Antimicrobial and Improvement Effects of Tea Tree and Lavender Oils on Acne Lesions 1 Bok Young Kim, 2 Sujin Shin 1 Songho College, kby998603@hanmail.net 2 Corresponding author Soonchunhyang University, ssj1119@sch.ac.kr Abstract This study investigated the antimicrobial effects and improvements associated with an aromatic oil intervention program to treat acne lesions in 54 college students. The intervention was performed for 4 weeks. Data were collected using the acne intensity classification system, a Sebumeter, and a digital skin fluorescence diagnotor. The collected data were analyzed using the t-test, chi-square test, and paired t-test. Both the total number of Propionibacterium acnes and the number of inflammatory lesions were significantly reduced in the treated subjects. These results indicated that aroma oils have antimicrobial effects and improve in vivo acne lesions. Thus, tea tree and lavender oils may be alternative treatments for patients who do not prefer to use existing antibiotic treatments for their acne. Keywords: Acne, Aromatherapy, Skin Care 1. Introduction Acne occurs because of the composite actions of factors such as increased sebum secretion, androgen stimulation of sebaceous glands, inflammation caused by the formation of free fatty acids by Propionibacterium acnes, follicular parakeratosis, and genetic factors [1]. P. acnes is an important indicator of inflammation in acne patients [2,3], and these bacteria are mainly distributed in the sebaceous glands, inducing inflammations at the beginning of adolescence, in conjunction with sebum production, as the sebaceous glands mature [4]. Modern acne treatment involves the treatment of the various pathological elements of acne. Topical retinoids, which are vitamin A derivatives, are used to treat mild and common acne because they have comedolytic and anti-inflammatory effects; combinations of topical retinoids and oral antibiotics are used to treat moderate acne; and isotretinoin, which is an oral retinoid, is used for treating severe, nodular acne [5, 6]. Luk et al. [7] reported that P. acnes may become resistant to tetracycline, erythromycin, clindamycin, doxycycline, and minocycline in acne patients. Others have reported that antibiotic resistance occurs because of the emergence of antibiotic resistant bacteria, leading to problems, such as recurrence, when treatment is stopped [8, 9]. Microbial resistance led to aromatherapy being suggested as a treatment of existing acne [10], and other natural antimicrobial substances have also been explored as potential acne treatments in various regions worldwide [11-13]. Studies investigating the use of aromatic oils have included measurements of the oil s in vitro and in vivo antimicrobial effects [10, 14, 15-17] and their abilities to suppress sebum secretion [16, 18]. However, most studies have measured the oils in vitro effects against microorganisms, such as P. acnes, Staphylococcus aureus, and Staphylococcus epidermidis, whereas studies that investigated the clinical use of aromatic oils have reported improvements in the number of acne lesions, sebum secretion rates, changes in skin tone, subjective acne, and patient satisfaction. The present study comprehensively examined the effects of acne intervention programs that use tea tree or lavender oils. 2. Methods Journal of Convergence Information Technology(JCIT) Volume8, Number13, August 2013 339
The study was approved by the bioethics committee of Ewha Woman s University (IRB 2011-3-8); the participants provided informed consent. 2.1 Participants The present study was designed with a non-equivalent control group, pretest-posttest design and involved subjects recruited from among university students diagnosed with acne. Sample sizes were calculated using the G*power 3.1 program (Heinrich-Heine-Universität, Düsseldorf, Germany). With a power of 0.8, an effect size of 0.5, and an alpha of 0.05, the required numbers of subjects in the experimental and control groups were calculated to be 26, each. However, to account for potential dropout rates, 30 subjects were recruited for each group. Participants were randomly assigned into the control and experimental groups. The dropout rate was 10%, and the reasons for discontinuation were lack of time during the test (4 individuals) and missing questionnaire responses (2 individuals). 2.2. Measurements In the experimental and control groups, the subjects general characteristics, acne-related characteristics, number of P. acnes, number of human skin pathogens, number of acne lesions, and sebum secretion rates were measured. The number of acne lesions was reported based on the acne intensity classification system [19]. The sebum excretion rate, the number of P. acnes, and the human skin pathogens were measured using the Sebumeter R (SM 810 PC, Courage + Khazaka Electronic, Cologne, Germany) and a digital skin fluorescence diagnotor (ECOSkin, Healux, Goyang-City, Korea). The purpose of the study was explained to the research assistants, and to ensure the objectivity and consistency of data collection, they were also educated on the treatment methods. The treatment method and data collection processes were explained twice, for 1 h each time, to these individuals. In the present study, the acne intervention program was developed in consultation with a dermatologist, a family practice faculty member, and an aromatherapist. The aromatic oils used in the present study were permitted by the Korean Food & Drug Administration (notification number 2009-158), and judged to conform to the standards set by the Korea Laboratory Accreditation Scheme. The intervention was performed for 4 weeks, with both groups being provided with the same, baseline acne intervention program. Experimental group members were provided with a weekly acne treatment and, in addition, received a dermal application of a mixture of 3% tea tree oil, 2% lavender oil, and jojoba oil. These subjects also received the aroma oils, compounded as a home care prescription, which were applied to their skin twice a day, morning and evening, for 4 weeks. We demonstrated the dermal application, and the subjects were to keep the formulation on their skin for 5 minutes. The members of control group were only provided with the basic, weekly acne treatment. Both groups were educated on acne management, diet, sleep, smoking, and drinking during the experimental period. During the experimental period, the subjects visited this hospital once per week for a follow-up and to be provided with their baseline acne treatment. In the aroma oil-based acne intervention program, 1 subject complained of an itch 2 3 days after beginning the treatment. However, the symptom resolved shortly, and the subject participated in the balance of the intervention without subsequent adverse effects. In the post-test examination, the numbers of P. acnes, human skin pathogens, and acne lesions, as well as the sebum secretion rates, were measured, 4 weeks after the beginning of the experiment, using the same methodologies as during the pre-test. 2.3. Statistical analysis The collected data were analyzed using the SPSS WIN 20 program (SPSS, Chicago, IL, USA). The homogeneity verifications of the experimental and control groups were performed by the dependent sample t-test and the chi-square test, and the antimicrobial effects and the acne lesion improvements were analyzed using the paired t-test. 3. Results 340
Six study subjects dropped out of the study: 3 in the experimental group and 3 in the control group. This resulted in a final participation rate of 90%; the study involved 54 subjects, with 27 subjects in each of the 2 groups. 3.1. Inter-group homogeneity test The homogeneity of the general and acne-related characteristics of the experimental and control groups was tested, and the results showed no significant difference between the 2 groups, confirming that the 2 groups were homogeneous (Table 1). The dependent variables (the numbers of P. acnes, human skin pathogens, and acne lesions, and the sebum secretion rates) also did not show any significant differences between the 2 groups. Table 1. Test of the homogeneity of the general characteristics and dependent variables (N = 54) (n = 27) (n = 27) t or χ² p n(%)/m ± SD n(%)/m ± SD Gender Female Male 23(85.2) 4(14.8) 25(92.6) 2(7.4) 0.750.669 Age (yr) 21.5 ± 2.2 20.9 ± 1.8 1.218.229 Family history of acne Yes No 22(81.5) 5(18.5) 23(85.2) 4(14.8) 0.359.721 Sleep (hours) 6.5 ± 0.9 6.7 ± 0.9 2.294.550 Age of onset (yr) 15.0 ± 2.6 15.2 ± 2.9 13.629.255 Duration (yrs) Acne lesions* Numbers of P. acnes (/cm2) Human skin pathogens (/cm2) Numbers of lesions Sebum excretion (μg/cm2) 1 1.99 2 3.99 4 Both cheeks Others Right cheek Left cheek Right cheek Left cheek Noninflammatory Inflammatory Right cheek Left cheek 3(11.1) 5(18.5) 19(70.4) 23(37.7) 13(21.3) 3(4.9) 20(32.8) 2(3.3) 260.2 ± 292.3 318.4 ± 367.9 558.7 ± 442.0 569.1 ± 438.9 375.5 ± 353.4 164.5 ± 172.3 187.8 ± 218.8 288.0 ± 269.8 356.6 ± 256.2 268.9 ± 308.3 41.6 ± 13.7 35.9 ± 19.7 70.3 ± 31.6 54.2 ± 23.9 77.2 ± 35.9 131.5 ± 62.1 132.4 ± 61.9 *multiple responses;, control group;, experimental group 0(0.0) 14(51.9) 13(48.1) 25(39.1) 12(18.8) 4(6.2) 23(35.9) 0(0.0) 194.1 ± 240.3 170.6 ± 218.0 448.3 ± 438.1 431.1 ± 372.7 205.3 ± 423.9 211.3 ± 237.0 191.4 ± 226.0 291.1 ± 274.4 346.2 ± 292.6 208.6 ± 313.7 40.9 ± 14.0 36.4 ± 15.6 69.4 ± 26.7 52.4 ± 20.3 82.5 ± 30.3 129.1 ± 34.9 122.3 ± 52.0 0.309.505 0.750 1.147 1.132 1.421 1.019 0.907 1.795 0.922 1.246 1.603-0.830-0.060-0.042 0.138 0.712 0.177-0.115 0.121 0.307-0.582 0.173 0.648.669.786 1.000.372 1.000.369.078.361.219.115.410.952.967.891.480.860.909.904.760.563.863.520 341
3.2. Hypothesis testing 3.2.1. Antimicrobial effects The numbers of P. acnes on the foreheads of the subjects in the intervention group were significantly reduced (t = 3.100, p =.005) at the end of the intervention, compared with those prior to treatment. The total number of P. acnes showed a significant reduction in the experimental group following the intervention, compared with that those prior to the intervention (t = 3.061, p =.005). The numbers of human skin pathogens in the experimental (t = 0.424, p = 0.675) and control (t = 1.216, p = 0.235) groups showed no significant difference between the start and end of the intervention (Table 2). 3.2.2. Improvement effects on the acne lesions The number of non-inflammatory acne lesions was reduced in both the experimental (t = 3.406, p =.002) and control (t = 3.257, p = 0.003) groups. However, only the experimental group had a significant reduction (t = 5.544, p <.001) in the number of inflammatory lesions. The overall number of acne lesions was significantly reduced in both groups (experimental: t = 6.537, p <.001; control: t = 2.947, p =.007). The experimental group also showed a significant reduction in the sebum excretion rate (t = 3.144, p =.004); however, the control group demonstrated no significant reduction in sebum excretion (Table 2). Table 2. Hypothesis testing on the dependent variables (N = 54) Pre-intervention M ± SD Post-intervention M ± SD t p Numbers of P. acnes (/cm2) 2081.9 ± 1525.5 2081.9 ± 1525.2 1689.9 ± 1452.6 1241.9 ± 841.5 3.061 1.623.005 **.117 Human skin pathogens (/cm2) 1265.7 ± 1018.7 1248.7 ± 1114.4 1224.9 ± 1112.8 1152.9 ± 968.7 0.424 1.216.675.235 Numbers of lesions 77.4 ± 29.4 77.3 ± 27.7 70.3 ± 27.1 73.6 ± 27.9 6.537 2.947 <.001**.007** Non-inflammatory 41.6 ± 13.7 40.9 ± 14.0 39.6 ± 13.1 38.7 ± 13.6 3.406 3.257.002**.003** Inflammatory 35.9 ± 19.7 36.4 ± 15.6 30.7 ± 17.5 34.8 ± 16.1 5.544 1.767 <.001**.089 Sebum excretion (μg/cm2) 465.7 ± 116.7 455.7 ± 99.2 408.5 ± 106.6 450.6 ± 90.3 3.144 1.645.004**.112, control group;, experimental group; **p < 0.01 342
4. Discussion In the present study, the antimicrobial and lesion-improving effects of an acne intervention program using tea tree and lavender oils were documented. The present study employed a study design that objectively measured the effects of these aroma oils as part of an anti-acne therapy in a population of university students diagnosed with acne. Minimizing the use of antibiotics for the treatment of acne is recommended because of the problem of antibiotic resistance [20]. Thus, acne may be reduced by combining topical or oral antibiotics with aroma oils, such as tea tree and lavender oils. The present study provided the groundwork for acne intervention programs using such combination treatments by presenting the effects of tea tree and lavender oils on P. acnes and skin flora in subjects with acne. Most experiments investigating the antimicrobial effects of a substance on P. acnes involve collecting bacteria recovered from acne lesions or from a bacterial culture system and reporting the antimicrobial effects after culturing the bacteria, in the presence of the putative antimicrobial agent, for a certain period. The present study is meaningful in that it presented new results obtained using a digital fluorescence skin diagnosis system, in addition to subjective data. Previous studies have also reported significant decreases in P. acnes, detected by decreases in porphyrin fluorescence as measured by a digital fluorescence skin diagnosis system [21]. When the fluorescent particles detected by the fluorescence system were cultured, P. acnes and coagulase-negative staphylococci were both recovered [22]; P. acnes was the primary organism that fluoresced red [23, 24]. Thus, these observations may indirectly explain why the detected fluorescent porphyrin materials significantly decreased in the present study: the oils had an antimicrobial effect on the P. acnes, eliminating their ability to fluoresce red. Excessive sebum secretion is also commonly observed in acne patients and is known to be closely related to the development of acne [25, 26]. When changes in the number of acne lesions and sebum secretion rates were classified as acne lesion improvements, the experimental group showed significant decreases in both non-inflammatory and inflammatory lesions, whereas the control group showed a significant decrease of only the non-inflammatory lesions. These results are different from those in a study conducted by Yu et al. [16] in which a reduction in non-inflammatory lesions was not observed. This different outcome may be reflective of differences in the concentrations of the applied tea tree oils. In the Yu et al. study, 0.1% tea tree oil was used whereas the present study used a 3% tea tree oil concentration; the higher tea tree oil concentration might have resulted in a more significant noninflammatory lesion-reducing effect. Bassett et al. [27] reported that when 5% tea tree oil was applied for 3 months, both non-inflammatory and inflammatory lesions decreased significantly, thereby supporting the foregoing interpretation In addition, when sebum secretion rates were measured using a Sebumeter R, the experimental group, treated with the tea tree and lavender oil combination, showed a significant decrease in the mean sebum secretion rate; the control group did not show any significant change. Given the observed decrease in the sebum secretion rate in the experimental group, the aromatic oils are assumed to have been involved in skin cell regeneration and sebum secretion control [14, 28], producing the observed effects. When Park et al. [18] treated SZ95 cells (an immortalized human sebaceous gland cell line) with ethanol extracts of lavender, they showed significant decreases in sebum secretion. Their results support the findings of the present study. The current investigation suggests that an acne intervention program that uses a combination of tea tree and lavender oils may be effective for improving acne lesions because of its antimicrobial effects, its effect on inflammatory acne lesions, and its effect on the sebum secretion rates. Thus, such an acne treatment program may be effectively utilized, in combination with an existing acne treatment. 5. Conclusion This study revealed that acne intervention programs that combine aromatic oil therapy with a more conventional treatment methodology may be effective in reducing the number of P. acnes, the number of inflammatory acne lesions, and sebum secretion rates in a population with diagnosed acne. The present study is meaningful in that it addressed the pathological aspects of acne with an acne intervention program involving aromatic oils and provided evidence for the positive effects of tea tree and lavender oils for the treatment of acne. 343
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