Sarker 1

The Microbiology of Acne Avik Sarker Dr. Porter Microbiology 201H

Sarker 2 Within and on the human body, microorganisms in the range of hundreds of trillions take residence, which is collectively called the human microbiome. Bacteria of an unfathomable diversity inhabit sites such as the mouth, nose, intestinal lining, and skin, as well as others. Only recently has the gravity of its importance and the lack of understanding been realized; projects such as the National Institute of Healths Human Microbiome Project, launched in 2008, seek to rectify understanding of the relationship between the body and the microorganisms that cover it (19). One such region of the human body where much research is being and has been done over the years is sebaceous skin, where a prevalent disease, acne, still remains to be understood and fully treated. Acne affects 40 to 50 million Americans, making it one of the most common skin diseases encountered. Also known as acne vulgaris, it is defined as a skin condition characterized by blemishing, pimples, zits, whiteheads, blackheads, cysts, and nodules that occurs most commonly, but is not limited to, the upper body (2). These lesions cause discomfort in the affected and, if not treated properly, can cause scarring (1). Acne affects nearly 85 percent of all people at one point in their lives, but it occurs most commonly and prominently with adolescents. By the mid-teen years, greater than 40 percent of adolescents experience some sort of acne or scarring from acne-related causes (2). Because of the large section of the population that is affected by this skin condition, much research has been put into understanding the details of how and why acne forms at the microbial and molecular level. Pathophysiologically, acne arises from the formation of a plug within the numerous pilosebaceous units of the upper body, where acne commonly occurs. These pilosebaceous units comprise of a fine hair follicle surrounded by and connected with sebaceous glands,

Sarker 3 which contain specialized cells that release an oily fluid called sebum. This triglyceride-rich fluid travels to through the follicular canal out of the pores to the skin where it normally functions as a lubricant for the skin. However, this sebum may combine with the hair and skin cells to produce a plug, called a microcomedo. During puberty, the creation of excess sebum is in response to hormonal changes, which increases the possibility of microcomedo formation. This blockage of the follicular canal leads to the variety of lesions mentioned earlier, of which the most severe is a cyst, where a painful sac of pus forms that has the possibility of causing scar formation (16). It is important to note that the term acne rosacea is not related to the condition acne vulgaris, despite the similarity in appearance. Studies show that despite its similar appearance of redness and lesions appearing on similar locations on the body, acne rosacea is not associated with the same causes as acne vulgaris, specifically with the absence of action by Propionibacterium acnes in rosacea (9). Microbially speaking, skin contains a wide flora of bacteria inhabiting it. Members from the genera Actinobacteria, Firmicutes, Proteobacteria, and Bacteroidetes have all been found on skin, but in varying proportions depending on the location of the skin. Within sebaceous skin, one bacterium in particular, Propionibacterium acnes, has been found to dominate the microbial space (12). Other species of Propionibacterium and Staphylococcus epidermidis are also found in these areas. P. acnes in particular is found deep within the pores of the pilosebaceous units, especially in teenagers when they undergo puberty (14). The dominant nature of P. acnes within the microbiome of sebaceous skin makes it a primary focus of study concerning the nature of acne.

Sarker 4 P. acnes is a rod-shaped Gram-positive bacteria, belonging to the phylum Actinobacteria (15). It is a non-sporulating, slow growing, aerotolerant anaerobic bacteria that produce propionic acid as a product of fermentation, as its name would suggest. It is a resilient bacterium that has the ability to resist phagocytosis through the use of its complex, fibrous outer cell wall. Through the use of this cell wall, P. acnes are also able to survive phagocytosis, having been found to persist within macrophages. It has also been found to persist within completely anaerobic conditions without culture, further exemplifying its resilience and its ability to colonize such anaerobic conditions within the epidermis. This bacterium thrives with the follicle through the use of lipases that breaks down the sebum produced by the body (14). This is thought to help to aggravate the surrounding tissue through inflammatory responses, as will be discussed later. Besides its presence on the skin, P. acnes is also found in other areas of the body such as the oral cavity, the colon, and the inner lining of the eyelid, the conjunctiva. Within these situations other than the skin, P. acnes is known to cause infection, such as conjunctivitis (4). Concerns are especially higher for surgical procedures such as implantation of valves, joint replacements, and catheterization (6). P. acnes has been shown to be able to form biofilms on these biomaterials with increased antibiotic resistance, presenting a problem for doctors and their patients in the clinical setting (17). The etiology of acne, or the genesis of the symptoms associated with the disease, is not well characterized. However, several studies point to the role of P. acnes as encouraging a pro-inflammatory response. It has been found by researchers in Japan in 2009 that P. acnes plays a role in the increased lipogenesis of the sebaceous glands. Through inoculation of golden hamsters with disabled forms of P. acnes, these researchers observed

Sarker 5 increased accumulation of sebum within the hamster sebum ducts in the skin (8). Furthermore, a British study found that P. acnes induces a pathway within the epidermis related to the inflammatory response, through Toll-like receptors. These researchers found that acne-prone epidermal layers expressed higher level of Toll-like receptors when compared to that of the control. When in the presence of P. acnes, more signaling molecules called cytokines were present, helping to signal this pathway to activation (10). To help further confirm P. acnes role within the progression of acne vulgaris, a study done in Denmark in 2008 was done to show that acne was not caused by some other bacterium or microorganism that had not been cultured yet. Through the use of 16S rRNA analysis of samples of skin from acne patients, these scientists were able to find that the samples consisted of greater than 98 percent known species, with P. acnes, S. epidermidis, and P. granulosum comprising more than 95 percent of the flora. Despite having found a few uncultured bacteria within specific acne-affected patients, these bacteria were not omnipresent amongst all of the acne-affected patients. Additionally, they found specifically that P. acnes was the only bacteria colonizing the inside of the sebaceous gland, further helping to confirm the association between this bacteria and the condition (3). Perhaps most significant is the release of multi-institutional study in 2013 that finds the association between different strains of P. acnes and the prevalence of acne. The study compares the microbial diversity of the skin of healthy patients and acne-affected patients through the use of 16S rDNA sequencing. The researchers classified each unique 16S rDNA strand as a ribotype, which they used as a basis for comparison between the various microbiomes. They also classified population structures as different types of microbiomes,

Sarker 6 from types I to V. After compiling a comparison between the two types of patients, the researchers found that specific ribotypes and microbiome types were associated differently between the types of patients. In particular, they found that ribotypes 4 and 5 (associated with microbiome types 4 and 5) were mostly prevalent in acne patients but not in healthy patients. Conversely, they found ribotype 6 to associated with healthy patients but almost absent in acne prone patients. The researchers further found through specific loci comparison that the genome of ribotypes 4 and 5 were quite distinct from the others due to the presence of extra DNA within the chromosome and due to the presence of homologous plasmids between acne-associated strains (5). These findings come as significant as they drive the possibility further understanding of role of P. acnes within the microbiome of the skin. These findings may also drive further research into a finding an alternative treatment to the problem of acne with regards to restoring a microbial balance. Regarding treatment for acne vulgaris, acne is typically treated with a variety of topical antimicrobials and antibiotics. Compounds such as clindamycin, erythromycin, tetracycline, and benzoyl peroxide are used with high frequency. When tested clinically on patients, a mixture of clindamycin 1 percent and benzoyl peroxide 5 percent had a 66 percent success rate. These compounds are typically given together as using multiple antimicrobials were found to be more successful in treating the disease. When used separately, only 41 percent of the patients in the benzoyl peroxide group and 36 percent of the clindamycin group saw improvements as compared to the 66 percent that saw success when used together. With regards to oral vaccines, erythromycin, clindamycin, tetracyclines, and minocyclines have been shown to reduce swelling with moderate effectiveness. However, these compounds are typically reserved for the most severe cases

Sarker 7 of acne vulgaris as to prevent the formation of antibiotic resistant strains of bacteria. These topical and oral antibiotics are thought to inhibit the ability of the bacteria to induce the formation of cytokines that are involved in the immune inflammatory response (7). Other non-prescription products such as salicylic acid and sulfur based facial cleansers are typically bought as over the counter medicines (18). However, these topical products have all had their criticisms as they have a tendency to cause dryness, burning, and peeling of the skin (7). The costs have added up, however; in 2004, $2.2 billion was spent in the United States for over-the-counter and prescription products (2). Additional compounds called retinoids, first used in the 1970s, have been shown to be effective against treating acne. Commonly used retinoid compounds include tretinoin, adapalene, and tazarotene. These compounds are derived from Vitamin A and help to regulate the desquamation of epithelial cells. Tretinoin has been considered to be a successful treatment, improving the conditions of 53 percent of patients when used in a 0.05 percent gel. These compounds are also subject to the criticism that they cause dryness and peeling of the skin, however. A similar compound, called isotretinoin, has been shown to be effective when used in high dosages with success rates upwards of 89 percent. Being also derived from Vitamin A, isotretinoin also suffers from similar limitations - it causes dry skin and peeling as a side effect. However, the compound has also been found to have numerous adverse effects. Early after its initial usage, isotretinoin was found to be a teratogena compound that greatly increases the chances of birth mutations. Forty percent of exposed infants were found to have mutations within the first trimester, which restricts this drugs usage to people who are not pregnant. It is still used as a treatment mainly for the most severe cases of cystic acne (7).

Sarker 8 The treatments overviewed up to this point include agents that have been in use for quite some time. As seen, they have varying success rates; without full understanding of the etiology of acne, not all cases of acne can be treated with the same efficacy. Within the past couple of years, however, different research groups have developed experimental evidence that gives rise to the possibility of other forms of treatment. A paper published in 2013 in the Biological and Pharmacological Bulletin of The Pharmaceutical Society of Japan describes a purported method of infusing nanoparticle carriers with both tretinoin and tetracycline. By doing this, the researchers hoped to increase absorption of the drug within the skin. They found that through this technique, tetracycline was able to permeate epithelia in vitro with better efficacy, but tretinoin absorption was unchanged or lessened (11). This technique of enhancing absorption of an existing drug is one method of furthering drug treatment, although there is further research to do with this specific method. There is other research being done to target P. acnes as a possible way to reduce inflammation. In a multi-institutional article published in mBio in 2012, researchers explored the genetic diversity of bacteriophages that infect P. acnes and their ability to kill it. These researchers found that such bacteriophages display little genetic diversity, yet also display the ability to kill a wide variety of P. acnes through lysis and without great ability to form lysogensthat is, become dormant with the host DNA. This lends itself to the possibility as part of a topical bacteriophage therapy, although there are concerns about the development of resistance among the bacteria (13). Perhaps with the information from the newer article from 2013 describing the prevalence of specific strains among healthy individuals killing all types of P. acnes may not necessarily be desired (7).

Sarker 9 With acne being the most common skin condition, it is crucial that its genesis, causes, and pathology be fully understood in order to treat it. Through recent research of P. acnes, its importance in the proliferation of acne vulgaris has become more understood, but more research is required for understanding the exact causes in the beginning stages of acne. A variety of treatments exist today, but only with limited success due to the lack of understanding of the microbiome. Through future research, development of treatments with the microbiome in mind will become key in fighting the teenage nightmare.

Sarker 10 Literature Cited 1. "Acne Vulgaris - Topic Overview." WebMD. WebMD, 3 Feb. 2011. Web. 15 Apr. 2013. 2. "Acne." American Academy of Dermatology. American Academy of Dermatology, 2005. Web. 2 Apr. 2013. 3. Bek-Thomsen, Malene, Hans Bredsted Lomholt, and Mogens Kilian. Acne is not associated with yet-uncultured bacteria. Journal of Clinical Microbiology 46.10 (2008): 3355-3360. Web. 2 Apr. 2013. 4. Brggemann, H. "66 Skin: Acne and Propionibacterium acnes Genomics." (2010). Web. 2 Apr. 2013. 5. Fitz-Gibbon, Sorel, Shuta Tomida, Bor-Han Chiu, Lin Nguyen, Christine Du, Minghsun Liu, David Elashoff, Marie C Erfe, Anya Loncaric, Jenny Kim, Robert L Modlin, Jeff F Miller, Erica Sodergren, Noah Craft, George M Weinstock and Huiying Li. Propionibacterium acnes Strain Populations in the Human Skin Microbiome Associated with Acne. Journal of Investigative Dermatology 2013.21 (2013). Nature Publishing Group. 28 Feb. 2013. Web. 2 Apr. 2013. 6. Grice, Elizabeth A. and Julia A. Segre. "The skin microbiome." Nature Reviews Microbiology 9.4 (2011): 244-253. Web. 2 Apr. 2013. 7. Haider, Aamir, and James C. Shaw. Treatment of Acne Vulgaris. Journal of the American Medical Association 292.6 (2004): 726-735. Web. 2 Apr. 2013. 8. Iinuma, Katsuhiro, Takashi Sato, Noriko Akimoto, Norihisa Noguchi, Masanori Sasatsu, Setsuko Nishijima, Ichiro Kurokawa and Akira Ito. Involvement of Propionibacterium acnes in the Augmentation of Lipogenesis in Hamster

Sarker 11 Sebaceous Glands In Vivo and In Vitro. Journal of Investigative Dermatology 129 (2009): 21132119. Nature Publishing Group. 12 Mar. 2009. Web. 2 Apr. 2013 9. Jahns, Anika C, Lundskog B, Dahlberg I, Curiche Tamayo N, McDowell A, Patrick S and Alexeyev OA. No link between rosacea and Propionibacterium acnes. APIMS 120.11 (2012): 922-925. Web. 2 Apr. 2013. 10. Jugeau, S., Tenaud, I., Knol, A.C., Jarrousse, V., Quereux, G., Khammari, A. and Dreno, B. Induction of toll like receptors by Propionibacterium acnes. British Journal of Dermatology 153.6 (2005): 1105-1113. Web. Apr. 2 2013. 11. Lin, Chih-Hung, Lin, Chih-Hung, Yi-Ping Fang, Saleh Abdulah Al-Suwayeh, S. Y. Yang, and J. Y. Fang. "Percutaneous absorption and antibacterial activities of lipid nanocarriers loaded with dual drugs for acne treatment." Biological & pharmaceutical bulletin 36.2 (2012): 276-286. Web. 2 Apr. 2013. 12. Madigan, Michael T. Brock Biology of Microorganisms. Boston: Pearson, 2012. Print. 13. Marinelli, Laura J., Sorel Fitz-Gibbon, Clarmyra Hayes, Charles Bowman, Megan Inkeles, Anya Loncaric, Daniel A. Russell, Deborah Jacobs-Sera, Shawn Cokus, Matteo Pellegrini, Jenny Kimb, Jeff F. Miller, Graham F. Hatfull, and Robert L. Modlina. "Propionibacterium acnes Bacteriophages Display Limited Genetic Diversity and Broad Killing Activity against Bacterial Skin Isolates." MBio 3.5 (2012). Web. 2 Apr. 2013. 14. Perry, A. L., and Peter A. Lambert. "Propionibacterium acnes." Letters in applied microbiology 42.3 (2006): 185-188. Web. 2 Apr. 2013. 15. "Propionibacterium Acnes." U.S. National Library of Medicine. U.S. National Library of Medicine, 2011. Web. 2 Apr. 2013.

Sarker 12 16. "Questions and Answers About Acne." National Institute of Arthritis and Musculoskeletal and Skin Diseases. National Institute of Arthritis and Musculoskeletal and Skin Diseases, Oct. 2012. Web. 2 Apr. 2013. 17. Ramage, Gordon Michael M. Tunney, Sheila Patrick, Sean P. Gorman, and James R. Nixon. "Formation of Propionibacterium acnes Biofilms on Orthopaedic Biomaterials and their Susceptibility to Antimicrobials." Biomaterials 24.19 (2003): 3221-3227. Web. 2 Apr. 2013. 18. Terrie, Yvette C. "Acne: Causes, Prevention and Treatment." US News. U.S. News & World Report, 06 Apr. 2013. Web. 06 Apr. 2013. 19. Zimmer, Carl. "Tending the Body's Microbial Garden." The New York Times. The New York Times, 19 June 2012. Web. 23 Mar. 2013.