Inflammation in acne vulgaris: leukocyte attraction and cytotoxicity by comedonal material

The chemoattraction of comedonal material for leukocytes was evaluated. Material from open comedones attracted mononculear leukocytes but did not attract polymorphonuclear leukocytes. At higher concentrations, comedonal material was cytotoxic for leukocytes of both types. Of the comedonal components tested, free fatty acids produced the greatest cytotoxicity. The attraction and killing of leukocytes by comedonal components may be the mechanisms for the initiation or the enhancement (or both) of inflammation in acne vulgaris.

Cytotaxin production by comedonal bacteria (Propionibacterium acnes, Propionibacterium granulosum and Staphylococcus epidermidis)

The potential role of different species of comedonal bacteria as chemotactic stimuli in the inflammatory phase of acne vulgaris was investigated by comparing 12 strains of Staphylococcus epidermidis, 11 strains of Propionibacterium acnes, and 5 strains of P. granulosum for production of cytotaxin in vitro. Results indicated that not only were there marked differences in cytotaxin production between different strains of the same species grown under identical growth conditons, but there were often significant differences in cytotaxin activity of the same strain grown in different media. This finding is discussed in relation to development of inflammation in quiescent comedones in acne vulgaris.

Complement C3 and immunoglobulin in inflammatory acne vulgaris

In patients with moderate to severe inflammatory acne, complement (C3) was detected by immunofluorescence in sixteen early inflammatory acne lesions but in only one of thirteen biopsies of non-inflamed skin from acne sites. C3 deposition occurred particularly in the walls of small dermal blood vessels and at the dermo-epidermal junction. IgM was identified in vessel walls in four of sixteen early lesions. In eight late inflammatory lesions C3 deposition was much less prominent and was present in vessel walls in only two. None of the late lesions showed vascular deposition of IgM. The observations indicate that complement activation occurs in inflammatory acne and it is suggested that this may play a pathogenic role in the inflammation.

Complement activation in acne vulgaris: consumption of complement by comedones

Comedones, the contents of acne lesions, were shown to consume scomplement hemolytic activity in normal serum. This consumption was stimulated by the addition of serum from patients with inflammatory acne. Absorption of acne serum with Propionibacterium acnes cells removed all stimulating activity. Immunoelectrophoretic analysis of serum incubated with comedones revealed the conversion of C3 and factor B in normal serum. The addition of acne serum resulted in cleavage of C4. In serum treated with ethylene glycol-bis(beta-aminoethyl ether)-N,N'-tetraacetic acid, only C3 and factor B were converted. This indicates that comedones may activate complement by either the classical or the alternative pathway. It is suggested that P. acnes cells in comedonal material are responsible for the complement activation.

A method for the assay of inflammatory mediators in follicular casts

A method is presented whereby inflammatory mediators may be detected and quantified in individual follicular casts. Lysozyme, lactoferrin, IgG, IgM, C3 and material reacting with antiserum to polymorphonuclear leukocytes (PMN) were assayed by functional and immunologic methods. By these techniques, lysozyme, IgG and anti-PMN reactive material were detected in clinically uninflamed follicular casts from acne subjects.

Activation of complement-a mechanism for the inflammation in acne

An immunofluorescence investigation of thirty-six non-inflamed and thirty-four inflamed acne lesions has been carried out. Fluorescence for C3, unaccompanied by fluorescence for immunoglobulins, was found in the walls of dermal blood vessels or at the basement membrane zone of the comedo or at both these sites in fifty-seven lesions. Fluorescence for C3 accompanied by fluorescence for immunoglobulins was found in nine lesions. In two papules and three nodules the comedo was surrounded or replaced by a mononuclear cell infiltrate. These findings have been taken to indicate that cellular immune mechanisms are a late event and activation of complement is an early event in the pathogenesis of inflammation in acne. The mechanism of complement activation remains uncertain.

Levamisole treatment of inflammatory acne. Restoration of impaired T-cell function accompanied by clearing of the lesions

Serum hemolytic complement activity and its components C3, C4 and C1q, serum immunoglobulins A, M and G and peripheral E-rosette forming cells were determined in 11 patients with inflammatory acne. IgG levels were increased and the E-rosette formation was markedly impaired. Levamisole treatment restored the E-rosette formation and improved or cured the inflammatory lesions in 10 out of 11 patients.

Neutrophil functions in acne conglobata

Chemotaxis, random migration, phagocytosis, spontaneous and stimulated NBT reduction were evaluated in neutrophils from the peripheral blood of 8 patients with acne conglobata and were found to be normal. Only 2 patients had an increased spontaneous NBT reduction, and another exhibited a defect in neutrophil adhesiveness. On this basis, intrinsic defects of the major neutrophil functions, as evaluated in vitro, can be excluded in acne conglobata.

Analysis of the water soluble extract of comedones

The water soluble fraction of 713 open comedones, pooled from both the face and back of 47 subjects representing all grades of acne, were analyzed for total protein content, carbohydrate content, and for identification of specific proteins. In the water soluble fraction, the protein content represented 11.5%, and carbohydrate content 0.2% of the total comedonal crude weight. Esterase and hyaluronidase activity was demonstrated. Propionibacterium acnes antigenic material, serum albumin, and serum Zn alpha 2 glycoprotein, a minor serum constituent, were identified by immunodiffusion and immunoelectrophoresis.

Complement activation in acne vulgaris: in vitro studies with Propionibacterium acnes and Propionibacterium granulosum

To better define the role of bacteria in inflammatory acne vulgaris, we have investigated the ability of four strains of Propionibacterium acnes and three strains of Propionibacterium granulosum to activate complement. Complement activation was assayed by incubating normal human serum with varying concentrations of each strain and measuring residual total hemolytic complement activity. When serum was tested unaltered, P. acnes strains were approximately threefold more potent than an equal weight of P. granulosum in consuming complement, which could reflect classical and/or alternative pathway activation. All strains also consumed complement in serum chelated with ethyleneglycol-bis (beta-aminoethyl ether)-N,N'-tetraacetic acid, which selectively assays alternative pathway activation. Incubation of unaltered serum with both P. acnes and P. granulosum resulted in immunoelectrophoretic conversion of C4, C3, and factor B of the alternative pathway. Incubation of chelated serum resulted in conversion of C3 and factor B. These data taken together suggest that both species can activate complement through either pathway. Serum incubated with P. acnes was chemotactic for polymorphonuclear leukocytes, and this chemotactic activity was largely C5 dependent as shown by antibody inhibition. It is suggested that complement activation may occur in vivo in acne, and the inflammatory response may be contributed to by the generation of C5-dependent chemotactic factors.

Cellular immunity to P. acnes in the normal population and patients with acne vulgaris

Patients with varying degrees of acne, acne-free adult controls and samples of cord blood were investigated for cell mediated immunity to P. acnes using a leukocyte migration inhibition test. Despite the fact that the mean migration index tended to decrease with acne severity, only the patients with severe acne showed cell-mediated immunity. It is suggested that when cellular immunity arises it is a late event which may contribute to inflammation but is probably not a factor in its initiation.

Leukocyte motility in acne conglobata

Leukocytes derived from the peripheral blood of 10 patients with acne conglobata demonstrated enhanced chemotactic and random migratory activities in comparison with leukocytes from 10 healthy subjects. This enhancement is most probably secondary to the state of chronic infection and inflammation. These findings probably rule out a defect in leukocyte motility as a cause of the severity of the lesions in acne conglobata.

Lymphocyte transformation in subjects with nodulo cystic acne

Patients with severe nodulo-cystic acne are known to have elevated serum antibody levels and increased immediate hypersensitivity reactions to Propionibacterium acnes. This organism is the predominant bacterium in normal pilosebaceous follicles of human skin, and can be consistently isolated from pustular lesions in acne. Previously it had been observed that delayed cutaneous hypersensitivity reactions to P. acnes were negative in patients with acne. The present study investigated the proliferative response of lymphocytes from patients with nodulo-cystic acne to phytohaemagglutinin (PHA) and P. acnes antigen stimulation. The response to PHA stimulation was within normal limits. The response to P. acnes antigen showed a significant increase over control values obtained by testing lymphocytes from acne-free subjects. Thus cell mediated immunity to P. acnes may be present in subjects with severe inflammatory acne. These findings raise the possibility that reactions to P. acnes may contribute to intensifying the inflammatory response in acne lesions.

Serum IgE in dermatitis and dermatosis: an analysis of 497 cases

Serum IgE values from 497 patients with various forms of dermatitis, dermatosis, and tinea pedis were analyzed statistically and compared with values from 95 normal controls. The median and geometric mean values were significantly elevated (except in acne without atopy, lichen planus, and tinea pedis), even after exclusion of patients with a history of atopy or of cutaneous reaction to food or drugs. Serum IgE levels and atopic dermatitis have a close correlation. A modest positive correlation (p approximately equal to .05) appeared between the log serum IgE level and peripheral blood absolute eosinophil count in 80 cases of atopic dermatitis. A unique group of adult nonatopic patients had acquired generalized dermatitis and markedly elevated serum IgE levels (greater than 12,000 ng/ml). Our results suggest that, in most common dermatologic disorders, elevated serum IgE is a secondary phenomenon rather than a primary causative factor.

Acne arthralgia

A syndrome of arthralgia associated with one form of acne is described. Orthopaedic surgeons should be alert to the association of profound arthralgia and myalgia with this particular variant of acne vulgaris. Thirteen patients are described, all of whom are adolescent boys with a chronic moderately active acne which suddenly became extremely aggressive and toxic. The symptoms and signs included proximal arthralgia and myalgia, fever, elevated sedimentation rate, and altered immunoglobulins. Control of acne and conservative physical therapy resulted in complete resolution of the musculoskeletal complaints.

In vitro phagocytosis of Candida albicans by peripheral polymorphonuclear neutrophils of patients with recurrent infections:Case reports of serum-dependent abnormalities

The "in vitro" phagocytosis of C. albicans by peripheral polymorphonuclear neutrophils (PMN) of 25 healthy subjects and of 27 patients with recurrent infections was performed in autologous serum and in normal pooled AB serum. In AB serum PMN of the patients phagocytosed C. albicans significantly better than PMN of healthy subjects. In 9 out of 27 patients the phagocytosis of C. albicans by the patient's PMN was markedly lower in autologous serum than in AB serum. Four patients with extreme serum-dependent abnormalities in the phagocytosis of C. albicans by their PMN's are described more in detail.

Acne from an immunological perspective

Patients with acne vulgaris, particularly those with severe inflammatory forms of the disease, are known to have high titers of serum antibodies, and intensified immediate hypersensitivity reactions to P. acnes antigens. The significance of this fact has not been clarified, but it is possible that antigen-antibody reactions involving P. acnes in the perifollicular dermis could intensify the inflammatory response in certain forms of acne. Further studies utilizing newer, more sophisticated techniques are needed to identify the role of P. acnes antigens in affecting such fundamental phenomena as chemotaxis, cell-mediated immunity, activation of the complement cascade and reticuloendothelial system stimulation. Answers to these basic questions have the pathogenesis of that common but even more complex disease, acne.

Levels of antibody to Staphylococcus epidermidis in patients with acne vulgaris

Sera from 23 patients with acne vulgaris of varying degrees and sera from 15 patients with skin diseases other than acne were tested for antibody levels to Staphylococcus epidermidis by use of bacterial agglutination and agar-gel immunodiffusion. Antibody levels to S epidermidis varied from 0 to 1:160 in both the patients with acne and in the control groups. There was no correlation between the antibody level to S epidermidis and the degree of acne. In a previous investigation it was found that antibody levels to Corynebacterium acnes are significantly increased in serum from patients with papulopustular and cystic acne. Both S epidermidis and C acnes can frequently be isolated from lesions in acne. The fact that antibody levels are increased to C acnes but not to S epidermidis may indicate that the mere presence of an organism in the acne lesion is not sufficient stimulation for antibody formation. The increase of antibody to C acnes which was demonstrated previously in patients with severe acne vulgaris may therefore reflect a direct involvement of the organism in the acne process.