Am J Clin Deimotol 2012; 13 (6): 357-304

LEADING ARTICLE 1175-05Ó1 /12/OOCI6^)357/S49.95/0

Adis © 2012 Springer International Publishing A S . All rights reserved.

Newer Approaches to the Treatment of Acne Vulgaris

Thierry Simormrt
Private Practice, Brussels, Belgium

AbStrOCt The multifactorial etiology of acne vulgaris makes it challenging to treat. Current treatments include
topical retinoids, benzoyl peroxide, topical and systemic antibiotics, azelaic acid, and systemic isotretinoin.
Adjunctive and/or emerging approaches include topical dapsone, taurine bromamine, resveratrol, chemical
peels, optical treatments, as well as complementary and alternative medications. The purpose of this paper is
to discuss the therapies available for acne and their latest developments, including new treatment strategies
(i.e. re-evaluation of the use of oral antibiotics and avoidance of topical antibiotic monotherapy, use of
subantimicrobial antibiotic dosing, use of low-dose isotretinoin, optical treatments), new formulations
(microsponges, liposomes, nanoemulsions, aerosol foams), new combinations (fixed-combination products
of topical retinoids and topical antibiotics [essentially clindamycin] or benzoyl peroxide), new agents (topical
dapsone, taurine bromamine, resveratrol) and their rationale and likely place in treatment. Acne vaccines,
topical natural antimicrobial peptides, and lauric acid represent other promising therapies.

1. Introduction are compounded by the profusion of available treatments and

Acne vulgaris is one of the most common disorders en-
countered in dermatology practice.t''^' Epidemiologie studies
in Western industrialized countries estimated the prevalence
of acne in adolescents to be between 50% and 95%, depend-
ing on the method of lesion counting.t^"^' Although acne is
a disease primarily of adolescence, it may, to some degree,
persist into adulthood in a significant proportion of in-
dividuals, particularly women.['*•*' The disease burden of acne
has the ability to elicit in some sufferers significant mental
health concerns due to a heightened sense of shame relating to
appearance.'^'^i
Current understanding of acne pathogenesis continues to
evolve. Acne is an androgen-dependent disorder of piloseb-
aceous follicles. There are four primary pathogenic factors that
interact to produce acne lesions: (i) increased and altered an-
drogen-dependent sebum production; (ii) altered keratinization
leading to comedones; (iii) Propionibacterium acnes follicular
colonization; and (iv) release of inflammatory mediators into
the skin.l'-^J Although family history and environment factors
have an important role in the disease, the exact sequence of
events and how they interact remains unclear. Management,
therefore, is a multifactorial approach with several treatment
options targeted toward the multiple factors contributing to
acne pathogenesis. Treatment decisions for patients with acne
by the relative paucity of trials with active comparators. Con-
cerns about antibiotic resistance and isotretinoin safety as well
as the rise of novel adjunctive treatments bring new perspectives
to the treatment of acne. Alternatives to refractory acne,
aversion to prescription medications, adverse effects to con-
ventional therapy, and poor adherence to conventional therapy
drive interest in novel approaches. This review summarizes the
latest developments in the treatment of acne and their rationale
and likely place in treatment.
1.1 Literature Search Parameters
An extensive search was performed at the beginning of the
project. A systematic electronic search strategy was used to
retrieve all the recently published (January 2007-December
2011) clinical trials investigating therapies for acne. This review
focused on the therapy of acne and not on other forms of acne.
We obtained data from MEDLINE (National Library of
Medicine), PubMed, Current Contents, Homlnform (Glasgow)
[database of references to journal articles and books on home-
opathy], reference lists, and textbooks. There was no restriction
on language. The selected keywords were 'acne,' 'comedones,'
'vulgaris,' 'treatment,' 'therapy,' 'retinoids,' 'isotretinoin,' 'ben-
zoyl peroxide,' 'azelaic acid,' 'antibiotics,' 'dapsone,' 'laser,'
'light therapies,' 'vaccines,' and 'antimicrobial peptides.'
358 Simonart

2. Acne Therapy Table I. Conventional, emerging, and experimental anti-acne therapies for
acne vulgaris
The large number of products and product combinations,
Therapies Main concerns
and the scarcity of comparative studies, has led to disparate
Conventional
guidelines. Because of the paucity of evidence, these guidelines
Topical therapies
rely on the opinions of experts, many of whom declare significant
Topical retinoids Local irritation
potential conflicts of interest.'^'^"'^' Conventional treatments
include topical retinoids, benzoyl peroxide, azelaic acid, topical Fixed-combination products of topical Local irritation

and systemic antibiotics, systemic isotretinoin, and combined retinoids and topical antibiotics or BPO
BPO Local irritation
oral contraceptives for women.[^-'"'^l Novel approaches en-
compass recent developments in conventional treatments as Azelaic acid Local irritation

well as emerging therapies. These different therapies are sum- Topical antibiotics Antibiotic resistance

marized in table I. Systemic therapies

Isotretinoin Safety concerns
Systemic antibiotics Antibiotic resistance
2.1 Retinoids Oral contraceptives Lack of comparisons with
other standard therapies
2.1.1 Topical Refinoid Therapy
Emerging
Topical retinoids represent a mainstay of acne treatment
Lack of comparisons with
because they expel mature comedones, reduce microcomedone Topical dapsone
other standard therapies
formation, and exert anti-inflammatory effects through a
Lack of comparisons with
number of pathways, including downregulating toll-like re- Taurine bromamine
other standard therapies
ceptors, cytokines, and nitric oxide.''^^ Topical retinoids have a
Lack of comparisons with
favorable safety profile distinct from the toxicity of their sys- Chemical peels
other standard therapies,
temic counterparts. They are contraindicated in pregnancy, and local adverse effects
women of childbearing age must use effective contraception. Optical treatments Lack of comparisons with
Local adverse effects, including erythema, dryness, itching, and other standard therapies, local
stinging, occur frequently during the early treatment phase. adverse effects, high cost
Their impact varies with the vehicle formation, skin type, fre- Complementary and alternative Inconclusive results
quency and mode of application, use of moisturizers, and envi- medications
ronment factors such as sun exposure or temperature.''^1 They do Sodium sulfacetaminde Clinical data limited to case
not seem to cause temporary worsening of acne lesions.'"*^ series

The broad anti-acne activity and safety profile of topical Resveratrol Clinical data limited to one
open-label pilot study
retinoids justifies their use as first-line treatment in mild to
moderate forms of acne, more particularly in comedonal forms Experimental

of acne, as well as for maintenance therapy;''"'^^ these agents
can also minimize the potential for relapse; which is part of the
natural history of acne.''^^
A meta-analysis of five multicenter, randomized, inves-
tigator-blind trials involving 900 patients showed adapalene
0.1% gel to be as effective as, but less irritating than tretinoin
0.025% gel,''*] so that adapalene should be selected in prefer-
ence to tretinoin and isotretinoin.
Fixed-combination products of topical retinoids and topical
antibiotics (essentially clindamycin) or benzoyl peroxide are
significantly more efficacious in reducing the number of inflam-
matory and non-inflammatory lesions compared with retinoid
monotherapy.''^""! Furthermore, patients taking combination
therapy show faster signs of improvement.'^°] The quicker onset
Vaccination, natural antimicrobial peptides Absence of published clinical
data
BPO=benzoyl peroxide.
of action is believed to lead to greater patient adherence and to
reduce the amount of antibiotic exposure and risk of P. acnes
resistance.
Lately, formulation technology has focused on providing
more efficient penetration of the retinoids into the skin layers or
greater stability to the retinoid molecules so that lower con-
centrations of retinoids might afford better tolerability, but
maintain good efficacy. These potential novel systems for agent
delivery include microsponges, liposomes, nanoemulsions, and
aerosol foams. A micronized formulation of tretinoin (0.05%)

Adis © 2012 Springer International Publishing AG. Ali rigtits reserved. A m J Clin Dermatoi 2012; 13 (6)
Newer Approaches to Acne
gel has been developed that provides a more efficient delivery of
tretinoin, because of its optimal particle size, no degradation by
benzoyl peroxide, and better cutaneous tolerability than tretinoin
microsphere (0.1%) gel without compromising efficacy.'^''•^•^1
Retinoic acid-loaded, solid, lipid nanoparticles represent an-
other interesting alternative to reduce retinoic acid-induced
skin irritation without reducing efficacy.t^^^ Retinol has a lower
biologic activity but a better tolerability. Combination prod-
ucts using retinol with substances with anti-inflammatory and
antibacterial activity might increase this biologic
2.1.2 Isotretinoin Therapy
Oral isotretinoin was approved for use in acne in 1982.
Targeting the four primary pathogenic factors of acne, it re-
mains arguably the most effective acne medication available.
Although comparative trials are missing, clinical experience
confirms that the relapse rates after treatment with isotretinoin
are the lowest among all the available therapies. Originally, it
was reserved for severe, recalcitrant, nodular acne that was
unresponsive to topical therapy. Although many authorities
believe that isotretinoin should be reserved for severe acne not
responding to appropriate antibiotics and topical therapy, the
pubhshed data and opinion of some experts support systemic
isotretinoin being considered as the first-hne treatment for se-
vere papulopustular, moderate nodular, and severe nodular/
conglobate acne.t''^'^"'^'^^-^^' Reasons supporting oral iso-
tretinoin as a first-line treatment for severe acne include clinical
effectiveness, prevention of scarring, and quick improvement of
a patient's quahty of life.
The evidence on the best dosage, including cumulative dos-
age, is rare and partly conflicting. In most trials, higher dosages
have lead to better response rates whilst having less favorable
safety/tolerability profiles. However, there is cumulative evi-
dence that low-dose isotretinoin might be a useful treatment
option for moderate acne.'^^'^^l Attempts to determine the cu-
mulative dose necessary to obtain an optimal treatment re-
sponse and low relapse rate have not yet yielded sufficient
evidence for a strong recommendation. Research is also needed
to investigate whether isotretinoin could be beneficial if used
sooner for moderate cases. Although effective against severe
acne, isotretinoin is associated with significant adverse effects,
including cheilitis, dry skin and mucous membranes, epistaxis,
increased risk of cutaneous Staphylococcus aureus infections,
temporary worsening of lesions, photosensitivity, increased
serum lipids, myalgias, hyperlipidemia, pseudotumor cerebri,
and teratogenicity.''^' Associations with inflammatory bowel
disease are controversial.'^^'^°' There are plausible biologic
mechanisms by which retinoids might induce psychopathol-
Adis © 2012 Springer International Publlstiing AG. All rights reserved.
359
^ A systematic review of isotretinoin use and depression
and suicidal behavior published in 2007 did not find any evi-
dence to support the notion that depressive symptoms or
diagnosis increased after treatment, and some in fact, demon-
strated a trend toward fewer or less severe depressive symptoms
after isotretinoin therapy.'^'' The picture is a complex one as
depression and suicidal ideation occur with severe acne in the
absence of isotretinoin treatment.^^^'^^^ The current recom-
mendation is that patients with severe acne with a history of
attempted suicide should not automatically be refused iso-
tretinoin but should be monitored for suicidal behavior after
treatment has ended.t^''^ Claims of injury have fueled hysteria
among laypersons about the use of this drug. Overwhelmed
with worries of its potential adverse effects, the public forgets
that withholding isotretinoin therapy is not without its own
risks. Isotretinoin therapy can prevent hfelong and permanent
physical and psychological scarring that comes as a matter of
course with severe acne.'^'^^-^^-^^' Over 20 million people
worldwide have taken the drug, with several studies demon-
strating its safety and few long-term adverse effects.'^^'
2.2 Antibiotics
2.2.1 Topical Antibiotics
How topical antibiotics improve acne has not been clearly
defined, but they seem to act directly on P. acnes colonization
and its subsequent proinflammatory effects on comedogenesis.
The most commonly used topical antibiotics are clindamycin
and erythromycin. However, studies on P. acnei resistance have
highlighted the need for treatment guidelines to restrict the use
of antibiotics in order to limit the emergence of resistant strains.
It has been argued that the most likely effect of resistance is to
reduce the clinical efficacy of antibiotic-based treatment regi-
mens to a level below that which would occur in patients with
fully susceptible flora.'^^l Some trials have suggested a clear
association between P. acnes resistance to the appropriate an-
tibiotic and poor therapeutic response.'^^' There is a gradual
decrease in the efficacy of topical erythromycin in clinical trials
of therapeutic intervention for acne, which is probably related
to the development of antibiotic-resistant propionibacteria.t^^^
Decreased clinical efficacy of antibiotics for dermatologie
conditions other than acne or for non-dermatologic infectious
diseases appears as another major threat. Monotherapy with
topical antibiotics is thus no longer recommended.^''"'^'^^"^^1
2.2.2 Systemic Antibiotics
Although antibiotics have shown effectiveness in terms of
reducing the number of acne lesions, most antibiotic courses are
Am J Clin Dermatol 2012:13 (6)
360
not curative. The use of antibiotics for acne has been questioned
owing to resistance concerns, especially since they are re-
peatedly used for long periods at low doses. Furthermore, there
is a low evidence level that oral antibiotics are more effective
than topical preparations for mild-to-moderate facial acne.'^^'
Tetracyclines are the first-hne oral antibiotic therapy in acne.
Overall, there is insufficient evidence to support one tetra-
cycline over another in terms of efficacy.''*^] There could be no
justification in continuing to use minocycline as a first-hne
therapy in acne because of an uncertainty safety profile and a
lack of advantages over other tetracyclines (i.e. first-generation
cyclines, doxycycline and lymecychne).'''^''*']
In the range of dosages investigated in the clinical studies,
the tetracycline dosage seems to have no impact on efficacy.''*^'
Although two trials of subantimicrobial dosing (i.e. the pre-
scription of low doses that are anti-inflammatory but not
antimicrobial) have shown a reduction in the number of in-
flammatory and non-inflammatory lesions,'''^-'*^' the studies are
too small to make rehable estimates of bacterial resistance that
could be promoted by the lower doses used.
As a consequence of resistance concerns, the use of oral
antibiotics should be limited (indication, duration) and topical
antibiotic monotherapy should be avoided.'^''"'^•^*'^*] Other
recommendations are that we should use stricter cross-infection
control measures when assessing acne in the clinic and combine
any topical/systemic antibiotic therapy with broad-spectrum
antibacterial agents, such as benzoyl peroxide.'"'^*'''^]
Although oral macrolides like erythromycin may represent
an alternative in patients who are intolerant or allergic to tet-
racyclines and may be used in pregnancy, there is little evidence
to support the use of other oral antibiotics (i.e. chndamycin,
cotrimoxazole, quinolones).
2.3 Benzoyl Peroxide
Benzoyl peroxide is a safe and effective over-the-counter
preparation that reduces the number of P. acnes by suppress-
ing growth without the risk of resistance selection. Low con-
centration (2.5% or 5%) benzoyl peroxide is recommended,
since it is less irritating and there is no clear evidence that
stronger preparations are more effective.''*^i Single-agent ben-
zoyl peroxide works as well as oral antibiotics. It has greater
activity than topical tretinoin against inflammatory lesions.''*^'
The anti-acne activity and safety profile of benzoyl peroxide
justifies its use as first-line treatment in mild to moderate
forms of acne, more particularly in papular/pustular forms
of acne.''^''**! Several studies suggest that the efficacy of ben-
zoyl peroxide can be enhanced when used in combination
Adis © 2012 Springer internatianai Publishing AG. Aii rights reserved.
Simonart
with topical retinoids, antibiotics (essenti
and, more recently, nadifloxacin'''^'), and tertiary amines,
such as an allylamine. However, a recent systematic review
showed that combination products containing benzoyl per-
oxide were only incrementally better than benzoyl peroxide
alone.'"*«]
2.4 Azeloic Acid
Azelaic acid has both antimicrobial and anticomedonal prop-
erties. The data on azelaic acid (15% or 20%) show an inferior
efficacy compared with benzoyl peroxide'"*^'^"] in reducing non-
inflammatory lesions but a similar efficacy in reducing inflam-
matory lesions.'''''^°] There are very little data comparing the
efficacy of adapalene, topical isotretinoin, or topical antibiotics
with azelaic acid. Azelaic acid shows a trend towards a better
tolerability/safety profile compared with benzoyl peroxide
(5%),''*') topical adapalene,'^«] and tretinoin.'^']
2.5 Topical Dapsone
Topical dapsone 5% gel offers documented efficacy for the
reduction of both inflammatory and non-inflammatory acne
lesions. Topical dapsone is superior to placebo but has yet to be
compared with standard topical treatments. It has been proven
safe, presenting none of the hématologie risks associated with
oral dapsone. With regard to safety, the studies demonstrated
that the concentrations of dapsone and N-acetyl dapsone re-
main low and do not accumulate over time once steady state is
reached. Topical dapsone 5% gel also appears to be safe to use in
patients with glucose-6-phosphate dehydrogenase deficiency.'^^]
Data suggest the vehicle formulation enhances healing and
contributes to tolerability, making topical dapsone 5% gel a
worthwhile anti-inflammatory treatment for patients with
mild-to-moderate
2.6 Taurine Bromamine
Taurine bromamine, the product of taurine and hypobro-
mous acid, exerts anti-inflammatory and antibacterial properties
against P. acnes and Staphylococcus epidermidis. In a double-
blind investigation, the efficacy and safety of 3.5 mM taurine
bromamine cream versus clindamycin gel were comparable.''^'
These data suggest that taurine bromamine can be used as a
topical agent in the treatment of acne, especially in patients who
have already developed antibiotic resistance, but needs to be
confirmed by further studies.
A m J Ciin Dermatoi 2012; 13 (6)
Newer Approaches to Acne
2.7 Chemical Peels
The most common chemicals used include a-hydroxy acids
such as glycolic acid and ß-hydroxy acids such as salicylic
acids.f'^^l In vitro data demonstrate that glycolic acid has mod-
erate growth inhibitory and bactericidal effects on P. acnesP^^
Search of the literature revealed very few clinical trials of peels
in acne;'^^' a majority of these trials included small numbers of
patients, were not controlled, and were open label. The evi-
dence that is available does support the use of chemical peels in
acne as all trials had generally favorable results despite differ-
ences in assessments, treatment regimens, and patient pop-
ulations. Notably, no studies of chemical peels have used an
acne medication as a ^ phate lasers, photodynamic therapy (PDT), and pulsed diode
2.8 Other Topical Therapies
Salicylic acid is an exfoliant and is a component of many
over-the-counter preparations. No studies support routine use
of salicylic acid in preference to other topical therapies. Some
data suggest that the addition of salicylic acid to other topical
therapies (i.e. clindamycin plus benzoyl peroxide) may improve
the clinical outcome.t'^1
An over-the-counter emollient foam, containing sodium
sulfacetaminde 10% and sulfur 5% exhibiting moisturization
properties as well as antibacterial activities against P. acnes
in vitro has been shown to be effective in a limited series of
patients with acne.'^^' Further studies are obviously required to
assess its usefulness.
Recently, a single-bhnd, vehicle-controlled, pilot study
showed positive results for resveratrol on acneic skin. Resver-
atrol is a natural phytoalexin exhibiting activity against
P. acnes as well as anti-inflammatory properties and is produced
by some spermatophytes, such as grapes and other plants.t^'
2.9 Oral Oontraceptives
All types of combined oral contraceptives seem to be effec-
tive in reducing inflammatory and non-inflammatory acne le-
sions, but there is no clear evidence that those containing ad-
ditional cyproterone offered any further beneflt.I^'l Although
there are few studies comparing combined oral contraceptives
with other acne treatments, hormonal therapy is regarded as an
excellent choice for women who need oral contraception.f^'^''*'^'
However, dermatologists have historically been reluctant to
prescribe oral contraceptives for acne because of long-standing
recommendations requiring a preliminary pelvic examination
and Papanicolaou smear before initiation of therapy. In recent
Adis © 2012 Springer International Publishing AG. Ail rights reserved.
361
guidehne shifts, expert panels and major health organizations
have reached a consensus that oral contraceptive provision no
longer necessitates the performance of a pelvic examination and
Papanicolaou smear.I^^' Another Cochrane review failed to
show any benefit of spironolactone for acne, based on limited
studies.'*^'
2.10 Optical Treatments (Laser Therapy, Light Sources, and
Photodynamic Therapy)
Optical therapies that have been used to treat acne include
broad-spectrum continuous-wave visible light (blue and red),
intense pulsed light, pulsed dye lasers, potassium titanyl phos-
laser.
Light therapy is based on the observation that P. acnes is
capable of synthesizing chromophores such as porphyrins.'^^'
Whereas blue light has been shown to photoinactivate P. acnes,
it does not penetrate skin very far. On the other hand, red light,
which is less effective at porphyrin activation, can reach deeper
sebaceous glands.t^^' Compared with light therapy, lasers have
the abihty to concentrate coherent light on a smaller area of
tissue. Although there are some studies of the treatment of non-
inflammatory lesions with laser and light sources, the published
evidence is still very scarce. There is conflicting evidence regard-
ing the efflcacy of red light against inflammatory lesions com-
pared with placebo. Blue hght has superior efficacy against
inflammatory lesions/total lesions compared with placebo.^^^'^^'
The combination of blue-red light therapy may act synergistically
and be more effective at reducing the number of inflammatory
lesions.'^'^ There is insufficient evidence regarding the efflcacy of
all other light and laser interventions compared with placebo.'^''
PDT refers to the use of aminolevulinic acid, methyl-
aminolevulinic acid, or other photosensitizing agents to en-
hance the effect of subsequent light or laser therapy. Topical
appUcation of these molecules results in significant build-up of
porphyrins in sebaceous glands and the efficacy of PDT in acne
is believed to be related in part to a decrease in sebaceous gland
activity following light activation of the photosensitizer. Most
trials of PDT showed some benefit, which was greater with
multiple treatments, and better for non-inflammatory acne
lesions. However, the improvements in inflammatory acne
lesions were not better than with topical adapalene 1% gel.t™'
There are also some studies showing that treatment with the
infrared 1450 nm diode laser reduces inflammatory acne lesions
and may provide a long-term remission in acne. The presumed
mechanism of acne improvement is through heating of the se-
baceous gland and reduced sebaceous gland activity.'^"'
Am J Clin Dermatol 2012; 13 (6)
362
A photopneumatic platform (Isolaz™; Aesthera Corpo-
ration, Pleasanton, CA, USA) combining vacuum pressure
with a broadband light source device has also been shown to
improve mild to moderate inflammatory and comedonal
acne.'^^'^^] The vacuum suction raises target structures in the
dermis closer to the surface of the skin prior to exposure, al-
lowing for more efficient energy transmission.''^''^]
The clinical development of optical therapies is also limited
by adverse effects, including pain, erythema, edema, crusting,
hyperpigmentation, and pustular eruptions.'^^'™]
Thus, although optical therapy may improve acne initially, a
standardized treatment protocol, longer term outcomes, com-
parisons with conventional acne therapies, and widespread
chnical experience are still lacking. Accordingly, optical treat-
ments are not included among first-line treatments,'*''™] espe-
cially with current high costs.
2.11 Complementary and Alternative Medicotions
The use of complementary and alternative medications
(CAMs) in acne is widespread and there is a growing public
demand for the application of CAMs to acne.''"''^' A systematic
review of CAMs for the treatment of acne in 2006 identified
15 randomized controlled trials covering various approaches
such as Aloe vera, pyridoxine, fruit-derived acids, kampo
(Japanese herbal medicine), and ayurvedic herbal treat-
ments.''^] Although mechanisms of potential benefit for some
of the CAMs were biologically plausible, the included studies
were generally of poor méthodologie quality and inconclusive.
Analogously, a systematic review of botanical products for
acne failed to provide any good-quality evidence of bene-
fit.'''*'"] There is no controlled trial evaluating the efficacy of
homeopathic remedies in acne.'"'
2.12 Nutrition
Some level of evidence supports the association of acne and
high glycémie loads, certain dairy products (especially milk),
and refined sugar product ingestion.''*'"] The apparent
absence of acne in native non-Westernized populations, the
Kitavan Islanders of Papua New Guinea and the Ache hunter-
gatherers of Paraguay,'^°] has led to the proposal that high
glycémie loads in a Western diet could have a role in acne,
perhaps through hyperinsulinemia leading to increased an-
drogens, increased insulin-like growth-factor-1, and altered
retinoid signaling.'^""^^] A randomized controlled trial showing
that a low glycémie load diet might improve acne provides
preliminary support for this theory.'«'] Future studies are re-
Adis © 2012 Springer internationai Publishing AG. Aii rights reserved.
Simonart
quired to determine if dietary modification will reduce long-
term acne burden.
2.13 Promising Therapies
In the more distant future, vaccination with killed P. acnes
and sialidase-based vaccines may lead to novel avenues of im-
munologie intervention.'^'«^]
Over the past years, natural antimicrobial peptides have
attracted considerable interest as a new type of antimicrobial
agent for several reasons, including their relative selectivity
towards targets (microbial membranes), their rapid mechanism
of action and, above all, the low frequency in selecting resistant
strains. Several antimicrobial peptides including epinecidin-
and granulysin-derived peptides, omiganan pentahydrochloride,
and frog skin peptides have been found to exert activity against
P. acnej.'«'''«'] The anti-inflammatory effects combined with
potent antimicrobial activities and Oa-production-inhibition
activities of cathelicidin indicate its potential as a novel ther-
apeutic option for acne.'«^]
The strong activity of lauric acid (C12:0) against P. acnes,
a middle chain, free fatty acid commonly found in natural
products, also highlights its potential as an alternative treat-
ment option to the antibiotic therapy of acne.'«*]
3. Conclusions
Acne continues to remain a challenge to practicing chnicians
and dermatologists. As the pathogenesis of acne lesions is
complex, so is the myriad of available treatments. Despite sig-
nificant developments, oral isotretinoin remains so far the most
effective acne medication available. Given the restrictions
placed on the use of isotretinoin and the increase in antibiotic-
resistant strains of P. acnes, there is a high clinical need for new
treatments.
Acknowledgments
No sources of funding were used to prepare this article. The author has
no conflicts of interest that are directly relevant to the content of this
article.
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Correspondence: Dr Thierry Simonart, Private Practice, av. Gounod 27,
B-1070 Brussels, Belgium.
E-mail: tsimonar@ulb.ac.be
A m J Clin Dermatol 2012; 13 (6)
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