The Role of Toll-Like Receptors in the Pathophysiology of Acne

Plant Phenolics in the Prevention and Therapy of Acne: A Comprehensive Review

Plants are a rich source of secondary metabolites, among which phenolics are the most abundant. To date, over 8000 various polyphenolic compounds have been identified in plant species, among which phenolic acids, flavonoids, coumarins, stilbenes and lignans are the most important ones. Acne is one of the most commonly treated dermatological diseases, among which acne vulgaris and rosacea are the most frequently diagnosed. In the scientific literature, there is a lack of a detailed scientific presentation and discussion on the importance of plant phenolics in the treatment of the most common specific skin diseases, e.g., acne. Therefore, the aim of this review is to gather, present and discuss the current state of knowledge on the activity of various plant phenolics towards the prevention and treatment of acne, including in vitro, in vivo and human studies. It was revealed that because of their significant antibacterial, anti-inflammatory and antioxidant activities, phenolic compounds may be used in the treatment of various types of acne, individually as well as in combination with commonly used drugs like clindamycin and benzoyl peroxide. Among the various phenolics that have been tested, EGCG, quercetin and nobiletin seem to be the most promising ones; however, more studies, especially clinical trials, are needed to fully evaluate their efficacy in treating acne.

A Polylysine dendrigraft is able to differentially impact Cutibacterium acnes strains preventing acneic skin

With a view to reducing the impact of Cutibacterium acnes on acne vulgaris, it now appears interesting to modify the balance between acneic and non-acneic strains of C. acnes using moderate approach. In the present study, we identified that a G2 dendrigraft of lysine dendrimer (G2 dendrimer) was able to modify membrane fluidity and biofilm formation of a C. acnes acneic strain (RT5), whereas it appeared no or less active on a C. acnes non-acneic strain (RT6). Moreover, skin ex vivo data indicated that the G2 is able to decrease inflammation (IL1α and TLR2) and improve skin desquamation after of C. acnes acneic strains colonization. Then, in vivo data confirmed, after C. acnes quantification by metagenomic analysis, that the G2 cream after 28 days of treatment was able to increase the diversity of C. acnes strains versus placebo cream. Data showed also a modification of the balance expression between C. acnes phylotype IA1 and phylotype II abundances. Taken together, the results confirm the interest of using soft compounds in cosmetic product for modifying phylotype abundances as well as diversity of C. acnes strains could be a new strategy for prevent acne vulgaris outbreak.

Surfactin-oleogel with therapeutic potential for inflammatory acne vulgaris induced by Propionibacterium acnes

Accumulating evidence suggested that suppression of Propionibacterium acnes-induced inflammation was a promising strategy to alleviate acne vulgaris. This study evaluated the alleviating effect of surfactin-oleogel on P. acnes-induced inflammatory acne vulgaris in mice. Epidermis morphology and histopathological examination showed that surfactin-oleogel effectively ameliorated the P. acnes-induced epidermis swelling and erythema. Surfactin-oleogel reduced the epidermis thickness to 48.52% compared to the model control group. The colony of P. acnes in the epidermis was decreased by 1 log CFU/mL after receiving surfactin-oleogel treatment. Furthermore, surfactin-oleogel attenuated oxidative stress in the epidermis by increasing the activities of superoxide dismutase, catalase, and glutathione peroxidase. In addition, the expression of inducible nitric oxide synthase, nitric oxide, cyclooxygenase-2, pro-inflammatory cytokines (e.g. tumour necrosis factor-α and interleukin-1β), and nuclear factor kappa-B in the epidermis were reduced after treating with surfactin-oleogel. Moreover, total cholesterol and free fatty acids were decreased, whereas the treatment of surfactin-oleogel increased triglycerides and linoleic acid content. Besides, immunohistochemical assay and real-time PCR analysis indicated that surfactin-oleogel blocked the TLR2-mediated NF-κB signalling pathways in the epidermis. Consequently, our results demonstrated that surfactin-oleogel had antibacterial and anti-inflammation activities to treat P. acnes-induced inflammatory acne vulgaris.Key points• Surfactin-oleogel effectively relieves inflammation and oxidative stress caused by P. acnes.• Surfactin-oleogel effectively reduced the P. acnes colony.• Surfactin-oleogel relieves P. acnes-induced inflammation by inactivated the TLR-mediated NF-κB.

A systematic review of N-acetylcysteine for treatment of acne vulgaris and acne-related associations and consequences: Focus on clinical studies

Acne vulgaris is one of the most common dermatologic disorders affects people of all races and ethnicities and has many adverse effects on the quality of life. The increased bacterial resistance to antibiotics has reduced the effectiveness of treatment with these agents. There is an increasing focus on the involvement of oxidative stress in the pathophysiology of acne. This study investigates the effect of N-acetylcysteine (NAC) as an antioxidant in the treatment of acne vulgaris. This systematic review was conducted through a search in databases such as Science Direct, PubMed, Scielo, and Medline using keywords including acne vulgaris, anti and NAC, and all the keywords associated with each of the subtitles. The factors affecting the occurrence and expansion of acne include increased sebum synthesis, hyperkeratinization of pilosebaceous units, colonization with Propionibacterium acnes, and increased release of inflammatory mediators and ROS. Studies have shown that glutathione stimulation following the administration of NAC increases glutathione levels for the detoxification of oxygen-free radicals. Moreover, NAC prevents the synthesis and release of inflammatory cytokines such as TNF-α, IL-8, IL-6, MP9, and IL-1β and has shown antibacterial activities against important bacteria including E. coli, S. epidermidis, Pseudomonas, and Klebsiella. This medication has anti-proliferative effects and is also used for excoriation and PCOD. The results of the present study showed the beneficial effects of using NAC in patients with acne vulgaris in terms of the disease complications and comorbidities. Given its diverse functional mechanisms, this medication can be used to treat acne and its consequences.

Going, Toll-like receptors in skin inflammation and inflammatory diseases

The Indian Ayurvedic physicians knew the concept of inflammation dating back to 1500 BC. The continuous progress in the immunology of inflammation has explained its undiscovered mechanisms. For example, the discovery of Toll-like receptor 4 (TLR4) in humans (1997) has revolutionized the field of infection biology and innate immunity. The laboratory mice have shown twelve TLRs and express TLR10 (CD290) as a disrupted pseudogene, and humans have ten functional TLRs. Now, it is well established that TLRs play a significant role in different infectious and inflammatory diseases. Skin inflammation and other associated inflammatory diseases, including atopic dermatitis (AD), acne vulgaris, and psoriasis, along with many skin cancers are major health problems all over the world. The continuous development in the immunopathogenesis of inflammatory skin diseases has opened the window of opportunity for TLRs in studying their role. Hence, the manuscript explores the role of different TLRs in the pathogenesis of skin inflammation and associated inflammatory diseases. The article starts with the concept of inflammation, its origin, and the impact of TLRs discovery on infection and inflammation biology. The subsequent section describes the burden of skin-associated inflammatory diseases worldwide and the effect of the geographical habitat of people affecting it. The third section explains skin as an immune organ and explains the expression of different TLRs on different skin cells, including keratinocytes, Langerhans cells (LCs), skin fibroblasts, and melanocytes. The fourth section describes the impact of TLRs on these cells in different skin-inflammatory conditions, including acne vulgaris, AD, psoriasis, and skin cancers. The article also discusses the use of different TLR-based therapeutic approaches as specific to these inflammatory skin diseases.

A strategic review on the involvement of receptors, transcription factors and hormones in acne pathogenesis

Acne vulgaris is a very common pilosebaceous inflammatory disease occurring primarily on the face and also rare on the upper arms, trunk, and back, which is caused by Propionibacterium, Staphylococcus, Corynebacterium, and other species. Pathophysiology of acne comprises of irregular keratinocyte proliferation, differentiation, increased sebum output, bacterial antigens and cytokines induced inflammatory response. Treatment of acne requires proper knowledge on the pathophysiology then only the clinician can come out with a proper therapeutic dosage regimen. Understanding the pathophysiology not only includes the mechanism but also involvement of receptors. Thus, this review is framed in such a way that the authors have focused on the disease acne vulgaris, pathophysiology, transcription factors viz. the Forkhead Box O1 (FoxO1) Transcription Factor, hormones like androgens and receptors such as Histamine receptors, Retinoic receptor, Fibroblast growth factor receptors, Toll like receptor, Androgen receptor, Liver X-receptor, Melanocortin receptor, Peroxisome proliferator-activated receptor and epidermal growth factor receptors involvement in the progression of acne vulgaris.

Treatment Modalities for Acne

Acne is a common inflammatory skin disease which affects the pilosebaceous units of the skin. It can have severe psychological effects and can leave the patient with severe skin scarring. There are four well-recognized pathological factors responsible for acne which is also the target for acne therapy. In this review, different treatment options are discussed, including topical (i.e., retinoids, and antibiotics) and systemic (i.e., retinoids, antibiotics, and hormonal) treatments. Since the general public has been showing an increasing interest in more natural and generally safer treatment options, the use of complementary and alternative medicines (CAM) for treating acne was also discussed. The use of physical therapies such as comedone extraction, cryoslush therapy, cryotherapy, electrocauterization, intralesional corticosteroids and optical treatments are also mentioned. Acne has been extensively researched with regards to the disease mechanism as well as treatment options. However, due to the increasing resistance of Propionibacterium acnes towards the available antibiotics, there is a need for new treatment methods. Additionally, the lack of necessary evidence on the efficacy of CAM therapies makes it necessary for researchers to investigate these treatment options further.

How does our increased understanding of the role of inflammation and innate immunity in acne impact treatment approaches?

A supplement article recently published in the Journal of the European Academy of Dermatology and Venereology by Dréno et al., members of the Global Alliance to Improve Outcomes in Acne group, summarized the data for the emerging concept that inflammation in general and the innate immune system specifically play a central role in the pathogenesis of acne. This review, entitled "Understanding innate immunity and inflammation in acne: implications for management", also discusses the impact of different treatment options on the innate immune response and inflammation. The aim of the present summary is to provide a synopsis of the key points made in the paper, from the members of the Global Alliance, as relevant to the main article within this supplement: "Recent advances in the use of adapalene 0.1%/benzoyl peroxide 2.5% to treat acne patients with moderate to severe acne".

Recent advances in acne pathogenesis: implications for therapy

Acne pathogenesis is a multifactorial process that occurs at the level of the pilosebaceous unit. While acne was previously perceived as an infectious disease, recent data have clarified it as an inflammatory process in which Propionibacterium acnes and innate immunity play critical roles in propagating abnormal hyperkeratinization and inflammation. Alterations in sebum composition, and increased sensitivity to androgens, also play roles in the inflammatory process. A stepwise approach to acne management utilizes topical agents for mild to moderate acne (topical retinoid as mainstay ± topical antibiotics) and escalation to oral agents for more resistant cases (oral antibiotics or hormonal agents in conjunction with a topical retinoid or oral isotretinoin alone for severe acne). Concerns over antibiotic resistance and the safety issues associated with isotretinoin have prompted further research into alternative medications and devices for the treatment of acne. Radiofrequency, laser, and light treatments have demonstrated modest improvement for inflammatory acne (with blue-light photodynamic therapy being the only US FDA-approved treatment). However, limitations in study design and patient follow-up render these modalities as adjuncts rather than standalone options. This review will update readers on the latest advancements in our understanding of acne pathogenesis and treatment, with emphasis on emerging treatment options that can help improve patient outcomes.

Resveratrol Demonstrates Antimicrobial Effects Against Propionibacterium acnes In Vitro

Introduction

Resveratrol (3,5,4′-trihydroxystilbene) is an antioxidant that has multiple biologic effects including antimicrobial properties. Acne vulgaris is a disease of the pilosebaceous unit, characterized by an inflammatory host immune response to the bacteria Propionibacterium acnes (P. acnes). This study sought to determine whether resveratrol may be a potential treatment for acne vulgaris.

Methods

Colony-forming unit (CFU) assays together with transmission electron microscopy using P. acnes treated with resveratrol or benzoyl peroxide were used to assess antibacterial effects. Blood was drawn from healthy human volunteers, and 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium (MTS) assays were used to assess cytotoxicity in monocytes and keratinocytes.

Results

Resveratrol demonstrated sustained antibacterial activity against P. acnes, whereas benzoyl peroxide, a commonly used antibacterial treatment for acne, demonstrated a short-term bactericidal response. A combination of resveratrol and benzoyl peroxide showed high initial antibacterial activity and sustained bacterial growth inhibition. Electron microscopy of P. acnes treated with resveratrol revealed altered bacterial morphology, with loss of membrane definition and loss of well-defined extracellular fimbrial structures. Resveratrol was less cytotoxic than benzoyl peroxide.

Conclusion

The sustained antibacterial activity and reduced cytotoxicity versus benzoyl peroxide demonstrated by resveratrol in this study highlight its potential as a novel therapeutic option or adjuvant therapy in the treatment of acne vulgaris.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-014-0063-0) contains supplementary material, which is available to authorized users.

Role of hormones in acne vulgaris

OBJECTIVE

To elucidate the role of endogenous hormones like testosterone, progesterone, estrogen, insulin-like growth factor, insulin and glucocorticoids in a common skin condition acne vulgaris.

DESIGN AND METHODS

We conducted a systematic review of the literature and abstracted the data for every published cut point.

RESULTS

We screened more than 1000 studies and found that serum testosterone, progesterone, glucocorticoids, insulin and insulin-like growth factors are increased in patients with acne vulgaris and serum estrogen levels are low in patients.

CONCLUSIONS

Various endogenous hormones play important role in the pathogenesis of acne vulgaris. Thus, in the clinical practice it is important to evaluate serum levels of these hormones and patients must be treated accordingly to avoid serious endocrine disorders at an early age.

Optimizing use of oral antibiotics in acne vulgaris

Oral antibiotics are commonly used to treat acne vulgaris, primarily in patients presenting with moderate to severe facial or truncal disease severity. These agents are most appropriately used in combination with a topical regimen containing benzoyl peroxide and a topical retinoid. The most common oral antibiotics for treating acne vulgaris are the tetracycline derivatives, although macrolide agents such as erythromycin have also been used extensively. Over the past 4 decades, as the sensitivity of Propionibacterium acnes to several oral and topical antibiotics has decreased, the efficacy of oral tetracycline and erythromycin has markedly diminished, leading to increased use of doxycycline, minocycline, and other agents, such as trimethoprim/sulfamethoxazole.

Fatores etiopatogênicos da acne vulgar

A acne vulgar é uma das dermatoses mais freqüentes na população em geral. Encontra-se na literatura grande número de trabalhos científicos referentes sobretudo a sua etiopatogenia. No entanto, dado o grande número de informações geradas a respeito, dificilmente consegue-se reuni-las em entendimento comum. Esta revisão literária foi proposta a fim de abordar os mecanismos etiopatogênicos clássicos da acne vulgar (produção sebácea, hiperqueratinização folicular, colonização bacteriana folicular e inflamação glandular) e o mecanismo coadjuvante principal, a influência hormonal.

Toll-like receptors in skin infections and inflammatory diseases

The skin is the ultimate example of the function of innate immunity, it alerts the host of danger by many systems including sensing pathogen-associated molecule patterns (PAMPs) through Toll-like receptors and other pattern recognition receptors (PRRs), yet normally provides defense without inflammation. The skin responds rapidly to invading microbes by producing antimicrobial peptides or other antimicrobial intermediates before cytokine release results in inflammation. To achieve maximal immune responses for clearing invading microbes, the activation of select PRRs in skin then initiates and shapes adaptive immune responses through the activation of dendritic cells and recruitment of T cell subsets. Importantly, cross-talk between TLRs can influence this system in several ways including augmenting or suppressing the immune response. As a consequence of their pivotal role, TLR responses need to be tightly controlled by associated negative regulators or negative feedback loops to prevent detrimental effects from TLRs overactivation. This review focuses on describing the involvement of TLRs in the development of skin infections and inflammatory diseases, and highlights the potential application of TLR agonists or antagonists in these skin diseases.

In vitro modulation of TLR-2, CD1d and IL-10 by adapalene on normal human skin and acne inflammatory lesions

The anti-inflammatory mechanisms of adapalene, a synthetic retinoid used for the treatment of acne patients, are partially understood. They seem particularly related to the modulation of the non-specific immunity. Recent studies have shown that Toll-like receptor (TLR)-2 expression, a receptor of the innate immune system, was increased in acne lesions and could play an essential role in acne-linked inflammation. The aim of our study was to investigate the new mechanisms of the anti-inflammatory activity of adapalene in vitro, and more specifically the modulatory effect of adapalene on the expression of TLR-2, CD1d, a cell surface glycoprotein that plays a role as antigen-presenting molecules and is responsible for the development of cutaneous inflammation, and also on the expression and the secretion of the anti-inflammatory interleukin (IL)-10 cytokine. Both explants of normal human skin and explants of acne patients were incubated with adapalene (10(-7) or 10(-6) M) or the control medium for 24 h. Evaluation of epidermal expression by immunohistochemistry showed a decreased expression of TLR-2 and IL-10 in explants of normal skin and explants of acne with adapalene. On the contrary, adapalene increased CD1d expression in explants of acne patients. Thus, adapalene can modulate the epidermal immune system by increasing the CD1d expression and by decreasing the IL-10 expression by keratinocytes. Moreover, these modulations could increase the interactions between dendritic cells and T lymphocytes and could strengthen the antimicrobial activity against Propionibacterium acnes. The decreased expression of TLR-2 by the keratinocytes can contribute to explain the anti-inflammatory activity of adapalene observed in clinical practice.

Topical immunomodulation: modes of action with clinical correlation

Many classes and preparations of immunomodulators are available to the clinician, serving as stimulatory or inhibitory influences on a variety of disease states. To maximize their efficacy, it is important for the clinician to take a step back from the usual routine of treating symptoms and consider the immune processes that took place to create inflammation, tumors, or responses to infections. From there, after considering the short-term and long-term consequences of the treatment, one can match the immune profile of the disease to the treatment. Most importantly, immunomodulators provide the opportunity to do what is best for the patient at that time, as well as for control of the future of the disease, whether it is acute or chronic.

Pathophysiologie der Akne

Several pathogenic factors contribute to the development of acne, among them, seborrhea, follicular hyperkeratosis, propionibacteria, and inflammatory events. This article reviews current knowledge of these pathogenic factors.