When my teenage children developed acne, like most parents, I took them to a GP and a dermatologist for advice. Both visits inevitably ended with a three-month course of antibiotics. I was very surprised to find that antibiotics were being offered as the first line of treatment for acne. Why is this a problem? Because antibiotics damage our microbiome. The microbiome plays a crucial role in our immune system, endocrine system, digestive system and nervous system. And using antibiotics to treat acne clearly ignores the connection between our gut and the rest of our health.
Whether antibiotics are bactericidal (kill bacteria) or bacteriostatic (stop bacterial growth), broad-spectrum antibiotics are now prescribed to treat acne, meaning that antibiotics impact the entire microbiome, indiscriminately. There are two reasons why this is problematic. First, our health depends on a balanced gut microbiome, but when antibiotics disrupt this balance, all of our systems suffer. Second, by rendering the gut microbiome ineffective, inflammatory activity is reduced. Less inflammation can lead to less acne, which is why antibiotics continue to be prescribed as anti-inflammatories to treat acne. Inflammation is a good thing because it is a sign that our body is fighting to stay healthy. It means that our immune system is working. The problem with inflammation is chronic inflammation, when the body overreacts to any particle or microorganism that enters the body and cannot distinguish good from bad.
If antibiotics act as anti-inflammatories for acne, shouldn't we be prescribing anti-inflammatories instead? And, more importantly, is damaging our immune system acceptable collateral damage for treating acne? In these times of epidemics and pandemics, we believe these issues need to be amplified and brought to the public's attention.
A balanced microbiome means a constantly readjusting world of microorganisms living together, including bacteria, viruses, fungi, and other microorganisms.
A Silent Pandemic
Bacteria cleverly find ways to survive when threatened, with surviving strains becoming resistant to the initial threat (such as the antibiotics used to target it). Many antibiotics have become useless as a result. Too few antibiotics have been discovered to address bacterial resistance. The effectiveness of antibiotics is a sham; the more they are used, the more useless they become. Today, we are facing a silent pandemic because we lack effective antibiotics. The misuse and overuse of antibiotics as prescription drugs is one cause. The use of antibiotics in the animal food industry, which also creates antibiotic-resistant strains, is suspected to be another, as these resistant bacteria find their way into human bodies. In 2015, recognizing the urgency of the problem, WHO established a global surveillance group to monitor antibiotic use, called GLASS - Global Antimicrobial Resistance Surveillance System, https://www.who.int/glass/en/ and here for information in French .
Antibiotics for acne treatment
According to researchers at the University of Pennsylvania, American dermatologists prescribe more antibiotics per doctor than any other medical specialty. Typically, the first line on a prescription for anyone with acne is an antibiotic.
Acne treatment protocols were developed over 30-40 years ago, predating the scientific discoveries of the “Human Genome Project” that culminated in 2000, and the ongoing “Human Microbiome Project.” These projects were a turning point in human history, leading to breakthroughs in molecular science, genetics, the human microbiome, and other scientific fields. Our understanding of the role of the microbiome in human health and skin is still in its infancy. However, we know enough to say that the microbiome plays a critical role.
How does antibiotic resistance occur?
- Large number of bacteria. Some are resistant to antibiotics
- Antibiotics kill the bacteria that cause disease, but also the good bacteria that protect the body from infection.
- Resistant bacteria now have favorable conditions to grow and dominate
- Bacteria can even pass on their drug resistance to other bacteria and create further problems.
When antibiotics are applied to the skin to target acne, they eradicate or render ineffective multiple types of bacteria, not just the bacteria that causes acne (Cutibacterium acnes or C. acnes). This is problematic for two reasons. Eradicating large populations of various types of bacteria opens the door for the remaining bacteria to take over. This creates an imbalance in the bacterial population, and the skin loses some of its ability to defend itself against external aggressors, repair itself, and communicate with our immune system. Additionally, malignant bacteria survive, and those that survive are the antibiotic-resistant strains.
Over the past few decades, data on bacterial resistance in acne have accumulated worldwide. In 1999, a study demonstrated 4% bacterial resistance to clindamycin in the treatment of acne. A 2014 Danish study reported that 52% of acne patients carried at least one of the clindamycin-resistant C. acnes strains. In 2016, a study showed 90.4% bacterial resistance to clindamycin in acne. Other studies have shown that once antibiotic treatments are completed, resistant C. acnes strains cause acne again. But when antibiotics are used again to treat acne, they are ineffective. Although antibiotics were first used as an acne treatment because of their ability to eradicate bacteria from the skin, scientists have now discovered that the anti-inflammatory side effects of antibiotics may be the main mode of action against acne. So why continue to use antibiotics? Why not just prescribe anti-inflammatories?
Antibiotics on the skin in the form of topical creams
To improve the efficacy and bacterial resistance against C. acnes, a mixture of retinoids or benzoyl peroxide with antibiotics (topical creams) has been developed in recent years. However, this does not solve the problem of overuse of antibiotics, nor the problem of skin irritation or other side effects of retinoid or benzoyl peroxide use. This is because benzoyl peroxide generates free radicals on the skin. Free radicals are molecules that damage our cells and the DNA they contain.
More importantly, this acne treatment also ignores the important role of the skin microbiome in healthy skin, including C. acnes (known as the bacteria that causes acne). C. acnes is an important member of a balanced and healthy skin microbiome, but it has the ability to become pathogenic when certain conditions are met, leading to acne. Scientists are still mapping the different strains of bacteria found on our skin, and the many substrains of C. acnes are not yet fully understood.
At Skin Diligent, we believe that prescription treatments like antibiotics for acne are controversial at best. Thanks to advances in science, we now know that acne is not an isolated skin condition but is linked to the dysregulation of one or more systems. We can target acne (and improve health) by modulating our diet, managing our stress, and limiting the chemicals we expose ourselves to.
To prevent antibiotic resistance worldwide, stopping the prescription of antibiotics to treat acne would be a step in the right direction.
Tule Park, Co-Founder of Skin Diligent
References:
pubmed.ncbi.nlm.nih.gov/9920982/
pubmed.ncbi.nlm.nih.gov/26955094/
pubmed.ncbi.nlm.nih.gov/24577497/
ncbi.nlm.nih.gov/pmc/articles/PMC5029230/