Shannon Humphrey, MD, FRCPC, FAAD
Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
Acne vulgaris (AV) is among the most common dermatological disorders seen by dermatologists, affecting approximately 85% of people between the ages of 12 and 24 years.1 Emerging evidence suggests that acne is associated with epidermal barrier impairments, including stratum corneum (SC) barrier permeability.2 There is also mounting evidence to demonstrate an association between AV and inherent epidermal barrier dysfunction involving increased filaggrin expression and decreased ceramide levels.2 While topical therapy remains a key therapeutic approach in the clinical management of AV, it can be associated with side effects that may compromise the SC and impair patient adherence. The use of adjunctive cleansers and moisturizers can help mitigate treatment side effects and subsequently enhance therapeutic efficacy.
Pathophysiology & Clinical Presentation
- The four main pathophysiologic features of AV are:3
- Androgen-mediated stimulation of sebaceous gland activity
- Abnormal keratinization leading to follicular plugging (comedone formation)
- Proliferation of Propionibacterium acnes (P. acnes) within the follicle
- Genetic factors, stress and diet may also influence the development of acne.
- Some data suggest that patients with AV suffer from inherently compromised facial SC barrier permeability, and that the severity of AV may correlate with the degree of SC barrier impairment and decreased levels of free sphingosine and total ceramides, suggesting a deficiency of the intercellular lipid membrane.2
- Some medications used to treat AV can alter SC integrity and function, either via the active ingredient, the vehicle, or both. This can result in signs and symptoms of cutaneous irritation such as erythema, scaling and a burning or stinging sensation.2
- Recent data show that the experience of just one treatment-related side effect (e.g., irritation, dryness, redness) significantly, negatively impacts adherence to acne treatment.4
Topical therapy is used for mild to moderate acne and also for maintenance therapy in all severity levels (Table 1).
- Evidence-based treatment guidelines recommend fixed-dose combination topical benzoyl peroxide (BPO)-adapalene or BPOclindamycin for treatment of mild-moderate papulopustular acne.5
- Retinoids are comedolytic, anticomedogenic and anti-inflammatory.
- BPO is an antimicrobial agent that has some keratolytic effects and does not contribute to antibiotic resistance.
- Antibiotics have antimicrobial and anti-inflammatory effects. They can be used in conjunction with BPO lotion, gel or wash to limit antibiotic resistance. They should not be used for maintenance therapy.
- Topical dapsone gel is antimicrobial and antineutrophilic.
- New fixed-dose retinoid-based combination therapies are available (e.g., tretinoin and clindamycin)
- Both topical retinoids and BPO can cause symptoms of skin irritation.
|Acne Pathogenic Factors||Retinoids|
|Reduces production of sebum|
|Targets P. acnes||X||X|
|Normalizes keratinization and desquamation||X||X|
|Table 1. Topical acne therapies and their pathogenic targets|
Cleansers & Moisturizers
- The goal of cleansing for patients with acne or acne-prone skin is to remove surface dirt, sweat, excess oil, exfoliated cells and micro-organisms without irritating or disrupting the skin’s protective barrier.
- Regular use of mild cleansers is an important component of effective acne management as a hydrated SC absorbs medication more readily and is less prone to irritation.
- Routine cleansing may enhance antimicrobial activity and decrease the risk of infection.
- Simplified treatment and skin care regimes should be recommended, including the use of an appropriate moisturizer and washing with a mild, soap-free cleanser twice daily.4
Types of Cleansers
- To date, limited published data exist to inform the clinical management of AV with regard to cleansers and moisturizers. Recommendations are based largely on general knowledge (e.g., non-soap based cleansers).
- Ideally, cleansers for acne skin should be: non-comedogenic, non-acnegenic, non-irritating, and non-allergenic.6
- A wide spectrum of skin cleansing agents exist for acne ranging from lipid free cleansers, syndets and astringents to exfoliants and abrasives.7
- Anionic detergents (i.e., soaps) can alter the natural pH of skin, which is normally between 5.3 and 5.9.
- An increase in pH can result in increased transepidermal water loss (TEWL), which causes dryness. Further, an increase in pH may facilitate microbial growth, which can exacerbate AV.8
- Abrasive cleansers can promote SC barrier dysfunction and contribute to signs and symptoms of irritation: these should be avoided.
- Suitable cleansers for acne-prone skin are generally based on mild synthetic surfactants that minimize the potential for skin barrier disturbances.
- Non-ionic surface-acting agents (e.g., silicone and polysorbate) are less likely to cause irritation and are formulated to the same pH as the skin (5.5).
- Silicone surfactants (e.g., dimethicone) such as Spectro®, are effective at eliminating surface debris without completely stripping away protective oils.
- Cleansers that contain zinc coceth and zinc gluconate, such as Cetaphil® DermaControl, also provide astringent properties without irritation or alteration to the pH level of the skin, and the zinc complex absorbs excess oil for a matte appearance of the skin.
- Cleansers containing emollients, such as Cetaphil® DermaControl, Effaclar, Spectro® and Cetaphil® Gentle Skin Cleanser can minimize damage to the SC barrier by emulsifying dirt and oil for easy removal. Additionally, Cetaphil® DermaControl contains humectants, which attract moisture to the skin in order to alleviate the drying effects of cleansing.
Types of Moisturizers
- Effective moisturizers combine humectants and emollients to prevent or reduce water evaporation, draw moisture up from deeper layers, alleviate xerosis and maintain skin barrier integrity.
- Moisturizers should also prevent primary irritation.
- Broad spectrum UVA/UVB sun protection is also important for patients with AV, particularly for those on topical and systemic retinoid therapy.9
- The different types of moisturizers include (Table 2):
- Protein rejuvenators10
- Ceramide dominant
- Moisturizers containing ceramides have recently entered the market and work to replace naturally occurring lipids in the SC.
- The only published clinical trial data studying an adjunctive moisturizer in AV patients concerns Cetaphil® DermaControl. It contains ceramides and an oil-absorbing zinc complex. It is non-comedogenic, non-irritating, nonacnegenic and non-greasy.
- The recent development of oleosome technology, which is also present in Cetaphil® DermaControl, enables the delivery of broad spectrum UVA/UVB sun protection (SPF 30). This technology effectively reduces the concentration of filters being applied to the skin, decreasing the potential for skin sensitivity reactions.9
Acne Therapy & Adherence
- Treatment adherence in patients with AV is a significant problem and is documented at approximately 50%.4
- An estimated 30-40% of patients using topical acne treatment formulations do not comply with their prescribed regimen.11
- Clinical variables that have been shown to negatively impact adherence include age, patient satisfaction with treatment, and knowledge about acne treatment.4
- Irritation resulting from topical medications and the emergence of bacterial resistance to both topical and oral antibiotics remain significant barriers to good treatment adherence.
- Recent advances in vehicle technology have improved efficacy, local tolerance and adherence.12
- Additionally, novel delivery mechanisms and vehicles, such as pumps and foams, are convenient and preferred by patients, which may also improve adherence.13
- The appropriate selection and use of moisturizers has positive effects on treatment adherence.4
- Patient satisfaction with treatment and clinical improvement as evaluated by a dermatologist have been shown to improve treatment adherence and may also improve patient self-esteem.4
- Discuss realistic treatment expectations with patients and consider dosing strategies that can enhance adherence (Table 3).
|Type||Mode of Action||Example ingredient||Indication||Possible side effects|
|1. Occlusive||It physically blocks water loss|
|2. Humectants||Attracts water to the SC|
|3. Emollients||Smoothes skin by filling the spaces between skin flakes with droplets of oil|
|4. Rejuvenators||Claim to rejuvenate the skin by replenishing essential proteins|
|5. Ceramide dominant||Replaces ceramides deficient in skin barrier|
|Table 2. Types of moisturizers|
Adjunctive Skin Care in Acne: Clinical Evidence
- Alleviating dryness and improving skin comfort by using a moisturizer concomitantly with retinoid therapy could enhance treatment efficacy. Data from a randomized, splitface study showed the application of a moisturizing cream applied twice daily for 15 days by patients taking either oral isotretinoin (10-20 mg) for two months or topical tretinoin 0.05% for one month provided significant improvements, compared with baseline, in the levels of skin dryness, roughness and desquamation induced by either drug.14 As well, skin properties and discomfort were substantially improved.
- Results from a study evaluating a facial moisturizer with SPF 30 and ceramide precursor formulated for blemish prone skin with 0.05% tretinoin found a patient preference for the moisturizer.9 It was a randomized, investigator-blinded, split-face study assessing erythema, scaling and dryness in patients with blemish prone skin. While both sides developed skin irritation, it worsened in the non-moisturized sides. Notably, all five parameters, namely erythema, scaling, dryness, stinging/burning and pruritus were improved on the sides treated with moisturizer.
- Adjunctive use of moisturizer with a topical tretinoin cream improved tolerance of the treatment.9
|Topical therapy active|
|Topical therapy vehicle|
|Adjunctive skin care|
|Table 3. Strategies to reduce irritation associated with topical acne therapy|
Skin barrier impairment in patients with AV can negatively impact acne treatment. Therefore, providing patient-specific skin care recommendations, including product selection and proper use, is an important part of the clinical management of AV and may improve patient tolerance to treatment.2 The adjunctive use of appropriate gentle soap-free cleansers and non-comedogenic moisturizers, ideally products that also restore SC barrier function, provide SPF protection and reduce side effects of topical acne therapy, are recommended. Moreover, they are preferred by patients and will likely improve treatment adherence.
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- Vender R, et al. Patient preferences in acne: a point-of-care educational initiative. Poster presentation.
- Laquieze S, et al. J Drugs Dermatol. 2006 Nov-Dec;5(10):985-90.