Richard A. Bojar

The effects of acne treatment with a combination of benzoyl peroxide and erythromycin on skin carriage of erythromycin resistant propionibacteria

Summary Concomitant application of 5% w/w benzoyl peroxide and 3% w/w erythromycin has previously been shown to prevent the overgrowth, on the skin of acne patients, of crythromycin‐resistant coagulase‐negative staphylococci, which occurs when the antibiotic is used alone. Two in vivo studies were carried out to assess the ability of the same therapeutic combination to inhibit the growth of pre‐existing erythromycin‐resistant propionibacteria and to prevent the selection of resistant strains during treatment. A double‐blind clinical trial in 37 patients with mild to moderate acne vulgaris showed that the combination brought about a > 3 log10 c.f.u. reduction in total propionibacterial numbers/cm2 after 6 weeks therapy (P < 0.001, Wilcoxons matched pairs) and also significantly reduced the number of erythromycin‐resistant propionibacteria (P < 0.05). In contrast, erythromycin alone reduced the total propionibacterial count by < 1.5 log10 c.f.u./cm2 after 6 weeks (P < 0.05) and did not affect the number of erythromycin‐resistant strains. The combined formulation was significantly more effective at reducing total propionibacterial numbers at 6 (P < 0.01, Mann‐Whitney) and 12 weeks (P < 0.05) than erythromycin alone, although, after 12 weeks, the anti‐propionibacterial efficacy of both preparations was less marked. Five patients on combination therapy, and five treated with erythromycin alone, acquired erythromycin‐resistant strains de novo at week 6 or week 12. In an open study in 21 acne patients, who each carried > 103 c.f.u. erythromycin‐resistant propionibacteria/cm2 skin pretreatment, the combination of erythromycin and benzoyl peroxide reduced the total propionibacterial count by > 2.5 log10 and the number of erythromycin‐resistant strains by a similar amount (P < 0.001, Wilcoxon). This was accompanied by highly significant reductions in acne grade and lesion counts (P < 0.001). These data suggest that the combination of 5% w/w benzoyl peroxide and 3% w/w erythromycin has greater in vivo antipropionibacterial activity than 3% w/w erythromycin alone, and brings about significant clinical improvement in acne patients with high numbers of erythromycin‐resistant propionibacterial strains pretreatment.

A randomized, double-blind comparison of a clindamycin phosphate/benzoyl peroxide gel formulation and a matching clindamycin gel with respect to microbiologic activity and clinical efficacy in the topical treatment of acne vulgaris

BACKGROUND One approach to suppressing the overgrowth of antibiotic-resistant bacteria is to develop combination products composed of active constituents with complementary but distinct mechanisms of antibacterial action. OBJECTIVE The purpose of this study was to compare the antimicrobial and clinical efficacy and tolerability of clindamycin phosphate 1%/benzoyl peroxide 5% gel formulation with matching clindamycin 1% gel in the treatment of acne vulgaris. METHODS This 16-week, single-center, double-blind, randomized, parallel-group study compared the combination gel with clindamycin monotherapy applied BID in patients 13 to 30 years of age with mild to moderate acne and facial Propionibacterium acnes counts > or = 10(4) colony-forming units per square centimeter of skin. RESULTS Seventy-nine patients were enrolled and randomly assigned to receive the combination gel (n = 40) or clindamycin monotherapy (n = 39). Seventy patients (50 males, 20 females; mean age, 18.2 years) were included in the intent-to-treat group. The combination gel treatment produced significantly greater reductions (P < or = 0.046) from baseline in total lesion counts and in numbers of inflammatory lesions and comedones compared with clindamycin monotherapy. Greater reductions in the severity of acne also were observed in the physicians and patients Clinical Global Improvement scale scores and in other secondary efficacy measurements. Reductions in clindamycin-resistant P acnes counts were observed relative to baseline in the combination gel group; in contrast, P acnes counts increased by >1,600% in the clindamycin monotherapy group at week 16 (P = 0.018 vs combination gel). Reductions in inflammatory (r2 = 0.31; P = 0.016) and total (r2 = 0.28; P = 0.027) lesions were correlated with decreases in clindamycin-resistant bacteria. Also, significant correlations were observed between the percent change from baseline in total lesion counts (r2 = 0.44; P < 0.001) and comedo counts (r2 = 0.50; P < 0.001) and the log10 change from baseline in total P acnes counts. CONCLUSIONS The total P acnes count (P = 0.002) and the clindamycin-resistant P acnes count (P = 0.018) were significantly reduced after 16 weeks of treatment with combination gel compared with clindamycin monotherapy. These reductions in total P acnes and clindamycin-resistant P acnes counts correlated with reductions in total acne lesions.

Inhibition of erythromycin‐resistant propionibacteria on the skin of acne patients by topical erythromycin with and without zinc

Summary Propionibacteria resistant to high concentrations of erythromycin [minimal inhibitory concentration (MIC)≥0·5 mg/ml) are now commonly isolated from the skin of antibiotic‐treated acne patients. This double‐blind study was carried out to assess the ability of 4% w·v erythromycin with and without 1–2% w/v nine acetate to reduce the numbers of erythromycin‐resistant propionibacteria in vivo, and also to monitor the acquisition of resistant strains de novo during therapy. Under laboratory conditions, erythromycin‐resistant propionibacteria were shown to be as sensitive to zinc acetate as fully sensitive strains. In vivo, the erythromycin/zinc complex and erythromycin alone produced highly significant reductions in total propionibacteria (P<0·01) and in the number of erythromycin‐resistant strains (P<0·01 at 8 weeks). After 12 weeks, resistant propionibacteria were re‐acquired, or acquired de novo. by three patients treated with erythromycin alone and four patients treated with the erythromycin/zinc complex. In contrast, changes in numbers of Micrococcaceae were slight and. after 12 weeks, erythromycin‐resistant strains were predominant in both treatment groups. In vitro MIC determinations suggested that this finding might be explained by the exceptionally high degree of erythromycin resistance displayed by some staphylococcal strains (MIC>4 mg/ml) and by the relative insensitivity of all staphylococcal strains to zinc acetate. Krythromycin with and without zinc was clinically effective, and both preparations produced significant reductions in acne grade, and inflamed and non‐inflamed lesion counts (F<0·001). In particular, 11 of 12 patients who harboured >103 c.f.u. erythromycin‐resistant propionibacteria/cm2 skin pretreatment (seven on the erythromycin/zinc complex and five on erythromycin alone) showed clinical improvement, with a>50% reduction in acne grade and/or lesion count. These results show that topical 4% w/v erythromycin with and without zinc eradicates erythromycin‐resistant propionibac‐teria in vivo, and is thus therapeutlcally effective in patients who harbour such strains.

Differential innate immune responses of a living skin equivalent model colonized by staphylococcus epidermidis or staphylococcus aureus

Staphylococcus epidermidis is a commensal on skin, whereas Staphylococcus aureus is a transient pathogen. The aim was to determine whether the skins innate defence systems responded differently to these microorganisms. Differential gene expression of a human skin equivalent (SE) model was assessed by microarray technology, in response to colonization by S. epidermidis or S. aureus. Only a small number of transcripts were significantly (P<0.0001) increased (12) or decreased (35) with gene expression changes of >2-fold on SEs colonized with S. epidermidis compared with controls (no colonization). Expression of one innate defence gene, pentraxin 3 (PTX3), was upregulated, while psoriasin, S100A12, S100A15, beta defensin 4, beta defensin 3, lipocalin 2 and peptidoglycan recognition protein 2 were downregulated. In contrast, large numbers of transcripts were significantly increased (480) or decreased (397) with gene expression changes of >2-fold on SEs colonized with S. aureus compared with controls. There was upregulation in gene expression of many skin defence factors including Toll-like receptor 2, beta defensin 4, properdin, PTX3, proinflammatory cytokines tumour necrosis factor-alpha, IL-1 alpha, IL-1 beta, IL-17C, IL-20, IL-23A and chemokines IL-8, CCL4, CCL5, CCL20 and CCL27. These differences may partly explain why S. epidermidis is a normal skin resident and S. aureus is not.

Cosmetics: what is their influence on the skin microflora?

Human skin has a resident, transient and temporary resident microflora. This article considers the possibilities of topical products influencing the balance of the microflora. The resident micro-organisms are in a dynamic equilibrium with the host tissue and the microflora may be considered an integral component of the normal human skin. The great majority of these micro-organisms are gram-positive and reside on the skin surface and in the follicles. The host has a variety of structures, molecules and mechanisms which restrict the transient and temporary residents, as well as controlling the population and dominance of the resident group. These include local skin anatomy, hydration, nutrients and inhibitors of various types. The resident microflora is beneficial in occupying a niche and denying its access to transients, which may be harmful and infectious. Also, the residents are important in modifying the immune system. In the healthy host the microflora causes few and temporary problems. Therefore, it is of interest that topical products have little or no effect on the ecology of the microflora. A range of mechanisms by which long-term use of cosmetics may influence the microflora are considered. Although the risks associated are low, it is argued that it is necessary to monitor these changes in ecology and use technologies of modeling and bioinformatics to predict outcomes, whether good, neutral or of concern.

Propionibacterium acnes and acne.

Acne is a multifactoral disease which is restricted to man and usually presents during and immediately after puberty [1, 2]. The disease is localized to skin regions such as the face, back and chest, with a high number of sebaceous follicles [1, 2] and the condition has been associated with a high sebum excretion rate (SER) [1, 2]. The disease in its various forms and severity is treatable utilizing a range of topical and systemic drugs [1]. The use of cis-retinoic acid to successfully manage severe cases of acne has greatly affected research into the cause of acne and the mechanisms which lead to non-inflamed and inflamed lesions. However, important questions remain unanswered: what causes the variety of the distribution of lesions in patients? what factors are involved in the initiation of inflammation? is Propionibacterium acnes involved in the initiation process? and what mechanisms are involved in the natural regression of the disease in the majority of patients when they reach their mid-twenties? This communication proposes hypotheses, which place P. acnes as an important contributing factor in acne, and it is intended that the hypotheses should provoke increased experimental activity to answer the questions previously listed.

In vitro modulation of human keratinocyte pro- and anti-inflammatory cytokine production by the capsule of Malassezia species

Malassezia spp. are commensal, cutaneous fungi that are implicated in seborrhoeic dermatitis. We hypothesize that the lipid-rich capsule of Malassezia spp. masks the organism from host detection, and depletion of this layer elicits an inflammatory response. To test this, preparations of capsulated or acapsular [10% (v/v) Triton X-100 treated], viable and nonviable, exponential or stationary phase Malassezia furfur, Malassezia globosa, Malassezia obtusa, Malassezia restricta, Malassezia slooffiae and Malassezia sympodialis, were incubated with normal human keratinocytes. Proinflammatory (IL-6, IL-8, IL-1alpha and tumour necrosis factor-alpha) and anti-inflammatory cytokine (IL-10) release and intracellular IL-10 concentrations were quantified using enzyme-linked immunosorbent assays. Capsulated Malassezia yeasts stimulated limited or no production of inflammatory cytokines, and increased intracellular IL-10 (P < 0.05). Removal of the capsule of many Malassezia preparations caused a significantly increased production of IL-6, IL-8 and IL-1alpha, and a decrease in intracellular IL-10. Notably, acapsular viable, stationary phase M. globosa caused a 66-fold increase in IL-8 production (P < 0.001) and acapsular nonviable, stationary phase M. furfur caused a 38-fold increase in IL-6 production (P < 0.001) and a 12-fold decrease in intracellular IL-10 (P < 0.001). These results support the hypothesis that the lipid layer of Malassezia spp. modulates cytokine production by keratinocytes. This has implications in the pathogenesis of seborrhoeic dermatitis.

Genome Sequence and Analysis of a Propionibacterium acnes Bacteriophage

Cutaneous propionibacteria are important commensals of human skin and are implicated in a wide range of opportunistic infections. Propionibacterium acnes is also associated with inflammatory acne vulgaris. Bacteriophage PA6 is the first phage of P. acnes to be sequenced and demonstrates a high degree of similarity to many mycobacteriophages both morphologically and genetically. PA6 possesses an icosahedreal head and long noncontractile tail characteristic of the Siphoviridae. The overall genome organization of PA6 resembled that of the temperate mycobacteriophages, although the genome was much smaller, 29,739 bp (48 predicted genes), compared to, for example, 50,550 bp (86 predicted genes) for the Bxb1 genome. PA6 infected only P. acnes and produced clear plaques with turbid centers, but it lacked any obvious genes for lysogeny. The host range of PA6 was restricted to P. acnes, but the phage was able to infect and lyse all P. acnes isolates tested. Sequencing of the PA6 genome makes an important contribution to the study of phage evolution and propionibacterial genetics.

Microbiological effect of photodynamic therapy (PDT) in healthy volunteers: a comparative study using methyl aminolaevulinate and hexyl aminolaevulinate cream

Background.  Acne vulgaris is a common skin problem that affects up to 90% of adolescents. Colonization of the duct with Propionibacterium species is one of the factors implicated in the development of acne. Owing to the increasing incidence of antibiotic resistance, there has been an greater interest in the development of new methods to treat acne. Early studies have shown that photodynamic therapy (PDT) with aminolaevulinic acid (ALA) can lead to prolonged improvement in acne. Newer derivatives of ALA such as methyl aminolaevulinate hydrochloride (MAL) and hexyl aminolaevulinate hydrochloride (HAL) have been developed for use in PDT, with the potential benefits of higher lipophilicity and penetration potential.

Follicular concentrations of azelaic acid after a single topical application

Follicular concentrations of azelaic acid (AzA) were determined in vivo using a rapid, non‐invasive method, after a single topical application of 20% (w/w) AzA cream, in order to establish whether the in vitro antimicrobial effects observed in previous studies are relevant in vivo. Preweighed amounts of 20% (w/w) AzA cream were applied over demarcated areas on the forehead and back of nine young adults, and samples were taken over a period of 5 h. AzA was removed from the skin surface by washing with acetone, and follicular casts were collected using cyanacrylate gel. The samples were centrifuged to remove particulate matter, and the supernatants derivatized for analysis by HPLC. Although the results showed wide‐ranging variability, the follicular concentration increased as the amount present on the surface declined. The maximum follicular concentrations of AzA attained ranged from 7.5 to 52.5 ng (μg of follicular casts)−1 and 0–5 to 23–4 ng (μg of follicular casts)−1 in samples taken from the back and forehead, respectively. Assuming an average density of follicular material of 0.9 g ml−1, the mean maximum follicular concentration attained on the back was between 36 and 251 mmol/l, and on the forehead was between 2 and 112 mmol/l, and indicates that the concentration of AzA attained in follicular casts after a single topical application is comparable with the concentration required to inhibit the growth of Propionibacterium acnes and Staphylococcus epidermidis, in vitro.