Recent Updates in Pathophysiology and Treatments in Adult Acne

I thank the authors for a nice summary of updates on acne pathophysiology and novel treatments. My personal favorite topic was the role of the microbiome in acne. We have known that acne patients and healthy controls have different compositions of skin and gut microbiota. Now, we even see that acne treatment can alter the microbiome. In particular, treatment with oral antibiotics can lead to perturbations in not only the skin but also the gut microbiome (in addition to causing antibiotic resistance, which is another issue). Although consequences of long-term oral antibiotic use in acne are yet to be elucidated, literature from other disciplines have suggested that gut dysbiosis can be linked to chronic inflammation, obesity, cancer, cardiovascular disease, and neuropsychiatric conditions, such as dementia, depression, and anxiety. I started out as a gut mucosal immunologist before entering dermatology, and I am a believer that gut dysbiosis plays an important role in inflammatory skin conditions, including acne. Knowing this, it’s hard not to question whether I am staying faithful to my oath to “do no harm” whenever I prescribe oral antibiotics. Well, I still use antibiotics when necessary. However, I make every effort to minimize their use and the length of use.

Fortunately, there are other options. I agree with the authors on using topical and oral retinoids as the cornerstone therapy, as well as spironolactone for females for long-term treatment.  Topical anti-androgen clascosterone cream has been a great option, although insurance coverage has limited its use for my patients. I would love to see a study to evaluate the impact of low-dose narrow-spectrum antibiotics such as sarecycline on the microbiome (to see if the perturbations are less).   

In addition to these conventional therapies, supplements can be incorporated for those who desired a more holistic approach, including pantothenic acid, L-carnitine, zinc, probiotics, omega 3, and borage seed oil. For female hormonal acne, myoinositol and diindolmethane can be considered. This practice has allowed me to limit the use of long-term antibiotics in acne. 

Lastly, I emphasize nutrition counseling and appreciate that the authors brought light to the importance of diet in acne. Why is nutrition worth talking about? Because among the factors that shape the microbiome, nutrition is one that is modifiable. 

Here are some nutrition tips that I share with my acne patients:

• Increase fiber (30+ grams daily), which serves as a prebiotic that feeds the beneficial commensal bacteria
• Add probiotics as a supplement or as fermented foods
• Replace cow’s milk with plant-based milk
• Reduce sugary and fatty foods, reduce sugary drinks
• Eat real, whole foods to replace processed foods

These recommendations align with those of our colleagues who treat metabolic diseases, such as heart disease, diabetes, and obesity—which are increasing at alarming rates, even in youth. These recommendations can also help improve mental health, as the emerging gut–brain axis literature suggests. 

Patients are particularly motivated to treat visible conditions such as acne. Wouldn’t it be incredible if our young acne patients can be inspired to adapt habits that reduce their risk of inflammatory ailments in the long run? I sincerely hope that a holistic way of treating “beyond the skin” can become a mainstream phenomenon in dermatology. We have the privilege and responsibility to do so much more than clear the skin.