Oral versus topical antibiotics

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The two systematic reviews located also provided comparative data on the use of oral versus topical antibiotics.14,81 A number of other non-systematic reviews and individual RCTs were also located, giving a total of 20 studies,127,147-159 six of which also included a placebo control arm.87-92 (see Web Table 13.8). Twelve used double-dummy designs to maintain blinding. Oral antibiotics have a delayed onset of activity; therefore studies of shorter duration may be biased in favour of the topical agent.

The evidence from three RCTs suggests that minocycline, 50 mg twice daily, produces comparable results against both NIL and IL as 1% clindamycin applied twice daily.153-155 The trials enrolled fewer than 100 patients and were therefore underpowered to conclusively state equivalence.

Six RCTs compared oral tetracycline 250 mg twice daily with 1% clindamycin twice daily.9091 127 147-149 Only one RCT was longer than 8 weeks duration149 and only one study was adequately powered (305 patients) but was of inadequate duration.91 This study found that at 8 weeks there was no significant difference in the percentage reductions obtained with either tetracycline 250 mg twice daily or 1% clindamycin applied twice daily in pustules (68% versus 76%) and papules (63% versus 68%) in patients with moderate-to-severe acne. However, the physician rated the clindamycin therapy as good to excellent in a greater number of cases -86/105 compared with 66/103 (P<0-05). Four of the other studies failed to detect any significant differences between the therapies, with the fifth finding that clindamycin caused a significantly greater percentage reductions in IL (57% versus

72% (P<0-001)) at 8 weeks in patients with mild acne.90 The 12-week study found no difference.149

Tetracycline, 250 mg twice daily, produced similar changes in lesion counts at 12 weeks to topically applied 1-5% erythromycin in a single RCT of 54 patients with moderate-to-severe acne.152 Although numerically erythromycin produced greater percentage changes, these were not significant. None of the four RCTs located found any differences in overall grade between oral tetracycline, 250 mg twice daily, and topically applied 1-5% mecleocycline twice daily; both were superior to placebo in the three studies that also used a placebo control.151 None of the studies used ITT analysis. At 8-12 weeks, oral tetracycline 250 mg twice daily was found to produce similar reductions in overall grade to topical 0-5% tetracycline, with one trial finding no effect on comedones.87-89

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