Moisturizers for Acne: What are their Constituents?

| May 20, 2014

Leena Chularojanamontri, MD; Papapit Tuchinda, MD;
Kanokvalai Kulthanan, MD; Kamolwan Pongparit, MD
Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Abstract
Acne is a chronic inflammatory disease of the pilosebaceous unit that affects almost all teenagers. Different treatments offer different modes of action, but aim to target acne pathology. Topical therapies, such as benzoyl peroxide, retinoids, antibiotics with alcohol-based preparations, and salicylic acid, can cause skin irritation resulting in a lack of patient adherence. Some physicians recommend patients use moisturizers as adjunctive treatment of acne, especially when either topical benzoyl peroxide or a retinoid is prescribed. Furthermore, some evidence shows that moisturizers can contribute independently to improve signs and symptoms of acne. Moisturizers contain three main properties, which are occlusive, humectant, and emollient effects. Currently, many moisturizers claim to be suitable for acne treatment. This article aims to provide a review of the active ingredients and properties of those moisturizers. Fifty-two moisturizers for acne were included for analysis. Most of the products (92%) have anti-inflammatory properties apart from occlusive, humectant, and emollient effects. Anti-acne medications, including salicylic acid, benzoyl peroxide, and retinol, were found respectively in 35, 10, and 8 percent of the moisturizer products containing anti-inflammatory properties. More than half of the products contain dimethicone and/or glycerin for its moisturizer property. Aloe vera and witch hazel are botanical anti-inflammatories that were commonly found in this study. Scientific data regarding some ingredients are discussed to provide a guide for physicians in selecting moisturizers for acne patients.
(J Clin Aesthet Dermatol. 2014;7(5):36–44.)

Acne is a chronic inflammatory disease of the pilosebaceous unit that affects almost all teenagers between the ages of 15 and 17 years.[1] Clinical features include oily skin, noninflammatory lesions (open and closed comedones), inflammatory lesions (papules and pustules), and various degrees of scarring. Increased sebum production under androgen control, alteration of the keratinization, follicular colonization by Propionibacterium acnes, and inflammation are four main processes in the pathogenesis of the disease.
Different treatments of acne offer different modes of action, but aim to target the four aspects of acne pathology. Topical therapies, such as benzoyl peroxide (BP), retinoids, antibiotics with alcohol-based preparations, and salicylic acid (SA), can cause skin irritation resulting in a lack of patient adherence. Similarly, oral isotretinoin, which is the most effective medication for acne, usually causes dry skin, cheilitis, and photosensitivity.[1] Dryness or skin irritation may cause barrier disruption of the stratum corneum leading to increased transepidermal water loss (TEWL) and production of inflammation.[2] Thus, some physicians recommend patients use moisturizers as adjunctive treatment of acne, especially when either topical BP or retinoid is prescribed.[3] Furthermore, some evidence shows that moisturizers can contribute independently to improve signs and symptoms of acne.[1]
Moisturizers contain three main properties, which are the occlusive, humectant, and emollient effects. The occlusive ingredients physically block TEWL by forming a hydrophobic film on the skin surface and within the superficial interstitium between corneocytes.[4–5] Occlusive agents, such as petrolatum, lanolin, mineral oil, paraffin, squalene, and silicone derivatives (dimethicone, cyclomethicone), are usually greasy.[4] Silicone derivatives are often used in combination with petrolatum, which make them greasy. However, silicone derivatives that have not been combined with other ingredients are not greasy. The second property of moisturizers is humectant, which attracts water from the dermis to epidermis. Examples of humectants are glycerin (glycerol), sodium lactate, ammonium lactate, hyaluronic acid, sorbitol, urea, and alpha hydroxyl acids.[1,4] The other property of moisturizers is emollient, which smooths skin by filling space between skin flakes with a droplet of oil.[1] Emollients include a vast array of compounds ranging from esters to long chain alcohols, such as isopropyl isostearate, caster oil, propylene glycol, octyl stearate, and dimethicone.[1] One ingredient of moisturizers can have more than one property, such as dimethicone, which has both occlusive and emollient properties. Other ingredients including topical medications for acne and botanical anti-inflammatory substances are sometimes added to moisturizers for acne.
Currently, many moisturizers that are available either over the counter or online claim that they are suitable for acne treatment. The current study was designed to investigate the active ingredients and properties of those moisturizers.

Material and Methods
The authors used the key words “moisturizers” and “acne” to search for moisturizers that are available online. Only moisturizers that claimed they are suitable for acne, blemishes, and pimples were selected to identify their ingredients and properties. The same inclusion criteria were used for moisturizers that are available over the counter. Each moisturizer with its corresponding ingredients was entered into a Microsoft Excel (Seattle, Washington) spreadsheet and then evaluated for their ingredients and properties.

Results
Fifty-two products were included for analysis. “href=”http://jcadonline.com/wp-content/uploads/Tuchindatable1_may2014.jpg”>Table 1
demonstrates the active ingredients and their properties that the authors were able to identify in the products. Some ingredients also have an oil-reducing property, which may be suitable for oily skin. Ninety-two percent (48/52) of the products have anti-inflammatory properties apart from occlusive, humectant, and emollient effects. “href=”http://jcadonline.com/wp-content/uploads/Tuchindatable2_may2014.jpg”>Table 2
demonstrates a list of the products and their ingredients that do not contain anti-inflammatory properties. Anti-acne medications, including SA, BP, and retinol were found, respectively, in 35 percent (17/48), 10 percent (5/48), and 8 percent (4/48) of the moisturizer products containing anti-inflammatory effects ( “href=”http://jcadonline.com/wp-content/uploads/Tuchindatable3_may2014.jpg”>Table 3
“href=”http://jcadonline.com/wp-content/uploads/Tuchindatable3continued_may2014.jpg”>Table 3 continued
“href=”http://jcadonline.com/wp-content/uploads/Tuchindatable4_may2014.jpg”>Table4
). Twenty-two of 48 products (46%) contained other anti-inflammatory substances without anti-acne medications ( “href=”http://jcadonline.com/wp-content/uploads/Tuchindatable5_may2014.jpg”>Table 5, “href=”http://jcadonline.com/wp-content/uploads/Tuchindatable5continued_may2014.jpg”>Table 5 continued
). More than one-half of all products contain dimethicone and/or glycerin for their moisturizing properties. Aloe vera and witch hazel, botanical anti-inflammatories, were commonly found in the products as well.

Discussion
Topical therapies, including SA, BP, retinoids, and antibiotics are effective in managing acne, but are associated with local adverse effects, such as irritation and dryness. A concomitant use of moisturizers can enhance efficacy, alleviate dryness, and improve skin comfort. The study by Laquieze et al6 showed that using moisturizers provided a significant improvement in skin dryness and comfort to the patients who were treated with oral or topical isotretinoin. From the study described herein, the authors found that SA was the most common anti-acne medication added in the moisturizers for acne. SA has comedolytic effects by breaking down follicular plugs because of its lipophilic nature and anti-inflammatory capability by affecting arachidonic acid cascade.[7–10] However, SA is likely to cause local skin peeling when used at concentrations of 2% or more.[11] Thus, moisturizing properties in the products can relieve the irritation effect of SA. O’Goshi et al12 demonstrated an increase in skin hydration of the skin of swine after applying 10% SA in petrolatum once daily for five days. The continuous effect was also detected over two weeks after cessation of application.[12]
Similarly, BP and retinols are regarded as irritative agents. BP has greater activity than topical (iso)tretinoin against inflammatory lesions while retinoids work well for comedolytic effects and decrease sebum excretion.[1] Although the concentration of BP used for acne is limited by local skin irritation, there were no significant differences in frequency and severity of irritation between the use of 5% and 2.5% BP.[13] The study by Matsunaga et al showed that the adjunctive use of a moisturizer (Cetaphil®, Galderma Laboratories, L.P.) improved local tolerance of adapalene gel.[6]
Dimethicone and glycerin were the most common ingredients found in the products. Dimethicone and cyclomethicone are silicone derivatives and usually used in oil-free facial moisturizers.[4] The term “oil-free” implies that this substance does not contain either mineral oil or vegetable oil.[4] Dimethicone reduces TEWL without a greasy feel and contains both occlusive and emollient properties. It is suitable for acne and sensitive patients as it is noncomedogenic and hypoallergenic. Cyclomethicone is a thicker silicone that has similar properties as dimethicone. The authors found that other ingredients, such as petrolatum, lanolin, and mineral oil, were occasionally added in the 52 products analyzed, as they have some drawbacks for acne-prone skin. The use of lanolin is limited by odor, expense, and the fact that it is a common cause of allergic contact dermatitis.[4,14] Mineral oil is a lightweight inexpensive oil that is odorless and tasteless. One of the main concerns for its use is that it is comedogenic. However, there are different grades of mineral oil, including industrial grade and cosmetic grade. Some experts believe that cosmetic grade mineral oil is noncomedogenic.[4,15]
Glycerin is the most effective humectant available to increase stratum corneum hydration.[16] If the concentration of glycerin is too high, it will create a sticky feeling on skin. Hyarulonic acid and sodium pyrrolidone carboxylic acid (PCA), which are humectants, may be used in addition to glycerin to decrease stickiness. It should be noted that application of a humectant alone can increase TEWL. For example, glycerin (glycerol) can increase TEWL by 29 percent.[4] Thus, a humectant agent is usually combined with an occlusive ingredient when used as a moisturizer. The authors found that glycerin (humectant) and dimethicone (occlusive agent) were usually used in combination in the 52 products analyzed.
Metals and botanical extracts are sometimes added in the moisturizers for their anti-inflammatory properties. Ginkgo biloba, green tea, aloe vera, allantoin, and licochalcone are botanical anti-inflammatory agents that are commonly used in the current market.[17] Aloe vera and witch hazel, which were found commonly in this study, also have skin-soothing properties.[17] The anti-inflammatory effect of aloe vera results from inhibition of cyclooxygenase in the arachidonic pathway. The concentration of aloe vera should be at least 10 percent in order to have a moisturizing effect.[4,17] Witch hazel is commonly used as an astringent in people with oily skin. Its high tannin content obtained by steam distillation of the plant may cause astringent action. Hamamelis ointments, known as witch hazel ointments, are used as acne cosmeceuticals.[4,17]
Currently, there are many metals, such as zinc, copper, selenium, aluminum, and strontium, that are used in cosmeceuticals.[17] Well-established scientific data support the anti-inflammatory and wound healing benefits of zinc. Alkaline phosphatase requires multiple zinc ions, which are involved in adenosine monophosphate metabolism.[4,17] This action has a role in restraining an inflammatory response.
In conclusion, the authors aim was to investigate the ingredients and properties of moisturizers claimed to be suitable for use in acne patients. Some scientific data regarding the properties and mechanisms of action were provided to aid physicians in selecting a suitable moisturizer for their acne patients.

References
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2. Lynde C. Moisturizers for the treatment of inflammatory skin conditions. J Drugs Dermatol. 2008;7:1038–1043.
3. Gollnick H, Cunliffe W, Berson D, et al. Management of acne: a report from a global alliance to improve outcomes in acne. J Am Acad Dermatol. 2003;49:S1–S37.
4. Del Rosso JQ. Moisturizers: Function, formulation and clinical applications. In: Draelos Z, Dover JS, Alam M, eds. Cosmeceuticals. 2nd ed. China: Saunders Elsevier; 2009: 97–102.
5. Nemes Z, Steinert PM. Bricks and mortar of the epidermal barrier. Exp Mol Med. 1999;31:5–19.
6. Laquieze S, Czernielewski J, Rueda MJ. Beneficial effect of a moisturizing cream as adjunctive treatment to oral isotretinoin or topical tretinoin in the management of acne. J Drugs Dermatol. 2006;5:985–990.
7. Akarsu S, Fetil E, Yucel F, et al. Efficacy of the addition of salicylic acid to clindamycin and benzoyl peroxide combination for acne vulgaris. J Dermatol. 2012;39:433–438.
8. Cunliffe WJ, Holland DB, Clark SM, et al. Comedogenesis: some new aetiological, clinical and therapeutic strategies. Br J Dermatol. 2000;142:1084–1091.
9. Bowe WP, Shalita AR. Effective over-the-counter acne treatments. Semin Cutan Med Surg. 2008;27:170–176.
10. Lee HS, Kim IH. Salicylic acid peels for the treatment of acne vulgaris in Asian patients. Dermatol Surg. 2003;29:1196–1199.
11. Bikowski J, Callender VD, Del Rosso JQ, et al. Combining clindamycin 1%-benzoyl peroxide 5% gel with multiple therapeutic options. Cutis. 2006;78:13–20.
12. O’ Goshi KI, Tabata N, Sato Y, Tagami H. Comparative study of the efficacy of various moisturizers on the skin of the ASR miniature swine. Skin Pharmacol Appl Skin Physiol. 2000;13:120–127.
13. Mills OH, Kligman AM, Pochi P, Comite H. Comparing 2.5%, 5%, and 10% benzoyl peroxide on inflammatory acne vulgaris. Int J Dermatol. 1986;25:664–667.
14. Zirwas MJ, Stechschulte SA. Moisturizer allergy diagnosis and management. J Clin Aesthet Dermatol. 2008;1:38–44.
15. Draelos ZD. Acne cosmeceutical myths. In: Draelos Z, Dover JS, Alam M, eds. Cosmeceuticals. 2nd ed. China: Saunders Elsevier; 2009: 179–181.
16. Draelos ZD. Dry skin. In: Draelos Z, Dover JS, Alam M, eds. Cosmeceuticals. 2nd ed. China: Saunders Elsevier; 2009: 173–174.
17. Draelos ZD. Cosmetics and Dermatological Problems and Solutions. 3rd ed. London: Informa Healthcare; 2011.

Category: Literature Review, Past Articles

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