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.
. 
Adjunctive Skincare for Acne

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

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

18  Journal of Current Clinical Care Volume 5, Issue 1, 2015


 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

19  Journal of Current Clinical Care Volume 5, Issue 1, 2015


 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

20  Journal of Current Clinical Care Volume 5, Issue 1, 2015


Adjunctive Skincare for Acne
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 bar-
rier disturbances such as:
• Non-ionic surface-acting
agents (e.g., silicone and
polysorbate) are less likely to
cause irritation and are for-
mulated to the same pH as
the skin (5.5).
• Silicone surfactants (e.g.,
dimethicone) such as Spec-
tro, are effective at eliminat-
ing surface debris without
completely stripping away
protective oils.
• Cleansers containing emol-
lients, such as Cetaphil Der-
macControl, CeraVe and
Spectro can minimize dam-
age to the SC barrier by
emulsifying dirt and oil for
easy removal. Additionally,
Cetaphil Dermacontrol and
CeraVe contain ceramide
lipids which work to replace
those lost during washing.
• Cleansers that contain zinc
coceth and zinc gluconate,
such as Cetaphil Dermacon-
trol, also provide astringent
properties without irritation
or alteration to the pH level
of the skin, and the zinc
complex absorbs excess oil
21  Journal of Current Clinical Care Volume 5, Issue 1, 2015
for a matte appearance of
the skin.
Types of Moisturizers
Effective moisturizers combine
humectants and emollients to pre-
vent or reduce water evaporation,
draw moisture up from deeper lay-
ers, alleviate xerosis, and maintain
skin barrier integrity, and they
should also prevent primary irri-
tation. As well, broad-spectrum
UVA/UVB protection is also impor-
tant for patients with AV, par-
ticularly for those on topical and
systemic retinoid therapy.9
The different classes of mois-
turizers include: occlusives,
humectants, emollients, protein
rejuvenators, and ceramide-domi-
nant (Table 2).
Ceramide-dominant moistur-
izers contain lipids that are simi-
lar to the intercellular lipids found
within the SC. The combinations
of these lipids, specifically cera-
mide, cholesterol and fatty acids,
aid in repairing the lipid bilay-
ers and SC barrier function which
are affected by extreme dry, cold
weather conditions, soaps, sol-
vents, and some medications, by
replacing key, naturally occur-
ring lipid components.10 The only
published clinical trial data study-
ing adjunctive moisturizer in AV
patients is Cetaphil (DermaCon-
trol: CDM). It contains ceramides
and an oil-absorbing zinc complex.
It is non-comedogenic, non-irritat-
ing, non-acnegenic and non-greasy.

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.

22  Journal of Current Clinical Care Volume 5, Issue 1, 2015


Adjunctive Skincare for Acne
Additionally, moisturizers that con-
tain zinc gluconate, such as CDM,
may provide sebum regulation.
The recent development of
oleosome technology, which is also
present in CDM, enables the deliv-
ery of broad-spectrum UVA/UVB
sun protection (SPF 30). This tech-
nology effectively reduces the con-
centration of filters being applied
to the skin, reducing the potential
for skin sensitivity reactions.9
Acne Therapy and Adherence
Treatment adherence in patients
with AV is a significant problem
and is documented at approxi-
mately 50%.4 An estimated
Table 3: Strategies to Reduce Irritation
Associated with Topical Acne Therapy
Topical Therapy Active – careful selection of topical
therapy
– partially solubilized or
micronized retinoid
– combination therapy to
minimize irritation
Topical Therapy Vehicle – cream > gel
– hydrogel > alcohol gel
– excipients (humectants,
emollients)
Application Technique – 1g applied to DRY face QHS
with emollient
– consider alternate days
– consider short contact
Adjunctive Skincare – Gentle, non comedogenic
cleanser & emollient
Counseling – expectations
– application technique
– strategies to mitigate AEs
23  Journal of Current Clinical Care Volume 5, Issue 1, 2015
30–40% of patients using topical
acne treatment formulations do not
comply with their prescribed regi-
men.11
Irritation resulting from topi-
cal medications and the emergence
of bacterial resistance to both topi-
cal and oral antibiotics remain sig-
nificant barriers to good treatment
adherence. Recent advances in
vehicle technology have improved
efficacy, local tolerance, and adher-
ence.12 Additionally, novel deliv-
ery mechanisms, such as pumps,
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
Alleviating dryness and improving
skin comfort by using a moisturizer
concomitantly with retinoid therapy
could enhance treatment efficacy.
Data from a randomized, split-face
study showed the application of a
ceramide dominant moisturizer
applied twice daily for 15 days by
patients taking either oral isotreti-
noin (10–20 mg) for at least two
months or topical tretinoin 0.05%
for at least one month provided sig-
nificant improvements, compared
with baseline, in the levels of skin
dryness, roughness, and desquama-
tion induced by either drug.14 As
well, skin properties and discomfort
were substantially improved. Some
strategies to reduce irritation associ-
ated with topical acne therapy are
outlined in Table 3.

Adjunctive Skincare for Acne

SUMMARY OF KEY POINTS

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

A randomized, open label, sides with moisturizer.9

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

24  Journal of Current Clinical Care Volume 5, Issue 1, 2015


Adjunctive Skincare for Acne
tively augment the efficacy of
topical medications in reducing
acne lesions.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,
is recommended. Moreover, this
approach is preferred by patients
and will likely improve treatment
adherence.
This article was first published in
Skintherapy letter online http://
www.skintherapyletter.com.
References
1. Leyden JJ. A review of the use of combination thera-
pies for the treatment of acne vulgaris. J Am Acad
Dermatol 49(3 Suppl):S200-10 (2003 Sep).
2. Thiboutot D and Del Rosso JQ. Acne vulgaris and
the epidermal barrier. J Clin Aesthet Dermatol
2013;6(2):18–24.
3. Haider A, Shaw JC. Treatment of acne vulgaris. JAMA
2004;292(6):726–35.
4. Dréno B, Thiboutot D, Gollnick H, et al. Large-scale
worldwide observational study of adherence with
acne therapy. Int J Dermatol 2010;49(4):448–56.
25  Journal of Current Clinical Care Volume 5, Issue 1, 2015
5. The Guideline Subcommittee “Acne” of the European
Dermatology Forum. European Dermatology Forum
guideline on treatment of acne. Berlin: Author; 2011.
Available at: http://www.euroderm.org/images/sto-
ries/guidelines/Guideline-on-the-Treatmentof-Acne.
pdf.
6. Solomon BA, et al. Clin Dermatol.1996;14:95–9. <AU:
Please insert article title>
7. Mukhopadhyay P. Cleansers and their role in various
dermatological disorders. Indian J Dermatol 2011;
56(1):2–6. Available at: http://www.ncbi.nlm.nih.gov/
pmc/articles/PMC3088928/.
8. Decker A and Graber EM. Over the counter acne treat-
ments. J Clin Asthet Dermatol 2012;5(5):32–40. Avail-
able at: http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3366450/.
9. E. Schorr, F. Sidou, N. Kerrouche, J.Drugs in Dermatol
2012;11(9)957–60.
10. Marino C. Skin physiology, irritants, dry skin, and mois-
turizers. Washington State Department of Labor and
Industries. 2001 (revised 2006). Available at: http://
www.lni.wa.gov/Safety/Research/Dermatitis/files/
skin_phys.pdf.
11. Finlay AY. J Eur Acad Dermatol Venereol.
1999;12(Suppl 2):S77.
12. Koo J. How do you foster medication adherence
for better acne vulgaris management? Skinmed.
2003;2(4):229–33.
13. Vender R, et al. Patient preferences in acne: a point-
of-care educational initiative. Poster presentation.
<AU: Please add the name, location, and date for the
conference.>
14. Laquieze S, Czernielewski J, Rueda MJ. Benefi-
cial effect of a moisturizing cream as adjunctive
treatment to oral isotretinoin or topical tretinoin
in the management of acne. J Drugs Dermatol
2006;5(10):985–990.