Topical Antibiotic Monotherapy Only Provides Mild Benefit for Patients with Acne Vulgaris: A Systematic Review and Network Meta-analysis.

Abstract

Background and objectives: Topical antibiotics have long been used in acne management owing to their antibacterial and anti-inflammatory properties. However, the comparative efficacy and safety profiles of antibiotic monotherapy have not been systematically synthesized. The network meta-analysis aims to determine the relative efficacy and safety of topical antibiotics for acne vulgaris.

Methods: We searched MEDLINE via PubMed, Embase, Cochrane Library, Web of Science, Google Scholar, and ClinicalTrials.gov from 1 January, 2000, to 22 August, 2023, with an updated search on 21 October, 2025. Randomized controlled trials comparing topical antibiotic monotherapy with placebo or other topical antibiotics in patients with acne vulgaris were included. Efficacy outcomes include mean absolute reduction in inflammatory lesions, non-inflammatory lesions, and total lesions, and treatment success (defined as a 2-grade reduction in the Investigator's Global Assessment). The primary safety outcome was discontinuation because of adverse events.

Results: This review included 32 studies comprising 34 randomized controlled trials with 22,645 patients. Compared with placebo, only dapsone 5% [- 29.8 (95% confidence interval [CI] - 55.4 to - 4.1)] and erythromycin 2% [- 24.0 (95% CI - 45.7 to - 2.1)] significantly reduced inflammatory lesion counts. For non-inflammatory lesion counts, azithromycin 2% [- 58.9 (95% CI - 85.5 to - 31.7)], erythromycin 2% [- 42.0 (95% CI - 69.8 to - 14.0)], metronidazole 2% [- 14.6 (95% CI - 20.8 to - 8.6)], and minocycline 4% [- 5.1 (95% CI - 9.2 to - 2.2)] showed a significant reduction. However, no treatment showed a significant improvement in total lesion counts compared to placebo. Regarding Investigator's Global Assessment improvement, analysis was limited to three drugs because of inconsistent reporting; results showed that clindamycin 1% [1.6 (95% CI 1.1 to 2.3)], GDC 268 lotion (clindamycin phosphate topical lotion 1%) [2.2 (95% CI 1.1 to 4.4)], and minocycline 4% [2.2 (95% CI 1.5 to 3.5)] were superior to placebo. Data on discontinuation because of adverse events showed significant heterogeneity, which needs cautious interpretation.

Conclusions: Current evidence indicates that topical antibiotic monotherapies yield inconsistent efficacy and uncertain safety across different lesion types. Given the lack of robust evidence for consistent superiority over placebo and the global concern for antibiotic resistance, routine antibiotics monotherapy should be limited in the management of acne vulgaris.

Clinical trial registration: PROSPERO registration number: CRD42022297060.