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Skin Ecology during Sebaceous Drought—How Skin Microbes Respond to Isotretinoin

2018; Elsevier BV; Volume: 139; Issue: 3 Linguagem: Inglês

10.1016/j.jid.2018.09.023

1523-1747

William H. McCoy, Elaine Otchere, Bruce A. Rosa, John Martin, Caroline Mann, Makedonka Mitreva,

Skin Protection and Aging

Twenty-five percent of acne vulgaris patients are prescribed oral antibiotic courses lasting longer than 6 months (Barbieri et al., 2017Barbieri J.S. James W.D. Margolis D.J. Trends in prescribing behavior of systemic agents used in the treatment of acne among dermatologists and nondermatologists: a retrospective analysis, 2004–2013.J Am Acad Dermatol. 2017; 77: 456-463Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar). These courses can cause significant collateral damage (dysbiosis, antibiotic resistance) (Leyden et al., 2014Leyden J.J. Del Rosso J.Q. Baum E.W. The use of isotretinoin in the treatment of acne vulgaris: clinical considerations and future directions.J Clin Aesthet Dermatol. 2014; 7 (S3–21)PubMed Google Scholar). Acne antibiotics target Cutibacterium (formerly Propionibacterium) acnes (Scholz and Kilian, 2016Scholz C.F.P. Kilian M. The natural history of cutaneous propionibacteria, and reclassification of selected species within the genus Propionibacterium to the proposed novel genera Acidipropionibacterium gen. nov., Cutibacterium gen. nov. and Pseudopropionibacterium gen. nov.Int J Syst Evol Microbiol. 2016; 66: 4422-4432Crossref PubMed Scopus (275) Google Scholar). This bacterium is associated with acne and can cause opportunistic infections (Achermann et al., 2014Achermann Y. Goldstein E.J.C. Coenye T. Shirtliff M.E. Propionibacterium acnes: from commensal to opportunistic biofilm-associated implant pathogen.Clin Microbiol Rev. 2014; 27: 419-440Crossref PubMed Scopus (355) Google Scholar). Though antibiotics improve acne, the only “cure” is isotretinoin, a non-antimicrobial (Weissmann et al., 1981Weissmann A. Wagner A. Plewig G. Reduction of bacterial skin flora during oral treatment of severe acne with 13-cis retinoic acid.Arch Dermatol Res. 1981; 270: 179-183Crossref PubMed Scopus (39) Google Scholar), systemic retinoid. While an isotretinoin course improves acne in most patients, 10%–20% of patients require retreatment (Leyden et al., 2014Leyden J.J. Del Rosso J.Q. Baum E.W. The use of isotretinoin in the treatment of acne vulgaris: clinical considerations and future directions.J Clin Aesthet Dermatol. 2014; 7 (S3–21)PubMed Google Scholar). Sebum and C. acnes levels decrease during treatment and then recover to pretreatment levels (Leyden and McGinley, 1982Leyden J.J. McGinley K.J. Effect of 13-cis-retinoic acid on sebum production and Propionibacterium acnes in severe nodulocystic acne.Arch Dermatol Res. 1982; 272: 331-337Crossref PubMed Scopus (52) Google Scholar), but acne remission frequently persists for life. As such, our understanding of isotretinoin’s mechanism remains unclear. The post-pubertal lipid-rich pilosebaceous unit (PSU) is dominated by C. acnes communities (1–13 strains/person) (Fitz-Gibbon et al., 2013Fitz-Gibbon S. Tomida S. Chiu B.-H. Nguyen L. Du C. Liu M. et al.Propionibacterium acnes strain populations in the human skin microbiome associated with acne.J Invest Dermatol. 2013; 133: 2152-2160Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar, Scholz et al., 2014Scholz C.F.P. Jensen A. Lomholt H.B. Brüggemann H. Kilian M. A novel high-resolution single locus sequence typing scheme for mixed populations of Propionibacterium acnes in vivo.PLoS One. 2014; 9: e104199Crossref PubMed Scopus (91) Google Scholar). Specific C. acnes strains and genomic elements have been associated with normal skin and others with acne (Barnard et al., 2016Barnard E. Shi B. Kang D. Craft N. Li H. The balance of metagenomic elements shapes the skin microbiome in acne and health.Sci Rep. 2016; 6: 39491Crossref PubMed Scopus (108) Google Scholar, Fitz-Gibbon et al., 2013Fitz-Gibbon S. Tomida S. Chiu B.-H. Nguyen L. Du C. Liu M. et al.Propionibacterium acnes strain populations in the human skin microbiome associated with acne.J Invest Dermatol. 2013; 133: 2152-2160Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar). Until recently though, no studies had investigated the microbial community response to acne therapy. In 2017, two groups reported that short-term acne treatments (6–10 weeks, antimicrobial and non-antimicrobial) changed the facial skin microbiome (Coughlin et al., 2017Coughlin C.C. Swink S.M. Horwinski J. Sfyroera G. Bugayev J. Grice E.A. et al.The preadolescent acne microbiome: a prospective, randomized, pilot study investigating characterization and effects of acne therapy.Pediatr Dermatol. 2017; 34: 661-664Crossref PubMed Scopus (25) Google Scholar, Kelhälä et al., 2018Kelhälä H.-L. Aho V.T.E. Fyhrquist N. Pereira P.A.B. Kubin M.E. Paulin L. et al.Isotretinoin and lymecycline treatments modify the skin microbiota in acne.Exp Dermatol. 2018; 27: 30-36Crossref PubMed Scopus (36) Google Scholar). Neither study examined patients after acne remission or after they discontinued treatment. In parallel with these groups, we have been pursuing work focused on answering these questions. We hypothesized that successful acne treatment with isotretinoin would shift an “acne microbiome” to resemble that found in normal skin. Over approximately 2 years in St. Louis, MO, we performed a pilot observational, prospective study comparing isotretinoin-treated acne subjects versus two untreated control groups (normal skin, acne) (see Supplementary Table S1 online). There were no significant differences in demographics among the groups. Exclusion criteria were history of non-acne facial rash or prestudy exposures that might affect acne, immunity, or microbes (Figure 1a). Isotretinoin subjects were evaluated before (time point [T] 1, 0 months), during (T2, 2 months; T3, 5–7 months), and after (T4, +5 months) treatment. Control individuals were evaluated at 0, 2, 5, and 10 months. Acne severity (Global Evaluation Acne score), skin sampling, control samples, targeted metagenomic next-generation sequencing (16S rRNA gene V1–V2 hypervariable region), and genomic analyses were performed, as previously described (Figure 1b) (Fitz-Gibbon et al., 2013Fitz-Gibbon S. Tomida S. Chiu B.-H. Nguyen L. Du C. Liu M. et al.Propionibacterium acnes strain populations in the human skin microbiome associated with acne.J Invest Dermatol. 2013; 133: 2152-2160Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar, Grice et al., 2009Grice E.A. Kong H.H. Conlan S. Deming C.B. Davis J. Young A.C. et al.Topographical and temporal diversity of the human skin microbiome.Science. 2009; 324: 1190-1192Crossref PubMed Scopus (1840) Google Scholar, Kong et al., 2017Kong H.H. Andersson B. Clavel T. Common J.E. Jackson S.A. Olson N.D. et al.Performing skin microbiome research: a method to the madness.J Invest Dermatol. 2017; 137: 561-568Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar). See the Supplementary Materials online for further details. We designed our sampling protocol to be integrated into a routine, 5–15 minute physician visit for acne. Subjects were sampled as they presented to clinic (i.e., no standardized skin hygiene regimen) with only minimal prestudy washout (Figure 1a). We swabbed active facial acne or malar cheek if no acne was present. Swabs were obtained rapidly ( 1 year prior) suggests that this increased α-diversity is temporary (see Supplementary Figure S6 online). On a genus level, our culture-independent genomic approach now validates the prior suggestion of culture-dependent studies that C. acnes globally declines throughout treatment (see Supplementary Figure S7a online). We also observed that Staphylococcus species increase initially but then decrease before treatment completion (see Supplementary Figure S7b), an observation not previously reported but in line with prior assessments of dry skin (Grice et al., 2009Grice E.A. Kong H.H. Conlan S. Deming C.B. Davis J. Young A.C. et al.Topographical and temporal diversity of the human skin microbiome.Science. 2009; 324: 1190-1192Crossref PubMed Scopus (1840) Google Scholar). Four taxa not previously associated with acne remission increase during therapy and remain elevated: Rothia, Flavobacterium, Enterobacter, and Micrococcus (Figures 2a and b, and see Supplementary Figure S7c–e and Supplementary Tables S4–S7 online). Isotretinoin T1 appears distinct from the control individuals (Figure 2a, and see Supplementary Figure S7), possibly because of prior acne treatments. Although levels of Propionibacterium species globally decrease during treatment, there appear to be varying effects on subtaxa within this genus. Our V1–V2 hypervariable region analysis suggests that Propionibacterium genus de novo V1–V2 ribotypes (V1V2_RTs) can differentiate four different Propionibacterium species and three C. acnes subspecies (Figure 2c and d, and see Supplementary Materials, Supplementary Figures S8–S10, and Supplementary Tables S8 and S9 online). V1V2_RT3, one of the eight most abundant V1V2_RTs, trends upward during and after treatment (Figure 2e, and see Supplementary Figure S11c online), as compared with acne-associated V1V2_RT6 (see Supplementary Figure S11e; see Supplementary Figures S12–S18 for additional information). Furthermore, a majority of our subjects had a distinct Propionibacterium community emerge during and then remain after isotretinoin treatment (low Propionibacterium, see Supplementary Figure S7a; high V1V2_RT3, Figures 2e, and see Supplementary Figure S11c). The proportion of the remaining subjects (38%: high Propionibacterium, low V1V2_RT3) is similar to that reported for isotretinoin-treated patients requiring future oral acne therapy (antibiotics/isotretinoin). We suggest that isotretinoin creates a Propionibacterium “population bottleneck” that selects for “healthy” Propionibacterium communities (Figure 2f) and other sebaceous skin taxa that persist after treatment, resulting in long-term acne remission (i.e., normal skin). This investigation confirmed prior work and greatly expands our understanding of acne pathogenesis by identifying microbial features of isotretinoin-mediated acne remission, yet many questions still remain. Do “healthy” skin taxa (e.g., V1V2_RT3, Rothia) promote clear skin, or are they correlated only with a clinical phenotype? If they are involved, when must they be present (before, during, or after therapy), where do they reside, and how long must they remain? Do posttreatment Propionibacterium communities predict the need for future treatments? We hope that our work will inspire future studies to answer these questions and ultimately lead to the development of “prebiotic fertilizers,” strain-selective “weed killers,” and/or probiotic Propionibacterium strains that optimize PSU ecosystems while avoiding antibiotic “collateral damage.” All subjects provided written informed consent. Washington University Institutional Review Board approved all protocols and consent forms. Deposition of DNA and RNA sequences: DDBJ/EMBL/GenBank KCKB01000000. William H McCoy: http://orcid.org/0000-0001-5115-3793 Elaine Otchere: http://orcid.org/0000-0002-2975-9665 Bruce A Rosa: http://orcid.org/0000-0002-6820-446X John Martin: http://orcid.org/0000-0003-1235-5952 Caroline M Mann: http://orcid.org/0000-0002-4624-2131 Makedonka Mitreva: http://orcid.org/0000-0001-9572-3436 The authors state no conflict of interest. This study was funded through a 2015 American Acne and Rosacea Society Clinical Research Grant. Author support during these studies also included the Oliver Langenberg Physician Scientist Training Pathway (to WHM) and Washington University MA/MD Research Program (to EA). Download .pdf (16.55 MB) Help with pdf files Supplementary Materials