# _Cutibacterium acnes_ Dysbiosis: Alternative Therapeutics for Clinical Application
### C. acnes Clinical Relevance  
In acne, _C. acnes_ can influence hair follicles, causing them to become plugged with sebum, dead skin cells, and bacteria. This creates an ideal environment for the formation of comedones (blackheads and whiteheads). Virulence factors, such as lipases and proteases, can then exacerbate inflammation and tissue damage, breaking down lipids and proteins, hence contributing to the pathogenesis of acne lesions [3]. In post-surgical infections, _C. acnes_ may enter sterile tissues during surgical procedures through contaminants from the patient's skin, the air in the operating room, surgical instruments, or even the surgical team [5]. Considering that biofilms can be formed on surgical implants, tissues, or medical devices, the treatment can become a challenge, as the access to the bacteria is limited, due to the biofilm barrier, leading to bacteria proliferation and localized infections [6]. \begin{table}
\begin{tabular}{p{142.3 pt} p{142.3 pt}} \hline \hline
**Virulence Factors** & **Function** \\ \hline \hline \multirow{2}{*}{Lipases} & Enzymes involved in the metabolization of sebum and free fatty acid release and triglycerides. \\ \hline \hline \multirow{2}{*}{Polyunsaturated Fatty Acid Isomerase} & Catalyzation and isomerization of linoleic acid. \\ \hline \multirow{2}{*}{Hyaluronate Lyase} & Promotes the degradation of hyaluronic acid andololalablablaother glycosaminoglycans, such as chondro-4-sulfate, chondro-6-sulfate, and dermatan sulfate, of the extracellular matrix in the epidermis and dermis. \\ \hline \multirow{2}{*}{Glycosidase} & Disruption of carbohydrate and glycan structures that constitute the eukaryotic host glycolipids and glycoproteins. \\ \hline \multirow{2}{*}{Sialidase} & Discard the sialic acid from sialoglycoconjugates. \\ \hline \multirow{2}{*}{Radical oxygenase} & Reduction of the oxygen free radicals. \\ \hline \multirow{2}{*}{Sortase F} & Capacity to covalently attach to various proteins, including adhesion factors. \\ \hline \multirow{2}{*}{Porphyrin} & Fluorescent molecules that can stimulate inflammatory host reactions. \\ \hline \multirow{2}{*}{Biofilm} & Matrix that provides bacterial resistance to adverse compounds, such as antibiotics \\ \hline \multirow{2}{*}{Adhesin dermatan-sulfate protein} & Molecular surface components that recognize adhesive molecules of the matrix. \\ \hline \multirow{2}{*}{Christie–Atkins–Munch–Petersen Factors} & Promote the formation of pores in host cells membranes. \\ \hline \hline \end{tabular}
\end{table} 
Table 1: C. acnes virulence factors and respective function. Since _C. acnes_ can metabolize the lipids produced by the human's sebaceous glands, the density of this bacterium tends to be higher in lipid-rich areas of the human body, such as the face and upper thorax [7]. This distribution is correlated with the risk of infections observed in iatrogenic procedures (post-surgical procedures in shoulders, heart, hip, and others) and to the manifestation of AV. In fact, a study performed on the University affiliated with the Hospital Network in Wisconsin identified 77 patients from post-operative cultures that tested positive for _C. acnes_: 61% were neurosurgical, 17% orthopedic, 9% cardiothoracic, 8% general surgery, and 5% from other departments [7]. The infections caused by _C. acnes_ were associated with a significant morbidity in these patients and are often underestimated due to the difficulties regarding growth and detection of this bacterium in cultures [6]. Although post-surgery shoulder infections can happen due to several other microorganisms, such as _Staphylococcus aureus_ and _Staphylococcus epidermidis_, studies regarding post-surgical infections, such as shoulder arthroplasty, detected _C. acnes_ as the main cause in 50 to 60% of the cases [8]. Moreover, infective endocarditis, i.e., the occurrence of an infection on a heart valve and endocardial surfaces, that can lead to a systematic infection, thus raising the risk of patient mortality [9], showed that _C.