The Dilemma of Long-Term Antibiotic Use

For individuals grappling with scarring alopecia, a group of inflammatory conditions leading to permanent hair loss, long-term anti-inflammatory treatment is often necessary. Doxycycline, an antibiotic, has become a common therapeutic choice. However, the extended use of high doses raises concerns about potential adverse effects.

• Standard Treatment: Doxycycline is frequently prescribed for its anti-inflammatory properties in managing scarring alopecia.
• Long-Term Risks: Prolonged use of high-dose doxycycline can disrupt gut microbes and contribute to antibiotic resistance.

The question arises: Is there a safer, equally effective alternative? A recent study suggests that lower doses of doxycycline may offer a solution.

the Study: low vs. high-Dose Doxycycline

Researchers conducted a retrospective study involving 241 adults with scarring alopecia to compare the effectiveness and safety of low-dose versus high-dose doxycycline. The study defined:

• Low-Dose Doxycycline: No higher than 50 mg daily (27.4% of patients).
• High-Dose Doxycycline: No lower than 100 mg daily (72.6% of patients).

The most prevalent scarring alopecia subtypes among the participants were:

• Lichen planopilaris (50.2%)
• Frontal fibrosing alopecia (45.6%)
• Central centrifugal cicatricial alopecia (15.4%)

The findings revealed that low-dose doxycycline was just as effective as the high dose in reducing inflammation severity, even after accounting for adjunctive therapies.

There was also no significant difference in the progression of hair loss,number of scalp symptoms,patient-reported perceptions of disease status or change in objective hair measurements between the dose groups.

Carli Needle, BA, medical student at NYU Grossman School of Medicine

Safety and Tolerability

Beyond efficacy, the study highlighted the improved safety profile of low-dose doxycycline.

• Adverse Events: 23.4% of patients on high-dose doxycycline reported adverse events, compared to only 12.1% on the low dose.
• Discontinuation Due to GI Symptoms: 25% of high-dose patients discontinued treatment due to gastrointestinal issues, versus 16.7% of low-dose patients.

This suggests that lower doses not only perform as well but are also better tolerated by patients.

Not only did low-dose doxycycline perform as effectively as the high dose, but it also resulted in fewer adverse events.

Anna Brinks, BA, medical student at NYU Grossman School of Medicine

The benefits extend beyond patient-reported side effects.

Not only is there a lower risk of side effects described by the patient, but likely a lower risk of side effects when it comes to disrupting the good bacteria that help protect us.

Kristen Lo Sicco, MD, associate professor

Implications for Clinical Practice

The study’s findings have significant implications for how dermatologists approach the treatment of scarring alopecia. Experts suggest that low-dose doxycycline should be considered as the first-line treatment option.

The rationale behind this recommendation is rooted in the understanding of doxycycline’s mechanism of action.

We use doxycycline to treat scarring alopecia for its anti-inflammatory activity, and we certainly know that the subantimicrobial dosing harnesses the anti-inflammatory activity of doxycycline, so why would we unnecessarily use a higher dose of doxycycline?

Kristen Lo Sicco, MD, associate professor

By using a lower, subantimicrobial dose, clinicians can leverage the anti-inflammatory benefits of the drug while minimizing the risks associated with higher doses, such as gut microbiome disruption and antibiotic resistance.

Looking Ahead

the hope is that this research will led to a shift in clinical practice, ultimately benefiting patients who require long-term treatment for these chronic conditions.By prioritizing low-dose doxycycline as a first-line option, dermatologists can provide effective treatment with a reduced risk of adverse events.

Contact Facts

For further information, please contact:

• Anna Brinks, BA: anna.brinks@nyulangone.org
• kristen Lo Sicco, MD: dermatology@healio.com
• Carli Needle, BA: carli.needle@nyulangone.org
• Jerry Shapiro, MD, FAAD: dermatology@healio.com