DERMATOLOGY EDUCATIONAL RESOURCE

Adjunctive Skincare for Acne

ABSTRACT
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 stratum corneum and impair patient adherence. The use of adjunc-
tive cleansers and moisturizers can help mitigate treatment side effects and subsequently enhance therapeutic
efficacy. Providing patient-specific skin care recommendations, including product selection and proper use, is an
important part of the clinical management of AV and may adjunctively augment the efficacy of topical medica-
tions in reducing acne lesions.

KEYWORDS: acne vulgaris, adherence, cleansers, moisturizers

Introduction
Acne vulgaris (AV) is among the most common dermatological disorders seen by
dermatologists, affecting approximately 85% of people between the ages of 12–24.1
Emerging evidence suggests that acne is associated with epidermal barrier impair-
ments, including stratum corneum (SC) barrier permeability. 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 and Clinical Presentation

The four main pathophysiologic features of AV are listed below3:
1. Androgen-mediated stimulation of sebaceous gland activity
2. Abnormal keratinization leading to follicular plugging (comedone formation)

ABOUT THE AUTHOR

Shannon Humphrey, MD, FRCPC, FAAD, Director of Continuing Medical Education, Clinical Instructor, Department of
Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada.
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Adjunctive Skincare for Acne

3. Proliferation of Propionibac- rience of just one treatment-related

terium acnes within the fol- side effect (e.g., irritation, dryness,
licle redness) significantly, negatively
4. Inflammation impacts adherence with acne treat-
ment.4
Genetic factors, stress, and diet
may also influence the develop- Topical Therapy
ment of acne.3 Topical therapy is used for mild to
Some data suggest that patients moderate acne and also for mainte-
with AV suffer from inherently nance therapy in all severity levels
compromised facial SC barrier per- (Table 1).
meability, and that the severity of Evidence-based treatment
AV may correlate with the degree guidelines recommend fixed-
of SC barrier impairment, and dose combination topical BPO-
decreased levels of free sphingosine adapalene or benzoyl peroxide
and total ceramides, suggesting a (BPO)-clindamycin for treatment
deficiency of the intercellular lipid of mild-moderate papulopustular
membrane.2 acne.5 Retinoids are comedolytic,
Some medications used to treat anticomedogenic, and anti-inflam-
AV can alter SC integrity and func- matory. BPO is an antimicrobial
tion, either via the active ingredi- agent that has some keratolytic
ent, the vehicle, or both. This can effects and does not contribute to
result in signs and symptoms of antibiotic resistance. Also, antibi-
cutaneous irritation such as ery- otics have antimicrobial and anti-
thema, scaling, and a burning or inflammatory effects. They can
stinging sensation.2 be used in conjunction with BPO
Recent data show that the expe- lotion, gel, or wash to limit anti-

Table 1: Topical Acne Therapies and Their Pathogenic Targets

Acne Pathogenic Factors Retinoids Benzoyl Antibiotics
Adapalene Peroxide Clindamycin
Tazarotene Erythromycin
Tretinoin
Reduces production of sebum
Targets Propionibacterium acnes X X
Normalizes keratinization and desquamation X X
Anti-inflammatory X X X
Source: Reproduced with permission from: Wilford J and Humphrey S. Topical Acne Therapy Advances 2011. Vancouver, BC: Skin
Therapy Letters.com. Available at: http://www.skintherapyletter.ca/fp/2011/7.4/1.html

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 Adjunctive Skincare for Acne

biotic resistance. They should not oil, exfoliated cells, and micro-
be used for maintenance therapy. organisms without irritating or
Additionally, topical dapsone gel is disrupting the skin’s protective
antimicrobial and antineutrophilic barrier.
and new fixed-dose retinoid-based Regular use of mild cleans-
combination therapies are availa- ers is an important component of
ble; however, both topical retinoids effective acne management as it
and BPO can cause symptoms of prepares the skin to receive topi-
skin irritation. cal medications, improving drug
absorption. Routine cleansing may
Cleansers and Moisturizers enhance antimicrobial activity
The goal of cleansing for patients and decrease the risk of infection.
with acne or acne-prone skin is to Simplified treatment and skin care
remove surface dirt, sweat, excess regimes should be recommended,

Adjunctive Skincare for Acne

Stratum corneum

Stratum lucidum
Stratum granulosum

Normal
Skin Section

Stratum spinosum
Epidermis

Dermis

Stratum corneum containing surface Cleanser containing

dirt, sweat, excess oil, exfoliated cells removed dirt, oil, cells, etc.
and micro-organisms. Water
rinse
Topical medication

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 Adjunctive Skincare for Acne

including the use of an appropri- non-irritating, and non-allergenic.6

ate moisturizer and washing with A wide spectrum of skin cleans-
a mild, soap-free cleanser twice ing agents exist for acne ranging
daily.4 from lipid-free cleansers, syndets,
and astringents to exfoliants and
Types of Cleansers abrasives.7 Anionic detergents (i.e.,
To date, limited published data soaps) can alter the natural pH of
exist to inform the clinical manage- skin, which is normally between
ment of AV with regard to cleansers 5.3 and 5.9. An increase in pH can
and moisturizers. Recommenda- result in increased transepidermal
tions are based largely on general water loss (TEWL), which causes
knowledge (e.g., non-soap). Ideally, dryness. Further, an increase in pH
cleansers for acne skin should be: may facilitate microbial growth,
non-comedogenic, non-acnegenic, which can exacerbate AV.8 Abrasive

Stratum Corneum Barrier Permeability (Brick Wall Analogy)

Healthy Skin SC Barrier Impairment

Patients with
Epidermal barrier deficiency of
is maintained intercellular lipid
by “mortar” membrane have less
between “bricks” “mortar” between
the “bricks”

Moisture Escaping Skin Irritants Entering Skin

Without SC Barrier Without SC Barrier

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Adjunctive Skincare for Acne

cleansers can promote SC barrier for a matte appearance of

dysfunction and contribute to signs the skin.
and symptoms of irritation. These
should be avoided. Types of Moisturizers
Suitable cleansers for acne- Effective moisturizers combine
prone skin are generally based on humectants and emollients to pre-
mild synthetic surfactants that vent or reduce water evaporation,
minimize the potential for skin bar- draw moisture up from deeper lay-
rier disturbances such as: ers, alleviate xerosis, and maintain
skin barrier integrity, and they
• Non-ionic surface-acting should also prevent primary irri-
agents (e.g., silicone and tation. As well, broad-spectrum
polysorbate) are less likely to UVA/UVB protection is also impor-
cause irritation and are for- tant for patients with AV, par-
mulated to the same pH as ticularly for those on topical and
the skin (5.5). systemic retinoid therapy.9
• Silicone surfactants (e.g., The different classes of mois-
dimethicone) such as Spec- turizers include: occlusives,
tro, are effective at eliminat- humectants, emollients, protein
ing surface debris without rejuvenators, and ceramide-domi-
completely stripping away nant (Table 2).
protective oils. Ceramide-dominant moistur-
• Cleansers containing emol- izers contain lipids that are simi-
lients, such as Cetaphil Der- lar to the intercellular lipids found
macControl, CeraVe and within the SC. The combinations
Spectro can minimize dam- of these lipids, specifically cera-
age to the SC barrier by mide, cholesterol and fatty acids,
emulsifying dirt and oil for aid in repairing the lipid bilay-
easy removal. Additionally, ers and SC barrier function which
Cetaphil Dermacontrol and are affected by extreme dry, cold
CeraVe contain ceramide weather conditions, soaps, sol-
lipids which work to replace vents, and some medications, by
those lost during washing. replacing key, naturally occur-
• Cleansers that contain zinc ring lipid components.10 The only
coceth and zinc gluconate, published clinical trial data study-
such as Cetaphil Dermacon- ing adjunctive moisturizer in AV
trol, also provide astringent patients is Cetaphil (DermaCon-
properties without irritation trol: CDM). It contains ceramides
or alteration to the pH level and an oil-absorbing zinc complex.
of the skin, and the zinc It is non-comedogenic, non-irritat-
complex absorbs excess oil ing, non-acnegenic and non-greasy.
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Adjunctive Skincare for Acne

Table 2: Different Classes of Moisturizers

Class How does it Work? Example ingredient What is it used for? Possible side effects

1. Occlusive It physically blocks • Petrolatum • Xerosis • Messy

water loss • Lanolin • Atopic dermatitis • Some can cause
• Mineral • Prevention of folliculitis (mineral oil)
• Oil irritant contact • May cause pimples
• Zinc oxide dermatitis • Some may cause
contact dermatitis
(lanolin)

2. Humectants Attracts water to • Glycerin • Xerosis • Some may cause

the stratum corneum • Sorbitol • Ichthyosis irritation (urea, lactic
• Urea • Skin rejuvenation acid)
• Alpha-hydroxy acids
• Sugars

3. Emollients Smoothes skin by • Cholesterol • Reduces skin • Not always effective

filling the spaces • Squalene roughness
between skin flakes, • Fatty acids
with droplets of oil

4. Rejuvenators Claims to rejuvenate • Collagen • Skin rejuvenation • Unlikely to work

the skin by • Keratin because the protein
replenishing • Elastin molecules are too
essential proteins large to cross the
epidermis
• Some may cause
contact dermatitis

5. Ceramide- Replaces ceramides Ceramides, Cholesterol, Ceramide lipid • Efficacy may be

dominant deficient in skin barrier fatty acids • replacement impaired in severe
• SC lipid barrier repair disease
• Prevention of
transepidermal water
loss
Occlusive effect to
prevent water loss,
repair lipid layers,
restore barrier
Table adapted from acneguide.ca.

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Adjunctive Skincare for Acne

Additionally, moisturizers that con- 30–40% of patients using topical

tain zinc gluconate, such as CDM, acne treatment formulations do not
may provide sebum regulation. comply with their prescribed regi-
The recent development of men.11
oleosome technology, which is also Irritation resulting from topi-
present in CDM, enables the deliv- cal medications and the emergence
ery of broad-spectrum UVA/UVB of bacterial resistance to both topi-
sun protection (SPF 30). This tech- cal and oral antibiotics remain sig-
nology effectively reduces the con- nificant barriers to good treatment
centration of filters being applied adherence. Recent advances in
to the skin, reducing the potential vehicle technology have improved
for skin sensitivity reactions.9 efficacy, local tolerance, and adher-
ence.12 Additionally, novel deliv-
Acne Therapy and Adherence ery mechanisms, such as pumps,
Treatment adherence in patients are convenient and preferred by
with AV is a significant problem patients, which may also improve
and is documented at approxi- adherence.13
mately 50%.4 An estimated The appropriate selection and
use of moisturizers has positive
Table 3: Strategies to Reduce Irritation effects on treatment adherence.4
Associated with Topical Acne Therapy Alleviating dryness and improving
skin comfort by using a moisturizer
Topical Therapy Active – careful selection of topical concomitantly with retinoid therapy
therapy could enhance treatment efficacy.
– partially solubilized or
Data from a randomized, split-face
micronized retinoid
study showed the application of a
– combination therapy to
minimize irritation
ceramide dominant moisturizer
applied twice daily for 15 days by
Topical Therapy Vehicle – cream > gel
patients taking either oral isotreti-
– hydrogel > alcohol gel
noin (10–20 mg) for at least two
– excipients (humectants,
emollients)
months or topical tretinoin 0.05%
for at least one month provided sig-
Application Technique – 1g applied to DRY face QHS
nificant improvements, compared
with emollient
– consider alternate days
with baseline, in the levels of skin
– consider short contact dryness, roughness, and desquama-
tion induced by either drug.14 As
Adjunctive Skincare – Gentle, non comedogenic
well, skin properties and discomfort
cleanser & emollient
were substantially improved. Some
Counseling – expectations strategies to reduce irritation associ-
– application technique
ated with topical acne therapy are
– strategies to mitigate AEs
outlined in Table 3.
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Adjunctive Skincare for Acne

SUMMARY OF KEY POINTS

Irritation resulting from topical medications and the Alleviating dryness and improving skin comfort by
emergence of bacterial resistance to both topical using a moisturizer concomitantly with retinoid
and oral antibiotics remain significant barriers to therapy could enhance treatment efficacy.
good treatment adherence.
The adjunctive use of appropriate gentle soap-free
Providing patient-specific skin care recommenda- cleansers and non-comedogenic moisturizers that
tions, including product selection and proper use, is also restore SC barrier function, provide SPF protec-
an important part of the clinical management of AV tion, and reduce side effects of topical acne therapy
and may adjunctively augment the efficacy of topi- is recommended and is preferred by patients and
cal medications in reducing acne lesions. will likely improve treatment adherence..

A randomized, open label, sides with moisturizer.9

investigator blinded split-face
study of erythema, scaling, and Conclusion
dryness in patients using a cera- Because the skin barrier can be
mide dominant lotion formulated impaired in patients with AV, treat-
for acne prone skin with 0.05% ment can be negatively impacted,
tretinoin found a patient prefer- which can further exacerbate skin
ence for the moisturizer. While barrier defects and acne patho-
both sides developed skin irri- genesis. Therefore, providing
tation, it worsened in the non- patient-specific skin care recom-
moisturized sides. Notably, all five mendations, including product
parameters, namely erythema, selection and proper use, is an
scaling, dryness, stinging/burn- important part of the clinical man-
ing and pruritus were improved on agement of AV and may adjunc-

+
CLINICAL PEARLS
Topical dapsone gel is antimicrobial and antineutrophilic and new fixed-dose retinoid-based combination therapies are available
and this allows us to improve adherence with therapy and target multiple pathogenic mechanisms with one treatment.

Oleosome technology 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, reducing the potential for skin sensitivity reactions.

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Adjunctive Skincare for Acne

5. The Guideline Subcommittee “Acne” of the European

tively augment the efficacy of Dermatology Forum. European Dermatology Forum
guideline on treatment of acne. Berlin: Author; 2011.
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acne lesions.2 The adjunctive use ries/guidelines/Guideline-on-the-Treatmentof-Acne.
pdf.
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cleansers and non-comedogenic Please insert article title>
7. Mukhopadhyay P. Cleansers and their role in various
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pmc/articles/PMC3088928/.
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side effects of topical acne therapy, ments. J Clin Asthet Dermatol 2012;5(5):32–40. Avail-
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2012;11(9)957–60.
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adherence. turizers. Washington State Department of Labor and
Industries. 2001 (revised 2006). Available at: http://
www.lni.wa.gov/Safety/Research/Dermatitis/files/
This article was first published in skin_phys.pdf.
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