Rightly or wrongly, antibiotics are often seen as a reset button for acne. Skin improves, inflammation settles and for a time it can feel as though the problem is finally under control. What tends to follow, however, is disappointment. Breakouts slowly return, sometimes within weeks or sometimes months later. Understandably, this causes a lot of frustration with sufferers wondering why something that “worked” failed to last. However, much of the disappointment comes from a misunderstanding of what antibiotics can and can’t do. In this article, we explore why acne so commonly comes back after antibiotics and how to prevent recurrence.
What do Antibiotics Actually do for Acne?
Antibiotics are an important tool in acne control but they play a very distinct and different role to other common acne treatments like retinoids or hormonal therapies. In addition to killing acne causing bacteria, the main role of antibiotics is to reduce inflammation through their direct anti-inflammatory effects. Knowing how they work is important because it explains both why antibiotics can help and why they rarely offer long-lasting control by themselves.
Acne develops through a combination of pore clogging, excess sebum (oil) production, bacterial overgrowth and inflammation. Antibiotics influence only part of this process. They do not normalise cell turnover to prevent pores getting clogged with oil and dead skin cells or reduce oil production which cause microcomedones and acne breakouts in the first place. Nor do antibiotics address the hormonal drivers of acne which are important as excess androgen sensitivity cause increased oil production. They are most valuable in controlling active inflammatory acne breakouts. However, when you stop them, the underlying conditions that allowed acne to develop in the first place remain largely unchanged. That’s why acne tends to comes back after stopping antibiotics.
Why is it a Problem to Use Antibiotics in Isolation?
Antibiotics can produce convincing early improvement in acne. Redness settles, lesions shrink and the skin appears calmer. This often creates the impression that the acne itself has been treated, when in reality there’s only been suppression of the inflammation and reduction of bacterial overgrowth. The biological processes that generate acne such as oil gland activity, pore clogging and androgen hormone sensitivity remain unchanged beneath the surface. So when antibiotics are stopped, acne breakouts re-emerge because the conditions that allow acne to form are intact. The problem is not antibiotic use itself. The main problems of using antibiotics of acne in isolation include:
- False Hope: Visible improvement can mask the ongoing activity of acne drivers. This can lead to premature discontinuation. Even if the full course is completed, success may lead to the impression that the acne is cured and hence there is no plan for maintenance or transition.
- Relapse: Without agents that address pore clogging, excess oil or hormonal signalling the acne will almost certainly come back after stopping antibiotics.
- Diminishing Returns: Each course may reduce inflammation, but the baseline behaviour of the skin does not change. Over time, the response becomes shorter-lived and less reliable. This is due to either the underlying drivers of the acne becoming worse or you develop antibiotic resistance.
- Microbiome Disruption: Repeated antibiotic exposure alters the skin and gut microbiome. This can shift inflammatory responses hence increasing the chances of relapse or even worsening the severity of acne.
- Ignores Acne Drivers: Androgen sensitivity and pore clogging are vital for acne development but antibiotics have no effect on them.
- Delays Treatment: Short-term improvement followed by relapse can lead to restarting the antibiotic (sometimes even changing the type or strength of them). This delays the introduction of more appropriate disease-modifying therapies that address the underlying controls.
- Don’t Treat Non-inflammatory Acne: Antibiotics do not tend to have a meaningful effect on blackheads, whiteheads or microcomedone formation which are all mild forms of acne and precursors to inflammatory acne.
- Ignores Post-acne Sequelae: Antibiotics have no effect on post-inflammatory hyperpigmentation, erythema or acne scarring which are often the most persistent and distressing features of adult acne.
None of this means antibiotics should be avoided altogether. The problem is using antibiotics without a parallel long-term strategy to modify the drivers of acne. With strategic use, they can be valuable tools for controlling acute acne breakouts whilst allowing longer-term treatments take effect.
How to Prevent Acne Coming Back After Stopping Antibiotics
When acne returns after antibiotics, the common response is to escalate. This usually involves extending the course, increasing the dose or switching to another antibiotic. While this may produce short-term improvement, it rarely delivers long-lasting control. Instead, it increases the risk of side effects, microbiome disruption and antibiotic resistance as it doesn’t address why the acne returned in the first place. The thing to remember is that the issue is usually not that the antibiotic was inadequate but a misunderstanding of its role. Antibiotics provide temporary control of inflammatory acne. Preventing relapse requires a careful transition from short-term suppression to long-term modification of acne behaviour. The key strategies to prevent acne coming back after stopping antibiotics include:
- Start a Retinoid Before Stopping Antibiotics: Prescription retinoids like Tretinoin and adapalene remain the cornerstone of long-term acne control. By normalising keratinisation within the pore, they reduce pore clogging and microcomedone formation. This prevents new acne from developing once antibiotics are withdrawn. Retinoids can also help target post acne marks and scars.
- Maintain Anti-inflammatory Actions: Azelaic acid provides ongoing anti-inflammatory and antimicrobial support without resistance risk.You can easily find it in a range of over the counter skincare products and by prescription for higher strengths. unlike antibiotics, it also improves post-inflammatory hyperpigmentation, erythema and texture.
- Address Congestion Directly: Regular use of an exfoliant like Salicylic acid 3-4 times a week can also reduce pore clogging. These exfoliants are especially helpful for managing non inflammatory acne as well as skin texture and dark marks.
- Target Hormonal Drivers: In people where androgen sensitivity is the main driver of their acne, treatments like spironolactone or Winlevi can help reduce the excess oil production due to the actions of androgen hormones on the oil glands.
- Avoid Repeated Antibiotic Courses: Recurring courses of antibiotics may transiently suppress inflammation but it does not change baseline acne behaviour. It also increases the risk of antibiotic resistance which may mean that they will stop working all together on your skin.
- Support Skin Barrier Function: An impaired skin barrier perpetuates inflammation. Ensure you use hydrating and moisturising products and avoid irritating your skin to allow your barrier to remain healthy and function correctly.
- Modify Lifestyle Factors: Poor sleep, chronic stress and nutritionally deficient diets can all trigger acne breakouts. Whilst lifestyle changes alone rarely treat acne, they can meaningfully reduce frequency and severity of flare-ups alongside with adequate treatment.
- Use Relapse as Diagnostic Feedback: Acne returning after any treatment indicates that the primary driver is still not under control. Take a moment and work with your doctor to further optimise your treatment plan and address any gaps.
Acne that returns after antibiotics is not a failure of the treatment. It just reflects the limits of what antibiotics can do. They serve as a stabilising measure that provides short term control of inflammatory acne breakouts. Long-term control relies on having disease-modifying treatments and that address the underlying drivers of acne. These should ideally be in place before stopping antibiotics to ensure maintenance. As always, remember that acne is a chronic skin condition which not only varies from person to person but even within an individually. It is highly sensitive to internal health and external factors so take a whole approach to treating it. If your acne is persistent or severe, it’s best to work closely with your health provider to ensure that your treatment plan focuses on both immediate suppression and long term changing of acne behaviour.
At City Skin Clinic, we are extremely passionate about personalised skincare. Our virtual skin clinic offers safe and effective custom skin treatments. Where appropriate our doctors use ingredients such as Tretinoin, Hydroquinone, Azelaic acid, Clindamycin and Spironolactone to treat skin conditions like acne, hyperpigmentation, melasma and skin ageing. Start your online consultation today. The journey towards great skin starts here.
This article is intended for general informational purposes only and is not a substitute for medical advice, diagnosis or treatment. Always consult a qualified medical provider for any medical concerns or questions you might have.
