When my teenage children developed acne, like most parents, I took them to see a general practitioner and a dermatologist for advice. Both consultations inevitably ended with a three-month prescription for antibiotics. I was very surprised to discover that antibiotics were offered as the first solution to treat 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 the use of antibiotics to treat acne clearly ignores the link between our gut and the rest of our health.
Whether antibiotics are bactericidal (kill bacteria) or bacteriostatic (stop bacterial growth), broad-spectrum antibiotics are prescribed today to treat acne, which means that antibiotics have an impact on the entire microbiome, without discrimination. There are two reasons why this is a problem. First, our health depends on a balanced gut microbiome, but when antibiotics disrupt this balance, all our systems suffer. Second, by making 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 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 the good from the bad.
If antibiotics act as anti-inflammatories for acne, shouldn't we prescribe anti-inflammatories instead? And, more importantly, is damaging our immune system an acceptable collateral damage for treating acne? In these times of epidemics and pandemics, we believe these questions must be amplified and brought to the public's attention.
A balanced microbiome means a world in constant readjustment of microorganisms living together, including bacteria, viruses, fungi, and other microorganisms.
A Silent Pandemic
Bacteria intelligently find ways to survive when threatened, with the surviving strains thus becoming resistant to the initial threat (such as the antibiotics used to target them). Many antibiotics have become useless as a result. Too few antibiotics have been discovered to deal with bacterial resistance. The effectiveness of antibiotics is hanging by a fool's game; the more we use them, the more useless they become. Today, we are facing a silent pandemic because we are running out of effective antibiotics. The misuse and overconsumption of antibiotics as prescription drugs are 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 end up in human organisms. In 2015, recognizing the urgency of the problem, the WHO created a global monitoring group to track the use of antibiotics, called GLASS - Global Antimicrobial Resistance Surveillance System, https://www.who.int/initiatives/glass and here for information in French.
Antibiotics for acne treatment
According to researchers at the University of Pennsylvania, American dermatologists prescribe more antibiotics per physician than any other medical specialty. In general, the first line on a prescription for anyone suffering from acne is an antibiotic.
Acne treatment protocols were developed over 30 to 40 years ago and therefore predate the scientific discoveries of the "Human Genome Project" which culminated in 2000, continued with the "Human Microbiome Project" (still ongoing). These projects were an inflection point in human history, paving the way for breakthrough advances in the fields of molecular science, genetics, the human microbiome, and other scientific fields. Even today, our understanding of the role of the microbiome on human health and the skin is in its infancy. However, we know enough to say that the microbiome plays a crucial role.
How does antibiotic resistance occur?
- Large number of bacteria. A few are resistant to antibiotics
- Antibiotics kill the bacteria causing the illness, but also the good bacteria that protect the body from infections
- The resistant bacteria now have favorable conditions to grow and dominate
- Bacteria can even transfer their drug resistance to other bacteria and thus create further problems.
When antibiotics are applied to the skin to target acne, they eradicate or render ineffective several types of bacteria, not just the bacteria responsible for acne (Cutibacterium acnes or C. acnes). This is a problem 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; the skin loses part of its ability to defend itself against external aggressors, to repair itself, and to communicate with our immune system. Moreover, malicious bacteria survive, and those that survive are the antibiotic-resistant strains.
Over the last few decades, data on bacterial resistance in acne have accumulated worldwide. In 1999, a study demonstrated 4% bacterial resistance against clindamycin in acne treatment. A 2014 Danish study reported that 52% of acne patients carried at least one of the clindamycin-resistant strains of C. acnes. In 2016, a study showed 90.4% bacterial resistance against clindamycin in acne. Other studies have shown that once antibiotic treatments are finished, resistant C. acnes strains cause acne again. But when antibiotics are used again to treat acne, they are ineffective. Although antibiotics began to be used as an acne treatment because of their power to eradicate skin bacteria, scientists have now discovered that the anti-inflammatory side effects of antibiotics might be the primary 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 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 antibiotic overconsumption, nor the problem of skin irritation or other side effects of using retinoids or benzoyl peroxide. Indeed, benzoyl peroxide generates free radicals on the skin. Free radicals are molecules that damage our cells and the DNA they contain.
Most importantly, this acne treatment also ignores the important role of the skin microbiome on healthy skin, including C. acnes (known as the bacteria responsible for acne). C. acnes is an important member of a balanced and healthy skin microbiome, but it has the capacity to become pathogenic when certain conditions are met, which then leads to acne. Scientists are still mapping the different strains of bacteria present on our skin, and the many sub-strains of C. acnes have not yet been fully understood.
At Skin Diligent, we believe that prescription treatments like antibiotics for treating acne are, at best, controversial. 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 are exposed 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/
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