Acne vulgaris (1).txt

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Original ArticleOriginal Article Original ArticleOriginal ArticleA PROSPECTIVE STUDA PROSPECTIVE STUDA PROSPECTIVE STUDY TO DETERMINE THE EFFECTIVENESS OFY TO DETERMINE THE EFFECTIVENESS OFY TO DETERMINE THE EFFECTIVENESS OFCLINDCLINDCLINDAMYAMYAMYCIN (ALLOPCIN (ALLOPCIN (ALLOPAAATHY), BERBERIS AQUIFOLIUMTHY), BERBERIS AQUIFOLIUMTHY), BERBERIS AQUIFOLIUM(OREGON GRAPE-HOMEOP(OREGON GRAPE-HOMEOP(OREGON GRAPE-HOMEOPAAATHY) AND AZADIRACHTTHY) AND AZADIRACHTTHY) AND AZADIRACHTA INDICA INDICA INDICAAA(NEEM-A(NEEM-A(NEEM-AYURVEDIC) MEDICYURVEDIC) MEDICYURVEDIC) MEDICAAATIONS AGAINST THE MICROORGANISMTIONS AGAINST THE MICROORGANISMTIONS AGAINST THE MICROORGANISMCCCAUSING ACNE VULGARIS.AUSING ACNE VULGARIS.AUSING ACNE VULGARIS.

Asima Banu, Eswari.L Akilesh HumnekarABSTRACT:

Context: Acne vulgaris is the most commonpsychologically distressing skin disorder which istreated with indiscriminate use of oral and topicalantibiotics mainly targeted against the anaerobicorganism Propionibacterium acnes,without muchconsideration given to other causative microorganisms.

Objectives: This study was therefore undertaken toisolate the probable aerobic organisms causing acnevulgaris and to demonstrate the resistance andsensitivity pattern to the commonly used antibioticClindamycin. Also traditional acne medications like

Berberis aquifolium and Azadirachta indica which aresupposed to have antimicrobial effects and are usedas over the counter medications were testedagainst the isolated microbes to make a comparativestudy. This type of comparative study is first of itskind and shall help the dermatologists to selectjudicially from the cafeteria of medications availablefor treating acne.

Design: prospective comparative study of threemonths duration.

Study setting: patients attending Dermatology OPD

of Bowring and Lady Curzon Hospital

Patients presenting with pustular or nodulocysticacne, between 13 to 50 years of age.

Results: 40 patients were included in the studyamong which 70 %( 28 patients) belonged to agegroup 20-29 year. Samples from 40% (16) patientsshowed growth of Staphylococcus aureus organismon aerobic culture. Followed by 32.5 %( 13) samples



isolating Coagulase negative Staphylococcus aureus(CONS). 68.8% of isolated Staphylococcus aureus

showed sensitivity to Clindamycin, 12.5% showedsensitivity to Berberis aquifolium and 18.8%showedsensitivity to Neem.

76.9%, 69.2% and 30.8% samples which grewCoagulase negative Staphyloccocus aureus (CONS)showed sensitivity to Clindamycin, Berberisaquifolium and Neem respectively. Gram negativeorganisms showed resistance to all threemedications.

Conclusion: This study shows that Staphylococcusaureus and CONS are most commonly isolatedaerobic organism from acne. These are still sensitiveto Clindamycin compared to medications of othersystems of acne management like homoeopathy andayurveda .CONS showed significant sensitivity tohomeopathic medication too. We suggest in vivostudies for better evaluation and comparison.

INTRODUCTION:

Acne vulgaris is common human skin diseasecharacterized by areas of skin with multiple noninflammatory follicular papules or comedones and byinflammatory papules, pustules and nodules in itsmore severe forms. Although not a serious threat togeneral health, acne is one of the most sociallydistressing skin condition, especially for adolescentsresulting in diminished self esteem, socialwithdrawal due to embarrassment and depression(1) .Due to development of resistance in microorganismscausing acne to common antibiotics and thedifferences in species and strains of the

microorganisms in different regions, a research inthe method of therapy seems indispensable(2) .

Propionibacterium acnes an anaerobic pathogen,plays important role in the pathogenesis of acne and

International Journal of Basic Medical Science - July 2011, Vol : 2, Issue : 2International Journal of Basic Medical Science - July 2011, Vol : 2, Issue : 278



Asima Banu, et al, Determine the Effectiveness of www.ijbms.com Asima Banu, et al, Determine the Effectiveness of www.ijbms.commany studies have been undertaken targeting thisorganism,but not many studies involving the aerobicmicrobes. The aerobic bacteria reported to causeacne a re Staphylococcus e pidermidis,Staphylococcus aureus, and micrococcus spp. [3]

During the last 20 years, the number of topical andsystemic drugs for the treatment of acne vulgarishas been enriched(4) . The indiscriminate use ofantibiotics whether topically or orally has raisedconcerns globally about the development and spreadof resistant organisms and the fears about resultingantibiotic resistance(5).There are many productsavailable for treatment of acne, however thosetreatment that are most effective tend to havegreater potential for side effects, need a greatdegree of monitoring. A number of topical antibioticshave been tried in acne vulgaris, but erythromycinand clindamycin preparations are the most popular.

Stoughton and Resh did the first definitive work with

topical clindamycin in acne vulgaris. It has been foundto be as effective as systemic tetracyclines, topicalerythromycin and topical benzoyl peroxide.Clindamycin penetrates the skin and retains itsbiological activity against P. acnes even in contactwith skin. The concentration of clindamycin in thecomedonal material is more than sufficient tosuppress the growth of P.acnes. There is aconcurrent reduction in the free fatty acid levels onthe skin surface (6). Since acne vulgaris is a recurrentcondition repeated use of antibiotics is notrecommended because of the side effects and is alsonot cost effective for patients.

The development of antibiotic resistance and theemergence of 'super bugs' is a serious worldwideproblem, caused primarily by the misuse and overuseof antibiotics. Antibiotic resistance of the residentcutaneous bacterial flora is a well recognizedconsequence of systemic antibiotic therapy (7)Therefore we must broaden our view of how toprevent and treat microbial infections to includealternatives that are not centered upon standardantibiotic therapy or we risk the possibility ofeventually having no defense against thesemicrobes. While many Natural products claim to

have antimicrobial properties, very little researchhas been conducted to investigate their claims.

Berberis aquifolium, also known as mountain grapeor oregon grape is extensively used by homeopaths intreatment of acne. The specific action of this agentis in scaly, pustular and other skin diseases due tothe disordered condition of the blood. It is the mostreliable alternative when the influence of thedyscrasia is apparent in the skin. It is given freely



during the treatment of skin diseases where analternative is considered an essential part of the

(9)treatment .

Neem Neem or Azadirachta Indica is a large,evergreen tree and has strong health maintainingproperties. The antibacterial, antifungal & bloodpurifying properties of Neem are useful in skindisorders and keep the skin healthy. Neem isimplicated in effectively killing the bacteria thatcause Acne and studies prove that Neem will reduceinflammation. It cleanses the skin and also helps inclearing acne scars.

Hence this study was undertaken to identify thecommonest aerobic organism causing acne in ourhospital and also to evaluate the efficacy ofcommonest used antibiotic Clindamycin againstthese organism in comparison with alternativetraditional preparations like Berberis aquifolium(Oregon grape) and Azadirachta indica (Neem)powder which are reported to have nourishing, anti

inflammatory, anti microbial activities which in turnhelp to control acne.

To the best of our knowledge this is the first suchcomparative study that has been undertaken in India.

OBJECTIVES:

1.To identify aerobic bacteria that causes acne.2.To compare the antibiotic sensitivity andresistance pattern of commonly used allopathic

(clindamycin), homeopathic (berberisaquifolium), ayurvedic (Neem) medicines againstthe isolated bacteria .MATERIALS AND METHODS:

Study Design: A Prospective Comparative study

Study setting: Study was conducted in theDepartment of Microbiology in B & LCH over a periodof three months.

International Journal of Basic Medical Science - July 2011, Vol : 2, Issue : 2 79



www.ijbms.com Asima Banu, et al, Determine the Effectiveness of www.ijbms.com Asima Banu, et al, Determine the Effectiveness ofSOURCE OF DATA

Samples obtained from nodulocystic and pustularskin lesions of acne patients attending OPD ofDermatology in Bowring and Lady Curzon Hospital.

SAMPLE SIZE-n 1= 40. 40 patients were enrolledin the study

INCLUSION CRITERIA:

1.Those patients who had acne at least for oneweek duration.2.Patients between 13yrs to 50 yrs.EXCLUSION CRITERIA:

1.Patients having bleeding in the acne.2.

Patients who are more than 50 yrs.MEHODLOGY

The samples (pus from acne) were collectedin the dermatology department with sterileprecautions by using sterile cotton swabs. Swabswere placed in sterile container and transported tolab immediately. Aerobic culture were done onMacconkey agar, Blood agar and Chocolate agar andwere incubated at 37 'C, for 18 hours and if there isno growth, then up to 48 hours. The isolatedorganisms were identified using standardidentification techniques. Antibiotic sensitivity was

done using standard Kirby Bauer's Method using

[10-13]

CLSI guidelines.

Preparation of disk solution

Commercially available Clindamycin(Hi-mediadisc)with a concentration of 2 microgram/ml disk wereused. The modified paper disc diffusion was employedto determine the antibacterial activity of solventextract of ayurvedic and homeopathic preparations.

For antibacterial properties, 0.1 ml bacterialsuspension of 105CFU ml-1was uniformly spread onNutrient Agar plate to form lawn cultures. Themethanol extracts were prepared in such a mannerthat ultimate amount (in dry form) in each disc cameto 1mg in Azadirachta indica and 2 microgram inBerberis aquifolium. The blotting paper discs (10mmdiameter) were soaked in various diluted extract,dried in oven at 60 degree C to remove excess of



solvent and tested for their antibacterial activityagainst bacterial pathogens by disc diffusion

0

technique. After incubation for 24 h at 37 C, zone ofinhibition of growth was measured in mm.

The Antibiograms obtained were statisticallycompared and data analysed.

RESULTS OF THE STUDY:

40 patients were included in the study among which70%(28 patients) belonged to age group 20-29years, 25% (10 patients) belonged to 14-19 yearsage group and 5%(2 patients) belonged to age group30 and above. 57.5% (28 patients) were males and42.5% (17 patients) were females.

57.5% (23) patients had duration of diseasebetween 1 to 5 years. 35%(14 patients) hadduration of disease less than 1 year and 7.5% (3)patients had duration of disease for more than 5

years.

Organisms isolated: (table 1)

Samples from 40% (16) patients showed growth ofStaphylococcus aureus organism on aerobic culture.Followed by 32.5%(13) samples isolating Coagulasenegative Staphylococcus aureus (CONS),12.5%(5)samples isolating Pseudomonas species, 7.5%(3)samples isolating Klebsiella spp and 2.5%, (1)Pseudomonas aeruginosa and 2.5%(1) each ofmultiple isolates of Klebsiella with Pseudomonas sppand Staphylococcus aureus with Klebsiella spp.

Sensitivity and resistance of the organisms toClindamycin (allopathic), Oregon grape (Homeopathic)and Neem(ayurvedic) drugs: (table2)

68.8% of isolated Staphylococcus aureus showedsensitivity to Clindamycin, 12.5% showed sensitivityto Oregon grape and 18.8%showed sensitivity toNeem.

76.9%, 69.2% and 30.8% samples which grewCoagulase negative Staphyloccocus aureus showedsensitivity to Clindamycin, Berberis aqua folium and

Neem respectively.

20% of Pseudomonas patients showed sensitivityonly to Neem and none were sensitive to Clindamycinand Oregon grape.




Asima Banu, et al, Determine the Effectiveness of www.ijbms.com Asima Banu, et al, Determine the Effectiveness of www.ijbms.comSamples which isolated Klebsiella spp, Klebsiella withPseudomonas and Pseudomonas aeurginosa were100% resistant to all these groups of drugs.

Sample that isolated Staphylococcus aureus andKlebsiella showed 100% sensitivity to Clindamycinand none to Oregon grape and Neem.

DISCUSSION:

Acne has many psychiatric and psychologicalimplications than most other dermatologicalconditions. Acne vulgaris is a common skin diseasewith potential complications that are more than skindeep. The past two decades have seen a worldwideupsurge in the use of traditional medicine (TM) andcomplementary and alternative medicine (CAM) inboth developed and developing countries. In India thecorresponding figure is 65%. Herbal preparationsare widely used as self-medication for acuteconditions; practitioners of herbal medicine tend to

concentrate on treating chronic conditions. [14]Western allopathic medicine emphasizes the use ofantibiotics and other medicines and approaches todefend against germs or microbes. Therefore thepresent study was conducted to investigateantibacterial p roperties o f Ayurvedic andhomeopathic preparations, which is less studied andused in Indian traditional Medicine in comparisonwith commonly used allopathic drugs in acne.

In our study 70% of patients were in the age group of20-29 years which suggest that hormonal influenceof that particular age group play major role in

causation of acne. 57.5% were males and thissuggests no significant difference in occurrence ofacne in males and females. Significant difference wasseen in the duration of disease between patientgroup, patients with disease duration of 1-5 yearswere 57.5% compared to 35% <1 year and 75% > 5year of disease duration, which shows that in spiteof therapeutic intervention acne vulgaris is a chroniccondition.

Staphylococcus aureus (40%) and CONS (32.5%)were the most commonly isolated aerobicmicroorganisms isolated from pus of acne Patients.

A similar study (1) showed aerobic organisms,Staphylococcus a ureus, Staphylococcus

epidermidis , and Micrococcus spp as thecommonest aerobic organisms. Among the isolatedStaphylococcus aureus of which 60% wereMethicillin resistant (MRSA) but Clindamycinsensitive and CONS were significantly moresensitive to Clindamycin compared to ayurvedic andhomeopathic drugs. In addition these gram positive



organisms were relatively sensitive to ayurvedic andhomeopathic drugs. Gram negative organismsshowed 100% resistance to these ayurvedic andhomeopathic drugs. Though neem and Oregon grapeare reported to have antimicrobial properties ourstudy shows that they were effective only againstfew gram positive organisms and had no effectagainst gram negative organisms. Klebsiella spp andPseudomonas spp were 100% resistant to all threegroups of drugs, which shows that Clindamycinwhich is widely used for acne is not effective in caseswhich yield in gram negative microorganism.

In discriminate use of antibiotics over prolongedperiod results in development of antibioticresistance. While many herbal and homoepathicproducts claim to have anti microbial properties,very little research has been conducted toinvestigate their claims. This study shows theseproducts have very limited anti microbial activityespecially against gram negative micro organism.

LIMITATIONS :

1.Anaerobic organisms were not isolated andtherefore the sensitivity pattern of theseorganisms against the study medications werenot evaluated.2.Since this is an invitro study regardingsensitivity of micro organisms to the studymedications the other pathomechanisms incausing acne were not addressed and thehealing properties of the study medicationsother than antimicrobial effects were notevaluated.

CONCLUSION:

This study shows that Staphylococcus aureus andCONS are most commonly isolated aerobic organismfrom acne patients. These are still sensitive to




www.ijbms.com Asima Banu, et al, Determine the Effectiveness of www.ijbms.com Asima Banu, et al, Determine the Effectiveness ofClindamycin compared to other system of acnemanagement like homoeopathy and ayurveda .CONSshowed significant sensitivity to homeopathicmedication too. Allopathic drugs usually provideeffective therapy for bacterial infections, but thereis an increasing problem of antibiotic resistance likedevelopment of MRSA and a continuing need for newsolutions. Hence now herbal and homeopathic drugsare preferred to allopathic drugs. But careful clinicaldiscretion and testing of antimicrobial sensitivitypatterns are recommended before initiatingtreatment of acne.

REFERENCES

1.Hassanzadeh P, Bahmani M, Mehrabani D.Bacterial resistance to antibiotics in acnevulgaris: An in vitro study. Indian J Dermatol2008; 53:122-42.

Ross JI, Snelling AM, Eady EA, Cove JH, CunliffeWJ, Leyden JJ, et al . Phenotypic and genotypiccharacterization of antibiotic-resistantPropionibacterium acnes isolated from acnepatients attending dermatology clinics inEurope, the USA, Japan and Australia. Br JDermatol 2001; 144:225-7.3.Acne Microbial Basis of World of Microbiologyand Immunology. 2003

Organisms isolatedNumber of

patients(n=40)%1.Staphylococcus aureus 16 40.02.CONS 13 32.53.Pseudomoas spp 5 12.54.Klebsiella spp 3 7.55.Klebsiella spp+Pseudomonas spp 1 2.56.Pseudomoas aeruginosa 1 2.57.Staphylococcus aureus +Klebsiella spp 1 2.5Table 1: Organisms isolated

4.Gollnick HP, Krautheim A. Topical treatment inacne: current status and future aspects.Dermatology 2003; 206:29-36.5.Harkaway KS .Antibiotic resistance patterns incoagulase-negative staphylococci aftertreatment with topical erythromycin, benzoylperoxide, and combination therapy-Br JDermatol 01-JUN-1992; 126(6): 586-901.



6.Khanna VN. Topical clindamycin hydrochloride1% in acne vulgaris. Indian J Dermatol VenereolLeprol 1990; 56:377-807.Neu HC. The crisis in antibiotic resistance.Science 1992; 257: 10641073.1. Staphylococcus aureus 16 5(31.3%) 11(68.8%) 14(87.5%) 2(12.5%) 13(81.3%) 3(18.8%)2. CONS 13 3(23.1%) 10(76.9%) 4(30.8%) 9(69.2%) 9(69.2%) 4(30.8%)3. Pseudomoas spp 5 5(100%) 0(0%) 5(100%) 0(0%) 4(80%) 1(20%)4. Klebsiella spp 3 3(100%) 0(0%) 3(100%) 0(0%) 3(100%) 0(0%)5. Klebsiella spp +Pseudomonas spp 1 1(100%) 0(0%) 1(100%) 0(0%) 1(100%) 0(0%)6. Pseudomoas aeruginosa 1 1(100%) 0(0%) 1(100%) 0(0%) 1(100%) 0(0%)7. Staphylococcus aureus+Klebsiella spp 1 0(0%) 1(100%) 1(100%) 0(0%) 1(100%) 0(0%)Table 2. Organisms isolated and sensitivity report of Clindamycin, Bereberis aquifolium and Azadirachta indica




Asima Banu, et al, Determine the Effectiveness of www.ijbms.com Asima Banu, et al, Determine the Effectiveness of www.ijbms.com8.Kunin CM. Resistance to antimicrobial drugs aworldwide calamity 1980: 582. Ann Intern Med1993; 118: 557569.Ellingwood, Group VI. Agents influencing thecharacter of the blood. [1] » Chapter I.Alteratives with antiseptic properties. [2] TheAmerican Materia Medica: 191910.British Society of Antimicrobial Chemotherapy.A guide to sensitivity testing: Report of workingparty on antibiotic sensitivity testing. JAntimicrob Chemother 27 (Suppl D):P. 1, 1991.11.National Committee for Clinical LaboratoryStandards. Performance Standards forAntimicrobial Susceptibility Testing. 8thInformational Supplement. Villanova Pa, USA,ML100 S12, 2002.12.

Basic Laboratory Procedures in ClinicalBacteriology. 2 nd Edition. Eds. J. Vandepitte etal. World Health Organization, Geneva, 2003.13.CLSI Clinical and Laboratory StandardsInstitute. Performance S tandards forAntimicrobial Susceptibility Testing. SixteenthInformational Supplement. Clinical andLaboratory Standards Institute, Chicago.Document M100-S16, 2006.14.Tambekar, D.H., B.S. Khante S.B. Dahikar andY.S. Banginwar, 2007, Antibacterial properties

of contents of Triphala;An Traditional IndianHerbal Preparations, Continental j .Microbiology1,(3): 8-12.Authors :

1.Asima BanuAssociate professorDepartment: Department of MicrobiologyBangalore-560004. asima.banu @gmail.com2.Dr.Eswari.LSenior Resident, Department of dermatology




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Acne vulgaris (1).txt