Birth control pills seem to work as well as antibiotics for long-term treatment of acne in women, according to a new review of past clinical trials.

After six months, both treatments reduced acne by just over 50 percent, prompting dermatologists to call the Pill a good alternative for some women and a means of avoiding the drawbacks of stronger oral acne medications or long-term antibiotic use.

Past research has shown that both antibiotics and birth control pills can improve acne, but the new review compared the two options side-by-side and found antibiotics worked better after three months, but after six months of use, results were about equal.

“Oral contraceptives (OCPs) take longer to work because they have a different mechanism of action,” said Dr. Kelly H. Tyler, who was not involved in the new review.

“Antibiotics have anti-inflammatory properties, and OCPs do not have those same properties, so the reduction in acne is going to be more gradual and less dramatic in the beginning,” said Tyler, a dermatologist at Ohio State University in Columbus.

Antibiotics help to reduce inflammation of existing acne, whereas oral contraceptives reduce free or circulating androgens, lowering production of the oily sebum that plugs pores, which lowers the risk of new acne developing, she told Reuters Health by email.

The review included 32 randomized controlled trials of antibiotics or oral contraceptives for treating acne. In general, after three months of treatment, antibiotics had reduced the number of whiteheads or cysts by 48 percent, compared to 37 percent with oral contraceptives.

But by six months, oral contraceptives had caught up, reducing acne by 55 percent, compared to 53 percent with antibiotics, according to the results published in the Journal of the American Academy of Dermatology.

The authors caution that the antibiotics trials they analyzed included both men and women, which interferes with the comparison to the contraceptive trial results because hormones do play such an important role in acne.

Nonetheless, they write, the findings suggest birth control pills “may have a more important first-line preventive role in chronic acne than previously accepted.”

Dr. Steven R. Feldman, a dermatologist at Wake Forest University School of Medicine in Winston-Salem, North Carolina, agreed. “This confirms that birth control pills are a good solid treatment for acne, and they’re probably underutilized,” he told Reuters Health.

The Food and Drug Administration has approved many birth control medications for treating acne as well as preventing pregnancy, so there should be no barrier to prescribing them, but dermatologists may still be reluctant, said Feldman, who was not involved in the new study.

Dermatologists often recommend low-dose hormonal birth control as an option for female patients, but don’t actually write a prescription for it, he told Reuters Health. Then the patient returns to her primary care doctor, who may write the prescription, and when the acne clears up the patient does not return to the dermatologist.

If the hormonal option does not work, the patient does return to the dermatologist, which gives dermatologists a biased impression of how effective the drugs are, he said.

“Given the desire to minimize antibiotic resistance and exposure, hormonal birth control could be a good alternative,” Feldman said.

Both antibiotics and birth control can interfere with other medications, and both options have side effects, said Dr. Robert Dellavalle, chief of the dermatology service at the Denver VA Medical Center.

“Severe allergic reactions are very rare but more common with antibiotics,” he told Reuters Health by email. “Blood clots are more common with oral contraceptives.”

According to the review, oral contraceptives are more effective than he had previously assumed, said Dellavalle, who was not involved in the study.

Even if a woman’s employer refuses to reimburse for birth control, they would be required to reimburse for the same hormonal medication prescribed for acne rather than for preventing pregnancy, Feldman said.

“They may or may not cover birth control, but they do cover treatment for acne,” he said. “There should be no issue.”

“Even if you got a denial from your insurer, probably a quick appeal letter might well get that corrected,” he said.

For women with severe acne, a combination of hormonal birth control and antibiotics may lessen symptoms and remove the need for Isotretinoin, a much stronger oral acne medicine that carries a serious risk of birth defects, Feldman said.

Women using Isotretinoin are required to avoid pregnancy because the drug has been shown to be teratogenic, meaning it causes serious abnormalities in a developing fetus.

Feldman said he does not prescribe medications that are so “horribly teratogenic” to women of childbearing age if there is another option that may work. He prescribes hormonal birth control first, to see if it will help clear up the skin and prevent pregnancy in the coming weeks and months. Only if acne is a persistent problem, then he may prescribe the stronger medication as well.

Men do not have to worry about potential birth defects, Feldman noted. “For severe acne in men with scarring, you might even go to Isotretinoin first.”

SOURCE: Journal of the American Academy of Dermatology, online May 28, 2014.

###

Meta-analysis comparing efficacy of antibiotics versus oral contraceptives in acne vulgaris

A review of 226 publications yielded 32 randomized controlled trials that met our inclusion criteria. At 3 and 6 months, compared with placebo, both antibiotics and OCPs effected greater percent reduction in inflammatory, noninflammatory, and total lesions; the 2 modalities at each time point demonstrated statistical parity, except that antibiotics were superior to OCPs in percent reduction of total lesions at 3 months (weighted mean inflammatory lesion reduction: 3-month course of oral antibiotic treatment = 53.2%, 3-month course of OCPs = 35.6%, 3-month course of placebo treatment = 26.4%, 6-month course of oral antibiotic treatment = 57.9%, 6-month course of OCPs = 61.9%, 6-month course of placebo treatment = 34.2%; weighted mean noninflammatory lesion reduction: 3-month course of oral antibiotic treatment = 41.9%, 3-month course of OCPs = 32.6%, 3-month course of placebo treatment = 17.1%, 6-month course of oral antibiotic treatment = 56.4%, 6-month course of OCPs = 49.1%, 6-month course of placebo treatment = 23.4%; weighted mean total lesion reduction: 3-month course of oral antibiotic treatment = 48.0%, 3-month course of OCPs = 37.3%, 3-month course of placebo treatment = 24.5%, 6-month course of oral antibiotic treatment = 52.8%, 6-month course of OCPs = 55.0%, 6-month course of placebo treatment = 28.6%).
Eubee Baughn Koo, BS,
Tyler Daniel Petersen, MA,
Alexandra Boer Kimball, MD, MPH