Less Can Be More: Study Finds Low-Dose Doxycycline Works Well for Scarring Alopecia, With Fewer AEs

"Low-dose doxycycline demonstrated similar effectiveness to high-dose therapy in managing lymphocytic scarring alopecia while being associated with fewer adverse events and a lower rate of treatment discontinuation," the researchers wrote.

To evaluate treatment outcomes with low-dose doxycycline in lymphocytic scarring alopecia, Carli Needle BA, The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY, and colleagues conducted a retrospective review of 241 patients diagnosed between 2009 and 2023. The cohort had a mean age of 58.4 years and was predominantly female (82.6%), with 49.8% identifying as White and 14.1% as Black. The most frequently diagnosed conditions included lichen planopilaris (50.2%), frontal fibrosing alopecia (45.6%), and central centrifugal cicatricial alopecia (15.4%). Of the total, 64 patients (27.4%) received low-dose doxycycline (20 mg twice daily, 40 mg daily, or 50 mg daily), while 175 (72.6%) were treated with high-dose regimens (50 mg twice daily, 100 mg daily, or 100 mg twice daily).

All patients also received adjunctive therapies, most commonly intralesional corticosteroids (56.4%), topical corticosteroids (46.1%), and 5% topical minoxidil (31.5%). Treatment outcomes were assessed based on inflammation severity, scalp symptoms, hair loss stability, and patients’ perceptions of their condition.

Based on the study, the researchers reported the following findings:

• No significant differences were observed between low- and high-dose doxycycline groups in terms of improvement in inflammation severity, hair loss stability, or the number of scalp symptoms.
• There were similar results in the subgroup of patients with lichen planopilaris and frontal fibrosing alopecia, with no significant differences across inflammation, hair loss stability, or symptom count.
• After adjusting for adjunctive treatments, patient-reported outcomes did not significantly differ between dose groups.
• High-dose doxycycline was associated with a higher rate of adverse events (23.4%) compared to low-dose treatment (12.1%).
• The most common adverse events were gastrointestinal symptoms (11.4% in high-dose vs 6.0% in low-dose) and photosensitivity or rash (6.9% vs 4.6%).
• Doxycycline dosage had to be reduced or discontinued due to adverse events in 20.4% of high-dose patients versus 9.1% of low-dose patients.

The authors concluded that low-dose doxycycline offers comparable efficacy to high-dose regimens in managing lymphocytic scarring alopecias while demonstrating improved tolerability and fewer adverse events. They emphasized the potential of low-dose therapy as a safer treatment option and highlighted the need for prospective studies to further validate its effectiveness and long-term benefits in this patient population.

Reference:

Needle, C., Brinks, A., Pulavarty, A., Kearney, C., Nohria, A., Desai, D., Shapiro, J., & Lo Sicco, K. (2025). Efficacy and Tolerability of Low-Dose Versus High-Dose Doxycycline in the Management of Lymphocytic Scarring Alopecias. Journal of the American Academy of Dermatology. https://doi.org/10.1016/j.jaad.2025.02.028