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International Journal of Research in Dermatology | September-October 2020 | Vol 6 | Issue 5 Page 1
International Journal of Research in Dermatology
Bansal M et al. Int J Res Dermatol. 2020 Sep;6(5):xxx-xxx
http://www.ijord.com
Review Article
Contemporary pursuits of vinegar from scullery to dermatology
Mansi Bansal1*, Umesh Budhiraja2, Himanshu Bansal3
INTRODUCTION
The word “vinegar” is derived from two French words,
Vin and Aigre meaning sour wine1. In England vinegar
was first made from soured malt liquors and for this
reason it was also known as alegar. Based on the raw
materials used, the vinegar produced may be classified
into grain vinegar and fruit vinegar. Apple cider vinegar
is produced from red apples. It is a two-stage
fermentation process, first the conversion of fermentable
sugars to ethanol by yeasts, usually Saccharomyces
species, and the second the oxidation of ethanol by
bacteria, usually Acetobacter species (Figure 1).
Possibly vinegar was the first antibiotic known to man.
Hippocrates applied it to his patients in 400 B.C. For
treatment of “lichen” and warts, he recommended
concentrated vinegar in the form of washes and vapor, In
cases of vitiligo, leprosy, and psoriasis, he recommended
use of concentrated vinegar.2 It is well documented that
thieves had used vinegar during the great plague of
Europe, in order to avoid contracting an infection while
vandalising and stealing valuables from the dead corpse
of the plague victims. Fetzer reports that vinegar was
employed in the civil war with considerable success to
prevent an incipient attack of scurvy among soldiers. It
was employed during the First World War in the
treatment of wounds. Jarvis discusses the use of vinegar
as liniment to treat lameness, poison ivy, shingles, night
sweats, burns, varicose veins, impetigo, and ringworm.
Kromer records the use of vinegar as a beautifier.
Lucrezia Borgia is said to have bathed in vinegar daily to
keep herself fresh and well-groomed.1
The ingestion of vinegar is reported to be associated with
satiety and decreased intake of subsequent meals; hence it
can contribute to weight loss and control obesity. Vinegar
has positive influence in cardiovascular diseases, seen as
a significant reduction in systolic blood pressure. It
induces apoptosis of leukemia cells and inhibits the
proliferation of the cancer cells. The antiglycemic effect
ABSTRACT
Vinegar is widely available as a food ingredient for flavouring and as a preservative. It is one of the oldest skin
remedy known to mankind. However, its status in treatment regimens has declined over the decades. This article is an
attempt to highlight its therapeutic armamentarium in dermatology, venereology and leprosy. Acetic acid in vinegar
has antibacterial, antifungal and antiviral properties. This review talks about various studies of acetic acid for various
indications, such as screening for cervical cancer, healing of chronic wounds, atopic dermatitis, onychomycosis,
marine dermatoses, acne vulgaris, warts, in sclerotherapy and many others dermatoses. Combination therapies and
newer indications are also described in this article. Recently, its antiviral action in vitro has been demonstrated against
the ongoing coronavirus disease of 2019 (COVID-19) pandemic.
Keywords: Vinegar, Acetic acid, Dermatoses, Vital staining, Black peel, Dermatology
1Department of Dermatology, Venereology, Leprosy, Kaya Skin Clinics, New Delhi, India
2Guru Gobind Singh Hospital, New Delhi, India
3PGIMS, Rohtak, Haryana, India
Received: 01 August 2020
Accepted: 10 August 2020
*Correspondence:
Dr. Mansi Bansal,
E-mail: mansib18@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/issn.2455-4529.IntJResDermatol20203539
Bansal M et al. Int J Res Dermatol. 2020 Sep;6(5):xxx-xxx
International Journal of Research in Dermatology | September-October 2020 | Vol 6 | Issue 5 Page 2
of vinegar is explored and vinegar is reported to alter the
blood glucose concentration.3
Therapeutic effects of vinegar arising from the inherent
bioactive components including acetic acid, gallic acid,
catechin, ephicatechin, chlorogenic acid, caffeic acid, p-
coumaric acid, and ferulic acid. Out of all these
components, acetic acid is primarily responsible for its
ant oxidative, antidiabetic, antimicrobial, antitumor,
antiobesity, antihypertensive, and cholesterol-lowering
responses.4
This is the first such review in English literature. This
article is an attempt to conceptualize the various
therapeutic and diagnostic uses in a plethora of skin
conditions.
Figure 1: Production process of vinegar.
METHODS
As this is an old drug which was forgotten over the years,
there are only a few randomized, placebo-controlled or
double-blind studies on its use. This makes it difficult to
carry out meta-analysis studies. The present review aims
to explore the various uses of vinegar in the field of
dermatology. For this purpose, we searched PubMed,
Google Scholar and Cochrane library database using the
following keywords “vinegar in dermatology,” vinegar in
skin disease” and “acetic acid in dermatology.” Review
articles, original articles and case reports were included
in the search.
CHEMISTRY AND PHARMACOLOGY
Acetic acid is a weak organic acid with the chemical
formula CH3COOH. Glacial acetic acid is the trivial
name used to refer to pure acetic acid in an anhydrous
state. It is a colourless, hygroscopic, weak acid that is
available in concentrations of 99.5% to 100%. A number
of acetic acid products are commercially available.5
After oral administration, acetic acid is readily absorbed,
uptake then occurs in liver and peripheral tissues. It is
metabolized via acetyl-CoA in the tricarboxylic acid
cycle in liver and skeletal muscle.
The acetic acid concentration typically ranges from 4% to
8% by volume for commercially available vinegar.
MECHANISM OF ACTION
Acetic acid being a weak organic acid can readily cross
cell membranes. Because of the equilibrium between
their ionised and non-ionised forms, the latter of which
freely cross hydrophobic membranes. This leads to the
collapse of proton gradients which are necessary for ATP
synthesis and result in death of the micro- organism.6,7
There are in vitro and in vivo studies showing its effect
against various microorganisms.
Antibacterial
Acetic acid alters the pH and makes micro environment
hostile for the growth. Also it decreases induced
inflammatory cytokine release and increases monocyte
phagocytic capacity. Yagnik et al in their study, cultured
E. coli and S. aureus in presence of acetic acid to
determine the anti-microbial activity. They found the
inhibitory concentration for S. aureus to be 2.5% and for
E. coli 0.1% acetic acid.8 Another study by Halstead et al
revealed good activity of acetic acid against the majority
of the organisms were Proteus vulgaris, P. aeruginosa, A.
baumannii, ß-haemolytic Streptococci A and B, S.
epidermidis, S. aureus, and Enterococcus faecalis; which
Bansal M et al. Int J Res Dermatol. 2020 Sep;6(5):xxx-xxx
International Journal of Research in Dermatology | September-October 2020 | Vol 6 | Issue 5 Page 3
eradicated after just 30 minutes of exposure.7 Bjarnsholt
et al found that P. aeruginosa and S. aureus biofilms
were completely eradicated by the 0.5% and 1% acetic
acid respectively.9 Cortesia et al. have shown acetic acid
to be an effective tuberculocidal disinfectant, with 30
minutes of exposure to 6% acetic acid resulting in an 8-
log10 reduction in viable Mycobacterium tuberculosis.10
Antifungal
In an infection induced model of denture stomatitis,
acetic acid resulted in anti-fungal activity against
Candida Spp which was comparable to nystatin in terms
of reducing microbial adherence and destruction.11
Yagnik et al found that 5% acetic acid restricted growth
for C. albicans on culture plates.8 On disc diffusion
assay, Aspergillus niger and Saccharomyces cerevisiae
have shown high susceptibility to 25% acetic acid.12
Antiviral
Vinegar and its active component acetic acid has shown
remarkable antiviral activity against severe acute
respiratory syndrome (SARS) CoV-2 virus. Acetic acid
causes inactivation and dis-aggregation of
haemagglutinin glycoproteins (found on the surface of
infuenza viruses) by generating a low pH-dependent
conformational change. It destroys the viral envelope and
inhibits viral transmission.13,14 Vinegar is effective in
inhibiting the infectivity of virus by lowering the titer by
90% in the nasopharyngeal swab. Also, fumigation of
vinegar at low concentration (0.34%) ameliorated the
symptoms of mild SARS-CoV-2 infection at a faster
rate.14,15
INDICATIONS IN DERMATOLOGY
Acetic acid in different concentrations has been used for a
variety of indications; diagnostic as well as therapeutic.
Diagnostic indications
As a vital staining agent to look for suspicious areas of
malignant change.
A piece of gauze soaked with the acetic acid (3-5%) is
applied to a cleaned and dried mucosa/lesion. The effect
of vital stain is recorded as positive if the lesion changed
its colour to opaque white and negative if no change or
change to transparent white. Acetic acid removes the
glycoprotein layer and increase the visibility of epithelial
cell nuclei by dehydration. Normal cells absorb the light
and don’t change colour, whereas abnormal cells with a
higher nucleus: cytoplasm ratio appear acetowhite with
brighter, more marked and more distinguishable borders.
Cervical cancer: The application of 3%–5% acetic acid,
which might cause affected areas to turn white, has been
used by various authors to detect genital mucosa with
dysplastic changes. Studies of cervical cancer screening
with acetic acid in India and western countries have
shown sensitivity ranging from 49% to 92% and
specificity from 49% to 90%.16,17
Oral mucosal cancer: Vinuth et al studied the dysplastic
changes in normal looking mucosa in tobacco users with
5% acetic acid as the vital staining agent. The sensitivity
and specificity were 97% and 50% respectively.18
Bhalang et al found the sensitivity, specificity, and
accuracy of using acetic acid for oral cancer examination
were 83.33%, 84.21%, and 83.64%, respectively (Figure
2). Also the results of clinical examination using 5%
acetic acid correlated with the expression of p53 in the
cellular level.19
Basal cell cancer: In Mohs micrographic surgery, after
excision the tissue is immersed in acetic acid to look for
the acetowhitening and then visualized with confocal
microscope to look for atypia.20
Figure 2: (A) lesion on the floor of the mouth of a
patient before acetic acid application(asterisks), (B)
The same lesion as in A after the application of acetic
acid. Mild chronic inflammation, squamous cell
carcinoma.19
Therapeutic indications
Chronic wounds: Wound healing is a complex process
influenced by intrinsic and extrinsic factors. The pH of
the wound affect oxygen release, angiogenesis, protease
activity and bacterial toxicity. Chronic non-healing
wounds have an alkaline pH and most pathogenic
bacteria require a pH value higher than 6. Healing occurs
more readily in an acid environment.21
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Acetic acid lowers the pH of the wound, reducing
bacterial protease activity.22,23 It also leads to increase in
macrophage fibroblast activity and reduces toxicity of
bacterial end products.23,24 All these actions collectively
lead to rapid decontamination with improved granulation.
Also, due to its action on biofilm, it accelerates wound
healing by reducing wound contamination and infection
and having therapeutic efficacy against multi-drug
resistant Pseudomonas aeruginosa and Staphylococcus
aureus.25
Acetic acid soaks in the concentration of 0.1-5% has been
used in the management of ulcers of varying etiology;
traumatic, venous, diabetic, decubitus, IV drug abuse,
fracture and open reduction associated ulcers, neuropathic
ulcers, erosions and ulcers associated with epidermolysis
bullosa (Table 1).
Atopic dermatitis (AD): It is a chronic disorder with
defect in epidermal barrier. There is increase in epidermal
pH, high transepidermal water loss and skin colonization
with S. aureus. Lim et al. in a study found comparable
efficacy of bleach and apple cider vinegar compresses
when locally applied to eczematous skin of AD patients.27
Diluted acetic acid baths decreases epidermal pH and has
action on S. aureus superinfection, reducing the courses
and duration of systemic antibiotics. However, it has no
role in improving the skin barrier in atopics.28
Table 1: Vinegar soaks for wound irrigation.
Acetic acid (vinegar) soak solution26
Sterile normal saline (0.9% Nacl) and white vinegar
Preparation method:
Mix one part vinegar with four parts normal Saline.
(0.9% NaCl)
Wet a sterile gauze pad with the vinegar mixture.
Place on the wound and soak the wound for 10-15
minutes, twice a day before you shower/wound cleaning
regime.
Inflammatory acne: Black peel is a new chemical
composition based on black acetic acid mixed with
jasmonic acid, salicylic acid, potassium iodide and
biosulfur. Acetic acid has a role in pustular and
nodulocystic acne. It produces frosting on the acne
lesions within minutes of application. It acts on
Propionibacterium acnes biofilm and decreases
inflammation by reducing cytokine release.29
Pediculosis capitis: It is an ectoparasitic disease caused
by an infestation of Pediculus humanis capitis. Prior
priming of nit infested hair with vinegar(4% acetic acid)
for 3 minutes dissolves the cementing substance that
attaches nits to hair shaft and can make combing easier
for removal of nits.30
A randomized controlled trial compared the effect of
coconut oil, vinegar plus coconut oil versus 1%
permethrin shampoo in the treatment of pediculosis.
Permethrin shampoo and vinegar plus coconut oil had
cure rates of 98% and 94%, respectively. They found that
coconut oil with vinegar can be used as an alternative
therapy to permethrin.31
Aquatic and marine dermatoses
All Cnidarians possess highly coiled hollow harpoon like
microtubules called nematocysts on their tentacles that
inject a toxin into the skin upon contact.
Jelly fish dermatoses: Presentations in humans range
from local reactions, a whip like sting pattern, bulla
formation, urticaria, allergic contact dermatitis, erythema
nodosum, and granuloma annulare to life threatening
anaphylaxis, haemolysis, cardiac arrhythmias, and renal
failure, especially with stings of the Portuguese man of
war (Physalia physalis) and box jellyfish (Chironex
fleckeri). Irukandji syndrome results from contact with
another variety of box jellyfish Carukia barnesi. In
suspected cases, vinegar is poured on the areas of tentacle
contact for atleast 30sec to stop further nematocysts
discharge.
Corals and coral cuts: Coral injuries may be caused by
nematocysts stings and lacerations. Coral cuts harbor a
potential for infection, foreign body granulomas, and
delayed wound healing. Lacerations from the calcium
carbonate exoskeleton of hard corals introduce debris,
bacteria, and nematocysts into the wound. Soft corals
harbour a potent neurotoxin known as palytoxin. Fire
coral stings should be rinsed with seawater to remove
undischarged nematocysts. Then the sting area be
compressed with 5% acetic acid for 15-30 min.
Sponges dermatitis: Marine sponges Neofibularia
nolitangere (“touch me not” sponge) and Tedania ignis
(fire sponge) may cause fiberglass dermatitis like irritant
skin lesions. Microciona prolifera (red moss sponge) may
cause immediate stinging, burning, and erythema due to
the effect of the crinotoxin The use of adhesive tape is
recommended for spicule removal, while acetic acid
compresses followed by topical steroids aid in treating
the effects of the crinotoxins.32,33
Fungal infections
Acetic acid soaks for 10-15min before applying topical
antifungals resulted in faster clearance in toe nail
onychomycosis due to its action on biofilm and better
penetration of antifungals.34 Eertmans et al in their study
compared acetic acid based nail polish with 5%
amorolfine for onychomycosis and found comparable
efficacy of both the products. There was significant
improvement in dystrophy, discolouration and thickening
with 6 months of daily application.35 The efficacy and
safety of apple cider vinegar as an adjunct to 2%
ketoconazole shampoo compared to 2% ketoconazole
shampoo alone in treating tinea versicolor was studied. It
was found that the symptoms resolved faster in the and
Bansal M et al. Int J Res Dermatol. 2020 Sep;6(5):xxx-xxx
International Journal of Research in Dermatology | September-October 2020 | Vol 6 | Issue 5 Page 5
percentage of treatment success favored the apple cider
vinegar-ketoconazole group compared to the control
group.36
Warts
The successive topical application of highly concentrated
acetic acid solutions (up to 99%) alleviated warts,
presumably due to the mechanical destruction of wart
tissue.37
Chronic papillomatous dermatitis
Warty excrescences around urostomies resulting from
leaks and pooling of urine. Acetic acid soaks (4-6%) of
the local area at each bag change have found to be
effective, by neutralizing ammonia from urea splitting
bacteria.33
Alkali burns
Acetic acid is used as neutralizing agent in case of burns
caused by alkali solutions. It reacts with alkalis with the
carboxyl group, neutralizing their action.
Photodamaged skin
40% acetic acid peel has shown to act as an exfoliant and
it decreases melanin content in the horny layers of
epidermis.38 Acetic acid, being hygroscopic can be used
in different dilutions for skin rejuvenation.
Hair growth
Since ancient times, vinegar has been used as a hair
cleanser and conditioner, as it smoothens the cuticles and
unclogs the pores by restoring acidic pH. It has also been
thought to increase scalp blood flow and thereby
promoting hair growth. Lee et al showed vinegar induced
telegen-to-anagen conversion and size of hair follicle
increase was observed in gross and histological
examinations. Also, the RT-PCR revealed a dose-
dependent increase in the expression level of IGF-1, KGF
and VEGF mRNA by vinegar in mice skin. The results
obtained were comparable to that of the positive control
minoxidil 3% group.39
Sclerosant
Acetic acid readily cross lipid membranes and causes
denaturation at 40-50% concentration. There are studies
showing its efficacy as sclerosant in lymphangiomas,
renal cysts and hepatocellular carcinoma.40,41
Melasma
Elghblawi has shown marked response with black peel in
melasma due inhibition to tyrosinase activity.42
CUTANEOUS ADVERSE EFFECTS OF ACETIC
ACID
Irritant contact dermatitis: patch tests were applied to the
upper back with serial dilutions of acetic acid. Patch test
reactions to acetic acid were of a primarily irritating
nature rather than of an allergic genesis. It was seen to be
well tolerated up to 20% dilutions, beyond this level
incidence of irritant reactions are high. Most common
reaction include erythema with and without edema.43
Patients with atopic dermatitis showed a significantly
lessened skin tolerance for acetic acid and higher
incidence of irritant reactions.28, 43
Chemical burns: partial or complete thickness burns have
been reported on application of glacial acetic acid or
undiluted acetic acid.5 Vaginal burns, bleeding and
blistering if accidently high concentration is applied.3
CONCLUSION
Traditionally vinegar has been used as a food flavouring
agent and preservative. Despite being used as a medicine
for over a century, vinegar remains a good therapeutic
option for the treatment of several dermatoses as a drug
of choice or as an adjunct to the therapies for various
dermatoses. The advantages of using vinegar are its easy
availability, cost effectiveness, convenient preparation
method, makes it a sustainable choice of drug. This
article is an attempt to summarize the various
dermatologic indications of this drug. Studies should be
carried out in order to establish naturally occurring, low-
cost and effective herbal remedies as prophylactic and/or
complimentary measures in preventing metabolic
disorders in both developing and under-developed
countries.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
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