TherapyDosageAdverse effectsCaveatsEvidenceCost*

  • Doxycycline (Oracea; anti-inflammatory/subantimicrobial dose)†

  • 40 mg once per day (30 mg per 10-mg modified-release capsule)

  • 20 mg twice per day

  • Dose-related phototoxicity, GI adverse effects, pill esophagitis, pseudotumor cerebri, cutaneous hyperpigmentation (bluish/brownish discoloration of skin, mucous membranes)

  • Decreased absorption with vitamins, antacids, metal ions

  • Contraindicated in pregnancy and lactation

  • No generation of antibiotic resistance demonstrated

  • RCTs and open-label studies (large, high-quality studies)

  • NA ($$$$$) for 40 mg

  • $$ for 20 mg

  • Doxycycline (antimicrobial dose)

  • 100 mg once or twice per day

  • Tetracycline-related adverse effects as above

  • Candidiasis

  • Decreased absorption with vitamins, antacids, metal ions

  • Contraindicated in pregnancy and lactation

  • RCTs (few) and historical use

  • $ for 60 capsules

  • $$ for 60 tablets

  • Tetracycline

  • 250 to 500 mg twice per day

  • Tetracycline-related adverse effects as above

  • Candidiasis

  • Decreased absorption with vitamins, antacids, metal ions

  • Contraindicated in pregnancy and lactation

  • Must be taken at least one hour before or two hours after meal

  • RCTs (few) and historical use

  • $

  • Minocycline (Minocin)

  • 50 to 100 mg twice per day or once per day for long-acting

  • Tetracycline-related adverse effects as above

  • Vertigo/dizziness, autoimmune hepatitis, drug-induced lupus-like syndrome

  • Drug rash with eosinophilia and systemic symptoms

  • Contraindicated in pregnancy and lactation

  • Historical use

  • $ ($$$$$)

  • Metronidazole (Flagyl)

  • 250 mg once per day

  • Disulfiram (Antabuse) reaction with alcohol, seizures, neuropathy

  • Candidiasis

  • Drug interaction with lithium, anticoagulants, phenytoin (Dilantin)

  • Small studies

  • $ ($$$)

  • Azithromycin (Zithromax)

  • 500 mg once per day for three consecutive days per week

  • 250 mg once per day for three days per week

  • GI adverse effects, prolonged QT interval, hepatotoxicity, cholestasis

  • Candidiasis

  • Caution in older patients

  • Small studies, case reports

  • $ ($$$) for 500 mg

  • $ ($$) for 250 mg

  • Erythromycin

  • 250 mg twice per day

  • High incidence of GI adverse effects, prolonged QT interval

  • High incidence of drug interactions

  • Caution in older patients

  • Small studies

  • $$$$

  • Clarithromycin (Biaxin)

  • 250 to 500 mg twice per day

  • High incidence of GI adverse effects, prolonged QT interval

  • High incidence of drug interactions

  • Caution in older patients

  • Small studies

  • $$$ ($$$$$) for 250 mg

  • $$$ ($$$$$) for 500 mg

  • Isotretinoin

  • 0.3 mg per kg per day or 10 to 20 mg per day initially for 4 to 6 months, followed by microdose therapy (0.03 to 0.17 mg per kg per day)

  • Teratogenicity, hyperlipidemia, hepatotoxicity, depression, dry skin, photosensitivity, impaired night vision

  • Patients must enroll in National iPledge Program; physicians require special training to prescribe

  • Refractory papulopustular and phymatous subtypes

  • RCTs (few)

  • $$$$ to $$$$$, depending on which generic is used and the dosage