Rosacea and Dry Eyes Part 6 - the Tetracyclines (including Doxycycline and Minocycline)

Fast forward 40,000 years from cave paintings (or so) and we have a better understanding of rosacea, including the biological underpinnings and stressors that drive this response today. Adapting and annotating from a Johns Hopkins Review Article: ‘stressors, including ultraviolet light from the sun, microbes (Demodex has stepped into the spotlight lately - see my post here: https://www.eyethera.com/blog/demodex-the-tiny-mite-with-a-big-effect-on-dry-eye-disease ), trauma, emotional stress, and some hormones, may stimulate the release of “neurotransmitters” and contribute to the dilating blood vessels, flushing, and increased skin sensitivity, stinging, itch, and lower pain thresholds in patients with rosacea. Interestingly, pain fibers have been found to be increased in erythematotelangiectatic rosacea. Ion channels that regulate cell functions are (over) expressed in rosacea, on nerves, corneal surface cells, mast (allergy) cells and/or immune cells, making them highly reactive to thermal, chemical and/or mechanical stimulation.’

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003

This was echoed and elaborated in a more recent review of Rosacea: “Dilation of lymphatic and blood vessels with exposure to extreme temperatures, spices, and alcohol has been observed in rosacea.” and “in addition, expression of matrix metalloproteinases (involved in inflammation) and vascular endothelial growth factor (invoved in blood vessel growth) is increased in rosacea. In rosacea, microbes may trigger activation of the immune response. This hypothesis is supported by an increased number of organisms, such as Demodex folliculorum on the skin and helicobacter pylori infection in the gut of patients with rosacea.”
https://www.ncbi.nlm.nih.gov/books/NBK557574/#article-28642.s5

The reason this is important, is that one of the more accepted treatments for rosacea is antibiotic therapy from the Tetracycline class (including Doxycycline and Minocycline). These antibiotics can interfere with the matrix metalloproteinases (reducing inflammation) and can kill helicobacter pylori (the bacteria commonly linked to stomach ulcers and thought to potentially lead to stomach cancers). These antibiotics are relatively cheap, often covered by health insurance plans and can be effective at reducing the skin and eye redness, sensitivity and irritation from rosacea. So why isn’t everyone with rosacea on these antibiotics?

Probably the number one reason is that these antibiotics don’t know the difference between “good” and “bad” germs - they simply take out any germ that is susceptible. This has the potentially adverse effect of encouraging resistant germs to “take over.” These can be yeast (not being a bacteria, they aren’t affected by these antibiotics and require specialized anti-yeast” medications to recover). Other germs with a drug-resistant profile are increasing in numbers and in their capacity for harm - but since they are resistant to most antibiotics, they pose a greater threat once they “turn bad” and cause diseases.

Fortunately, at the (low) dosages commonly recommended for treating rosacea, the effect on gut germs can be limited and this can potentially circumvent some of the harsher issues. But there are other issues that also need to be addressed. Because they are acidic in nature, they can be a little rough on a sensitive stomach - so taking them with food is often recommended. However foods containing calcium can bind to the antibiotic and make it difficult to absorb it (so it can run through the gut without getting into the bloodstream, where it would be needed to help fight facial and ocular rosacea). Probiotics like yogurt can help restore healthy germs to the gut after the antibiotic knocked them out. But yogurt is high in calcium, so while it is a good food for those taking these antibiotics, it is important to stagger the yogurt (or other calcium-rich foods) 1-2 hours before or after the antibiotic to allow optimal absorption. It is also advisable to not take the antibiotic right before bedtime, as it can get caught in the esophagus (before getting to the stomach) and cause ulcers or irritation (the stomach is naturally acidic and can usually easily handle it).

Add to that, the fact that it can negate the effects of birth control pills - but also is known to affect fetuses badly (causing birth defects) - so women of childbearing age need to be especially careful not to get pregnant while taking these antibiotics. It is also worth noting that patients who can sunburn - will be more prone to sunburning while taking these antibiotics. (It increases the damaging effects of Ultraviolet light on skin treated with the Tetracycline-type antibiotics - so it isn’t the drug that sunburns you - it is the sun that sunburns - just more easily). This means those on these antibiotics need to be extra careful when exposing themselves to the sun (covering up and wearing appropriate amounts of sun blocking lotions or creams). Taking them with a tall glass of water and a bit of bread or fruit after dinner - but at least an hour or two before bedtime can often allow them to do their best without significant stomach or lower gut side effects. Taking them at night can also limit the sunburning - (when the dose in the skin is the highest when there is no sunshine to sunburn.)

Lastly, it is possible to become allergic to the entire Tetracycline group from taking any one of these related antibiotics. This can be especially problematic for those who really need this particular antibiotic (like those with Lyme disease - where this is the preferred first line treatment against the Lyme organism). While the common allergic reaction is a rash, more severe allergies are possible - so when in doubt, best to immediately contact your doctor - or if not immediately available or in severe cases, to go immediately to the nearest Emergency Room.

Despite these potential adverse events and special considerations, Tetracyclines can be a good fit for many patients and side effects are usually easily mitigated - so I consider them on a case by case basis. There are also many treatment options apart from the Tetracyclines and it is best to work with a good dry eye specialist to determine what is best for you. We will delve further into this in future posts!

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463