Can doxycycline be used to treat skin and soft tissue infections?

Doxycycline for Skin and Soft Tissue Infections

Yes, doxycycline is a strongly recommended oral antibiotic option for skin and soft tissue infections, particularly when methicillin-resistant Staphylococcus aureus (MRSA) is suspected or confirmed. 1

Primary Indications

Doxycycline is specifically recommended for:

• MRSA skin infections - When MRSA is suspected or confirmed in impetigo, ecthyma, or other purulent SSTIs, doxycycline is a first-line oral option alongside clindamycin and trimethoprim-sulfamethoxazole 1
• Purulent SSTIs - The 2014 IDSA guidelines strongly recommend doxycycline for purulent skin infections, especially in the era of community-acquired MRSA 1
• Mild to moderate infections - Appropriate for outpatient management when systemic signs are absent or minimal 1

Dosing and Duration

Standard dosing is 100 mg orally twice daily 2

• Treatment duration: 7-14 days for most uncomplicated skin infections, individualized based on clinical response 1, 2
• Both doxycycline formulations (hyclate and monohydrate) have identical antimicrobial activity and dosing 2

Coverage Considerations

Important limitation: Doxycycline alone does not reliably cover β-hemolytic streptococci 1

• When streptococcal coverage is needed (non-purulent cellulitis, erysipelas), combine doxycycline with a beta-lactam antibiotic such as penicillin, cephalexin, or amoxicillin 1, 2
• For purulent infections where S. aureus is the primary concern, doxycycline monotherapy is appropriate 1

Clinical Effectiveness

Doxycycline demonstrates superior outcomes compared to beta-lactams for MRSA infections:

• Retrospective cohort data showed beta-lactam therapy had nearly 4-fold higher treatment failure rates (adjusted OR 3.94) compared to tetracyclines for community-onset MRSA SSTIs 3
• Most MRSA strains remain susceptible to doxycycline, with median susceptibility rates of 95% 3
• Clinical cure rates are comparable to other MRSA-active agents when used appropriately 4

Specific Clinical Scenarios

Impetigo and ecthyma: When MRSA is suspected or confirmed, doxycycline is recommended as a 7-day oral regimen 1

Abscesses and furuncles: Doxycycline is appropriate after incision and drainage when antibiotic therapy is indicated 1, 3

Cellulitis: Use only with beta-lactam combination for non-purulent cellulitis; monotherapy acceptable for purulent cellulitis with MRSA 1

Critical Contraindications

Absolutely contraindicated in children under 8 years of age due to risk of permanent dental staining 2

Common Pitfalls to Avoid

• Do not use doxycycline monotherapy for non-purulent cellulitis or erysipelas - these are typically streptococcal and require beta-lactam coverage 1
• Re-evaluate patients in 24-48 hours when starting empiric doxycycline to verify clinical response, as treatment failure can occur 1
• Do not assume all tetracyclines are equivalent - minocycline may have superior efficacy in some MRSA infections compared to doxycycline, though both are acceptable 5, 3
• Verify local MRSA susceptibility patterns - while most community MRSA remains susceptible, resistance can occur 3, 4

Alternative Considerations

When doxycycline fails or is contraindicated, alternative oral MRSA-active agents include:

• Trimethoprim-sulfamethoxazole 1
• Clindamycin (though resistance is increasingly common) 1
• Linezolid or tedizolid for severe cases 1