Clinics in Dermatology (2018) 36, 299–305

Aromatherapy, botanicals, and essential oils

in acne
Warren J. Winkelman, MD, PhD ⁎
Nestlé Skin Health Investigation, Education, Longevity Development (SHIELD), New York, NY

Abstract Complementary and alternative medicine approaches are popular among some patient segments
due to the perception that they are “natural” and thus are believed to be less likely to be dangerous, to be less
toxic, or to cause fewer side effects. In dermatology, these can include aromatherapy, botanicals, and essen-
tial oils (plant extracts). Preliminary evidence, biological activity studies, and small pilot clinical trials con-
ducted outside of North America, mostly in young adults, suggest that some may have value in acne
treatment. When additional research and larger clinical trials are conducted, both clinicians and patients will
be able to understand the risks and benefits compared with allopathic remedies.
© 2018 Elsevier Inc. All rights reserved.

Introduction The terms complementary and alternative refer to different

Acne is one of the most common dermatologic diseases and
can affect individuals from early adolescence through
adulthood.1–3 Both the primary lesions of acne (papules, pus-
tules, and comedones) and the secondary lesions (postinflam-
matory hyperpigmentation, erythema, and scarring) can have
considerable psychosocial impact, regardless of the patient’s
age.4 Complementary and alternative medicine (CAM) treat-
ments are popular with patients and consumers in many areas
of medicine, including dermatology,5 largely because they are
perceived to be more “natural” than allopathic prescriptive
medicines and thus are believed to be less toxic and safer, with
fewer side effects.6
⁎ Corresponding author. Tel.: +1 646 495 3045.
E-mail address: warren.winkelman@galderma.com.
concepts—alternative is use of a nonmainstream therapeutic
approach instead of allopathic prescription and over-the-
counter medications, whereas complementary is use of non-
mainstream therapies together with allopathic medications.5
Patients may anticipate that these therapeutic approaches go
beyond the minimization of their clinical manifestations, po-
tentially “boosting” their immune systems or promoting their
general wellness.5 In dermatology, common CAM approaches
can include topical agents (generally plant extracts), essential
oils/aromatherapy, herbal therapy, and acupuncture.5
Although few CAM approaches have received rigorous
evaluation in terms of Western medicine, particularly in chil-
dren or adolescents,5 there have been some investigations into
use of CAM for management of acne. This review focuses on
the use of essential oils and aromatherapy in acne. Existing ev-
idence for CAM therapies has come from small pilot studies;
in some cases, more research with larger controlled clinical tri-
als is warranted in the evaluation of the effectiveness of com-
plementary therapy for acne.7

https://doi.org/10.1016/j.clindermatol.2018.03.004
0738-081X/© 2018 Elsevier Inc. All rights reserved.
300
Clarification of relevant terms
When discussing essential oils and aromatherapy, botani-
cals is a somewhat nonspecific term, referring to most plant-
based chemicals (phytochemicals), and may describe complex
plant extracts, containing many chemical moieties or pure sin-
gle compounds.8,9 Examples of single-compound botanicals
well known in dermatology include psoralens, capsaicin, indi-
go, and podophyllin. Two complex polyphenol phytochemical
botanicals studied for acne therapeutics include green tea ex-
tract and aloe vera leaf oil.10–12
The term essential oils refers to botanicals that are volatile
plant extracts with distinctive scents (ie, the so-called essence
of the plant). Essential oils may be used in a variety of ways,
such as mixed in a gel; compounded into a paste or spray; or
applied via bath, massage, or inhalation (Figure 1). These oils
are believed to be absorbed through the upper part of the der-
mis. Aromatherapy refers to the therapeutic use of aromatic es-
sential oils.8,9
The US Food and Drug Administration (FDA) distin-
guishes cosmetics from drugs, and essential oils can be consid-
ered either depending on intended use. According to the FDA,
cosmetics are “articles intended to be rubbed, poured, sprin-
kled, or sprayed on, introduced into, or otherwise applied to
the human body … for cleansing, beautifying, promoting at-
tractiveness, or altering the appearance.”13 The FDA definition
of a drug is “articles intended for use in the diagnosis, cure,
mitigation, treatment, or prevention of disease” and “articles
(other than food) intended to affect the structure or function
of the body of man or other animals.”14 Under the FDA frame-
work, categorization of essential oils as a cosmetic refers to the
claim of a fragrance marketed for promoting attractiveness, but
those marketed with certain “aromatherapy” claims, such as
reducing the number of acne lesions or improving acne, meet
the definition of a drug. Similarly, a massage oil intended to
lubricate skin and impart fragrance is considered cosmetic;
however, one marketed for relieving skin irritation is
considered a drug.
Fig. 1 Examples of essential oils and plants used to create essential oils. (Courtesy Can Stock Photo/duskbabe, with permission.)
W.J. Winkelman
Insights from the literature
Mechanisms of action
There are several theories of how aromatherapy can
achieve therapeutic effects; proposals include systemic effects
(acting as drug or enzyme), placebo effects, or general affec-
tive or “reflectorial” effects that induce positive moods.15
Multiple organic compounds are present in essential oils and
have differing therapeutic actions (Table 1).9 Essential oils typ-
ically comprise multiple natural volatile organic compounds
and can be extracted from almost any plant part; for example,
eucalyptus and peppermint oil are extracted from leaves, lav-
ender and rose oils from flowers, juniper and sandalwood from
woody parts of the plant, vetivert and calamus from the roots,
and benzoin and frankincense oils from sap.9 These oils often
include a mixture of many organic compounds with therapeu-
tic properties, which reflect relative amounts of each com-
pound contained in the oil.9 Wound-healing properties occur
with oils high in ketones, but antimicrobial/anti-infectious
properties are associated with oils high in alcohols.9
Essential oils and aromatherapy as alternative
therapy for acne
Tea tree oil
The essential oil derived from the plant Melaleuca alternifo-
lia is known as tea tree oil (TTO) and has been used medicinal-
ly in some countries for many decades.16 Unlike many other
botanicals, TTO has been well characterized and an interna-
tional standard has been formulated.17 Most TTO marketed
in the United States contains approximately 100 terpenes, with
the most abundant (40%) being terinen-4-ol. TTO has broad-
spectrum antimicrobial activity via nonspecific cell membrane
damage.18–20 It is an ingredient in many over-the-counter
products for acne (face and body washes and cleansers, soaps,
Aromatherapy, botanicals, and essential oils in acne 301

Table 1 Organic compounds present in essential oils and their toners, treatment gels or lotions, blemish sticks, masks).21 An
proposed therapeutic actions evidence-based review of botanicals for dermatologic use re-
Organic Proposed therapeutic actions ported that TTO “may have potential to become standard treat-
compounds ment” for acne.22
Several clinical studies of TTO have been performed in acne;
Acids Anti-infectious, immunostimulants
in a single-blind study, 124 participants with mild to moderate
Aromatic Anti-infectious, immunostimulants
aldehydes acne were given either 5% TTO or 5% benzoyl peroxide.23
C10 alcohols Anti-infectious, immunostimulants There were significant reductions in inflammatory and come-
C15 and C20 Estrogen-like activity donal lesions with both treatments. TTO had a slower onset
alcohols of action but better tolerability than benzoyl peroxide.23 In a
Aldehydes Anti-infectious, calming, litholytic randomized 45-day controlled trial of 5% TTO versus vehicle
Coumarins Balancing, calming in 60 participants with mild to moderate acne, TTO, when ap-
Esters Antispasmodic, calming plied twice daily for 20 minutes and then rinsed off with water,
Lactones Balancing, calming was superior to vehicle in reducing total, inflammatory, and
Ketones Cicatrizing (wound healing), mucolytic, noninflammatory lesions (Figure 2). In addition, TTO was
litholytic, calming
well tolerated, although a small proportion of patients experi-
Oxides Expectorant, antispasmodic
enced pruritus, burning, and scaling.17 Unfortunately, a recent
Phenols Anti-infectious, immunostimulants
Phenyl methyl Anti-infectious, antispasmodic Cochrane analysis judged the evidence supporting use of TTO
esters to be of low quality due to methodological and reporting lim-
C10 terpenes Anti-infectious, cortisone-like activity itations, notably of the aforementioned study.24
C15 terpenes Antihistamines, antiallergic
From Stevensen.9 Lactobacillus-fermented Chamaecyparis obtusa leaf
extract

Chamaecyparis obtusa is a species of cypress that grows in

Asia and is widely used in the cosmetic industry. Fermentation

Placebo Group

Fig. 2 Effect of tea tree oil on acne severity index and total lesion counts (secondary outcome measure). (From Enshaieh et al,17 with
permission.)
302
of C. obtusa by Lactobacillus fermentum (LFCO) yields an ex-
tract that has strong inhibitory effects on Propionibacterium
acnes. In a 2014 study of an 8-week randomized, controlled
split-face study to compare LFCO with TTO 5% (n = 34 par-
ticipants with mild to moderate acne),25 inflammatory lesions
were reduced by 65.3% with LFCO compared with a 38.2%
reduction with TTO (Figure 3). A faster onset of action was
documented with LFCO (P b .05), as well as a greater effect
on inflammation and inflammatory markers (Figure 4). In ad-
dition to the effect on inflammatory lesions, LFCO was also
associated with diminished noninflammatory lesions (52.6%,
P b .05). LFCO was sebosuppressive and associated with a re-
duction in size of sebaceous glands, with concomitant lower
sebum output. Although both treatments resulted in significant
reductions in acne lesions, LFCO was superior. The authors of
the report compared the rapid onset of action with that of top-
ical retinoids and antibiotics, suggesting that LFCO “might
partly overcome the side effects” associated with traditional
acne medications.
Fig. 3 (A) Changes in inflammatory acne lesion counts and (B) noninflammatory lesion counts with Lactobacillus-fermented Chamaecyparis
obtusa (LFCO) and tea tree oil (TTO). (From Kwon et al,25 with permission.)
W.J. Winkelman
Copaiba
Copaiba is a stimulating oleoresin obtained from the trunk
of varieties of the South American tree genus Copaifera.26 It
has been used for centuries in Central and South America, par-
ticularly in Brazil, where it is considered a “skin-healing
agent.”26 The oil resin is used in traditional medicine for its
anti-inflammatory, healing, and antiseptic qualities. The thera-
peutic actions of Copaiba are primarily attributed to diterpene
compounds in the oil, which serve the plant as biologic de-
fenses against predators and pathogens.26 In a 21-day
double-blind study of Copaiba essential oil versus placebo in
patients with mild inflammatory acne, assessments used stan-
dardized photographs and analysis of area occupied by acne
pustules.26 There was a decrease of the acne lesions in the af-
fected areas in both treated and control regions.26 Unfortunate-
ly, it is very difficult to compare changes in the acne lesions
with traditional acne studies due to the use of nonstandardized
outcome measures.
Aromatherapy, botanicals, and essential oils in acne 303

Fig. 4 Histologic analysis of skin. (A) Hematoxylin-eosin stain at baseline and 8 weeks with histopathologic inflammation scores at each visit
shown in the graphs (inflammation around sebaceous gland with acne lesion). Immunohistochemical stain intensity from the (B) Lactobacillus-
fermented Chamaecyparis obtusa (LFCO) side and (C) tea tree oil (TTO) side. (D) Semiquantitative reverse transcription polymerase chain reac-
tion analysis of frozen skin samples at baseline and week 8. *P b .05. GAPDH, glyceraldehyde-3-phosphate dehydrogenase. (From Kwon et al,25
with permission.)

Essential oils and aromatherapy as complemen-
tary therapy in acne
Sandalwood oil
Sandalwood oil is used as a therapeutic agent in many
Asian countries to treat inflammatory and cutaneous erup-
tions.27,28 It has antibacterial actions against Staphylococcus
aureus, Staphylococcus epidermidis, and P acnes at concen-
trations of 0.06% and lower.27 Anti-inflammatory effects are
thought to occur via inhibition of cyclooxygenase 1 and 2
and 12-lipoxygenase pathways, as well as in
lipopolysaccharide-stimulated dermal fibroblasts and keratino-
cyte models.27 Another model that employed synthetic sandal-
wood induced wound healing in human keratinocytes.29
Recently, sandalwood oil 0.5% was formulated with salicylic
acid for evaluation in acne patients. An 8-week open-label
study involved 42 participants with mild to moderate acne
who were treated with a four-part regimen of 0.5% salicylic ac-
id with sandalwood in a cleanser, serum, spot treatment, and
mask. Participants used the cleanser twice daily, morning
and night, applied the serum after cleansing, had the option
of using spot treatment on individual blemishes up to 3 to 4
times per day, and employed a mask 3 times per week. A total
of 89% of participants had disease improvement versus base-
line as rated on global assessment scores. Mean decreases in
inflammatory lesions were 37%, noninflammatory lesions
25%, and total lesions 31%. The products were generally well
tolerated, with burning, dryness, and stinging being the most
common treatment-related complaints.27
Rosemary extract
Rosemary extract contains at least three bioactive com-
pounds: rosmarinic acid, carnosol, and carnosic acid.30 These
have different modulatory effects on cytokine production. In
vivo mouse models have found inhibition of P. acnes–induced
inflammation via inhibition/suppression of cytokine produc-
tion. Additionally, rosemary extract may reduce nuclear factor
kB activation and normalize Toll-like receptor protein 2
in vitro.30 Although the addition of rosemary extract may con-
tribute anti-inflammatory actions to cosmeceutical or dermato-
logic products,30 injection of rosemary extract is not
associated with skin irritation or inflammation in the mouse
model.
304
Jeju essential oil
Jeju essential oil is derived from Thymus plants.31 Jeju es-
sential oil may have antibacterial activities with effects
against P acnes,31 according to a 2009 study, in which the
researchers suggest the agent may be useful for treating
acne patients.
Korean citrus
Citrus oils from Citrus obovoides and Citrus natsudaidai
have been tested for antibacterial activity against P. acnes
and S. epidermidis.32 Results indicated lower P. acnes secre-
tion of interleukin 8 and tumor necrosis factor α, suggesting
potential utility in acne.32
Conclusions
Currently there is weak clinical evidence that TTO 5% may
be used as an alternative acne therapy. Several agents may be
helpful as complementary therapy due to biologic plausibility,
but there is little clinical evidence. There is as yet no proof of
psychosocial outcome effectiveness, cost effectiveness, or any
other economic advantages, and no insights into impact on post-
inflammatory hyperpigmentation in patients with darker skin
tones. Despite the lack of evidence, dermatologists would be
served well to at least understand complementary and
alternative remedies when their patients ask about such agents
and their potential clinical value in the management of their
acne.
Acknowledgments
Valerie Sanders assisted in the preparation of the
manuscript.
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W.J. Winkelman is an employee of Nestlé Skin Health Investigation, Educa-
tion, and Longevity Development (SHIELD), a sister company of Galderma
Laboratories, LP, which markets an over-the-counter acne product containing
an essential oil.