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The focus of this article is on Acne vulgaris and the possible role of essential oils and aromatheray in the treatment of this skin condition. It reviews the scientific literature behind these topics and suggests a number of essential oils that may be effective in the treatment of acne.
Acne vulgaris: Possible Role of Essential Oils in the Treatment of Acne
Aetiology and management of acne vulgaris
Being the most prevalent skin condition, acne vulgaris is both physically and emotionally distressing for sufferers and conventional treatment approaches offer limited success. By providing an overview of the causes and mechanisms of the disorder, this article seeks to highlight the potential for aromatherapy treatments and identifies areas for future research to support the role of natural products as alternative treatments.
Acne vulgaris is one of the most common skin diseases, if not the most common. The reported prevalence of acne varies from 35% to 90% of adolescents (Stathakis et al., 1997), with gender, and age variations. The pathogenesis of acne is multifactorial, with primary features being increased sebum production, proliferation of Propionibacterium acnes, abnormal follicular keratinisation, and inflammation (Katsambas, 2000). Genetic factors may also contribute to the disorder, although precise mechanisms and influences are not yet fully understood.
Systemic and topical pharmaceutical treatments target some or all of these pathogenic factors with varying rates of success with each having significant drawbacks and limitations. All skin pathologies are distressing for the sufferer, but are sometimes thought of as unimportant when compared with diseases involving other organ systems. However, recent studies have examined the quality of life for acne sufferers and researchers have identified correspondingly high levels of anxiety and depression in many cases.
One study looking at a group with relatively severe acne reported emotional problems that were as great as those reported by patients with chronic disabling asthma, epilepsy, back pain or arthritis (Mallon et al., 1999). This paper explores the potential of using aromatherapy in the treatment and management of this condition, thus, offering sufferers more than temporary topical relief.
Pathology of acne vulgaris
Acne is principally a disorder affecting adolescents with the first signs commonly being observed in early puberty. For some unfortunate individuals, acne can persist into middle age and evidence from twin studies has led to the suggestion that it may be an inherited condition (Goulden et al., 1999).
It begins earlier in females than males, reflecting the earlier onset of puberty however, in later teen years, the severity of acne is worse in males than in females which is compatible with the relationship between androgenous hormones and sebum secretion (Stathakis et al., 1997).
Acne is distributed on sites with the largest and most abundant sebaceous glands: the face, neck, chest, upper back, and upper arms. There are four main factors in the development of acne:
Androgenous hormones are of particular interest when examining the pathogenesis of acne. Playing a key role in modulating hair growth and sebum production in the pilosebaceous unit, testosterone is converted to dihydrotestosterone, the most active androgen metabolite in the sebaceous gland. The end result of enhanced local androgen production can include alopecia areata, hirsutism, and acne (Mercurio and Gogstetter, 2000).
In acneic skin, androgenic stimulation of the glands leads to hyperseborrhoea and the characteristically shiny appearance of a greasy skin. However, this is not the same as saying that androgens cause acne as many factors appear to be involved in the process and there is a need for several to combine for acne to develop.
Sebum is a complex mixture of squalene, wax esters, triglycerides, and cholesterol esters. Individual differences in sebaceous lipid composition are under genetic and hormonal control and higher levels of squalene and wax esters, combined with lower levels of free fatty acids, have been seen in acne patients (Pugliese, 1996). It has been shown that acneic skin contains much less linoleic acid than control subjects (Morganti et al., 1997) and there is an apparent relationship between this and the hypercornification of the pilosebaceous duct, a key factor in the formation of comedones, the early lesions of acne.
The pilosebaceous unit consists of the hair shaft (pilo), the sebaceous gland, and the duct, which leads to the skin surface and is commonly referred to as a pore. The duct (the infundibulum) can be divided into the upper epidermal part and the lower dermal part. Stratum corneum lines the whole duct and the area closest to the skin surface sheds corneocytes normally, together with cells from the rest of the epidermis. However, in acneic skin, due to changes not yet fully understood, cells of the infundibulum become abnormally adherent and instead of being shed and discharged freely through the duct, these cells form a hyperkeratotic plug – a microcomedo – in the canal.
As previously mentioned, linoleic acid deficiency has been suggested as a causative factor in this process (Brown and Shalita, 1998). As microcomedones enlarge, these greasy plugs, made up of a mixture of keratin, sebum, and bacteria, topped by a layer of melanin, become the visually familiar early acneic lesions, whiteheads, and blackheads. Table 1 lists some characteristics of the primary lesions present in acne.
Table 1 Terminology of acneic skin lesions
Although acne is not an infectious disease and is not in any way related to dirty skin, the role of cutaneous microflora is important. At puberty, the number of microorganisms on the skin rapidly increases. Table 2 lists normal skin commensals, which proliferate during puberty, with P. acnes being particularly significant in the development of acne.
Prepubertal skin is virtually free from P. acnes colonisation however, following androgenic stimulation of the duct and the subsequent hypersebborhoea, an ideal environment exists for bacterial proliferation.
As stated, the basic acne lesion is the comedone but in many cases there is progression to a second inflammatory stage, triggered by the release of pro-inflammatory mediators produced by both P. acnes and from corneocytes in the pilosebaceous duct. These inflammatory mediators penetrate the surrounding tissues, leading to the formation of papules, nodules, and pustules and eventually rupturing of the duct (Cunliffe, 2001).
Classification of acne
According to Pugliese (1996), there is no standard classification of acne, with dermatologists dividing it into grades according to the number and severity of lesions present and Table 3 shows one grading system. Assessing the severity of acne is an important part of the management of the condition, for pharmacists, physicians, and aromatherapists. Table 4 is an example of assessment criteria used by pharmacists in the UK (Cunliffe, 2001).
The severity depends both on how the acne appears visually and how the condition affects the individual both psychologically and socially (Cunliffe, 2001). Evaluating and managing an individuals’ psychological reaction to this visually distressing condition is an area of care where aromatherapy has many strengths. It is very common for sufferers to have tried several treatments and for these to have had limited success, which leads to unfulfilled hope, frustration and despair further complicating the emotional state.
The traditional practice of addressing skin problems with the topical application of plant-derived medicines is as ancient as mankind and certainly predates the culture of ancient Egypt (Brown and Dattner, 1998). At a time when the side effects and limitations of conventional acne treatments are becoming increasingly apparent, not least the increased prevalence of antibiotic resistance (Espersen, 1998), aromatherapy has a significant role in managing this common condition.
Topical retinoids are prescribed as first line treatment for comedone reduction and these include, tretinoin (0.025% and 0.5% strength) cream and gels, isotretinoin gel, and new formulations of all tretinoin, such as Acticin. A reduction of inflamed lesions may also be achieved, since the microclimate of the pilosebaceous duct is affected. Topical antimicrobials are predominately used in the management of inflammatory acne and include benzoyl peroxide, topical antibiotics such as clindamycin, erythromycin, tetracycline, and azelaic acid, the latter having activity against both P. acnes and comedones.
Benzoyl peroxide has the beneficial effect of not inducing P. acnes resistance and is frequently formulated with topical antibiotics in a single preparation. Topical therapy, however, has the drawback of producing a mild degree of primary irritant dermatitis in most instances.
The oral antibiotics, tetracycline, minocycline, erythromycin, and trimethoprim, are all highly active against P. acnes and readily penetrate the pilosebaceous duct. Oral antibiotics are indicated for the management of moderate acne and usually prescribed for 6–8 months.
They are often co-prescribed with topical therapy, but the same antibiotic must be used to avoid potentiation of P. acnes resistance. Many oral antibiotics produce abdominal colic, diarrhoea and vaginal candidiasis, while poor compliance is often found to be the cause of an inadequate response. Tetracyclines may also rarely result in drug-induced lupus erythematous or a dose-duration pigmentation, whilst trimethoprim is associated with a drug rash in 5% of patients.
Oral retinoids such as isotretinoin (Roaccutane) and hormonal therapy such as Dianette (35 lg ethinyloestradiol and cyproterone acetate) are the only agents to affect seborrhoea. Dianette carries the same side effects as other forms of the contraceptive pill, but may also result in more weight gain due to the ethinyloestradiol content.
Oral isotretinoin is a hospital drug indicated for severe acne. It is the only antiacne drug which suppresses all the aetiological factors of acne and in nearly all patients will produce 100% clearance with 60% of patients suffering no recurrence (Cunliffe, 2001). Its limitation in more widespread usage is due to the many systemic and mucocutaneous side effects it produces, the most important systemic side effect being the 100% incidence/risk of teratogen-icty. Myalgia, arthralgia, headaches, malaise, mood swings, depression and many other side effects are also listed in the Roaccutane data sheet.
Chelitis, facial dermatitis, nasal crusting, conjunctivitis, and secondary infection with Staphylococcus aureus are the most noted mucocutaneous unwanted effects. Physical treatments include aspiration of large cysts, if less than one-week-old or cryotherapy on more established cysts, which will induce a low-grade inflammatory response to the old injury.
As acne is not related to poor hygiene, it is incorrect to overemphasise the need for skin washing, which can lead to irritation and dryness. There are several aromatherapeutic approaches which can be adopted, following an individual assessment of each case. Antibacterial essential oils can be selected, both to reduce bacterial proliferation and perhaps more importantly in terms of limiting the progression into severe inflammatory acne, by reducing the release of inflammatory mediators by P. acnes.
There is currently a paucity of research evidence for essential oil efficacy in acne treatments, with most existing research being limited to identifying the beneficial role of Melaleuca alternifolia, which is widely used in topical treatments. One study showed results from a single-blind, randomised clinical trial on 124 patients, comparing the efficacy and skin tolerance of 5% tea tree gel with 5% benzoyl peroxide lotion for cases of mild to moderate acne. Both significantly reduced the number of inflammed and non-inflammed lesions, although the onset of tea tree’s action was slower. Significantly, there were fewer side effects recorded by those using the tea tree gel (Bassett et al., 1990).
In a study comparing major components of tea tree oil (terpinen- 4-ol, a-terpineol, and a-pinene) all were found to be active against P. acnes, whereas cineole was inactive. This study supported the use of tea tree oil in acne treatments and demonstrated that terpinen-4-ol was not the sole active constituent of the oil (Raman cited in Stevensen, 1998).
In the absence of extensive research in this particular area, a review of available aromatherapy texts shows a range of essential oils that are recommended for this condition. Table 5 lists some essential oils which may be helpful to include in treatments.
It is suggested that key actions which are necessary for the effective treatment and management of this condition should include antibacterial – existing data showing activity against P. acne appear to be limited to Melaleuca alternifolia. However, other oils with an empirical reputation for antibacterial effects may possess significantly useful antibacterial properties. In addition, selecting essential oils to reduce inflammation will prevent this unpleasant development which leads to post-acne scarring. Acne scarring has different forms and is directly related to the depth and severity of inflammation and the ability of the individual to heal the acne lesions (Goodman, 2001).
The choice of vehicle used in topical applications will largely be determined by personal preference. Patient compliance in any treatment regime is crucial, as treatment is usually long-term and as previously stated, poor patient compliance has been identified as being responsible for the failure of some conventional treatments. Lotions and gels are generally pleasant to use, being nongreasy and having a slightly drying effect, countering hyperseborrhoeic oily skin.
For aromatherapists making their own base products, the inclusion of therapeutic quality hydrosols in these vehicles will provide an enhanced anti-inflammatory effect, as they appear to have significant anti-inflammatory properties (Harris and Harris, 2000). The treatment regime can include twice daily skin cleansing with appropriate hydrosols. Catty (2001) suggests the following as anti-inflammatories: Chamaemelum nobile, Achillea millefolium, and Citrus aurantium var.amara flos.
Exfoliation assists in the shedding of cells from the stratum corneum, including cells from the pilosebaceous duct, and is a cornerstone of natural acne treatments. Exfoliation should not be done excessively nor with aggressive agents as overstimulation of the epidermis may lead to an aggravation of the hypercornification of the pilosebaceous duct (Pugliese, 1996).
Table 6 shows natural ingredients which may be used as exfoliants. The application of plant oils allows them to seep into the pilosebacous ducts, hence, increasing exfoliation and desquamation of the stratum corneum. In one double-blind placebocontrolled randomised cross-over study (Letawe et al., 1998), linoleic acid was topically applied to comedones in patients with mild acne.
Results showed a 25% reduction in comedone size over a 1 month period, compared with no change in the placebo-treated group. It was suggested that topical linoleic acid may play a role in the treatment of acne. Both safflower and sunflower oils are rich in linoleic acid (Price, 1999) and therefore may play a useful role in aromatherapy practice by normalising hypercornified ducts and preventing comedo formation.
In addition, Price states that jojoba wax has a similar molecular structure to sebum and can regulate sebum production making it useful in acne treatment. This is certainly an area recommended for further investigation and study, to provide firm evidence of the value of adopting natural approaches to acne resolution.
The psychological impact of acne
Acne vulgaris significantly affects patients’ quality of life and the older the sufferer, the greater the psychological distress, regardless of the severity of acne (Lasek and Chren, 1998). Furthermore, it is known that women with acne are significantly more embarrassed and emotionally affected by their condition than men.
Clinical depression and suicidal thoughts have been identified among acne patients (Gupta and Gupta, 1998) and awareness of psychiatric comorbidity is crucial for those working with acne sufferers. Many patients experience a worsening of their symptoms during periods of stress and Cunliffe (2001) suggests a link between the well-known effects of stress on the pituitary–adrenal axis and androgenic stimulation of the pilosebaceous unit.
One major advantage of adopting an essential oil based holistic treatment approach is that in addition to utilising pharmacological effects of the oils, the patient benefits from their coexisting psychological actions. Taking Santalum album as an example of synthesising both clinical and holistic approaches to acne treatments, key pharmacological actions include anti-inflammatory, antibacterial, lymphatic decongestant, and emollient (Erligmann, 2001).
In addition to these physically beneficial qualities, sandalwood is a renowned nervine with a strong empirical pedigree in addressing disorders of the psyche. The potential for addressing the aggravation in symptoms due to stress identified by Cunliffe is clear. There are several essential oils with similarly traditional beneficial effects on body and mind which could be used in this regard, for example, Lavandula angustifolia, Pelargonium graveolens, and Cymbopogon martinii.
There is much scope for using essential oils and carrier oils in the treatment of acne vulgaris but at the present time there is a lack of research evidence to prove the efficacy of a broad range of these products. However, this should not deter aromatherapists from using traditional data to aid in their oil selection and by closely following developments in this area it is entirely possible that aromatherapy practices will be adapted and enhanced by future research.
Finally it is most important that the psychological impact of this common and distressing condition is adequately recognised and addressed by aromatherapists who may be well placed to offer much needed hope and support for sufferers.
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The international Journal of Aromatherapy 2002 vol. 12 no.2
© 2002 Elsevier Science Ltd. All rights reserved.
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