Advertisement
Journal of Shoulder and Elbow Surgery

Efficacy of combinational therapy using blue light and benzoyl peroxide in reducing Cutibacterium acnes bioburden at the deltopectoral interval: a randomized controlled trial

Published:August 31, 2021DOI:https://doi.org/10.1016/j.jse.2021.08.008

      Background

      The purpose of this study was to compare the efficacy of blue light therapy (BLT) and 5% topical benzoyl peroxide (BPO) gel in combination with standard chlorhexidine (CHX) preparation in eradicating Cutibacterium acnes at the deltopectoral interval measured by positive, quantitative culture findings.

      Methods

      Adult male volunteers were randomized to 1 of 3 treatment groups: BPO, BLT, and BPO followed by BLT. Contralateral shoulders served as matched controls. Volunteers randomized to BPO applied the gel for a total of 5 treatments. In the BLT group, a single 23-minute treatment was administered at an estimated irradiance of 40 mW/cm2 (radiant exposure, 55.2 J/cm2). In the BPO-BLT group, volunteers received both treatments as described earlier. After treatment with either BPO, BLT, or both, a single swab culture was taken from the treatment shoulder. Next, control and treatment shoulders were prepared with CHX, and cultures were taken from each shoulder. Cultures were sent for anaerobic quantitative growth analysis with both polymerase chain reaction and Sanger sequencing confirmation of presumptive C acnes colonies.

      Results

      This study enrolled 60 male volunteers, 20 per group, with no loss to follow-up. After treatment but prior to CHX administration, all culture samples in the BPO group and BLT group grew C acnes. Prior to CHX, 16 samples (80%) in the BPO-BLT group grew C acnes. On quantitative analysis, the BPO group and BPO-BLT group had significantly less growth of C acnes compared with the BLT group after treatment but prior to CHX (P < .05 for each). Following CHX administration, the BPO and BPO-BLT groups had significantly fewer positive culture findings (odds ratios of 0.03 and 0.29, respectively) and less quantity of growth compared with their control arms (P < .05). This was not seen in the BLT group. For quantitative between-group analysis, no significant synergistic effects were seen with BPO-BLT compared with BPO alone (P = .688). There was no difference in side effects between groups.

      Conclusion

      The combination of topical BPO and CHX was effective at eliminating C acnes in most cases. BLT alone did not demonstrate effective antimicrobial properties against C acnes at the radiant exposure administered in this study. Combining BPO and BLT did not lead to significant synergistic antimicrobial effects. Both BPO and BLT are safe with few, transient side effects reported. More work is needed to determine whether BLT at higher radiant exposures or serial treatment results in bactericidal effects against C acnes in vivo.

      Level of evidence

      Keywords

      To read this article in full you will need to make a payment

      References

        • Achermann Y.
        • Goldstein E.J.C.
        • Coenye T.
        • Shirtliff M.E.
        Propionibacterium acnes: from commensal to opportunistic biofilm-associated implant pathogen.
        Clin Microbiol Rev. 2014; 27: 419-440https://doi.org/10.1128/CMR.00092-13
        • Achermann Y.
        • Sahin F.
        • Schwyzer H.K.
        • Kolling C.
        • Wust J.
        • Vogt M.
        Characteristics and outcome of 16 periprosthetic shoulder joint infections.
        Infection. 2013; 41: 613-620https://doi.org/10.1007/s15010-012-0360-4
        • Ammad S.
        • Gonzales M.
        • Edwards C.
        • Finlay A.Y.
        • Mills C.
        An assessment of the efficacy of blue light phototherapy in the treatment of acne vulgaris.
        J Cosmet Dermatol. 2008; 7: 180-188https://doi.org/10.1111/j.1473-2165.2008.00386.x
        • Ash C.
        • Dubec M.
        • Donne K.
        • Bashford T.
        Effect of wavelength and beam width on penetration in light-tissue interaction using computational methods.
        Lasers Med Sci. 2017; 32: 1909-1918https://doi.org/10.1007/s10103-017-2317-4
        • Ashkenazi H.
        • Malik Z.
        • Harth Y.
        • Nitzan Y.
        Eradication of Propionibacterium acnes by its endogenic porphyrins after illumination with high intensity blue light.
        FEMS Immunol Med Microbiol. 2003; 35: 17-24https://doi.org/10.1111/j.1574-695X.2003.tb00644.x
        • Barolet D.
        Light-emitting diodes (LEDs) in dermatology.
        Semin Cutan Med Surg. 2008; 27: 227-238https://doi.org/10.1016/j.sder.2008.08.003
        • Bhargava S.
        • Listopadzki T.
        • Diletti S.
        • Crane J.K.
        • Duquin T.R.
        • Boyle K.K.
        Effect of blue light and photosensitizers on Cutibacterium acnes on shoulder periprosthetic joint infection isolates.
        J Bone Jt Infect. 2020; 5: 187-197https://doi.org/10.7150/jbji.46199
        • Boyd J.M.
        • Lewis K.A.
        • Mohammed N.
        • Desai P.
        • Purdy M.
        • Li W.-H.
        • et al.
        Propionibacterium acnes susceptibility to low-level 449 nm blue light photobiomodulation.
        Lasers Surg Med. 2019; 51: 727-734https://doi.org/10.1002/lsm.23087
        • Bumah V.V.
        • Masson-Meyers D.S.
        • Tong W.
        • Castel C.
        • Enwemeka C.S.
        Optimizing the bactericidal effect of pulsed blue light on Propionibacterium acnes—a correlative fluorescence spectroscopy study.
        J Photochem Photobiol B. 2020; 202: 111701https://doi.org/10.1016/j.jphotobiol.2019.111701
        • Dai T.
        • Gupta A.
        • Murray C.K.
        • Vrahas M.S.
        • Tegos G.P.
        • Hamblin M.R.
        Blue light for infectious diseases: Propionibacterium acnes, Helicobacter pylori, and beyond?.
        Drug Resist Updat. 2012; 15: 223-236https://doi.org/10.1016/j.drup.2012.07.001
        • Dessinioti C.
        • Katsambas A.
        Propionibacterium acnes and antimicrobial resistance in acne.
        Clin Dermatol. 2017; 35: 163-167https://doi.org/10.1016/j.clindermatol.2016.10.008
        • Dizay H.H.
        • Lau D.G.
        • Nottage W.M.
        Benzoyl peroxide and clindamycin topical skin preparation decreases Propionibacterium acnes colonization in shoulder arthroscopy.
        J Shoulder Elbow Surg. 2017; 26: 1190-1195https://doi.org/10.1016/j.jse.2017.03.003
        • Duvall G.
        • Kaveeshwar S.
        • Sood A.
        • Klein A.
        • Williams K.
        • Kolakowski L.
        • et al.
        Benzoyl peroxide use transiently decreases Cutibacterium acnes load on the shoulder.
        J Shoulder Elbow Surg. 2020; 29: 794-798https://doi.org/10.1016/j.jse.2019.06.026
        • Egglestone A.
        • Ingoe H.
        • Rees J.
        • Thomas M.
        • Jeavons R.
        • Rangan A.
        Scoping review: diagnosis and management of periprosthetic joint infection in shoulder arthroplasty.
        Shoulder Elbow. 2019; 11: 167-181https://doi.org/10.1177/1758573218779076
        • Frangiamore S.J.
        • Saleh A.
        • Grosso M.J.
        • Alolabi B.
        • Bauer T.W.
        • Iannotti J.P.
        • et al.
        Early versus late culture growth of Propionibacterium acnes in revision shoulder arthroplasty.
        J Bone Joint Surg Am. 2015; 97: 1149-1158https://doi.org/10.2106/JBJS.N.00881
        • Gold M.H.
        • Andriessen A.
        • Biron J.
        • Andriessen H.
        Clinical efficacy of self-applied blue light therapy for mild-to-moderate facial acne.
        J Clin Aesthet Dermatol. 2009; 2: 44-50
        • Gold M.H.
        • Biron J.A.
        • Sensing W.
        Clinical and usability study to determine the safety and efficacy of the Silk’n Blue Device for the treatment of mild to moderate inflammatory acne vulgaris.
        J Cosmet Laser Ther. 2014; 16: 108-113https://doi.org/10.3109/14764172.2013.854638
        • Gold M.H.
        • Rao J.
        • Goldman M.P.
        • Bridges T.M.
        • Bradshaw V.L.
        • Boring M.M.
        • et al.
        A multicenter clinical evaluation of the treatment of mild to moderate inflammatory acne vulgaris of the face with visible blue light in comparison to topical 1% clindamycin antibiotic solution.
        J Drugs Dermatol. 2005; 4: 64-70
        • Halstead F.D.
        • Thwaite J.E.
        • Burt R.
        • Laws T.R.
        • Raguse M.
        • Moeller R.
        • et al.
        Antibacterial activity of blue light against nosocomial wound pathogens growing planktonically and as mature biofilms.
        Appl Environ Microbiol. 2016; 82: 4006-4016https://doi.org/10.1128/AEM.00756-16
        • Hancock D.S.
        • Rupasinghe S.L.
        • Elkinson I.
        • Bloomfield M.G.
        • Larsen P.D.
        Benzoyl peroxide + chlorhexidine versus chlorhexidine alone skin preparation to reduce Propionibacterium acnes: a randomized controlled trial.
        ANZ J Surg. 2018; 88: 1182-1186https://doi.org/10.1111/ans.14848
        • Heckmann N.
        • Heidari K.S.
        • Jalali O.
        • Weber A.E.
        • She R.
        • Omid R.
        • et al.
        Cutibacterium acnes persists despite topical clindamycin and benzoyl peroxide.
        J Shoulder Elbow Surg. 2019; 28: 2279-2283https://doi.org/10.1016/j.jse.2019.06.016
        • Heckmann N.
        • Sivasundaram L.
        • Heidari K.S.
        • Weber A.E.
        • Mayer E.N.
        • Omid R.
        • et al.
        Propionibacterium acnes persists despite various skin preparation techniques.
        Arthroscopy. 2018; 34: 1786-1789https://doi.org/10.1016/j.arthro.2018.01.019
        • Holmes S.
        • Pena Diaz A.M.
        • Athwal G.S.
        • Faber K.J.
        • O’Gorman D.B.
        Neer Award 2017: a rapid method for detecting Propionibacterium acnes in surgical biopsy specimens from the shoulder.
        J Shoulder Elbow Surg. 2017; 26: 179-185https://doi.org/10.1016/j.jse.2016.10.001
        • Horneff III, J.G.
        • Hsu J.E.
        • Voleti P.B.
        • O’Donnell J.
        • Huffman G.R.
        Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain.
        J Shoulder Elbow Surg. 2015; 24: 838-843https://doi.org/10.1016/j.jse.2015.03.008
        • Hsu J.E.
        • Whitson A.J.
        • Woodhead B.M.
        • Napierala M.A.
        • Gong D.
        • Matsen F.A.
        Randomized controlled trial of chlorhexidine wash versus benzoyl peroxide soap for home surgical preparation: neither is effective in removing Cutibacterium from the skin of shoulder arthroplasty patients.
        Int Orthop. 2020; 44: 1325-1329https://doi.org/10.1007/s00264-020-04594-x
        • Kadler B.K.
        • Mehta S.S.
        • Funk L.
        Propionibacterium acnes infection after shoulder surgery.
        Int J Shoulder Surg. 2015; 9: 139-144https://doi.org/10.4103/0973-6042.167957
        • Khan U.
        • Torrance E.
        • Townsend R.
        • Davies S.
        • Mackenzie T.
        • Funk L.
        Low-grade infections in nonarthroplasty shoulder surgery.
        J Shoulder Elbow Surg. 2017; 26: 1553-1561https://doi.org/10.1016/j.jse.2017.01.008
        • Kleinpenning M.M.
        • Smits T.
        • Frunt M.H.A.
        • van Erp P.E.J.
        • van de Kerkhof P.C.M.
        • Gerritsen R.M.J.P.
        Clinical and histological effects of blue light on normal skin.
        Photodermatol Photoimmunol Photomed. 2010; 26: 16-21https://doi.org/10.1111/j.1600-0781.2009.00474.x
        • Kolakowski L.
        • Lai J.K.
        • Duvall G.T.
        • Jauregui J.J.
        • Dubina A.G.
        • Jones D.L.
        • et al.
        Neer Award 2018: benzoyl peroxide effectively decreases preoperative Cutibacterium acnes shoulder burden: a prospective randomized controlled trial.
        J Shoulder Elbow Surg. 2018; 27: 1539-1544https://doi.org/10.1016/j.jse.2018.06.012
        • Leyden J.J.
        Effect of topical benzoyl peroxide/clindamycin versus topical clindamycin and vehicle in the reduction of Propionibacterium acnes.
        Cutis. 2002; 69: 475-480
        • Menendez M.E.
        • Moverman M.A.
        • Puzzitiello R.N.
        • Pagani N.R.
        • Namdari S.
        A break-even analysis of benzoyl peroxide and hydrogen peroxide for infection prevention in shoulder arthroplasty.
        J Shoulder Elbow Surg. 2020; 29: 2185-2189https://doi.org/10.1016/j.jse.2020.06.019
        • Morton C.A.
        • Scholefield R.D.
        • Whitehurst C.
        • Birch J.
        An open study to determine the efficacy of blue light in the treatment of mild to moderate acne.
        J Dermatolog Treat. 2005; 16: 219-223https://doi.org/10.1080/09546630500283664
        • Paithankar D.Y.
        • Sakamoto F.H.
        • Farinelli W.A.
        • Kositratna G.
        • Blomgren R.D.
        • Meyer T.J.
        • et al.
        Acne treatment based on selective photothermolysis of sebaceous follicles with topically delivered light-absorbing gold microparticles.
        J Invest Dermatol. 2015; 135: 1727-1734https://doi.org/10.1038/jid.2015.89
        • Patel A.
        • Calfee R.P.
        • Plante M.
        • Fischer S.A.
        • Green A.
        Propionibacterium acnes colonization of the human shoulder.
        J Shoulder Elbow Surg. 2009; 18: 897-902https://doi.org/10.1016/j.jse.2009.01.023
        • Pottinger P.
        • Butler-Wu S.
        • Neradilek M.B.
        • Merritt A.
        • Bertelsen A.
        • Jette J.L.
        • et al.
        Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening.
        J Bone Joint Surg Am. 2012; 94: 2075-2083https://doi.org/10.2106/JBJS.K.00861
        • Qiu B.
        • Al K.
        • Pena-Diaz A.M.
        • Athwal G.S.
        • Drosdowech D.
        • Faber K.J.
        • et al.
        Cutibacterium acnes and the shoulder microbiome.
        J Shoulder Elbow Surg. 2018; 27: 1734-1739https://doi.org/10.1016/j.jse.2018.04.019
        • Rao A.J.
        • Chalmers P.N.
        • Cvetanovich G.L.
        • O’Brien M.C.
        • Newgren J.M.
        • Cole B.J.
        • et al.
        Preoperative doxycycline does not reduce Propionibacterium acnes in shoulder arthroplasty.
        J Bone Joint Surg Am. 2018; 100: 958-964https://doi.org/10.2106/JBJS.17.00584
        • Sabetta J.R.
        • Rana V.P.
        • Vadasdi K.B.
        • Greene R.T.
        • Cunningham J.G.
        • Miller S.R.
        • et al.
        Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during shoulder surgery.
        J Shoulder Elbow Surg. 2015; 24: 995-1004https://doi.org/10.1016/j.jse.2015.04.003
        • Saper D.
        • Capiro N.
        • Ma R.
        • Li X.
        Management of Propionibacterium acnes infection after shoulder surgery.
        Curr Rev Musculoskelet Med. 2015; 8: 67-74https://doi.org/10.1007/s12178-014-9256-5
        • Scheer V.M.
        • Bergman Jungestrom M.
        • Lerm M.
        • Serrander L.
        • Kalen A.
        Topical benzoyl peroxide application on the shoulder reduces Propionibacterium acnes: a randomized study.
        J Shoulder Elbow Surg. 2018; 27: 957-961https://doi.org/10.1016/j.jse.2018.02.038
        • Scheer V.M.
        • Jungeström M.B.
        • Serrander L.
        • Kalén A.
        • Scheer J.H.
        Benzoyl peroxide treatment decreases Cutibacterium acnes in shoulder surgery, from skin incision until wound closure.
        J Shoulder Elbow Surg. 2021; 30: 1316-1323https://doi.org/10.1016/j.jse.2020.12.019
        • Singh J.A.
        • Sperling J.W.
        • Schleck C.
        • Harmsen W.
        • Cofield R.H.
        Periprosthetic infections after shoulder hemiarthroplasty.
        J Shoulder Elbow Surg. 2012; 21: 1304-1309https://doi.org/10.1016/j.jse.2011.08.067
        • Stull J.D.
        • Nicholson T.A.
        • Davis D.E.
        • Namdari S.
        Addition of 3% hydrogen peroxide to standard skin preparation reduces Cutibacterium acnes–positive culture rate in shoulder surgery: a prospective randomized controlled trial.
        J Shoulder Elbow Surg. 2020; 29: 212-216https://doi.org/10.1016/j.jse.2019.09.038
        • Tremblay J.F.
        • Sire D.J.
        • Lowe N.J.
        • Moy R.L.
        Light-emitting diode 415 nm in the treatment of inflammatory acne: an open-label, multicentric, pilot investigation.
        J Cosmet Laser Ther. 2006; 8: 31-33https://doi.org/10.1080/14764170600607624
        • van Diek F.M.
        • Pruijn N.
        • Spijkers K.M.
        • Mulder B.
        • Kosse N.M.
        • Dorrestijn O.
        The presence of Cutibacterium acnes on the skin of the shoulder after the use of benzoyl peroxide: a placebo-controlled, double-blinded, randomized trial.
        J Shoulder Elbow Surg. 2020; 29: 768-774https://doi.org/10.1016/j.jse.2019.11.027
        • Wang Y.
        • Wang Y.
        • Wang Y.
        • Murray C.K.
        • Hamblin M.R.
        • Hooper D.C.
        • et al.
        Antimicrobial blue light inactivation of pathogenic microbes: state of the art.
        Drug Resist Updat. 2017; 33-35: 1-22https://doi.org/10.1016/j.drup.2017.10.002
        • Wheeland R.G.
        • Koreck A.
        Safety and effectiveness of a new blue light device for the self-treatment of mild-to-moderate acne.
        J Clin Aesthet Dermatol. 2012; 5: 25-31