Acne, the Skin Microbiome, and Antibiotic Treatment

Haoxiang Xu; Huiying Li


Am J Clin Dermatol. 2019;20(3):335-344. 

In This Article

Abstract and Introduction


Acne vulgaris is a chronic skin disorder involving hair follicles and sebaceous glands. Multiple factors contribute to the disease, including skin microbes. The skin microbiome in the follicle is composed of a diverse group of microorganisms. Among them, Propionibacterium acnes and Malassezia spp. have been linked to acne development through their influence on sebum secretion, comedone formation, and inflammatory response. Antibiotics targeting P. acnes have been the mainstay in acne treatment for the past four decades. Among them, macrolides, clindamycin, and tetracyclines are the most widely prescribed. As antibiotic resistance becomes an increasing concern in clinical practice, understanding the skin microbiome associated with acne and the effects of antibiotic use on the skin commensals is highly relevant and critical to clinicians. In this review, we summarize recent studies of the composition and dynamics of the skin microbiome in acne and the effects of antibiotic treatment on skin microbes.


Acne vulgaris (commonly called acne) is a common, chronic skin disease that arises in the hair follicle and often involves inflammation. Approximately 85% of adolescents and young adults are affected by the disease,[1] while moderate and severe acne accounts for 15–20% of cases.[2] Based on the data from the Global Burden of Disease study in 2013, acne accounted for 0.29% of all skin conditions, which contributed 1.79% to the global burden of disease. Acne ranks second among the most common dermatological conditions after dermatitis.[3]

Four factors have been thought to contribute to acne: hyper-secretion of sebum, abnormal proliferation and differentiation of keratinocytes in the hair follicle, bacterial colonization, and host inflammatory response.[4] Among these factors, the skin commensal Propionibacterium acnes is thought to trigger an inflammatory response and lead to subclinical and inflammatory acne lesions.[5]

Skin is colonized by hundreds of microorganisms, which occupy different cutaneous environmental niches and form various communities.[6] When the normal flora is disturbed or the host immune defense is weakened, opportunistic microorganisms may trigger or aggravate certain skin diseases.[7] The relationship between skin microorganisms and acne has long been implicated but not fully elucidated. With the rise of the microbiome field in recent years, new findings from studies of the skin microbiome have provided improved understanding of the role of skin microorganisms in health and acne.[8–12]

Antibiotics have been an effective and widely used treatment for acne in the past four decades. However, worldwide increase of antibiotic resistance due to frequent and long-term use of antibiotics raises significant concern regarding how the commensal skin microbiome and its protective role for the skin are affected. A better understanding of the relationship among acne, the skin microbiome, and antibiotic treatment may provide new insight on the treatment of the disease while restoring a healthy microbiome.