Although minocycline has various indications, it is used primarily as one of a number of oral antibiotics available for the treatment of acne. See the NICE Clinical Knowledge Summary on acne vulgaris (which does not recommend minocycline for the treatment of acne) for a general overview of this condition.
Unlike some other drugs in its class (for example, tetracycline and oxytetracycline) minocycline is available as a once‑daily treatment and does not need to be taken on an empty stomach. However, there are concerns about its place in therapy:
there are safety concerns specific to minocycline (see below)
there is no clear evidence that minocycline is more effective or better tolerated than other tetracyclines
alternative once‑daily treatments such as doxycycline and lymecycline are available
minocycline has a relatively high acquisition cost.
Minocycline has been associated with the following patterns of serious reactions (Cochrane review, CD002086, 2012):
early‑onset dose‑related toxicity reactions resulting in single organ dysfunction (including potentially fatal liver failure)
autoimmune disorders (such as systemic lupus erythematosus‑like syndrome, which has a strong relationship with duration of exposure, and autoimmune hepatitis)
hypersensitivity reactions (including eosinophilia, pneumonitis and nephritis).
In addition, minocycline can cause slate-grey hyperpigmentation of the skin, which may be irreversible (Drug and Therapeutics Bulletin, 2006).
The Cochrane review (CD002086) found no evidence to justify the use of minocycline for first-line treatment of acne. There was no evidence that minocycline was more effective than other commonly used acne treatments, including other tetracyclines. It was not possible to reliably estimate the likelihood of having an adverse effect while taking minocycline, but it was associated with more severe adverse effects than doxycycline. Also, unlike other tetracyclines, minocycline was associated with lupus erythematosus. In addition, there is no evidence to suggest that the extended‑release preparation is safer than standard minocycline preparations.
As well as important quality issues, minocycline remains one of the more costly oral options for the treatment of acne. In 2011, the UK Cochrane Centre and NICE produced a QIPP case study on minocycline for acne vulgaris, which estimated that substituting minocycline with an alternative tetracycline could save the NHS approximately £2.2 million.