The immunology of Propionibacterium acnes and acne

Unveiling the mechanism of essential oil action against skin pathogens: from ancient wisdom to modern science

Essential oils are among the most well-known phyto-compounds, and since ancient times, they have been utilized in medicine. Over 100 essential oils have been identified and utilized as therapies for various skin infections and related ailments. While numerous commercial medicines are available in different dosage forms to treat skin diseases, the persisting issues include their side effects, toxicity, and low efficacy. As a result, researchers are seeking novel classes of compounds as substitutes for synthetic drugs, aiming for minimal side effects, no toxicity, and high efficacy. Essential oils have shown promising antimicrobial activity against skin-associated pathogens. This review presents essential knowledge and scientific information regarding essential oil's antimicrobial capabilities against microorganisms that cause skin infections. Essential oils mechanisms against different pathogens have also been explored. Many essential oils exhibit promising activity against various microbes, which has been qualitatively assessed using the agar disc diffusion experiment, followed by determining the minimum inhibitory concentration for quantitative evaluation. It has been observed that Staphylococcus aureus and Candida albicans have been extensively researched in the context of skin-related infections and their antimicrobial activity, including established modes of action. In contrast, other skin pathogens such as Staphylococcus epidermidis, Streptococcus pyogens, Propionibacterium acnes, and Malassezia furfur have received less attention or neglected. This review report provides an updated understanding of the mechanisms of action of various essential oils with antimicrobial properties. This review explores the anti-infectious activity and mode of action of essential against distinct skin pathogens. Such knowledge can be valuable in treating skin infections and related ailments.

The therapeutic effect of tanshinone IIA on Propionibacterium acnes-induced inflammation in vitro

Acne vulgaris, a chronic inflammatory skin disease, affects many adolescents. New therapeutic agents for acne allow for a higher therapeutic activity, but fewer side effects. Tanshinone IIA, a natural product, has been proved to exhibit antibacterial and anti-inflammatory abilities in many diseases. However, its antibacterial and anti-inflammatory activities against Propionibacterium acnes have not been described. In the present study, the broth microdilution method was used to evaluate the antibacterial activity of tanshinone IIA and it had an inhibitory effect on the growth of P. acnes. Enzyme-linked immunosorbent assay and quantitative real-time PCR were used to investigate the effect of tanshinone IIA on IL-1β, IL-8, and TNF-α expression, and western blot was used to examine TLR2, NF-κB, and intercellular cell adhesion molecule-1 (ICAM-1) protein level induced by P. acnes in THP-1 cells. Results showed that the expression of inflammatory cytokines and TLR2, NF-κB, ICAM-1 protein levels were inhibited by Tanshinone IIA, suggesting that tanshinone IIA appeared to suppress P. acnes-induced inflammation by blockade of TLR2/NF-κB signaling pathway. In conclusion, the present study revealed the inhibitory effect of tanshinone IIA on P. acnes-induced inflammation, providing an evidence to support the mechanism of anti-acne properties of tanshinone IIA.

Taxonomy, Physiology, and Natural Products of Actinobacteria

Actinobacteria are Gram-positive bacteria with high G+C DNA content that constitute one of the largest bacterial phyla, and they are ubiquitously distributed in both aquatic and terrestrial ecosystems. Many Actinobacteria have a mycelial lifestyle and undergo complex morphological differentiation. They also have an extensive secondary metabolism and produce about two-thirds of all naturally derived antibiotics in current clinical use, as well as many anticancer, anthelmintic, and antifungal compounds. Consequently, these bacteria are of major importance for biotechnology, medicine, and agriculture. Actinobacteria play diverse roles in their associations with various higher organisms, since their members have adopted different lifestyles, and the phylum includes pathogens (notably, species of Corynebacterium, Mycobacterium, Nocardia, Propionibacterium, and Tropheryma), soil inhabitants (e.g., Micromonospora and Streptomyces species), plant commensals (e.g., Frankia spp.), and gastrointestinal commensals (Bifidobacterium spp.). Actinobacteria also play an important role as symbionts and as pathogens in plant-associated microbial communities. This review presents an update on the biology of this important bacterial phylum.

A honey trap for the treatment of acne: manipulating the follicular microenvironment to control Propionibacterium acnes

Today, as 40 years ago, we still rely on a limited number of antibiotics and benzoyl peroxide to treat inflammatory acne. An alternative way of suppressing the growth of Propionibacterium acnes is to target the environment in which it thrives. We conjecture that P. acnes colonises a relatively “extreme” habitat especially in relation to the availability of water and possibly related factors such as ionic strength and osmolarity. We hypothesise that the limiting “nutrient” within pilosebaceous follicles is water since native sebum as secreted by the sebaceous gland contains none. An aqueous component must be available within colonised follicles, and water may be a major factor determining which follicles can sustain microbial populations. One way of preventing microbial growth is to reduce the water activity (a_w) of this component with a biocompatible solute of very high water solubility. For the method to work effectively, the solute must be small, easily diffusible, and minimally soluble in sebaceous lipids. Xylose and sucrose, which fulfil these criteria, are nonfermentable by P. acnes and have been used to reduce water activity and hence bacterial colonisation of wounds. A new follicularly targeted topical treatment for acne based on this approach should be well tolerated and highly effective.

Potent antimicrobial action of triclosan-lysozyme complex against skin pathogens mediated through drug-targeted delivery mechanism

Triclosan (TCS), an antimicrobial agent that inhibits bacterial fatty acid synthesis by blocking the active site of enoyl-ACP reductase (FabI), is a water-insoluble agent that limits its therapeutic candidacy. We have recently shown that the water solubility and antimicrobial activity of TCS were greatly enhanced when complexed to lysozyme (LZ). This study is to examine the therapeutic potential of triclosan-lysozyme (T-LZ) complex against common skin pathogens expressing different levels of FabI, and to delineate the drug-targeting mechanism by lysozyme. The T-LZ exhibited superior antimicrobial activity against two bacterial skin pathogens, Propionibacterium acnes and Corynebacterium minutissimum, while yeast pathogens, Candida albicans and Malassezia furfur lacking FabI enzyme were insensitive to the complex. Unlike free TCS or LZ, the T-LZ complex exhibited a potent antibacterial activity under a wide range of pH condition and salt concentration. Interestingly, P. acnes expressing greater amount of FabI was more susceptible to the T-LZ complex than C. minutissimum that produces lesser amount of the enzyme. A sensitive assay of FabI activity revealed that P. acnes and C. minutissimum treated with the complex exhibited significant inhibition of the intracellular FabI activity than cells treated with free TCS, indicating the efficiency of lysozyme to specifically deliver TCS to its target (FabI) in the cytoplasm of bacterial cells. These results demonstrate, for the first time, that lysozyme is a potential drug carrier that allows specific targeting to the microbial cells of the water-insoluble triclosan and highlights the potency of the complex for the treatment of skin bacterial infections.

Production of superoxide anions by keratinocytes initiates P. acnes-induced inflammation of the skin

Acne vulgaris is a chronic inflammatory disorder of the sebaceous follicles. Propionibacterium acnes (P. acnes), a gram-positive anareobic bacterium, plays a critical role in the development of these inflammatory lesions. This study aimed at determining whether reactive oxygen species (ROS) are produced by keratinocytes upon P. acnes infection, dissecting the mechanism of this production, and investigating how this phenomenon integrates in the general inflammatory response induced by P. acnes. In our hands, ROS, and especially superoxide anions (O₂^•−), were rapidly produced by keratinocytes upon stimulation by P. acnes surface proteins. In P. acnes-stimulated keratinocytes, O₂^•− was produced by NAD(P)H oxidase through activation of the scavenger receptor CD36. O₂^•− was dismuted by superoxide dismutase to form hydrogen peroxide which was further detoxified into water by the GSH/GPx system. In addition, P. acnes-induced O₂^•− abrogated P. acnes growth and was involved in keratinocyte lysis through the combination of O₂^•− with nitric oxide to form peroxynitrites. Finally, retinoic acid derivates, the most efficient anti-acneic drugs, prevent O₂^•− production, IL-8 release and keratinocyte apoptosis, suggesting the relevance of this pathway in humans.

Acne vulgaris is a chronic inflammatory disorder of the sebaceous follicles. It is the most common skin disease, affecting up to 80% of individuals at some point between the ages of 11 and 30 years. Propionibacterium acnes (P. acnes) plays a role in the development of inflammatory acne lesions, but whether it causes inflammation by itself or through indirect mechanisms is not clear yet. Therefore, by exposing epidermal cells to P. acnes in vitro, we tested whether reactive oxygen species (ROS) production (oxidative burst) was involved in the inflammatory process. We found that one particular ROS, superoxide anion, was generated by epidermal cells following P. acnes stimulation. This phenomenon is associated with the production of a soluble pro inflammatory molecule, IL-8, and epidermal cell death. The abrogation of P. acnes-induced oxidative burst by the most commonly used and most efficient treatments of acne suggests that superoxide anions produced by epidermal cells are critical in the development of acne inflammatory lesions.

Expression, purification, crystallization and preliminary X-ray diffraction analysis of the soluble domain of PPA0092, a putative nitrite reductase from Propionibacterium acnes

The soluble domain (residues 483-913) of PPA0092, a putative copper-containing nitrite reductase from Propionibacterium acnes KPA171202, has been overexpressed in Escherichia coli. The purified recombinant protein was crystallized using the hanging-drop vapour-diffusion method. X-ray diffraction data were collected and processed to a maximum resolution of 2.4 A. The crystal belonged to space group P2(1)3, with unit-cell parameters a = b = c = 108.63 A. Preliminary diffraction data show that one molecule is present in the asymmetric unit; this corresponds to a V(M) of 2.1 A(3) Da(-1).

Direct visualization of Propionibacterium acnes in prostate tissue by multicolor fluorescent in situ hybridization assay

Prostate tissues from patients with prostate cancer and benign prostatic hyperplasia (BPH) frequently contain histological inflammation, and a proportion of these patients show evidence of Propionibacterium acnes infection in the prostate gland. We developed a multicolor fluorescent in situ hybridization (FISH) assay targeting P. acnes 23S rRNA along with a 14-kb region of the P. acnes genome. This assay was used to analyze prostate tissues from patients with prostate cancer and BPH. P. acnes infection of the prostate gland was demonstrated in prostatic tissue in 5 of 10 randomly selected prostate cancer patients. FISH analysis and confocal laser microscopy imaging revealed intracellular localization and stromal biofilm-like aggregates as common forms of P. acnes infection in prostate tissues from both prostate cancer and BPH patients. A sequential analysis of prostate tissue from individual patients suggested that P. acnes can persist for up to 6 years in the prostate gland. These results indicate that P. acnes can establish a persistent infection in the prostate gland. Further study is needed to clarify the link between this bacterium and prostatic inflammation which may contribute to the development of BPH and prostate cancer.

Genomics of Actinobacteria: tracing the evolutionary history of an ancient phylum

Actinobacteria constitute one of the largest phyla among bacteria and represent gram-positive bacteria with a high G+C content in their DNA. This bacterial group includes microorganisms exhibiting a wide spectrum of morphologies, from coccoid to fragmenting hyphal forms, as well as possessing highly variable physiological and metabolic properties. Furthermore, Actinobacteria members have adopted different lifestyles, and can be pathogens (e.g., Corynebacterium, Mycobacterium, Nocardia, Tropheryma, and Propionibacterium), soil inhabitants (Streptomyces), plant commensals (Leifsonia), or gastrointestinal commensals (Bifidobacterium). The divergence of Actinobacteria from other bacteria is ancient, making it impossible to identify the phylogenetically closest bacterial group to Actinobacteria. Genome sequence analysis has revolutionized every aspect of bacterial biology by enhancing the understanding of the genetics, physiology, and evolutionary development of bacteria. Various actinobacterial genomes have been sequenced, revealing a wide genomic heterogeneity probably as a reflection of their biodiversity. This review provides an account of the recent explosion of actinobacterial genomics data and an attempt to place this in a biological and evolutionary context.

Variable expression of immunoreactive surface proteins of Propionibacterium acnes

Despite accumulating data implicating Propionibacterium acnes in a variety of diseases, its precise role in infection remains to be determined. P. acnes antigen-specific CD4(+) T cells are present in early inflamed acne lesions and may be involved in the inflammatory response; however, little is known about the specific antigens involved. In this study, B cell and T cell antigens from P. acnes expression libraries were cloned and evaluated and the four predominant proteins identified were investigated. Two of these antigens share some homology with an M-like protein of Streptococcus equi and have dermatan-sulphate-binding activity (PA-25957 and 5541). The remaining two antigens, PA-21693 and 4687, are similar to the product of the Corynebacterium diphtheriae htaA gene from the hmu ABC transport locus, although only one of these (PA-21693) is encoded within an hmu-like operon and conserved amongst a range of clinical isolates. All four proteins contain an LPXTG motif, although only PA-21693 contains a characteristic sortase-sorting signal. Variation in the expression of PA-4687, 25957 and 5541 is evident amongst clinical isolates and is generated both by frameshifts associated with the putative signal peptide and by variable numbers of repeat regions toward the carboxy-terminus, potentially generating heterogeneity of molecular mass and antigenic variation. In addition, in the case of PA-25957, a frameshift in a C-rich region at the extreme carboxy-terminus eliminates the LPXTG motif in some isolates. For the dermatan-sulphate-binding PA-25957, IgG1 antibody in serum from acne-positive donors was shown to be specific for the amino-terminal region of the protein, which also contains a CD4(+) T cell epitope. In contrast, serum from acne-negative donors shows an IgG2 and IgG3 antibody subclass response to the carboxy-terminal region. These data have implications for the potential role of P. acnes in inflammatory acne and other diseases.

Resolution of inflammatory acne vulgaris may involve regulation of CD4+ T-cell responses to Propionibacterium acnes

BACKGROUND

Propionibacterium acnes has been strongly implicated in inflammatory acne. However, its role in the disease is unclear. It has been hypothesized that an immune response to P. acnes and/or P. acnes heat shock proteins (HSPs) may play a role in the pathogenesis of inflammatory acne.

OBJECTIVES

To compare the cell-mediated immune response to P. acnes and HSPs in acne patients, nonacne controls and individuals with resolved acne.

METHODS

The proliferative response of peripheral blood mononuclear cells (PBMC) from acne patients, resolved acne donors and healthy controls to P. acnes, P. acnes HSP60 and HSP70, and mycobacterial HSPs was assessed by lymphocyte transformation assay (LTA). The proliferative response of purified CD4+ T cells was further analysed by limiting dilution analysis (LDA). Contingency tables (G-test) were used to analyse the proportion of individuals in each group showing a positive proliferative response for LTA or data fitting single-hit kinetics for LDA.

RESULTS

Analysis of stimulation of PBMC with P. acnes, P. acnes HSP60 and HSP70 in the LTA showed the proportion of positive responders to be independent of subject group. However, the proportion of acne patients with a positive response to mycobacterial HSPs was significantly higher than those for the other subject groups. Analysis of LDA data showed the proportion of resolved donors with responses to P. acnes fitting the single-hit kinetics model to be significantly lower than those of the other groups. There were no significant differences in responses to other antigens.

CONCLUSIONS

The significantly lower proportion of resolved donors demonstrating a single-hit kinetics response to P. acnes by LDA may represent negative regulation of the CD4+ T-cell response to P. acnes in these subjects.

Insights in the Pathogenic Potential of Propionibacterium acnes From Its Complete Genome

One of the long-lasting open questions in understanding acne is the role of the skin bacterium Propionibacterium acnes. Opinions within the scientific community diverge regarding the importance of this Gram-positive bacterium not only in acne but also in other P. acnes-associated diseases. The recently decoded genome gives us some clues with respect to its pathogenic potential and its strategies to survive in the harsh environment of human skin. This review focuses on the major findings of the genome sequence. Special attention has been drawn to the cell surface composition of P. acnes, its antigenic potential, and to enzymes that are potentially involved in degrading skin-derived substances.

Comparison of five antimicrobial regimens for treatment of mild to moderate inflammatory facial acne vulgaris in the community: randomised controlled trial

BACKGROUND

We investigated the efficacy and cost-effectiveness of five antimicrobial regimens for mild to moderate facial acne and whether propionibacterial antibiotic resistance affects treatment response.

METHODS

In this randomised, observer-masked trial, 649 community participants were allocated one of five antibacterial regimens. Primary outcomes were patients' self-assessed improvement and reduction in inflamed lesions at 18 weeks. Analyses were by intention to treat.

FINDINGS

Moderate or greater improvement at 18 weeks was reported in 72 (55%) of 131 participants assigned oral oxytetracycline plus topical placebo, 70 (54%) of 130 assigned oral minocycline plus topical placebo, 78 (60%) of 130 assigned topical benzoyl peroxide plus oral placebo, 84 (66%) of 127 assigned topical erythromycin and benzoyl peroxide in a combined formulation plus oral placebo, and 82 (63%) of 131 assigned topical erythromycin and benzoyl peroxide separately plus oral placebo. Most improvement occurred in the first 6 weeks. Treatment differences for the proportion of people with at least moderate improvement were: minocycline versus oxytetracycline -1.2% (unadjusted 95% CI -13.3 to 10.9); combined erythromycin and benzoyl peroxide versus oxytetracycline 11.1% (-0.7 to 22.9) and versus minocycline 12.3% (0.4 to 24.2); erythromycin and benzoyl peroxide separately versus combined formulation -3.5% (-15.2 to 8.2); benzoyl peroxide versus oxytetracycline 5.0% (-7.0 to 17.0), versus minocycline 6.2% (-5.8 to 18.2), and versus combined formulation -6.1% (-17.9 to 5.7). Benzoyl peroxide was the most cost-effective treatment. Efficacy of both tetracyclines was reduced by pre-existing tetracycline resistance.

INTERPRETATION

Topical benzoyl peroxide and benzoyl peroxide/erythromycin combinations are similar in efficacy to oral oxytetracycline and minocycline and are not affected by propionibacterial antibiotic resistance.

Evidence for diversity within Propionibacterium acnes: a comparison of the T-cell stimulatory activity of isolates from inflammatory acne, endocarditis and the laboratory

BACKGROUND

Propionibacterium acnes is primarily associated with the pathogenesis of acne vulgaris but reports are increasing in number implicating P. acnes in other diseases such as abscess formation, meningitis and endocarditis. The pathogenicity of P. acnes is thought to be partly due to the interaction of the bacterium with the immune system. Historically, investigations have focused on humoral and cell-mediated immune responses to P. acnes antigens without attention to the possibility that different antigens may be expressed by different isolates.

OBJECTIVE

Investigations were performed to determine whether there were differences between a laboratory strain of P. acnes (P-37) and fresh clinical isolates in their ability to stimulate naive and adult lymphocytes.

MATERIAL AND METHODS

The fresh isolates were collected from a patient with inflammatory acne and a patient with P. acnes-induced prosthetic valve endocarditis. The lymphocyte transformation assay was used to detect responses to whole-cell suspensions of stationary phase P. acnes isolates during 7 days of incubation.

RESULTS

The acne isolate was significantly more stimulatory for cord blood mononuclear cells (CBMNCs) than the laboratory isolate (P. acnes P-37) at day 4 of incubation. There were no significant differences between the three strains at any other time points. However, the isolate cultivated from inflammatory acne was significantly more stimulatory for peripheral blood mononuclear cells (PBMNCs) from acne donors than the endocarditis isolate or the laboratory strain at most time points. There were no significant differences between the endocarditis strain and the laboratory strain.

CONCLUSION

It can be hypothesized that in case of P. acnes-induced endocarditis lymphocyte stimulation is a disadvantage for the microorganism and therefore a lack of lymphocyte stimulation may be relevant to the pathogenesis of endocarditis.

The Complete Genome Sequence of Propionibacterium Acnes, a Commensal of Human Skin

Propionibacterium acnes is a major inhabitant of adult human skin, where it resides within sebaceous follicles, usually as a harmless commensal although it has been implicated in acne vulgaris formation. The entire genome sequence of this Gram-positive bacterium encodes 2333 putative genes and revealed numerous gene products involved in degrading host molecules, including sialidases, neuraminidases, endoglycoceramidases, lipases, and pore-forming factors. Surface-associated and other immunogenic factors have been identified, which might be involved in triggering acne inflammation and other P. acnes-associated diseases.

Cosmetics: what is their influence on the skin microflora?

Human skin has a resident, transient and temporary resident microflora. This article considers the possibilities of topical products influencing the balance of the microflora. The resident micro-organisms are in a dynamic equilibrium with the host tissue and the microflora may be considered an integral component of the normal human skin. The great majority of these micro-organisms are gram-positive and reside on the skin surface and in the follicles. The host has a variety of structures, molecules and mechanisms which restrict the transient and temporary residents, as well as controlling the population and dominance of the resident group. These include local skin anatomy, hydration, nutrients and inhibitors of various types. The resident microflora is beneficial in occupying a niche and denying its access to transients, which may be harmful and infectious. Also, the residents are important in modifying the immune system. In the healthy host the microflora causes few and temporary problems. Therefore, it is of interest that topical products have little or no effect on the ecology of the microflora. A range of mechanisms by which long-term use of cosmetics may influence the microflora are considered. Although the risks associated are low, it is argued that it is necessary to monitor these changes in ecology and use technologies of modeling and bioinformatics to predict outcomes, whether good, neutral or of concern.

Prevalence of antibiotic-resistant propionibacteria on the skin of acne patients: 10-year surveillance data and snapshot distribution study

BACKGROUND

Cutaneous propionibacteria are implicated in acne pathogenesis, although their exact role in the genesis of inflammation is still poorly understood. Agents, including antibiotics, that reduce the numbers of propionibacteria on skin are therapeutic. Resistance in the target organism is a well-recognized consequence of antibiotic therapy for acne but formal prevalence and distribution data are lacking.

OBJECTIVES

To monitor the prevalence of skin colonization by antibiotic-resistant propionibacteria in acne patients attending the dermatology out-patient clinic at Leeds General Infirmary over a 10-year period beginning in 1991, and to examine the distribution of resistant strains on acne-prone skin and in the nares.

METHODS

Propionibacterial samples were obtained from the skin surface of the worst affected site (usually the face) of 4274 acne patients using a moistened swab. The swab was used to inoculate agar plates with and without selective antibiotics. After anaerobic incubation at 37 degrees C for 7 days, the amount of growth in the presence of each antibiotic was scored on a scale from 0 to 5+. A small number of patients (72) were selected for more detailed quantitative sampling at six different sites to examine the distribution of resistant propionibacteria on acne-prone skin and in the anterior nares.

RESULTS

The proportion of patients carrying strains resistant to one or more commonly used antiacne antibiotics rose steadily from 34.5% in 1991 to a peak of 64% in 1997. The prevalence dropped to 50.5% during 1999 and then rose again to 55.5% in 2000. Resistance to erythromycin was the most common and the majority of erythromycin-resistant strains were cross-resistant to clindamycin. Resistance to tetracyclines was less common in all years and with little increase over time. The more detailed quantitative study in 72 patients showed that population densities of resistant propionibacteria varied considerably between sites and between individuals. Almost invariably, patients were colonized with resistant strains at multiple sites, including the nares.

CONCLUSIONS

Skin colonization with antibiotic-resistant propionibacteria is much more common now than a decade ago. Resistant propionibacteria are widely distributed on acne-prone skin and in the nares. This suggests that they will be very difficult to eradicate using existing therapeutic regimens, especially from the nasal reservoir.

Heat shock proteins and inflammatory acne vulgaris: molecular cloning, overexpression and purification of a propionibacterium acnes GroEL and DnaK homologue

Propionibacterium acnes is associated with inflammatory acne. The genes encoding two putative mediators of inflammation, the heat shock proteins GroEL and DnaK, were cloned from this organism and sequenced. groEL and dnaK encode proteins of 56.8 and 66.4 kDa, respectively, which show a high degree of homology (>75% similarity) to the GroEL and DnaK proteins of mycobacteria and streptomycetes. The promoter regions of both genes contain inverted repeat sequences believed to be involved in the transcriptional regulation of heat shock genes. Recombinant P. acnes GroEL and DnaK were overexpressed in Escherichia coli with C-terminal histidine tags. The recombinant proteins were purified from E. coli by metal affinity chromatography. These proteins will now be used in immunological investigations to determine their role in inflammatory acne.

Is acne an infection of blocked pilosebaceous follicles? Implications for antimicrobial treatment

A model is proposed which is based on the assumption that acne is due to infection of functionally blocked pilosebaceous follicles by propionibacteria. Noninflamed lesions, which are first visible during the adrenarche in acne-prone individuals, do not contain propionibacteria. Comedogenesis appears to be independent of bacterial infection and may be driven by high levels of bioactive interleukin-1 alpha derived from ductal hyperkeratinocytes. The stimulus which triggers interleukin-1 alpha production is unknown. Formalin killed Propionibacterium acnes failed to stimulate production of the cytokine by cultured human keratinocytes in vitro. Inflamed lesions are thought to arise from microcomedones, but the initiating events are unknown. Evidence that propionibacteria are involved in the generation of inflammatory lesions is inconclusive. The cellular infiltrate is consistent with a type IV hypersensitivity response to one or more persistent lesional antigens, not necessarily bacterial. The potent adjuvant activity of P. acnes would up-regulate the immune response to any antigen which came into contact with the mononuclear cell infiltrate. Antibiotics are widely used in the treatment of acne, and their effects in selecting a predominantly resistant commensal population are well recognized. Although they reduce numbers of propionibacteria on the skin, other modes of action may contribute to or explain their therapeutic efficacy. At a time when there is global concern that antibiotic resistance rates in common bacterial pathogens may threaten our future ability to control bacterial infections, practices which promote the spread of antibiotic-resistant bacteria must be fully justified. A thorough reappraisal of the role of propionibacteria in acne is overdue. It is likely that further experimental work is needed to confirm or refute that P. acnes is aptly named.