When my teenage children developed acne, like most parents, I took them to see a GP and a dermatologist for advice. Both consultations inevitably ended with a prescription of 3-months of antibiotics. It was so baffling to discover that antibiotics were offered as the first solution to treat acne. Why would this be a problem? Because antibiotics damage our microbiome. The microbiome plays crucial roles 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 guts and the rest of our health.
Whether the antibiotics are bactericidal (kill bacteria) or bacteriostatic (stops bacterial growth), broad spectrum antibiotics are used to treat acne, which means antibiotics impact the whole microbiome, without discrimination. There are 2 reasons why this is an issue. Firstly, our health depends on a balanced gut microbiome but when antibiotics wreak havoc to this balance, all our systems are negatively affected as a consequence. Secondly, by rendering the gut microbiome ineffective, there is less inflammatory activity. Less inflammation can lead to less acne, so for this reason, antibiotics continue to be prescribed as an anti-inflammatory to treat acne. Inflammation is a good thing, as it is a sign that our body is fighting to stay healthy. It means our immune system is working. The problem with inflammation is the chronic inflammation, when the body over reacts to any particle/micro organism that enters the body and can't distinguish the good from the bad.
If antibiotics are anti-inflammatories for acne, shouldn't anti-inflammatory drugs be prescribed instead? And more importantly, does wreaking havoc to our immune system an acceptable collateral damage to treat acne? In times of epidemics and pandemics, we feel these questions should be amplified and brought to the public's attention.
A balanced microbiome means a constantly balancing world of micro-organisms that live together, including bacteria, viruses, fungi and other micro-organisms.
Antibiotics - The silent pandemic
Bacteria cleverly finds ways to survive when they are under threat, with surviving strains becoming resistant to the original threat (such as the antibiotics used to target it). Many antibiotics have been made useless as a result. There aren’t enough antibiotics discovered to cope with the bacterial resistance. The efficacy of antibiotics hangs in a number game, the more they are use, the more useless they become. Today, we are facing a quiet pandemic because we are running out of effective antibiotics. The misuse and overuse of antibiotics as prescription drugs is one cause. The use of antibiotics on animal food production, that also create antibiotic resistant strains, is suspected to be another as those resisting bacteria end up in human systems. In 2015, recognising the urgency of the problem, WHO has created a global surveillance group to monitor the use of antibiotics called GLASS – Global Antimicrobial Resistance Surveillance System, https://www.who.int/glass/en/
Antibiotics to treat acne
According to researchers at the University of Pennsylvania, US dermatologists prescribe more antibiotics per doctor than any other medical specialty. Globally, the first line of prescription for anyone with acne is antibiotics.
The protocol for acne treatment has been developed more than 30-40 years ago and they pre-date the scientific discoveries of the Human Genome Project that culminated in 2000, followed by the Human Microbiome Project (still ongoing). The projects were an inflection point in human history, paving the way for massive progress in cellular science, genetics, human microbiome and other fields of science. Even today, our understanding of the role of the microbiome on the human health and skin is in its infancy. However, we do know enough to say that microbiome plays a crucial role in human health.
World Health Organisation
When antibiotics are used to target acne, they wipe out large populations of various types of bacteria or render them ineffective, which opens the door for the unaffected remaining micro-organisms to overtake. This creates an imbalance of micro-organism population that make the microbiome ineffective in executing its many roles. Moreover, clever bacteria survive, and the surviving ones become antibiotic resistant strains.
Data has been accumulating globally in the last decades on the bacterial resistance on acne. In 1999, a study showed a 4% bacterial resistance against clindamycin when treating acne. In 2016, a study showed a 90.4% bacterial resistance against clindamycin in acne. A Danish study in 2014 reported that 52% of acne patients carried at least one of C. acnes resistant strain to clindamycin. Further studies have shown that after the antibiotic treatments are finished, the resistant C. acnes strains cause acne again. But when antibiotics are used again to treat acne, they are ineffective. Although antibiotics started as an acne treatment because of its power to eradicate skin bacteria, scientists have now discovered that perhaps the anti-inflammatory side effects of antibiotics could be the main mode of action against acne. So why continue to use antibiotics? Why not prescribe anti-inflammatory?
Antibiotics on the skin as topical creams
To improve efficacy and bacterial resistance against C. acnes, a mix of retinoids or benzoyl peroxide with antibiotics (topical creams) have been developed in recent years. However, this doesn't resolve the overuse of antibiotics and doesn’t address the problem of skin irritation or other side effects of using retinoids or benzoyl peroxide. In fact, benzoyl peroxide generates free radicals on the skin. Free radicals are molecules that damage our cells and the DNA inside.
More importantly, this acne treatment also ignores the important role of skin microbiome on healthy skin, including C. acnes (known as the acne causing bacteria). C. acnes is an important member of a balanced, healthy skin microbiome, but has the capacity to become pathogenic when certain conditions are met, which then lead to acne. Scientists are still mapping the various strains of bacteria on our skin and the many sub-strains of C. acnes haven't been fully understood yet.
At Skin Diligent, we believe medicated treatments like antibiotics to treat acne are controversial at best. Thanks to the advances of science, we now know acne is not an isolated skin condition but linked to the deregulation of one or more systems. We can target acne (and improve health) by modulating what we eat, how we manage our stress and limiting the chemicals we expose ourselves to.
To prevent the antibiotic resistance around the world, stopping the prescription of antibiotics to treat acne would be a step in the right direction.
Tule Park, co-founder of Skin Diligent