Key Lessons for the Hair Specialist — Donovan Hair Clinic

Doxycycline is frequently used for the treatment of scarring alopecias including lichen planopilaris, frontal fibrosing alopecia and folliculitis decalvans. Sometimes it’s used in dissecting cellulitis. One side effect that hair specialists need to be aware of and counsel patients is the side effect of doxycycline induced “esophagitis” (inflammation of the esophagus). Tetracyclines are antibiotics that commonly cause pill esophagitis, with doxycycline being the most frequent. These medications have a low pH when dissolved in solution, such as saliva, and cause transient esophageal injury. There is a direct toxic effect on the esophageal mucosa. The mucosa heals after medication withdrawal although antiacids and mucosal protectants are used to help speed up resolution and prevent further damage.

I read with interest a report in the Indian Journal of Gastroenterology from Jan 2022 of 4 patients who developed doxycycline esophagitis. The 4 patients had taken doxycycline as as treatment or prophylaxis against COVID 19. The authors reported that doxycycline was among many popular treatments against COVID 19 in India in 2021 despite the fact it had no proven benefits to treat COVID 19. The authors state that they normally see one case of doxycycline esophagitis every 4 years but over a short span in 2021 they saw 4 cases of esophagitis in a span of one month.

All the four patients using doxycycline, (one male and three female) presented with sudden onset of odynophagia (pain on swallowing) within 1 to 2 h after taking first dose of doxycycline (100 mg). The physicians advised all patients to stop doxycycline and start sucralfate (a medication to treat stomach ulcers). All the four patients recovered symptomatically within 5 days of stopping doxycycline.

Conclusion and Key Points

This is a nice study with a happy ending and reminds us all of a few key points about how to use doxycycline to prevent esophagitis.

Doxycycline induced esophagitis can be very painful and some patients even feel like they are having a heart attack. It is usually benign but needs to be taken seriously as rarely ulcers and perforation can occur. Doxycycline is the most well known of the antibiotics that can cause esophagitis. Other antibiotics can cause esophagitis too, including other tetracyclines, clindamycin, metronidazole, ciprofloxacin, and amoxicillin. A variety of other pills can cause including iron, vitamin C, bisphosophates, NSAIDs, cancer drugs

There are a few key points that we need to counsel patients about to avoid this extremely painful situation from happening.

  1. Doxycycline should be taken with a good amount of water (250 mL or more). This helps speed up transit time through the stomach.

  2. Patient should not lie down but sit up 1-2 hours.This helps speed up transit time through the stomach. One should never take before going to bed.

  3. It should not be taken with calcium or iron and ideally not take with vitamin C.

  4. It is okay to take doxycycline with food as bioavailability is not altered much. It is not okay to take tetracycline itself with food

  5. Alcohol use needs to be limited when using doxycycline as they two together can worsen esophagitis. Moderate alcohol consumption is okay for some patients but high alcohol use can really trigger a severely painful esophagitis.

  6. Capsules may be more likely to cause esophagitis than pills

  7. Extended release (sustained release) versions have higher chance of causing esophagitis.

As in this study treatment involves stopping the drug when possible. Proton pump inhibitors are used as well as antiacids. Oral sucralfate helps form a barrier in the esophagus to protect it. One should avoid alcohol and extremely hot or extremely cold foods and acidic foods as the lining of esophagus is healing.


Panigrahi M et al. A recent surge of doxycycline-induced pill esophagitis during the corona virus disease 2019 (COVID-19) pandemic. Indian J Gastroenterol 2022 Jan 7;1-2.

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