Doxycycline-Induced Esophageal Ulceration in A Young Female Treated for Acne Vulgaris: A Preventable Adverse Drug Reaction Due To Improper Pill Intake Posture: A Case Report

Abstract

Doxycycline is a common antibiotic used in skin care, especially for treating moderate to severe acne in young adults. It is usually safe, but it can sometimes cause a painful problem in the food pipe called esophageal irritation or ulcers. This side effect is not well known but can be easily avoided. We describe the case of a 21-year-old college student who started taking doxycycline 100 mg once a day for acne. After just three days, she began feeling a sharp, burning pain in her chest. Swallowing food became painful, and the pain got worse with each meal. At first, it seemed like heartburn, but soon it became so bad that she had trouble eating and drinking. Later, she mentioned she had been taking the medicine at night while lying in bed, with only a small amount of water. A test called endoscopy showed several small ulcers in the middle part of her food pipe. These are typical signs of injury caused by pills. Based on the timing and how she took the medicine, doxycycline was the likely cause. This case shows that even common medicines can cause serious problems if not used properly. The good news is this can be prevented. Patients should be told to take doxycycline with a full glass of water and stay upright for at least 30 minutes. Small instructions like these can protect patients from harm.

Keywords

Introduction

Acne vulgaris is one of the most frequently encountered dermatologic conditions globally, with a prevalence that peaks during adolescence and early adulthood. Epidemiological studies suggest that nearly 85% of individuals between the ages of 12 and 24 will experience acne to some degree, with varying severity and duration¹. Although often perceived as a benign or self-limiting condition, acne can have profound psychosocial effects. It is well established that visible facial acne can result in significant emotional distress, social withdrawal, low self-esteem, and in some cases, depression and anxiety, particularly in young people navigating formative educational and social environments² ³. Pathophysiologically, acne arises from a multifactorial process involving sebaceous gland hyperactivity, abnormal follicular keratinization, colonization by Cutibacterium acnes (formerly Propionibacterium acnes), and inflammatory mediator release at the pilosebaceous unit?. Based on lesion type and severity, acne is classified into non-inflammatory (open and closed comedones) and inflammatory (papules, pustules, nodules, cysts) variants. While mild acne may be managed effectively with topical agents such as retinoids, benzoyl peroxide, and antimicrobials, moderate to severe inflammatory acne often necessitates systemic therapy?.Among systemic agents, oral antibiotics, particularly from the tetracycline class, remain a cornerstone of acne management. Doxycycline has emerged as a preferred first-line option due to its broad-spectrum antibacterial activity, anti-inflammatory properties, once-daily dosing, and comparatively favorable side effect profile?. It acts by inhibiting the 30S ribosomal subunit of bacteria, thus blocking protein synthesis and reducing proliferation of C. acnes. In addition, doxycycline modulates inflammatory pathways by inhibiting matrix metalloproteinases, thereby helping reduce erythema and lesion count?. These dual actions make it highly effective in reducing both active lesions and long-term scarring in acne patients. However, despite its overall safety and utility, doxycycline is not devoid of risk. While gastrointestinal disturbances, photosensitivity, and vaginal candidiasis are among the more recognized adverse effects, a lesser-known yet clinically significant complication is pill-induced esophagitis and esophageal ulceration?. This phenomenon is caused by the prolonged contact of the capsule with the esophageal mucosa, usually due to inadequate water intake or recumbent posture shortly after ingestion. Doxycycline is particularly caustic to the esophageal lining, as its dissolution in an acidic environment produces a low pH solution that can directly damage the mucosal epithelium?. What makes this ADR especially notable is its preventability. Research has consistently shown that simple behavioral instructions such as taking the pill with at least 200 mL of water and remaining upright for at least 30 minutes can dramatically reduce the incidence of this complication¹?. Unfortunately, these instructions are often omitted during routine prescribing, particularly in high-volume outpatient dermatology clinics where time constraints or the perception of doxycycline as a "routine drug" may lead to under-communication of safety protocols¹¹. This is especially concerning in young or first-time users, who may be unaware of such precautions and are at higher risk of developing medication-related complications. Clinically, doxycycline-induced esophageal injury typically manifests within 3 to 7 days of starting therapy. Patients often report sudden-onset retrosternal pain, odynophagia (painful swallowing), dysphagia (difficulty swallowing), and occasionally, a burning sensation that mimics gastroesophageal reflux disease or even cardiac symptoms¹². These symptoms may significantly impact the patient's ability to eat, drink, or sleep, resulting in physical discomfort and anxiety. Importantly, because this ADR is not widely discussed with patients, they may fail to connect the onset of symptoms with the antibiotic, leading to delayed presentation or misdiagnosis unless the clinician specifically considers this possibility. Endoscopic evaluation in suspected cases often reveals shallow, well-circumscribed ulcers in the mid-esophagus, particularly around the region of the aortic arch, where anatomical compression increases the likelihood of capsule retention¹³. Treatment is generally conservative: immediate cessation of the offending drug, along with administration of mucosal protective agents (e.g., sucralfate), acid suppression therapy (e.g., proton pump inhibitors), and dietary adjustments, typically leads to symptom resolution within 7 to 10 days. Long-term complications such as strictures are rare but have been reported in delayed or untreated cases¹?. This case report aims to highlight this preventable yet impactful adverse reaction through the example of a young Indian female receiving doxycycline for acne vulgaris, who developed esophageal ulceration due to improper administration practices. The case not only reinforces the therapeutic value of doxycycline but also emphasizes the critical role of prescriber-patient communication in ensuring treatment safety.

Case Presentation

A 21-year-old previously healthy female college student presented to the dermatology outpatient clinic with concerns regarding persistent acne lesions on her face, which she reported had been progressively worsening over the past 12 to 15 months. The patient described a history of multiple erythematous papules, pustules, and comedonal lesions primarily affecting her bilateral cheeks and mandibular area. She noted that her acne would often flare up in association with her menstrual cycle, becoming more inflamed and painful during those periods. These episodes occasionally involved the development of deeper nodules that would resolve over several days, often leaving behind post-inflammatory erythema but no scarring. She denied a personal or family history of severe cystic acne .She had previously used over-the-counter topical products, including salicylic acid cleansers and benzoyl peroxide formulations, with limited improvement. Approximately four months prior to presentation, she had been prescribed a combination topical regimen consisting of clindamycin phosphate 1% gel and benzoyl peroxide 2.5% wash by her general practitioner. However, her adherence was inconsistent due to perceived dryness and irritation, and she reported minimal benefit. Her past medical history was otherwise unremarkable. She had no history of gastrointestinal, respiratory, cardiovascular, endocrine, or autoimmune disorders. She was not taking any regular medications and had no known drug allergies. She was not using hormonal contraceptives and denied any use of herbal or alternative therapies. She was a non-smoker and consumed alcohol socially, with no history of substance abuse. There was no recent history of travel, infections, or weight loss. On physical examination, the patient appeared well, with stable vital signs and no signs of systemic illness. Dermatological examination revealed moderate inflammatory acne vulgaris characterized by numerous closed comedones, scattered inflammatory papules and pustules over the bilateral malar and mandibular regions, and mild seborrhea. There were no nodules or cysts at the time of examination. No atrophic or hypertrophic scarring was noted. The rest of her physical examination, including oropharyngeal, cardiovascular, pulmonary, and abdominal assessments, was within normal limits.A clinical diagnosis of moderate inflammatory acne vulgaris was established. Based on the extent of inflammatory lesions and inadequate response to topical therapies, systemic antibiotic therapy was deemed appropriate. The patient was initiated on doxycycline 100 mg orally once daily, in combination with topical adapalene 0.1% gel to be applied nightly. She was given basic counseling regarding sun protection and the potential adverse effects of doxycycline, including gastrointestinal discomfort and photosensitivity. However, detailed instructions about pill administration posture and fluid intake were inadvertently omitted during the consultation, likely due to time constraints and high outpatient volume. Three days following the initiation of doxycycline, the patient began to experience sudden onset retrosternal pain, which she described as a sharp, burning sensation localized behind the sternum. The pain developed approximately 24 hours after the second dose and progressively worsened with subsequent doses. She also reported odynophagia, particularly with swallowing solid foods and hot liquids. The pain was exacerbated while eating and was accompanied by a sensation of discomfort in the chest during meals. She denied associated symptoms such as fever, chills, cough, hoarseness, nausea, vomiting, hemoptysis, hematemesis, abdominal pain, or weight loss. There was no history of ingestion of caustic substances, NSAIDs, or alcohol binge prior to symptom onset. After two more days of persistent symptoms, the patient returned to the dermatology clinic for evaluation. Upon further inquiry, she revealed that she had been taking the doxycycline capsule at night, usually around midnight, while lying in bed, and swallowed the capsule with only a small sip of water—approximately two or three mouthfuls, which she estimated to be around  30 ml . She stated that she was unaware of any specific requirements regarding the posture or volume of water necessary while taking oral medications and had not received such instructions previously. Her vital signs were stable: blood pressure 112/70 mmHg, heart rate 78 bpm, respiratory rate 16/min, temperature 36.8°C, and oxygen saturation 98% on room air. Physical examination at this visit was again unremarkable. Oral cavity and oropharyngeal inspection showed no ulcerations or erythema. Cardiopulmonary auscultation was normal. There was no cervical lymphadenopathy or epigastric tenderness. A preliminary diagnosis of drug-induced esophageal irritation was considered.Due to the persistence and severity of odynophagia and the absence of upper respiratory or gastrointestinal symptoms pointing to alternative causes, she was referred for upper gastrointestinal endoscopy (esophagogastroduodenoscopy) for further evaluation. Esophagogastroduodenoscopy (EGD) was performed by a gastroenterologist under conscious sedation. The procedure revealed multiple shallow, discrete ulcerations with sharply demarcated erythematous borders in the mid-esophagus, located approximately 25 to 30 cm from the incisors. The ulcers were non-bleeding and appeared longitudinal in orientation. No evidence of active bleeding, strictures, masses, or retained pill fragments was observed. The remainder of the esophagus, including the upper esophageal sphincter, proximal and distal esophagus, gastroesophageal junction, and stomach, appeared grossly normal. There were no signs of erosive esophagitis or Barrett’s changes. Biopsies were deferred given the classic appearance of the lesions and the absence of suspicious or atypical findings suggestive of malignancy, infection, or systemic disease. The endoscopic findings were deemed characteristic of pill-induced esophagitis, specifically attributable to doxycycline-induced esophageal ulceration. The temporal relationship between symptom onset and drug initiation, the patient’s reported pill intake habits, and the typical location of injury in the mid-esophagus all supported the diagnosis.

Management of ADR

Following the confirmation of doxycycline-induced esophageal ulceration by upper gastrointestinal endoscopy, the immediate priority was to eliminate the inciting factor and provide symptomatic relief while promoting mucosal healing. The offending agent doxycycline 100 mg daily was discontinued immediately upon clinical suspicion and definitively stopped after endoscopic confirmation of mid-esophageal ulcerations. The patient was managed conservatively, as she was clinically stable, systemically well, and able to tolerate small amounts of oral fluids despite discomfort. A non-invasive, outpatient treatment plan was initiated, focusing on gastric acid suppression, mucosal protection, -symptom control, and dietary modifications.

1. Pharmacological Management

• Sucralfate suspension 1 g, administered orally four times daily (qid) before meals and at bedtime, was prescribed. Sucralfate acts as a mucosal barrier, adhering to ulcerated tissue and protecting it from further acid exposure and mechanical irritation, thereby accelerating healing.

• A proton pump inhibitor (PPI), specifically pantoprazole 40 mg once daily, was initiated to reduce gastric acid secretion and maintain an esophageal environment conducive to mucosal regeneration. While the injury was localized to the esophagus and not caused by acid reflux, acid suppression was deemed beneficial in promoting recovery and reducing associated esophageal discomfort.

• The patient was advised to temporarily avoid NSAIDs, aspirin, or any medications that could exacerbate mucosal injury during the recovery period.

2. Dietary and Lifestyle Recommendations

• A soft, bland diet was recommended to minimize mechanical trauma and irritation during swallowing. The patient was advised to avoid spicy, acidic, very hot, or coarse-textured foods until her symptoms fully resolved.

• Caffeinated and carbonated beverages were discouraged due to their potential for exacerbating discomfort.

• Adequate hydration (at least 2 liters of water daily) was emphasized to support healing and to prevent further pill-induced esophageal injury.

3. Patient Education and Behavioral Modification

In-depth counselling was provided regarding proper pill ingestion technique, with specific emphasis on:

• Taking all future oral medications with at least 200–250 mL of water (approximately   one full glass).

• Remaining in an upright position for at least 30 minutes after swallowing any pill or capsule.

•Avoiding late-night medication intake unless necessary, particularly while in bed or in a reclining position.

•Avoiding dry swallowing of any oral medications.

4. Follow-up and Outcome Monitoring

The patient was followed up closely over the subsequent days. Within 72 hours, she reported significant improvement in odynophagia and chest discomfort. By day 5, she was able to consume a regular diet with only mild discomfort, and by day 10, all symptoms had completely resolved. There were no complications such as bleeding, weight loss, or secondary infections during the recovery phase.

5. Adjustment of Acne Management Plan

Given the adverse reaction to systemic doxycycline, a decision was made to withhold further systemic antibiotics. The patient’s acne regimen was transitioned to a topical-only approach, consisting of:

•Adapalene 0.1% gel applied nightly.

•Benzoyl peroxide 2.5% wash, used in the morning to reduce microbial load and inflammation.

•Continued strict sun protection and skin barrier maintenance with a non-comedogenic moisturizer.

The patient was advised that her acne might respond more slowly to topical agents alone but was reassured that consistent use would yield gradual improvement. The possibility of hormonal therapy or other systemic options was reserved for future consideration if topical treatment proved inadequate

DISCUSSION

Doxycycline remains one of the most commonly prescribed oral antibiotics in dermatology, especially in the treatment of moderate to severe inflammatory acne vulgaris. It is valued for its dual antimicrobial and anti-inflammatory properties, its efficacy against Cutibacterium acnes, and its generally favorable safety profile. However, like all systemic therapies, doxycycline is not without its risks. One important, yet often under-recognized, complication is pill-induced esophagitis and esophageal ulceration, which, although rare, can lead to considerable morbidity if not promptly identified and addressed 15. Pill-induced esophageal injury was first described in the 1970s and has since been associated with over 100 different medications 16. Doxycycline, along with other tetracyclines like tetracycline and minocycline, is one of the most commonly implicated agents 17. The mechanism involves direct caustic injury to the esophageal mucosa, which occurs when a tablet or capsule adheres to the esophageal lining and dissolves locally, releasing acidic or alkaline contents 18. The injury typically affects the mid-esophagus, which is anatomically predisposed to delayed transit due to its compression between the aortic arch and the left atrium 19. Patients with doxycycline-induced esophageal ulceration often present with sudden-onset retrosternal chest pain, odynophagia (painful swallowing), and dysphagia, usually within a few days of starting therapy 20. The discomfort can be severe and is often misattributed to gastroesophageal reflux disease (GERD) or even cardiac causes in early stages 21. Because many patients do not associate their symptoms with a new medication, diagnosis is frequently delayed. Endoscopic evaluation typically reveals one or more discrete, sharply marginated ulcerations in the mid-esophagus, often described as “punched-out” lesions 22. Biopsy is not routinely required unless other pathologies are suspected, such as infectious esophagitis or malignancy 23. This case clearly demonstrates the classic clinical course and endoscopic features of doxycycline-induced esophageal ulceration. The patient, a young healthy female with no prior comorbidities, began experiencing symptoms shortly after initiating doxycycline for acne. Notably, her medication administration habits taking the capsule with minimal water while lying down at bedtime were the primary risk factors 24. These behaviors are unfortunately common among young adults and are often not explicitly addressed during prescribing 25. Management of pill-induced esophagitis is typically supportive and conservative. Immediate cessation of the offending medication is the cornerstone of therapy. Pharmacologic treatment often includes the use of proton pump inhibitors (to reduce gastric acid exposure) and sucralfate suspension (to form a protective barrier over the ulcerated mucosa), along with dietary adjustments to minimize mechanical trauma during swallowing 26. In most cases, complete symptom resolution occurs within 7 to 14 days, and endoscopic healing is generally rapid 27. More important than treatment, however, is prevention. This adverse effect is largely avoidable through proper patient education. Clinicians should routinely instruct patients taking doxycycline or similar medications to:

•Ingest the capsule with at least 200–250 mL of water (a full glass),

•Avoid taking the medication right before bed, and

•Remain upright for at least 30 minutes after swallowing 28.

Unfortunately, these simple yet vital precautions are frequently omitted during hurried outpatient consultations, especially when prescribing familiar drugs such as doxycycline 29. In dermatology, where doxycycline is a first-line agent and often prescribed to young, otherwise healthy individuals, the assumption of safety can lead to under-communication of risk 30. This case highlights the importance of clinician-patient communication and medication literacy, especially in ambulatory care settings. It underscores the need for written and verbal counseling about proper drug administration when initiating systemic therapy. Additionally, incorporating medication safety checklists, digital prescribing alerts, or brief educational handouts in dermatology clinics could serve as effective reminders for both patients and providers 31. In summary, while doxycycline is an effective and generally safe treatment for acne vulgaris, it carries a real risk of esophageal ulceration when taken incorrectly. This case reinforces the need for heightened awareness of pill-induced esophagitis and emphasizes that a few seconds of preventive counseling can spare patients days of pain and distress. As the dermatologic community continues to advocate for evidence-based care, attention to medication safety and patient education must remain a priority 32.

CONCLUSION

This case report demonstrates how a commonly used and generally safe medication like doxycycline can cause a painful and avoidable complication when not taken properly. Doxycycline remains one of the most effective oral antibiotics for treating moderate-to-severe acne vulgaris due to its ability to reduce both bacteria and inflammation. However, like all medications, it carries risks especially when patients are not fully informed about the correct way to take it .In this case, the patient developed esophageal ulceration after taking doxycycline with little water and lying down soon afterward. This caused the capsule to lodge in the esophagus, where it slowly dissolved and irritated the lining, leading to painful symptoms. Fortunately, stopping the medication and starting simple treatment helped the patient recover quickly without long-term harm.What makes this situation important is that it could have been easily prevented. Taking doxycycline with a full glass of water and staying upright for at least 30 minutes after swallowing are simple but critical steps that can prevent this type of injury. Unfortunately, these instructions are often not clearly explained to patients, especially in busy clinics or during routine prescriptions. This case highlights the need for doctors, pharmacists, and other healthcare providers to take a few extra moments to educate patients about how to take medications safely. Young patients, in particular, may not be aware of the risks that come with certain drugs, even if they are commonly used.By improving patient education and awareness, we can reduce unnecessary complications, improve comfort and safety during treatment, and help patients stay on track with their acne therapy. Simple preventive measures can make a big difference in clinical outcomes and patient satisfaction.

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