Can topical clindamycin (antibiotic) cause diarrhea?

Topical Clindamycin and Diarrhea Risk

Yes, topical clindamycin can cause diarrhea, including severe colitis, as the antibiotic is absorbed through the skin surface. 1

Mechanism and Risk

• Topical application of clindamycin results in absorption of the antibiotic through the skin, which can disrupt normal intestinal microbiota 1
• This disruption can lead to overgrowth of Clostridium difficile, which produces toxins that cause diarrhea and colitis 1, 2
• The FDA drug label specifically warns that diarrhea, bloody diarrhea, and colitis (including pseudomembranous colitis) have been reported with topical clindamycin use 1

Clinical Evidence

• Case reports have documented pseudomembranous colitis occurring after topical application of clindamycin for acne vulgaris 3
• In one documented case, a 24-year-old woman developed abdominal cramping and diarrhea five days after starting topical therapy with 1% clindamycin for facial acne 3
• A study of 32 acne patients found that 4 of 19 patients using topical clindamycin had C. difficile detected in their stool during treatment, though none developed diarrhea in this small sample 4

Risk Factors

• The risk of developing diarrhea from clindamycin (any route) appears to be higher in:
  • Patients over 20 years of age 5, 6
  • Female patients 5, 6
• Interestingly, studies of systemic clindamycin have not found a clear relationship between dose or duration of therapy and diarrhea risk 5, 6

Clinical Presentation and Timing

• Diarrhea from clindamycin typically begins within the first few days of treatment
  • In studies of systemic clindamycin, 52.3% of patients developed diarrhea within 48 hours of starting therapy 5
  • 75.3% developed diarrhea within five days of starting therapy 5
• However, diarrhea can also develop after discontinuation of the medication 5

Management Recommendations

• When significant diarrhea occurs, topical clindamycin should be discontinued 1
• For severe cases with confirmed C. difficile infection, treatment may include:
  • Oral vancomycin (500mg to 2g daily in 3-4 divided doses for 7-10 days) 1
  • Supportive care for fluid replacement 1, 7
• Antiperistaltic agents such as opiates and diphenoxylate with atropine should be avoided as they may prolong or worsen the condition 1

Prescribing Considerations

• The FDA label for topical clindamycin specifically states that physicians should consider whether other agents might be more appropriate due to this potential risk 1
• This is particularly important for patients with a history of:
  • Regional enteritis
  • Ulcerative colitis
  • Previous antibiotic-associated colitis 2

Monitoring

• Patients using topical clindamycin should be informed about the potential risk of diarrhea and instructed to report persistent or severe diarrhea 1
• Diagnostic workup for significant diarrhea may include:
  • Stool culture for C. difficile
  • Stool assay for C. difficile toxin
  • Large bowel endoscopy in severe cases 1