COMMENTARY
modulate IL-17 and IL-22 production, as Liu PT, Krutzik SR, Kim J et al. (2005) Cutting edge:
well as the expression of IL-17 receptors
on PBMCs from healthy donors in vitro.
Looking ahead
This interesting and provocative work
by Agak et al. (2014) poses many
fascinating new questions relating to
initiating events in acne pathogenesis
and mechanisms of inflammation.
Further in vivo work should determine
whether some or all of these findings
have relevance to the clinical setting,
with a view toward informing the
development of novel therapies.
CONFLICT OF INTEREST
The authors state no conflict of interest.
REFERENCES
Agak GW, Qin M, Nobe J et al. (2014) Propioni-
bacterium acnes induces an interleukin-17
response in acne vulgaris that is regulated
by vitamin A and vitamin D. J Invest Dermatol
134:366–73
Chronnell CMT, Ghali LR, Ali RS et al. (2001)
Human [bgr] Defensin-1 and -2 expression in
human pilosebaceous units. Upregulation in
Acne Vulgaris Lesions 117:1120–5
Dispenza MC, Wolpert EB, Gilliland KL et al.
(2012) Systemic isotretinoin therapy nor-
malizes exaggerated TLR-2-mediated innate
immune responses in acne patients. J Invest
Dermatol 132:2198–205
Ingham E, Eady EA, Goodwin CE et al. (1992) Pro-
inflammatory levels of interleukin-1 alpha-like
bioactivity are present in the majority of open
comedones in acne vulgaris. J Invest Derma-
tol 98:895–901
Jeremy AHT, Holland DB, Roberts SG et al. (2003)
Inflammatory events are involved in acne
lesion initiation. J Investig Dermatol 121:20–7
Kang S, Cho S, Chung JH et al. (2005) Inflamma-
tion and extracellular matrix degradation
mediated by activated transcription factors
nuclear factor-kB and activator protein-1 in
inflammatory acne lesions in vivo. Am J
Pathol 166:1691–9
Kim J, Ochoa M-T, Krutzik SR et al. (2002)
Activation of Toll-Like receptor 2 in acne
triggers inflammatory cytokine responses.
J Immunol 169:1535–41
Layton AM, Morris C, Cunliffe WJ et al. (1998)
Immunohistochemical investigation of evol-
ving inflammation in lesions of acne vulgaris.
Exper Dermatol 7:191–7
Lee S, Kim J-M, Jeong S et al. (2010) Protease-
activated receptor-2 mediates the expression
of inflammatory cytokines, antimicrobial pep-
tides, and matrix metalloproteinases in kera-
tinocytes in response to Propionibacterium
acnes. Arch Dermatol Res 302:745–56
Leeming JP, Holland KT, Cuncliffe WJ (1988) The
microbial colonization of inflamed acne vul-
garis lesions. Br J Dermatol 118:203–8
310 Journal of Investigative Dermatology (2014), Volume 134
Nakatsuji T, Kao MC, Zhang L et al. (2010) Sebum
all-trans retinoic acid down-regulates TLR2 free fatty acids enhance the innate immune
expression and function. J Immunol 174: defense of human sebocytes by upregulating
2467–70 [beta]-defensin-2 expression. J Invest Derma-
tol 130:985–94
Mouser PE, Baker BS, Seaton ED et al. (2003)
Propionibacterium acnes-reactive t helper-1 Norris JFB, Cunliffe WJ (1988) A histological and
cells in the skin of patients with acne vulgaris. immunocytochemical study of early acne
J Invest Dermatol 121:1226–8 lesions. Br J Dermatol 118:651–9
Nagy I, Pivarcsi A, Koreck A et al. (2005) Distinct Plewig G, Kligman A (eds) (2000) Acne and
strains of propionibacterium acnes induce sele- Rosacea. Berlin: Springer-Verlag
ctive human [beta]-Defensin-2 and interleukin-8 Qin M, Pirouz A, Kim M-H et al. (2013) Propio-
expression in human keratinocytes through nibacterium acnes induces IL-1[beta] secre-
toll-like receptors. J Invest Dermatol 124: tion via the NLRP3 inflammasome in human
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bacterium acnes and lipopolysaccharide Trivedi NR, Gilliland KL, Zhao W et al. (2006)
induce the expression of antimicrobial Gene array expression profiling in acne
peptides and proinflammatory cytokines/ lesions reveals marked upregulation of genes
chemokines in human sebocytes. Microbes involved in inflammation and matrix remo-
Infect 8:2195–205 deling. J Invest Dermatol 126:1071–9
See related article on pg 381
New Insights into Acne Pathogenesis:
Propionibacterium Acnes Activates the
Inflammasome
Emmanuel Contassot1 and Lars E. French1
The precise contribution of the commensal bacterium Propionibacterium acnes
(P. acnes) in the inflammatory response associated with acne vulgaris remains
controversial. In this issue Qin et al. show that P. acnes induces robust IL-1b
secretion in monocytic cells by triggering the activation of the NLRP3 inflamma-
some. In vivo, the encounter of P. acnes and macrophages in the peri-follicular
dermis could locally result in the release of substantial amounts of IL-1b and
therefore exacerbate inflammation. Such findings suggest that molecules targeting
IL-1b and/or the NLRP3 inflammasome may constitute new treatment possibilities
for acne vulgaris.
Journal of Investigative Dermatology (2014) 134, 310–313. doi:10.1038/jid.2013.505
Acne vulgaris is a common inflamma- mation, and bacterial colonization of
tory skin disease affecting B80% of the pilo-sebaceous unit by Propioni-
individuals at some time during their bacterium acnes (P. acnes), a common
lives (Williams et al., 2012). The dis- anaerobic Gram-positive commensal of
ease, affecting the pilo-sebaceous unit, normal skin. Increased sebum pro-
is a multifactorial process involving both duction and follicular hyperkeratosis
endogenous and exogenous factors, are thought to be initial events leading
including increased sebum production, to a change of the pilo-sebaceous milieu
altered follicular keratinization, inflam- that favors the proliferation of P. acnes
1
Dermatology Department, University Hospital of Zürich, Zürich, Switzerland
Correspondence: Lars E. French, Dermatology Department, University Hospital, Gloriastrasse 31, Zürich
8091, Switzerland. E-mail: lars.french@usz.ch
 COMMENTARY

Clinical Implications dent manner (Leeming et al., 1988;

Vowels et al., 1995; Bojar and Holland,
 Concepts of the role(s) of Propionibacterium acnes in acne must now be 2004; Kurokawa et al., 2009). In addi-
expanded. tion, sebocytes have been suggested to
 Inflammasome activation accompanies P. acnes activation of monocytes in secrete IL-8 in response to P. acnes expo-
the skin, releasing inflammatory mediators, including interleukin-1b. sure (Nagy et al., 2006). Despite this pro-
 Specific inhibitors of inflammasome-mediated inflammation may repre- gress, the exact molecular mechanism(s)
sent a new class of treatment for acne. by which P. acnes contributes to inflam-
mation in acne still remains incompletely
understood. In this issue, Qin et al.
provide novel evidence that P. acnes
contributes to the inflammatory response
(Kurokawa et al., 2009). Pro-inflam- 2009), and its precise role(s) in acne seen in acne by triggering the activation
matory cytokines including interleukin- pathogenesis are still unclear. It has of the NLRP3-inflammasome in antigen-
1a (IL-1a) and tumor necrosis factor-a been suggested that P. acnes, which loca- presenting cells (APCs), subsequently
(TNFa) are, among others, considered to lizes and proliferates preferentially in leading to enhanced IL-1b secretion.
be responsible for the further follicular the lipid-rich environment of the pilo- The inflammasome is a cytoplasmic
hyperkeratinization and the inflam- sebaceous unit, may contribute to the molecular complex that can rapidly
matory lesions characteristic of acne development of inflammatory lesions by initiate inflammation upon sensing
(Gollnick, 2003; Zouboulis et al., 2005; releasing chemotactic factors, by indu- pathogen- and danger-associated mole-
Kurokawa et al., 2009). Controversy cing the secretion of IL-6 and IL-8 by cular patterns (PAMPs/DAMPs) by regu-
exists, however, concerning the signifi- follicular keratinocytes, and by inducing lating the secretion of caspase-1 acti-
cance of the commensal P. acnes in the IL-1b, TNF-a, IL-8, and IL-12 by mono- vation-dependent cytokines including
development of acne (Kurokawa et al., cytic cells in a Toll-like receptor 2-depen- IL-1b (Strowig et al., 2012). Several

Early-stage inflammatory acne lesion Late-stage inflammatory acne lesion

Sebum accumulation Proliferation of P. acnes
Proliferation of P. acnes Follicular rupture
Mild inflammation Important inflammation

Epidermis

?
Sebaceous
Dermis gland

Hair follicle

Macrophage
P. acnes P2X7
Dendritic cell
TLR K+ Neutrophil
me

ROS mtDNA
aso

Phagocytosis
mm

LRR
infla

NACHT
Cat.B
P3-

PYD
NLR

Lysosomal Caspase-1
Ca++
disruption
Mitochondria
ER
NFκB
IL-1β IL-1β
Pro-IL-1β
Nucleus Cytoplasm

Figure 1. Model of P. acnes-driven inflammasome activation in acne. Altered follicular keratinization, sebum hyperproduction, and Propionibacterium
acnes (P. acnes) colonization/growth within the pilo-sebaceous unit results in disruption of the follicular epithelium. P. acnes can then leak out of the
pilo-sebaceous unit and get into contact with myeloid cells such as macrophages, thereby triggering molecular events involved in NLRP3-inflammasome
activation, subsequent local release of bioactive IL-1b, and neutrophil-rich local inflammation. An earlier interaction between P. acnes and myeloid cells,
either by migration of the latter into the follicular space or ‘‘leakage’’ of P. acnes into the peri-follicular dermis, leading to inflammasome activation is not
excluded but remains to be demonstrated. Cat.B, cathepsin B; mtDNA, mitochondrial DNA; ROS, reactive oxygen species; TLR, Toll-like receptor.

www.jidonline.org 311
 COMMENTARY
types of inflammasomes have been
described, the best studied to date
being the NLRP3-inflammasome. The
NLRP3-inflammasome can be activated
by a large variety of structurally distinct
DAMPs and PAMPs, and certain
bacterial toxins. The structural diversity
of NLRP3-inflammasome activators
suggests that these factors do not inte-
ract with a component of the NLRP3-
inflammasome, but that they activate it
by inducing a common upstream signal.
Several models have been proposed to
explain how such diverse signals can lead
to this selective activation (Strowig et al.,
2012). They include the gene-
ration of reactive oxygen species (ROS),
K þ efflux, and lysosomal rupture (Stutz
et al., 2009; Jin and Flavell, 2010). K þ
efflux and lysosomal rupture account for
NLRP3-inflammasome activation during
bacterial infection such as, for example,
infection caused by Chlamydia pneu-
moniae (He et al., 2010), Klebsiella
pneumonia (Willingham et al., 2009),
Porphyromonas gingivalis (Huang et al.,
2009), or Neisseria gonorrhoeae (Duncan
et al., 2009). In addition, it has been
shown that multiple NLRP3-inflamma-
some activators induce Ca2 þ signaling,
the latter promoting mitochondrial
damage (Murakami et al., 2012). Taken
together, the stimuli activating NLRP3
generate certain signals of cellular stress
originating from the mitochondria
(Nakahira et al., 2011; Shimada et al.,
2012), referred to as signal 2, comple-
mentary to signal 1, which is provided by
TLRs and is crucial for the transcriptional
upregulation of NLRP3 and pro-IL-1b
(Bauernfeind et al., 2009).
In this issue, Qin et al. show that
P. acnes is a potent trigger of NLRP3-
inflammasome activation, resulting in
caspase-1 activation, and mature IL-1b
secretion in human monocytes. Qin
et al. (2014) demonstrate that P. acnes-
induced NLRP3-inflammasome activa-
tion involves K þ efflux—an event
known to be required for inflammasome
activation—as evidenced by the
reduced IL-1b secretion obtained with
glibenclamide, an inhibitor of ATP-sen-
sitive K þ channels such as P2X7. Note-
worthy, Qin et al. also demonstrate by
immunolabeling that mature caspase-1
and NLRP3 expression colocalizes with
tissue macrophages around the pilo-
312 Journal of Investigative Dermatology (2014), Volume 134
sebaceous follicles in acne biopsies,
providing evidence of NLRP3-inflamma-
some activation within acne lesions.
The novel data reported by Qin et al.
suggest that the triggering of inflamma-
tion by P. acnes is dependent on access
of the bacterium to myeloid cells as
well as their ability to phagocytose the
bacteria and trigger a NLRP3-inflam-
masome-dependent innate immune
response. The exact site of uptake of
P. acnes by phagocytes is unclear to
date, but the encounter of P. acnes with
phagocytes such as macrophages or
dendritic cells may occur upon rupture
of the pilo-sebaceous unit, allowing
bacteria to spread into the environment
nearby, where they can be taken up by
dermal APCs including macrophages.
Previous reports showed that P. acnes,
when distributed in the extracellular
space recruits and can be phagocytosed
by macrophage-like cells (Nakatsuji
et al., 2008, 2011). Indeed, inflamma-
tory cells, and notably macrophages,
likely serving as sentinels, are present
in high numbers in the immediate
proximity of pilo-sebaceous follicles of
the uninvolved acne skin, as well as in
early stage inflammatory acne lesions,
but in contrast, not around the pilo-
sebaceous units of normal skin from
healthy individuals (Jeremy et al.,
2003). The uptake of bacteria by
phagocytes around the pilo-sebaceous
follicles is very likely to induce multiple
level signals involving on the one hand
nuclear factor-kB-mediated induction of
pro-IL-1b and on the other hand, signals
possibly involving mitogen-activated
protein kinase, resulting ultimately in
inflammasome activation and bioactive
IL-1b secretion (Tsai et al., 2013).
Identification of molecular events
occurring in dermal APCs upon encoun-
ter of P. acnes, notably local inflamma-
some-mediated IL-1b production, opens
avenues for the development of new
anti-inflammatory agents or to the use
of existing medications for the treatment
of severe forms of acne. Recently, clini-
cal reports have appeared suggesting
therapeutic effect of drugs targeting
IL-1b signaling in patients with auto-
inflammatory syndromes in which
acne is a symptom. This is the case for
PAPA syndrome (pyogenic arthritis, pyo-
derma gangrenosum, and acne),
SAPHO syndrome (synovitis, acne, pus-
tulosis, hyperostosis, and osteitis), and
PASH syndrome (pyoderma, acne, and
suppurative hidradenitis) (Brenner
et al., 2009; Braun-Falco et al., 2012;
Wendling et al., 2012). In these
patients, blocking IL-1 signaling has
been reported to reduce the severity of
acne symptoms. Furthermore, and in
accordance with data provided in this
issue by Qin et al. showing that either
inflammasome deficiency or IL-1b block-
ade prevents P. acnes-induced inflamma-
tory responses, recent interim results from
a phase 2 double-blind placebo-
controlled trial assessing a monoclonal
antibody to IL-1b (Gevokizumab, Xoma-
052) have shown that 0.6 mg kg  1
Gevokizumab given once per month for
3 consecutive months induced a statis-
tically significant reduction in inflam-
matory lesion counts compared with
placebo in patients with moderate to
severe acne (Xoma, 2013).
Taken together, the study from Qin
et al. demonstrates that P. acnes can
induce robust IL-1b secretion from
monocytic cells in an NLRP3-dependent
manner and establish P. acnes as an
etiological factor of acne-associated
inflammation. Such findings combined
with the observation that caspase-1 and
NLRP3 are expressed in vivo in dermal
macrophages surrounding the pilo-
sebaceous follicles in acne lesions, sug-
gesting that molecules targeting IL-1b
and/or upstream events in inflam-
masome activation may provide new
treatment possibilities for acne vulgaris.
CONFLICT OF INTEREST
The authors state no conflict of interest.
REFERENCES
Bauernfeind FG, Horvath G, Stutz A et al. (2009)
Cutting edge: NF-kappaB activating pattern
recognition and cytokine receptors license
NLRP3 inflammasome activation by regulat-
ing NLRP3 expression. J Immunol 183:
787–91
Bojar RA, Holland KT (2004) Acne and Propioni-
bacterium acnes. Clin Dermatol 22:375–9
Braun-Falco M, Kovnerystyy O, Lohse P et al.
(2012) Pyoderma gangrenosum, acne, and
suppurative hidradenitis (PASH)–a new auto-
inflammatory syndrome distinct from PAPA
syndrome. J Am Acad Dermatol 66:409–15
Brenner M, Ruzicka T, Plewig G et al. (2009)
Targeted treatment of pyoderma gangre-
nosum in PAPA (pyogenic arthritis, pyoderma

gangrenosum and acne) syndrome with
the recombinant human interleukin-1 recep-
tor antagonist anakinra. Br J Dermatol 161:
1199–201
Duncan JA, Gao X, Huang MT et al. (2009)
Neisseria gonorrhoeae activates the protei-
nase cathepsin B to mediate the signaling
activities of the NLRP3 and ASC-containing
inflammasome. J Immunol 182:6460–9
Gollnick H (2003) Current concepts of the patho-
genesis of acne: implications for drug treat-
ment. Drugs 63:1579–96
He X, Mekasha S, Mavrogiorgos N et al. (2010)
Inflammation and fibrosis during Chlamydia
pneumoniae infection is regulated by IL-1 and
the NLRP3/ASC inflammasome. J Immunol
184:5743–54
Huang MT, Taxman DJ, Holley-Guthrie EA et al.
(2009) Critical role of apoptotic speck protein
containing a caspase recruitment domain
(ASC) and NLRP3 in causing necrosis and
ASC speck formation induced by Porphyro-
monas gingivalis in human cells. J Immunol
182:2395–404
Jeremy AH, Holland DB, Roberts SG et al. (2003)
Inflammatory events are involved in acne
lesion initiation. J Invest Dermatol 121:
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of NLRP3 inflammasome activation. J Clin
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Kurokawa I, Danby FW, Ju Q et al. (2009) New
developments in our understanding of acne
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The microbial colonization of inflamed
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203–8
Murakami T, Ockinger J, Yu J et al. (2012) Critical
role for calcium mobilization in activation of
the NLRP3 inflammasome. Proc Natl Acad Sci
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Nagy I, Pivarcsi A, Kis K et al. (2006) Propioni-
bacterium acnes and lipopolysaccharide
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tides and proinflammatory cytokines/chemo-
kines in human sebocytes. Microbes Infect
8:2195–205
Nakahira K, Haspel JA, Rathinam VA et al. (2011)
Autophagy proteins regulate innate immune
responses by inhibiting the release of
mitochondrial DNA mediated by the NALP3
inflammasome. Nat Immunol 12:222–30
Nakatsuji T, Shi Y, Zhu W et al. (2008) Bioengi-
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Proteomics 8:3406–15
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Propionibacterium acnes CAMP factor and
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Qin M, Pirouz A, Kim MH et al. (2014) Propioni-
bacterium acnes induces IL-1beta secretion
via the NLRP3 inflammasome in human
monocytes. J Invest Dermatol 134:381–8
COMMENTARY
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NLRP3 inflammasome during apoptosis. results of an open study. Ann Rheum Dis 71:
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3502–11 HMGB1 release via inflammasome-depen-
Tsai HH, Lee WR, Wang PH et al. (2013) dent and -independent pathways. J Immunol
Propionibacterium acnes-induced iNOS 183:2008–15
and COX-2 protein expression via ROS- XOMA Announces Encouraging Interim Results From
dependent NF-kappaB and AP-1 activa- Gevokizumab Phase 2 Study for Moderate
tion in macrophages. J Dermatol Sci 69: to Severe Acne Vulgaris. http://investors.xoma.
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proinflammatory cytokines by a soluble factor 17, 2013.
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See related article on pg 423
Crossing Barriers; Restoring Barriers?
Filaggrin Protein Replacement
Takes a Bow
Alan D. Irvine1,2,3
In this issue of the Journal, Stout and colleagues report a novel and creative
approach to replacement of genetically determined absence or deficiency of
epidermal proteins. While these early data are certainly interesting, further validation
work is required to determine the utility of this approach in genodermatoses.
Journal of Investigative Dermatology (2014) 134, 313–314. doi:10.1038/jid.2013.506
One in ten Europeans carries at least one mined deficiencies in FLG produc-
filaggrin (FLG) loss-of-function (LOF) tion, FLG expression is downregulated
mutation (Irvine and McLean, 2006). secondarily in AD due to the disease
These common variants are the stron- per se (Kezic et al., 2011), as recently
gest genetic risk yet identified for atopic reviewed (McAleer and Irvine, 2013). In
dermatitis (AD), with an overall odds addition to a role as an AD risk gene,
ratio for AD of B4 (Rodriguez et al., FLG LOFs are modifiers of disease
2009). In addition to the risk of AD within AD. Individuals with AD who
posed by LOF mutations, variation in carry a FLG LOF mutation are more
FLG repeat numbers (10, 11, or 12 likely to develop asthma, to have more
repeats; intragenic copy-number varia- severe and more persistent disease, to
tion) also confers significant risk of have allergic sensitizations, and to
AD (Brown et al., 2012). Furthermore, develop eczema herpeticum (McAleer
in addition to these genetically deter- and Irvine, 2013).
1
Department of Paediatric Dermatology, Our Lady’s Children’s Hospital Crumlin, Dublin, Ireland;
2
National Children’s Research Centre, Our Lady’s Children’s Hospital Crumlin, Dublin, Ireland and
3
Clinical Medicine, Trinity College Dublin, Dublin, Ireland
Correspondence: Alan D. Irvine, Department of Paediatric Dermatology, Our Lady’s Children’s Hospital
Crumlin, Dublin 12, Ireland. E-mail: irvinea@tcd.ie
www.jidonline.org 313