Staphylococcus epidermidis: A Potential New Player in the Physiopathology of Acne?

BACKGROUND: Cutibacterium acnes has been identified as one of the main triggers of acne. However, increasing knowledge of the human skin microbiome raises questions about the role of other skin commensals, such as Staphylococcus epidermidis, in the physiopathology of this skin disease. SUMMARY: This review provides an overview of current knowledge of the potential role of S. epidermidis in the physiopathology of acne. Recent research indicates that acne might be the result of an unbalanced equilibrium between C. acnes and S. epidermidis,according to dedicated interactions. Current treatments act on C. acnesonly. Other treatment options may be considered, such as probiotics derived from S. epidermidis to restore the naturally balanced microbiota or through targeting the regulation of the host's AMP mediators. Key Messages: Research seems to confirm the beneficial role of S. epidermidis in acne by limiting C. acnes over-colonisation and inflammation.

Intrinsic Defect in Keratinocyte Function Leads to Inflammation in Hidradenitis Suppurativa.

Hidradenitis suppurativa (HS) is a chronic, inflammatory, debilitating, follicular disease of the skin. Despite a high prevalence in the general population, the physiopathology of HS remains poorly understood. The use of antibiotics and immunosuppressive agents for therapy suggests a deregulated immune response to microflora. Using cellular and gene expression analyses, we found an increased number of infiltrating CD4(+) T cells secreting IL-17 and IFN-γ in perilesional and lesional skin of patients with HS. By contrast, IL-22-secreting CD4(+) T cells are not enriched in HS lesions contrasting with increased number of those cells in the blood of patients with HS. We showed that keratinocytes isolated from hair follicles of patients with HS secreted significantly more IL-1ß, IP-10, and chemokine (C-C motif) ligand 5 (RANTES) either constitutively or on pattern recognition receptor stimulations. In addition, they displayed a distinct pattern of antimicrobial peptide production. These findings point out a functional defect of keratinocytes in HS leading to a balance prone to inflammatory responses. This is likely to favor a permissive environment for bacterial infections and chronic inflammation characterizing clinical outcomes in patients with HS.

Identification of three hidradenitis suppurativa phenotypes: latent class analysis of a cross-sectional study.

To identify the underlying subtypes of hidradenitis suppurativa (HS), we performed latent class analysis on prospective clinical data of 618 consecutive patients seen between 2002 and 2010. The median patient age was 31 years (Q1=26; Q3=38), median age at HS onset was 20 years (16-25), and median Sartorius score was 18 (11-19); 34.4% of patients were of Hurley stage II or III. A three-class model showed the best fit. Latent class 1 (LC1) patients (48%) had a high probability of breast and armpit lesions (0.74) and hypertrophic scars (0.41). LC2 patients (26%) had a high probability not only of breast and armpit lesions (0.96) but also of lesions in the ears, chest, back, or legs (0.55); follicular lesions (pilonidal sinus: 0.48; comedones: 0.74); severe acne (0.47); and a family history of HS (0.44). Compared with LC1 patients, LC2 patients were more often male (odds ratio, 4.6; 95% confidence interval, 3-7; P<0.001) and current smokers (2.2; 1.3-3.9; P=0.005), and had greater disease severity (odds ratio, 1.6; 1.3-1.9; P<0.001). LC3 was characterized by gluteal involvement (0.54), papules, and folliculitis (0.71). LC3 patients were less often obese (0.6; 0.3-0.95; P=0.03) and had less severe disease (0.9; 0.7-1.1; P<0.001). These three phenotypes ("axillary-mammary", "follicular", and "gluteal") may help stratify patients for clinical trials.

Differential diagnosis of facial acne on black skin.

The diagnosis of acne is usually easy, but there are some pitfalls to be avoided. 'Keloid acne of the neck' and beard folliculitis are not acnes in the usual sense: both are inflammatory and fibrous reactions of the hair follicles and frizzy hair; no retentional lesions, blackheads and microcysts--are visible. Gram negative folliculitis classically occurs in acneic male subjects who have undergone extensive treatment with general antibiotics or local antiseptics, but 'de novo' cases do exist. On black skin, this condition is not exceptional, it occurs in both sexes and usually takes the nodular form. The diagnosis should be considered if there is any aggravation of acne which is resistant to classic treatment, with painful nodules on the cheeks. Treatment is based on appropriate antibiotherapy for several weeks and possibly, in a second phase, on Isotretinoin. Pityrosporum folliculitis occurs mainly on the trunk. More frequent in men than in women, it is chiefly observed in subjects living in a hot, humid climate. Demodicidosis is manifested by outbreaks of papular or papulopustular lesions of the face. On black skin the principal differential diagnosis is acne. The presence of numerous parasites is necessary for diagnosis. Clinically speaking, an important sign is when the eyelids are affected. Ivermectin is effective. Acneiform dermatitis may be induced by depigmenting preparations containing powerful dermocorticoids. It is therefore important, in cases of very inflammatory acne, to look for the other clinical signs of voluntary depigmentation. In countries where it is endemic, lepromatous leprosy should be considered. Other common dermatitis may simulate acne or else be associated with it, such as eruptive hidradenoma or molluscum contagiosum. Analysis of the different elementary lesions and the absence of retentional lesions generally enable a diagnosis to be established.

Acne as seen by adolescents: results of questionnaire study in 852 French individuals.

Acne can have an important psychological impact. We surveyed 852 adolescents aged 12-25 years about their knowledge of acne and its treatment in a non-medical context. The study involved a questionnaire administered to callers to a youth telephone helpline in France. Callers were categorized into those who currently had acne, those who had had acne previously, and those who had never had acne. Most respondents (66.2%) had experienced acne symptoms, which were mild in 50.2% of cases and severe in 16% of cases. Often, acne had been long-lasting (>12 months in 49.6% of cases). Many thought that gender, excess weight, eating dairy products, and physical activity did not influence acne, and that frequent washing could improve acne. Eating chocolate and snacks, smoking cigarettes, sweating, not washing, touching/squeezing spots, eating fatty foods, using make-up, pollution, and menstruation were thought to worsen acne. The majority (80.8%) did not believe acne to be a disease, but rather a normal phase of adolescence, yet 69.3% agreed it should be treated. There was a preference for topical vs. systemic treatment. Many (38.6%) of the respondents with acne had not consulted a physician. Almost two-thirds of respondents wanted more information about acne. Providing more information about acne might increase the likelihood of them consulting a physician and getting better treatment for the condition.

Pharmacological properties of Myrtacine® and its potential value in acne treatment.

This study aimed at evaluating the antiproliferative, antibacterial, and anti-inflammatory properties of an ethanolic myrtle extract (Myrtacine®) in vitro, characterising its potential active compounds (myrtucommulones A and B') by structural analysis, and evaluating their biological activity. Antiproliferative activity was assessed by the BrdU incorporation assay in HaCat keratinocytes and inhibitory and bactericidal activities against P. ACNES strains by measuring the minimal inhibitory concentration (MIC) and D value. Anti-inflammatory effect was evaluated by measuring 6-keto-prostaglandin F1 α and [³H]-arachidonic acid metabolite production in keratinocytes stimulated for inflammation. Myrtacine® inhibited keratinocyte proliferation by 27 % and 76 % at 1 and 3 µg/mL, respectively (p < 0.001). A comparable effect, though less marked, was observed with 5 µg/mL myrtucommulones A and B' (-36 % and -28 %, respectively). Myrtacine® inhibited erythromycin-sensible and -resistant P. ACNES strains growth with MICs of 4.9 µg/mL and 2.4 µg/mL, respectively. Myrtucommulone B' and myrtucommulone A displayed a similar inhibitory activity against both strains (for both strains, MIC = 1.2 µg/mL and about 0.5 µg/mL, respectively). At 3 and 10 µg/mL, Myrtacine® significantly decreased all metabolite production from cyclooxygenase (81 % and 107 %, p < 0.0001) and lipoxygenase (52 % and 95 %, p < 0.001) pathways. Finally, Myrtacine® exhibited a concentration-dependent anti-lipase activity at 100 µg/mL and 1 mg/mL, as it decreased lipase activity by respectively 53 % and 100 % (p < 0.01 for both). In conclusion, in vitro, Myrtacine® demonstrated antiproliferative, antibacterial, and anti-inflammatory properties that may be of value to exert a global action in the treatment of acne lesions.

Back and face involvement in hidradenitis suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) may be associated with face and back lesions which are considered as acne. OBJECTIVE: To describe the skin lesions of a group of patients with HS. METHODS: Twelve patients were selected from a series of 648 patients on the basis of their specific skin lesions. RESULTS: The patients (mostly male) had typical hidradenitis. On their face or back they had one or several of the following skin lesions which are not seen in acne: hypertrophic rope-like bridged scars, raised plaques with multiple carbuncle-like openings or with ulcerations, 'worm-eaten scars' and coalescent nodules with round ulcerations. All patients had deep round scars. Several had a pilonidal cyst or large epidermal cysts. Isotretinoin had been used by 7 patients with no effect. CONCLUSION: Some HS patients have specific lesions of the face and back which are not acne and have to be treated differently.

Factors influencing the clinical evaluation of facial acne.

Existing scoring systems for facial acne focus on the lesions themselves, but clinical decisions are based on a general assessment of severity, including the time since onset, the site(s) of involvement, the patient's history, and the response to prior treatments. The aim of this study was to investigate the influence of some of these factors on the global assessment of acne severity. Involvement of the trunk, prior systemic treatment and a positive family history of acne increased the severity score. Inclusion of these factors could help to compose more homogeneous groups for clinical trials.

Clinical characteristics of a series of 302 French patients with hidradenitis suppurativa, with an analysis of factors associated with disease severity.

BACKGROUND: Factors associated with the severity of hidradenitis suppurativa (HS) are not known. OBJECTIVE: We sought to identify factors associated with the severity of HS. METHODOLOGY: The severity of disease in a series of 302 consecutive patients with HS was assessed using the Sartorius score. RESULTS: Atypical locations were more common in men than in women (47.1% vs 14.8%; P < .001). Men also had more severe disease (median Sartorius score: 20.5 vs 16.5; P = .02). Increased body mass index (P < .001), atypical locations (P = .002), a personal history of severe acne (P = .04), and absence of a family history of HS (P = .06) were associated with an increased Sartorius score. The Sartorius score was highly correlated with the intensity and duration of pain and suppuration (all P values < .001). LIMITATIONS: The referral center base of the study may have biased recruitment. CONCLUSION: Our data showed a significant association between the severity of HS and several clinical and behavioral factors. Prospective studies are needed to confirm the prognostic role of these factors.

Creation of a tool to assess adherence to treatments for acne.

BACKGROUND: Acne is a disorder in which adherence has a major impact on treatment outcome. OBJECTIVE: To create an easy-to-use tool to assess treatment adherence, based on a questionnaire that can be used on a daily basis by dermatologists. METHODS: First, we evaluated adherence by comparing responses to a self-administered questionnaire with the dermatologist's prescription. Second, concordance was assessed between adherence and each question of a dermatologist-directed questionnaire (DDQ) administered during the consultation. Third, DDQ questions were combined to construct a mini-questionnaire, and these combinations were tested to maximize specificity. RESULTS: The study included 246 patients, who were prescribed topical treatment alone, combined treatment (excluding oral isotretinoin) or oral isotretinoin alone. The mini-questionnaires for oral and topical treatments had 89% specificity for detecting poor adherence. An inappropriate answer to one question classified the patient as a probable poor compliance. CONCLUSIONS: Our mini-questionnaires provide dermatologists with specific tools to rapidly identify poor compliance.

Prevalence and factors associated with hidradenitis suppurativa: results from two case-control studies.

BACKGROUND: Conflicting opinions have been reported regarding the epidemiology of hidradenitis suppurativa. OBJECTIVE: We sought to evaluate the prevalence of hidradenitis suppurativa and to identify associated factors. METHODOLOGY: Prevalence was evaluated using a representative sample of the French population (n=10,000). Associated risk factors were assessed using two case-control studies, one population-based with 67 self-reported patients and 200 control subjects, and the other clinic-based with 302 medically assessed patients and 906 control subjects. RESULTS: The prevalence was 1% of the French population. Multivariate analyses showed a strong association with current smoking in self-reported (odds ratio=4.16, 95% confidence interval [2.99-8.69]) and in medically assessed (odds ratio=12.55 [8.58-18.38]) populations. Association with body mass index was significant in medically assessed patients (odds ratio=1.12 [1.08-1.15]) for each increase of 1 U of BMI. LIMITATIONS: A causal relationship could not be established with such a cross-sectional study. CONCLUSION: Hidradenitis suppurativa is a common disease, frequently associated with smoking and being overweight.

Management of skin ageing: how to combine cosmetic procedures.

Skin ageing may be physiological and/or a result of photoageing. To provide comprehensive management of ageing skin, it is essential to make a thorough diagnosis before any therapeutic decision is made. The most appropriate treatment(s) may then be offered to the patient. This comprehensive approach to care requires knowledge of the mechanisms of skin ageing and the advantages and drawbacks of the different therapeutic approaches available, in order to arrive at the best therapeutic strategy and to meet patient expectations. There are very many different therapeutic approaches, and in the context of work by a group of European experts it seems appropriate to propose a therapeutic strategy for the overall management of skin ageing to help dermatologists in their daily work with patients. This therapeutic strategy is based both on an analysis of the literature and the personal experience of the experts.

Acne on pigmented skin.

Acne on pigmented skin occurs in Africans and their descendants, as well as in patients with a skin phototype above IV. Acne is common in Africans and is often the primary reason for consulting a dermatologist. Acne on pigmented skin is principally inflammatory acne. The sequelae in terms of pigmentation are often the main reason for consulting a dermatologist, and take precedence over the acne itself. Research is needed into cosmetic acne and steroid-induced dermatitis, which are common in users of skin bleaching products. The treatment for acne in pigmented skin involves the same medicines as used in acne in white skin. Of the available topical treatments, benzoyl peroxide is particularly effective for the inflammatory component. Retinoids act on both the retentional and inflammatory components of acne and have skin bleaching properties. Tetracyclines are essential on initiation of treatment, regardless of severity. They prevent an inflammatory episode at the onset of acne and rapidly improve the inflammatory component. Minocycline should not be prescribed in African patients. Fatal cases of hypersensitivity have been described, with a particular frequency in this population. Doxycycline is effective, but has photosensitizing properties. Lymecycline is well tolerated. Isotretinoin is indicated for nodular acne. The same precautions for use should be followed as in all cases of acne. The skin bleaching effects are considerable. Photoprotection should generally be imposed, but, in patients with black skin, photoprotective agents are often not applied. The administration of a cosmetic containing a skin bleaching agent combined with a photoprotective agent for application in the morning, instead of hydrating cream, is acceptable to patients, improves compliance, and is effective.

Living with acne. A study of adolescents' personal experiences.

BACKGROUND: Acne can have important psychological repercussions. OBJECTIVES: We studied adolescents' perceptions of acne, in a nonmedical context. METHODS: Between November 2004 and January 2005, a questionnaire was presented to adolescents calling a youth helpline. It focused on perceptions of acne and, among callers with personal experience of acne, its severity and treatment. Callers were divided into those with acne, those having had acne and those never having had acne. RESULTS: The questionnaire was completed by 1,566 callers. It showed that 51% of respondents with acne did not seek medical help; acne has as big a psychological impact as some far severer diseases; many respondents with no history of acne said they were very worried that they would develop this skin disorder. CONCLUSIONS: This study underlines the major psychological impact of acne. Young people need to be informed that acne can be treated.

Physiopathology of acne vulgaris: recent data, new understanding of the treatments.

Acne is the most frequent reason for seeing a dermatologist, but its physiopathology is not completely well-known. Yet understanding of the mechanisms of action of the different acne treatments is very important to optimize their use. A lot of new data on the physiopathology have recently been published in the acne field. This paper summarizes the main points of these new facts.

Incidence and risk factors for thalidomide neuropathy: a prospective study of 135 dermatologic patients.

Thalidomide is effective in several cutaneous diseases. Peripheral neuropathy is the most important adverse event limiting its use. Its incidence rate and its relation to thalidomide doses remain unclear. We prospectively monitored 135 patients treated with thalidomide for various dermatologic diseases for 2 y in order to estimate the annual incidence rate and risk factors for neuropathy. Patients underwent standardized neurologic examination and nerve conduction studies prior to, and regularly during treatment. Risk factors for neuropathy were assessed using a Cox proportional-hazards model. Clinical and electrophysiologic evidence of a thalidomide-induced neuropathy were present in 25.2% of the patients; however, when considering all potential cases, this rate reached 55.6%. The incidence rate was maximal during the first year of treatment (20%). The risk of neuropathy was related to the daily dose whatever the duration of treatment (p<10-3). Considering a daily dose < or =50 mg per day as reference, the relative risk for thalidomide neuropathy was 8.2 for a daily dose comprised between 50 and 75 mg per day and 20.2 for a daily dose >75 mg per day (p<10-3). No neuropathy occurred for daily doses < or =25 mg per day. The neuropathy was subclinical in nearly a quarter of patients with such an adverse event. These data confirm the high rate of thalidomide neuropathy and identify the daily dose as the main risk factor. The risk of neuropathy seems to be negligible for doses less than 25 mg per day, whatever the duration of therapy.

[Cosmetic treatments and acne]. / Soins cosmétiques et acné.

Cosmetic products contribute to the efficacy of anti-acneic treatment. Cleaning bars without soap and lotions are to be preferred to soaps. Morning application of moisturizing creams compensate for dryness and irritation induced by topical treatment. Some of these cosmetic products may have a limited efficacy of the shiny appearance and/or acne lesions. Scrubs, abrasive sponges, masks and patches have a very limited usefulness. Make up and camouflage techniques are authorized, provided that the products have been tested non comedogenic and non acne-genic.