REVIEW

Oral Antibiotic
Treatment Options for
Acne Vulgaris
ABSTRACT by HILARY BALDWIN, MD
Dr. Baldwin is the Medical Director of the Acne Treatment and Research Center in Brooklyn, New York and is with Rutgers Robert
Acne vulgaris is the most common dermatological Wood Johnson Medical Center in New Brunswick, New Jersey.
disease in the United States, affecting up to 85
J Clin Aesthet Dermatol. 2020;13(9):26–32

A
percent of teenagers. While the American Academy
of Dermatology has established guidelines
regarding acne treatment in general, the variability
among acne treatments, even within a given
Acne vulgaris is the most common skin treatment (e.g., benzoyl peroxide, antibiotics,
class, prevents establishment of a straightforward disorder encountered in dermatology practice and retinoids) is generally used as first-line
regimen. For example, moderate to severe acne is in the United States, affecting approximately 85 treatment in cases of mild-to-moderate acne
generally treated with an oral antibiotic, although percent of teenagers and sometimes persisting with comedonal lesions and inflammatory
several options are available—both across and into and throughout adulthood.1–3 Although lesions.4 Systemic treatment (e.g., oral
within antibiotic classes. The aim of this review is not life-threatening, acne can have a significant antibiotics and hormonal therapy) can be used
to report the efficacy and safety data available for adverse psychological and physical impact.4 as first-line treatment in cases of moderate-
commonly prescribed oral antibiotics. While there Many patients with acne report feelings of to-severe acne, in combination with a topical
are currently no data to support superiority of one
depression, anxiety, emotional stress, or agent.2,4 While it is outside the scope of this
drug over another, there are substantial differences
in safety profiles and brand-specific features that
poor self-image, and severe acne can lead review to discuss each treatment type in detail,
may make one antibiotic preferable over another. to permanent scarring in up to 20 percent of Table 1 provides a summary of recommended
KEY WORDS: doxycycline; minocycline; cases.4,5 treatment options. This review will focus on the
sarecycline; azithromycin; antibiotic resistance Acne is a disease of the pilosebaceous unit efficacy and safety of oral antibiotics that are
with a complex pathology. Currently, there commonly used or available to treat acne.
are thought to be at least four synergistic,
biological mechanisms that contribute to acne ORAL ANTIBIOTICS
pathogenesis, which is primarily inflammatory The American Academy of Dermatology
in nature.6,7 These include increased sebum supports the use of oral antibiotics for treating
production, follicular hyperkeratinization, moderate and severe acne, and oral antibiotics
local inflammatory cascades, and microbial have been a mainstay of acne treatment for over
proliferation of Cutibacterium acnes (or C. 50 years.4 It is well-accepted that antibiotics are
acnes, formerly Propionibacterium acnes).8,9 The efficacious in reducing acne severity and have an
complex interplay of these biological pathways overall acceptable safety profile.
makes effective treatment of acne difficult. In recent years/decades, however, there
Nonetheless, there are a variety of therapeutics has been growing concern regarding the
available, each targeting one or more of these development of antibiotic resistance.10 As such,
pathogenic processes.2–4 some previously employed antibiotics (e.g.,
Pharmacological treatments for acne include erythromycin and clindamycin) are no longer
a variety of topical and systemic agents. Topical used clinically because of their high rates of

FUNDING: The development of this article was supported by an unrestricted grant from Journey Medical Corporation.
DISCLOSURES: Dr. Baldwin serves on the speaker’s bureau, consults for, and/or attends medical advisory boards for Almirall,
Galderma, Valeant Pharmaceuticals, Sun Pharmaceutical, Mayne Pharma, EPI Health, and Journey Medical Corporation.
CORRESPONDENCE: Hilary Baldwin, MD; Email: [email protected]

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resistance.11 The concern is serious enough that TABLE 1. Treatment algorithm for the management of acne vulgaris in adolescents and young adults4
the Centers for Disease Control and Prevention MILD MODERATE SEVERE
(CDC) and the World Health Organization
First- line Treatment
(WHO) now actively promote campaigns aimed
Topical Combination Therapy**
to confront antibiotic resistance.10,12 The CDC
Benzoyl Peroxide (BP) or Topical BP + Antibiotic or Retinoid + BP or Oral Antibiotic + Topical Combination
encourages antibiotic stewardship, which Retinoid Retinoid + BP + Antibiotic Therapy**
asserts that physicians must act responsibly -or- -or- BP + Antibiotic or Retinoid + BP or
when prescribing antibiotics, with the hope Topical Combination Therapy** Oral Antibiotic + Topical Retinoid + BP Retinoid + BP + Antibiotic
that this will limit the development and/or BP + Antibiotic or Retinoid + BP -or- -or-
expansion of antibiotic resistance.10 The WHO’s or Retinoid + BP + Antibiotic Oral Antibiotic + Topical Retinoid + BP Oral Isotretinoin
“global action plan” has five strategic objectives, + Topical Antibiotic
aimed both at the community (e.g., improving Alternative Treatment
awareness and understanding) and providers Consider Alternate Combination
(e.g., optimizing use).12 Add Topical Retinoid or BP (if not on Therapy
Consider Change in Oral Antibiotic
Apart from the tetracycline class of antibiotics already) -or-
-or-
(doxycycline, minocycline and sarecycline), -or- Consider Change in Oral Antibiotic
Add Combined Oral Contraceptive or
the potential benefit of oral antibiotics often Consider Alternate Retinoid -or-
Oral Spironolactone (females)
-or- Add Combined Oral Contraceptive or
outweighs the potential risks, and they Consider Topical Dapsone Oral Spironolactone (females)
-or-
remain a mainstay of moderate-to-severe -or-
Consider Oral Isotretinoin
acne treatment. With currently available Consider Oral Isotretinoin
clinical studies and data, there is a consensus ** indicates that the drug may be prescribed as a fixed combination product or as separate component
that no one antibiotic is superior to another
regarding efficacy.13,14 The safety profiles,
however, differ considerably.15,16 In this article, followed by azithromycin and trimethoprim- by Jeremy et al20 that showed inflammation
we will review previous research for several sulfamethoxazole. is present far in advance of clinically
antibiotics currently used, including doxycycline, The tetracyclines. Among oral antibiotics recognizable lesions—known as the prelesional
minocycline, azithromycin, and trimethoprim- used to treat acne, tetracycline has the longest folliculocentric inflammatory phase. While
sulfamethoxazole, and one recently introduced history, having been discovered in the 1940s all tetracyclines share these anti-microbial
to the market, sarecycline. Studies included and FDA-approved in 1953. While effective, its and anti-inflammatory MOAs, there is
were those that evaluated treatment response side effect profile, need for frequent dosing, and significant variability regarding side effect
in patients with acne. susceptibility to antibiotic resistance have made profiles, discussed below, that account for
Among acne studies, there are several metrics it unpopular, and it is no longer considered the preferential prescription of one over the
of efficacy that are commonly reported.17 a standard treatment regimen.14 There are, other.16,18,21
Perhaps most frequently used is the change in however, several tetracycline derivatives that Doxycycline. The first tetracycline derivative
inflammatory lesions from baseline to endpoint, were chemically adapted to provide additional to come to market was doxycycline, approved
expressed as either absolute change or percent benefits.11 Thus, this review will focus not by the FDA in 1967 and still one of the
change. Similarly, the absolute or percent on tetracycline as a drug, but rather on the most commonly used antibiotics in clinical
change in non-inflammatory lesions (i.e., individual drugs that fall within the tetracycline practice.14,22 Relative to its parent tetracycline,
open or closed comedones) might be recorded, class (i.e., doxycycline, minocycline, and doxycycline is more lipophilic, making it optimal
although this is less common in studies of oral sarecycline). for penetrating and accumulating in the
antibiotics, as they are generally more effective Each of these “second-generation” sebaceous gland—where C. acnes resides and
for inflammatory lesions. A common subjective tetracyclines share the same mechanisms of proliferates.11 Two formulations of doxycycline
measure is the investigator’s global assessment action (MOA); the chemical is transported are available—doxycycline hyclate and
(IGA), which considers the quality and quantity into bacterial cells, binds the 30S unit of the doxycycline monohydrate, which are different
of acne lesions. While the IGA is a five-point ribosome, and inhibits protein synthesis. In salt forms of the same active drug. Doxycycline
scale based on acne severity (ranging from addition to their antibacterial action, the hyclate is more water-soluble than doxycycline
0=clear to 4=severe), results are generally tetracyclines demonstrate multiple anti- monohydrate and might be more ulcerogenic
dichotomized in trials such that a participant inflammatory properties.18 The therapeutic and susceptible to causing gastrointestinal (GI)-
has IGA “success” (score of 0 or 1; clear or almost effect of tetracyclines in acne might be due, associated side effects.23,24 Their differences are
clear, respectively) or IGA “failure” (score >1). at least in part, to reduction in neutrophil more relevant for manufacturing purposes than
Change in inflammatory lesions will be the chemotaxis and inhibition of proinflammatory for assessing efficacy, however.25
emphasis of efficacy results for this review. cytokines and matrix metalloproteinases.19 The side effect profile of doxycycline is
This review will begin by summarizing The anti-inflammatory actions may be superior to that of tetracycline, although there
studies of tetracycline-class antibiotics, particularly important considering research are potential adverse events that should be

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TABLE 2. Common side effects of oral antibiotics effective in reducing the number of overall
lesions, suggesting that a large part of the
SIDE EFFECTS DOXYCYCLINE MINOCYCLINE SARECYCLINE AZITHROMYCIN TMP-SMX
efficacy of doxycycline stems from its role as an
Gastrointestinal anti-inflammatory agent.29
x x x x x
disturbance
A review article that gathered results from
Nausea x x x x x tetracycline treatment studies for acne between
Photosensitivity x * 1962 and 2006 showed that doxycycline was
Permanent tooth consistently effective, although results were
x x x variable between studies.17 The largest reduction
discoloration
Bone growth impairment x x * in inflammatory lesions was 75 percent, and the
lowest reduction in inflammatory lesions was 23
Vestibular adverse events x**
percent.17 Efficacy results, reported as reduction
Cutaneous in inflammatory lesions, are summarized in
x
hyperpigmentation
Table 3.
Esophagitis x * x Due to the popularity of doxycycline, several
Allergic reactions x x x x x brands are available, each boasting additional
Drug hypersensitivity benefits aside from their efficacy in treating
x x *
syndrome acne. Acticlate is available as a functionally
Vaginal yeast infections x x x x scored tablet, and dosage can be easily modified
Elevated blood urea without requiring a new prescription.30 Doryx is
x x enteric-coated, which makes it more resistant
nitrogen level
Fetal harm x x x x to breakdown by stomach acids.31 There is also
Doryx MPC (modified polymer coating), extends
Severe cutaneous reactions x
absorption even longer, potentially reducing
Hematologic reactions x GI-related side effects.32 Targadox is the smallest
*Insufficient data for verification at time of publication branded doxycycline and does not require
**Vestibular adverse events are highest in immediate-release formulations of minocycline. Extended-release pill splitting.33 Its excipients are gluten-free,
minocycline formulations display an adverse event profile similar to placebo.36 lactose-free, vegan, and non-GMO, making it
amenable to most patient dietary restrictions/
taken into consideration (Table 2). Most of recommended for children younger than eight preferences.33 All brands may be taken once
doxycycline’s side effects are mild and/or can be years of age and women during pregnancy.26 daily with or without food.
prevented with proper measures.14 Doxycycline Similarly, all tetracyclines have been shown to Minocycline. Another tetracycline derivative,
is frequently associated with phototoxicity; it impair bone growth by forming a stable calcium minocycline, was FDA-approved after
interacts with ultraviolet (UV) rays, making an complex and thus should be avoided in children doxycycline, in 1971, and continues to be a
individual more susceptible to severe sunburn. and during pregnancy.27 popular treatment option for moderate to severe
Gastrointestinal disturbance is a common side Doxycycline has a long history of safe and acne.14,22 Of the tetracyclines, minocycline is the
effect of doxycycline treatment and might effective treatment in acne patients. An early most lipophilic, making it easily accessible for
present as nausea, vomiting, and/or diarrhea. study by Plewig et al28 (1970) evaluated penetrating and accumulating in the sebaceous
Doxycycline is amenable to being taken with the efficacy of doxycycline in 62 patients gland, where C. acnes colonizes.11 The high
food—which might lessen GI discomfort— in a double-blind crossover study. A “good” absorption rate of minocycline is beneficial
although its absorption is reduced by or “excellent” response in the reduction of in multiple facets—it may be taken with
approximately 20 percent with food.11 When it inflammatory lesions was reported in 33 percent food, which may increase patient adherence;
is taken to treat acne, however, this reduction in of patients receiving doxycycline. Statistically, lower doses are required; and less active drug
absorption is believed to have minimal clinical improvement from baseline was significant with remains in the GI tract, which might limit the
relevance. Pill esophagitis—inflammation or doxycycline treatment, but not placebo. In a disturbances commonly seen with doxycycline.
esophageal ulcers—can occur when taking clinical study by Moore et al,29 662 patients were Consumption with dairy products does not
doxycycline. Like other side effects, however, it randomized to one of three treatments—a decrease the bioavailability of minocycline.
is largely avoidable if patients take medication 40mg dose of modified-release doxycycline, a Photosensitivity is rare with minocycline.
with a large glass of water and do not lie 100mg dose of doxycycline, or placebo. After Because the permeability of minocycline is so
down shortly after ingesting medication.14 16 weeks of treatment, reduction in lesion high, however, it is more susceptible to crossing
Lastly, there is the potential for permanent count and success rate were evaluated. For both the blood-brain barrier, which can promote
tooth discoloration in individuals with outcome measures, doxycycline treatment was acute vestibular adverse events, such as
developing teeth. This is a side effect shared superior to placebo. Interestingly, the lower dizziness and vertigo.11,14 In addition, although
by all tetracycline derivatives which are not dose of modified-release doxycycline was more rare, there is the potential for severe adverse

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effects, like hyperpigmentation (sometimes TABLE 3. Reduction in inflammatory lesions with various treatment times*
irreversible), drug hypersensitivity, Stevens- ENDPOINT DOXYCYCLINE MINOCYCLINE SARECYCLINE AZITHROMYCIN TMP-SMX
Johnson syndrome, and autoimmune, lupus-like 3 weeks NA 65%59 NA 55%59 NA
reactions (Table 2).26 4 weeks 25–46% 17,21,60
32% 36
NA 23%60 NA
In the last couple of decades, extended-
5 weeks NA NA NA NA 62%+6
release (ER) minocycline formulations have
6 weeks NA 51% NA NA NA
come to the market. Rather than the rapid
8 weeks 39%60 41%–69%17,21,36 NA 36%60 NA
absorption and high peak concentration seen
with immediate-release (IR) minocycline, 10 weeks NA NA NA NA 48% +56
ER formulations regulate the rate at which 12 weeks 48%–75%17,60 27%–91%13,17,36 50%–52%43,44 55%60 NA
minocycline is released and systemically 23% to
16 weeks NA NA NA NA
available.34,35 Although the efficacy for ER and IR 51%17,44,60
minocycline is similar, reported severe adverse 18 weeks NA 22%13,17 NA NA NA
events are reduced with the ER formulation.14,35 20 weeks NA 52%13,17 NA NA NA
Unlike doxycycline and immediate-release 24 weeks 50%17,21 74%13,17,21 NA NA NA
minocycline, extended-release minocycline NA: not available
underwent traditional Phase III studies and has +TMP-SMX study did not evaluate absolute number of inflammatory lesions but rather a grade based on number and
been evaluated in two randomized, double- severity of lesions56
*Doses may differ across studies
blind, placebo-controlled trials.36 Combined,
924 subjects received weight-based minocycline
or placebo for 12 weeks, at which time two to tablets.38 MinoLira is the first dual-release inflammatory lesions were reduced by 52.7
primary endpoints were assessed: mean percent minocycline tablet used for treating acne and percent, compared to 38.3 percent in placebo-
change in inflammatory lesions and percentage was FDA-approved in 2017.39 Each of the three treated patients.43 Two larger, identically
of subjects with an Evaluator’s Global Severity brands promotes once-daily, weight-based designed Phase III clinical trials of 1,702
Assessment (EGSA) of clear or almost clear. dosing and can be taken with or without food. completed patients also showed an approximate
Across the two studies, mean percent Sarecycline. Sarecycline is the newest 50-percent reduction in inflammatory lesions,
improvement in inflammatory lesions ranged tetracycline derivative introduced into the compared to approximate 35-percent in
from 43.1 to 45.8 percent for minocycline, market and was FDA-approved in 2018. As placebo-treated patients.44 Additionally,
compared to 30.8 to 31.7 percent for placebo.36 a tetracycline derivative, it shares the same 22 percent of participants achieved IGA
In patients treated with minocycline, 15.9 to protein synthesis inhibitory MOA as those success at 12 weeks.44 The drug was generally
17.3 percent achieved success, compared to previously described. However, sarecycline well-tolerated with minimal side effects in
only 7.9 to 9.5 percent treated with placebo.36 claims to be a narrow-spectrum antibiotic, comparison to placebo.
No effect was seen on non-inflammatory which might lower the chance of developing Seysara is the first and only sarecycline
lesions. A review article that compiled results antibiotic resistance.3,40 Recently, it was shown available.
from minocycline (both immediate-release that C. acnes strains displayed a low propensity Azithromycin. Unlike any previously
and extended-release) treatment studies for for the development of resistance to sarecycline, discussed antibiotics, azithromycin is a
acne between 1962 to 2006 showed that, with a spontaneous mutation frequency being macrolide antibiotic. Macrolides also inhibit
similar to doxycycline, the efficacy was quite 10-10 at 4-8 X MIC. Clinical relevance has yet to protein synthesis, although in a different way
variable between studies.13 The most significant be explored.40 Sarecycline is also indicated to from tetracyclines—by binding the 50S subunit
reduction in inflammatory lesions was 91 treat acne in patients as young as nine years of the ribosome.45 Azithromycin is a derivative
percent and the lowest reported reduction in of age, whereas other tetracyclines lack this of erythromycin. As mentioned previously,
inflammatory lesions was 22 percent. indication.41 Thus, sarecycline treatment might erythromycin was once used as an effective acne
The adverse events associated with be preferred in young children, although it therapy, but widespread antibiotic resistance
immediate-release minocycline (primarily is important to note that children aged 9 to has rendered it less useful.3,11 Azithromycin is
vestibular) have caused a surge in marketed 12 comprised only one percent of the clinical used to treat serious systemic infections, and
extended-release minocyclines that are dosed study population, and additional research is its use for acne is generally reserved for select
based on patient weight.35 Solodyn and Ximino warranted.42 Sarecycline comes with the same cases, such as in patients for whom tetracyclines
are commonly prescribed, and MinoLira was warnings of tooth discoloration and impaired are contraindicated.46
most recently launched to the market. Solodyn bone growth as other tetracycline derivatives. An important differentiator of azithromycin
was first to market with an extended-release Like minocycline, its dosing is weight-based, from other antibiotics is its safety profile during
formulation and was FDA-approved in 2006.37 once-daily, and can be taken with or without pregnancy and lactation (Table 2). Animal
Ximino, approved in 2012, is the first and food.41 studies show that the drug crosses the placenta
only extended-release minocycline available In its Phase II clinical trial evaluating 285 but is not associated with fetal harm.47 Thus, this
in a capsule form, which some people prefer patients, after 12 weeks of 1.5mg/kg treatment, may be the preferred treatment if pregnancy

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must be taken into consideration.48 Additionally, patients with acne who were refractory to because it is used off-label and as a third-line
azithromycin has rapid uptake from circulation, tetracycline treatment.53,57 agent. Sarecycline has not yet been studied as a
followed by a slow release.49 The extended half- While TMP-SMX treatment of acne is off- direct comparator to any other oral antibiotic.
life is conducive to less frequent dosing, which label, two brands are commonly used: Bactrim
might improve adherence.50 The bioavailability and Septra. Both are also available as a double- DISCUSSION
of azithromycin is decreased when taken with strength formulation. There are no features that At present, doxycycline, minocycline,
food. would suggest superiority of one brand over the and sarecycline are are the most commonly
Papers evaluating the efficacy of azithromycin other. prescribed antibiotics for acne treatment,
date back to 1997. The case series included only and both have a long history of efficacy and
three patients, and in each patient, azithromycin HEAD-TO-HEAD TRIALS safety.22 While the identification of “the best”
reduced total number of inflammatory lesions.51 A systematic review by Simonart17 oral antibiotic for acne would certainly simplify
A larger trial (N=64) examining different evaluated randomized trials and was designed a treatment regimen, data do not exist that
azithromycin doses supported the early to specifically compare the efficacy of permit such a conclusion to be drawn.
findings. The Global Acne Grading System was different tetracyclines. The review, however, Inconsistencies across trials make it
the outcome measure, and for all doses, mean reported no significant difference in number impossible to justly compare products.3
acne score significantly decreased at the end of either inflammatory (n=32 trials) or Methodological variation is commonly
of the first (30%–33%), second (46%–50%), non-inflammatory (n=23 trials) lesions. A seen in randomization, blinding, number
and third month of treatment (70%–76%) randomized, double-blind study by Olafsson58 of participants, study duration, dosing, and
when compared to baseline.52 Numerous dosing compared doxycycline and minocycline primary/secondary outcome measures.
regimens have been recommended since then, treatment effect in 64 patients with acne Additionally, it is important to keep in
some of which call for infrequent dosing, which over 12 weeks. A significant reduction in all mind that most studies included in this
might be more convenient for patients.3 types of acne lesions (pustules, papules, open review, by necessity, assessed treatment
There are no specific brands marketed for the comedones, and closed comedones) was outcome following monotherapy. However,
treatment of acne. observed at 12 weeks, and doxycycline and in clinical practice, oral antibiotics are rarely
Trimethoprim/sulfamethoxazole (TMP- minocycline were found to be equally effective. prescribed as monotherapy. The multifactorial
SMX). TMP-SMX was approved by the FDA in Similarly, a meta-analysis by Kim48 evaluated pathophysiology of acne calls for the use of
1973. The two antibiotics work synergistically results from six trials that compared oral several agents to attack the disease from
to inhibit folate synthesis in bacteria.53 While azithromycin pulse therapy and doxycycline numerous directions. The combination of oral
not indicated for acne, it is frequently used off- daily therapy. Four outcome measures were antibiotics with benzoyl peroxide, combination
label.54 Because it is the agent most commonly compared at 12 weeks: remaining inflammatory antibiotics, and topical retinoids is standard of
used to treat adults with community-acquired lesions, remaining non-inflammatory lesions, care.3 Additionally, oral antibiotic monotherapy
methicillin-resistant Staphylococcus aureus patients’ self-assessment, and investigators’ is discouraged due to the potential development
(MRSA) infections, it should be used sparingly assessment. In each case, there was no of antibiotic resistance.2,4
due to the concern of antibiotic resistance. significant difference between groups. Even When choosing an oral antibiotic for
TMP-SMX is also reserved for third-line after a sensitivity analysis was conducted to treating acne, there are no data identifying
therapy due to the possibility of rare, though account for potential bias, neither outcome a clearly superior product. Rather, prescriber
severe and potentially life-threatening, adverse measure—inflammatory lesions nor choice might come down to personal or
events, such as Stevens-Johnson syndrome (SJS) investigators’ assessment—significantly patient preference, such as delivery vehicle
and toxic epidermal necrolysis (TEN).53 TMP-SMX differed between groups.48 (e.g., capsule vs. tablet), dietary restrictions,
is one of the few medications considered “high” An extensive minocycline-focused Cochrane gastrointestinal sensitivity, sun exposure,
risk for inducing SJS or TEN, and risk is highest review published in 2012 concluded that and past experiences with antibiotics. The
when the drug has been recently initiated and in minocycline is an effective treatment for tetracycline class is probably superior to other
patients infected with HIV.3,55 In both diseases, moderate to moderately severe acne, but there antibiotics due to its dual action of antibacterial
severe epidermal necrosis causes extensive skin was no evidence that it is better than other and anti-inflammatory activities. Additionally,
detachment and is life-threatening.55 commonly used acne treatments, including oral tetracyclines are generally inexpensive and well-
Data regarding the use of TMP-SMX in doxycycline or macrolide antibiotics.13 Reviews tolerated. Between doxycycline, minocycline,
treating acne are limited. However, a double- by Del Rosso14 and Kircik21 similarly concluded and sarecycline, side effect profile might be a
blind study of 43 patients by Hersle 56 (1972) that doxycycline and minocycline display a determining factor.61 Doxycycline is generally
showed that the acne score (a calculation by the similar efficacy to one another. Studies have associated with more upfront, bothersome side
authors based on lesion number and severity) compared azithromycin to either doxycycline or effects, like GI upset and photosensitivity.27
decreased by 62 percent after just five weeks minocycline.14,21,59 In each case, both drugs were Immediate-release minocycline is associated
of treatment with TMP-SMX, compared to 9 deemed effective and there were no significant with a high incidence of vestibular adverse
percent in placebo-treated patients. TMP-SMX group differences.45,60 events, but the extended-release formulations
might be particularly effective in treating in Comparative trials with TMP-SMX are limited and sarecycline have reduced these dramatically

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