Comparative efficacy of clindamycin and benzoyl peroxide for in vivo suppression of Propionibacterium acnes

Distinct skin microbiome modulation following different topical acne treatments in mild acne vulgaris patients: A randomized, investigator-blinded exploratory study

The effects of topical non-antibiotic acne treatment on skin microbiota have rarely been demonstrated. In the study, we randomized 45 mild acne vulgaris participants into three treatment groups, including a cream-gel dermocosmetic containing Aqua Posae Filiformis, lipohydroxy acid, salicylic acid, linoleic acid, niacinamide and piroctone olamine (DC), retinoic acid 0.025% cream (VAA) and benzoyl peroxide 2.5% gel (BP). At months 0, 1 and 3, skin specimens were swabbed from the cheek and forehead and sequenced by targeting V3-V4 regions of the 16 S rRNA gene. QIIME2 was used to characterize bacterial communities. Acne severity, sebum level and tolerability were assessed concomitantly in each visit. We found that both VAA and BP could significantly reduce the bacterial diversity at month 1 (p-value = 0.010 and 0.004 respectively), while no significant reduction was observed in DC group. The microbiota compositions also significantly altered for beta diversity in all treatments (all p-value = 0.001). An increased Cutibacterium with decreased Staphylococcus relative abundance was observed at months 1 and 3 in DC group, while an opposite trend was demonstrated in VAA and BP groups. These findings suggest a potential impact of DC, VAA and BP on the diversity and composition profiles of the skin microbiota in mild acne participants.

Efficacy of antimicrobial washes before shoulder surgery against Cutibacterium: a systematic review and meta-analysis

Background

Cutibacterium acnes is a commensal intradermal microorganism that is commonly isolated at revision shoulder arthroplasty. Standard practice chlorhexidine gluconate (CHG) skin preparation agents have limited effectiveness at eradicating C. acnes in the dermis. Benzoyl peroxide (BPO) has demonstrated effectiveness against C. acnes. This meta-analysis compares the efficacy of at-home shoulder decolonization before surgery using CHG vs. BPO to reduce shoulder C. acnes burden.

Methods

This was a Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review. PubMed and MEDLINE databases were searched for studies evaluating the effects of CHG and BPO in reducing C. acnes at the shoulder. Trial results were extracted and pooled using a random effects model, separating data from randomized controlled trials (RCTs) and non-RCTs. Methodologic quality of studies was assessed using the Cochrane Risk of Bias Assessment Tools.

Results

Ten studies (589 patients) were included. RCTs showed that both BPO and CHG led to significant reductions in culture positivity compared with negative controls (risk ratio [RR] with 95% confidence interval [CI] = 0.20 [0.13, 0.30], P < .0001 and 0.46 [0.37, 0.57], P < .0001, respectively). Non-RCT data demonstrated similar results comparing BPO and CHG to the control (RR with 95% CI = 0.34 [0.21, 0.57], P < .0001 and 0.31 [0.20, 0.49], P < .0001, respectively). Comparing BPO and CHG, RCT data showed a significant reduction in culture positivity with BPO (RR with 95% CI = 0.46 [0.27, 0.77], P < .009). Of RCTs, 5 were low and one was of moderate risk of bias. Of non-RCTs, 3 had low risk of bias, whereas one had moderate risk of bias.

Conclusion

This review demonstrated that preoperative CHG and BPO can reduce C. acnes at the shoulder. However, BPO exhibits greater efficacy than CHG, potentially because of the compound's ability to penetrate the dermis. BPO is a simple and economical agent that may reduce joint exposure to C. acnes in shoulder surgery.

Simultaneous determination of tazarotene, clindamycin phosphate and their active metabolites in Bama mini-pig skin by LC-MS/MS: Application to the development of a tazarotene/clindamycin phosphate cream

Topical tazarotene combined with clindamycin phosphate can significantly improve the adherence and outcomes for the treatment of acne vulgaris than monotherapy, a novel tazarotene (0.05%)/clindamycin phosphate (1.2%) cream is thus developed. However, the pharmacokinetics and potential interaction of tazarotene and clindamycin phosphate in skin when formulated together remain unknown, which should be investigated to assess this novel cream. In the present work, a sensitive and rapid LC-MS/MS method for simultaneous determination of tazarotene, clindamycin phosphate and their active metabolites tazarotenic acid, clindamycin in Bama mini-pig skin was developed and reported for the first time. After pretreatment of the skin samples, the analytes were well separated on a Hypersil BDS C₈ column (4.6 × 100 mm, 2.4 μm) using 0.2% (v/v) formic acid-0.1% (w/v) ammonium acetate water solution and acetonitrile as mobile phase in linear gradient elution. Quantification of tazarotene, clindamycin phosphate and their active metabolites tazarotenic acid, clindamycin was conducted under positive electrospray ionization mode using multiple reactions monitoring detection. The LC-MS/MS method was fully validated and then applied to the dermal pharmacokinetic study of the tazarotene/clindamycin phosphate cream. According to the obtained results, tazarotene and clindamycin phosphate did not have any drug-drug interaction when they were formulated together in the cream for topical application. Their absorption and metabolism features in the skin were also characterized, which can support the clinical medication regimen of tazarotene/clindamycin phosphate cream.

Prevention of Cutibacterium acnes infection in arthroscopic shoulder surgery: a systematic review

BACKGROUND

Cutibacterium acnes is a gram-positive anaerobe that can lead to postoperative shoulder infections. The purpose of this study was to determine the incidence of C acnes infections following shoulder arthroscopy and evaluate the efficacy of perioperative antibiotic prophylaxis in the prevention of these infections.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that evaluated the prevalence and clinical indications of C acnes infections after various arthroscopic shoulder surgical procedures. Patients were assessed based on positive culture rates, the contraction of infection, and antibiotic regimens used to prevent infection.

RESULTS

A total of 9 studies (1 level I, 5 level II, 1 level III, and 2 level IV) met the inclusion criteria, including a total of 3758 patients with a mean age of 59.9 years (range, 17-87 years) at the time of surgery. The mean follow-up time was 1.6 months (range, 1.0-12.0 months). Overall, 37.3% of patients (173 of 464) had positive C acnes skin and/or joint culture results, and in 0.22% of patients (8 of 3586), a C acnes infection was diagnosed postoperatively. The application of a topical benzoyl peroxide antibiotic in the days leading up to surgery significantly reduced the positive culture rate from 41.6% to 9.6% (P < .001).

CONCLUSIONS

C acnes infections occur at a very low rate (0.22%) following shoulder arthroscopy. The application of a topical benzoyl peroxide antibiotic in the days leading up to surgery in combination with preoperative antibiotic prophylaxis significantly reduces the prevalence of C acnes in shoulder arthroscopy patients.

The presence of Cutibacterium acnes on the skin of the shoulder after the use of benzoyl peroxide: a placebo-controlled, double-blinded, randomized trial

HYPOTHESIS AND BACKGROUND

We hypothesized that benzoyl peroxide (BPO) would reduce the presence of Cutibacterium acnes on the skin of the shoulder by 50% compared with placebo. Infections after shoulder surgery are most commonly caused by C acnes. Current prophylactic methods do not effectively reduce the bacterial load of this bacterium. However, it seems that BPO may reduce C acnes on the skin of the shoulder. Therefore, this study aimed to investigate the effect of BPO on the presence of C acnes on the shoulder skin.

METHODS

A double-blinded, randomized, placebo-controlled trial was performed including healthy participants aged between 40 and 80 years. Thirty participants with C acnes on the shoulder skin according to baseline skin swabs were randomized into the BPO or placebo group. After gel application 5 times, skin swabs were taken to determine the presence of C acnes.

RESULTS

Forty-two participants were screened for the presence of C acnes to include 30 participants with the bacterium. Participants with C acnes at baseline were 7.4 years younger than participants without C acnes (P = .015). One participant in the placebo group dropped out before application because of fear of adverse events. After application, C acnes remained present in 3 of 15 participants (20.0%) in the BPO group and in 10 of 14 participants (71.4%) in the placebo group, resulting in a 51.4% reduction in the presence of C acnes.

CONCLUSION

Applying BPO 5 times on the shoulder skin effectively reduces C acnes. Consequently, BPO may reduce the risk of postoperative infections.

An update on formulation strategies of benzoyl peroxide in efficient acne therapy with special focus on minimizing undesired effects

Benzoyl peroxide (BPO) in the form of over the counter monotherapeutics or prescription-only combinations is a key component of topical acne therapy, but its unfavourable side effect profile reduces the therapeutic value of this compound. Various galenic approaches have been pursued to resolve this ambivalence, but only a few have managed to enter the market. This article aims to give a comprehensive overview of the published experimental vehicle systems and to identify the fundamental rationales. With regard to the formulation, an increase in the tolerability of BPO can essentially be achieved by combining BPO with re-fattening and moisturizing substances, by incorporating it and controlling its release, as well as by targeted deposition of the active ingredient at the site of action, i.e. drug targeting. Recently, novel particulate formulations have been proposed that combine several of these design principles and are expected to bring new developments in this dynamic field of research.

Benzoyl peroxide and clindamycin topical skin preparation decreases Propionibacterium acnes colonization in shoulder arthroscopy

BACKGROUND

Propionibacterium acnes is a gram-positive anaerobe that can lead to devastating postoperative shoulder infections. The objective of this study was to investigate whether a benzoyl peroxide and clindamycin preoperative skin preparation reduces the incidence of P. acnes colonization during shoulder arthroscopy.

METHODS

Sixty-five shoulder arthroscopy patients were prospectively enrolled. A skin culture specimen was taken at the preoperative visit from standard arthroscopic portal sites. Topical benzoyl peroxide 5% and clindamycin 1.2% (BPO/C) gel was applied to the shoulder every night before surgery. Skin culture was repeated in the operating room before preparation with chlorhexidine gluconate. Shoulder arthroscopy proceeded, with final culture specimens obtained from within the shoulder.

RESULTS

P. acnes skin colonization remained similar to prior studies at 47.7% (31 of 65 patients.) With >1 application, BPO/C was 78.9% (15 of 19 patients) effective in eliminating P. acnes superficial colonization. With 1 application, it was 66.7% (8 of 12 patients) effective in eliminating superficial colonization. Deep colonization was reduced to 3.1% (2 of 65 patients) compared with previous studies of 15% to 20% (P = .006). BPO/C was 100% effective at decreasing deep colonization with >1 application.

CONCLUSIONS

P. acnes skin colonization is high at arthroscopic shoulder portals, especially in men. Despite standard skin preparation and prophylactic antibiotics, the rate of joint inoculation is much higher than the rate of infection reported in the literature. BPO/C effectively reduces P. acnes colonization in shoulder arthroscopy. It should be considered for use before shoulder procedures with a time-related trend of >1 application.

Efficacy of Intense-pulsed Light Therapy with Topical Benzoyl Peroxide 5% versus Benzoyl Peroxide 5% Alone in Mild-to-moderate Acne Vulgaris: A Randomized Controlled Trial

Objective:

Acne vulgaris is a disease of pilosebaceous unit with multifactorial pathogenesis and threats patients' social functioning. There is a growing research to find faster, more effective, and easy to use treatments. The aim of this study is to evaluate the efficacy of benzoyl peroxide 5% (BP) with and without concomitant intense-pulsed light (IPL) therapy in mild-to-moderate acne vulgaris.

Methods:

In this controlled trial, 58 eligible patients with mild-to-moderate acne and Fitzpatrick skin phototype III and IV were randomly allocated to two groups. All patients were asked to use a thin layer of BP every night. The IPL therapy was administered at the end of first, 2^nd, and 3^rd months. Acne Global Severity Scale (AGSS), Acne Severity Index (ASI), and total lesion counting (TLC) along with patient satisfaction were recorded. Patients were also examined 1 month after the final therapeutic visit.

Findings:

The IPL group showed greater reduction in AGSS (P < 0.001) and TLC (P = 0.005) than the control group. However, the difference in ASI was not significant (P = 0.12). Patients in IPL groups were more satisfied than control group (P < 0.001).

Conclusion:

Adding IPL to BP can result better response to BP alone. In acne treatment, combination therapy such as IPL and other topical agents should be kept in mind.

A Derivative of the Thiopeptide GE2270A Highly Selective against Propionibacterium acnes

A chemical derivative of the thiopeptide GE2270A, designated NAI003, was found to possess a substantially reduced antibacterial spectrum in comparison to the parent compound, being active against just a few Gram-positive bacteria. In particular, NAI003 retained low MICs against all tested isolates of Propionibacterium acnes and, to a lesser extent, against Enterococcus faecalis. Furthermore, NAI003 showed a time- and dose-dependent killing of both a clindamycin-resistant and a clindamycin-sensitive P. acnes isolate. Gel shift experiments indicated that, like the parent compound, NAI003 retained the ability to bind to elongation factors Tu (EF-Tus) derived from Escherichia coli, E. faecalis, or P. acnes, albeit with reduced efficiency. In contrast, EF-Tus derived from the NAI003-insensitive Staphylococcus aureus or Streptococcus pyogenes did not bind this compound. These results were confirmed by in vitro studies using a hybrid translation system, which indicated that NAI003 can inhibit most efficiently protein synthesis driven by the P. acnes EF-Tu. P. acnes mutants resistant to NAI003 were isolated by direct plating. With one exception, all analyzed strains carried mutations in the tuf gene, encoding EF-Tu. Because of its selective effect on P. acnes in comparison to resident skin flora, NAI003 represents a promising candidate for the topical treatment of acne, which has already completed a phase 1 clinical study.

A current review of topical benzoyl peroxide: new perspectives on formulation and utilization

Benzoyl peroxide (BPO) is the most widely used topical acne treatment, with significant antibacterial, antikeratolytic, and comedolytic activity. It has been shown to be extremely effective as monotherapy and in combination with antibiotics or retinoids for managing comedonal and inflammatory acne lesions. As numerous clinical studies have shown, the combination of BPO plus a topical antibiotic is not only more effective but also is often better tolerated than either agent alone. Unlike antibiotics, no bacterial resistance has been noted. Adding BPO to any long-term antibiotic regimen in acne is generally recommended to help reduce populations of drug-resistant variants. Although effective combinations of BPO and antibiotics or retinoids are used, BPO monotherapy can also be extremely effective in treating mild to moderate acne with no resistance issues.

Pharmacotherapy of acne

BACKGROUND

Acne results from the interplay of several pathophysiologic factors, in particular seborrhoea, follicular hyperkeratosis, propionibacteria and inflammation. Recently, it has become clear that inflammatory events are important not only in the course, but also in the initiation of the disease.

OBJECTIVE

The study undertook an evaluation of the effectiveness of currently available pharmacotherapeutic treatment options for acne.

METHODS

After a Medline-based literature search, this article critically reviewed substances used topically (among others, retinoids, antimicrobials, salicylic acid and azelaic acid) and systemically (antibiotics, isotretinoin, hormones and zinc) as well as their combinations with respect to pharmacology, clinical efficacy and side effects.

RESULTS

Modern acne pharmacotherapy provides substances that antagonize one or more of the major pathophysiologic factors of acne. When the clinical picture but also patients' motivation and wishes are appropriately considered, current pharmacotherapy of acne is rational and effective.

Fluorescence digital photography of acne using a light-emitting diode illuminator

BACKGROUND/PURPOSE

The fluorescence findings of several dermatological diseases, such as erythrasma, tinea versicolor, and acne are helpful for diagnosis and follow-up. However, many experience difficulty taking photographic images of fluorescence. The aim of this study was to develop a 405 nm light-emitting diode (LED) system for fluorescence digital photography of acne and to determine whether such a diode can be used to evaluate acne.

METHODS

Eight healthy acne patients were compared with controls by fluorescence digital photography using a digital camera equipped with a 405 nm LED illuminator. Digital photographs were taken by two different ways of exposure, i.e. appropriate exposure level and longer exposure. One side of the nose, cheek, and glabella was compared. The numbers and extents of fluorescence dots were counted and measured. As normal controls, seven individuals with apparent oiliness and no acne were enrolled.

RESULTS

Red fluorescent facial dots were observed and photographed digitally using the 405 nm LED illuminator. These were more numerous and extensive on the glabella and cheeks of acne patients.

CONCLUSION

Fluorescence digital photography of acne was successfully performed using a 405 nm LED illuminator. This illuminator could be used for acne evaluations.

Efficacy of oral isotretinoin in the control of skin and nasal colonization by antibiotic-resistant propionibacteria in patients with acne

BACKGROUND

Skin colonization by antibiotic-resistant propionibacteria is commonplace among acne patients globally. Increasing attention is now being paid to how resistance rates might be reduced to preserve the future efficacy of antibiotics, especially erythromycin and clindamycin in acne therapy.

OBJECTIVE

To assess the efficacy of oral isotretinoin in the control of antibiotic-resistant propionibacteria.

METHODS

Acne patients (72 in the U.K., 62 in the U.S.A.) colonized with high numbers of antibiotic-resistant propionibacteria were sampled before, during and 12 weeks after oral isotretinoin therapy. Propionibacterial samples were collected from five acne-prone skin surface sites using a detergent scrub method and from the anterior nares using moistened swabs. Total and antibiotic-resistant propionibacteria were enumerated by viable counting on media with and without selective antibiotics.

RESULTS

After 16 weeks of oral isotretinoin therapy, mean population densities of viable propionibacteria and variants resistant to erythromycin, clindamycin or tetracycline had fallen by more than 90% at all skin sites and in the nares. The sole exception was a smaller reduction in tetracycline-resistant strains on the lower back. In general, greater reductions were observed on skin than in the nares. By the end of the treatment period only three patients (all in Philadelphia) yielded no antibiotic-resistant strains from any site. Post-treatment, propionibacterial counts remained well below pretreatment levels but had begun to recover on the face and in the nares. The recovering propionibacterial population included both susceptible and resistant strains. Changes during and post-treatment at the two centres were similar but not identical.

CONCLUSIONS

Oral isotretinoin effectively reduced skin and nasal colonization by antibiotic-resistant propionibacteria. However, viable populations of resistant isolates persisted post-treatment at multiple sites. Novel methods are required to eradicate antibiotic-resistant propionibacteria completely, especially from the nasal reservoir.

A guide to antibiotic resistance in bacterial skin infections

The emergence of bacterial resistance to commonly used antibiotics is not new. In this review we have tried to cover the ever increasing problems facing the treatment and containment of bacterial skin infections. We have tried to give an overview of the varied mechanisms by which bacteria gain and spread antimicrobial resistance, whilst dealing with the patterns of resistance exhibited by some of the commonly encountered organisms. Where there is evidence, we have formulated an approach on how to tackle antibiotic resistance. Where there is a lack of evidence we have formulated what we perceive to be appropriate guidelines.

Topical antibacterial therapy for acne vulgaris

Topical antibiotics and benzoyl peroxide, are the two main topical antibacterial treatments indicated for mild-to-moderate acne vulgaris. Topical antibiotics act both as antibacterial agents suppressing Propionibacterium acnes in the sebaceous follicle and as anti-inflammatory agents. Benzoyl peroxide is a powerful antimicrobial agent that rapidly destroys both bacterial organisms and yeasts. Topical clindamycin and erythromycin have been proven to be effective against inflammatory acne vulgaris in concentrations of 1-4% with or without the addition of zinc. However, none of the antibacterials tested was more effective than benzoyl peroxide, which also has the advantage of not being associated with antimicrobial resistance. Topical antibacterial therapy should be discontinued once improvement is observed. If no improvement is observed within 6-8 weeks, the agent should be discontinued and a therapeutic switch considered. The primary limitation of benzoyl peroxide for some acne vulgaris patients is cutaneous irritation or dryness.Antibacterial therapy can be used in combination with other agents. Combining topical antibiotics and topical retinoids may enhance the efficacy, since the retinoid will improve the penetration of the antibiotic. Combining a topical antibiotic with benzoyl peroxide may increase the bactericidal effect of the antibiotic and reduce the potential for bacterial resistance. Topical and oral antibacterials should not be used in combination for the treatment of acne vulgaris, since this association may increase the risk of bacterial resistance.

Topical antibacterial treatments for acne vulgaris : comparative review and guide to selection

Topical antibacterial agents are an essential part of the armamentarium for treating acne vulgaris. They are indicated for mild-to-moderate acne, and are a useful alternative for patients who cannot take systemic antibacterials. Topical antibacterials such as clindamycin, erythromycin, and tetracycline are bacteriostatic for Propionibacterium acnes, and have also been demonstrated to have anti-inflammatory activities through inhibition of lipase production by P. acnes, as well as inhibition of leukocyte chemotaxis. Benzoyl peroxide is a non-antibiotic antibacterial agent that is bactericidal against P. acnes and has the distinct advantage that thus far, no resistance has been detected against it. Combined agents such as erythromycin/zinc, erythromycin/tretinoin, erythromycin/isotretinoin, erythromycin/benzoyl peroxide, and clindamycin/benzoyl peroxide are increasingly being used and have been proven to be effective. They generally demonstrate good overall tolerability and are useful in reducing the development of antibacterial resistance in P. acnes. The selection of a topical antibacterial agent should be tailored for specific patients by choosing an agent that matches the patient's skin characteristics and acne type. Topical antibacterial agents should generally not be used for extended periods beyond 3 months, and topical antibacterials should ideally not be combined with systemic antibacterial therapy for acne; in particular, the use of topical and systemic antibacterials is to be avoided as far as possible.

Update on pathogenesis and treatment of acne

Acne vulgaris is a common cutaneous disorder of the pilosebaceous follicle. More than 45 million people are affected with acne vulgaris. In addition, 80% of people in the United States report that they suffered from acne at one point in life. It is estimated that US consumers spend $1.2 billion each year for the treatment of acne. Typically, lesions are pleomorphic and range from open and closed comedones to inflammatory papules, pustules, cysts, and nodules, and scarring may result. The disease is important, with a significant effect on patients' self-esteem. The pathogenesis is only partially understood and is multifactorial. Successful management of acne requires an understanding of the pathophysiology of disease. The first half of this review discusses new discoveries in the pathogenesis of acne, and the second half introduces new and time-honored therapies.