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DOI: 10.1111/j.1468-3083.2011.04397.x

ORIGINAL ARTICLE

The effects of systemic isotretinoin and antibiotic therapy

on the microbial floras in patients with acne vulgaris
P.Y. Bas ak,,* E.S. Cetin, _I. Gurses, A.G. Ozseven

Department of Dermatology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey

Department of Microbiology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey

Dermatologist, Krkkale State Hospital, Kirikkale, Turkey

Department of Microbiology, Faculty of Medicine, Resident, Suleyman Demirel University, Isparta, Turkey
*Correspondence: P.Y. Bas ak. E-mail: pinarbasak@hotmail.com

Abstract
Background Although there are several studies about the alteration in skin flora, limited number of reports about
changes in the microbial contents and their resistance profile of other body sites in patients treated with isotretinoin
for acne vulgaris.
Objectives The aim of this study was to investigate the effects of systemic isotretinoin and antibiotic therapy on
the microbial floras of oropharynx, nose and feces in acne patients.
Methods Treatment groups of isotretinoin and antibiotics consisting of 20 and 15 patients, respectively were
included. Microbiological culture samples were taken at baseline and once a month during 46 months of treatment
period.
Results Difference in microbial flora throughout the treatment period was detected at least among one of all
culture samples of 15 (75%) and 5 (33%) patients in isotretinoin and antibiotic groups. There was statistically
significant difference between two groups in means of alteration of the microbial flora (P 0.013). The difference
was definitely observed among nasal cultures (65%) in isotretinoin group and fecal cultures (20%) in the other.
Staphylococcus aureus colonization was prominent in the microbial floras of nose and oropharynx and 2 of 14 nasal
isolates were detected to be methicilline resistant while Escherichia coli with extended spectrum beta lactamase
activity was detected in fecal floras of patients in isotretinoin group.
Conclusions Systemic isotretinoin and antibiotic treatments in acne patients precisely caused variations in the
microbial floras of several sites of the body, while isotretinoin was commonly more responsible than antibiotics.
Knowing that alterations in the microbial colonization of the flora regions may preceede infectious disease and
bacterial resistance, treatment options and follow-up procedures in acne vulgaris should be carefully determined to
reduce the risk of destruction of the microbial flora.
Received: 3 October 2011; Accepted: 23 November 2011

Conflict of interest
None declared.

Introduction
Oral isotretinoin and antibiotics namely tetracyclines and macrolides are considered as successful therapeutic choices for acne vulgaris. However, there are remarkable reports emphasizing the
presence of alteration in the cutaneous microbial flora during
treatment with these agents. An interesting point is that each of
these treatment modalities might increase the possibility of causing
a resistant phenotype permanent which is an undesirable consequence in this type of benign condition.1,2 Changes in the antibiotic resistance profiles and quantitative levels of Propionibacterium
acnes were mainly investigated in previous studies.35 Decremental
numbers of P. acnes and Gram negative bacilli were detected
although Staphylococcus aureus colonization was reported to be

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increased.6 In addition, skin colonization with resistant propionibacteria and secondary folliculitis most commonly associated with
Gram negative enteric bacteria have also been suggested for
treatment failure among these patients.7,8
Normal oropharyngeal flora includes anaerobic and aerobic
species like Peptostreptococcus and viridans streptococci which are
rarely considered as pathogenic.9 Staphylococcus species, importantly S. aureus, may also be part of the normal oropharyngeal
flora, but S. aureus is more likely to be pathogenic.10 Nevertheless,
the main site of S. aureus colonization is regarded as anterior nares
and this reservoir is found to be responsible for the facial skin
colonization and consequently furonculosis and folliculitis of the
several skin sites.5,6,11 Moreover, gastrointestinal tracts of colonized

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Effects of isotretinoin on microbial floras in acne

patients are proposed to be the main sources of infections with

multidrug resistant organisms. It is considered that early detection
of colonization with extended spectrum beta lactamase (ESBL)producing Escherichia coli can provide an early and appropriate
management of infections with these organisms because of their
clinical implications and limited therapeutic options.12,13
Although there are several studies about the alteration in the
skin flora concerning P. acnes and its antibiotic resistance
state35,7,8 there are limited number of reports about the changes
in microbial contents and their resistance profile of other body
sites, e.g. oropharynx, nose and intestinal tract in patients treated
with isotretinoin for acne vulgaris. In this study, the effects of systemic isotretinoin and antibiotic therapy on the microbial floras of
nose, oropharynx and faeces in patients with acne vulgaris were
investigated.

Materials and methods

Subjects

This study included thirty-five patients with acne vulgaris who

have no history of infectious or systemic diseases and have not
been using systemic or topical antibiotic and antiacne therapy for
the preceding 4 weeks. Clinical assessments were performed and
severity of the disease was determined by using previously
described global acne grading system. Cases with total score of
118 were considered as mild; 1930, moderate; 3138, severe and
greater than 39, very severe acne.14 The patients were randomized
into two groups of systemic isotretinoin and antibiotic therapy
(azithromycin or doxycycline) by considering acne severity. The
first group, consisting of 20 patients, was treated with isotretinoin,
0.51 mg kg day, until the cumulative dose of 120 mg kg was
achieved. Fifteen patients in the second group were treated with
either azithromycin 500 mg day, for three consecutive days, for
three times a month during 3 months, or doxycycline 100 mg day
for 3 months. Eleven of the patients in the antibiotic group were
treated with azithromycin and the remaining four patients were
treated with doxycycline. All patients had given informed consent
about the study.
Collection and processing of microbiological specimens

Oropharynx, nose and faeces cultures were taken at baseline and

once a month during 46 months of treatment period. The culture specimens from oropharynx and nares of subjects were taken
with a sterile swab using standard clinical techniques. Swabs were
inoculated on to trypticase soy agar with 5% sheeps blood, and
Mannitol Salt agar (BD Diagnostic Systems Sparks, MD, USA),
and they were incubated at 35 C to 37 C for 2448 h. After
incubation, plates were examined for growth and colonies were
identified to species level using macroscopic examination, Gram
staining, catalase, slide and tube coagulase tests using BBL Crystal
Identification Systems (Gram positive ID Kit, Becton Dickinson
and Company, MD, USA). Methicillin susceptibilities of the

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333

S. aureus strains were determined by the KirbyBauer disc diffusion method with cefoxitin (30 lg) discs following the criteria of
the Clinical and Laboratory Standards Institute.15
Faeces samples were directly inoculated on to blood agar and
eosin methylene blue agar, and on to xylose lysine deoxycholate
and Salmonella-Shigella agar after enrichment in Selenit F
buyyon. For the screening of ESBL-producing Enterobactericeae,
samples were also inoculated on to the screen agar plates with
two divisions, one half of which were consisted of Drigalski
agar with 1.5 lg mL cefotaxime (DR-CTX) and the other half
consisting of MacConkey agar with 2 lg mL ceftazidime
(MC-CAZ). All the plates were incubated at 37 C and checked
for growth after 2448 h. Growth on the MC-CAZ and or the
DR-CTX half-dish together with the strains ability to ferment
lactose was taken to signify a presumptive ESBL organism. All
the visible colonies on screen agar plates were identified to species level by using conventional methods like Gram staining,
catalase and oxidase tests and by using BBL Crystal Identification Systems (Enteric Nonfermenter ID Kit, Becton Dickinson
and Company, MD, USA) and evaluated for ESBL production
using phenotypical methods according to the recommendations
of CLSI.15
Presence of any difference in the microbial floras throughout
the treatment period was evaluated and the two treatment groups
were compared statistically for the frequency of this difference.
Statistical evaluation

Pearson chi-squared, McNemar, logistic regression and Fishers

exact tests were used and the significance level was set at P < 0.05.
Statistical analysis was performed by using PASW statistics 18 and
Epi-Info-Statcalc statistical programmes.

Results
Twenty-four female patients and 11 male patients with acne vulgaris between the ages of 15 and 24 (20.14 2.02) were enrolled in
the study. The duration of acne ranged from 4 months to 10 years
(55.37 27.96 months). The patients had mild (5, 14.3%), moderate (25, 71.4%) or severe (5, 14.3%) disease and acne lesions
were localized only on the face (12, 34.3%), only on the trunk (1,
2.9%) and both on face and trunk (22, 62.9%). The two treatment

Table 1 Number and percentage of patients with differentiation

of microbial flora in at least one of all culture samples throughout the treatment period
Isotretinoin
(n = 20)
Oropharynx
Nose
Faeces

Systemic
antibiotic
(n = 15)

25

6.6

0.207*

13

65

6.6

0.001

20

20

1.00*

*Fishers exact test.

Pearson chi-square test.

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Bas ak et al.

334

Table 2 Number and percentage of patients colonized with S. aureus in the oropharyngeal and nasal cultures and ESBL positive
E. coli in the faecal floras before and after the treatments
Isotretinoin (n = 20)
After

Systemic antibiotic (n = 15)

Before

Before

Oropharynx

15

40

0.063

%
0

After
0

%
0

Nose

15

14

70

0.001*

1.00

Faeces

20

0.125

20

33.3

0.625

1.00

*McNemar test.

groups were assigned as isotretinoin treated group (n = 20) and

age and gender-matched antibiotic treated group (n = 15). There
was no differences in terms of either duration or severity of acne
between the two groups (P > 0.05).
Isolation of viridans streptococci, coagulase negative staphylococcus or diphteroid bacilli has been defined as normal flora of
the oropharynx and nose whereas beta haemolytic streptococci,
S. aureus, Gram negative bacilli and Candida albicans were
defined as colonization or potential pathogens. In addition, isolation of Salmonella spp., Shigella spp., Pseudomonas aeruginosa and
ESBL positive Gram negative bacilli from faecal samples were
defined as the difference in the enteric flora. Difference of the
microbial flora throughout the treatment period was detected in
at least one of all culture samples of 15 (75%) and 5 (33.3%)
patients in isotretinoin and antibiotic groups, respectively. There
was a statistically significant difference between two groups in
terms of alteration of the microbial flora (P = 0.013, v2 = 6.08).
The difference was definitely observed among nasal cultures
(65%) in isotretinoin group and faecal cultures (20%) in the
other. In addition, there was difference only in the nasal colonization in 8 of 13 patients (61.5%) in isotretinoin group. Although
statistically significant difference was detected in rate of nasal colonization between two groups (P = 0.001, v2 = 12.15), differentiation of faecal flora was similar in both the treatment groups
(Table 1).
Methicillin sensitive S. aureus colonization was detected in three
patients (15%) in each of the oropharyngeal and nasal floras
whereas normal enteric flora was established in all cases before isotretinoin treatment. However, after isotretinoin treatment S. aureus was isolated in 8 (40%) and 14 patients (70%) oropharyngeal
and nasal floras, respectively (Table 2). Moreover, 2 of 14 isolates
of nasal S. aureus were detected to be methicilline resistant and 4
of the faecal E. coli isolates displayed ESBL activity after treatment
with isotretinoin. Statistically significant difference was detected in
nasal carriage of S. aureus due to isotretinoin treatment
(P = 0.001) (Table 2).
Gram negative bacilli colonization was detected in only one for
each of oropharyngeal and nasal cultures before systemic antibiotherapy, although the only alteration in these flora regions was
penicillin sensitive S. pneumonia for oropharynx and Gram negative bacilli for nose. However, faecal colonization with ESBL positive E. coli was detected in three patients before therapy and in five

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patients after the therapy (Table 2). Another alteration in the

faecal flora was found in one patient as Enterococcus faecalis
colonization, whereas no other difference was detected among the
rest of the patients during systemic antibiotherapy.
The difference in colonization of nasal flora was statistically significant in patients who were treated with isotretinoin, compared
with the antibiotic group (Fishers P = 0.001). No difference was
detected between the two treatment groups in terms of difference
in oropharyngeal and faecal colonization. In addition, neither age
and gender of the patients nor severity, localization and duration
of the disease was found to be significantly correlated with microbial colonizations of each body site in both the isotretinoin and
systemic antibiotic treated groups.

Discussion
This study demonstrates not only increased alteration rates in the
microbial contents of nasal and oropharyngeal floras but also
emergence of resistant strains especially in faecal flora due to isotretinoin treatment for acne. This confirms the findings of previous reports although most of them were about the alteration in
the skin flora concerning P. acnes.4,5,16,17
Leyden and James11 and Williams et al.18 suggested that the
appearance of furonculosis and folliculitis was related with the
increase in nasal S. aureus colonization in acne patients under isotretinoin treatment. It was also reported that S. aureus colonization in the anterior nares was increased from 2.5% to 70% after
5 months of isotretinoin therapy for acne conglobata.5 Similarly,
S. aureus was recovered from the anterior nares of 64% of patients
treated during a 5-month course of isotretinoin.11 Supporting the
findings of these previous studies, significant increase in S. aureus
colonization from 15% to 70% after isotretinoin treatment demonstrated both the important effect of isotretinoin in the alteration
of nasal flora and its significant difference from the antibiotic
group, in the present investigation. Topically applied antibiotics to
anterior nares during isotretinoin treatment was reported to
diminish S. aureus colonization11,18 and prevent clinical infection
after therapy.11 Therefore, topical antibiotics to anterior nares
might be suggested in patients receiving isotretinoin for acne
although their routine application was reported to be not justifiable.18
In this study, S. aureus colonization in oropharynx was found
to be 40% due to isotretinoin whereas there was no difference in

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Effects of isotretinoin on microbial floras in acne

the antibiotic group, but the difference between two treatment

groups was not statistically significant. Changes of S. aureus increment in the floras of the nose and oropharynx due to isotretinoin
might be explained by the dryness of these mucosal sites caused by
isotretinoin. Thus, dryness could facilitate the colonization of bacteria herein or lead to difficulty in elimination of the colonized
microorganisms from the mucosa. Previously, it has been shown
that the rate of MRSA colonization in the community ranges from
0.26% to 9.2%, depending on the population characteristics.19,20
In this research, MRSA was isolated in two patients out of 35
(5.7%) and in both these patients they were in the nasal floras of
isotretinoin treated group. Resistance of S. aureus is either
acquired from other organisms or a result of internal chromosomal mutation in response to antimicrobial pressures.21 In the
light of the present study, a similar mechanism of emerging resistant strains of S. aureus due to isotretinoin pressure may also be
suggested.
Longer duration of topical or systemic antibiotic treatment in
acne vulgaris was reported to be associated with increased staphylococcal colonization in skin and mucosal floras pursued by antibiotic resistance and serious skin or internal infections due to
resistant strains.2224 However, S. aureus carriage in nasal and oropharyngeal floras was not detected whereas faecal colonization
with ESBL positive E. coli was found to be insignificant in the antibiotic-treated group, in this study. Previously, antibiotic induced
alterations in bowel flora have also been studied extensively with
variable results. It has been noted that a significant reduction in
anaerobes, coli forms and streptococci has been detected after tetracycline treatment. In concert with these changes, there was an
ingrowth of resistant organisms like E. coli, Candida, S. aureus and
Pseudomonas.25,26 Selection of drug resistant E. coli during
treatment has been considered of special importance since E. coli
generally constitute the aerobic faecal flora and may give rise to
various types of infections.27 Moreover, there was increasing evidence that bacterial colonization can influence cell surface receptors and one organism could have an effect on the infectivity of
another.28 Although the use of antibiotics has been reported as a
cause of colonization or infection with antibiotic resistant microorganisms in previous studies, there are limited data about isotretinoin. This investigation demonstrated that the effect of
isotretinoin in the alteration of faecal flora was not significantly
different from the antibiotic group. Dryness of the skin and
mucosa during isotretinoin treatment were reported to result with
the elimination of gram negative bacteria from the anterior nares,
axilla and face.4,5 In contrast, increased ESBL positive E. coli in faecal flora due to isotretinoin might be considered as an impressive
and novel finding of this study.
Oral isotretinoin was reported to reduce skin and nasal colonization by antibiotic resistant propionibacteria. However, resistant
isolates of propionibacteria persisted especially at the nasal reservoir in the post-treatment period.17 In addition to striking effects
of isotretinoin on cutaneous microbial flora, the emergence of

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335

resistant strains of S. aureus and E. coli in nasal and faecal floras as

presented in this study should deserve attention.
In this study, S. aureus was isolated in nasal floras in 3 of 35
patients (8.5%) with acne vulgaris who have not used any systemic
treatment. This ratio was lower than 30% reported for the healthy
population,29 and no change was displayed due to systemic antibiotic treatment. In accordance with our study, Marples et al.30 also
found lower nasal colonization rates of S. aureus in acne patients
than those in the healthy population, but detected decrease in
the colonization rates of S. aureus after 3 months of antibiotic
treatment.
Resistant strains of staphylococcus in the skin floras of close relatives of the patients with acne vulgaris who were under antibiotherapy for longer periods were also reported.31 Thus,
staphylococcae can easily be transmitted to healthy people by
direct contact or shared materials. Therefore, not only the patient
under acne treatment, but also his her close relatives may be
affected. In the light of this finding, it may importantly be suggested that several flora regions should be carefully followed-up
for bacterial colonization to detect and control possible infections
in patients treated with systemic antibiotics and especially isotretinoin for acne.
Nasal colonization with S. aureus was reported to persist up to
6 months and tend to be eliminated spontaneously after then.5
The majority of infections were manifested during the latter
months of therapy and the first 3 months after isotretinoin treatment, although the rate of developing an infection was reported as
4% by Leyden and James.11 The limitation of the present study is
that patients could not be followed-up after 46 months of treatment period, since they did not prefer giving culture samples, so
we cannot put forward a suggestion whether or not the colonized
microorganisms caused any infections in these patients. Even so, it
should be kept in mind that early detection of colonized patients
is additionally important for the limitation of recently emerging
infections caused by community-acquired antibiotic resistant
microorganisms.

Conclusion
Systemic isotretinoin and antibiotic treatments in acne patients
precisely caused variations in the microbial floras of several sites of
the body, although isotretinoin was commonly more responsible
than antibiotics. Once a patients body site was colonized with
resistant bacteria, it may become stabilized and may persist for a
long time regardless of the treatment procedures.13 Knowing that
alterations in the microbial colonization of the flora regions may
precede an infectious disease and bacterial resistance,11,18,24 the
findings of our study present considerable background to propose
that alteration of these floras due to isotretinoin treatment for
acne vulgaris can provide a source of resistant bacterial infections.
For this reason, treatment options and follow-up procedures in
acne vulgaris should be carefully determined to reduce the risk of
destruction of the microbial flora.

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