[LITERATURE REVIEW]

The Role of Skin Care as an

Integral Component in the
Management of Acne Vulgaris
Part 1: The Importance of Cleanser and Moisturizer
Ingredients, Design, and Product Selection
JAMES Q. DEL ROSSO, DO, FAOCD
Clinical Professor (Dermatology Adjunct Faculty), Touro University College of Osteopathic Medicine, Henderson, Nevada; Private
Dermatology Practice, Las Vegas Skin & Cancer Clinics/West Dermatology Group, Las Vegas and Henderson, Nevada

ABSTRACT
Acne vulgaris is a very common facial skin disorder accounting for approximately 10 percent of all visits to
ambulatory
dermatology practices across the United States annually. Over time, greater attention has been directed to the
roles of
multiple epidermal barrier functions in various dermatological disorders, especially the stratum corneum
permeability
barrier and antimicrobial barrier. As a result, it has become readily apparent that professional direction of skin
care is
very important in the overall management of acne vulgaris. This article discusses several reasons that
support the
importance of incorporating specified skin care recommendations and instructions into the overall management
plan for
acne vulgaris. In addition, the article reviews formulation characteristics and some of the scientific data on
two
commercially available products that are recommended for use as a skin care regimen in patients with acne-
prone and
acne-affected skin, a foam wash and a moisturizer with a sun protection factor 30 broad spectrum
photoprotection rating.
The rationale for inclusion of specific ingredients are discussed along with an overview of research results
including use
in patients with acne vulgaris. (J Clin Aesthet Dermatol. 2013;6(12):19–27.)

cne vulgaris (AV) has long been considered the most preadolescent girls present with multiple facial
A common skin disorder overall, and has been reported
to affect nearly 70 percent of adolescents. 1 Although well
comedonal lesions, often with forehead predominance,
and in many cases also exhibit some superficial
known as a common disorder affecting the facial and papules/pustules (Figure 1). In a five-year longitudinal
truncal skin of many teenagers, AV also commonly affects study of preadolescent-premenstrual girls with AV as just
pre-teens and post-teens, with the latter group inclusive described (N=871), higher serum levels of
of women with persistent AV and late-onset AV. 2–4 Many dihydroepiandrosterone sulfate (DHEA-S) and
clinicians including pediatric dermatologists have testosterone (free and total) were noted, which correlated
observed that pediatric acne is starting earlier in many with persistence of severe comedonal AV and also
patients, primarily due to earlier onset of adrenarche. increased severity of inflammatory AV over time. 6 The
Preadolescent AV, currently defined as between 7 and 11 “extra androgen drive” present in this subset of young
years of age, is not often associated with an underlying girls serves as a good predictor that a greater severity of
endocrinopathy. 5 Many AV will emerge over time and is associated with
pilosebaceous enlargement and

DISCLOSURE: Dr. Del Rosso has served as a consultant, advisory board participant, clinical investigator, and/or speaker for Allergan, Bayer
Healthcare (Dermatology), Eisai, Galderma, Medicis (a division of Valeant), Obagi Medical Products, Onset Dermatologics, PharmaDerm, Primus,
Promius, Quinnova, Ranbaxy, Taro Pharmaceuticals, TriaBeauty, Unilever, Valeant, and Warner-Chilcott. Dr. Del Rosso has provided consultation
services for Galderma on the products discussed in this manuscript and has received compensation for those services, but did not receive
compensation for his participation in the publication of this article (Part 1), including authorship and submission. This article was written solely by
the author. Internal review by Galderma to check for accuracy of content was completed prior to submission of the article to the journal and the peer-
review process. All of the final content and wording of the article solely reflects the writing and authorship of Dr. Del Rosso. ADDRESS
CORRESPONDENCE TO: James Q. Del Rosso, DO; E-mail: [email protected]

[December 2013 • Volume 6• Number12]

19
 acne defined within the ages of 7 and 11 years. 17 In
addition, many adult women with post-teen acne are
encountered in clinical practice, with some presenting in
their mid-to-late 20s or in their 30s with AV similar to what
they experienced as teens (persistent AV), or AV that they
are first experiencing with little to no prior history of AV
(late-onset AV).3,4 As AV involves the face in 97 percent of
cases with or without truncal involvement, the visibility of
AV is psychologically problematic for many affected
individuals.18 Scarring and dyschromia are unfortunate
physical sequelae after resolution of AV lesions that
prolong the adverse psychosocial effects of AV for many
people. However, what is not always fully appreciated
during the limitations of an office visit is that many
patients are affected from a psychosocial perspective,
Figure 1. Pre-adolescent acne vulgaris. An 11-year-old with adverse consequences reported that alter both
girl presented with multiple closed comedones and overall quality of life and mental health status. 8,19
scattered superficial inflammatory papules/pustules with Ultimately, AV is overall the most common dermatological
a marked predominance of forehead involvement. disorder seen in office-based dermatology practices,
Photograph courtesy of James Q. Del Rosso, DO, FAOCD affecting many teenagers, preadolescents, and post-
teenage adults, and almost always affects facial skin with
or without truncal involvement. As acne is not curable, it
has a protracted course over several years in most
increased sebum production (“oily skin”). 6,7 Ultimately, the affected individuals even with treatment, and can be late
age range of patients who commonly present with AV has in onset, especially in adult women. Prolonged
broadened to include more pre-teen and post-teen dyschromias are a common sequelae of acne, which also
patients. This change requires that dermatologists causes various forms of scarring in some cases. Acne can
address the specific questions, concerns, and clinical be managed effectively; however, this requires consistent
challenges that commonly affect these subsets of AV adherence with long-term therapy and timely adjustments
patients, with obvious emphasis on efficacy and safety in the treatment regimen when the character and severity
considerations, but also the potential psychosocial impact change over time. It is also common for acne to impart
on different patient subsets.8 Additionally, education adverse psychosocial effects that can significantly impair
about fundamental skin care recommendations for quality of life and in some cases cause profound anxiety
patients with AV is appreciated by patients and has been and/or depression. Therefore, it is important for
shown to reduce signs and symptoms of cutaneous dermatology practices to incorporate a well-organized and
irritation.9–13 AV is an equal opportunity disease, affecting comprehensive approach to the evaluation and
individuals of all ethnicities and skin colors. management of patients with AV.
Based on representative data from the National
Ambulatory Medical Care Survey (NAMCS) that assesses
leading diagnoses in patient visits to dermatologists from EXPANDED INFORMATION SOURCES AND
1993 to 2009, AV ranks among the top five dermatological ACCESSIBLE CARE FOR ACNE OUTSIDE
diagnoses most commonly encountered in dermatology OF DERMATOLOGY PRACTICES
practices in the United States. 14,15 In 2009, AV accounted There is an extensive network of communications that
for 10.2 percent of all visits to US dermatologists in promote care for AV outside of seeing a dermatologist.
outpatient practices.16 These include television-based and web-based
In the review of NAMCS data from 1993 to 2009, AV infomercials on specific products, retail stores dedicated
was found to be the leading diagnosis in African only to skin care, classic “department stores” with
American, Asian Pacific Islander, and Hispanic patients designated skin care sections, skin care/spa centers
and was second only to actinic keratosis in the directed by nondermatologists, printed electronic or “hard
Caucasian patient population.14 Another study aimed copy” advertisements on the internet or in countless
to define the prevalence and clinical presentations of magazines and other publications, and the plethora of
AV in 2,895 female patients of different races. It was OTC products for AV available at pharmacies that are
found among the entire group of female patients marketed by many cosmetic and pharmaceutical
included in the study that African Americans had the companies. As a result, patient expectations are set at a
highest prevalence of AV (37%), followed by Hispanics high bar when encountering a dermatologist for
(32%), Asians (30%), Caucasians (24%), and management of AV, as they expect a level of service and
Continental Indians (23%).15 the quality of the outcome to be far superior to what they
AV is a common, chronic, inflammatory, facial skin can obtain by just going to a search engine on their
disorder that can affect individuals from any race, computer or from an aesthetician at a spa or skin care
ethnicity, or cultural background. The onset of AV is center that is not dermatologist-supervised. Therefore, it
usually shortly before or during early adolescence; is important for the dermatology practice to efficiently
however, some cases start in latter childhood with the provide an office visit experience that is highly
subset of preadolescent educational and includes the integration of proper skin
care
20 [ D e c e m b e r2 0 1 3 • V o l u m e 6 • N u m b e r 1 2 ]
and product selection along with medication response, reasonable expectations, and follow-up
selection and proper use. Ultimately, the instructions are all vital to the
dermatologist and his or her staff are encouraged to
understand the scientific rationale for proper skin
care in AV management, why specific products are
selected, and how they are to be utilized and
integrated with topical medications for AV.
Professional treatment. In addition to the large
volume of patients with AV who seek care from
dermatologists across the United States, many more
undergo professional treatment, both medical and
procedural, via their primary care physician. AV
accounted for 0.4 percent of all outpatient visits to all
US physicians in 2009, reflecting a large number of
visits for AV to primary care physicians including
pediatricians.16 The recent publication, Evidence-Based
Recommendations for the Diagnosis and Treatment of
Pediatric Acne, developed through the combined
efforts of the American Academy of Pediatrics and the
American Acne and Rosacea Society, and accepted by
the AAP as its policy, should assist practitioners with
the management of AV in pediatric patients. 20
Over-the-counter and nonphysician-directed
options. In addition, many individuals seek advice
and/or elect to self-treat by purchasing products that
are marketed for AV and sold over-the-counter (OTC) at
pharmacies, via the internet, or at retail stores and
skin care/cosmetic centers, which have large sections
designed to attract individuals with skin-related needs,
including OTC treatments for AV. Many cosmetic
companies and pharmaceutical companies have
divisions dedicated to the development and marketing
of OTC products and treatment systems, which include
many for AV. In addition to OTC products applied to
skin, many patients undergo a variety of physical
procedures (i.e., nonablative devices, photodynamic
therapy [PDT], peels, extraction procedures) offered at
spas and cosmetic centers that fall outside of the
realm of dermatologist-supervised care for AV. The
level of knowledge and education about AV by
providers of services who are not under the direction of
a dermatologist or physician well-versed in
dermatology are unknown and likely to be highly
variable in quality.

THE IMPORTANCE OF DERMATOLOGISTS

MAINTAINING THEIR FOCUS ON COMMON
DISORDERS SUCH AS ACNE
Simply stated, people with AV have many options in
seeking information and accessing therapies outside of
the care provided by the dermatologist, thus creating
an important challenge to the dermatologist and his or
her staff during encounters with patients presenting
with AV. It is important for the dermatologist and his or
her entire staff to provide a high level of well-
coordinated service and comprehensive care to
patients with AV as they can easily seek treatment
elsewhere, including via the internet or other
nondermatologist-directed options. Patient education
focused on AV itself, treatment selection, proper
medication use, the importance of adherence with the
full regimen, possible adverse effects, time course of
overall success of AV management. What is often sufferers around the world.” Interestingly, this leading
forgotten, however, is the importance of proper skin care page that Ask Jeeves provided did not indicate who
and product selection in the treatment of AV, especially as comprises “our staff”—the people who are making specific
AV itself and many of the therapies used to treat AV (i.e., product recommendations—and did not include any type
benzoyl peroxide, topical retinoids, oral isotretinoin) can of disclaimer suggesting that the individual consult with a
induce impairment of the stratum coneum (SC) dermatologist or their physician if their acne was not
permeability barrier, resulting in increased transepidermal responsive to any treatments or was worsening.
water loss (TEWL), xerotic and inflammatory skin changes, Dermatologists need to be keenly aware that the internet
and increased skin sensitivity. If there is any question and many other sources of information that do not
regarding the public interest level about AV, one can see evaluate the patient with AV and other conditions are
the enormous magnitude of interest by going to one of the commonly consulted and trusted by the public. These
major internet search engines such as Google, separately products would disappear from websites and retail
searching “acne” and “acne treatment,” and seeing the locations if people, many of whom are or have been our
plethora of options and the number of “results” directed at patients, were not buying and using them.
these two subject areas. On May 21, 2013, the author
found 25,100,000 results when searching “acne” and EPIDERMAL BARRIER
9,390,000 when searching “acne treatment” on Google. DYSFUNCTIONS IN ACNE VULGARIS
When Ask Jeeves was searched for “What are the best Management of AV obviously requires the rational
treatments for acne?” the first response was a proprietary selection of therapeutic agents and modalities
page entitled Acne Treatment Reviews. This page stated, commensurate with the severity of AV and other patient-
“See which acne treatment products are best for your skin related factors, adherence with the therapeutic regimen,
and discover which acne ingredients are actually better and appropriate follow up. However, proper skin care
than a prescription.” This page tabulated five brand OTC provides adjunctive value to the medical regimen and can
and/or internet-based “scientific actives” products/product reduce local tolerability reactions associated with topical
systems containing ingredients, such as benzoyl peroxide, medications.9,11–13
salicyclic acid, and sulfur, and five brand OTC and/or Epidermal barrier impairments innate to acne.
internet-based “natural extracts” products/product Although much more research is needed on the
systems “proven to heal skin” containing ingredients, such structural and functional integrity of the SC and
as green tea, passion flower, and sage extract. Under the epidermal barrier functions inherent to acne-prone and
tables that outlined the top five lists, there was a by-line acne-affected skin, there is some evidence of SC
that stated, “The acne treatments listed in this site were permeability impairment
carefully selected by our staff and recommended by acne

[December 2013 • Volume 6 • Number 12] 21

innate to AV.9,10,21,22 Sebum secretion, SC lipids, TEWL, and These multiple effects of topical retinoids on skin,
skin conductance (corneometry) were determined in 36 which account for their therapeutic benefit, also create
male patients between the ages of 14 and 26 years who an initial
presented with mild-to-moderate AV as compared to a
control group comprised of 29 age-matched male
subjects.21 The patients with AV demonstrated higher
levels of both sebum secretion and TEWL along with
decreased SC conductance. The increase in TEWL and
decrease in SC hydration (determined through
corneometry) demonstrates the presence of SC
permeability barrier impairment innate to AV. The patients
with AV also exhibited markedly diminished SC levels of
free sphingosine and total ceramides.21 These latter
findings support a deficiency of the intercellular lipid
membrane, which provides at least a partial explanation
for decreased TEWL, and correlate directly with SC
permeability barrier dysfunction.10,21 In addition, the
increase in TEWL and the decrease in SC hydration were
of greater magnitude in subjects with moderate AV
severity as compared to subjects with mild AV severity
and in normal controls, suggesting that the magnitude of
SC permeability barrier impairment correlates directly with
the severity of AV.21 It is not known whether the qualitative
or quantitative changes in SC structure and/or function
noted with AV occur only in association with the
inflammation present in active AV or if they are also
present in the epidermis of unaffected facial skin of AV
patients where AV lesions are not present at the time of
SC testing. Nevertheless, untreated skin in individuals
with AV exhibit impairment of the SC permeability barrier
that is important to correct as part of the management of
AV in order to reduce signs and symptoms of facial
irritation, dryness (i.e., peeling due to faulty
desquamation), and skin sensitivity. 9,10,21

Medication-induced epidermal changes. Some

topical medications and/or vehicle formulations
and oral medications used to treat AV can induce
changes within the epidermis that alter barrier
functions, especially the SC permeability barrier.
9,10,23–28

Benzoyl peroxide. Benzoyl peroxide (BP) has been

shown to increase TEWL by 1.8-fold in a study
evaluating a 10% formulation and has also been shown
to reduce cutaneous levels of vitamin E (tocopherol). 23
Concomitant use of topical tocotrienol, an isomer of
vitamin E, along with application of BP did not offset an
increase in TEWL, but did reduce BP-induced SC lipid
peroxidation, likely through the antioxidant
replenishment from the applied vitamin E isomer
(tocotrienol).23 It appears based on these data that BP
can adversely modify two epidermal barrier functions
by producing impairment of both the antioxidant
barrier and the SC permeability barrier. 10,23
Topical retinoids. Topical retinoids have been shown
to modulate epidermal keratinization and
differentiation, downregulate expression of toll-like
receptor-2 (TLR2), decrease dermal matrix degradation
through inhibition of the activator protein-1 (AP-1)
pathway and matrix metalloproteinases (MMPs), and
alter various transcription factors involved in cascades
of skin inflammation.24,26,27,29–31
adjustment phase over the first few weeks of use that Interestingly, patients initiate some of these approaches
correlates with “dermatitis changes” that may be visible on their own when using topical acne therapies (i.e.,
clinically in some patients with variable interpatient temporarily stopping use, cutting back on frequency of
severity.10,26 Many patients develop some magnitude of use, moisturizer use).31
“retinoid dermatitis” characterized by erythema, fine In both animals and human skin research models,
scaling, and desquamation, within the initial 1 to 3 weeks topical retinoid application has been shown to induce
after starting application of a topical retinoid; these acanthosis, hypergranulosis, and a relative decrease in SC
changes are often mild with the availability of improved thickness, and in murine skin, application of a topical
vehicles, and are characteristically transient with retinoid increased epidermal labeling index, with a
continued application of the topical retinoid over the first plateau effect noted after approximately one week as
2 to 4 weeks of use. 10,29,30 Most patients treated with a acanthosis peaked.26 Interestingly, acanthosis reverted
topical retinoid exhibit initial signs and symptoms of skin partially toward baseline after approximately two weeks
irritation that are clinically absent or negligible and that followed by a steady-state equilibrium, which persisted
resolve after a few weeks, especially with improved thereafter, correlating with the typical time course of
vehicle formulations. In cases where the initial retinoid retinoid dermatitis.10 It is believed that the visible retinoid
dermatitis is mildly visible but tolerable, proper skin care dermatitis commonly observed after starting topical
assists in mitigating signs, such as fine redness and retinoid therapy reflects at least partially the modes of
scaling. In occasional cases, the magnitude of cutaneous action that a topical retinoid induces within the
irritation is severe enough to warrant discontinuation of epidermis.10,26 Concurrent moisturizer use to pre-
use. However, dermatologists commonly adjust the emptively reduce the SC permeability barrier impairment
regimen by incorporating approaches to topical retinoid and increase in TEWL that can be induced by topical
therapy that are often successful in getting past the retinoid application has been reported, and is a common
hurdle of skin irritation that some patients experience technique that is self-initiated by patients to reduce signs
when first starting a topical retinoid for acne. These and symptoms of skin irritation and dryness. 31 In a study
approaches include temporary discontinuation coupled of 50 women between the ages of 35 and 55 years
with proper adjunctive skin care, use of a vehicle shown to treated with tretinoin cream 0.025% for facial photoaging,
be well tolerated, stopping the retinoid for 5 to 7 days application of a moisturizer for two weeks before and
then restarting with a reduced frequency of application during tretinoin treatment prevented an increase in
(i.e., every other night instead of every night) for the first TEWL.24 Retinoid-induced desmosomal shedding within
few weeks, and using a topical retinoid with a track record the stratum spinosum, a reduction in tonofilaments, and
of low irritation potential and comparable efficacy. deposition on non-mucin glycoconjugates results in

22 [ D e c e m b e r2 0 1 3 • V o l u m e 6 • N u m b e r 1 2 ]
greater skin fragility due to overall management of AV selected for that individual
loosening (dyscohesion) within the patient. This approach focuses on the individual
upper SC, and has been shown to
occur with oral and topical
retinoids.26 The SC dyscohesion
associated with topical retinoid use
explains why patients report
superficial denudation of skin after
undergoing tape strip-type
techniques to remove un-wanted
hair usually on the upper lip or
eyebrow region.10
Oral isotretinoin. Oral isotretinoin
predictably induces xerotic and
desquamative cutaneous changes, also
related to SC dyscohesion, which is of a
greater magnitude than with topical
retinoid therapy.10,26,28 The marked
sebosuppressive effect of oral
isotretinoin also induces a change in the
cutaneous microflora, with greater
tendency for staphylococcal
colonization.28 The alterations in the SC
permeability barrier associated with
both topical and oral retinoid therapy do
not appear to be related to reductions or
alterations in SC lipids that comprise the
intercellular lipid membrane of the
SC.26,28 The changes in epidermal
surface lipids that are due to the
sebosuppressive effects and altered
sebum lipid content induced by oral
isotretinoin are not believed to
significantly influence SC permeability
barrier function.26,28

DEVELOPMENT OF SKIN CARE

FORMULATIONS DESIGNATED
FOR USE IN ACNE-PRONE AND
ACNE-AFFECTED SKIN
There is good practical and scientific
rationale for the routine use of proper
skin care in patients with AV, especially
those undergoing professionally
recommended therapy. Use of proper
skin care for facial skin is helpful when
AV is actively present
(acne-affected skin) and also during periods of
quiescence when facial acne is essentially clear and
well controlled (acne-prone skin). To add, both groups
(acne-affected skin and acne-prone skin) are
commonly using over-the-counter or prescription
therapies for acne that can cause SC permeability
barrier damage, which can be subclinical or visibly
apparent with signs of dermatitis. In both cases,
proper skin care is beneficial for these patients.
Importantly, dermatologist-directed skin care,
selected by the dermatologist and his or her
designated staff (i.e., physician assistant, nurse
practitioner, nurse, medical assistant) provides
recommendations and instructions on proper use, thus
demonstrating to the patient (and parents/guardian
when applicable) a strong professional interest in the
 patient beyond the obvious selection of prescription
therapies and possibly physical modalities, and obviates
questions that patients have while at the office, but often
do not ask. As a result, the patient with AV may remain
confused regarding the proper general care of their skin
including what products they should use and how to
integrate them with topical medication use. To add,
dermatologist-directed skin care reduces the likelihood
that the patient will self-select skin care or
nonprescription acne treatment products that are
advertised and promoted for use in people with AV, often
with spurious and unsubstantiated claims. Many of these
products can induce skin irritation that actually sabotages
the acne therapy prescribed by the dermatology office. It
is important that the patient be informed of the rationale
for both the recommended skin care products and the
medications selected along with specific information on
how

[December 2013 • Volume 6 • Number 12] 23

and when to use them. with the individual products that demonstrate little-to-
Several options are available for selection of a no irritation potential, absence of comedogenicity, no
gentle cleanser and moisturizer as well as worsening of AV, diminished facial shine and skin
photoprotectant formulations. Unfortunately, there is a oiliness due to sebum absorption, decrease in TEWL,
conspicuous absence of many studies evaluating increase in skin hydration, broad spectrum
specific skin care products (specifically cleansers, photoprotection (SPF 30), and little-to-no elicitation of
moisturizers, and photoprotectants) in patients with AV sensitization or irritancy potential based on preclinical
both with and without concomitant treatments, and clinical testing.43–45
especially well-designed studies that compare the A complete review of the formulations of the foam
advantages and disadvantages of specific formulations wash and moisturizer with SPF 30 designed for use in
and ingredients. The following summarizes a skin care patients with AV and acne-prone skin is beyond the
system that includes a gentle foam wash primarily for scope of this paper; however, a few general comments
facial cleansing (Cetaphil® DermaControl™ Foam Wash, will assist the reader in understanding what the
Galderma Laboratories, L.P., Fort Worth, Texas), included ingredients are designed to provide,
hereafter referred to as foam wash, and a moisturizer especially for patients with acne-prone skin and acne-
with sun protection factor 30 (SPF 30) (Cetaphil ® affected skin, and what potential advantages may be
DermaControl™ Moisturizer SPF 30, Galderma), offered for many of the patients with AV. The
hereafter referred to as moisturizer SPF 30. Both moisturizer SPF 30 also incorporates sebum absorbant
formulations were specifically designed for use on ingredients that are helpful for “oily skin” that is
acne-prone skin and acne-affected skin with rationale diffuse on facial skin or affects certain focal areas,
for inclusion of specific ingredients and are supported such as the forehead and central face, but are not
by studies evaluating characteristics such as problematic for non-oily skin (i.e., do not cause
cutaneous irritation, comedogenicity, acnegenicity, dryness), and has been studied in patients using
photoprotection, and data related to clinical use. topical medications for AV with favorable results
There are three tables that assist the reader in reported.43–45 It is important to recognize that all topical
understanding many of the major ingredients incorporated products may be associated with skin tolerability
into the foam wash and/or into the moisturizer SPF 30. reactions or lack of preference with some users. The
Table 1 depicts major ingredients in the foam wash and a foam wash and moisturizer were well tolerated with
basic outline of rationale for their inclusion. 13,32–39 Table 2 high ratings for patient satisfaction and cosmetic
depicts major ingredients in the moisturizer SPF 30 and acceptability by most patients who participated in
also lists basic features that explain the rationale for their studies with these products. More than 85 percent of
inclusion.36–42 Table 3 outlines many of the studies 91 study patients reported their impression that the
completed moisturizer SPF 30 helped them better tolerate their
acne
24 [ D e c e m b e r2 0 1 3 • V o l u m e 6 • N u m b e r 1 2 ]
treatment.43,44 The following discusses information designation.43 The SPF 30 designation of the
from a “top line” perspective on both the foam moisturizer SPF 30 was
wash and moisturizer SPF 30, with additional
information on formulation and study data available
through direct contact with the manufacturer or in
the literature.
Foam Wash
• Surfactant. The foam wash utilizes a novel
surfactant (zinc coceth sulfate), which helps to
balance tolerability, improves the ability to lather,
effectively cleans skin and removes surface
debris (i.e., dirt, sebum), and retains its
effectiveness at a low pH.34
• Skin type. The foam wash can be used in
patients with oily skin, normal skin, dry skin,
or combination skin (“T-zone”).
• Clinical use. The foam wash was utilized as a
component of the skin care regimen (along with
moisturizer SPF 30) in patients undergoing
treatment for AV with a variety of topical
medications, such as retinoids and BP-containing
formulations (N=91).43,44 The majority of study
subjects were pleased with the cosmetic
acceptability and lack of irritation associated with
use of the foam wash.
Moisturizer SPF 30
• Barrier protection/repair. The moisturizer with SPF
30 has been shown to reduce TEWL and increase
skin hydration, including when used in patients
who are under active treatment with a variety of
topical medications for AV, such as topical
retinoids and BP-containing formulations.43–45
– The formulation contains pseudoceramide-5 (5 N-
2-hydroxyhexadecanoyl sphinganine), which has
been shown in a reconstructed human skin model
and in vivo (in patients with atopic skin) to
increase (epidermal) cutaneous levels of
endogenous ceramides likely via intracutaneous
conversion.42,43,46,47 The use of pseudoceramides
as a means of delivering ceramides in topical
products is well established in the skin care
industry, primarily due to the high cost of
endogenous ceramides and the demonstration of
endogenous ceramide delivery within the SC after
application of some pseudoceramides (i.e.,
pseudoceramide 5).46–48
– As the level of cutaneous ceramides has
been shown in one study to be decreased in
AV, and directly correlated with the severity
of AV, and ceramides are the predominant
component of the intercellular lipid
membrane of the SC which functions to
modulate TEWL, the incorporation of
pseudoceramide 5 (a ceramide precursor),
along with other ingredients designed to
diminish cutaneous irritation and
inflammation, (ie. allantoin, glycyrrhetinic
acid) is scientifically rational.21
• Photoprotection. The moisturizer SPF 30 is broad
spectrum with three sunscreens included in a
lower total concentration (15%) as compared to
several other brand moisturizers with a SPF 30
established in accordance with new testing – The inclusion of SPF 30 obviates the need to
guidelines from the 2011 United States Food purchase an additional sunscreen product that
and Drug Administration (FDA) Final Rule.43 may not get utilized regularly, adds an
– The ability to use a lower concentration of additional topical application step that my
sunscreen filtering agents is due to use of reduce compliance, can independently cause
oleosomes (oil-bodies), which are lipid-based skin irritation that confounds clinical
plant-derived organelles with a small central oil assessment, and stacks on an additional cost
droplet core surrounded by an outer lamellar to the management program.
layer.41,43,49 The individual sunscreen ingredients • Skin type. The moisturizer SPF 30 can be
are housed within individual oleosomes, which used in patients with oily skin, normal skin,
serves to partition the sunscreens and reduces dry skin, or combination skin (“T-zone”). 43
their degradation by not allowing physiochemical The moisturizer with SPF 30 specifically
interaction between the sunscreen ingredients includes ingredients adaptable for use in oily
prior to application.41,43 The lipid-based emulsion skin (silica microbeads and corn starch) that
of small olesome spheres and the reduced are sebum-absorbant and do not directly
sunscreen concentration provided by oleosome induce dryness so they are not problematic
partitioning of sunscreen ingredients enhances if applied to dry skin.
the favorable tolerability and lack of irritancy of – “Facial shine” refers to the shiny appearance of
the moisturizer formulation and allows for even facial skin, often most pronounced on the
dispersion of sunscreen upon application to skin. forehead, cheeks, and chin, that is created
– The moisturizer SPF 30 inherently provides by the accumulation of sebum on the skin
photoprotection as is commonly desired in a surface. This is often accentuated in flash-
daily moisturizer product that is also designed lighted photographs where these shiny areas
to protect against incidental UV exposure. This are magnified in intensity by light reflectance.
is advantageous in patients with AV as they are Facial shine is bothersome to many patients
commonly on medications where with acne as part of their concerns about
photoprotection is specifically recommended in having “oily skin” and can be temporarily
product monographs, FDA-approved package reduced in magnitude to some degree by the
inserts, and other publications (i.e., topical application of nonirritating agents that absorb
retinoids, oral tetracyclines, BP-containing sebum. Ingredients that can absorb sebum are
products).50–55 commonly incorporated into cosmetic products

[December 2013 • Volume 6 • Number 12] 25

 promoted to reduce “oily skin” (i.e., kaolin, talc, This article reviews the significance of
bentonite). Application of the moisturizer SPF incorporating
30 reduced “facial skin” over a time period of
at least a few hours and up to eight hours in
some patients; skin shininess and surface
sebum levels were reduced on both the
forehead and cheeks after application using
Sebumeter (Courage+Khazaka electronic
GmbH, Cologne, Germany) and Sebutape
(CuDerm, Dallas, Texas) measurements,
respectively.43 Incorporating ingredients that
can reduce skin oiliness and facial shine into
the moisturizer SPF 30 can reduce the need for
the patient to apply an additional OTC product
used specifically for “oil control”. Avoiding the
need for the patient to purchase that
additional product prevents any associated
skin irritation potential and another cost.
• Clinical use. The moisturizer SPF 30 was utilized
as a component of the skin care regimen (along
with the foam wash) in patients treated for AV
with various topical medications (N=91),
including retinoids and BP-containing
formulations, and in a 4-week randomized,
investigator/evaluator-blinded, split-face
comparison study (N=31), where tretinoin 0.05%
cream was applied to both sides of the face at
bedtime 30 minutes after facial cleansing, and
the moisturizer SPF 30 was randomized to be
applied regularly to one side of the face each
morning.43–45
– In the split-face study with topical tretinoin,
91.2 percent of study subjects observed that
the moisturizer SPF 30 was not irritating to
their facial skin. Also, 88.2 percent reported no
facial skin stinging or burning and also that
their facial skin appeared less greasy or less
oily on the side where the moisturizer SPF 30
was applied.45

SUMMARY
AV is a very common inflammatory facial skin
disorder that predominantly affects teenagers, but is
also frequently seen in preteens, and post-teens,
including adult women with either persistent AV or
late-onset AV. There is some evidence that impairment
of the SC permeability barrier is inherent to AV and/or
to the inflammation that occurs in association with AV.
In addition, many of the topical medications used to
treat AV, and some of the vehicles used, may induce
impairment of the SC permeability barrier either via an
innate mode of action and/or by inducing cutaneous
irritation. The resultant increase in TEWL and decrease
in epidermal water content (hydration) that occurs
when the SC permeability barrier is compromised leads
to skin inflammation, scaling, peeling, and symptoms
of sensitive skin, all of which create greater difficulty
with further application of topical therapy for AV. Oral
isotretinoin also impairs the SC permeability barrier by
causing corneocyte dyscohesion and also induces
marked sebosuppression and alteration in the
cutaneous microflora.
dermatologist-selected skin care into the overall 7. Lucky AW, Biro FM, Huster GA, et al. Acne vulgaris in
management plan for AV for both the patient and the premenarchal girls. An early sign of puberty
clinician. It also discusses much of the “top line” associated with rising levels of
information on formulation characteristics and ingredients dehydroepiandrosterone. Arch Dermatol.
and the available data on both a brand foam wash and a 1994;130:308–314.
brand moisturizer SPF 30. These two products were 8. Fried RG, Webster GF, Eichenfield LF, et al. Medical
designed to be used together as a skin care regimen, or and psychosocial impact of acne. Semin Cutan Med
may be used separately with other skin care products if Surg. 2010;29(2 Suppl 1):9–11.
preferred by the clinician, in patients with acne-prone skin 9. Del Rosso JQ, Levin J. The clinical relevance of maintaining
and acne-affected skin. The available data supports both the functional integrity of the stratum corneum in both
the foam wash and moisturizer SPF 30 as options that are healthy and disease-affected skin. J Clin Aesthet Dermatol.
likely to be favorable from both scientific and patient 2011;4(9):22–42.
preference perspectives in many patients affected by AV, 10. Thiboutot D, Del Rosso JQ. Acne vulgaris and the
especially those who are undergoing treatment with epidermal barrier: is acne vulgaris associated with
topical medications for AV. inherent epidermal abnormalities that cause
impairment of barrier functions? Do any topical acne
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