Catherine Zip, MD, FRCPC
Division of Dermatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
Conflicts of Interest:
CZ has no conflicts to disclose.
A triad approach to the treatment of acne and rosacea has been recommended. This integrated management approach includes patient education, selection of therapeutic agents, and initiation of an appropriate skin care regime. Proper skin care in patients undergoing treatment of both acne and rosacea includes use of products formulated for sensitive skin that cleanse, moisturize and photoprotect the skin. Both acne and rosacea are associated with epidermal barrier dysfunction, which can be mitigated by suitable skin care practices. Appropriate skin care recommendations for patients with acne and rosacea will be discussed.
acne, emollients, rosacea, photoprotection, skin barrier dysfunction, sunscreen, topical, transepidermal water loss
Acne vulgaris is the most common skin disease seen in dermatology office practice. Optimal management includes, in addition to selection of an appropriate therapeutic regimen, patient education and integration of proper skin care. Providing instructions on skin care and cosmetics to female acne patients improves quality of life compared to patients to whom no instructions are given.1
Acne is associated with impaired epidermal barrier function.2 Decreased stratum corneum hydration and reduced free sphingosine and total ceramide, indicative of an impaired stratum corneum intercellular lipid membrane, has been demonstrated in patients with acne. Although sebum excretion is increased in acne patients, alteration in the lipid composition of acne skin may further impair barrier function. Moreover, medications used to treat acne can alter stratum corneum integrity and function. An increase in transepidermal water loss has been shown with use of benzoyl peroxide, likely due to damage to the stratum corneum.3 Treatment with topical retinoids results in enhanced desquamation, reducing stratum corneum thickness and function. Use of appropriate skin care products in patients being treated for acne has been shown to increase adherence to pharmacological treatment and improve treatment outcomes.4
Although the majority of acne patients believe that suboptimal skin care and dirt on the skin contribute to acne,5 there are little scientific data to guide our recommendations regarding cleansing of acne prone skin.
The optimal frequency of cleansing is unclear, but most dermatologists recommend twice daily washing with a mild cleanser. One small study of males with mild to moderate acne compared the effect of face washing with a gentle cleanser once, twice or four times daily on acne severity.6 Although no statistically significant differences were noted between the groups, significant improvement in both open comedones and total inflammatory lesions were seen in the group washing twice daily. Worsening of acne was observed in the study group who washed once a day, whereas washing four times daily did not adversely affect acne severity.
Although more frequent facial cleansing may not aggravate acne, aggressive scrubbing of the involved areas should be avoided to prevent irritation and trauma to underlying comedones, leading to increased inflammation.
As acne prone skin is associated with epidermal barrier dysfunction which can be aggravated by acne medications, regular use of an emollient is an importance part of acne therapy. Use of a noncomedogenic and nonacnegenic moisturizer is typically recommended. However, due to difficulties in testing for both comedogenicity and acnegenicity, including variability in individual patient susceptibility to acne formation, ensuring that a product will not trigger acne in a particular patient can be difficult.7
Sun protection should also be recommended to acne patients.8 A systemic review found no convincing evidence that natural sunlight improves acne, although such studies are inherently difficult to conduct.9 Several oral acne treatments, including doxycycline and isotretinoin, are potentially photosensitizing.10 The US Food and Drug Administration official labelling for medications containing benzoyl peroxide and topical retinoids advises sun avoidance,11,12 although no effect on ultraviolet Binduced erythema was shown with use of either benzoyl peroxide or adapalene in one study13. In addition to providing sun protection, the emollient component of the sunscreen may improve epidermal barrier function. Finally, sun protective measures may prevent or minimize postinflammatory hyperpigmentation, particularly in patients with higher skin types.14
TAs is the case with acne, proper skin care is an important component of the management of rosacea. A triad approach to rosacea care has been suggested, which includes treatment, patient education regarding triggers, and advice as to appropriate skin care and cosmetics.15 In a questionnaire sent to over 7000 individuals registered in the Canadian Rosacea Awareness Program, respondents expressed a strong interest in receiving more information on skin care, makeup and psychological aspects of rosacea.16
The involved skin of rosacea has been shown to exhibit increased transepidermal water loss due to impaired epidermal barrier function.17 Rosacea prone skin is also hyper-reactive; cutaneous insult results in prolonged vasodilation, exhibited clinically as facial erythema. Furthermore, the presence of an impaired stratum corneum barrier increases the irritancy of skin care products by enhancing penetration into the skin. Hence, skin care practices that optimize barrier function should be recommended.
Although skin cleansing is an important component of general skin care, surfactants contained in skin cleansers can weaken epidermal barrier function by disrupting proteins and lipids in the stratum corneum.18 Given the fact that patients with rosacea have impaired barrier function and a higher susceptibility to irritants, including sodium lauryl sulphate, mild cleansing is important.
The type of surfactant in the cleanser as well as its hydrogen ion concentration (pH) are major factors contributing to the irritant potential of a cleanser.18 Mild cleansers include synthetic detergents (syndets) and lipid-free cleansers. Syndet liquid cleansers or bars contain synthetic detergents and less than 10% soap. They have a favorable pH (5.5-7) and provide effective cleansing with less irritation potential than true soaps. Lipid-free cleansers have a neutral or slightly acidic pH. They are effective cleansers that leave a moisturizing film on the skin but do not lather.
Studies have shown benefits of mild cleansing in patients with rosacea. In a 4-week randomized, double-blind study of 70 patients with moderate rosacea who were using metronidazole 1% gel, subjects were instructed to use either a soap bar or a mild syndet bar. Use of the syndet cleanser reduced dryness, burning, stinging and itching compared to use of the soap bar.19
In addition to recommending an appropriate cleanser, physicians should advise rosacea patients to wash with lukewarm water, as hot water causes vasodilation and increased facial erythema. Mechanical trauma to the skin should also be minimized, including avoidance of granular exfoliants.
Astringents and toners, which are typically applied after cleansing, should likewise be avoided, as they tend to increase erythema and remove desirable oil from the skin.
Use of appropriate moisturizers has several potential benefits in the management of rosacea. As rosacea skin has been shown to have increased transepidermal water loss, use of an emollient may improve barrier function and reduce dryness. Improved barrier function may also lead to reduced skin sensitivity and improved tolerance of topical medications.20
Regarding choice of emollient, those containing potential irritants such as urea, glycolic acid, lactic acid, menthol and camphor should be avoided. Although the barrier dysfunction associated with rosacea may potentially increase allergenicity of skin care products, minimal data is available on the prevalence of contact allergy in rosacea patients.21 However, as fragrances can cause both irritant and allergic reactions, fragrance-free products should be recommended. Cream type moisturizers are generally preferred over thin lotions and gels.
Daily sun protection is an important component of rosacea management. Sun exposure is a common trigger of acute flares of rosacea, and chronic photodamage may also contribute to the pathogenesis of rosacea.22 Acute ultraviolet light may aggravate rosacea by stimulating proinflammatory peptide production, reducing cutaneous antioxidant reserves, and increasing production of reactive oxygen species.23 However, finding a welltolerated sunscreen can be difficult for rosacea patients. Selecting a cream based product containing an inorganic ultraviolet light filter and a silicone derivative, such as dimethicone orcyclomethicone, may reduce the likelihood of irritation.
Optimal management of both acne and rosacea includes initiation of an appropriate skin care regimen. This entails providing patients with advice regarding appropriate cleansing, moisturizing, and photoprotecting of the affected areas. Providing recommendations regarding skin care has been shown to improve quality of life in female acne patients and to be an unmet need in patients with rosacea. Integration of appropriate skin care in this patient population will improve barrier dysfunction and tolerability of prescribed therapy, leading to improved adherence and better treatment outcomes.
- Matsuoka Y, Yoneda K, Sadahira C, et al. Effects of skin care and makeup under instructions from dermatologists on the quality of life of female patients with acne vulgaris. J Dermatol. 2006 Nov;33(11):745-52.
- Thiboutot D, Del Rosso JQ. Acne vulgaris and the epidermal barrier. J Clin Aesthet Dermatol. 2013 Feb;6(2):18-24.
- Weber SU, Thiele JJ, Han N, et al. Topical alpha-tocotrienol supplementation inhibits lipid peroxidation but fails to mitigate increased transepidermal water loss after benzoyl peroxide treatment of human skin. Free Radic Biol Med. 2003 Jan;34(2):170-6.
- De Lucas R, Moreno-Arias G, Perez-Lopez M, et al. Adherence to drug treatments and adjuvant barrier repair therapies are key factors for clinical improvement in mild to moderate acne: the ACTUO observational prospective multicenter cohort trial in 643 patients. BMC Dermatol. 2015 Sept;15:17.
- Tan JK, Vasey K, Fung KY. Beliefs and perceptions of patients with acne. J Am Acad Dermatol. 2001 Mar;44(3):439-45.
- Choi JM, Lew VK, Kimball AB. A single-blinded, randomized, controlled clinical trial evaluating the effect of face washing on acne vulgaris. Pediatr Dermatol. 2006 Sept-Oct;23(5):421-7.
- Draelos ZD. Cosmetics in acne and rosacea. Semin Cutan Med Surg. 2001 Sept;20(3):209-14.
- Bowe WP, Kircik LH. The importance of protoprotection and moisturization in treating acne vulgaris. J Drugs Dermatol. 2014 Aug;13(suppl 7):s89-s94.
- Magin P, Pond D, Smith W, et al. A systemic review of the evidence for ‘myths and misconceptions’ in acne management: diet, face-washing and sunlight. Fam Pract. 2005 Feb;22(1):62-70.
- Drucker AM, Rosen CF. Drug-induced protosensitivity: culprit drugs, management and prevention. Drug Saf. 2011 Oct; 34(10):821-37.
- Acanya® (clindamycin phosphate and benzoyl peroxide) Gel, 1.2%/2.5%, for topical use [Prescribing information]; revised February 2014. Valeant Pharmaceuticals, Bridgewater, NJ. Available at: http://www.acanyagel.com/ AcanyaPumpPI_FINAL.pdf. Accessed March 20, 2017.
- Tazorac® (tazarotene) cream, 0.05% and 0.1%, for topical use [Prescribing information]; revised December 2013. Allergan, Inc., Irvine, CA. Available at: https://www.allergan.com/assets/pdf/tazorac_cream_pi. Accessed March 20, 2017.
- Cetiner S, Ilknur T, Ozkan S. Phototoxic effects of topical azelaic acid, benzoyl peroxide and adapalene were not detected when applied immediately before UVB to normal skin. Eur J Dermatol. 2004 Jul-Aug;14(4):235-7.
- Molinar VE, Taylor SC, Panya AG. What’s new in objective assessment and treatment of facial hyperpigmentation? Dermatol Clin. 2014 Apr;32(2):123-35.
- Elewski BE, Draelos Z, Dreno B, et al. Rosacea-global diversity and optimized outcome: proposed international consensus from the rosacea international expert group. J Eur Acad Dermatol Venereol. 2011 Feb;25(2):188-200.
- Shear NH, Levine C. Needs survey of Canadian rosacea patients. J Cutan Med Surg. 1999 Apr;3(4):178-81.
- Dirschka T, Tronnier H, Folster-Holst R. Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis. Br J Dermatol. 2004 Jun;150(6):1136-41.
- Farris PK. Skin care based on science: improving outcomes in rosacea. Cosmetic Dermatol. 2012 Feb;25(2):72-8.
- Subramanyan K, Johnson AW. Role of mild cleansing in the management of sensitive skin. Poster presented at the American Academy of Dermatology 61st Annual Meeting. San Francisco, CA, Mar 21-16, 2003.
- Del Rosso JQ. The use of moisturizers as an integral component of topical therapy for rosacea: clinical results based on the assessment of skin characteristics study. Cutis. 2009 Aug;84(2):72-6.
- Jappe U, Schafer T, Schnuch A, et al. Contact allergy in patients with rosacea: a clinic-based, prospective epidemiological study. J Eur Acad Dermatol Venereol. 2008 Nov;22(10):1208-14.
- Del Rosso JQ. Adjunctive skin care in the management of rosacea: cleansers, moisturizers, and photoprotectants. Cutis. 2005 Mar;75(Suppl 3):17-21.
- Del Rosso JQ. Advances in understanding and managing rosacea: part 1: connecting the dots between pathophysiological mechanisms and common clinical features of rosacea with emphasis on vascular changes and facial erythema. J Clin Aesthet Dermatol. 2012 Mar;5(3):16-25.