Dermatol Clin 23 (2005) 575 – 581
Current therapy
Cosmetics in the Treatment of Acne Vulgaris
Ella L. Toombs, MDa,b,*
a
Aesthetic Dermatology of Dupont Circle, Washington, DC, USA
b
US Food and Drug Administration Office of Cosmetics and Colors, Washington, DC, USA
Worldwide, acne vulgaris is one of the skin dis-
orders for which patients most frequently consult the
dermatologist. In most cases, the cause of this
disease—which can be chronic—remains an enigma.
Because acne is limited to the skin of the head, chest,
and upper arms, aggressive topical therapy that mini-
mizes or eliminates the use of oral drugs (particularly
oral antibiotics) and the attendant risks of antibiotic
resistance, drug toxicity, and drug interaction is desir-
able. Fortunately, there are topical products available
which when used properly can ameliorate or palliate
the signs of acne and significantly improve the pa-
tients’ appearance and self esteem (Box 1) [1 – 5].
Training programs provide dermatology residents
with basic knowledge of the fundamentals of acne
vulgaris: demographics, pathology, and medical treat-
ment. In the private practice setting, patients require
more individualized care and attention. Patients ask
questions about cosmetics, and the dermatologist
should be prepared to give informed advice to assure
compliance and successful treatment outcome [3].
What differentiates drugs, cosmetics, and
cosmeceuticals?
The drugs, devices and cosmetics used in the
practice of dermatology are regulated by the Food
and Drug Administration under the congressionally
* Aesthetic Dermatology of Dupont Circle, 1612 18th
Street NW, Washington, DC 20009.
E-mail address: ella.toombs@verizon.net
0733-8635/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.det.2005.04.001
mandated Food, Drug, and Cosmetic Act. According
to this act, a drug is an ‘‘article intended for use in
the diagnosis, cure, mitigation, treatment, or preven-
tion of disease in man or any other animals. . .
intended to affect the structure or any function of
the body.’’ A cosmetic is defined as an ‘‘article
intended to be rubbed, poured, sprinkled, or sprayed
on the human body for the purpose of cleansing,
beautifying, promoting attractiveness, or altering the
appearance without affecting the body’s structure or
function.’’ Drugs undergo rigorous premarket ap-
proval in an effort to demonstrate safety and efficacy.
Cosmetics, on the other hand, should not make thera-
peutic claims and must be in compliance with the Fair
Packaging and Labeling Act. Safety is assumed. The
regulations prohibit cosmetics from being adulterated
or misbranded and include strict requirements for
packaging and labeling, including ‘‘the declaration of
ingredients.’’ There are over 5000 cosmetic ingre-
dients. For the dermatologist, the ingredient panel is
the key to understanding how the cosmetic will per-
form and its appropriateness for a given patient. The
intent, however, is that the consumer should be able
to determine whether a specific ingredient could ren-
der the cosmetic harmful. Currently, the Food, Drug,
and Cosmetic Act does not recognize the term ’’cos-
meceutical’’; therefore, the products referred to will
be categorized as either drugs or cosmetics [6 – 8].
Antiacne drugs
Standard therapy for acne vulgaris and nodulo-
cystic acne is based on well-characterized patho-
physiologic changes and the correlative clinical signs.
Accordingly, patients with comedones are candidates
derm.theclinics.com
576
Box 1. Function of common cosmetic
ingredients
Propylene glycol: humectant, skin
conditioning, viscosity-decreasing
agent, solvent
Glycerin: humectant, emollient
Stearic acid: surfactant/cleansing
agent, surfactant/emulsifying agent
Glyceryl stearate: skin-conditioning
agent/emollient, surfactant/
emulsifying agent
Laureth-23: surfactant/cleansing
agent, surfactant/solubilizing agent
Isopropyl palmitate: binder, skin
conditioner/emollient
Cetyl alcohol: emulsion stabilizer,
opacifyer, surfactant/emulsifier,
surfactant/foam booster,
viscosity-increasing agent
(aqueous and nonaqueous)
Stearyl alcohol: emulsion stabilizer,
surfactant, foam booster,
viscosity increaser
Soy sterol: skin conditioner/emollient
Hydrolyzed collagen: skin and
hair conditioner
Dimethicone: antifoaming agent,
skin conditioner/occlusive
Safflower oil: skin conditioner/occlusive
Methyl/propyl paraben: preservative
Triethanolamine: pH adjuster
Sodium hydroxide: preservative,
pH adjuster
Ascorbic acid: antioxidant, pH adjuster
This data is not intended to be
all-inclusive.
for topical retinoids. Patients with papular lesions
respond to retinoids in conjunction with benzoyl
peroxide. As pustular lesions develop, topical anti-
biotics are added to the retinoid and benzoyl peroxide
applications. Therefore, a patient whose disease is
similar to that depicted in Fig. 1 would apply a topical
antibiotic followed by a prescription formulation of
10% benzoyl peroxide lotion in the morning and a
high-potency 0.1% retinoid cream followed a topical
antibiotic at night. Combination products are avail-
able (erythromycin or clindamycin with benzoyl
peroxide); the concentrations of active drug may
be less than individually manufactured products,
toombs
Fig. 1. Clear gel moisturizer.
and it may be more difficult to define the causative
agent should an adverse event occur. Benzoyl per-
oxide in lotion or aqueous solution and tretinoin in a
cream base may be preferable and less drying (Box 2)
(Table 1) [2,3].
Cosmetics
Cleansers
The spectrum of skin cleansing products appro-
priate for acne patients includes: lipid-free cleansers,
synthetic detergent bars (syndets), astringents, and
exfollients. Lipid-free cleansers contain moisturizing
ingredients and are pH-formulated (pH 4.3 – 6.5) for
skin compatibility (pH 6.0). Ideally, lipid free cleans-
ers should not contain dyes, fragrances, or sensitiz-
ing preservatives (parabens); the ingredient panel
should contain fewer than 10 chemicals. These cleans-
ers are good choices for patients in the initial treat-
ment phase while the skin is adapting to topical
medications. Syndet bars tend to be more alkaline;
however, those containing zinc or salicylic acid may
be used after the skin has regained its barrier integ-
rity. Astringents (toners) are alcohol-based leave-on
liquids that help remove oil from the skin and are
excellent for makeup removal. Exfoliates, which are
designed for very oily skin, are astringents with
Box 2. Pathophysiology of acne vulgaris
 Abnormal keratinization of the follicu-
lar infundibulum
 Increased sebum production
 Colonization of the follicle by Propi-
onibacterium acnes
 acne vulgaris treatment 577

Table 1 exfoliate cleansers or as leave-on solutions are well-

Treatment of acne tolerated adjuncts with the additional benefit of
Lesion type Drug humectantancy. African Americans who develop post-
Comedones Topical retinoids inflammatory hyperpigmentation demonstrate sig-
Papules Plus benzoyl peroxide nificant improvement of pigmented lesions when
Pustules Plus topical antibioticsa adjunctive use of astringent and/or exfoliating cleans-
Nodules Plus oral antibiotics/intralesional steroids ers is added to the treatment regimen [16 – 19].
Cysts Isotretinoin
Scars Surgery
Sulfur
a
In female patients of child-bearing potential, oral con- For over half a century, sulfur has been used in
traceptives may be indicated. dermatology as an antibacterial, antifungal, and cor-
neolytic agent. When incorporated into a mask, its
antibacterial, corneolytic, and nongreasy occlusive
corneolytics added. Cleansers with ground fruit pits effects are evident by the excellent response. The
or other granular materials may be excessively abra- activity of topical antibiotic and benzoyl peroxide
sive [9 – 11]. solutions is augmented by the addition of sulfur
[20,21].
Moisturizers
Moisturizers are designed to temporarily restore Retinol
the integrity and hydration of the stratum corneum. Topical retinols at concentrations of 1% or less
Generally, moisturizers are formulated as creams or are available in several cosmetic formulations. Al-
lotions composed of humectants (chemicals that at- though not pharmacologically or clinically equivalent
tract water to the epidermis from the dermis), emol- to retinoic acid, these lipophilic chemicals can exert
lients (which fill the gaps between the squamous a corneolytic effect, particularly in the hair follicle.
cells), and occlusive agents (which retain moisture). Retinol metabolism occurs primarily in the epidermis,
The combination of these ingredients makes the skin with little if any percutaneous absorption; however,
look and feel smoother. Facial moisturizers for acne- administration during pregnancy should not be rec-
prone patients are nonocclusive clear gels or solutions ommended. For the patient who decides not to use
that contain noncomedogenic humectants and emol- tretinoin, retinol is a viable alternative [22].
lients. These light facial moisturizers are compatible
with topical antiacne drugs (Boxes 1 and 2, Fig. 1)
[12 – 15].
Weeks 1 to 4

Corneolytics Improvement is obvious during the first 4 weeks

Corneolytics are cosmetic ingredients that when of treatment with tretinoin, benzoyl peroxide, and
applied to skin result in intercorneocyte cell detach-
ment. Well-known examples include salicylic acid,
beta-hydroxy acid, glycolic acids, lactic acid, trichlor-
acetic acid, and resorcinol. Concentration, pH, and
vehicle are important factors in determining the
outcome. The lipophilic nature of salicylic acid
makes it an excellent comedolytic. Twenty to thirty
percent salicylic acid in an alcohol base or as part of
Jessner’s formula as an in-office chemical peel has
demonstrated comedolytic/corneocytic activity for
many years. Cleansers containing salicylic in con-
centrations of 2% to 5% are very effective adjunctive
agents. Leave-on salicylic gels in 2% concentra-
tions work well for spot treatment. Hydrophilic gly-
colic acids when used in conjunction with keratolytic
drugs can result in corneolysis sufficient to help
eliminate active papules and pustules. Glycolic acids
in concentrations of less than 10% as wash-off and Fig. 2. Comedones, papules, and pustules.
578 toombs

Weeks 4 to 8
Box 3. Ingredients in cosmetics for initial
antiacne therapy
Following the first 4 weeks of therapy, the skin
is less dry and scaly as it has begun to adjust to the
Lipid free cleanser
topical drugs. Cleansers can be changed to products
Water
that have mild keratolytic activity and/or help re-
Propylene glycol
move oil from the skin. Options include wash-off
Glycerin
alpha-hydroxy acid humectants or mild astringents
Cetyl alcohol
without keratolytics, such as witch hazel, or for more
Strearyl alcohol
oily skin very low concentrations of acetone/alcohol
Hydroxycellulose
formulations. The goal at this time point is to
accelerate normalization of follicular hyperkeratini-
Moisturizer zation and increase the penetration of the topically
Humectants applied drugs. The previously described moisturizer
Water can be applied as needed during the day.
Glycerin
Propylene glycol
Hyaluronic acid Weeks 8 to 12
Urea
Lactic acid
After 8 weeks, the skin has adjusted to the topi-
Polyethylene glycol cally applied drugs. Corneocytic astringents such as
Sorbitol exfoliates containing salicylic acid are applied once
Emollients or twice daily with gauze before the topical medi-
Water cine. In office, superficial beta- or alpha-hydroxy acid
Stearyl and cetyl alcohols peels (30%) help loosen open comedones (which are
Dimethicone then extracted); unroof closed comedones, papules,
Stearic acid and pustules (if still present); and provide exfolia-
Isopropyl palmitate tion adequate to aid in the resolution of superficial
Glyceryl stearate hyperpigmentation in more deeply pigmented pa-
Dicapryl ether tients [16 – 19].
Isopropyl mysristate
Collagen, elastin
Weeks 12 to 16

Pustules are generally nonexistent, the patient is

instructed to decrease the frequency of application of
twice-daily topical antibiotics; however, a secondary
goal is adjustment of the skin and patient compli-
ance. Patients will experience peeling, drying, tight-
ness, and irritation—especially during this early
period—as a result of increased epidermal cell turn-
over and transepidermal water loss. These symptoms
can be alleviated using a lipid-free liquid cleanser
applied with the fingertips (no cloths) and liberal
application of an appropriate moisturizer. An option
that patients find beneficial is cleansing with an in-
expensive wash-off hair conditioner. Although water
is the primary ingredient, many hair conditioners con-
tain chemicals similar to those in lipid-free cleansers.
However, the presence of dyes, fragrances, and nu-
merous other ingredients may be of concern in certain
patients. Female patients who wear foundation are
instructed to choose water-based makeup (Fig. 2,
Box 3, and Table 1). Fig. 3. Appearance following 12 weeks of therapy.
 acne vulgaris treatment 579

Table 2 discontinued and replaced with 10% to 20% leave-

Algorithm for cosmetics as adjunctive treatment for acne on glycolic acid solutions or water-based lotions.
vulgaris Patients are instructed in the use of weekly chemical
Week Drug Cosmetic peels at home (20%) decreasing further the applica-
1 0.1% Tretinoin cream Lipid-free cleansing lotion tion of tretinoin. An oil absorbing lotion is applied
10% Benzoyl Gel or solution facial during the day [19].
peroxide lotion moisturizer
Topical antibiotic Water-based foundation
solution for females Week 20 to 24
5 0.1% Tretinoin cream Change: mild corneolytic
10% Benzoyl wash-off cleanser; Tretinoin is discontinued, and an in-office peel is
peroxide lotion astringent cleanser
performed. Home peels and sulfur mask are con-
Topical antibiotic
solution
tinued. Spot salicylic acid gel is used for any new
9 0.1% Tretinoin cream Add: exfoliate cleansers; lesion. In the event of recurrence, drug therapy can be
10% Benzoyl office chemical peel (30%) reinstutited in reverse order (ie, tretinoin, benzoyl
peroxide lotion peroxide, topical antibiotic) (Fig. 4 and Table 2).
Topical antibiotic Cosmetic options for patients who want some-
solution thing different could include a mild alpha-hydroxy or
13 0.1% Tretinoin cream Add: sulfur mask; office salicylic wash-off cleanser, and an astringent or
10% Benzoyl lotion chemical peel (30% – 50%) exfoliate morning and night. A corneocytic solution
17 0.1% Tretinoin cream Add: corneolytic solutions; or gel is applied in the morning; topical retinol is
oil adsorbent; home
applied at night alternating with home peels and
chemical peels
21 None Add: spot keratolytic gels
sulfur masks. A corneocytic cleanser could be used
with prescription benzoyl peroxide with or without
topical antibiotics. Retinol could be substituted for
the topical antibiotic to once daily for 2 weeks and tretinoin if an exfoliate cleanser is combined with
discontinue. If lesions recur, the antibiotic can be re- home chemical and office chemical peels. Unfortu-
started. A sulfur-containing mask is applied nightly, nately, 20% benzoyl peroxide is no longer commer-
alternating with tretinoin. Thirty to 50% alpha-
hydroxy acid or Jessner’s peels are completed in the
office (Fig. 3 and Table 2) [16]. Box 4. Cosmetic alternatives in treatment
of acne vulgaris

Weeks 16 to 20 Cleansers

Benzoyl peroxide applications are decreased to Wash-off alpha hydroxy acid

every other day for 2 weeks, after which they are (5% – 10%)
Beta hydroxy acid exfoliate (2%)
Acetone-containing astringent
Sulfur syndet bar
Zinc syndet bar
Beta hydroxy wash-off cleanser
Alpha hydroxy exfoliate

Leave-on products

Retinol cream
Alpha hydroxy solution
Beta hydroxy solution
Beta hydroxy/alpha hydroxy solution
Sulfur mask
Oil-absorbing lotion
20% home chemical peel
Fig. 4. Marked improvement after 20 weeks of therapy.
580 toombs

cially available; however, it can be compounded

Box 5. Cosmetic summary
using a lipid-free cleanser as the vehicle and applied
as a leave on product. Similarly, 2% salicylic, 3%
Cleansers
sulfur in glycerin, and witch hazel can replace com-
Mild
mercially available exfoliates (Box 4).
Water
Glycerin
Cetyl alcohol
Propylene glycol Summary
Stearyl alcohol
Hydroxycellulose Dermatologists are skin professionals. Derma-
Astringents tology patients use cosmetics—everyone uses a
Witch hazel cleanser. Incorporating cosmetics in the acne vulgaris
Glyceine treatment regimen supports the concept of the
Acetone dermatologist as the skin care expert (Box 5).

Masks
Sulfur Acknowledgments
Salicylic acid
Kaolin Special thanks to Drs. Mary Lupo and Zoe Draelos
Bentonite for bringing cosmetics to the attention of dermatolo-
Titanium dioxide gists through their publications and presentations.
Zinc oxide

Oil absorbers
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