Macrolide Antibiotics offer alternative treatment options to the well known tetracycline antibiotics. In recent years good studies have shown that some of these macrolides are safe and effective in treating rosacea.

Commonly prescribed Macrolides include: erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin), dirithromycin (Dynabac), roxithromycin (Rulid, Surlid)

Here is a brief introduction from Linda Sy’s `Skin411 Digest January 2005‘, Summaries and commentaries from recent dermatologic journals: Rosacea Therapy. Medical editor: Margaret S. Choa M.D.

ORAL MEDICATIONS

2. Macrolides – Oral erythromycin is given to rosacea patients when there are contraindications such as allergy, intolerance or resistance to tetracyclines and in pregnancy, lactation and patients younger than 12 years of age. Erythromycin is in pregnancy category B.

The second-generation macrolides, clarithromycin and azithromycin, have been found in recent studies to be effective in reducing erythema and rosacea papules/pustules. Benefits of second-generation macrolides are improved bioavailability and lack of gastrointestinal side effects in comparison with erythromycin.

The following paper gives some background to the use of macrolides and disease such as acne, rosacea and blepharitis.

Use of macrolides and tetracyclines for chronic inflammatory diseases. Ann Pharmacother. 2005 Jan;39(1):86-94. Epub 2004 Nov 23

OBJECTIVE: To review the efficacy of macrolides and tetracyclines in several chronic inflammatory conditions.

DATA SOURCES: Searches of MEDLINE (1966-March 2004) and an extensive bibliography search were undertaken. Key terms included acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis.

STUDY SELECTION AND DATA EXTRACTION: Data were obtained primarily from randomized placebo-controlled trials upon which key recommendations are based.

DATA SYNTHESIS: Antibiotics are often prescribed for months or even years for treatment of chronic inflammatory conditions such as acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis. Randomized controlled trials have shown that azithromycin is useful in the management of cystic fibrosis and the tetracyclines are beneficial in the management of rheumatoid arthritis, acne, blepharitis, and periodontitis. Several large, randomized controlled trials have failed to show any benefit of macrolides in the secondary prevention of cardiovascular disease. No randomized placebo-controlled clinical trials have been performed to assess the efficacy of macrolides or tetracyclines in patients with rosacea.

CONCLUSIONS: The use of tetracyclines and macrolides for rosacea is based primarily on anecdotal reports or open-label trials. Limited clinical trials support the use of tetracyclines or macrolides in acne, blepharitis, periodontitis, rheumatoid arthritis, and cystic fibrosis. Trials to date do not support the use of antibiotics for secondary prevention of cardiovascular disease.

A follow-on the the above article is a question and answer article that gives some useful high level comments ; For Our Patients (PDF).

Macrolides and Tetracyclines for Chronic Inflammatory Diseases

What diseases are macrolides and tetracyclines used for?

Macrolides (for example, erythromycin, clindamycin) and tetracyclines are antibiotics used to treat infections. They are also increasing being studied or used for chronic conditions such as acne, rosacea (a skin disorder that causes flushing of the face, neck and upper chest), blepharitis (inflammation of the eyelids), periodontitis (inflammation of the gums), rheumatoid arthritis, coronary artery disease, and cystic fibrosis. These drugs have anti-inflammatory properties, as well as the ability to inhibit or kill pathogens that may cause these diseases.

Why is there a concern about these drugs in the treatment of chronic inflammatory diseases?

Doxycycline and the newer macrolides are now recommended for the treatment of some types of pneumonia. Overuse of these antibiotics may decrease their effectiveness against respiratory pathogens that cause short-term illnesses, such as pneumonia.

Which antibiotics should be chosen for chronic inflammatory diseases?

Antibiotics are often prescribed for months or even years for acne. Researchers recommend low-dose doxycycline for extended time periods. Current recommendations for rosacea include long-term doxycycline, minocycline, tetracycline, or erythromycin. However, no major clinical trials have been performed to assess their effectiveness.

The American Academy of Ophthalmology recommends the chronic use of either doxycycline or tetracycline for the management of blepharitis.

Periodontitis can be treated for long periods with low doses of doxycycline. Larger clinical trials are needed to confirm the role of macrolides in periodontitis.

Azithromycin, a macrolide, has been used in patients with cystic fibrosis because of its antibacterial and antiinflammatory properties. Patients receiving this drug maintain better lung function, require fewer courses of intravenous antibiotics, and have improved quality of life. However, there are no data demonstrating a stronger survival benefit in patients who have taken macrolides.

Results from published clinical trials do not support the use of macrolides or other antibiotics for the prevention of a repeat heart attack or stroke. Of note, two trials are continuing to study the role of macrolides in the prevention of cardiovascular disease. For patients suffering from rheumatoid arthritis, it appears that minocycline has some effect on the progression of the disease. However, measures of improvement were often difficult to measure with certainty. Further studies are needed to better define the role of minocycline in the treatment of this disease.

How serious is the resistance to antibiotics becoming?

Resistance to one or more antibiotics increased from 35% in 1991 to 56% in 2000. Resistance to erythromycin, clindamycin, and tetracycline approximately doubled over this period. Resistance to the macrolides is increasing and may have reached rates up to 43%.

What approaches should be followed to preserve the effectiveness of antibiotics against acute infectious diseases?

Alternative antiinflammatory medications should be used for chronic inflammatory conditions whenever possible. For instance, high-dose ibuprofen and oral corticosteroids may be beneficial for patients with cystic fibrosis. Clinical trials comparing the effectiveness of antiinflammatory agents with antibiotics should be performed.

Following are links to more studies relating to the use of systemic and topical antibiotics to treat rosacea.

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