significant proportion of acne-associated P. acnes bacteria in the United States and Europe have now acquired some level of resistance to Macrolide antibiotics.

Macrolide Antibiotics

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Nitroimidazoles

Nitroimidazole Family Members: Metronidazole (Flagyl).
Frequency of Use For Acne Treatment: Occasional.
General Efficacy as Acne Treatments: Poor.
Frequency of High-Level Antibiotic Resistance: Very Common.

Nitroimidazole antibiotics are used to treat infections that are caused by both bacteria and parasites. Nitroimidazoles work by disrupting the ability of microbes to synthesize new DNA.

Metronidazole is the only member of the Nitroimidazole family that is routinely used in the treatment of acne. Topical Metronidazole is also a common treatment for Rosacea. Antibiotic susceptibility testing indicates that P. acnes bacteria are naturally resistant to Metronidazole. However, many individuals with acne report improvements in their symptoms following use of Metronidazole. These improvements may be the result of Metronidazole’s ability to kill other types of bacteria that can contribute to acne symptoms (eg. S. aureus).

Nitroimidazole Antibiotics

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Oxazolidinones

Oxazolidinone Family Members: Linezolid (Zyvox) and Tedizolid (Sivextro).
Frequency of Use For Acne Treatment: Rare.
General Efficacy as Acne Treatments: Unknown.
Frequency of High-Level Antibiotic Resistance: Rare.

Oxazolidinones are a relatively new class of antibiotics that are used to treat certain types of inections caused by gram-positive bacteria. Oxazolidinones prevent bacteria from synthesizing new proteins by preventing N-formylmethionyl-tRNA from binding to the bacterial ribosome.

Oxazolidinones are rarely used in the treatment of acne. However, antibiotic susceptibility testing indicates that they are active against the acne-causing P. acnes bacteria. These antibiotics may become more widely used as acne treatments in the future.

Oxazolidinone Antibiotics

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Penicillins

Penicillin Family Members: Amoxicillin (Amoxil), Ampicillin (Polycillin), Ampicillin + Clavulanic Acid (Augmentin), Cloxacillin (Cloxapen), Dicloxacillin (Diclocil)Flucloxacillin (Floxapen), Penicillin G (BenzylPenicillin), Penicillin V (Phenoxymethylpenicillin).
Frequency of Use For Acne Treatment: Occasional.
General Efficacy as Acne Treatments: Good.
Frequency of High-Level Antibiotic Resistance: Rare.

Penicillin was discovered in 1920s by the Nobel Prize winning scientist Alexander Fleming. The discovery of Penicillin revolutionized the treatment of bacterial infections and initiated the modern era of antibiotics. Penicillins are beta lactam antibiotics that are structurally related to the Cephalosporins. Penicillin antibiotics work by damaging the cell wall of susceptible bacteria. They are most effective against gram positive bacteria, a group that includes the acne-causing P. acnes bacterium.

Penicillins are available in topical and oral formulations, both of which are occasionally used for the treatment of acne. Individuals with acne have generally reported positive results from treatments with Penicillin family antibiotics. Antibiotic susceptibility testing has shown that most P. acnes bacteria are extremely sensitive to Penicillins.

Penicillin Antibiotics

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Pleuromutilins

Pleuromutilin Family Members: Retapamulin (Altabax).
Frequency of Use For Acne Treatment: Occasional.
General Efficacy as Acne Treatments: Good.
Frequency of High-Level Antibiotic Resistance: Rare.

Pleuromutilins are new class of antibiotics that are used to treat certain types of infections caused by gram-positive bacteria. Pleuromutilins work by preventing bacteria from synthesizing new proteins via inhibition of a bacterial enzyme called Peptidyl Transferase.

Antibiotic susceptibility testing indicates that P. acnes bacteria are highly sensitive to Pleuromutilin antibiotics, such as Retapamulin. Retapamulin is the only antibiotic in this family that is currently approved for human use. Retapamulin is used as a topical treatment for several kinds of skin infections, including acne. Patient reports and clincal research indicate that topical Retapamulin can significantly improve acne symptoms for most patients. The use of topical Retapamulin as a treatment for acne is likely to become more common as this medication becomes more widely available.

Pleuromutilin Antibiotics

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Quinolones

Quinolone Family Members: Ciprofloxacin (Cipro), Gatifloxacin (Tequin), Gemifloxacin (Toplon), Levofloxacin (Levaquin), Moxifloxacin (Avelox), Nadifloxacin (Nadixa), Nalidixic Acid (Wintomylon), Norfloxacin (Norflox), Ofloxacin (Floxin) and Sparfloxacin (Zagam).
Frequency of Use For Acne Treatment: Uncommon.
General Efficacy as Acne Treatments: Good.
Frequency of High-Level Antibiotic Resistance: Rare.

Quinolones are a class of broad-spectrum antibiotics that were discovered in the 1960s. Quinolones inhibit bacterial growth by preventing bacteria from reading and duplicating their DNA. Quinolones are effective against both gram-negative and gram-positive bacteria.

Quinolones are commonly used in combination with other antibiotics. They are rarely used for long term treatments or prophylaxis. This is because bacteria can develop resistance to Quinolones easire than they can to most other antibiotics. Quinolones also tend to have higher rates of side effects than other antibiotics.

Laboratory testing indicates that P. acnes bacteria are generally susceptible to most antibiotics in the Quinolone family. However, Quinolones are not commonly used for the treatment of acne vulgaris. Patient reports indicate that oral Quinolones can improve acne symptoms in many patients, at least temporarily. Most Quinolones are only available in oral formulations, but there is one fairly new Quinolone for topical use that is gaining some buzz – Nadifloxacin. Topical Nadifloxacin is not available in all countries, but several studies suggest that this medication can significanly improve acne symptoms in some individuals. Because it is administered topically, Nadifloxacin has a much better safety profile than most oral antibiotics.

Quinolone Antibiotics

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Rifamycins

Rifamycin Family Members: Rifabutin (Mycobutin), Rifampicin (Rifampin), Rifapentine (Priftin).
Frequency of Use For Acne Treatment: Rare.
General Efficacy as Acne Treatments: Unknown.
Frequency of High-Level Antibiotic Resistance: Rare.

Rifamycins were discovered in the 1950’s. Rifamycins work by preventing bacteria from reading their own DNA (they block RNA synthesis). Rifamycins are important components of the combined antibiotic therapies used to treat tuberculosis. Because Rifamycins are an essential part of anti-tuberculosis therapy, their use in the treatment of other infections has been restricted in some places. Antibiotic resistance to Rifamycins tend to develop faster than resistance to other antibiotics.

Antibiotic susceptibility testing indicates that Rifamycins are very toxic to most strains of P. acnes bacteria. However, Rifamycins are rarely used for the treatment of acne vulgaris. Several research and patient reports suggest that Rifamycins (Rifampicin in particular) can be very effective at improving acne symptoms for some individuals. More research is needed on the utility of Rifamycin family antibiotics in the treatment of acne. Rifamycines are generally only available in oral formulations.

Rifamycin Antibiotics

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Sulfonamides

Sulfonamide Family Members: Co-Trimoxazole (Bactrim), Dapsone (Aczone), Mafenide (Sulfamylon), Silver Sulfadiazine (Silvadene), Sulfacetamide (Clenia)Sulfadimethoxine (Albon), Sulfadoxine (Sulphadoxine), Sulfafurazole (Sulfisoxazole), Sulfamethoxazole (SMX) and Sulfathiazole (Sulfatiazol).
Frequency of Use For Acne Treatment: Occasional.
General Efficacy as Acne Treatments: Good.
Frequency of High-Level Antibiotic Resistance: Rare.

Sulfonamides are a class of antibiotics whose molecules all contain sulfur atoms. They were among the first oral antibiotics to be used in human medicine and their use became widespread in the 1930s. Sulfonamides work by preventing bacteria from synthesizing an essential vitamin, Folate (Vitamin B9).

Antibiotics in the Sulfonamide family are available in many oral and topical formulations. Sulfonamides are also widely used in veterinary medicine. Antibiotic susceptibility testing indicates that ance-causing P. acnes bacteria tend to be moderately susceptible to Sulfonamides. Topical sulfonamides (eg. Dapsone, Mafenide, Silver Sulfadiazine and Sulfacetamide) are occassionally used for the treatment of mild to moderate acne symptoms (Acne Types: 1-3) and many individuals have reported positive results with these medications. Because Sulfonamides have a unique mechanism of action, they can be combined with many other acne medications.

Only one oral Sulfonamide antibiotic is routinely used as an acne treatment – Co-Trimoxazole. Co-Trimoxazole is a combination of two antibiotics Sulfamethoxazole and Trimethoprim. These two antibiotics work synergistically and are substantially more effective in together than either is alone. Co-Trimoxazole is an important acne treatment because it can be very effective for individuals with moderate to severe inflammatory acne (Acne Types: 3-4). However, Co-trimoxazole is not routinely prescribed for the treatment of acne vulgaris in many places. This is primarily the result of two factors. First, allergic reactions to oral Sulfonamides can be more severe than allergic reactions caused by other antibiotics. Second, the use of Co-Trimoxazole as an acne treatment is considered “off-label” in many countries, including the United States. As a result, many physicians do not feel comfortable considering Co-Trimoxazole for the treatment of acne. But for those patients without allergies to Sulfonamides, Co-trimoxazole treatments may yield substantial improvements in difficult-to-treat acne cases.

Sulfonamide Antibiotics

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Tetracyclines

Tetracycline Family Members: Demeclocycline (Declomycin), Doxycycline (Vibramycin), Lymecycline (Tetralysal), Minocycline (Minocin), Oxytetracycline and Tetracycline (Sumycin).
Frequency of Use For Acne Treatment: Very Common.
General Efficacy as Acne Treatments: OK.
Frequency of High-Level Antibiotic Resistance: Common.

Tetracyclines were discovered in the 1940s by the plant scientist Benjamin Duggar. Tetracyclines are a class of broad-spectrum antibiotics that work by inhibiting protein synthesis in susceptible bacteria via disruption of the 30S Ribosome. In the past, Tetracyclines were frequently used for the treatment of many different types of infections. But in the last thirty years, the efficacy of Tetracyclines has decreased substantially due to the spread of Tetracycline-resistant bacteria.

Tetracyclines are the antibiotic family of choice for many dermatologists when treating acne. Oral Tetracyclines are commonly used for the treatment of moderate to severe acne symptoms (Acne Types: 2-4). However, antibiotic susceptibility reports clearly demonstrate that Tetracycline-resistant P. acnes bacteria are common, particularly in certain regions of the world (eg. United States and Europe).

When acne is caused by Tetracycline-susceptible bacteria, treatment with Tetracyclines (particularly Minocycline) can be very effective. But current patient reports and clinical research indicate that Tetracyclines yield little to no improvement in acne symptoms for many individuals. The likely reason why Tetracyclines are so frequently used for the treatment of acne, despite their mediocre efficacy and the prevalence of Tetracycline-resistant P. acnes bacteria, is that many of the prescribing guidelines now in use for the treatment of acne were developed decades ago, when the patterns of antibiotic resistance among P. acnes bacteria were different.

Tetracycline Antibiotics

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Additional Antibiotics

BACITRACIN

Frequency of Use For Acne Treatment: Occasional.
General Efficacy as Acne Treatments: Unkown.
Frequency of High-Level Antibiotic Resistance: Common.

FOSFOMYCIN

Frequency of Use For Acne Treatment: Rare.
General Efficacy as Acne Treatments: Unkown.
Frequency of High-Level Antibiotic Resistance: Very Common.

GRAMICIDIN

Frequency of Use For Acne Treatment: Occasional.
General Efficacy as Acne Treatments: Unkown.
Frequency of High-Level Antibiotic Resistance: Common.

MUPIROCIN

Frequency of Use For Acne Treatment: Occasional.
General Efficacy as Acne Treatments: Poor.
Frequency of High-Level Antibiotic Resistance: Very Common.

NITROFURANTOIN

Frequency of Use For Acne Treatment: Rare.
General Efficacy as Acne Treatments: Unknown.
Frequency of High-Level Antibiotic Resistance: Rare.

TRIMETHOPRIM

Frequency of Use For Acne Treatment: Occasional.
General Efficacy as Acne Treatments: OK.
Frequency of High-Level Antibiotic Resistance: Rare.