Looking At Acne Differently- In Conversation With Dr. Anita Damodaran

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A severe case of nodular acne. Credit: Wikimedia commons
A severe case of nodular acne. Credit: Wikimedia commons

Acne is a skin condition occurring mainly on the face, chest and back with diverse contributors and is known to occur and last over varied periods of time. It not only affects at the time of puberty but can also last into late adulthood and even show up at the time of menopause.

Apart from being an aesthetic dampener, acne can also be painful and cause severe irritation. This makes it increasingly difficult to engage in day to day activities such as shaving, wearing helmets or glasses. Extensive research has and is being conducted to decode the root causes and treatments for acne.

Of the myriad factors accused to be acne-causing – diet, stress, hormones, lack of hygiene, dandruff, poor gut are some triggers that top the list. Treatments are offered by different schools of medicine based on their understanding of this condition.

Occurrence and Manifestation of Acne

Comedones are hair follicles that have been enlarged and clogged by sebum Credit: Wikimedia Commons
Comedones are hair follicles that have been enlarged and clogged by sebum Credit: Wikimedia Commons

P. acnes, is a bacteria that is present on everyone’s skin, but causes acne only in individuals with overly active sebaceous glands and clogged pores. Sebum/oil in right quantities is required to moisturize skin and when secreted in excess, sebum along with dead skin (shed keratin) serves as food for the bacteria that are trapped in the pores of the hair follicles on the skin’s surface. This leads to the formation of comedones, which develop from whiteheads/blackheads into lesions. Topical treatments address the issue on the surface, whilst certain cases require internal attention also.

credit: wikimedia commons
Credit: Wikimedia commons

Present treatments available

Vitamin supplements, Benzoyl peroxide, salicylic acid as treatment for milder acne and antibiotics, oral contraceptives and retinoid-related treatments coupled with chemical peels for severe acne have been dominating the medication scenario.

However, the degree of successful response is individual-specific and also to be noted are the side effects associated with these treatments. Severity of side effects vary from dry skin, gastric intestinal troubles, hair loss to birth defects in women on prolonged medication. Although much has been deciphered on the science driving acne, there is plenty of scope to improve the line of medications to provide side effects-free and permanent relief from this stubborn skin condition.

Recent research performed by Dr. Anita Damodaran and team at The Pond’s Institute has revealed further insights into the pathophysiology of acne and a promising treatment.

Dr. Anita Damodaran, Ph.D., Senior Research Scientist, The Pond’s Institute.
Dr. Anita Damodaran, Ph.D., Senior Research Scientist, The Pond’s Institute.

Dr. Anita Damodaran is a Senior Research Scientist and has addressed a few questions to help understand her research. Dr. Anita Damodaran and her team have unraveled the sequential progression of acne and have proposed a breakthrough finding on acne pathogenesis.

 

A novel formulation resulting in significant reduction of acne inflammation has been derived. These findings on the biology of post-inflammatory hyperpigmentation and acne were presented at the 10th Asian Dermatological Congress in Mumbai. They believe that both these dermatological discoveries will be greatly beneficial.

What is the sequence of events that lead to acne formation? Are pimples different from acne?

The pathophysiology of acne involves Keratinocyte hyper‐proliferation & abnormal differentiation, a drastic rise in sebum production, the over-proliferation of Propionibacterium acnes (P. acnes) bacteria and eventually the inflammation of the pilosebaceous duct.

Despite this knowledge, we have until recently failed to fully understand the initiation and sequence of events leading to acne. For the first time, using microarray technology for gene expression analysis, we showed that inflammation starts very early in comedones. Inflammatory markers were upregulated in whiteheads, traditionally seen as non-inflammatory acne, while keratin markers were upregulated in blackheads.

In the debate over how acne progresses, these results support the idea that lesions progress from blackheads to whiteheads to inflammatory acne. Acne is a term used to describe a common skin condition that affects hundreds of millions of people all over the world. It occurs in areas rich in sebaceous glands, such as the face, chest, and upper back. The medical term for pimples is acne. They can include the closed and open kinds (blackheads and whiteheads) and inflammatory lesions (papules and pustules), of varying grades. They generally involve scarring and post-inflammatory hyperpigmentation (PIH).

Can you tell us more about the novel technology you’ve discovered which significantly reduces acne inflammation?

After gaining a better understanding of the role inflammation plays in acne pathogenesis, we set out to find a new approach to reducing inflammation and acne. The Pond’s Institute developed a novel combination of anti-microbial actives, Thymol and Terpineol (TT) that resolves acne by killing and inhibiting P. acnes bacteria, thus lowering the inflammation response in keratinocytes.

TT works by binding to the efflux pump on the P. acnes surface membrane, blocking it and locking both active ingredients inside the cell where it can rapidly exert strong bactericidal activity.
TT works by binding to the efflux pump on the P. acnes surface membrane, blocking it and locking both active ingredients inside the cell where it can rapidly exert strong bactericidal activity.

TT works by binding to the efflux pump on the P. acnes surface membrane, blocking it and locking both active ingredients inside the cell where it can rapidly exert strong bactericidal activity. In human clinical studies, a cleanser with TT showed significant reduction of acne lesions from day 3 and displayed significantly better results at all time-points over the six-week study compared to a salicylic acid cleanser and placebo.

Our consumer insight research showed that most people only spend an average of 30 seconds washing their face. As such, we were looking for therapeutic agents that could exert powerful bactericidal effects in a very short time. We undertook high-throughput screening and tested more than 50 naturally occurring essential oils to determine those that displayed antimicrobial activity. We reviewed the top 10 agents identified this way, all of which were subject to a variety of different combinations. Through this testing process, a unique combination of Thymol and Terpineol (TT) was identified. Initial indications and benchmarking data from in-vitro testing demonstrated a significantly faster reduction in microbial count with the TT combination as compared with any others.

The Thymol and Terpineol combination is proven to be antibacterial. How are these better than antibiotics?

While we have not compared Thymol and Terpineol directly against antibiotics, we do know that the combination of Thymol and Terpineol provides rapid kill against P. acnes. This is especially relevant for products such as face washes where the product, and therefore the active ingredient is in contact with the bacteria for a very short time (approx. 30 seconds or less).

Tretinoin treatment is one of the most successful ways to treat stubborn acne, however it is accompanied with many side effects. Will this new combination of Thymol and Terpineol prove to be better?

We have not directly compared TT vs Tretinoin. It is known that one of the main complaints with Tretinoin is skin irritation and dryness. Our testing has shown that TT is well-tolerated and nonirritating. Our tests have also shown that it has a low skin irritation potential compared to ingredients like benzoyl peroxide. One of the factors that makes the novel discovery of TT so effective, is that it utilizes an antibacterial approach. It lowers the inflammation response in keratinocytes by killing and inhibiting P. acnes bacteria.

It is believed that touching or pricking a pimple can increase chances of scarring or pigmentation. But with dark-skinned individuals, post acne scarring or pigmentation occurs despite careful handling. Why does this happen?

Post-inflammatory hyperpigmentation is a common sequel to inflammatory dermatosis and is more prevalent in dark skinned individuals. Severe cases of acne often lead to PIH because the inflammatory process of acne stimulates melanocytes to produce and deposit more melanin leading to the hyperpigmentation of skin.

Studies have shown that PIH is prevalent in Asians with darker skin (Indians and Malays) than those with lighter skin (Chinese) suggesting that the degree of pigmentation and not race or ethnicity may be responsible for the development of PIH. Further acne-induced PIH can last between 1 to 5 years and can be more bothersome than acne itself. The management of PIH must first address the underlying inflammation to regulate and control further development of PIH. TT could help in regulating acne and eventually preventing the development of PIH or scars.

Is adult acne caused by hormonal changes driven by androgen effects, manageable using the Thymol-Terpineol?

Although we have not studied this population with TT, from what is known about adult and teenage acne pathology, both populations experience abnormal keratinic behavior, pore blockage and over population of P. acnes. Because Thymol and Terpineol target the overabundance of P. acnes, it will likely have a positive impact on an adult population as well.

What is the tentative duration required for improvement using Thymol-Terpineol?

As mentioned, one of our aims was to seek a powerful anti-bacterial agent that took effect in a very short time. The bactericidal effects of the TT combination were proven to take action within 15-30 seconds, resulting in a considerable reduction in acne lesions from day 3 onwards in a clinical study of 6 weeks. This was the basis behind the anti-acne breakthrough from The Pond’s Institute. This technology is now clinically proven to reduce acne significantly within 3 days.

Are the proposed anti-microbial actives suitable for treating body acne also?

Most often acne begins on the face. As acne progresses in severity, it begins to affect other areas of the body, especially the back, chest, neck, shoulders, and upper arms. Body acne has the same pathophysiology as facial acne, including increased sebum production, hypercornification of the pilosebaceous duct, and increased proliferation of P. acnes followed by inflammation. Although we have not specifically studied TT’s effect on body acne, because both facial and body acne follow a similar pathophysiology, TT would likely work for body acne as well.

Does dandruff lead to acne? If so how?

No, while both acne and dandruff are conditions marked by abnormal keratinic behavior, dandruff is a condition which occurs on the scalp and acne is a condition of the pilosebaceous duct. The two conditions have different pathophysiologies.

Acne is associated with hormonal factors, abnormal keratinic behavior in the pores, and an over-proliferation of the P. acnes bacteria. While dandruff is associated with sebum production, over-proliferation of a natural skin yeast call Malassezia and subsequent abnormalities in epidermal desquamation. Although Malassezia is a commensal skin fungus and is part of skin’s natural biome, some individuals may be more susceptible to the formation of dandruff because they have an abnormal stratum corneum which is easily perturbed by Malassezia formed sebum metabolites. There are very few published studies that look at the correlation between dandruff and acne but the studies that have been published do not tend to support the idea that the two conditions are closely related.

Often acne prone skin can suffer from redness, due to humidity or temperature changes. Is there any way to deal with this by calming the skin?

Emotional stress, heat and sweat are believed to be aggravating factors for acne sufferers of both sexes. Studies have shown that a local increase in skin temperature can result in a significant increase in sebum excretion. Hot baths and increases in humidity have also been suggested to aggravate acne through keratin hydration which subsequently reduces pore size and blocks the flow of sebum. In warmer climates, washing with cooler water and soothing the skin with moisturizers often provide acne suffers some sensorial relief.

Skin is the largest organ of the body and it mirror’s the individual’s health. Acne poses as one of the most painful, stubborn and yet fairly a common condition. Apart from traditional methods of treatment, extensive scientific research is introducing acne game-changers in the market and these seem more promising with prolonged and safer relief. Given that individuals respond differently to medications, discernment towards skin regimen is imperative.