Zoe D. Draelos, MD, discusses 3 mechanisms of action for treating acne- decrease nutrients, C acnes lesions and inflammation-and her tips for addressing these, such as facial cleansing products and the use of probiotics. Dr Draelos is a board-certified dermatology in private practice in High Point, North Carolina, and the president of Dermatology Consulting Services.
My name is Dr Zoe Diana Draelos and I’m President of Dermatology Consulting Services. I’m an expert in skin research and my research focuses on the development of topical prescription products, as well as over‑the‑counter formulations for acne.
I’m very interested in ways of treating acne that are innovative that involve over‑the‑counter preparations as well as prescription preparations. And my talk really focuses on acne treatment tips, things that you might wish to share with your patients but may not have thought about.
So, the first tip that I wanted really to talk about are ways of using products in novel directions to allow people to have better skin. So, there are 3 mechanisms really that are important in acne. The first is, as we all know that C acnes, which used to be P acnes but is now renamed C acnes, is necessary in order for acne to occur.
So, one way that you can address acne, both in the RX and the OTC world, is to decrease the nutrients available for the organism to grow. The second issue is if you can decrease the colonization of the skin by the C acnes, then you also decrease the numbers as well.
Then, finally, one of the reasons why acne scarring occurs, why the pustules and papules occur, is because of inflammation. So, the third mechanism of action is to decrease inflammation. So, if you can decrease the nutrients for C acnes to grow, you can decrease the number of C acnes lesions on the skin, and you can decrease inflammation, you can, indeed, improve acne.
So, let’s start by talking a little bit about these 3 mechanisms of action and what kinds of tips can be offered to combat each of these mechanisms of action. Well, one area that’s of interest, not only in the prescription world but also the OTC world, is the use of probiotics. And, probiotics are a whole new area in acne treatment.
The skin surface is basically a rich, nutrient broth, it has sweat, it has sebum, it has other environmental debris that basically coat the skin’s surface. Sebum is the nutrient for C acnes, so if you can cut down on the C acnes, then you can improve acne.
One of the ways that probiotics work is, basically, they take up space on the skin’s surface. Many probiotics don’t contain living bacteria, but they contain sonicated bacterial fragments. These bacterial fragments reside on the skin’s surface. They take up physical space and by doing so, they introduce a phenomenon known as physical interference.
When the dead bacteria take up space on the skin’s surface that is an area where C acnes cannot grow. So, if you think about the skin’s surface, it’s a battle for nutrients, it’s a battle for space. So, if you take up some of this space with bacterial fragments that are not pathogenic, you can decrease the colonization of C acnes.
We also know that probiotics can interfere chemically with the growth of organisms, such as Staph aureus. And, one of the organisms that is present on the skin’s surface in abundance is Staph epidermidis, a non‑pathogenic organism. This organism, actually, can be fermented and can ferment itself—glycerol.
Glycerol is a substance that’s frequently present on the fingertips. Staph epidermidis actually can create inhibition zones by fermenting the glycerol, which has an antibacterial or zone inhibition effect on C acnes.
So, Staph epidermidis, actually, on the skin’s surface interacting with substances in their present and skincare products can decrease the ability of C acnes to grow, which is another way of addressing C acne colonization.
Now, there are a lot of bacteria that can be put on the skin’s surface. And, probably the ones that are most commonly used are what are known as dairy propionic acid bacteria, or PABs. The two PABs that are commonly used are bifidobacterium and lactobacillus. And, you might recognize these organisms because they are the ones that are found in live‑culture yogurt and also found in other oral probiotic preparations, as well as some other dairy products.
So, what the dairy propionic acid bacteria do is they basically transiently colonize the skin. They produce antimicrobial substances and then, these antimicrobial substances decrease the growth of C acnes. Some of the preparations that contain live bacteria have dairy bacteria to basically prevent C acne colonization.
Another one of the substances besides fermented glycerol that can be produced by bacteria fermentation is succinic acid. Succinic acid is a short‑chain fatty acid, but it actually decreases inflammation and bacteria colonization that’s caused by C acnes. So, it’s possible that the bacterial fermentation of succinic acid results in protective effects as well.
Now, another area where you want to think about the prevention of acne is by what remains on the face. And, we always talk to people about diet and what they should eat and should not eat but it is important to recognize that all vegetable oils are comedogenic. The reason is that the C acnes bacteria can break those down.
So, while pepperoni pizza might not be the best thing for you to eat from a caloric standpoint, it’s also not the best thing for you to eat from an acne standpoint because it contains both animal and vegetable fats. So, any oily residue that’s left on your face after eating a pepperoni pizza will provide a growth media for C acnes. And, this is the reason why it’s very important for individuals to wash their face immediately after eating to remove all oily residue.
Many vegetable oils, especially olive oil, are very comedogenic. Olive oil is found in a lot of hair pomades and hair dressings as a hair oil and those are, indeed, comedogenic. Safflower oil, any botanical oils that come from plants are, indeed, comedogenic. So, it’s important to remember to avoid these substances that could indeed provide a nutrient source for C acnes to grow.
Now, another aspect to acne that’s also important is the hormonal considerations. And, many women are using birth controls that are progesterone‑dominant well into their 40s. And, many women are also using progesterone‑dominant IUDs, implants, as well as oral supplements that can either minimize menses to quarterly or eliminate menses altogether.
Hormones are a very different area and, indeed, it is important for women that are placed on hormone‑containing products to consider the effect that they might have on acne and possibly changing the form of contraception might be helpful in these women as well.
One thing that hormones do is they drive oil production on the face. And, of course, sebum is the food for C acnes. So, one way to control acne is to remove the sebum from the face. Now, clearly, washing with soap and water, that’s an excellent way to do it. But, many women during the day don’t want to wash because they don’t want to remove all of their facial cosmetics.
So, a common way of controlling oil is the use of facial blotting papers. And, these are very thin tissue papers that come in a little cassette, almost like a powder compact. They can be pressed into the face that will selectively absorb the oil while leaving the cosmetics behind.
The other thing that can be done is substances can actually be put on the face as part of the makeup that also controls the oil. These substances are known as mattifying lotions. And, they contain a silicone polymer ingredient known as cyclopentasiloxane. This is basically a silicone elastomer and it mixes with the oil and prevents the oil from creating an oily shine over the face. A silicone elastomer also can help absorb some of the oil, especially if it’s combined with a facial powder.
Facial powder contains a substance known as hydrous magnesium silicate, better known to many dermatologists as talc. And, talc is also capable of absorbing oils and once the oil is absorbed, it can no longer serve as a food substrate for the C acnes organisms.
Another interesting area in cleansing is the introduction of sonicating silicone‑head cleansing products. The silicone heads are different than the brush heads. The brush heads basically move the bristles back and forth but are easily deformable, whereas the silicone‑based heads work more like a windshield wiper on the skin’s surface and they’re actually able to traverse the surface of the pores.
Within the pores, there’s always a reservoir of oil and cellular debris, and possibly other substances, like old makeup. And so, many of the newer silicone-head scrubbing brushes for the face are actually better able to traverse the pores, remove that sebum reservoir, and clean within the pore itself.
Finally, another way that can be used to clean that milieu pore and alter that milieu, is the use of cleansing pads. And, these are textured cleansing pads that can contain salicylic acid, glycolic acid, or both. And, these also can work within the pore, destroying bacteria, removing the retained sebum and plugs, and thus, improving acne without over‑drying the skin.
So, I think what’s going to happen in the future is many people are going to become interested in combining some of these over‑the‑counter ideas. The use of probiotics, the use of mattifying lotions, oil‑blotting papers, silicone‑headed scrubbing brushes, all of which alter the microbiome. And, we know that acne is a microbiome disease caused by C acnes.
And so, all of these little tips and ideas that I’ve discussed are ways of improving the microbiome or normalizing the microbiome to decrease the colonization of C acnes and replace the C acnes with non‑pathogenic organisms such as Staph aureus or the lactobacillus organisms that are part of the propionic acne bacteria that we discussed.
So, these are some ideas that dermatologists can offer to patients as easy ideas that may result in acne improvement. Thank you very much.