BASIC/CLINICAL SCIENCE

Prospective, Randomized, Open-Label Trial Comparing the

Safety, Efficacy, and Tolerability of an Acne Treatment
Regimen with and without a Probiotic Supplement and
Minocycline in Subjects with Mild to Moderate Acne
Gordon W. Jung, Jennifer E. Tse, Isabella Guiha, and Jaggi Rao

Background: Systemic antibiotics are an effective treatment for acne vulgaris. However, intolerable side effects may invariably
occur.
Objective: To determine whether probiotics reduce the side effects imparted by systemic antibiotics while working
synergistically with the latter in treating inflammatory acne.
Methods: Forty-five 18- to 35-year-old females were randomly assigned to one of three arms in this prospective, open-label
study. Group A received probiotic supplementation, whereas group B received only minocycline. Group C was treated with both
probiotic and minocycline. Clinical and subjective assessments were completed at baseline and during the 2-, 4-, 8-, and 12-week
follow-up visits.
Results: All patients demonstrated a significant improvement in total lesion count 4 weeks after treatment initiation (p < .001),
with continued improvement seen with each subsequent follow-up visit (p < .01 ). At the 8- and 12-week follow-up visits, group C had
a significant decrease in total lesion count versus groups A (p < .001) and B (p < .01). Two patients (13%) from group B failed to
complete the study secondary to vaginal candidiasis.
Conclusion: Probiotics may be considered a therapeutic option or adjunct for acne vulgaris by providing a synergistic
antiinflammatory effect with systemic antibiotics while also reducing potential adverse events secondary to chronic antibiotic use.

Contexte: Les antibiotiques à action générale sont efficaces contre l'acné vulgaire, mais ils peuvent toujours produire des effets
indésirables intolérables.
Objectif: L'étude visait à déterminer si les probiotiques diminuaient les effets indésirables des antibiotiques à action générale,
tout en agissant en synergie avec ces derniers dans le traitement de l'acné inflammatoire.
Méthode: Quarante-cinq femmes, âgées de 18 à 35 ans, ont été dirigées au hasard vers l'un des trois groupes de traitement,
formés dans le cadre de cet essai prospectif, mené au su des parties; le groupe A a reçu un supplément probiotique; le groupe B, de la
minocycline seule; et le groupe C, le supplément probiotique et la minocycline. Il y a eu une évaluation clinique et subjective au
départ, puis à la 2e, 4e, 8e, et 12e semaine de suivi.
Résultats: Une diminution sensible du nombre total de lésions a été observée chez tous les sujets, 4 semaines après le début du
traitement (p < .001), diminution qui a été constatée à chacune des visites ultérieures de suivi (p < .01). Aux visites de la 8e et de la
12e semaine, une diminution importante du nombre total de lésions a été notée dans le groupe C comparativement aux groupes A (p
< .001) et B (p < .01). Deux patientes (13%) dans le groupe B n'ont pas terminé l'étude en raison d'une candidose vaginale.
Conclusions: Les probiotiques peuvent être envisagés comme formule thérapeutique ou appoint thérapeutique dans l'acné
vulgaire en produisant un effet anti-infiammatoire synergique avec celui des antibiotiques à action générale, en plus de diminuer les
effets indésirables possibles de l'emploi prolongé des antibiotiques.

From the Division of Dermatology and Cutaneous Sciences, Department
of Medicine, University of Alberta, Edmonton, AB; Shape MD,
Edmonton, AB; Acne Clinics of Canada, Edmonton, AB; and
Dermatology and Cosmetic Laser Associates of La ¡olla. La Jolla, CA.
The results of this study were presented at the 70th Annual Meeting of the
American Academy of Dermatology, March 16-20, 2012, San Diego, CA.
Address reprint requests to: Jaggi Rao, MD, FRCPC, Division of
Dermatology and Cutaneous Sciences, Department of Medicine,
University Dermatology Centre, 2-125 Clinical Sciences Bldg, Edmonton,
^ ^^^^ 2G3; e-mail: jrao@ualberta.ca.
^ ^ ^ 10.2310/7750.2012.12026
© 2013 Canadian Dermatology Association

DECKEI^
114 Canadian Dermatology Association I journal of Cutaneous Medicine and Surgery, Vol 17, No 2 (March/April), 2013: pp 114-122
 Acne Treatment with Minocycline and/or Probiotics

CNE VULGARIS is one of the most common
A dermatologie diseases affecting Western societies and
typically presents during the adolescent period.' Although
not life-threatening, acne causes significant morbidity, both
physically and psychologically. Specifically, severe acne has
been associated with high levels of anxiety, major depres-
sion, social isolation, aggressive behavior, and suicidal
ideation.^ Furthermore, poorly controlled acne can lead to
irreversible disfigurement.
Acne treatment, consisting of topical, systemic, and
light and laser therapies, is individualized and dependent
on the number and type of lesions a patient has. Oral
antibiotics have been used to treat a significant number of
acne patients with inflammatory disease, with the tetra-
cycline family being the most widely used.^ The tetra-
cyclines alter the course of acne lesions via its bacteriostatic
action against Propionibacterium acnes by inhibiting
bacterial protein synthesis.* In addition, antibiotics have
antiinflammatory properties through modulation of
cytokine and reactive oxygen species production and
reduction of leukocyte chemotaxis.^ Although effective,
with a 22 to 91% and 23 to 75% reduction of
inflammatory lesions after treatment with minocycline
and doxycycline,^ respectively, side effects from such
medications may occur, some of which may lead to
decreased compliance and/or discontinuation of the
antibiotic. Such adverse effects include gastrointestinal
disturbance, candidiasis, dizziness, lethargy, headaches,
blue staining of the teeth in pédiatrie patients, and
photosensitivity and photo-onycholysis.^
The side effects of antibiotic treatment may be reduced
via concomitant use of probiotics. Such live microorganisms
have been used for decades to alleviate abdominal symptoms
via maintenance of commensal intestinal organisms and
antiinflammatory mechanisms while imparting other health
benefits when administered in adequate amounts.^ However,
a review of the literature failed to identify studies assessing
the effects of probiotics with antibiotics on acne vulgaris.
The purpose of this study was to determine whether
probiotics reduced the side effects imparted by systemic
antibiotics while working synergistically with the latter in
treating inflammatory acne.
Methods
Subject Population
From May 2010 to April 2011, otherwise healthy,
nonpregnant female patients, 18 to 35 years of age with
Fitzpatrick skin types I to III, were enrolled in this
prospective, randomized, open-label study. Only subjects
with mild to moderate acne vulgaris, with a score of 2 or 3
via the Global Acne Assessment Scale (Table 1) and 20 to
50 total lesions (with at least 10 inflammatory lesions),
were included. The face was divided into five regions:
forehead, nose, chin, right cheek, and left cheek.
Patients were excluded from the trial if they had active
localized or generalized infections, a history of auto-
immune disease, or a history of mental illness. Pregnant or
breastfeeding patients were also excluded from the study.
Patients who smoked more than one pack per day, drank
more than three alcoholic beverages per day, were
concurrently using isotretinoin, or changed their oral
contraceptive therapy within the past 3 months were not
included in the trial. Those with a history of probiotic use
(supplement and/or food enhanced) within the month
prior to starting the study were excluded. Finally, subjects
with excessive facial hair or scars, which could interfere

Table 1. Global Acne Assessment Scale

Grade Description
Normal, clear skin with no evidence of acne vulgaris
Skin is almost clear; rare noninflammatory lesions present, with rare noninflamed papules (papules must be resolving and
may be hyperpigmented, although not pink-red), requiring no further treatment in the investigator's opinion
Some noninflammatory lesions are present, with few inflammatory lesions (papules/pustules only; no nodulocystic lesions)
Noninflammatory lesions predominate, with multiple inflammatory lesions evident; several to many comedones and
papules/pustules, and there may or may not be one small nodulocystic lesion
Inflammatory lesions are more apparent; many comedones and papules/pustules; there may or may not be a few
nodulocystic lesions
Highly inflammatory lesions predominate: variable number of comedones, many papules/pustules and nodulocystic lesions
The Global Acne Assessment Scale used to categorize patients as mild, moderate, or severe acne vulgaris in the current study. To qualify for the study,
subjects were to have mild to moderate acne as determined by the investigative staff (defined as a score of 2 or 3) in addition to having between 20 and 50
total lesions with at least 10 inflammatory lesions.

' Canadian Dermatology Association I Journal of Cutaneous Mediane and Surgery, Vol 17, No 2 (March/April), 2013: pp 114-122 115
 Jung et at
with clinical assessments, and those who had any facial
cosmetic procedures completed within the 3 months prior
to study initiation were excluded.
Study Design and Outcome Measures
Subjects were randomly assigned to one of three groups via a
computer-generated schema. Group A received only probio-
tic supplementation, whereas group B received only
minocycline. Group C was treated with both probiotic and
minocycline. Trenev Trio (professional)/Healthy Trinity
(retail) (Natren, Inc., Westlake Village, CA) was the probiotic
product assessed in this study, which included a combination
of Lactohadllus acidophilus (NAS super-strain, 5 billion
colony-forming units [CFU)/capsule], Lactobacillus del-
brueckii subspecies bulgaricus (LB-51 super-strain, 5 billion
CFU/capsule), and Biftdobacterium biftdum (Malyoth super-
strain, 20 billion CFU/capsule) microenrobed in an oil matrix
within a two-piece hard gel capsule.
Those randomized to a probiotic regimen (groups A
and C) were to take one probiotic capsule once in the
morning and once in the evening. Patients in the
minocycline arms (groups B and C) were advised to take
the antibiotic once after dinner. Those in group C were
instructed to take the probiotic at least 2 hours after their
minocycline dosage. All three arms of the study received a
standard topical acne medication (benzoyl peroxide 5%)
and a facial cleanser (Cetaphil Daily Facial Cleanser),
which were applied once in the morning and once in the
evening. Each group was treated with the same regimen
that was initiated and was prohibited frotn using
additional acne treatments for the duration of the 12
weeks they were enrolled in the study.
Clinical evaluations and digital photographs were
performed at baseline and during follow-up visits 2, 4, 8,
and 12 weeks from treatment initiation. Clinical assess-
ments included facial skin tolerability (degree of facial
roughness, mottled pigmentation, sallowness, dullness,
inflammation, irritation, peeling, itching, burning/sting-
ing, oiliness, scaling, xerosis, and erythema) on a 10-point
scale (0 = none; 1 to 3 = mild; 4 to 6 = moderate; 7 to 9
= severe) and acne lesion counts (total, noninflamed, and
inflamed). All of the clinical procedures and evaluations
were completed by expert designates and investigators
unaware of the patients' group assignments. As well,
patients were asked to complete a self-assessment survey
during each visit addressing the eftect of acne on their
quality of life.
All subjects were required to provide itiformed consent
and photograph release consent prior to entering the
116 Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 17, No 2 (March/April), 2013: pp 114-122
study. Ethics approval was granted by the Health Research
Ethics Board (Biomédical Panel) of the University of
Alberta on April 9, 2010.
Data Analysis
The efficacy of the three treatment regimens was
established by using a change in the average total, average
total inflamed, and average total noninfiamed lesion
counts along with a change in facial skin tolerability over
the 12-week study period. Patients' subjective accounts
with regard to their acne (quality of life) were also
analyzed at baseline and at the 12-week follow-up visit. All
statistical analyses were computed using the two-sample f-
test assuming equal variance, with the level of significance
set at p < .05 (confidence level 95%) using the per
protocol analysis strategy. Analysis included comparing
the effect of each treatment between two clinic visits within
each study group. The efficacy of the three treatment
regimens was also compared at each follow-up visit.
Results
Demographics and Adverse Events
Forty-five otherwise healthy female patients with Fitzpatrick
skin types I to III, aged 18 to 35 years of age, were enrolled in
the current study. Each arm of the study consisted of 15
patients. Two subjects (13%) from the minocycline-only
arm (group B) exited the study prematurely (one patient
prior to week 4 and one prior to week 8) secondary to
intolerable vaginal candidiasis. No patients complained of
any other adverse events.
Total Lesion Count
At baseline, patients in group A had an average total lesion
count of 30.5 (range 21^0). Similarly, at baseline, patients
in groups B and C had average total lesion counts of 30
(range 24-36) and 33 (range 24-41), respectively (Figure 1).
The percent decreases in total lesion count from
baseline for each group are presented in Table 2. By week
4, all three groups showed a significant improvement in
total lesion count from baseline (p < .001) with no
significant difference between groups [p > .05) (see
Figure 1 ). By week 8, all three groups showed a significant
improvement from week 4 (p = .001 for group A; p < .001
for groups B and C). Group C also showed a significantly
lower total lesion count versus both groups A (p < .001)
and B (p = .006) (see Figure 1). By week 12, all groups
 Acne Treatment with Minocycline and/or Probiotics

40 n

Baseline Week 2 Week 4 Week 8 Week 12

Figure 1. Change in total lesion counts (noninflamed and inflamed) over the 12-week study period. Blue, red, and green bars represent groups A,
B, and C, respectively. Error bars represent 95% confidence intervals.

showed a significant degree of improvement fi-om the
previous visit (p = .001 for group B; p < .001 for groups A
and C). Again, group C showed a significantly reduced
total lesion count than both groups A (p < .001) and B (p
< .001) at week 12 (see Figure 1).
Noninflamed Lesion Count
At baseline, patients in the probiotic-only arm had a mean
noninflamed lesion count of 19.8 (range 10-26). Groups B
and C had average total noninflamed lesion counts of 19.2
(range 13-23) and 20.7 (range 15-28), respectively (Figure 2).
The percent decreases in noninflamed lesion count from
baseline for each group are presented in Table 2. By week 4,
all three groups showed a significant improvement in
noninflamed lesion counts from baseline (p < .001) with no
significant difference between groups (p > .05) (see
Figure 2). All arms also experienced a significant improve-
ment from week 4 to week 8 (p = .003 for group A; p < .001
for groups B and C). By week 12, all groups again showed a
significant degree of improvement from the previous visit (p
= .02 for group B; p < .001 for groups A and C). In
addition. Figure 2 illustrates that group C experienced a
significantly lower total noninflamed lesion count than both
groups A (p = .03) and B (p = .001) at 12 weeks.
Inflamed Lesion Count
Group A had an average total inflamed lesion count of 10.7
(range 5-15), whereas groups B and C had mean total

Table 2. Percent Decrease in Total, Noninflamed, and Inflamed Lesion Counts from Baseline

Decrease in Total Lesion Count from Decrease in Noninflamed Lesion Decrease in Inflamed Lesion Count from
Baseline (%) Count from Baseline (%) Baseline (%)

Week Group A Group B Group C Group A Group B Group C Group A Group B Group C

4 38 33 41 46 40 38 46* 40* 38
8 52 56 67 59 56 62 59 56 62
12 67 67 82 70 65 77 70 65 77

Group A = probiotic only; group B = minocycline only; group C = probiotic and minocycline.
*Not significant (p > .05).

/^
' Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 17, No 2 (March/April), 2013: pp 114-122 117
 Jung et al
Baseline Week 2
Figure 2. Change in total noninflamed lesion counts over the 12-week study period. Blue, red, and green bars represent groups A, B, and C,
respectively. Error bars represent 95% confidence intervals.
inflamed lesion counts of 10.8 (range 2-15) and 12.3
(range 6-19), respectively (Figure 3).
The percent decreases in inflamed lesion count lrom
baseline for each group are presented in Table 2. By week 4,
only group C achieved a significant reduction in inflamed acne
lesions from baseline {p < .001) (see Figure 3), which was a
significant improvement versus group B {p = .04) (see Figure
3). By week 8, groups A and B also achieved significant
improvement from baseline [p < .001), whereas group C
continued to experience improvement from week 4 (p <
.001). At 8 weeks, group B demonstrated significanfly more
improvement than group A (p = .04), whereas group C
showed significanfly more improvement compared to the
other two arms (p < .001 versus group A; p = .006 versus
group B) (see Figure 3). By week 12, all groups again showed a
significant degree of improvement in inflamed lesion counts
fi-om the previous visit (p = .001 for group A; p = .007 for
group B; p < .001 for group C). Furthermore, group B showed
significanfly more improvement versus group A (p = .02),
whereas group C showed significanfly more improvement
compared to both groups A (p < .001) and B (p < .001).
Skin Tolerabüity
Over the 12-week study period, patients from all three
groups established a significant improvement in their facial
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 17, No 2 (March/April), 2013: pp 114-122
Week 4 Week 8 Week 12
skin roughness, mottled pigmentation, sallowness, dullness,
inflammation, and irritation (p < .001) (Figure 4). A
significant improvement with regard to facial skin peeling,
itching, burning, oiliness, scaling, dryness, and erythema
was also demonstrated in all three groups at the 12-week
follow-up visit (p < .001) (see Figure 4). Furthermore,
following 12 weeks of treatment with their appointed
regimens, compared to patients in groups A and B, subjects
in group C revealed a significant decrease in facial skin
dullness (mean difference 0.73 [p < .001] and 0.59 [p =
.004], respectively), inflammation (mean difference 0.79 [p
< .001] and 0.64 [p = .001], respectively), and erythema
(mean difterence 0.86 [p < .001] and 0.68 [p = .001],
respectively).
Quality of Life Assessment
At the 12-week follow-up visit, patients from all three
groups were significantly happier with their appearance,
more comfortable around others, less likely to avoid
people, less hopeless about their skin, and less frustrated
about their acne (Table 3). Patients in groups A and B were
less discouraged about their acne at the 12-week follow-up
appointment, whereas those in groups A and C were less
humiliated and those in groups B and C were less upset
about their acne (see Table 3). Finafly, patients in the
 Acne Treatment with Minocycline and/or Probiotics
16 -1
Baseline Week 2
Figure 3. Change in total inflamed lesion counts over the 12-week study period. Blue, red, and green bars represent groups A, B, and C,
respectively. Error bars represent 95% confidence intervals.
combination minocycline-probiotic arm of the study were
found to be more self-confident, more attractive to others,
less self-conscious around others, less embarrassed, and
less ugly at the end of the treatment period. Such findings
were not identified in the minocycline-only and probiotic-
only arms (see Table 3).
Discussion
In recent decades, the characterization of specific probiotic
strains in preventing and treating infections and allergic
and inflammatory disorders has progressed significantly.
Such beneficial health effects are believed to stem from the
symbiotic relationship between the intestinal microbiota
with the gut epithelium and mucosa. Specifically, the
commensal flora has been found to extract nutrients from
otherwise indigestible carbohydrates, compete with patho-
genic organisms for residence within the host's intestine,
and modulate the deleterious effects of the mucosal innate
and adaptive immune systems.^ More importantly, just as
different antibiotics generate unique effects, different
probiotic strains provide specific health benefits, which
may include a role in acne therapeutics.
Tetracyclines are effective and frequent therapeutic
options for inflammatory acne. Unfortunately, disturbance
• Canadian Dermatology Association I journal of Cutaneous Medicine and Surgery, Vol 17, No 2 (March/April), 2013: pp ¡14-122
Week 4 Week 8 Week 12
of the host's natural flora with antibiotic treatment can occur,
possibly resulting in intolerable gastrointestinal side effects
and affecting patient compliance. Although no subjects
experienced gastrointestinal disturbances in the current
study, a meta-analysis of 19 studies found a reduction of
52% (p < .001) in antibiotic-associated diarrhea with
probiotic use.^° Song and colleagues further found that
certain strains of Lactobacillus significantly maintained a
patient's bowel habits versus placebo when given during a
course of antibiotics for a respiratory tract infection." Hence,
antibiotic treatment of acne with concurrent administration
of probiotics may reduce intolerable gastrointestinal adverse
effects, improving patient compliance.
The vaginal microflora, consisting predominantly of
Lactobacillus species, may also be disrupted following
antibiotic use, leading to bacterial or fungal infections.
Although the mechanism of gastrointestinal to vaginal
transmission is unclear, exogenous Lactobacillus species used
on a consistent basis have been shown to colonize the female
genital tract.^^'^^ Hence, it seems possible that speciflc
probiotics used in conjunction with antibiotics may reduce
the risk of disrupting a healthy vaginal ecosystem and
populating the vaginal vault with pathogenic organisms.
This was supported by the current study as 13% of subjects
in the antibiotic-only arm developed vaginal candidiasis, an
119
 Jung et al
Figure 4. Baseline and week 12 follow-up photographs. Baseline
photographs of patients prior to randomization to the probiotic-only
(A), minocycline-only (B), or probiotic and minocycline combination
(C) arms are shown. The photographs at the week 12 follow-up visit
are also shown for patients completing the probiotic-only (D),
minocycline-only (E), and probiotic and minocycline combination
(F) arms of the study.
adverse event not experienced in the probiotic-only or the
probiotic-minocycline groups. Although such findings are
contradictory to a study completed by Pirotta and
colleagues,'* several studies do reveal positive results with
regard to the effect of different probiotic strains on recurrent
vulvovaginal candidiasis.^^''^ Furthermore, as it may require
time for exogenous probiotics to populate the vaginal
vault,^^ probiotic use prior to and during antibiotic
treatment may prove more effective in suppressing the
growth of harmful microorganisms in the internal female
genitalia versus starting these two forms of treatment at the
same time. Thus, future large-scale, multicentered studies
are necessary to clarify probiotics' role in preventing
antibiotic-associated vaginal candidiasis.
Not only can probiotics reduce the adverse events
associated with antibiotic treatment, but probiotics may
also provide a synergistic effect with the latter in treating
acne vulgaris. Patients in the combined minocycline-
probiotic arm of the current study experienced greater
improvement in their acne compared to subjects using
only one of these products (see Figure 1, Figure 2, and
'120 Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 17, No 2 (March/April), 2013: pp 114-122
Figure 3) and had an improved overall quality of life (see
Table 3). Such improvement may be secondary to the
antiinflammatory actions of both antibiotics and probio-
tics as the innate and adaptive immune systems have been
linked to acne pathogenesis. Upregulation of proinflam-
matory cytokines, including tumor necrosis factor a (TNF-
a), interleukin (IL)-lß, and IL-8, from sebocytes, kerati-
nocytes, and leukocytes, has led to the development of
acne lesions via activation of Toll-like receptors and GD14
by P. acnes and lipopolysaccharides.'^ Such inflammatory
results have been demonstrated to stem from activation of
the nuclear factor KB (NF-KB) and mitogen-associated
protein kinase (MAPK) pathways.'^ Furthermore, P. acnes
also triggers the adaptive immune system, with involve-
ment of T-helper 1 (Thl) cells and humoral immunity.'^'^^
Kwon and colleagues revealed a potential mechanism
in which probiotics can modulate inflammation. The
combination of five probiotic strains, which included
L. acidophilus and B. hiftdum, led to the generation of
regulatory dendritic cells and GD4'^ Foxp3^ T cells.^°
Abundance of such regulatory cells resulted in B and T
helper cell hyporesponsiveness without apoptosis, along
with suppression of cytokine production.^" Likewise, the
deleterious effects of TNF-a and interferon-y on the
intestinal epithelium were prevented by probiotics, a
finding that may be helpful for other inflammatory
conditions.^^ Tien and colleagues further supported the
antiinflammatory potential of probiotics via its inhibitory
action on the NF-KB pathway.^^ Although preliminary, the
promising role of probiotics as immunomodulatory or
antiinflammatory agents definitely underscores their
possible role in acne therapeutics in a solo or synergistic
manner with antibiotics.
Several limitations can be identified in the current study.
A small study population derived ftom a single community
practice and involving only fair-skinned female subjects
prevents extrapolation of the current results to a broader
scale. However, this preliminary study with novel findings
for acne treatment paves the way for future multicenter
studies in this field that involve a larger and more general
patient population. Also, although the quality of life
questionnaire was not validated, it was based on what was
thought to be the most important and practical issues for
addressing the subjective feelings of patients with acne.
Furthermore, this study focused only on the Trenev Trio
(professional)/Healthy Trinity (retail) probiotic combina-
tion; hence, extension of the current study results may not
pertain to other probiotic strains. Of course, future studies
should evaluate and compare the efficacy of different
probiotic strains or combinations for acne vulgaris.
 Acne Treatment with Minocycline and/or Prohiotics

Table 3. Subject Quality of Life Questionnaire

Mean Difference of Patient Quality of Life Responses from Baseline to the 12-Week Follow-up Visit*

Group A Group B Group C

With respect to your acne, do you feel Mean Difference* p Value Mean Difference* p Value Mean Difference* p Value
Unhappy with your appearance? 1.2 0.005 1.4 0.004 2.3 < .001
Uncomfortable around others? 0.9 0.029 0.7 0.041 1.5 < .001
Angry? 0.2 NS 0.4 NS 0.5 NS
Less self-confident? 0.5 NS 0.8 NS 1.4 .002
Self-conscious around others? 0.3 NS 0.7 NS 1.4 < .001
Uneasy? -0.1 NS 0.1 NS 0.4 NS
Discouraged? 1.8 < .001 2.2 < .001 3.3 NS
Like you want to avoid people? 1.9 < .001 2.5 < .001 2.9 < .001
Sad or down? -0.4 NS 0.3 NS 0.3 NS
Humiliated? 1.0 .005 1.1 NS 2.4 < .001
Embarrassed? -0.1 NS 0.1 NS 0.5 .024
Upset? 0.5 NS 0.6 .031 1.2 < .001
Hopeless about your skin? 1.9 < .001 2.2 < .001 3.3 < .001
Unattractive to others? 0.5 NS 0.9 NS 1.3 .008
Frustrated? 1.5 < .001 1.2 < .001 2.1 < .001
Ugly? 0.5 NS 0.9 NS 1.5 .002
Uncomfortable? -0.1 NS -0.1 NS -0.1 NS
NS = not significant.
*Quality of life questions were based on a 7-point scale (1, 2 = not at all; 3, 4, 5 = sometimes; 6, 7 = extremely), with the mean difference calculated from
the baseline visit response to the 12-week follow-up visit response for each group.

Conclusion 3. Simonart T, Dramaix M, De Maertelaer V. Efficacy of tetracyclines

This preliminary study introduces the possibility of
probiotics as a therapeutic option for acne. Not only may
probiotics reduce adverse events associated with chronic
antibiotic use, but they may also play a synergistic role with
antibiotics in treating acne via its antiinflammatory and
immunomodulatory properties while improving a patient's
quality of life. Nonetheless, future large multicenter studies
are warranted to evaluate and compare the efficacy of
difterent probiotic strains or combinations for acne vulgaris
prior to its regular use as an acne therapeutic agent.
Acknowledgment
Financial disclosure of authors and reviewers: None reported.
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