In addition to being one of the most prevalent and all-too-familiar skin conditions, acne is also one of the most common skin diseases for which patients have begun to seek alternative treatment therapies. learn more.
In addition to being one of the most prevalent and all-too-familiar skin conditions, acne is also one of the most common skin diseases for which patients have begun to seek alternative treatment therapies. For most, acne tends to be chronic, and many patients, feeling that they have exhausted conventional treatments, have sought out options that they consider safer or more effective. Surprisingly, despite decades of research, the conventional treatment armamentarium for acne remains somewhat limited. An additional challenge is that acne is not monomorphic and is classified into numerous clinical categories such as hormonal female acne, acne in pregnancy and lactation, adult acne, and adolescent acne. Treatment corresponds to the classification and the severity, but traditional therapies remain relatively limited and non-specific to these categories. As we accumulate more evidence for antibiotic resistance and the side effects of long-term oral therapies, as well as continue to try to overcome the irritation potential of mainstream topical therapies, there is growing interest in safe, efficacious, and tolerable alternative therapies.
As we examine the thinking about the pathogenesis of acne over time, it is important to see how alternative therapies may complement this knowledge evolution. The clinical and histological features of acne are well described, with conventional thinking that Propionibacterium acnes (P.acnes) bacteria-normally present on the skin-colonize the duct of the sebaceous gland, resulting in a non-inflammatory comedo or inflammatory papule, pustule or nodule.1 However, in the last decade much has been written that suggests an inflammatory state is present in the skin long before the clinical formation of an acne lesion.2 Additional evidence now suggests that several inflammatory mediators in the skin, as well as oxidative stress, may contribute to the early formation of acne lesions.3,4
NEXT: Antioxidants: Vitamin C and Nicotinamide
Antioxidants: Vitamin C and Nicotinamide
With evidence that oxidative stress in the skin contributes to acne formation, practitioners should consider available topical antioxidants as potential novel treatment modalities. Topical antioxidants such as Vitamin C and Nicotinamide have both demonstrated efficacy in acne therapy.
Vitamin C, or ascorbic acid, is a water-soluble vitamin that can be used. Antioxidants are commonly thought to have a role in treating aging skin or in cosmetic application, but randomized, controlled trials have found that topical application of a stable precursor of ascorbic acid is effective in reducing acne lesion counts, both alone or, in combination with a topical retinoid.5,6 Because vitamin C is notoriously unstable, it is advisable to consider the formulation when used for this application.
Nicotinomide, also known as niacinamide, is a water-soluble B vitamin. Numerous studies have investigated the use of nicotinamide both topically and orally for acne and reasonable evidence exists for the use of this agent topically in the treatment of acne. It has performed equally or superiorly to topical clindamycin in some studies.7,8,9 Nicotinomide has also been shown to inhibit IL-8 production in vitro, potentially explaining its anti-inflammatory properties in the skin.10
Botanicals: Tea Tree oil and Green tea
Botanicals have been used for years as medicinal agents. While many have been evaluated in the treatment of acne, there is promising evidence to support the use of both tea tree oil and green tea.
Tea tree oil is commonly used as a topical antimicrobial agent. The antiseptic properties of tea tree oil are thought to be due to its ability to disrupt the bacterial membrane.11 Topical tea tree oil has been shown to be superior to placebo, and comparable in efficacy to benzoyl peroxide.12,13 However, tea tree oil is also known to be extremely irritating, with a high contact allergen rate, so caution should be used in recommending this option without spot testing.
The dried, cured leaves of C. sinensis, or green tea, have been used medicinally for 5000 years.14 Most commonly, green tea is used orally to promote good health, but there is some evidence that when used topically, it can be helpful in the prevention of acne, perhaps through decreasing sebum production.15,16,17
The relationship between diet and acne has long been controversial. Perhaps one of the most common questions a patient will ask is: “Could it be anything I am eating?” The answer to that question has evolved over time, and growing evidence supports the role of diet in inflammation and acne. Contrary to conventional belief, dairy, carbohydrates, and a high glycemic diet may actually exacerbate acne, and converging evidence suggests avoidance or modulation of these dietary elements may help.18,19,20,21
Probiotics are another dietary modification worth considering in the treatment of acne. These live microorganisms are associated with a number of beneficial effects in the body. Not only have probiotics been shown to mitigate some of the adverse effects of long-term oral antibiotic therapy, but they may also potentially offer a reduction of inflammation in acne by decreasing the release of inflammatory cytokines.22 The probiotics most commonly used in over-the-counter supplementation are lactobacilli and bifidobacterium and they can be incorporated in oral form as part of a broader treatment regimen.
These are only some among the various alternative treatments currently available for acne, which include both evidence-based as well as more anecdotal applications. As the demand for alternative therapies grows and as the understanding of the pathophysiology of acne evolves, there are numerous other botanicals and antioxidants worth investigating.
1. Gollnick H, Cunliffe W, Berson D, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2003;49(1 Suppl):S1-37.
2. Thiboutot D, Gollnick H, Bettoli V, et al. New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne group. J Am Acad Dermatol. 2009;60(5 Suppl):S1-50.
3. Tanghetti EA. The role of inflammation in the pathology of acne. J Clin Aesthet Dermatol. 2013;6(9):27-35.
4. Bowe WP, Patel N, Logan AC. Acne vulgaris: the role of oxidative stress and the potential therapeutic value of local and systemic antioxidants. J Drugs Dermatol. 2012;11(6):742-6.
5. Ruamrak C, Lourith N, Natakankitkul S. Comparison of clinical efficacies of sodium ascorbyl phosphate, retinol and their combination in acne treatment. Int J Cosmet Sci. 2009;31(1):41-6.
6. Woolery-lloyd H, Baumann L, Ikeno H. Sodium L-ascorbyl-2-phosphate 5% lotion for the treatment of acne vulgaris: a randomized, double-blind, controlled trial. J Cosmet Dermatol. 2010;9(1):22-7.
7. Khodaeiani E, Fouladi RF, Amirnia M, Saeidi M, Karimi ER. Topical 4% nicotinamide vs. 1% clindamycin in moderate inflammatory acne vulgaris. Int J Dermatol. 2013;52(8):999-1004.
8. Morganti P, Berardesca E, Guarneri B, et al. Topical clindamycin 1% vs. linoleic acid-rich phosphatidylcholine and nicotinamide 4% in the treatment of acne: a multicentre-randomized trial. Int J Cosmet Sci. 2011;33(5):467-76.
9. Shalita AR, Smith JG, Parish LC, Sofman MS, Chalker DK. Topical nicotinamide compared with clindamycin gel in the treatment of inflammatory acne vulgaris. Int J Dermatol. 1995;34(6):434-7.
10. Grange PA, Raingeaud J, Calvez V, Dupin N. Nicotinamide inhibits Propionibacterium acnes-induced IL-8 production in keratinocytes through the NF-kappaB and MAPK pathways. J Dermatol Sci. 2009;56(2):106-12.
11. Carson CF, Hammer KA, Riley TV. Melaleuca alternifolia (Tea Tree) oil: a review of antimicrobial and other medicinal properties. Clin Microbiol Rev. 2006;19(1):50-62.
12. Enshaieh S, Jooya A, Siadat AH, Iraji F. The efficacy of 5% topical tea tree oil gel in mild to moderate acne vulgaris: a randomized, double-blind placebo-controlled study. Indian J Dermatol Venereol Leprol. 2007;73(1):22-5.
13. Bassett IB, Pannowitz DL, Barnetson RS. A comparative study of tea-tree oil versus benzoylperoxide in the treatment of acne. Med J Aust. 1990;153(8):455-8.
14. The Review of Natural Products Paperback – November 15, 2012 by Ara DerMarderosian Ph.D. (Author), John A. Beutler Ph.D. (Author) Publisher: Lippincott Williams & Wilkins; Seventh edition (November 15, 2012) Language: English. ISBN-10: 1574393464
15. Elsaie ML, Abdelhamid MF, Elsaaiee LT, Emam HM. The efficacy of topical 2% green tea lotion in mild-to-moderate acne vulgaris. J Drugs Dermatol. 2009;8(4):358-64.
16. Mahmood T, Akhtar N, Khan BA, Khan HM, Saeed T. Outcomes of 3% green tea emulsion on skin sebum production in male volunteers. Bosn J Basic Med Sci. 2010;10(3):260-4.
17. Yoon JY, Kwon HH, Min SU, Thiboutot DM, Suh DH. Epigallocatechin-3-gallate improves acne in humans by modulating intracellular molecular targets and inhibiting P. acnes. J Invest Dermatol. 2013;133(2):429-40.
18. Bowe WP, Joshi SS, Shalita AR. Diet and acne. J Am Acad Dermatol. 2010;63(1):124-41.
19. Ismail NH, Manaf ZA, Azizan NZ. High glycemic load diet, milk and ice cream consumption are related to acne vulgaris in Malaysian young adults: a case control study. BMC Dermatol. 2012;12:13.
20. Di landro A, Cazzaniga S, Parazzini F, et al. Family history, body mass index, selected dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young adults. J Am Acad Dermatol. 2012;67(6):1129-35.
21. Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial. J Am Acad Dermatol. 2007;57(2):247-56.
22. Muizzuddin N, Maher W, Sullivan M, Schnittger S, Mammone T. Physiological effect of a probiotic on skin. J Cosmet Sci. 2012;63(6):385-95.