AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Propionibacterium species are inhabitants of the skin and usually are nonpathogenic. As a result, they are common contaminants of blood and body fluid cultures. These species are slow-growing, nonsporulating, gram-positive anaerobic bacilli.

Propionibacterium species belong to the genera of Coryneforms and are the best studied because of their association with acne vulgaris. However, a number of other infections may be caused by Propionibacterium species, and these are described briefly in this article.

Propionibacterium acnes is found briefly on the skin of neonates, but true colonization begins during the 1-3 years prior to sexual maturity when numbers rise from fewer than 10/cm² to about 10⁶/cm², chiefly on the face and upper thorax. In the lipid-rich microenvironment of the hair follicle, P acnes produces inflammatory mediators that result in papules, pustules, and later, nodulocystic lesions that are typical of inflammatory acne.

Propionibacterium granulosum is found in the same areas but at numbers about one hundredth of those of P acnes.

Both P acnes and P granulosum may be isolated from the gastrointestinal tract.

Propionibacterium avidum is found in the axilla, rather than on exposed areas, and increases in numbers at puberty.

Propionibacterium propionicus has been implicated as a less common causative agent of a disease process similar to actinomycosis. The most common cause of actinomycosis is Actinomyces israeli.

Frequency

United States

Acne vulgaris is sufficiently common that it may be considered physiologic.

Race

Acne appears to be a familial condition and is less common in Japanese people than in the white American population.

Sex

In girls, acne may precede menarche by more than 1 year. The greatest number of cases is observed during the middle-to-late teenage period, and incidence decreases subsequently. Males are affected more frequently than females are, and males tend to have more severe involvement.

Age

Acne vulgaris is a self-limited disease involving the sebaceous follicles observed primarily in adolescents. Occasionally, it is present at birth, and mild cases may be observed in the neonatal period. During puberty, acne typically becomes a common problem. The condition often is an early manifestation of puberty. In very young patients, the predominant lesions are comedones, and inflammatory lesions are rare.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• Acne vulgaris
• • Propionibacterium acnes plays an important role in the pathogenesis of inflammatory acne–producing producing proinflammatory mediators, including lipases, neuraminidases, phosphatases, and proteases.
  • Acne usually affects the face and, to a lesser degree, the back, chest, and shoulders. On the trunk, lesions tend to be near the midline.
  • The 4 major pathophysiologic features of acne are the following:
  • • Hyperkeratinization
    • Sebum production
    • Bacterial proliferation
    • Inflammation
  • Lesions can be described in 3 categories
  • • Noninflammatory: Comedones are either open (black heads) or closed (whiteheads). The open comedo appears as a flat or slightly raised lesion with a central dark-colored follicular impaction of keratin and lipid. The closed comedo is a pale, slightly elevated, small papule without a visible orifice and is a potential precursor for the larger inflammatory lesions.
    • Inflammatory: Inflammatory lesions vary from small papules with an inflammatory areola to pustules (papulopustular) to large, tender, fluctuant nodules (nodular).
    • Scars: These appear as punched out pits of varying size and may have multiple openings.
  • Exacerbations of acne vulgaris may follow the ingestion of several drugs, such as iodides, bromides, glucocorticoids, and lithium, as well as the application of oil-containing compounds.
• Other infections
• Propionibacterium species have been identified rarely as causes of brain abscess, subdural empyema, dental infections, endocarditis, continuous ambulatory peritoneal dialysis (CAPD), conjunctivitis associated with contact lenses, and peritonitis.
• P acnes has been identified as a frequently recovered cause of anaerobic arthritis in association with prosthetic joints and, rarely, has been implicated in cases of osteomyelitis , as well as prosthetic vascular graft infections. Cardiovascular device–related infections secondary to P acnes typically presents in a subtle fashion: low grade fever, weight loss, malaise, and myalgias.
• P acnes has been isolated from an affected joint in rare cases of rheumatoid arthritis or chronic juvenile arthritis, presumably as a result of bacterial inoculation, usually during infiltration (injection).
• P acnes also has been implicated in certain spondyloarthropathies associated with florid acne vulgaris, in which it was isolated from bone foci and from the joints.
• P acnes has been reported as a cause of vision-threatening infectious keratitis when the cornea is compromised.
• P granulosum has been isolated as a cause, albeit rarely, of endocarditis.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Acne vulgaris: Comedones are not unique to acne. Senile comedones are common and are observed particularly in the periorbital area of elderly persons, and comedones may be present as a result of radiation therapy.

Acnelike lesions may be observed in patients with Behçet disease and in immunocompromised hosts. Disseminated cryptococcosis may present as acneiform eruption.

Other diseases of the sebaceous cysts include atheromas, keratin cysts, and the development of pilar cysts.

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Acne vulgaris: Although many laboratory studies have been performed, the findings have not been significant in general. Androgen levels may be appropriate in select cases.
• Other infections: In some high-risk patients, Propionibacterium species are capable of inducing significant infections, and efforts should be made to obtain specimens free of contamination by the normal flora of the mucous membranes and skin, where they reside. In addition, strict anaerobic technique should be followed in order to ensure isolation in suspected cases of Propionibacterium species infection.
• In cases of P acnes causing infectious keratitis, isolates are culture positive on thioglycolate broth. None became positive before 7 days of growth, and the recommendation is to monitor the culture for at least 10 days to ensure isolation of this fastidious organism.

Imaging Studies

• In cardiovascular device–related infections, P acnes can be difficult to recover in cultures of clinical specimens unless anaerobic cultures are obtained and held for extended periods. Computed tomography (CT) scans, ultrasonography, and magnetic resonance imaging (MRI) are useful in demonstrating fluid collection around a device, which can suggest infection. Percutaneous aspirate of the fluid with ultrasound or CT guidance may confirm device infection. Transesophageal echocardiography is required in order to visualize a vegetation in prosthetic valve endocarditis.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

• Acne vulgaris: Topical and oral agents act at various stages in the evolution of an acne lesion and may be used alone or in combination to enhance efficacy. Most cases are controlled with combinations of vitamin A acid, benzoyl peroxide, drying and peeling agents, and antibiotics. Topical agents should be applied to the entire affected area to treat existing lesions and to prevent the development of new ones. Potent topical steroid creams produce no short-term improvement in patients with moderate acne. Future treatments under study involve the potential use of laser therapy.
• Other infections: Determination of the clinical significance of an isolate of Propionibacterium species must be made with caution because this will influence the need to direct therapy against that isolate.

Surgical Care

• Acne vulgaris: Surgical care involves the manual removal of comedones and the drainage of pustules and cysts. When performed correctly, acne surgery speeds resolution and rapidly enhances cosmetic appearance. Scar revision by means of dermabrasion, excision, and gelatin matrix collagen implantation is performed in patients who are self-conscious about the pitted and craterlike scars that remain.

Consultations

• Acne vulgaris: Referral to a dermatologist may be appropriate for patients who do not respond to conventional treatment.
• Other infections: Isolation of Propionibacterium species in the settings described above may require the assistance of an infectious diseases specialist for interpretation.

Diet

In cases of acne vulgaris, no evidence supports the elimination of various foods such as sweets, chocolate, milk, and fatty foods. However, patients will indicate that they notice flares after the consumption of certain foods, such as chocolate. In these scenarios, eliminating the implicated food item would be reasonable if the patient feels that it is aggravating the condition.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

The following information pertains to the treatment of acne vulgaris primarily.

For other infections caused by Propionibacterium species, antibiotics used for the treatment of anaerobic infections usually suffice. These include the penicillins, carbapenems, and clindamycin. In addition, vancomycin and teicoplanin have been used. Some of these antibiotics are discussed after the treatment of acne vulgaris.

Drug Category: Keratolytics

These agents cause cornified epithelium to swell, soften, macerate, and then desquamate. Retinoids are now classified into 3 generations. The first comprises topical tretinoin and systemic isotretinoin. The second generation retinoids are used to treat psoriasis. The third-generation retinoids include adapalene and tazarotene, which are topical agents.

Drug Category: Antibiotics

These agents are useful in papular, pustular, and cystic acne and must be taken for weeks to be effective. They are typically used for many weeks or months to achieve maximum benefit.

Long-term antibiotics may be required and necessitate monitoring for adverse drug events. Females should be warned about the development of vaginitis secondary to Candida albicans.

Topical antibiotics are useful in mild pustular and comedone acne. These preparations include clindamycin, erythromycin, and Benzamycin (erythromycin 3%-benzoyl peroxide 5% gel).

Drug Category: Antiandrogen therapies

These agents are reserved for patients with acne who have clinical signs of androgen excess and for those in whom other treatments have failed. Used in women with treatment-resistant, late-onset, or persistent acne. Some of these women have signs suggestive of hyperandrogenism (eg, hirsutism, irregular menses, menstrual dysfunction), but others are without abnormalities. Serum androgen levels may or may not be elevated.

Three options are available. Estrogen suppresses ovarian androgens (oral contraceptives), glucocorticoids suppress adrenal androgen, and antiandrogens (eg, spironolactone, cyproterone acetate) act at the peripheral level.

Drug Category: Oral retinoids

Isotretinoin is related to vitamin A and is very effective to control acne and to induce long-term remissions.

Drug Category: Acne products

These agents may modify or inhibit inflammatory process.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Complications

• Acne vulgaris: The prognosis of acne vulgaris usually is favorable, and the only sequela is scarring, which can be minimized. For patients with scarring, the options include superficial peeling, tissue augmentation with injected materials, and the use of deep abrasive therapy.
• Other infections: These complications are described in the Clinical section.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Isotretinoin is contraindicated in pregnancy. A pregnancy test should be performed prior to commencing treatment, and patients should be warned about the drug's teratogenic effects.
• Though frequently a nonpathogen, never automatically assume that the presence of Propionibacterium species in a sterile body fluid culture is due to contamination until a thorough history and physical examination and assessment is completed.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Propionibacterium infection. Nodular-cystic acne.
	View Full Size Image
Media type:  Photo

Media file 2:  Propionibacterium infection. Pustular acne.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Chaudhry R, Dhawan B, Pandey A, et al. Propionibacterium granulosum: a rare cause of endocarditis. J Infect. Nov 2000;41(3):284. [Medline].
• Delyle LG, Vittecoq O, Bourdel A, et al. Chronic destructive oligoarthritis associated with Propionibacterium acnes in a female patient with acne vulgaris: septic-reactive arthritis?. Arthritis Rheum. Dec 2000;43(12):2843-7. [Medline].
• Habif TP. Acne. In: Clinical Dermatology. St Louis, Mo: Mosby;. 1996.
• Leyden JJ. Therapy for Acne Vulgaris. N Eng J Med. 1997;336:1156-1162.
• Mandell GL, Bennett JE, Dolin R. Principles and Practice of Infectious Diseases. 6th ed. New York, NY: Churchill Livingstone;. 2005.
• Webster G. Combination azelaic acid therapy for acne vulgaris. J Am Acad Dermatol. Aug 2000;43(2 Pt 3):S47-50. [Medline].

Article Last Updated: Apr 27, 2006