Long term topical application of lactic acid/lactate lotion as a preventive treatment for acne vulgaris

Introduction

Acne is a disorder involving the pilosebaceous units in the skin of the face, and the upper trunk. The agents available for the treatment of acne include topical agents such as 2% and 4% erythromycin with or without. 1.2% zinc acetate, 1 % clindamycin, 2.5-10% benzoyl peroxide, 0.025-0.1 % tretinion, 0.025% adapalene, and 20% azelaic acid. Each of these agents is highly effective for the treatment of acne, but almost invariably there is a recurrence of the lesions whenever the treatment is stopped, unless the tendency for developing acne has subsided by that time. In most patients, the disease tends to keep recurrring till the age of 25 years and thus the treatment has to be continued for all this period. Under these circumstances, the ideal approach would be to depend upon a topical treatment which can be used like a cosmetic on a regular basis and prevent acne till the patient is no more prone to develop acne. Such an agent has to be cosmetically acceptable and safe on prolonged usage.

With these considerations, Pasricha had used a formulation based on lactic acid/lactate system for the management of acne.[1] Lactic acid/ lactate is a cimponent of the normal skin-surface chemistry, and laboratory studies had revealed that lactic acid and sodium lactate both have a wide spectrum of antibacterial activity[2] and thus this possibly contributes significantly to the natural defence mechanisms of the skin. Being produced by the skin itself, lactic acid is not expected to cause any allergic or toxic reactions.[3] The present study was undertaken to evaluate if a regular use of topical applications of lactate lotion like a cosmetic can control acne.

Materials and methods

Forty consecutive patients having acne vulgaris were enrolled for the study, but only 22 patients completed the study period of 1 year. Pregnant woman, patients on oral contraceptives and patients known to have liver or adrenal dysfunction or any other systemic disease were excluded. The lesions present on the face at the rime of starting the treatment were counted and classified into, non-inflammatory lesions (open and closed comedones), inflammatory lesions (papules and pustules), and cystic lesions.

The patients were instructed to apply the 5% lactate lotion prepared in an aqueous base all over the face twice a day, after washing the face thoroughly with soap and water. Applications of the lactate lotion were continued even when the patient had no lesions. Patients having severe disease were in addition given 100 mg doxycycline per day for a period of 4 weeks. If the response to doxycycline was not adequate, the antibiotic was changed to ciprofloxacin 500 mg twice a day or erythromycin 500 mg twice a day for 4 weeks. Treatment with the antibiotic was repeated whenever the patient had severe exacerbations.

Re-evaluation was undertaken once a month when the lesions were counted separately for each category at each visit. The severity of the disease during follow up was recorded graphically [Figure - 1].

Results

Twenty-two patients, 17 males and 5 females, with duration of disease ranging from 15 years cimpleted the study. The lesion counts at the start of the treatment were 6-52 (21.27) for the inflammatory lesions, 5-293 (97.36) for the non-inflammatory lesions and 0-19 (3.18) for the cysts. At the end of the 1 year of treatment the lesions counts were 1-12 (4.64) for the inflammatory lesions, and 2-89 (19.18 for the non-inflammatory lesions. Cysts had disappeared in all the patients [Table - 1].

The maximal reduction with respect to the comedones was achieved between 8-30 weeks, and at the end of the first year, 5 (22.7%) patients had 90-100% improvement and 13 (59%) improvement. Two patients had less than 50% improvement.

The maximal reduction in the inflammatory lesion counts was achieved between 8-24 weeks and at the end of the first year, 9 (40.9%) patients had 50-90% reduction in the lesion counts. Cysts had disappeared in 2 patients at the end of 8 weeks, in 3 patients at 12 weeks, in 1 patient each at 16 and 20 weeks. In 5 patients cystic lesions developed during the treatment bur disappeared in 4 weeks in 4 patients and 8 weeks in 1 patient.

One patient did not show any change in the inflammatory lesions and the comedones and in another patient the lesion counts were higher at the end of 1 year with respect to both the comedones and the inflammatory lesions.

Doxycycline was given to 14 patients for 4-12 weeks at the beginning of the treatment because they severe acne. Seven of these patients showed an adequate response. The other 7 patients who did not respond adequately to doxycycline were given ciprofloxacin. Five of these patients responded to ciprofloxacin, and received the drug for 4-16 weeks. The patients who did not respond to even ciprofloxacin were given erythromycin, but only one of these responded to erythromycin. During the subsequent follow up, only 8 of these patients required systemic antibiotics to control the aggravations during the course of the disease.

Of the remaining 8 patients who did not need systemic antibiotic in the beginning, 6 required the antibiotics to control the aggravations during the course of the disease. All these patients were first given doxycycline, but 4 patients who did not show adequate response to doxycycline, were given ciprofloxacin and one of these patients who still did not respond adequately, was give erythromycin. The duration of the antibiotic therapy to control aggravations in these patients ranged from 4 to 20 weeks. Two patients did not require systemic antibiotics at all throughout the study period.

The aggrvating factors considered responsible for the aggravations by the patients before the start of the therapy were, diet in 2 patients, premenstrual flare in 2 patients, summer season in 9 patients, winter season in 1 patient and topical application of cream containing betamethasone and neomycin in 1 patient. During the treatment, the aggravating factors were psychological stress in 9 patients, premenstrual flare in 2 patients, application of hair oil in 2 patients and summer and rainly season in 16 patients. None of the patients considered food as the aggravating factor.

The side-effects observed during the treatment with ropical lactate were minimal and insignificant. These consisted of temporary pricking sensation over the lesions (27%), irritation (4.5%) and oilness of the face (18%). All these symptoms disappeared after the first few days. Nausea and abdominal disconfort were observed in 27% cases during the treatment with systemic antibiotics. None of the patients discontinued the treatment because of the side-effects.

Discussion

The conventional aproach for the treatment of one consists of using topical and/or systemic drugs along with other measures, and most of the remedies are useful for controlling the disease and mading the lesions disappeat. The main problem in acne however is that the lesions start appearing again whenever the treatment is withdrawn and this leads to a lot of frustration among the patients and also among the dermatologists. We feel that the rational approach for the management of acne should be to prevent acne so that the patient does not develop the lesions and the resultant scars. For this, it is essential to develop a schedule which can be used on a regular basis right from the time that the patient becomes vulnerable to develop acne (i.e. puberty) and continued up to the age of at least 25 years when the patient spontaneously stops developing further acne lesions.

Of the different medicines available for the topical treatment of acne, locate lotion is the only remedy which is non-toxic and non sensitizing as its main constituent is a normal metabiolite of the body. It was introduced for the treatment of acne with the presumption that the individuals who develop more severe forms of acne are probably secreting less lactic acid on their skin surface. Topical applications of lactic acid would thus reinforce the natural mechanism for controlling the bacterial proliferation on the skin.[1] The range of antibacterial activity of lactic acid/lactate had been shown to cover most of the pathogenic bacteria of significance to dermatology.[2] Swanbeck[4] had also proposed a similar mechanism for ethyl lactate, i.e. that ethyl lactate applied topically would penetrate the sebaceous follicle ducts where it would be hydrolysed to ethanol and lactic acid and thus reduce the pH. As a consequence, the bacterial lipolysis of sebum triglycerides to free fatty acids would be reduced.[5],[6] It seens however, that he failed to realize that lactic acid and even lactate have strong and a wide range of antibacterial activity.

A previous study on the efficacy of topical 5% lactate lotion in the treatment of acne vulgaris showed 61 % improvement in the inflammatory lesions and 43.3% in the non-inflammatory lesions at the end of 12 weeks.[7]

Management of acne is an art. The essential cimponents of the treatment include, a thorough cleaning of the skin and the hair, avoidance of greasy applications (hair oils and creams) to the skin and hair, regular use like a cosmetic of a topical antibacterial agent to prevent acne, and imtermittent use of systemic antibiotics whenever the disease is more severe.

Thus, with appropriate management and judicious use of additional modalities, the effect of acne can be reduced and the need for systemic antibiotics can be further minimized.